性別不一致

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性別不一致
同义词性别不安,性别焦虑
症状與一個人的性别指定有關的不适[1][2][3]
併發症飲食失調,自殺,抑鬱,焦慮,社會孤立[4]
类型性健康
相似疾病或共病性別認同性別表現方面的變動並不令人痛苦[1][3]
治療性別轉換心理治療[2][3]
藥物跨性別激素療法(例如:雄激素抗雄激素雌激素孕激素促性腺素释素
分类和外部资源
醫學專科精神病學心理學
ICD-11HA60
ICD-10F64.8、F64.9
ICD-9-CM302.6
MedlinePlus001527

性別不一致[a](英語:gender incongruence),又称性別不安(英語:gender dysphoria[b][c],旧称性别认同障碍/性身份障碍(英語:gender identity disorder)或易性症/異性症(英語:transsexualism[6][d],是指个体所经历过的性别与性别指定(及其相关性别角色或第一/二性征)之间存在显著且持续的不一致。性別不一致者通常是跨性別者

“性別認同障礙”在《精神疾病診斷與統計手冊》(DSM-5)2013年被重新分類為“性別不安”,以消除與術語“障礙”相關的污名。[7]于2022年1月1日生效的《国际疾病分类第十一版》(ICD-11)中,“性别认同障碍”被重新命名为“性別不一致”。

性別不一致與非常規性別不同。[8]根據美国精神医学学会的說法,性別不安的關鍵因素是「臨床上的顯著痛苦」。[1]一些跨性別和研究人員支持性別認同障礙的重新分類,因為他們說診斷會使非常規性別病理化,並強化了性別二元論的模型。[9][10][11]

有研究证据表明,性别不一致可能存在遗传原因。[12][13]性別不一致的治療可能涉及支持患者改變性別表現。透過激素替代療法性別重置手術可以用來协助這種改變。[2][3]治療還可能包括心理諮詢或心理治療。[3]

概念[编辑]

人具有“自己属于哪个性别的感觉,一种对自己是何種性别的自我认知”,这被称为性别认同,大多数人都有着与性别指定相同的性别认同,但在极少数情况下,有些人对他们的指派性别有着清晰的认识,但是并不认同这个性别的情况,有这种对性别认同不一的状态被称作性别不一致。

一般人可以很轻松的维持自己对出生性别的认同,但性別不一致者则不同。例如,在实验中让被试者尽可能快地写出尽可能多的、描述自己的语句,通常被试都会做出很多跟自己性别相关的描述。一般人做出的描述都会和其性别指定或社会普遍认同的相应性别特征一致。而性别不一致者却会做出很多跟自己性别指定相矛盾的描述。这种矛盾的性别认同往往会给人以严重的痛苦体验。

在过去,一般认为性别是由生殖器和染色体所决定的,并一直认为这和性别认同是一回事,但是解剖学上也有发现染色体与性腺所不同的性分化异常的情况。性别不一致被认为是一种由于某种原因,指派性别与涉及大脑性别认同的部分彼此不匹配的情况。

性别不一致与性倾向无关。性别不一致者可能会认为自己是异性恋、男同性恋、女同性恋或双性恋。[14]

症状[编辑]

一个人感觉到的性别与被分配的性别(通常在出生时)不一致而产生的困扰是性别不一致的主要症状[15][16]

出生时被分配为男性的人的性别不一致(通常被称为AMAB)倾向于遵循两种广泛的轨迹之一:早发或晚发。早发的性别不一致在童年时行为上就很明显。有时,这一群体的性别不一致会停止一段时间,他们会在一段时间内认同为同性恋者,然后再复发性别不一致。这类人在成年后通常会被其出生时的性别所吸引,通常被认定为异性恋。迟发的性别不一致并不包括早期儿童时期的明显迹象,但有些人报告说,他们在童年时曾有过成为异性的愿望,但没有向他人报告。[17]出生时被分配为男性的人,如果有迟发的性别不一致,通常会因性兴奋而变装。[18]出生时被分配为男性的的跨性别者,如果经历晚发的性别不一致,通常会被女性所吸引,并可能被认定为女同性恋或双性恋者,而早发的通常会被男性所吸引。[17]类似的模式也发生在出生时被分配为女性的人(AFAB)身上,经历早发的性别不一致的人最有可能被女性吸引,而晚发的人最有可能被男性吸引并被认定为同性恋。[17]在AFABs中,早发的性别不一致是最常见的。[17][18]

性別不一致兒童通常有以下情况:喜欢异性典型的玩具、游戏或活动;讨厌自己的生殖器;以及非常喜欢异性玩伴。[19]一些儿童也可能经历与与同龄層的社会隔离,焦虑,孤独和抑郁。[20]美國心理學會称,跨性别儿童比其他儿童更容易在学校,寄养,住宿治疗中心,无家可归者中心和少年司法方案中遭受骚扰和暴力。[21]

在青少年和成年人中,症状包括渴望成为另一性别并被当作另一性别对待。[19]成年性别不一致者面临更大的压力、孤独、焦虑、抑郁、自卑和自杀风险。[20]跨性别者还面临饮食失调[22]和药物滥用[23]的高风险。

在許多案例中性別不一致通常是在小時候就會出現,但也有在青春期或成人時才出現的可能,並且隨著年紀增長而越來越強烈[24]。由於許多文化並無法接受跨性別的行為,這種感覺往往為當事人以其家人、朋友帶來許多問題。在許多案例的報告中,也有人的不適感是覺得自己的身體「出了差錯」,或從一開始就不應該是如此。 以下症状一般被认为是性別不一致的表现。但这些症状并非所有性别不一致者都有表现。

原因[编辑]

当一个人因性别认同而感到不满时,性别不一致就会存在,从而导致他们情绪低落。[25]研究人员对性別不一致者的痛苦和损伤的本质持不同意见。一些研究人员认为,性别不一致者受苦是因为他们受到羞辱和暴力。[26]而且,如果社会性别分化不那么严格,跨性別就会遭受少一點的痛苦。[27]

性别不一致的确切成因尚未明确。[14]有研究证据表明,遗传因素在性别不一致的发展中起主要作用[28][29],性别认同被认为可能反映了生物、环境和文化因素的复杂相互作用。[30]

社会行动[编辑]

《中华人民共和国未成年人保护法》(2020年修订)规定,学校、幼儿园应当对未成年人进行适龄性教育。接纳人人在性取向、性别认同和性别表达方面享有平等的选择权,不遭受污名、歧视和暴力,是全面性教育的重要内容之一。儿童和青少年对性和性别多元的理解将有助于他们理解与识别和社会性别有关的歧视和偏见,培养宽容和尊重的价值观,学会接纳自己和他人,并进一步创造一个更友好的社会。[31]

診斷[编辑]

ICD-10[编辑]

根據《國際疾病與相關健康問題統計分類》第十版(1993),列出與性別認同有關的幾種疾病:[32][33]

  • 易性症(F64.0):渴望成為及被接受為相反性別的成員,通常伴隨著性別重置手術和激素治療的慾望。
  • 兒童性別認同障礙(F64.2):一個人對於自身的指定性別而持續強烈的痛苦,並且在青春期之前表現出來。
  • 其他性別認同障礙(F64.8)
  • 性別認同障礙,不明確(F64.9)
  • 性成熟障礙(F66.0):關於一個人的性別認同性取向的不確定性,導致焦慮或痛苦。[34]

DSM-4[编辑]

根據《精神疾病診斷與統計手冊》第四版(1994),要被診斷判定為「性別認同障礙」前,須達到五項條件: [35]

  • 必須要有證據顯示有強烈且持續的跨性別認同感。
  • 跨性別認同感不可以是因為認為另一種性別在文化上有更多優勢而產生的。
  • 同時也必須要有證據顯示對於天生的性別有持續性的不適應感,或是無法適應自己所屬性別的性別角色
  • 當事人不可同時擁有身體上的雙性人狀態(例如睾脂酮不敏症候族英语Androgen Insensitivity Syndrome先天性腎上腺增生症)。
  • 必須要有臨床上的證據能顯示當事人在社交、工作或其他重要領域上遭遇顯著的挫折或傷害。

DSM-5[编辑]

根據《精神疾病診斷與統計手冊》第五版(2013),要被診斷判定為「性別不安」前,青少年成人須至少符合兩個標準以及持續至少六個月:[36]

此外,該病症必須與臨床上顯著的痛苦或損害相關。[36]

DSM-5將性別不安從性偏離中移除,並將其納入其他的類別。[36]在性別認同障礙被批評為污名後,該診斷被重新命名為性別不安,[37]並刪除了子類別中的性取向兒童的診斷與成人的診斷被分開,如「兒童性別不安」。為兒童建立一種特定的診斷反映了兒童較少有能力洞察他們正在經歷的事情,或者讓他們表達自身正在經歷的事情。[38]如果一個人不符合性別不安的標準但仍有臨床上顯著的痛苦或損傷,則可以診斷出「其他性別不安」或「性別不安,不明確」。[36]

ICD-11[编辑]

根據《國際疾病與相關健康問題統計分類》第十一版(2019),對性別認同相關疾病的分類進行重大修訂。[39] 截至2018年8月 (2018-08),ICD-11這種情況列為「性別不一致」。[40]

  • 青春期或成年期性別不一致(HA60):取代 F64.0
  • 兒童性別不一致(HA61):取代 F64.2
  • 性別不一致,不明確(HA6Z):取代 F64.9

在ICD-11中,由于缺乏公共卫生或临床意义,双重角色异装癖被移除。[41]此外,已經移除了性成熟障礙[42]

在ICD-11中,其解釋類似於DSM-V的定義,但不需要明顯的痛苦或損害。[40]

在ICD-10中,按照当时的惯例,性别认同障碍被列入精神障碍一章。在整个20世纪,ICD和DSM都从精神病理学的角度探讨了跨性别,因为跨性别呈现出某人的性别指定和他们的性别认同之间的差异。由于这可能导致精神痛苦,因此被认为是一种精神障碍,痛苦或不适是核心诊断特征。[43][44][45]在2000年代和2010年代,这种观念受到了越来越多的挑战,因为一些人认为将跨性别视为一种精神障碍是一种耻辱。有人认为,跨性别者的痛苦和功能障碍应被视为社会对具有性别差异外表和行为的个人的排斥、歧视和(性)暴力的结果,这样做更为恰当。[46]研究表明,跨性别者比其他人群更有可能出现心理健康问题,但针对跨性别者的健康服务往往不足或不存在。由于通常需要一个正式的ICD代码来获得治疗和报销,世界卫生组织认为将跨性别从ICD-11中全部删除是不明智的。因此,决定将这一概念从精神障碍章节移至新的性健康章节。[41]

治疗[编辑]

诊断为性别不一致的治疗可能包括心理咨询、支持患者的性别表达、激素治疗或手术。这可能涉及到医疗干预(如激素治疗、生殖器手术、电解或激光脱毛、胸部/乳房手术或其他重建手术)导致的身体过渡。[14]治疗的目标可能仅仅是减少患者跨性别状态引起的问题,例如:为患者提供咨询,以减少与变装相关的内疚感。[47]

已有机构制定了指导方针来帮助临床医生。世界跨性别人士健康专业协会(WPATH)的护理标准被一些临床医生用作治疗指南。治疗指南通常遵循“减少伤害”模式。[48][49][50]

注释[编辑]

  1. ^ 世界卫生组织官方译名[5]
  2. ^ 也译作性别焦虑
  3. ^ 性别不一致和不安并非完全对应的关系,不需要造成不安的情绪,更接近于跨性别的总体概念。参见下文#ICD-11
  4. ^ 源自DSM-III(1980)、ICD-10。部分地区仍在使用这些称呼。

參考文獻[编辑]

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  28. ^ Heylens G, De Cuypere G, Zucker KJ, Schelfaut C, Elaut E, Vanden Bossche H, De Baere E, T'Sjoen G. Gender identity disorder in twins: a review of the case report literature. The Journal of Sexual Medicine. March 2012, 9 (3): 751–7. PMID 22146048. doi:10.1111/j.1743-6109.2011.02567.x. Of 23 monozygotic female and male twins, nine (39.1%) were concordant for GID; in contrast, none of the 21 same‐sex dizygotic female and male twins were concordant for GID, a statistically significant difference (P = 0.005)... These findings suggest a role for genetic factors in the development of GID. 
  29. ^ Diamond, Milton. Transsexuality Among Twins: Identity Concordance, Transition, Rearing, and Orientation. International Journal of Transgenderism. 2013, 14 (1): 24–38. S2CID 144330783. doi:10.1080/15532739.2013.750222. Combining data from the present survey with those from past-published reports, 20% of all male and female monozygotic twin pairs were found concordant for transsexual identity... The responses of our twins relative to their rearing, along with our findings regarding some of their experiences during childhood and adolescence show their identity was much more influenced by their genetics than their rearing. 
  30. ^ Rosenthal, Stephen M. Approach to the Patient: Transgender Youth: Endocrine Considerations. The Journal of Clinical Endocrinology & Metabolism. 2014-12-01, 99 (12): 4379–4389. ISSN 0021-972X. PMID 25140398. doi:10.1210/jc.2014-1919可免费查阅 (英语). 
  31. ^ 联合国教育、科学及文化组织.国际性教育技术指导纲要.北京:联合国教育、科学及文化组织,2017:22,42-75
  32. ^ International Classification of Diseases (ICD) F64 Gender identity disorders. World Health Organization. [9 August 2018]. (原始内容存档于2017-02-08). 
  33. ^ Potts, S; Bhugra, D. Classification of sexual disorders. International Review of Psychiatry. 1995, 7 (2): 167–174. doi:10.3109/09540269509028323. 
  34. ^ International Classification of Diseases. World Health Organization. [11 August 2018]. (原始内容存档于2018-09-02). 
  35. ^ Diagnostic criteria for Gender Identity Disorder 互联网档案馆存檔,存档日期2007-06-21. - DSM-IV & DSM-IV (TR)
  36. ^ 36.0 36.1 36.2 36.3 American Psychiatry Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-5) 5th. Washington, DC and London: American Psychiatric Publishing. 2013: 451–460. ISBN 0-89042-555-8. 
  37. ^ Gender Dysphoria in Children. American Psychiatric Association. May 4, 2011 [July 3, 2011]. (原始内容存档于2012-03-14). 
  38. ^ P 00 Gender Dysphoria in Children. American Psychiatric Association. [April 2, 2012]. (原始内容存档于2012-03-14). 
  39. ^ International Classification of Diseases. World Health Organization. [August 11, 2018]. (原始内容存档于2018-09-02). 
  40. ^ 40.0 40.1 Gender incongruence (ICD-11). icd.who.int. WHO. [August 28, 2018]. (原始内容存档于2018-08-01). 
  41. ^ 41.0 41.1 Reed GM, Drescher J, Krueger RB, Atalla E, Cochran SD, First MB, 等. Disorders related to sexuality and gender identity in the ICD-11: revising the ICD-10 classification based on current scientific evidence, best clinical practices, and human rights considerations. World Psychiatry. October 2016, 15 (3): 205–221. PMC 5032510可免费查阅. PMID 27717275. doi:10.1002/wps.20354. The ICD‐10 classification of Sexual dysfunctions (F52) is based on a Cartesian separation of “organic” and “non‐organic” conditions. 
  42. ^ Reed GM, Drescher J, Krueger RB, Atalla E, Cochran SD, First MB, Cohen-Kettenis PT, Arango-de Montis I, Parish SJ, Cottler S, Briken P, Saxena S. Disorders related to sexuality and gender identity in the ICD-11: revising the ICD-10 classification based on current scientific evidence, best clinical practices, and human rights considerations. World Psychiatry. October 2016, 15 (3): 205–221. PMC 5032510可免费查阅. PMID 27717275. doi:10.1002/wps.20354. 
  43. ^ Drescher J, Cohen-Kettenis P, Winter S. Minding the body: situating gender identity diagnoses in the ICD-11. International Review of Psychiatry. December 2012, 24 (6): 568–77. PMID 23244612. S2CID 12805083. doi:10.3109/09540261.2012.741575. Until the middle of the 20th century, with rare exceptions, transgender presentations were usually classified as psychopathological. 
  44. ^ Cohen-Kettenis PT, Pfäfflin F. The DSM diagnostic criteria for gender identity disorder in adolescents and adults. Archives of Sexual Behavior. April 2010, 39 (2): 499–513. PMID 19838784. S2CID 16336939. doi:10.1007/s10508-009-9562-y. The DSM has consistently approached gender problems from the position that a divergence between the assigned sex or “the” physical sex (assuming that “physical sex” is a one-dimensional construct) and “the” psychological sex (gender) per se signals a psychiatric disorder. Although the terminology and place of the gender identity disorders in the DSM have varied in the different versions, the distress about one’s assigned sex has remained, since DSM-III, the core feature of the diagnosis. 
  45. ^ Lawrence, Anne A. Gender Dysphoria. Beidel, Deborah C.; Frueh, B. Christopher (编). Adult Psychopathology and Diagnosis 8th. John Wiley & Sons. 2018: 634. ISBN 978-1-119-38360-4. The World Professional Association for Transgender Health (WPATH), for example, defined GD as “discomfort or distress that is caused by a discrepancy between a person’s gender identity and that person’s sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics)”  已忽略未知参数|name-list-style= (帮助)
  46. ^ Robles R, Fresán A, Vega-Ramírez H, Cruz-Islas J, Rodríguez-Pérez V, Domínguez-Martínez T, Reed GM. Removing transgender identity from the classification of mental disorders: a Mexican field study for ICD-11. The Lancet. Psychiatry. September 2016, 3 (9): 850–9. PMID 27474250. doi:10.1016/S2215-0366(16)30165-1. 
  47. ^ Leiblum, Sandra. Principles and Practice of Sex Therapy, Fourth Edition. The Guilford Press. 2006: 488–9. ISBN 978-1-59385-349-5. 
  48. ^ Committee On Adolescence. Office-based care for lesbian, gay, bisexual, transgender, and questioning youth. Pediatrics. July 2013, 132 (1): 198–203. PMID 23796746. doi:10.1542/peds.2013-1282可免费查阅. However, adolescents with multiple or anonymous partners, having unprotected intercourse, or having substance abuse issues should be tested at shorter intervals. 
  49. ^ www.glma.org Compendium of Health Profession Association LGBT Policy & Position Statements (PDF). GLMA. 2013 [August 27, 2013]. 
  50. ^ APA Policy Statements on Lesbian, Gay, Bisexual, & Transgender Concerns (PDF). American Psychological Association. 2011 [August 27, 2013]. BE IT FURTHER RESOLVED that APA recognizes the efficacy, benefit, and necessity of gender transition treatments for appropriately evaluated individuals and calls upon public and private insurers to cover these medically necessary treatments; 

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