Gender identity disorder and transsexualism
Gender identity disorder is a strong, persistent cross-gender identification condition in which 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.
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 one says and does to indicate to others or to oneself the degree to which one is male or female. For most people, gender identity and role are congruous. Those with gender identity disorder, however, 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 as 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.
Etiology and Pathophysiology
Although biologic factors, such as genetic complement and the prenatal hormonal milieu, largely determine gender identity, the formation of a secure, unconflicted gender identity and gender role is influenced by social factors, such as the character of the parents' emotional bond and the relationship that each of them has with the child.
When sex labeling and rearing are confusing (eg, in cases of ambiguous genitals or genetic syndromes altering genital appearance, such as androgen insensitivity), 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. Transsexuals usually have had gender identity problems in early childhood. However, most children with gender identity conflicts do not develop into adults with transsexualism.
Childhood gender identity problems are usually present by age 2. For some people, however, gender identity disorder does not manifest until adulthood. Children experiencing difficulty with gender identity commonly 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, and 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 sit to urinate and wish to be rid of his penis and testes. Most children with these disorders are not evaluated until they are age 6 to 9, at a point when the disorder is already chronic.
Diagnosis
Diagnosis in children requires the presence of both cross-gender identification (the desire to be or insistence that one is the other sex) and a sense of discomfort about one's sex or of substantial inappropriateness in one's 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. Gender role behaviors fall on a continuum of traditional masculinity or femininity, with a growing cultural recognition of the presence of people who 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 normative 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.
Assessment of adults focuses on determining whether there is significant distress or obvious impairment in social, occupational, or other important areas of functioning. Cross-gender behavior, such as cross-dressing, may not require any 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).
Rarely, transsexualism is associated with genital ambiguity or genetic abnormality (eg, Turner's syndrome, Klinefelter's syndrome). Most transsexuals who request treatment are natal males who claim a feminine gender identity and regard their genitals and masculine features with repugnance. Their primary objective in seeking help is not to obtain psychologic treatment but to obtain hormones and genital surgery that will make their physical appearance approximate their gender identity. The combination of psychotherapy, hormonal reassignment, and sex reassignment surgery is often curative.
Male-to-female transsexualism often first manifests in early childhood with participation in girls' games, fantasies of being female, avoidance of rough-and-tumble play and competitive games, and distress at the physical changes of puberty, often followed by a request during adolescence for feminizing somatic treatments. Many transsexuals adopt a convincing public feminine gender role. Some are satisfied with mastering a more feminine appearance and obtaining an identity card in the female role (eg, driver's license) that helps allow them to work and live in society as women. Others experience problems, which may include depression and suicidal behavior. The likelihood of a more stable adjustment may be increased by taking moderate doses of a feminizing hormone (eg, ethinyl estradiol 0.1 mg once/day) and with electrolysis and other feminizing treatments. Many transsexuals request sex reassignment surgery. The decision for surgery often raises important social problems for the patient. In follow-up studies, genital surgery has helped selected transsexuals live happier and more productive lives and so is justified in highly motivated, properly assessed and treated transsexuals who have completed a 1- to 2-yr real-life experience in the opposite gender role. Before surgery, patients often need assistance with “passing” in public, including gestures and voice modulation. Participation in gender support groups, available in most large cities, is usually helpful.
Female-to-male transsexualism is increasingly seen in medical and psychiatric practice as treatments improve. Patients ask for mastectomy early, then hysterectomy and oophorectomy. Androgenic hormones (eg, IM testosterone) are given to permanently alter the voice, induce a more masculine muscle and fat distribution, and enable 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.
Drug Information
-hypertrophied clitoris (metoidioplasty). Surgery may help certain patients achieve greater adaptation and life satisfaction. As with male-to-female transsexuals, such patients should meet the criteria established by the Harry Benjamin International Gender Dysphoria Association and have lived in the male gender role for at least 1 yr. Anatomic results of neophallus surgical procedures are often less satisfactory than neovaginal procedures for male-to-female transsexuals. Complications are common, especially in procedures that involve extending the urethra into the neophallus.
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