Gender identity disorders in children. Gender identity disorder

Gender identity disorder in children(previously transsexualism) is a psychosexual deviation, manifested in the child's rejection of his biological sex. The child often shows a desire to belong to the opposite sex or is convinced that he belongs to it. He is dissatisfied with gender, his anatomical features and gender roles accepted in society.

The disorder develops at the age of 3-5 years, less often in the lower grades of school, but always before adolescence. It is characterized by the persistence of symptoms - that is, the child behaves like a member of the opposite sex every day for several months or years.

There are no exact statistics for this deviation, since not all parents turn to a specialist when symptoms appear. A study conducted in the Scandinavian countries found that the frequency of this deviation is 1:11,000 among boys and 1:30,000 among girls. As you can see, boys are diagnosed with this diagnosis 3 times more often than girls. However, this ratio is explained not only by the peculiarity of the male psyche, but by the loyal attitude of parents and society to the fact that the girl behaves “like a man”.

In modern psychiatry, there is debate whether gender identity disorder can be considered a mental disorder. According to medical criteria, a mental disorder causes mental suffering to the patient himself or disrupts his ability to adapt to reality. This condition does not meet these criteria. Because suffering occurs only if others try to convince the child about his beliefs regarding gender. Otherwise, his mental and physical development does not differ from other children. In this regard, in some European countries, such people are called the middle sex, and their rights are enshrined at the legislative level.

The reasons

The probable cause of gender identity disorder is considered to be hormonal abnormalities in the mother during pregnancy. So diseases of the adrenal glands can cause a violation of testosterone levels, which affects the development of the fetus. However, recent studies confirm that one of the leading roles is played by psychological factors.

Organic causes:

pathology of the temporal lobes of the brain;
deficiency or excess of testosterone;
epilepsy;
schizophrenia (however, in this case, other symptoms characteristic of this disease also appear: paranoia, delusions, hallucinations).

Psychological reasons:

Child abuse. After the experience of violence, the child may develop the idea that his parents would have treated him better if he had been of the opposite sex.
Lack of attention from parents. Cross-dressing and demonstrative behavior may be an attempt to attract attention to yourself, arouse strong emotions in parents. Such a manner of drawing attention to oneself can manifest itself in self-centered demanding children.
Education in an incomplete family. For the formation of gender identification, the child must see a model of behavior of a representative of his gender. For boys, this may be a father, grandfather, or another man from his environment. The absence of a positive example of one's gender with which a child can identify can disrupt gender identity.
Difficult relationship between parents. For example, a child regularly witnesses family conflicts and sees how a parent of the same sex is humiliated. In this case, he may form an attitude that the opposite sex is better and stronger.
Excessive attachment to a parent of the opposite sex. Strong love and affection makes the child want to be like an object of adoration in everything and imitate even in small things.
Dissatisfaction with the sex of the child. For example, this happens in families where parents wanted a boy, but a girl was born. One or both parents do not hesitate to declare this and strive to raise her as a son. They buy clothes and toys for boys, bring up masculine qualities in them.
The indifference of parents to the manifestation of traits opposite to the given sex by the child. In some families, this behavior is even encouraged. For example, parents like that a girl grows up to be a tomboy, or perceive dressing a boy as a funny joke.
Emphasizing in the child the features characteristic of the opposite sex. For example, parents often admire the boy's good looks, take excessive care of his appearance, and take part in children's beauty contests. Preparing for power sports, where it is necessary to show strength and endurance, is harmful for a girl.

It should be noted that due to the fact that such a disorder is rare, it is not yet well understood. Therefore, the exact cause of its development can rarely be established.

Symptoms

With gender identity disorder, the child feels that he was born in the body of the wrong sex. For example, a child feels like a girl, but everyone tells him the opposite. This causes him bewilderment, and then protest or depression.

Parents can identify the disorder by the characteristics of the child's behavior.

For boys:

They show a strong desire to be like a girl, mother, sister. They put on women's clothing or simulate women's outfits with the help of improvised means.
They do not accept their sexual organs, considering them disgusting. They say that with age they will disappear.
They express regret that they were not born girls.
They convince others of their belonging to the female sex - "when I grow up, I will be a woman."
Prefers the company of girls and women, even if there are boys of the same age.
They try to imitate girls, adopt their demeanor;
They choose games that are typical for girls: daughters, mothers, princesses, witches. At the same time, typically boyish games and toys are rejected.
The character is dominated by delicacy, sensitivity, softness.
At school age, there is no sexual interest in the opposite sex, there is no childish love. All girls are perceived only as playmates or rivals.

For girls:

They show a feeling of discomfort from the need to live in the body of a girl. In adolescence, they seek to avoid changes that occur with the body - they rewind the chest, lose weight so that roundness does not appear in the hips and abdomen.
They are said to have or will have a penis and secondary male characteristics.
They say that they are male or when they grow up they will become men.
They show strong affection for their father, adopt his manner of behaving, try to imitate him.
They prefer the company of boys even in the presence of girls of the same age.
Refuses to urinate in a sitting position;
Prefers sports and active games. They do not like to play games typical for girls.
Dress in boys' clothes, never skirts or dresses.
Do not show sexual interest in the opposite sex at school age.

Both girls and boys with such disorders do not suffer from their beliefs and do not perceive their condition as a disease or deviation. Problems arise only if others show a negative reaction to their behavior. In this regard, boys are under more pressure, since the masculine behavior of girls is considered more socially acceptable.

It should be noted that in preschool children, the single or occasionally appearing symptoms described above cannot indicate a disorder. Children learn gender-role behavior during the first years of their lives. During this period, they necessarily commit acts inherent in the opposite sex. During play, young children often do not pay attention to gender stereotypes, as they have an inherent desire to try out new roles.

Not indicative of gender identity disorder

The desire to belong to the opposite sex, which is associated with specific privileges. For example: “I want to be a girl, everyone pities and protects them” or “I want to be a boy, they can climb trees and walk until late.”
The child agrees to take part in games that are characteristic of the opposite sex, imposed by peers. He strives to communicate and become part of the company.
During the game, he can wear clothes of the opposite sex. Predilection for bright beautiful things is typical for children of both sexes. It is enough to gently explain to the child that it is not necessary to do this and offer him something in return.

Also, gender identity disorders do not include cases associated with genetic abnormalities, when the child has signs of both sexes.

Diagnostics

The diagnosis of “gender identity disorder in children” according to the ICD-10 criteria is made if a child who has not reached puberty has persistently manifested deviations in gender-role behavior for more than 6 months.

For boys:

Discomfort caused by belonging to the male sex.
Strong desire to be a girl.
Frequent statements about belonging to the female sex.
One of two symptoms:

female model of behavior, wearing women's clothes, active participation in the games and hobbies of girls, while rejecting society, toys and games of boys;
rejection of one's sexual organs: disgust for them, wishing they were gone, saying that despite having them, she would grow up to be a woman.

For girls:

Discomfort caused by belonging to the female sex.
Statements that it would be better to be born a boy (not related to the sociocultural superiority of boys).
Claims that she is male or will become a male when she grows up.
One of two symptoms:

disgust for women's clothing, a strong desire to wear men's clothes and accessories;
rejection of female sexual characteristics, reluctance to grow breasts, menstruation, claims that she has (or will have in the future) a male penis.

Treatment

The treatment for gender identity disorder is psychotherapy. Medical treatment is rarely prescribed. Hormonal drugs are not used, since in children this condition is not associated with disorders in the work of the endocrine glands. In the event that the disorder is caused by epilepsy, then anticolvulsants are prescribed.

In the EU and the US, medical standards allow prescribing hormonal treatment to children to inhibit the development of secondary sexual characteristics and form their "desired" sex. In the CIS countries, this is not practiced, since it is believed that in adolescence a significant proportion of children get rid of the disorder under the influence of hormonal changes.

Psychotherapy

Psychotherapy for children of primary and secondary school age is carried out with their consent. Treatment is started if the child himself shows a desire to get rid of the disorder. If he is against, then they confine themselves to explanations within the framework of rational psychotherapy.

In any case, the work of a psychiatrist and psychologist will also be aimed at solving related problems. For example, they conduct trainings to help the child achieve emotional stability, aimed at reducing feelings of depression, anxiety, developing communication skills and eliminating conflicts with peers.

Rational psychotherapy

This direction is based on persuasion and re-education. In individual sessions, the psychotherapist in a form accessible to the child talks about the differences between the sexes and their meaning, the role of men and women in society. He pays special attention to the advantages and opportunities that the natural sex of the child gives and will give in the future. The child is taught what actions are considered right for his gender and age, and what actions should be avoided and why.

Cognitive Psychotherapy

The work of a psychotherapist is aimed at changing the child's thoughts regarding his body and gender. The child is formed the correct concept of his own body, the importance of all his organs, the importance and privileges of his natural sex. Sexuality education, conducted in a form that is accessible and interesting to the child, has a strong influence on his identification. And the younger the child, the stronger the influence of the psychotherapist, since at preschool age, beliefs determine his behavior.

gaming psychotherapy

During the game, situations are simulated in which the child must behave according to his natural sex, while showing all the best qualities inherent in the representatives of this sex. For example, the game "Superman Saves the Planet" or "Princess in a Magic Garden".

Family psychotherapy

At consultations, the question is decided how to behave with the child, accept his position or convince him, whether to inform others about the disorder. Parents are also taught how to cope with anxiety or rejection caused by the child's behavior. They are explained how it is necessary to adjust their behavior and the style of relationships in the family in order to change the child's attitude towards their gender.

Hypnotherapy

Treatment of the disorder with hypnosis should be carried out by a psychotherapist who has the appropriate training. As a rule, parents are also present at the sessions. A child in a state of hypnotic sleep is given a hypnotic suggestion. It can take the form of short, understandable formulas: “I like that I am a boy. I accept my body." Suggestion can be in the form of specially composed fairy tales, the essence of which is to convince the child that he is comfortable in his body.

Psychiatrists have established a pattern that the younger the child, the more successful the treatment. In this regard, parents are advised not to ignore the signs of the disorder, but to correct the child when denying his natural sex, to actively engage in the prevention of the disorder at home. If the symptoms persist for more than 6 months, then it is necessary to contact a child psychiatrist.

Possible consequences

Children and adolescents with this disorder often have behavioral and emotional problems. They are caused by the fact that the child suffers from a discrepancy between the sex with which he was born and his ideas about himself. Problems are greatly exacerbated by peer and adult pressure, ridicule, or physical aggression.

The most common consequence is depression. In children, it can be manifested by refusal to eat and other activities that previously aroused interest, tearfulness, irritability, negativism, isolation, insomnia, nightmares.

Among those who have the disorder in adulthood, in 14% of cases, a tendency to homosexuality is formed.

Lack of support, constant reproaches from parents, and bullying by peers can lead to suicide attempts.

Prevention

Prevention of gender identity disorders should be dealt with by parents from the first years of a child's life. The actions of parents should be aimed at teaching the child to accept his body and his gender naturally and calmly.

A positive example of the behavior of their gender. A boy should know how men behave. It is good if the father demonstrates such a model of behavior. Even if the parents are divorced, the mother should speak approvingly of him, set as an example his actions. In single-parent families, a role model can also be chosen among acquaintances or characters.
Warm relationship between parents. When a child sees admiration or approval for a parent of the same sex, he forms the attitude “It's good to be a boy, like dad. Mom praises him.
Taking care of your body. It is desirable that the example is set by a parent of the same sex as the child. Grooming includes not only hygiene, but also exercise, clothing, etc.
Frank and calm conversations with the child on any topic, including the relationship between the sexes and procreation. "Forbidden" topics and the formation of false shame in matters of gender can contribute to the development of the disorder.
Explain to the child what behavior is considered unacceptable for his gender. If parents notice behavior that does not correspond to the sex of the child, then this must be indicated: “Boys behave differently. You are a boy!"
P switching attention child in the event that the games do not correspond to the gender role. Distraction to something interesting is much more effective than a hard ban.
Getting to know your body. Starting from the age of two, children examine their body, including the genitals, with each undressing and bathing, while asking questions. Parents should calmly and kindly answer these questions, and not shame the child. Reaction “Don't touch! Don't look! Don't ask!", especially from a parent of the opposite sex, leads to the fact that the child perceives his genitals as something disgusting, which can later lead to a gender identity disorder.

In conclusion, we want to reassure parents. A study conducted by Australian scientists in 1995 found that in most children by adolescence or adolescence, this disorder resolves on its own, and only a few experience its manifestations in adulthood. This is also supported by the fact that among the interviewed adult transvestites and transgenders, there are rarely those who had gender identity disorder in childhood.

Gender identity disorder is a state of permanent self-identification with the opposite sex. In this condition, people feel as if they are enclosed in a body that is not compatible with their own perception of gender. They consider themselves victims of a biological error. Transsexuals are people who have a form of gender identity disorder that is extremely pronounced.

Actually, gender identity itself is considered a subjective sensation, when a person feels like a man or a woman. Gender identity is considered an internal feeling of femininity or masculinity. The external objective manifestation of a person's belonging to a man, a woman, or a bisexual state is a gender role. At the same time, a person’s behavior is as much as he wants to show himself or others, in order to convince to what extent “he is a woman” or “she is a man”. The role and gender identity of most people is the same. The discrepancy between gender identity and anatomical gender is a gender identity disorder. This mismatch is felt by transsexuals as heavy, long, disturbing, complex. This condition is called a "disorder" because of the distress it often causes. The treatment of such patients should not consist in dissuading them of their gender identity, but in adapting them.

Pathaphysiology and Cause of Identity Disorder and Transsexualism

Gender identity is mainly determined by the prenatal hormonal background, the genetic component and biological factors, however, in order to form a consistent and confident gender role and gender identity, the influence of some social factors is needed, such as the relationship between parents and the child and the nature of the emotional connection of one parent with another.

When upbringing and gender are ambiguous (for genetic syndromes in which the appearance of the genitals is disturbed, insensitivity to androgens, or if the child has genitals of both sexes), the child may be uncertain about his role and gender identity. However, the significance of external factors is controversial at the moment. If the upbringing and gender designation are unambiguous, then even the presence of the genitals of both sexes in the child will not violate his sexual identity. Transsexuals usually face the problem of gender identity in their early childhood. In adulthood, most people who had problems with gender identity in childhood do not experience.

Two years is usually the age at which problems with gender identity arise in children. There are also cases when gender identity disorder does not manifest itself until adolescence. Children who experience problems with gender identity often prefer clothes of the opposite sex, constantly and clearly want to take part in activities and games that are characteristic of the other sex, insist on belonging to the opposite sex, and have a negative attitude towards their own genitals. For example, a little girl insists that she can urinate standing up when her penis grows, while a boy, on the contrary, may urinate sitting down and clearly want to get rid of his genitals. This disorder is not diagnosed until 6-9 years of age, when the disorder is already chronic.

Diagnosis of transsexualism and identity disorders

To make this diagnosis for a child, it is necessary to have identification with the other sex (the child's conviction that he belongs to the opposite sex or his desire to be the opposite sex), as well as a significant mismatch of the child with his gender role or a feeling of discomfort in connection with his gender. The desire to gain any cultural advantage of the opposite sex should not be an identification with the other sex. For example, a boy who talks about wanting to be a girl just to get the same kind of attention that his younger sister is receiving most likely does not have a gender identity disorder. Behavior that falls on the continuum of traditional femininity or masculinity is associated with gender roles and cultural pressures that increase against people who do not quite fit the traditional dichotomy of women and men. In Western culture, the attitude towards the behavior of little girls as tomboys is more tolerant than the attitude towards the effeminate behavior of boys. In role play, many boys play mothers or girls by trying on mothers and sisters' clothes. Such behavior, as a rule, is the norm of development, and only in extreme cases is it preserved. Many boys with identity disorder as children do not have it as adults, but many are bisexual or homosexual.

In adults, diagnosis is aimed at determining the presence of severe distress or a clear violation in professional, social and other areas of functioning. Opposite-sex behavior, such as cross-dressing, may not require any treatment, provided it is observed without psychological distress or if the person has physical signs of both sexes (genitals of both sexes, congenital adrenal hyperplasia, insensitivity syndrome to androgens).

There are cases of association of transsexualism with the presence of genetic anomalies (Klinefelter or Turner syndrome) or the genitals of both sexes. The majority of transgender people in need of treatment are men who embrace a feminine identity and have great distaste for their own masculinity and genitalia. Basically, such people seek help not for the purpose of obtaining any psychological help, but for a different purpose, such as receiving hormones and surgical operations on their genitals in order to bring their appearance closer to their gender identity. A combination of hormone therapy, psychotherapy, and sex reassignment surgery often cures these patients.

Transsexualism transition from male to female most often first manifested in early childhood: participation in girls' play, fantasies of changing sex, avoidance of competitive and power games, distress with changes in physical fitness in puberty. Many of the transgender people are persuasive in accepting the female role, having the satisfaction of acquiring a effeminate appearance and obtaining papers that indicate their gender, which helps them to live and work in society as a woman. Others experience big problems from depression to suicidal behavior.

Transsexualism transition from woman to man is increasingly seen in psychiatric and medical practice as a treatable transsexualism. Such patients undergo mastectomy, hysterectomy, and then ovariectomy, as well as androgenic hormones that promote voice changes, male-type muscle distribution, and body and facial hair growth. Some patients insist on the formation of a neophallus (artificial phallus). For some patients, surgical treatment helps to better adapt and gain satisfaction from life.

The ICD-10 includes pathological gambling, pathological arson (pyromania), pathological stealing (kleptomania), pathological vagrancy (dromomania), and gender identity disorders (sexual desire) to disorders of inclination in psychopathy ICD-10.

Pathological gambling addiction manifests itself in frequent repeated episodes of participation in gambling, which is leading in the life of a person, leads to a decrease in social and professional skills, loss of material and family values. Such persons usually make large debts, break the tax law, evade family responsibilities. They experience a strong attraction to gambling, its irresistibility, uncontrollability of their actions. Outside of gaming activity, they represent the details of the game, experience episodes associated with the excitement of the game, constant internal tension. During such periods, they sleep anxiously, irritable, conflict, quarrelsome. They are distinguished from ordinary players by the grasp of gaming activities, violations of social forms of behavior, indifference to their impoverishment and the well-being of the family. In forensic psychiatric practice, such persons are extremely rare, usually in connection with financial offenses.

pyromania(pathological arson) are characterized by the desire to set fires and admire the fire. Distinguish pyromanias true and false (pseudopyromanias). In the latter cases, arson is committed for the purpose of revenge, concealment of any illegal acts, in a state of intoxication. True pyromaniac acts occur periodically at the height of an agitated state, the only motive of which is admiring the fire or defusing one's inner tension. At the same time, random objects are set on fire; such persons do not leave the fire that has arisen. They are often seen by those around them "enchanted" by the fire. The persons themselves describe these states as an irresistible attraction to fire, while experiencing pleasant sensations, they completely lack a sense of guilt, an assessment of the consequences of their actions. In some cases, they become sexually aroused. The type of fire and the actions of people in extinguishing the fire cause a discharge of affective tension, which is repeated in the future and leads to a desire for new arsons. Attraction disorder in the form of pyromania occurs in various forms of psychopathy and is formed into a clinically defined syndrome of attraction disorder.

Kleptomania(pathological theft) in the practice of forensic psychiatric examination is extremely rare, although persons held accountable for theft are quite often the subject of examination. With true kleptomania, as well as with other types of impulse disorders, an irresistible desire to steal occurs periodically. It is preceded by a feeling of internal tension, dissatisfaction, anxiety. Theft is always committed alone, is not connected with material necessity and, as a rule, does not entail personal enrichment. Objects accidentally caught in the patient's field of vision are stolen. After the theft, there are no signs of hiding the traces of the crime, and emotional stress is released. Persons who are repeatedly prosecuted for theft often motivate their actions with irresistible desire, but their behavior cannot be regarded as a disorder of inclinations if their actions do not correspond to the described clinical features of kleptomania.

Dromomania(pathological propensity to vagrancy) means that patients for no apparent reason leave their permanent place of residence and move aimlessly from one city to another, where they roam the streets, beg, and then leave it again. True dromomania must be distinguished from false. The latter is often observed in adolescence and is associated with complex relationships in the family (drunkenness of parents, cruel methods of punishment, etc.). Such adolescents, running away from home, live in attics, basements, sometimes move from place to place, join antisocial groups of adolescents or adults, where they become persons subject to the main forms of behavior of the group. In the future, they can run away from home even in the absence of traumatic situations. Such forms of vagrancy cannot be regarded as dromomanias, as they are conditioned by the situation and over time, as they grow older, they are compensated. This form of impulse disorder is not given in all classifications of mental disorders, however, in forensic psychiatric practice it occurs in a number of cases and needs a differentiated expert assessment.

Disorders of sexual desire and paraphilia. Modern sexopathology and psychiatry distinguish two types of pathological sexual desires: gender identity disorder and sexual preference disorder.

To gender identity disorders include male and female homosexuality (sodomy, lesbianism). The attitude towards these forms of sexual deviations among sexologists and legislators is ambiguous. Female homosexuality has never been prosecuted by law either in domestic or foreign legislation, while in a number of countries male homosexuality is considered a criminal offense. In accordance with the Criminal Code, only persons who have committed violent homosexual acts, including with minors, are subject to criminal liability (Articles 132-134).

Most often, bisexual acts take place, when a person in a situation of isolation performs homosexual sexual acts, but in ordinary life has normal sexual intercourse. Same-sex sexual relationships arise in situations of prolonged isolation (long voyages, penal colonies, etc.).

At the same time, there are cases in practice when violations of gender identity occur early, without visible external causes, and remain persistent. These cases are true disorders of sexual desire, as a rule, cannot be corrected and have an undoubted biological condition. It is in these cases that hormonal disturbances occur, and sometimes residual phenomena of early organic damage to the central nervous system.

Transsexualism - the desire to be accepted in society as a person of the opposite sex, with a sense of inadequacy and discomfort from one's anatomical sex. Such persons usually wear clothes that do not match their gender, use cosmetics to change their appearance, and resort to cosmetic surgery. Sometimes they lead a dual life, at work and in society they present themselves as persons of the same sex, and at home and in a narrow circle of acquaintances they try to show themselves as persons of the opposite sex.

As sexual desires deepen, some patients insist on sex reassignment surgery. This type of operation is carried out both in our country and abroad. However, this is possible only after consulting a psychiatrist, who must state the true form of transsexualism and the absence of any other mental disorders, as well as with the conclusions of a sexologist and endocrinologist. After a surgical intervention, such persons may be issued documents for a person of the opposite sex with a change in name accordingly. Individuals with this type of impairment rarely commit crimes.

Paraphilia usually formed early against the background of residual phenomena of organic brain damage, which are the biological basis for the formation of abnormal cravings. Special forms of sexual disorders develop in persons with signs of chronic alcoholism, which is facilitated by a general decline in personality, emotional coarsening, ignoring the standards of behavior with the destruction of the hierarchy of motives. The formation of paraphilia occurs from simple to more complex forms, it is possible to change the types of attraction with the appearance of aggressive and auto-aggressive tendencies and an increase in the social danger of such persons.

In the psychiatric classification, there is a description of many types of paraphilia, but forensic psychiatric significance has several forms: pedophilia (attraction to children), gerontophilia (attraction to the elderly), necrophilia (sexual intercourse with corpses), exhibitionism (exposing one's genitals), sadomasochism ( causing pain during intercourse).

Pedophilia - sexual attraction to children. It is usually observed in men, including the elderly, with certain sexual dysfunctions. These are depraved acts, accompanied by showing pornography, undressing children, examining their genitals, and masturbating. Sometimes sexual acts are performed with children, both in the usual and in a perverted form. Pedophilia can be combined with sadism. In such cases, children are injured, sometimes quite severe and incompatible with life. Pedophilic acts are committed both with strangers and with their own or adopted children.

Gerontophilia - a sexual preference disorder in which sexual intercourse is performed with the elderly and old people. Gerontophilia is a relatively rare perversion, often accompanied by sadistic tendencies or brutal murders.

Necrophilia - sexual attraction to corpses. It occurs predominantly in men. This type of attraction disorder is formed in persons with deep forms of psychopathy or mentally ill people. Necrophiles are often workers in morgues or cemeteries. They usually open graves or mock corpses in morgues. In expert forensic psychiatric practice, they are rare. They are held accountable for hooliganism and desecration of the bodies of the dead and their burial places.

Exhibitionism - a disorder of sexual desire, which manifests itself in a periodic or constant inclination to expose one's genitals, especially in front of persons of the opposite sex (more often in front of women), without the intention of sexual contact. Exposure is accompanied by sexual arousal with an erection. This type of inclination usually manifests itself at the height of emotional stress and alternates with light periods. Such acts are typical for persons with disorders of sexual desire such as exhibitionism.

Sadomasochism - achieving sexual satisfaction by causing suffering to a sexual partner (sadism). Such persons sometimes obtain sexual satisfaction by performing sexual acts with a victim in a state of agony. A variety of sadism is masochism - obtaining sexual satisfaction from the humiliation and suffering inflicted on him by a sexual partner. In practice, a combination of sadism with masochism is more common, which is the syndrome of sadomasochism. As a rule, these persons are characterized by serial murders, which are calculated by several victims. In ordinary life, sadomasochists do not show social maladjustment, they do not give the impression of persons with any mental anomalies, therefore crimes of this kind are difficult to solve.

Forensic Psychiatric Assessment of persons with similar disorders relies on the fact that in forensic psychiatric practice true impulse disorders are rare. Persons prosecuted for various crimes often talk about their attraction to theft, arson, vagrancy, etc. In these cases it is always necessary to distinguish between true disturbances of instincts and false. The latter usually have the character of fixed antisocial habits, lifestyle, psychological attitudes of the individual. The forensic psychiatric assessment of persons with the presence of such forms of behavior is based mainly not on the analysis of the same type of socially dangerous acts, but on the identification of the main soil on which they arise.

If these forms of behavior occur in patients with schizophrenia, manic-depressive psychosis, an organic disease of the central nervous system, then the solution of expert questions depends on the depth and severity of mental disorders characteristic of the underlying disease.

True disorders of attraction are characterized by certain patterns - this is the repetition of the same type of actions without any material interest, the absence of concealment of an illegal act, its pathological motivation, the subordination of actions to the nature of attraction.

Persons who, during the period of forensic psychiatric examination, did not reveal true disorders of drives, but only signs of psychopathy and not pronounced residual phenomena of organic damage to the central nervous system, are not subject to Art. 21 of the Criminal Code. They can be aware of the actual nature and social danger of their actions and direct them and are recognized sane.

The forensic psychiatric assessment of persons suffering from true impulse disorders, regardless of their content, is ambiguous. In cases where violations of impulses do not reach the degree of invincibility, in the presence of partial criticism of their actions, the struggle of motives before the act or are in the process of formation, it is permissible to apply Art. 22 of the Criminal Code of the Russian Federation. It provides for the presence of such a mental disorder that makes it impossible to fully realize the actual nature and social danger of one's actions or the ability to direct them. Application limited sanity to persons with disturbed inclinations implies the presence in the acts of these persons of the motivation for the act, corresponding to the form of disturbed inclinations.

In those cases when drive disorders become the leading feature, merge with the personality, cannot be corrected, the critical assessment of behavior as a whole is violated, the application of the article on insanity.

In the list of medical care for people with gender identity disorders who are diagnosed with transsexualism, psychotherapy is recommended. Its purpose is to enable such patients to realistically evaluate their ideas about the field in which he feels himself, to eliminate the possibility of conflicts in his personal life and at work in a biological sex role, to increase the scope of choice of behavior. After psychotherapy, the transsexual decides whether he will adapt in his body or try to live in the sex role he feels in order to gain experience, and also decide on radical methods (hormonal therapy, surgery).

The specialist also helps the transsexual to get used to their new biological gender after gender reassignment surgery. An anatomically altered person quite often feels flawed at first, although he aspired to a new life, but psychotherapy allows him to find himself and become more confident in a new gender role.

That is, psychotherapy supports a transsexual at various stages of medical care that are important for him.

How many sessions a certain transsexual patient will need, no one, the best specialist, can say for sure. This is due to the fact that each person is individual and everyone achieves the same goals for a different period. If the patient is told the minimum number of sessions, he will take them as a barrier and this will interfere with the effectiveness of the process.

That is why the psychotherapist, focusing on the personal and other characteristics of the patient, develops an individual psychotherapy program for him, sets the goals to be pursued, determines the duration and frequency of sessions.

The specialist must explain to the patient his right to choose the terms of therapy and the methods used in it. Psychotherapy is carried out without taking into account such stages of medical care as life experience in a different sex, hormonal therapy and sex reassignment surgery. It is possible that the patient will not resort to them if psychosocial adaptation is achieved. But the psychotherapist should in no case stop the transsexual from striving for the opposite sex role.

Principles and Methods

Recognize bi- and homosexual behavior and fantasies as the norm, when as transsexual desires to consider violations that cannot be corrected.

Explain the priority of the family, children of work on the behavioral desire to demonstrate their preferred gender role;

Strives to combine feminine and masculine manifestations in ordinary everyday life.

Find mental comfort.

Identify events that increase the patient's desire to fulfill a role other than his innate gender, thereby developing techniques to counteract this.

Psychotherapy for transsexuals can be of the following types:

cognitive;

psychodynamic

client-centered, etc.

In the period of preparation for sexual reorientation, rational and explanatory methods are used, family therapy is carried out with the patient's partners and his close relatives (individual and group). Also, therapeutic assistance is provided before the start of taking hormonal drugs and gender reassignment through surgery.

If patients have neuropsychiatric disorders, then in the course of psychotherapy they are shown sedatives, tranquilizers, nootropics, antidepressants.

It should be mentioned that a psychiatrist who diagnoses a patient with transsexualism cannot perform the functions of a psychotherapist for the latter. But if the patient refused psychotherapy, then the psychotherapist informs the leading patient specialist in writing. In this case, he also gives permission in writing for the passage of the TC treatment program, bypassing psychotherapy.

“There are already many means to correct or somehow compensate for the injustice committed by nature. But all this would not be enough if the evolution of mass consciousness did not go in parallel towards greater tolerance, breadth of views and respect for the personality of each person.

A. Belkin, "The Third Sex"

In recent years, there has been an increase in the number of persons wishing to change their gender in medical institutions. When a person insists on changing his gender, this always poses a difficult task for doctors and authorities - to allow or not to allow. What should be done in such cases: agree with the patient, perform the most complicated surgical operations to change the genital organs, and then issue a new passport or recognize his requirements as a mental deviation and actively treat him until his normal idea of \u200b\u200bhis gender is restored? What actually makes some people take such a step? In some cases, this is a manifestation of a distinct mental pathology (for example, in schizophrenia or psychopathy), in others it is a special worldview, but more often for such needs, there are still certain biological prerequisites. I will give excerpts from the case history of patient O., aged 22, diagnosed with Klinefelter's syndrome, who applied for a change of civil sex due to the fact that he is aware of himself as a woman.

Klinefelter syndrome is a genetic disease in males, which is based on a genetically determined deficiency of the male sex hormone testosterone.
With this disease, the number of female sex chromosomes is increased, i.e. female genes predominate over male. There may be several options for such an increase: 47, XXY; 47,XYY; 48,XXXY; 48,XYYY; 48XXYY; 49XXXXY; 49 XXXYY, the most common configuration is 47, XXY. Klinefelter's syndrome is not only the most common form of male hypogonadism, infertility, erectile dysfunction, gynecomastia, but also one of the most common endocrine pathologies, ranking third after diabetes mellitus and thyroid disease.

Let me tell you a case from medical practice.

The patient's visit to the clinic was initiated by his parents, who were trying to figure out their son's problem and bring him back to normal.

From the anamnesis it is known that from the age of 5 the patient began to try on women's things, fantasized and imagined himself as "Little Red Riding Hood". Playing with children in "daughters-mothers" he played the role of a grandmother, then an aunt. However, outwardly, he did not differ from his peers, wore a short haircut, men's clothes, preferred cars, boy games from toys. He went to sports sections (swimming, toekwondo), was mobile, sociable. From the age of 14, sexual fantasies appeared, sexual attraction to the male sex began to form. In my fantasies, I saw myself as a girl. This introduced a certain "confusion in thoughts", trying to comprehend this state. Ideas of inferiority appeared, mood decreased, sleep and appetite worsened. He became more closed, the circle of acquaintances narrowed, he tried to share his thoughts with close friends. Sexual fantasies were accompanied by masturbation, while the penis in their fantasies was associated with the vagina. Orgasm during masturbation, as later, occurred with an incompletely erect penis. At the age of 15, the first sexual experience with a male representative. He entered into sexual relations in order to understand his own orientation. In the process of sexual intercourse, I felt like a woman. Homosexual contacts have become regular and continue to this day. However, according to the mother, it is known that, at the age of 16-17, there was a romantic love for a peer. Gave her flowers, dedicated poems. The rupture of relations occurred at the initiative of the girl. The breakup was hard. He shared his experiences with his parents, asked for advice. In order to understand his feelings and determine his orientation, “understand his place in life”, he began to read various literature, including religious literature, tried to find an explanation for his condition. Until the age of 18, sexual fantasies with masturbation continued, he imagined himself as a girl. At the age of 18, sexual intercourse with a girl. He did this with his eyes closed, imagining that his partner was a man. He was disappointed, “there was a feeling that a homosexual contact had been made.” Over time, the inner fear, the feeling of "inner confusion" disappeared. I came to understand what a girl is. He began to enter into homosexual contacts, but they did not bring complete satisfaction, because. partners perceived him as a representative of the male sex. From the same time, he began to call himself in the feminine form (“I said”, “I went”, etc.).

At the age of 19, in a letter to his mother, he admitted that he was bisexual. O.'s parents sent her to Germany for treatment, where the first diagnosis was Klinefelter's syndrome. He was worried about his inferiority, there was a feeling of oppression, hopelessness, depression, the meaninglessness of further existence. Under pressure from his parents, “to calm them down,” he got married at the age of 20, but family life did not work out. The wife called O. a "genetic freak", the marriage was asexual. Soon the couple divorced. Failure in marriage “proved” to the patient that “he is a woman”, as a result, he began to persistently seek his recognition as a woman. He visited gay clubs and talked with transvestites. In order to distract his son from his worries and involve him in other activities, his parents took him to Cyprus. In Cyprus, he found a job as a programmer, his parents returned, and the patient found a plastic surgeon who performed feminizing mammoplasty for him. It "brought back a sense of confidence and calmness." Dated a man who "saw a woman in him." Returning a year later, he confronted his parents with a fact.

Behavior is uneven, at home she dresses in men's clothes. In communication with relatives, he responds to a male name. However, in the presence of outsiders, on the street and in public places, he begins to act demeanor and flirt, change his voice to a female, and refers to himself in the feminine gender. Calls herself Olga.

The patient is of asthenic type of addition. Above average height, long limbs. Hair on the female type, facial hair is absent. Breast plastic surgery done. He enters into conversation with ease. Neatly dressed, light makeup on his face, manicure on his hands, wears perfume. Hair is long, loose, clean. Unisex clothing (leather trousers, jacket). In gait, he tries to imitate the gait of a top model. He smiles, looks into his eyes, often changes his body position, trying to emphasize the presence of a female breast, coquettishly straightens his hair. The voice is insinuating, quiet. He answers questions in detail, without shyness, frankly. Asks to call him Olga. He considers himself a creative person, writes poetry, is prone to fantasizing. The mood is slightly upbeat. He connects this with a recent new acquaintance with a young man, quite nakedly talks about his personal life, readily demonstrates his chest. Prone to demonstrative behavior, mannered, cutesy. The fact of hospitalization is considered as a stage of preparation for an expert opinion on gender reassignment. At the same time, he doubts the expediency of the operation to form an artificial vagina, does not express ideas of rejection and disgust for his genitals. He explains the change of sex by the desire to correspond biologically to his "mental feeling". Wants to have a family, be a mother, adopt a child. Puts forward various "theories" of the synthesis of sex hormones in the brain. Criticism of his condition is incomplete, setting for treatment is formal.

An endocrinologist diagnosed the patient with Klinefelter's syndrome, with a pronounced androgen deficiency. Replacement therapy with male sex hormones was recommended. In order to determine further therapeutic tactics, the management of the clinic organized a consultation of three competent psychiatrists. Experts' ideas about what constitutes the essence of the patient's mental abnormalities differed greatly. One expert suggested the presence of a schizophrenic process in the framework of a simple or indolent form, with the presence of a defect and Klinefelter's syndrome, with a dominant violation of gender identity. The other is a gender identity disorder, a psychopathic syndrome against the background of organic cerebral insufficiency in a patient with hypogonadism, Klinefelter's syndrome. The third expert considered that in this case we are talking about a demonstrative personality disorder. All consultants were unanimous in one thing - the legitimate denial of transsexualism. According to the law, only transsexualism has no contraindications to gender reassignment. This provision was the clinical and legal basis for which our patient had no chance of a sex change. Despite the difference in the diagnostic interpretation of various psychopathological manifestations in a patient, it was possible to apply such an approach that made it possible to fit the patient's diverse symptoms into the framework of a single, voluminous multidisciplinary concept and choose an effective treatment strategy and tactics. As a result, the patient removed the implant, returned to male sex-role behavior, got a job.