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Gender Identity Disorder and Transsexualism

by George R. Brown, MD

Gender identity disorder is characterized by a strong, persistent cross-gender identification; people believe they are victims of a biologic accident and are cruelly imprisoned in a body incompatible with their subjective gender identity. Those with the most extreme form of gender identity disorder are called transsexuals. These disorders are considered mental disorders because the body does not match the person’s psychologic (felt) gender.

Core gender identity is a subjective sense of knowing to which gender one belongs, ie, the awareness that “I am a male” or “I am a female.” Gender identity is the inner sense of masculinity or femininity. Gender role is the objective, public expression of being male, female, or androgynous (blended). It is everything that people say and do to indicate to others or to themselves the degree to which they are male or female. For most people, there is congruity between their anatomic sex, gender identity, and gender role. However, those with gender identity disorder experience some degree of incongruity between their anatomic sex and their gender identity. The incongruity experienced by transsexuals is usually complete, severe, disturbing, and long-standing. Labeling the condition a “disorder” can add to the distress that frequently occurs, and the term should not be construed as being judgmental. Treatment is aimed at helping patients adapt rather than trying to dissuade them from their identity; in any case, the latter approach is ineffective.

Gender role behaviors fall on a continuum of traditional masculinity or femininity, with a growing cultural recognition that some people do not fit into the traditional male-female dichotomy. Western cultures are more tolerant of tomboyish behaviors in young girls (generally not considered a gender identity disorder) than effeminate or “sissy” behaviors in boys. Many boys role-play as girls or mothers, including trying on their sister’s or mother’s clothes. Usually, this behavior is part of normal development. Only in extreme cases does this behavior and an associated expressed wish to be the other sex persist. Most boys with gender identity disorder of childhood do not have the disorder as adults, but many are homosexual or bisexual as adults.

Etiology

Although biologic factors (eg, genetic complement, prenatal hormonal milieu) largely determine gender identity, the formation of a secure, unconflicted gender identity and gender role is influenced by social factors (eg, the character of the parents’ emotional bond, the relationship that each parent has with the child). Rarely, transsexualism is associated with genital ambiguity or a genetic abnormality (eg, Turner syndrome, Klinefelter syndrome).

When sex labeling and rearing are confusing (eg, in cases of ambiguous genitals or genetic syndromes altering genital appearance, such as androgen insensitivity syndrome), children may become uncertain about their gender identity or role, although the level of importance of environmental factors remains controversial. However, when sex labeling and rearing are unambiguous, even the presence of ambiguous genitals often does not affect a child’s gender identity.

Symptoms and Signs

Childhood gender identity problems are usually present by age 2. Children experiencing difficulty with gender identity commonly do the following:

  • Prefer cross-dressing

  • Insist that they are of the other sex

  • Intensely and persistently desire to participate in the stereotypical games and activities of the other sex

  • Have negative feelings toward their genitals

For example, a young girl may insist she will grow a penis and become a boy; she may stand to urinate. A boy may fantasize about being female, and avoid rough-and-tumble play and competitive games. He may sit to urinate and wish to be rid of his penis and testes. For boys with a gender identity disorder, distress at the physical changes of puberty is often followed by a request during adolescence for feminizing somatic treatments. Most children with these disorders are not evaluated until they are age 6 to 9, at a point when the disorder is already chronic.

Although most transsexuals began having gender identity problems in early childhood, some do not present until adulthood. Male-to-female transsexuals may be cross-dressers first and only later in life come to accept their cross-gender identity. Marriage and military service are common among transsexual men who seek to run from their cross-gender feelings. Once they accept their cross-gender (transgender) feelings, many transsexuals adopt a convincing public feminine gender role. Some are satisfied with mastering a more feminine appearance and obtaining an identity card (eg, driver’s license) as a female to help them work and live in society as women. Others experience problems, which may include depression and suicidal behavior.

Diagnosis

Diagnosis in children requires the presence of both of the following:

  • Cross-gender identification (the desire to be or insistence that they are the other sex)

  • A sense of discomfort about their sex or sense of substantial inappropriateness in their gender role

Cross-gender identification must not be merely a desire for perceived cultural advantages of being the other sex. For example, a boy who says he wants to be a girl so that he will receive the same special treatment his younger sister receives is not likely to have gender identity disorder.

Assessment of adults focuses on determining whether there is significant distress or obvious impairment in social, occupational, or other important areas of functioning.

Treatment

  • For selected, motivated patients, hormone therapy, sex reassignment surgery, and psychotherapy

Cross-gender behavior, such as cross-dressing, may not require treatment if it occurs without concurrent psychologic distress or functional impairment or if a person has a physical intersex condition (eg, congenital adrenal hyperplasia, ambiguous genitals, androgen insensitivity syndrome).

Most transsexuals who request treatment are natal males who claim a feminine gender identity and regard their genitals and masculine features with repugnance. However, as treatments improve, female-to-male transsexualism is increasingly seen in medical and psychiatric practice. Transsexuals’ primary objective in seeking medical help is not to obtain psychologic treatment but to obtain hormones and genital surgery that will make their physical appearance approximate their felt gender identity. The combination of psychotherapy, hormonal reassignment, and sex reassignment surgery is often curative when the disorder is appropriately diagnosed and clinicians follow the internationally accepted standards of care for the treatment of gender identity disorders, available from the World Professional Association for Transgender Health ( WPATH ).

Male-to-female transsexualism

Taking moderate doses of a feminizing hormone (eg, ethinyl estradiol 0.1 mg once/day) plus electrolysis and other feminizing treatments may make the adjustment to a feminine gender role more stable.

Many male-to-female transsexuals request sex reassignment surgery. Surgery involves removal of the penis and testes and creation of an artificial vagina. A part of the glans penis is retained as a clitoris, which is usually sexually sensitive and retains the capacity for orgasm in most cases. The decision to pursue sex reassignment surgery often raises important social problems for patients. Many of these patients are married and have children. A parent or spouse who changes sex will have substantial adjustment issues in all intimate relationships and may lose loved ones in the process. In follow-up studies, genital surgery has helped some transsexuals live happier and more productive lives and so is justified in highly motivated, appropriately assessed and treated transsexuals who have completed a 1- to 2-yr real-life experience in the opposite gender role. Before surgery, transsexuals often need assistance with passing in public, including help with gestures and voice modulation. Participation in gender support groups, available in most large cities, is usually helpful.


Female-to-male transsexualism

Patients ask for mastectomy early, then hysterectomy and oophorectomy. Androgenic hormones (eg, IM testosterone ester preparations 300 to 400 mg q 3 wk or equivalent doses of androgen transdermal patches or gels) are given to permanently alter the voice, induce a more masculine muscle and fat distribution, and promote growth of facial and body hair.

Patients may opt for an artificial phallus (neophallus) to be fashioned from skin transplanted from the inner forearm (phalloplasty) or for a micropenis to be created from fat tissue removed from the testosterone-hypertrophied clitoris (metoidioplasty). Surgery may help certain patients achieve greater adaptation and life satisfaction. Similar to male-to-female transsexuals, female-to-male transsexuals should live in the male gender role for at least 1 yr before surgery. Anatomic results of neophallus surgical procedures are often less satisfactory in terms of function and appearance than neovaginal procedures for male-to-female transsexuals. Complications are common, especially in procedures that involve extending the urethra into the neophallus.


Drugs Mentioned In This Article

  • Drug Name
    Select Trade
  • ESTRADERM, ESTROGEL, VIVELLE
  • DELATESTRYL

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