Kari Ann Martin, MD

Adults with gender identity disorder (GID)—commonly termed transsexualism—may seek psychiatric assessment and treatment for a variety of reasons. Some—but not all—might be candidates for hormone replacement therapies or sex reassignment surgery (SRS). For those with gender dysphoria, psychological assessment and psychotherapy are suggested and sometimes required.

Your role in the GID patient’s gender exploration and transition must be tailored to his or her gender identity and individual circumstances. For patients who are not candidates for surgery or cannot afford it, you may assist in exploring options for living with one’s gender identity.

WHAT IS GID?

Gender identity disorder is a rare, complex condition in which individuals of unambiguous genotype and phenotype identify with the opposite gender. One in 54,000 individuals are estimated to have GID:

• 75% are biologic males desiring reassignment to female gender (MTF)
  
• 25% are females desiring to be male (FTM).¹
  

Persons with GID who undergo sex reassignment surgery represent the severe, dramatic end of a wide spectrum of cross-gender identifications and behaviors that DSM-IV-TR (Table 1)² and the International Classification of Diseases (Table 2)³ have attempted to classify. GID does not describe intersex conditions such as incomplete masculinization or feminization syndromes with ambiguous genitalia.

Table 1

DSM-IV-TR criteria for gender identity disorder

Criterion A	A strong and persistent cross-gender identification defined as the desire to be or the insistence that one is of the other sex (must not be merely a desire for any perceived cultural advantages of being the other sex)
Criterion B	Persistent discomfort with one’s assigned sex or a sense of inappropriateness in the gender role of that sex
Criterion C	The disturbance is not concurrent with a physical intersex condition (such as partial androgen insensitivity syndrome or congenital adrenal hyperplasia)
Criterion D	The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
Source: Reference 2

Table 2

ICD-10 diagnoses for gender identity disorder in adults

Diagnosis	Criteria
Transsexualism	Desire to live and be accepted as a member of the opposite sex, usually accompanied by the wish to make his or her body as congruent as possible with the preferred sex through surgery and hormone treatment Transsexual identity has been present persistently for at least 2 years Is not a symptom of another mental disorder or a chromosomal abnormality
Dual-role transvestism	Individual wears clothes of the opposite sex to experience temporary membership in the opposite sex No sexual motivation for cross-dressing Individual does not desire a permanent change to the opposite sex
Other gender identity disorders	No specific criteria; could be used for persons with an intersexed condition
Gender identify disorder, unspecified	No specific criteria; could be used for persons with an intersexed condition
Source: Adapted from International Classification of Diseases, 10th ed. (ICD-10)

Persons with GID may find ways of living with nontraditional or cross-gendered identities that do not involve altering their bodies. Others feel they must create a physical body that reflects their core gender identity.

Epidemiologic studies of GID are rare, but in a survey by Rachlin et al⁴ of 23 MTFs and 70 FTMs:

• most underwent hormone therapy (64% of MTFs, 80% of FTMs) and/or name change (45% of MTFs, 72% of FTMs)
  
• none of the MTFs had breast augmentation, whereas 52% of FTMs had undergone mastectomy and reconstruction and another 33% were actively planning it
  
• 3% of FTMs had genital surgery, 16% were planning it, and 29% had decided definitely not to have it
  
• 9% of MTFs decided definitely not to have genital surgery; 23% had undergone genital surgery, and another 35% were actively planning it.
  

The MTF/FTM differences may reflect the efficacy of cross-hormone therapy in inducing breast growth in MTFs and the cosmetic disappointment, risks, and costs of phalloplasties for FTMs. For patients who pursue genital surgery, the incidence of postoperative regret is low: 5

Biologic basis. GID’s cause remains unknown. Organic differences in brain anatomy have been identified in patients with GID. Zhou et al⁶ showed that the volume of the central subdivision of the bed nucleus of the stria terminalis (BSTc)—a brain area essential for sexual behavior—is larger in men than in women. A female-sized BSTc was found in MTF GID patients.

Research, mainly on biologic boys, indicates that GIDs are usually associated with behavioral difficulties, relationship problems with peers and parents, and—most notably—separation anxiety disorder.⁷ An audit of the files of 124 children and adolescents with GID showed that 42% experienced loss of one or both parents, mainly through separation.⁸

Psychiatric comorbidity. Studies using standardized diagnostic instruments to assess psychiatric comorbidity in GID are rare. A study of 31 patients with GID found that many met diagnostic criteria for lifetime psychiatric comorbidity, including:

 

• 71% for Axis I disorders (primarily mood and anxiety disorders)
  
• 42% for comorbid personality disorders, primarily a cluster B diagnosis
  
• 45% for substance-related disorders
  
• 6.5% for psychotic disorders
  
• 3.2% for eating disorders.⁹
  

Persons with GID transgress the traditional binary gender system and as a consequence experience discrimination in employment, social services and housing.¹⁰ Jones and Hill¹¹ have proposed that these experiences result in vulnerability to Axis I disorders.

TREATING PATIENTS WITH GID

Psychotherapy. GID treatment decisions are made without clear prospective data. Standards of care are determined by the World Professional Association for Transgender Health (WPATH).¹² Psychotherapy is often given before SRS but is not required. The therapist is left to determine the treatment terms and goals.

Your role in treating patients with GID goes beyond making an accurate diagnosis, identifying comorbid psychopathology, and instituting a treatment plan. Other tasks include:

• counseling the patient about the range of treatment options and their implications
  
• engaging in psychotherapy
  
• ascertaining eligibility and readiness for hormones and surgical therapy
  
• making formal recommendations to medical and surgical colleagues
  
• documenting the patient’s relevant history in a letter of recommendation
  
• educating support systems
  
• being available for follow-up.
  

Because these tasks may be daunting for one clinician, you might consider referring the patient to a gender disorder clinic (see Related resources).

Candidates for triadic therapy. For appropriately screened adults with severe GID, the therapeutic approach relies on triadic therapy:

• a 3-phase approach centered around real-life experience in the desired role
  
• hormones of the desired gender
  
• and surgery to change the genitalia and secondary sex characteristics.
  

HORMONE THERAPY

WPATH has established eligibility and readiness criteria for HRT in patients with GID (Table 3). Administering cross-sex hormones (testosterone in women; estrogens in men) brings about important physical changes as well as psychological relief. The prescribing physician need not be an endocrinologist but should become well-versed in relevant data.

Table 3

WPATH criteria for hormone replacement therapy*

Eligibility criteria 3 criteria exist	Patient is at least age 18 Patient understands what hormones medically can and cannot do and their social benefits and risks Patients has had either: Providing hormones to patients who have not fulfilled criterion 3 can be acceptable in selected circumstances, such as to facilitate monitored therapy using hormones of known quality as an alternative to black-market or unsupervised hormone use
Readiness criteria All 3 must exist	Patient has had further consolidation of gender identity during the real-life experience or psychotherapy Patient has made some progress mastering other identified problems leading to improving or continuing stable mental health (this implies satisfactory control of problems such as sociopathy, substance abuse, psychosis, and suicidality Patient is likely to take hormones in a responsible manner
Source: World Professional Association for Transgender Health (WPATH)

Options include oral, injectable, and transdermal formulations (Table 4); physician discretion and patient preference determine the formulation used.

Table 4

Sample hormonal regimens for transsexual patients*

	Medication	Starting dose	Subsequent dose	When to change doses
Female to male	Testosterone enanthanate or testosterone cypionate	200 mg IM every 2 weeks	100 to 150 mg IM every 2 weeks	After masculinization complete and/or oophorectomy/hysterectomy
	Transdermal testosterone	5 mg to skin every day	Usually stays the same	Little data exist on efficacy; effective for maintenance, and may be less efficacious during transition
Male to female	Conjugated estrogens	1.25 mg/d (or 0.625 mg/d for smokers)	2.5 mg/d (Do not increase in smokers)	To obtain best clinical results, or if testosterone is not suppressed After sexual reassignment surgery, dose may be decreased without losing secondary sexual characteristics
	OR oral estradiol	1 mg/d	2 mg/d
	OR transdermal estradiol	0.1 mg patch/week	Two 0.1 mg patches/week
	Spironolactone	200 mg/d	May discontinue	After sexual assignment surgery
	Medroxyprogesterone†	10 mg/d	May increase to 20 to 40 mg/d (usually not needed)	If testosterone is not suppressed and patient/doctor does not want to increase estrogen
	OR micronized progesterone	100 mg bid	May discontinue after breast development is complete	Micronized progesterone is more costly but may lessen side effects of anxiety, as compared with medroxyprogesterone
* Professional consensus does not exist regarding the most efficacious and safest dosing regimens for gender transition. This table reflects reasonable starting and maintenance doses that are supported in the (admittedly less than optimal) medical literature, and reflect the author’s opinion and practice. This table is not meant to include all possible hormone regimens, only several of the most commonly used medications.
† Professional consensus does not exist regarding progesterone’s role in MTF transition.
Adapted and reprinted with permission from Table VII in Oriel KA. Medical care of transsexual patients. J Gay Lesbian Med Asso 2000;4(4):193.

IM testosterone therapy (standard dose 200 to 250 mg/2 weeks) is complicated by fluctuating serum testosterone levels. Fatigue or irritability can occur when serum testosterone levels are low (on days 10 to 17). Oral testosterone suppresses the menstrual cycle in only 50% of FTMs.

 

Transdermal testosterone is an option for biologic females who are leery of injections.¹³ Patches result in stable testosterone levels in the male range but may cause skin irritation in >50% of patients. Use transdermal estrogen in males with clotting abnormalities or who are age >40.

Medical workup. Basic medical monitoring includes serial physical examinations, vital signs, weight measurements, laboratory assessment, and screening for pelvic malignancies.

For biologic males receiving estrogen, pretreatment laboratory assessment includes free testosterone, fasting glucose, liver function tests, and complete blood count, with reassessment at 6 and 12 months and annually thereafter. Obtain pretreatment prolactin levels and repeat annually. If hyperprolactinemia fails to develop within 3 years, no further measurements are necessary. Monitor for breast and prostate cancer, and instruct patients to perform self-breast exams. Following orchiectomy, estrogen doses can be reduced by one-third to one-half.

For biologic women receiving androgen, obtain pretreatment liver function tests and complete blood count, then reassess at 6 months, 12 months, and annually thereafter. Do yearly liver palpation examinations.

Physiologic changes. Biologic males treated with estrogens can expect breast growth, redistribution of fat in keeping with female habitus, decreased upper body strength, decreased body hair, retardation of male pattern balding, diminished testicular size, and decrease in erection firmness and frequency. MTF transsexuals require electrolysis to remove facial hair, as HRT does not do this.

Biologic females treated with testosterone can expect deepening of the voice, clitoral enlargement, mild breast atrophy, increased facial and body hair and male-pattern baldness, increased upper body strength, weight gain, and decreased hip fat.

With effective and continuous dosages, most changes begin in 2 to 4 months, start becoming irreversible in 6 to 12 months, start to level off in 2 years, and are mostly complete in 5 years. Men with insufficient breast growth following HRT may pursue breast augmentation surgery.

Voice changes. Hormone therapy generally is presumed to “masculinize” the voice of FTM transsexuals. In one series, after initiation of hormone therapy, 12 of 16 (75%) FTM transsexuals believed they had a voice that always would be considered masculine.^14,15

For MTF transsexuals, no surgical technique of pitch elevation is satisfactorily safe and effective. The most widely used—cricothyroid approximation—may not be long-lasting and can decrease range, loudness, and vocal quality.¹³

HRT COMPLICATIONS

Medical complications. Biologic males treated with estrogens and progestins may be at increased risk for blood clotting, benign pituitary prolactinomas, infertility, weight gain, liver disease, gallstones, somnolence, hypertension, and diabetes mellitus.

Biologic females treated with testosterone may be at increased risk for acne, cardiovascular disease from shifts of lipid profiles to male patterns, benign and malignant liver tumors, and hepatic dysfunction.

Psychiatric issues. Physical masculinization occurs much more rapidly and results in a more convincing opposite sex appearance in FTMs than feminization does in MTFs.^16,17 Behaving masculine may be more socially acceptable for women and therefore easier than it is for men to behave convincingly feminine without being characterized.

Cross-sex hormones contribute to the expression of sex-dimorphic behaviors in adulthood.^18,19 Estrogen appears to influence affect intensity, whereas androgens influence aggression and sexual motivation. Earlier studies established that untreated MTFs and FTMs do not differ in sex hormone levels from their biologic counterparts.^20,21

After 3 months of HRT, transsexuals’ sex hormones are in the range of their identified sex. FTMs treated with androgens become more prone to aggression and exhibit increased sexual motivation and arousability associated with an overall dampened affect. MTFs treated with estrogen show decreased irritability and sexual arousability.²²

SEX REASSIGNMENT SURGERY

The cost of SRS often is prohibitive. Patients may turn to the Internet or foreign venues for hormone therapy and surgical procedures. Thailand is a popular overseas destination, where the average cost for MTF surgery is approximately $6,000 to $9,000. In the United States the cost of counseling, hormones, electrolysis, and surgeries is typically $30,000 to $40,000.²³

Surgical options are not limited to genital reassignment but include mammoplasty (breast augmentation for MTF), chest reduction surgery (FTM), trachea shave surgery, forehead/brow ridge contouring, chin and jaw contouring, scalp advancement surgery, cheek implant surgery, alarplasty (nasal base resection to narrow a nose), and chin contouring.

Some insurance companies assert that transsexual procedures are not medically necessary and are declining coverage. WPATH contends that sex reassignment is effective and medically indicated in severe GID.

Postsurgical outcomes. Patients who are emotionally healthy, have adequate social support, and attain reasonable cosmetic results are most satisfied with life after SRS.²⁴ In studies of GID patients, the best predictor of postoperative psychopathology was poor surgical results.²⁵

FTMs are transformed through the use of hormones and generally are not perceived as visibly different from other men. Genital surgery is often seen as a final step in completing the transition to the identified gender.

 

FTMs may elect to have their female reproductive organs removed, along with construction of male external genitalia through phalloplasty or metoidioplasty. The decision to pursue surgery and the type of procedure depend on peer influence.²⁶ Although a phalloplasty does not provide a fully functioning and completely authentic-appearing penis, most FTMs report being satisfied with life after surgery and have few regrets.^27-31

Long-term postoperative follow-up by the surgeon and mental health professional is associated with good psychosocial outcome.

Legal considerations. An individual’s new surgically created gender can cause legal complications in jurisdictions that do not recognize the new gender. Some states are amending laws to make allowances for these advances in medical science.³²

Related resources

• World Professional Association For Transgender Health. (formerly the Harry Benjamin International Gender Dysphoria Association [HBIGDA]). www.hbigda.org. Includes a directory of transgender organizations.
  
• North American gender programs and service centers
  CAMH Gender Identity Clinic. Toronto, Ontario, Canada
  Gender Identity Project, New York, NY
  Gendercare Gender Clinic (Web clinic for gender variance). www.gendercare.com.
  Ingersoll Gender Center, Seattle, Washington
  Johns Hopkins Center for Sexual Health & Medicine, Baltimore, Maryland
  Program in Human Sexuality, Transgender Services at the University of Minnesota
  
• Sexology organizations and information
  American Association of Sex Educators, Counselors, and Therapists. www.aasect.org.
  Kinsey Institute at Indiana University. www.indiana.edu/%7Ekinsey.
  Sexuality Information and Education Council of the United States. www.siecus.org.
  Social Science Research Council. www.ssrc.org.
  Society for the Scientific Study of Sexuality. www.sexscience.org.
  

Drug brand names

• Conjugated equine estrogens • Premarin
  
• Estradiol (oral) • Estrace
  
• Estradiol (transdermal) • Climara
  
• Medroxyprogesterone (oral) • Provera
  
• Medroxyprogesterone (IM) • Depo-Provera
  
• Micronized progesterone • Prometrium
  
• Spironolactone • Aldactone
  

Disclosure

The author reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Adults with gender identity disorder (GID)—commonly termed transsexualism—may seek psychiatric assessment and treatment for a variety of reasons. Some—but not all—might be candidates for hormone replacement therapies or sex reassignment surgery (SRS). For those with gender dysphoria, psychological assessment and psychotherapy are suggested and sometimes required.

Your role in the GID patient’s gender exploration and transition must be tailored to his or her gender identity and individual circumstances. For patients who are not candidates for surgery or cannot afford it, you may assist in exploring options for living with one’s gender identity.

WHAT IS GID?

Gender identity disorder is a rare, complex condition in which individuals of unambiguous genotype and phenotype identify with the opposite gender. One in 54,000 individuals are estimated to have GID:

• 75% are biologic males desiring reassignment to female gender (MTF)
  
• 25% are females desiring to be male (FTM).¹
  

Persons with GID who undergo sex reassignment surgery represent the severe, dramatic end of a wide spectrum of cross-gender identifications and behaviors that DSM-IV-TR (Table 1)² and the International Classification of Diseases (Table 2)³ have attempted to classify. GID does not describe intersex conditions such as incomplete masculinization or feminization syndromes with ambiguous genitalia.

Table 1

DSM-IV-TR criteria for gender identity disorder

Criterion A	A strong and persistent cross-gender identification defined as the desire to be or the insistence that one is of the other sex (must not be merely a desire for any perceived cultural advantages of being the other sex)
Criterion B	Persistent discomfort with one’s assigned sex or a sense of inappropriateness in the gender role of that sex
Criterion C	The disturbance is not concurrent with a physical intersex condition (such as partial androgen insensitivity syndrome or congenital adrenal hyperplasia)
Criterion D	The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
Source: Reference 2

Table 2

ICD-10 diagnoses for gender identity disorder in adults

Diagnosis	Criteria
Transsexualism	Desire to live and be accepted as a member of the opposite sex, usually accompanied by the wish to make his or her body as congruent as possible with the preferred sex through surgery and hormone treatment Transsexual identity has been present persistently for at least 2 years Is not a symptom of another mental disorder or a chromosomal abnormality
Dual-role transvestism	Individual wears clothes of the opposite sex to experience temporary membership in the opposite sex No sexual motivation for cross-dressing Individual does not desire a permanent change to the opposite sex
Other gender identity disorders	No specific criteria; could be used for persons with an intersexed condition
Gender identify disorder, unspecified	No specific criteria; could be used for persons with an intersexed condition
Source: Adapted from International Classification of Diseases, 10th ed. (ICD-10)

Persons with GID may find ways of living with nontraditional or cross-gendered identities that do not involve altering their bodies. Others feel they must create a physical body that reflects their core gender identity.

Epidemiologic studies of GID are rare, but in a survey by Rachlin et al⁴ of 23 MTFs and 70 FTMs:

• most underwent hormone therapy (64% of MTFs, 80% of FTMs) and/or name change (45% of MTFs, 72% of FTMs)
  
• none of the MTFs had breast augmentation, whereas 52% of FTMs had undergone mastectomy and reconstruction and another 33% were actively planning it
  
• 3% of FTMs had genital surgery, 16% were planning it, and 29% had decided definitely not to have it
  
• 9% of MTFs decided definitely not to have genital surgery; 23% had undergone genital surgery, and another 35% were actively planning it.
  

The MTF/FTM differences may reflect the efficacy of cross-hormone therapy in inducing breast growth in MTFs and the cosmetic disappointment, risks, and costs of phalloplasties for FTMs. For patients who pursue genital surgery, the incidence of postoperative regret is low: 5

Biologic basis. GID’s cause remains unknown. Organic differences in brain anatomy have been identified in patients with GID. Zhou et al⁶ showed that the volume of the central subdivision of the bed nucleus of the stria terminalis (BSTc)—a brain area essential for sexual behavior—is larger in men than in women. A female-sized BSTc was found in MTF GID patients.

Research, mainly on biologic boys, indicates that GIDs are usually associated with behavioral difficulties, relationship problems with peers and parents, and—most notably—separation anxiety disorder.⁷ An audit of the files of 124 children and adolescents with GID showed that 42% experienced loss of one or both parents, mainly through separation.⁸

Psychiatric comorbidity. Studies using standardized diagnostic instruments to assess psychiatric comorbidity in GID are rare. A study of 31 patients with GID found that many met diagnostic criteria for lifetime psychiatric comorbidity, including:

 

• 71% for Axis I disorders (primarily mood and anxiety disorders)
  
• 42% for comorbid personality disorders, primarily a cluster B diagnosis
  
• 45% for substance-related disorders
  
• 6.5% for psychotic disorders
  
• 3.2% for eating disorders.⁹
  

Persons with GID transgress the traditional binary gender system and as a consequence experience discrimination in employment, social services and housing.¹⁰ Jones and Hill¹¹ have proposed that these experiences result in vulnerability to Axis I disorders.

TREATING PATIENTS WITH GID

Psychotherapy. GID treatment decisions are made without clear prospective data. Standards of care are determined by the World Professional Association for Transgender Health (WPATH).¹² Psychotherapy is often given before SRS but is not required. The therapist is left to determine the treatment terms and goals.

Your role in treating patients with GID goes beyond making an accurate diagnosis, identifying comorbid psychopathology, and instituting a treatment plan. Other tasks include:

• counseling the patient about the range of treatment options and their implications
  
• engaging in psychotherapy
  
• ascertaining eligibility and readiness for hormones and surgical therapy
  
• making formal recommendations to medical and surgical colleagues
  
• documenting the patient’s relevant history in a letter of recommendation
  
• educating support systems
  
• being available for follow-up.
  

Because these tasks may be daunting for one clinician, you might consider referring the patient to a gender disorder clinic (see Related resources).

Candidates for triadic therapy. For appropriately screened adults with severe GID, the therapeutic approach relies on triadic therapy:

• a 3-phase approach centered around real-life experience in the desired role
  
• hormones of the desired gender
  
• and surgery to change the genitalia and secondary sex characteristics.
  

HORMONE THERAPY

WPATH has established eligibility and readiness criteria for HRT in patients with GID (Table 3). Administering cross-sex hormones (testosterone in women; estrogens in men) brings about important physical changes as well as psychological relief. The prescribing physician need not be an endocrinologist but should become well-versed in relevant data.

Table 3

WPATH criteria for hormone replacement therapy*

Eligibility criteria 3 criteria exist	Patient is at least age 18 Patient understands what hormones medically can and cannot do and their social benefits and risks Patients has had either: Providing hormones to patients who have not fulfilled criterion 3 can be acceptable in selected circumstances, such as to facilitate monitored therapy using hormones of known quality as an alternative to black-market or unsupervised hormone use
Readiness criteria All 3 must exist	Patient has had further consolidation of gender identity during the real-life experience or psychotherapy Patient has made some progress mastering other identified problems leading to improving or continuing stable mental health (this implies satisfactory control of problems such as sociopathy, substance abuse, psychosis, and suicidality Patient is likely to take hormones in a responsible manner
Source: World Professional Association for Transgender Health (WPATH)

Options include oral, injectable, and transdermal formulations (Table 4); physician discretion and patient preference determine the formulation used.

Table 4

Sample hormonal regimens for transsexual patients*

	Medication	Starting dose	Subsequent dose	When to change doses
Female to male	Testosterone enanthanate or testosterone cypionate	200 mg IM every 2 weeks	100 to 150 mg IM every 2 weeks	After masculinization complete and/or oophorectomy/hysterectomy
	Transdermal testosterone	5 mg to skin every day	Usually stays the same	Little data exist on efficacy; effective for maintenance, and may be less efficacious during transition
Male to female	Conjugated estrogens	1.25 mg/d (or 0.625 mg/d for smokers)	2.5 mg/d (Do not increase in smokers)	To obtain best clinical results, or if testosterone is not suppressed After sexual reassignment surgery, dose may be decreased without losing secondary sexual characteristics
	OR oral estradiol	1 mg/d	2 mg/d
	OR transdermal estradiol	0.1 mg patch/week	Two 0.1 mg patches/week
	Spironolactone	200 mg/d	May discontinue	After sexual assignment surgery
	Medroxyprogesterone†	10 mg/d	May increase to 20 to 40 mg/d (usually not needed)	If testosterone is not suppressed and patient/doctor does not want to increase estrogen
	OR micronized progesterone	100 mg bid	May discontinue after breast development is complete	Micronized progesterone is more costly but may lessen side effects of anxiety, as compared with medroxyprogesterone
* Professional consensus does not exist regarding the most efficacious and safest dosing regimens for gender transition. This table reflects reasonable starting and maintenance doses that are supported in the (admittedly less than optimal) medical literature, and reflect the author’s opinion and practice. This table is not meant to include all possible hormone regimens, only several of the most commonly used medications.
† Professional consensus does not exist regarding progesterone’s role in MTF transition.
Adapted and reprinted with permission from Table VII in Oriel KA. Medical care of transsexual patients. J Gay Lesbian Med Asso 2000;4(4):193.

IM testosterone therapy (standard dose 200 to 250 mg/2 weeks) is complicated by fluctuating serum testosterone levels. Fatigue or irritability can occur when serum testosterone levels are low (on days 10 to 17). Oral testosterone suppresses the menstrual cycle in only 50% of FTMs.

 

Transdermal testosterone is an option for biologic females who are leery of injections.¹³ Patches result in stable testosterone levels in the male range but may cause skin irritation in >50% of patients. Use transdermal estrogen in males with clotting abnormalities or who are age >40.

Medical workup. Basic medical monitoring includes serial physical examinations, vital signs, weight measurements, laboratory assessment, and screening for pelvic malignancies.

For biologic males receiving estrogen, pretreatment laboratory assessment includes free testosterone, fasting glucose, liver function tests, and complete blood count, with reassessment at 6 and 12 months and annually thereafter. Obtain pretreatment prolactin levels and repeat annually. If hyperprolactinemia fails to develop within 3 years, no further measurements are necessary. Monitor for breast and prostate cancer, and instruct patients to perform self-breast exams. Following orchiectomy, estrogen doses can be reduced by one-third to one-half.

For biologic women receiving androgen, obtain pretreatment liver function tests and complete blood count, then reassess at 6 months, 12 months, and annually thereafter. Do yearly liver palpation examinations.

Physiologic changes. Biologic males treated with estrogens can expect breast growth, redistribution of fat in keeping with female habitus, decreased upper body strength, decreased body hair, retardation of male pattern balding, diminished testicular size, and decrease in erection firmness and frequency. MTF transsexuals require electrolysis to remove facial hair, as HRT does not do this.

Biologic females treated with testosterone can expect deepening of the voice, clitoral enlargement, mild breast atrophy, increased facial and body hair and male-pattern baldness, increased upper body strength, weight gain, and decreased hip fat.

With effective and continuous dosages, most changes begin in 2 to 4 months, start becoming irreversible in 6 to 12 months, start to level off in 2 years, and are mostly complete in 5 years. Men with insufficient breast growth following HRT may pursue breast augmentation surgery.

Voice changes. Hormone therapy generally is presumed to “masculinize” the voice of FTM transsexuals. In one series, after initiation of hormone therapy, 12 of 16 (75%) FTM transsexuals believed they had a voice that always would be considered masculine.^14,15

For MTF transsexuals, no surgical technique of pitch elevation is satisfactorily safe and effective. The most widely used—cricothyroid approximation—may not be long-lasting and can decrease range, loudness, and vocal quality.¹³

HRT COMPLICATIONS

Medical complications. Biologic males treated with estrogens and progestins may be at increased risk for blood clotting, benign pituitary prolactinomas, infertility, weight gain, liver disease, gallstones, somnolence, hypertension, and diabetes mellitus.

Biologic females treated with testosterone may be at increased risk for acne, cardiovascular disease from shifts of lipid profiles to male patterns, benign and malignant liver tumors, and hepatic dysfunction.

Psychiatric issues. Physical masculinization occurs much more rapidly and results in a more convincing opposite sex appearance in FTMs than feminization does in MTFs.^16,17 Behaving masculine may be more socially acceptable for women and therefore easier than it is for men to behave convincingly feminine without being characterized.

Cross-sex hormones contribute to the expression of sex-dimorphic behaviors in adulthood.^18,19 Estrogen appears to influence affect intensity, whereas androgens influence aggression and sexual motivation. Earlier studies established that untreated MTFs and FTMs do not differ in sex hormone levels from their biologic counterparts.^20,21

After 3 months of HRT, transsexuals’ sex hormones are in the range of their identified sex. FTMs treated with androgens become more prone to aggression and exhibit increased sexual motivation and arousability associated with an overall dampened affect. MTFs treated with estrogen show decreased irritability and sexual arousability.²²

SEX REASSIGNMENT SURGERY

The cost of SRS often is prohibitive. Patients may turn to the Internet or foreign venues for hormone therapy and surgical procedures. Thailand is a popular overseas destination, where the average cost for MTF surgery is approximately $6,000 to $9,000. In the United States the cost of counseling, hormones, electrolysis, and surgeries is typically $30,000 to $40,000.²³

Surgical options are not limited to genital reassignment but include mammoplasty (breast augmentation for MTF), chest reduction surgery (FTM), trachea shave surgery, forehead/brow ridge contouring, chin and jaw contouring, scalp advancement surgery, cheek implant surgery, alarplasty (nasal base resection to narrow a nose), and chin contouring.

Some insurance companies assert that transsexual procedures are not medically necessary and are declining coverage. WPATH contends that sex reassignment is effective and medically indicated in severe GID.

Postsurgical outcomes. Patients who are emotionally healthy, have adequate social support, and attain reasonable cosmetic results are most satisfied with life after SRS.²⁴ In studies of GID patients, the best predictor of postoperative psychopathology was poor surgical results.²⁵

FTMs are transformed through the use of hormones and generally are not perceived as visibly different from other men. Genital surgery is often seen as a final step in completing the transition to the identified gender.

 

FTMs may elect to have their female reproductive organs removed, along with construction of male external genitalia through phalloplasty or metoidioplasty. The decision to pursue surgery and the type of procedure depend on peer influence.²⁶ Although a phalloplasty does not provide a fully functioning and completely authentic-appearing penis, most FTMs report being satisfied with life after surgery and have few regrets.^27-31

Long-term postoperative follow-up by the surgeon and mental health professional is associated with good psychosocial outcome.

Legal considerations. An individual’s new surgically created gender can cause legal complications in jurisdictions that do not recognize the new gender. Some states are amending laws to make allowances for these advances in medical science.³²

Related resources

• World Professional Association For Transgender Health. (formerly the Harry Benjamin International Gender Dysphoria Association [HBIGDA]). www.hbigda.org. Includes a directory of transgender organizations.
  
• North American gender programs and service centers
  CAMH Gender Identity Clinic. Toronto, Ontario, Canada
  Gender Identity Project, New York, NY
  Gendercare Gender Clinic (Web clinic for gender variance). www.gendercare.com.
  Ingersoll Gender Center, Seattle, Washington
  Johns Hopkins Center for Sexual Health & Medicine, Baltimore, Maryland
  Program in Human Sexuality, Transgender Services at the University of Minnesota
  
• Sexology organizations and information
  American Association of Sex Educators, Counselors, and Therapists. www.aasect.org.
  Kinsey Institute at Indiana University. www.indiana.edu/%7Ekinsey.
  Sexuality Information and Education Council of the United States. www.siecus.org.
  Social Science Research Council. www.ssrc.org.
  Society for the Scientific Study of Sexuality. www.sexscience.org.
  

Drug brand names

• Conjugated equine estrogens • Premarin
  
• Estradiol (oral) • Estrace
  
• Estradiol (transdermal) • Climara
  
• Medroxyprogesterone (oral) • Provera
  
• Medroxyprogesterone (IM) • Depo-Provera
  
• Micronized progesterone • Prometrium
  
• Spironolactone • Aldactone
  

Disclosure

The author reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Adults with gender identity disorder (GID)—commonly termed transsexualism—may seek psychiatric assessment and treatment for a variety of reasons. Some—but not all—might be candidates for hormone replacement therapies or sex reassignment surgery (SRS). For those with gender dysphoria, psychological assessment and psychotherapy are suggested and sometimes required.

Your role in the GID patient’s gender exploration and transition must be tailored to his or her gender identity and individual circumstances. For patients who are not candidates for surgery or cannot afford it, you may assist in exploring options for living with one’s gender identity.

WHAT IS GID?

Gender identity disorder is a rare, complex condition in which individuals of unambiguous genotype and phenotype identify with the opposite gender. One in 54,000 individuals are estimated to have GID:

• 75% are biologic males desiring reassignment to female gender (MTF)
  
• 25% are females desiring to be male (FTM).¹
  

Persons with GID who undergo sex reassignment surgery represent the severe, dramatic end of a wide spectrum of cross-gender identifications and behaviors that DSM-IV-TR (Table 1)² and the International Classification of Diseases (Table 2)³ have attempted to classify. GID does not describe intersex conditions such as incomplete masculinization or feminization syndromes with ambiguous genitalia.

Table 1

DSM-IV-TR criteria for gender identity disorder

Criterion A	A strong and persistent cross-gender identification defined as the desire to be or the insistence that one is of the other sex (must not be merely a desire for any perceived cultural advantages of being the other sex)
Criterion B	Persistent discomfort with one’s assigned sex or a sense of inappropriateness in the gender role of that sex
Criterion C	The disturbance is not concurrent with a physical intersex condition (such as partial androgen insensitivity syndrome or congenital adrenal hyperplasia)
Criterion D	The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
Source: Reference 2

Table 2

ICD-10 diagnoses for gender identity disorder in adults

Diagnosis	Criteria
Transsexualism	Desire to live and be accepted as a member of the opposite sex, usually accompanied by the wish to make his or her body as congruent as possible with the preferred sex through surgery and hormone treatment Transsexual identity has been present persistently for at least 2 years Is not a symptom of another mental disorder or a chromosomal abnormality
Dual-role transvestism	Individual wears clothes of the opposite sex to experience temporary membership in the opposite sex No sexual motivation for cross-dressing Individual does not desire a permanent change to the opposite sex
Other gender identity disorders	No specific criteria; could be used for persons with an intersexed condition
Gender identify disorder, unspecified	No specific criteria; could be used for persons with an intersexed condition
Source: Adapted from International Classification of Diseases, 10th ed. (ICD-10)

Persons with GID may find ways of living with nontraditional or cross-gendered identities that do not involve altering their bodies. Others feel they must create a physical body that reflects their core gender identity.

Epidemiologic studies of GID are rare, but in a survey by Rachlin et al⁴ of 23 MTFs and 70 FTMs:

• most underwent hormone therapy (64% of MTFs, 80% of FTMs) and/or name change (45% of MTFs, 72% of FTMs)
  
• none of the MTFs had breast augmentation, whereas 52% of FTMs had undergone mastectomy and reconstruction and another 33% were actively planning it
  
• 3% of FTMs had genital surgery, 16% were planning it, and 29% had decided definitely not to have it
  
• 9% of MTFs decided definitely not to have genital surgery; 23% had undergone genital surgery, and another 35% were actively planning it.
  

The MTF/FTM differences may reflect the efficacy of cross-hormone therapy in inducing breast growth in MTFs and the cosmetic disappointment, risks, and costs of phalloplasties for FTMs. For patients who pursue genital surgery, the incidence of postoperative regret is low: 5

Biologic basis. GID’s cause remains unknown. Organic differences in brain anatomy have been identified in patients with GID. Zhou et al⁶ showed that the volume of the central subdivision of the bed nucleus of the stria terminalis (BSTc)—a brain area essential for sexual behavior—is larger in men than in women. A female-sized BSTc was found in MTF GID patients.

Research, mainly on biologic boys, indicates that GIDs are usually associated with behavioral difficulties, relationship problems with peers and parents, and—most notably—separation anxiety disorder.⁷ An audit of the files of 124 children and adolescents with GID showed that 42% experienced loss of one or both parents, mainly through separation.⁸

Psychiatric comorbidity. Studies using standardized diagnostic instruments to assess psychiatric comorbidity in GID are rare. A study of 31 patients with GID found that many met diagnostic criteria for lifetime psychiatric comorbidity, including:

 

• 71% for Axis I disorders (primarily mood and anxiety disorders)
  
• 42% for comorbid personality disorders, primarily a cluster B diagnosis
  
• 45% for substance-related disorders
  
• 6.5% for psychotic disorders
  
• 3.2% for eating disorders.⁹
  

Persons with GID transgress the traditional binary gender system and as a consequence experience discrimination in employment, social services and housing.¹⁰ Jones and Hill¹¹ have proposed that these experiences result in vulnerability to Axis I disorders.

TREATING PATIENTS WITH GID

Psychotherapy. GID treatment decisions are made without clear prospective data. Standards of care are determined by the World Professional Association for Transgender Health (WPATH).¹² Psychotherapy is often given before SRS but is not required. The therapist is left to determine the treatment terms and goals.

Your role in treating patients with GID goes beyond making an accurate diagnosis, identifying comorbid psychopathology, and instituting a treatment plan. Other tasks include:

• counseling the patient about the range of treatment options and their implications
  
• engaging in psychotherapy
  
• ascertaining eligibility and readiness for hormones and surgical therapy
  
• making formal recommendations to medical and surgical colleagues
  
• documenting the patient’s relevant history in a letter of recommendation
  
• educating support systems
  
• being available for follow-up.
  

Because these tasks may be daunting for one clinician, you might consider referring the patient to a gender disorder clinic (see Related resources).

Candidates for triadic therapy. For appropriately screened adults with severe GID, the therapeutic approach relies on triadic therapy:

• a 3-phase approach centered around real-life experience in the desired role
  
• hormones of the desired gender
  
• and surgery to change the genitalia and secondary sex characteristics.
  

HORMONE THERAPY

WPATH has established eligibility and readiness criteria for HRT in patients with GID (Table 3). Administering cross-sex hormones (testosterone in women; estrogens in men) brings about important physical changes as well as psychological relief. The prescribing physician need not be an endocrinologist but should become well-versed in relevant data.

Table 3

WPATH criteria for hormone replacement therapy*

Eligibility criteria 3 criteria exist	Patient is at least age 18 Patient understands what hormones medically can and cannot do and their social benefits and risks Patients has had either: Providing hormones to patients who have not fulfilled criterion 3 can be acceptable in selected circumstances, such as to facilitate monitored therapy using hormones of known quality as an alternative to black-market or unsupervised hormone use
Readiness criteria All 3 must exist	Patient has had further consolidation of gender identity during the real-life experience or psychotherapy Patient has made some progress mastering other identified problems leading to improving or continuing stable mental health (this implies satisfactory control of problems such as sociopathy, substance abuse, psychosis, and suicidality Patient is likely to take hormones in a responsible manner
Source: World Professional Association for Transgender Health (WPATH)

Options include oral, injectable, and transdermal formulations (Table 4); physician discretion and patient preference determine the formulation used.

Table 4

Sample hormonal regimens for transsexual patients*

	Medication	Starting dose	Subsequent dose	When to change doses
Female to male	Testosterone enanthanate or testosterone cypionate	200 mg IM every 2 weeks	100 to 150 mg IM every 2 weeks	After masculinization complete and/or oophorectomy/hysterectomy
	Transdermal testosterone	5 mg to skin every day	Usually stays the same	Little data exist on efficacy; effective for maintenance, and may be less efficacious during transition
Male to female	Conjugated estrogens	1.25 mg/d (or 0.625 mg/d for smokers)	2.5 mg/d (Do not increase in smokers)	To obtain best clinical results, or if testosterone is not suppressed After sexual reassignment surgery, dose may be decreased without losing secondary sexual characteristics
	OR oral estradiol	1 mg/d	2 mg/d
	OR transdermal estradiol	0.1 mg patch/week	Two 0.1 mg patches/week
	Spironolactone	200 mg/d	May discontinue	After sexual assignment surgery
	Medroxyprogesterone†	10 mg/d	May increase to 20 to 40 mg/d (usually not needed)	If testosterone is not suppressed and patient/doctor does not want to increase estrogen
	OR micronized progesterone	100 mg bid	May discontinue after breast development is complete	Micronized progesterone is more costly but may lessen side effects of anxiety, as compared with medroxyprogesterone
* Professional consensus does not exist regarding the most efficacious and safest dosing regimens for gender transition. This table reflects reasonable starting and maintenance doses that are supported in the (admittedly less than optimal) medical literature, and reflect the author’s opinion and practice. This table is not meant to include all possible hormone regimens, only several of the most commonly used medications.
† Professional consensus does not exist regarding progesterone’s role in MTF transition.
Adapted and reprinted with permission from Table VII in Oriel KA. Medical care of transsexual patients. J Gay Lesbian Med Asso 2000;4(4):193.

IM testosterone therapy (standard dose 200 to 250 mg/2 weeks) is complicated by fluctuating serum testosterone levels. Fatigue or irritability can occur when serum testosterone levels are low (on days 10 to 17). Oral testosterone suppresses the menstrual cycle in only 50% of FTMs.

 

Transdermal testosterone is an option for biologic females who are leery of injections.¹³ Patches result in stable testosterone levels in the male range but may cause skin irritation in >50% of patients. Use transdermal estrogen in males with clotting abnormalities or who are age >40.

Medical workup. Basic medical monitoring includes serial physical examinations, vital signs, weight measurements, laboratory assessment, and screening for pelvic malignancies.

For biologic males receiving estrogen, pretreatment laboratory assessment includes free testosterone, fasting glucose, liver function tests, and complete blood count, with reassessment at 6 and 12 months and annually thereafter. Obtain pretreatment prolactin levels and repeat annually. If hyperprolactinemia fails to develop within 3 years, no further measurements are necessary. Monitor for breast and prostate cancer, and instruct patients to perform self-breast exams. Following orchiectomy, estrogen doses can be reduced by one-third to one-half.

For biologic women receiving androgen, obtain pretreatment liver function tests and complete blood count, then reassess at 6 months, 12 months, and annually thereafter. Do yearly liver palpation examinations.

Physiologic changes. Biologic males treated with estrogens can expect breast growth, redistribution of fat in keeping with female habitus, decreased upper body strength, decreased body hair, retardation of male pattern balding, diminished testicular size, and decrease in erection firmness and frequency. MTF transsexuals require electrolysis to remove facial hair, as HRT does not do this.

Biologic females treated with testosterone can expect deepening of the voice, clitoral enlargement, mild breast atrophy, increased facial and body hair and male-pattern baldness, increased upper body strength, weight gain, and decreased hip fat.

With effective and continuous dosages, most changes begin in 2 to 4 months, start becoming irreversible in 6 to 12 months, start to level off in 2 years, and are mostly complete in 5 years. Men with insufficient breast growth following HRT may pursue breast augmentation surgery.

Voice changes. Hormone therapy generally is presumed to “masculinize” the voice of FTM transsexuals. In one series, after initiation of hormone therapy, 12 of 16 (75%) FTM transsexuals believed they had a voice that always would be considered masculine.^14,15

For MTF transsexuals, no surgical technique of pitch elevation is satisfactorily safe and effective. The most widely used—cricothyroid approximation—may not be long-lasting and can decrease range, loudness, and vocal quality.¹³

HRT COMPLICATIONS

Medical complications. Biologic males treated with estrogens and progestins may be at increased risk for blood clotting, benign pituitary prolactinomas, infertility, weight gain, liver disease, gallstones, somnolence, hypertension, and diabetes mellitus.

Biologic females treated with testosterone may be at increased risk for acne, cardiovascular disease from shifts of lipid profiles to male patterns, benign and malignant liver tumors, and hepatic dysfunction.

Psychiatric issues. Physical masculinization occurs much more rapidly and results in a more convincing opposite sex appearance in FTMs than feminization does in MTFs.^16,17 Behaving masculine may be more socially acceptable for women and therefore easier than it is for men to behave convincingly feminine without being characterized.

Cross-sex hormones contribute to the expression of sex-dimorphic behaviors in adulthood.^18,19 Estrogen appears to influence affect intensity, whereas androgens influence aggression and sexual motivation. Earlier studies established that untreated MTFs and FTMs do not differ in sex hormone levels from their biologic counterparts.^20,21

After 3 months of HRT, transsexuals’ sex hormones are in the range of their identified sex. FTMs treated with androgens become more prone to aggression and exhibit increased sexual motivation and arousability associated with an overall dampened affect. MTFs treated with estrogen show decreased irritability and sexual arousability.²²

SEX REASSIGNMENT SURGERY

The cost of SRS often is prohibitive. Patients may turn to the Internet or foreign venues for hormone therapy and surgical procedures. Thailand is a popular overseas destination, where the average cost for MTF surgery is approximately $6,000 to $9,000. In the United States the cost of counseling, hormones, electrolysis, and surgeries is typically $30,000 to $40,000.²³

Surgical options are not limited to genital reassignment but include mammoplasty (breast augmentation for MTF), chest reduction surgery (FTM), trachea shave surgery, forehead/brow ridge contouring, chin and jaw contouring, scalp advancement surgery, cheek implant surgery, alarplasty (nasal base resection to narrow a nose), and chin contouring.

Some insurance companies assert that transsexual procedures are not medically necessary and are declining coverage. WPATH contends that sex reassignment is effective and medically indicated in severe GID.

Postsurgical outcomes. Patients who are emotionally healthy, have adequate social support, and attain reasonable cosmetic results are most satisfied with life after SRS.²⁴ In studies of GID patients, the best predictor of postoperative psychopathology was poor surgical results.²⁵

FTMs are transformed through the use of hormones and generally are not perceived as visibly different from other men. Genital surgery is often seen as a final step in completing the transition to the identified gender.

 

FTMs may elect to have their female reproductive organs removed, along with construction of male external genitalia through phalloplasty or metoidioplasty. The decision to pursue surgery and the type of procedure depend on peer influence.²⁶ Although a phalloplasty does not provide a fully functioning and completely authentic-appearing penis, most FTMs report being satisfied with life after surgery and have few regrets.^27-31

Long-term postoperative follow-up by the surgeon and mental health professional is associated with good psychosocial outcome.

Legal considerations. An individual’s new surgically created gender can cause legal complications in jurisdictions that do not recognize the new gender. Some states are amending laws to make allowances for these advances in medical science.³²

Related resources

• World Professional Association For Transgender Health. (formerly the Harry Benjamin International Gender Dysphoria Association [HBIGDA]). www.hbigda.org. Includes a directory of transgender organizations.
  
• North American gender programs and service centers
  CAMH Gender Identity Clinic. Toronto, Ontario, Canada
  Gender Identity Project, New York, NY
  Gendercare Gender Clinic (Web clinic for gender variance). www.gendercare.com.
  Ingersoll Gender Center, Seattle, Washington
  Johns Hopkins Center for Sexual Health & Medicine, Baltimore, Maryland
  Program in Human Sexuality, Transgender Services at the University of Minnesota
  
• Sexology organizations and information
  American Association of Sex Educators, Counselors, and Therapists. www.aasect.org.
  Kinsey Institute at Indiana University. www.indiana.edu/%7Ekinsey.
  Sexuality Information and Education Council of the United States. www.siecus.org.
  Social Science Research Council. www.ssrc.org.
  Society for the Scientific Study of Sexuality. www.sexscience.org.
  

Drug brand names

• Conjugated equine estrogens • Premarin
  
• Estradiol (oral) • Estrace
  
• Estradiol (transdermal) • Climara
  
• Medroxyprogesterone (oral) • Provera
  
• Medroxyprogesterone (IM) • Depo-Provera
  
• Micronized progesterone • Prometrium
  
• Spironolactone • Aldactone
  

Disclosure

The author reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

History: normal on paper

Mr. C, age 65, presents to an endocrinologist complaining of hot flashes and low libido. Initial testing shows low male testosterone, but a repeat test shows normal levels. No medical cause is found for his symptoms.

“My testosterone might be normal on paper,” Mr. C tells the endocrinologist, “but I’m not. I think I’m a woman.”

Mr. C requests referral to a female psychiatrist because he feels more comfortable discussing sexual issues with a woman. The endocrinologist refers him to me for evaluation.

Over 7 years, Mr. C’s other psychiatrist—a man—has been treating him for obsessive-compulsive disorder (OCD), anxiety disorder, and bipolar disorder type II. Mr. C takes paroxetine, 60 mg/d, for depressive symptoms and was taking divalproex, 1,500 mg/d, to stabilize his mood. He recently stopped divalproex because it was causing nausea and sedation.

During our initial visit, Mr. C says he’s “through pretending to be a man.” He says he first questioned his sexual identity in early childhood, when he sometimes dressed in his mother’s clothes for play. As an adult, he mostly cross-dresses in lingerie; he wears a woman’s tank top in public once or twice weekly underneath his polo dress shirt. Fifteen years ago, he suffered anorexia and bulimia while trying to look as svelte as a woman.

At 6 feet, 2 inches with good muscle tone and short, wavy black hair, Mr. C looks strikingly masculine. Now retired, he served in the Air Force and later worked as a commercial pilot and in construction. In private, however, he prefers gardening and cooking over sports and cars.

Mr. C is married but seldom has sexual intercourse with women. He gains sexual fulfillment by visualizing himself as a woman having sex with other women or with himself as a man. He denies interest in male-male sex.

The patient has been masturbating since age 5, mostly by rubbing his scrotum against a swing set pole he still keeps in his utility shed. He often tucks his penis to mimic female genitalia and makes believe his rectum is a vagina.

Box

Mr. C’s sexual identity and intimacy problems destroyed three marriages. His first two lasted 6 months and 2 years; the third ended after 10 years when his then-wife accused him of being gay. His fourth marriage has lasted 22 years and harbors much affection and foreplay but little intercourse.

Mr. C’s Mini-Mental State Examination score of 30 indicates no underlying dementia. He shows stable affect with no evidence of derailment, paranoia, thought blocking, or auditory hallucinations.

Medical examination results are normal. Negative urine toxicology screen rules out substance abuse, and negative rapid plasma reagin rules out syphilis. Testosterone is not rechecked because levels were normal 2 days before.

The author’s observations

I suspect gender dysphoria, which describes a heterogeneous group of persons who express varying degrees of distress with their anatomic sex and sometimes desire secondary opposite-gender sexual characteristics (Box).

Sexual identity in gender dysphoria is often fluid. Symptoms might suggest transvestism, then evolve to transsexualism. Recognizing this heterogeneity and fluidity is crucial to diagnosis and treatment.

Primary transsexualism. The term “transsexualism” describes persons who want to live and be accepted within the opposite sex.¹ The transsexual identity persists for ≥ 2 years and is not caused by another mental disorder or intersexed condition. Fetishism is classically absent and cross-dressing is not sexually gratifying. Most transsexuals want surgical and hormone treatment to make their bodies as congruent as possible with the preferred sex.

In 1994, DSM-IV recognized that some late-onset transsexuals showed features of comorbid transvestism and were sexually aroused by female dress and behaviors. Gender identity disorder (GID) replaced the term “transsexualism” and includes these individuals. A secondary diagnosis of transvestism is applied.

Secondary transsexualism. Case reports² describe psychosis-induced transsexual desires in patients with schizophrenia. Gender dysphoria improved as their schizophrenia symptoms lessened.

The relationship between transsexualism and schizophrenia has been debated. Hyde and Kenna³ view transsexualism as a schizophrenia spectrum disorder, whereas sexologists consider transsexualism and schizophrenia distinct syndromes that can occur simultaneously.

Affective disorders might also alter contentment with gender role, but the relationship is unclear. Case reports of patients with bipolar disorder suggest that gender dysphoria intensity fluctuates with affective excursions.⁴ O’Gorman,⁵ however, described a bipolar patient whose gender dysphoria was mitigated during manic episodes.

 

Paraphilias are sexual disorders with recurrent intense urges and fantasies that do not follow normative arousal patterns and can diminish capacity for sexual intimacy.⁶ Manifestations include exhibitionism, fetishism, frotteurism, pedophilia, masochism/sadism, voyeurism, and transvestic fetishism.

Dividing transsexualism and pure transvestism paraphilia into discrete categories is simplistic, as transvestites can develop secondary components of transsexualism. Hoenig and Kenna⁷ assert that transsexualism—though not an anomalous erotic preference—is almost always preceded by transvestism or accompanied by cross-gender fetishism.

Nonparaphilic sexual addiction—included in DSM-IV-TR as sexual disorder not otherwise specified—describes culturally acceptable sexual interests and behaviors that are frequent or intense enough to reduce capacity for sexual intimacy. Such behaviors include compulsive masturbation, repetitive promiscuity, and dependence on anonymous sexual encounters.

An addiction model conceptualizes paraphilia as a form of pleasure seeking that has become habitual and self-destructive. Treatment involves directing patients to 12-step groups patterned after Alcoholics Anonymous.

Other models place paraphilias and related disorders within the OCD spectrum.^8-13 Persons with OCD often are obsessed with sexual content and might grapple with religious and moral concerns about sexual issues. They typically consider their symptoms intrusive or senseless. Selective serotonin reuptake inhibitors—the standard medication for OCD—might alleviate paraphilia, but results are mixed.¹⁴

Mr. C’s symptoms. Mr. C shows features of GID and transvestism. His strong, persistent cross-gender identification and sense of inappropriateness with being a man indicate GID. His recurrent sexual urges and fantasies and impaired capacity for sexual intimacy suggest a paraphilia or transvestism.

The significance of Mr. C’s comorbid bipolar disorder and OCD is unclear. Both appeared controlled, but the potential for mania-induced hypersexuality cannot be ignored.

Diagnosing gender dysphoria

A thorough medical, psychiatric, and sexual history can reveal sexual identity symptoms’ source.

Consider a medical cause. Your medical workup may include a genital exam to check for irregularities such as hermaphrodism that can compound questions of sexual identity, and karyotyping to probe chromosomal anomalies, such as mosaicism or chimerism.

Consider schizophrenia or bipolar disorder, as mania or psychosis can cause aberrant sexual behavior. In gender-dysphoric patients with either disorder, treating the psychiatric comorbidity might alleviate the dysphoria. Watch for fluctuations in gender dysphoria intensity when you treat other psychopathologies.

Take a thorough sexual history. Being matter-of-fact while discussing unusual sexual acts will help the patient “open up” about his sexual problems. Ask him if he:

• showed gender-atypical behavior as a child, which can predict transsexualism or homosexuality has engaged in heterosexual, homosexual, or abnormal sexual acts; ask about frequency and preference
  
• is married or has a girlfriend. If so, are they getting along? How often do they have sex?
  
• cross-dresses. Does his partner cross-dress as well and, if so, do they cross-dress for sexual gratification or to identify with the opposite gender? Has this response changed over time? Where and how often do they cross-dress?
  
• is achieving sexual gratification. If so, how?
  
• has sexual fantasies involving breast-feeding, giving birth, or forced feminization through gender-changing surgeries or other means
  
• “tucks” his penis, urinates sitting down, or mimics other stereotypical feminine behavior.
  

Also find out how long these behaviors have persisted. Have they fluctuated? Have relationships, life stressors, or other factors influenced them?

The answers will uncover a motivation behind these behaviors, which is key to diagnosis. Sexual gratification as a motive suggests paraphilia, whereas a desire to live as a woman points to transsexualism. Because of the myriad presentations, multiple patient visits are necessary for a specific diagnosis.

Diagnosis: ‘i enjoy womanhood, but…’

I diagnose gender dysphoria, but because Mr. C’s mood is euthymic, I cannot discern how his mood instability might affect his dysphoria. His sexual fantasies are mood-congruent and evoke no shame.

Mr. C then states that he adamantly opposes living outwardly as a woman, and fears that an overt sex change would destroy his marriage and other relationships. Even so, he desires hormone therapy and surgical breast implants so he can more closely mimic physical womanhood and make masturbation more pleasurable. He says he would flatten his breasts with gauze while in public so he can continue to look like a man.

Though comfortable with his sexual fantasies, Mr. C laments that presenting himself as an “alpha male” drains his psychic energy.

The author’s observations

Mr. C meets criteria for GID and transvestism. Some transvestites also meet criteria for autogynephilia and report erotic arousal upon seeing oneself as a woman. Character pathology, specifically sexual fantasies associated with schizoid personality, might also contribute to unusual gender presentation. Sexologists also propose fluidity in gender identification across populations and over a person’s life span.

Autogynephilia—by which a man becomes sexually aroused by imagining or seeing himself as a woman¹⁵—usually is associated with transvestism. Autogynephiles often have sexual fantasies of possessing female anatomical structures, engaging in feminine behaviors, or performing female bodily functions such as lactation, menstruation, or childbirth.

 

Autogynephilia may be a misdirected heterosexuality and is more prevalent among male-to-female transsexuals who are attracted to women, both sexes, or neither sex than among those attracted only to men.¹⁶

Gender identity fluidity. Clinicians have recorded fluidity in gender identity (sense of masculinity or femininity) and sexual orientation (the sex to which one is attracted). Sexologists have tried to create scales that gauge these changes.

The Kinsey Heterosexual-Homosexual Rating Scale¹⁷ is based on Kinsey’s theory that men are not strictly heterosexual or homosexual. Scores between 0 and 6 indicate some degree of both (Table).

The Benjamin Gender Disorientation Scale, which measures gender identity variations, recognizes variability of gender dysphoria expression and underscores the difficulty of classifying patients who—like Mr. C—present with varied symptoms. The scale is available at www.wpath.org.

I did not administer the Kinsey or Benjamin scales to Mr. C. Although his case shows how innate sense of masculinity or femininity can vary among patients with gender dysphoria, his presentation has been stable, albeit unusual.

Mr. C’s symptoms. Mr. C shows autogynephilic features. He lacks the schizoid’s emotional inertness and his gender presentation is static, though dramatic. He appears to meet criteria for GID and transvestism, autogynephilic variant.

Schizoid and other personality disorders are associated with unusual sexual fantasies. Mr. C lacks primary schizoid features, such as flattened affectivity and indifference to close relationships.

Table

Kinsey Heterosexual-Homosexual Rating Scale

Score	Indicates…
0	Exclusively heterosexual
1	Predominantly heterosexual, incidentally homosexual
2	Predominantly heterosexual, more than incidentally homosexual
3	Equally heterosexual and homosexual
4	Predominantly homosexual, more than incidentally heterosexual
5	Predominantly homosexual, incidentally heterosexual
6	Exclusively homosexual
Source: Reference 17. Reprinted by permission of The Kinsey Institute for Research in Sex, Gender, and Reproduction, Inc., Indiana University, Bloomington.

The author’s observations

Mr. C is a poor candidate for hormone therapy or gender reassignment surgery because of his circumscribed desire to live as a woman at home. Also, sexual gratification is his primary motivation for wanting to develop breasts.

Treating gender dysphoria

Serotonergic agents such as fluoxetine have shown effectiveness for treating paraphilias and nonparaphilic sexual addiction in case reports.^18,19

Behavioral techniques, however, might have a more definite impact on gender dysphoria. Marks¹⁹ reported a 4-year remission of transsexualism in a patient after comorbid OCD improved with self-exposure therapy.

Psychotherapy will not resolve gender identity disorder but can promote a stable lifestyle and improve the patient’s chances for success in relationships, education, work, and gender identity expression.²⁰ Psychotherapy can also help determine patients’ readiness for sexual reassignment surgery.

Treatment: learning to accept

I refer Mr. C back to his primary psychiatrist, who adds aripiprazole, 5 mg/d, to address grandiosity and hypomania that emerged months after my initial evaluation.

I also refer Mr. C to a gender disorder specialist for psychotherapy directed at examining his history, understanding his dilemmas, and identifying unrealistic ideas and maladaptive behaviors. The therapist has been teaching Mr. C coping skills and educating him on gender disorders and normal gender variations in activities and interests. He has been attending weekly sessions for 4 months.

To address his resentment over trying to look manly, I assure him that he doesn’t need to assume additional “masculine” behaviors and attitudes, and that his height and features make him appear masculine.

Related resources

• World Professional Association for Transgender Health, formerly the Harry Benjamin International Gender Dysphoria Association (offers links to transgender resources, gender programs, and sexologists). www.hbigda.org.
  

Drug brand name

• Divalproex sodium • Depakote
  
• Fluoxetine • Prozac
  
• Paroxetine • Paxil
  

Disclosures

Dr. Martin reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

History: normal on paper

Mr. C, age 65, presents to an endocrinologist complaining of hot flashes and low libido. Initial testing shows low male testosterone, but a repeat test shows normal levels. No medical cause is found for his symptoms.

“My testosterone might be normal on paper,” Mr. C tells the endocrinologist, “but I’m not. I think I’m a woman.”

Mr. C requests referral to a female psychiatrist because he feels more comfortable discussing sexual issues with a woman. The endocrinologist refers him to me for evaluation.

Over 7 years, Mr. C’s other psychiatrist—a man—has been treating him for obsessive-compulsive disorder (OCD), anxiety disorder, and bipolar disorder type II. Mr. C takes paroxetine, 60 mg/d, for depressive symptoms and was taking divalproex, 1,500 mg/d, to stabilize his mood. He recently stopped divalproex because it was causing nausea and sedation.

During our initial visit, Mr. C says he’s “through pretending to be a man.” He says he first questioned his sexual identity in early childhood, when he sometimes dressed in his mother’s clothes for play. As an adult, he mostly cross-dresses in lingerie; he wears a woman’s tank top in public once or twice weekly underneath his polo dress shirt. Fifteen years ago, he suffered anorexia and bulimia while trying to look as svelte as a woman.

At 6 feet, 2 inches with good muscle tone and short, wavy black hair, Mr. C looks strikingly masculine. Now retired, he served in the Air Force and later worked as a commercial pilot and in construction. In private, however, he prefers gardening and cooking over sports and cars.

Mr. C is married but seldom has sexual intercourse with women. He gains sexual fulfillment by visualizing himself as a woman having sex with other women or with himself as a man. He denies interest in male-male sex.

The patient has been masturbating since age 5, mostly by rubbing his scrotum against a swing set pole he still keeps in his utility shed. He often tucks his penis to mimic female genitalia and makes believe his rectum is a vagina.

Box

Mr. C’s sexual identity and intimacy problems destroyed three marriages. His first two lasted 6 months and 2 years; the third ended after 10 years when his then-wife accused him of being gay. His fourth marriage has lasted 22 years and harbors much affection and foreplay but little intercourse.

Mr. C’s Mini-Mental State Examination score of 30 indicates no underlying dementia. He shows stable affect with no evidence of derailment, paranoia, thought blocking, or auditory hallucinations.

Medical examination results are normal. Negative urine toxicology screen rules out substance abuse, and negative rapid plasma reagin rules out syphilis. Testosterone is not rechecked because levels were normal 2 days before.

The author’s observations

I suspect gender dysphoria, which describes a heterogeneous group of persons who express varying degrees of distress with their anatomic sex and sometimes desire secondary opposite-gender sexual characteristics (Box).

Sexual identity in gender dysphoria is often fluid. Symptoms might suggest transvestism, then evolve to transsexualism. Recognizing this heterogeneity and fluidity is crucial to diagnosis and treatment.

Primary transsexualism. The term “transsexualism” describes persons who want to live and be accepted within the opposite sex.¹ The transsexual identity persists for ≥ 2 years and is not caused by another mental disorder or intersexed condition. Fetishism is classically absent and cross-dressing is not sexually gratifying. Most transsexuals want surgical and hormone treatment to make their bodies as congruent as possible with the preferred sex.

In 1994, DSM-IV recognized that some late-onset transsexuals showed features of comorbid transvestism and were sexually aroused by female dress and behaviors. Gender identity disorder (GID) replaced the term “transsexualism” and includes these individuals. A secondary diagnosis of transvestism is applied.

Secondary transsexualism. Case reports² describe psychosis-induced transsexual desires in patients with schizophrenia. Gender dysphoria improved as their schizophrenia symptoms lessened.

The relationship between transsexualism and schizophrenia has been debated. Hyde and Kenna³ view transsexualism as a schizophrenia spectrum disorder, whereas sexologists consider transsexualism and schizophrenia distinct syndromes that can occur simultaneously.

Affective disorders might also alter contentment with gender role, but the relationship is unclear. Case reports of patients with bipolar disorder suggest that gender dysphoria intensity fluctuates with affective excursions.⁴ O’Gorman,⁵ however, described a bipolar patient whose gender dysphoria was mitigated during manic episodes.

 

Paraphilias are sexual disorders with recurrent intense urges and fantasies that do not follow normative arousal patterns and can diminish capacity for sexual intimacy.⁶ Manifestations include exhibitionism, fetishism, frotteurism, pedophilia, masochism/sadism, voyeurism, and transvestic fetishism.

Dividing transsexualism and pure transvestism paraphilia into discrete categories is simplistic, as transvestites can develop secondary components of transsexualism. Hoenig and Kenna⁷ assert that transsexualism—though not an anomalous erotic preference—is almost always preceded by transvestism or accompanied by cross-gender fetishism.

Nonparaphilic sexual addiction—included in DSM-IV-TR as sexual disorder not otherwise specified—describes culturally acceptable sexual interests and behaviors that are frequent or intense enough to reduce capacity for sexual intimacy. Such behaviors include compulsive masturbation, repetitive promiscuity, and dependence on anonymous sexual encounters.

An addiction model conceptualizes paraphilia as a form of pleasure seeking that has become habitual and self-destructive. Treatment involves directing patients to 12-step groups patterned after Alcoholics Anonymous.

Other models place paraphilias and related disorders within the OCD spectrum.^8-13 Persons with OCD often are obsessed with sexual content and might grapple with religious and moral concerns about sexual issues. They typically consider their symptoms intrusive or senseless. Selective serotonin reuptake inhibitors—the standard medication for OCD—might alleviate paraphilia, but results are mixed.¹⁴

Mr. C’s symptoms. Mr. C shows features of GID and transvestism. His strong, persistent cross-gender identification and sense of inappropriateness with being a man indicate GID. His recurrent sexual urges and fantasies and impaired capacity for sexual intimacy suggest a paraphilia or transvestism.

The significance of Mr. C’s comorbid bipolar disorder and OCD is unclear. Both appeared controlled, but the potential for mania-induced hypersexuality cannot be ignored.

Diagnosing gender dysphoria

A thorough medical, psychiatric, and sexual history can reveal sexual identity symptoms’ source.

Consider a medical cause. Your medical workup may include a genital exam to check for irregularities such as hermaphrodism that can compound questions of sexual identity, and karyotyping to probe chromosomal anomalies, such as mosaicism or chimerism.

Consider schizophrenia or bipolar disorder, as mania or psychosis can cause aberrant sexual behavior. In gender-dysphoric patients with either disorder, treating the psychiatric comorbidity might alleviate the dysphoria. Watch for fluctuations in gender dysphoria intensity when you treat other psychopathologies.

Take a thorough sexual history. Being matter-of-fact while discussing unusual sexual acts will help the patient “open up” about his sexual problems. Ask him if he:

• showed gender-atypical behavior as a child, which can predict transsexualism or homosexuality has engaged in heterosexual, homosexual, or abnormal sexual acts; ask about frequency and preference
  
• is married or has a girlfriend. If so, are they getting along? How often do they have sex?
  
• cross-dresses. Does his partner cross-dress as well and, if so, do they cross-dress for sexual gratification or to identify with the opposite gender? Has this response changed over time? Where and how often do they cross-dress?
  
• is achieving sexual gratification. If so, how?
  
• has sexual fantasies involving breast-feeding, giving birth, or forced feminization through gender-changing surgeries or other means
  
• “tucks” his penis, urinates sitting down, or mimics other stereotypical feminine behavior.
  

Also find out how long these behaviors have persisted. Have they fluctuated? Have relationships, life stressors, or other factors influenced them?

The answers will uncover a motivation behind these behaviors, which is key to diagnosis. Sexual gratification as a motive suggests paraphilia, whereas a desire to live as a woman points to transsexualism. Because of the myriad presentations, multiple patient visits are necessary for a specific diagnosis.

Diagnosis: ‘i enjoy womanhood, but…’

I diagnose gender dysphoria, but because Mr. C’s mood is euthymic, I cannot discern how his mood instability might affect his dysphoria. His sexual fantasies are mood-congruent and evoke no shame.

Mr. C then states that he adamantly opposes living outwardly as a woman, and fears that an overt sex change would destroy his marriage and other relationships. Even so, he desires hormone therapy and surgical breast implants so he can more closely mimic physical womanhood and make masturbation more pleasurable. He says he would flatten his breasts with gauze while in public so he can continue to look like a man.

Though comfortable with his sexual fantasies, Mr. C laments that presenting himself as an “alpha male” drains his psychic energy.

The author’s observations

Mr. C meets criteria for GID and transvestism. Some transvestites also meet criteria for autogynephilia and report erotic arousal upon seeing oneself as a woman. Character pathology, specifically sexual fantasies associated with schizoid personality, might also contribute to unusual gender presentation. Sexologists also propose fluidity in gender identification across populations and over a person’s life span.

Autogynephilia—by which a man becomes sexually aroused by imagining or seeing himself as a woman¹⁵—usually is associated with transvestism. Autogynephiles often have sexual fantasies of possessing female anatomical structures, engaging in feminine behaviors, or performing female bodily functions such as lactation, menstruation, or childbirth.

 

Autogynephilia may be a misdirected heterosexuality and is more prevalent among male-to-female transsexuals who are attracted to women, both sexes, or neither sex than among those attracted only to men.¹⁶

Gender identity fluidity. Clinicians have recorded fluidity in gender identity (sense of masculinity or femininity) and sexual orientation (the sex to which one is attracted). Sexologists have tried to create scales that gauge these changes.

The Kinsey Heterosexual-Homosexual Rating Scale¹⁷ is based on Kinsey’s theory that men are not strictly heterosexual or homosexual. Scores between 0 and 6 indicate some degree of both (Table).

The Benjamin Gender Disorientation Scale, which measures gender identity variations, recognizes variability of gender dysphoria expression and underscores the difficulty of classifying patients who—like Mr. C—present with varied symptoms. The scale is available at www.wpath.org.

I did not administer the Kinsey or Benjamin scales to Mr. C. Although his case shows how innate sense of masculinity or femininity can vary among patients with gender dysphoria, his presentation has been stable, albeit unusual.

Mr. C’s symptoms. Mr. C shows autogynephilic features. He lacks the schizoid’s emotional inertness and his gender presentation is static, though dramatic. He appears to meet criteria for GID and transvestism, autogynephilic variant.

Schizoid and other personality disorders are associated with unusual sexual fantasies. Mr. C lacks primary schizoid features, such as flattened affectivity and indifference to close relationships.

Table

Kinsey Heterosexual-Homosexual Rating Scale

Score	Indicates…
0	Exclusively heterosexual
1	Predominantly heterosexual, incidentally homosexual
2	Predominantly heterosexual, more than incidentally homosexual
3	Equally heterosexual and homosexual
4	Predominantly homosexual, more than incidentally heterosexual
5	Predominantly homosexual, incidentally heterosexual
6	Exclusively homosexual
Source: Reference 17. Reprinted by permission of The Kinsey Institute for Research in Sex, Gender, and Reproduction, Inc., Indiana University, Bloomington.

The author’s observations

Mr. C is a poor candidate for hormone therapy or gender reassignment surgery because of his circumscribed desire to live as a woman at home. Also, sexual gratification is his primary motivation for wanting to develop breasts.

Treating gender dysphoria

Serotonergic agents such as fluoxetine have shown effectiveness for treating paraphilias and nonparaphilic sexual addiction in case reports.^18,19

Behavioral techniques, however, might have a more definite impact on gender dysphoria. Marks¹⁹ reported a 4-year remission of transsexualism in a patient after comorbid OCD improved with self-exposure therapy.

Psychotherapy will not resolve gender identity disorder but can promote a stable lifestyle and improve the patient’s chances for success in relationships, education, work, and gender identity expression.²⁰ Psychotherapy can also help determine patients’ readiness for sexual reassignment surgery.

Treatment: learning to accept

I refer Mr. C back to his primary psychiatrist, who adds aripiprazole, 5 mg/d, to address grandiosity and hypomania that emerged months after my initial evaluation.

I also refer Mr. C to a gender disorder specialist for psychotherapy directed at examining his history, understanding his dilemmas, and identifying unrealistic ideas and maladaptive behaviors. The therapist has been teaching Mr. C coping skills and educating him on gender disorders and normal gender variations in activities and interests. He has been attending weekly sessions for 4 months.

To address his resentment over trying to look manly, I assure him that he doesn’t need to assume additional “masculine” behaviors and attitudes, and that his height and features make him appear masculine.

Related resources

• World Professional Association for Transgender Health, formerly the Harry Benjamin International Gender Dysphoria Association (offers links to transgender resources, gender programs, and sexologists). www.hbigda.org.
  

Drug brand name

• Divalproex sodium • Depakote
  
• Fluoxetine • Prozac
  
• Paroxetine • Paxil
  

Disclosures

Dr. Martin reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

History: normal on paper

Mr. C, age 65, presents to an endocrinologist complaining of hot flashes and low libido. Initial testing shows low male testosterone, but a repeat test shows normal levels. No medical cause is found for his symptoms.

“My testosterone might be normal on paper,” Mr. C tells the endocrinologist, “but I’m not. I think I’m a woman.”

Mr. C requests referral to a female psychiatrist because he feels more comfortable discussing sexual issues with a woman. The endocrinologist refers him to me for evaluation.

Over 7 years, Mr. C’s other psychiatrist—a man—has been treating him for obsessive-compulsive disorder (OCD), anxiety disorder, and bipolar disorder type II. Mr. C takes paroxetine, 60 mg/d, for depressive symptoms and was taking divalproex, 1,500 mg/d, to stabilize his mood. He recently stopped divalproex because it was causing nausea and sedation.

During our initial visit, Mr. C says he’s “through pretending to be a man.” He says he first questioned his sexual identity in early childhood, when he sometimes dressed in his mother’s clothes for play. As an adult, he mostly cross-dresses in lingerie; he wears a woman’s tank top in public once or twice weekly underneath his polo dress shirt. Fifteen years ago, he suffered anorexia and bulimia while trying to look as svelte as a woman.

At 6 feet, 2 inches with good muscle tone and short, wavy black hair, Mr. C looks strikingly masculine. Now retired, he served in the Air Force and later worked as a commercial pilot and in construction. In private, however, he prefers gardening and cooking over sports and cars.

Mr. C is married but seldom has sexual intercourse with women. He gains sexual fulfillment by visualizing himself as a woman having sex with other women or with himself as a man. He denies interest in male-male sex.

The patient has been masturbating since age 5, mostly by rubbing his scrotum against a swing set pole he still keeps in his utility shed. He often tucks his penis to mimic female genitalia and makes believe his rectum is a vagina.

Box

Mr. C’s sexual identity and intimacy problems destroyed three marriages. His first two lasted 6 months and 2 years; the third ended after 10 years when his then-wife accused him of being gay. His fourth marriage has lasted 22 years and harbors much affection and foreplay but little intercourse.

Mr. C’s Mini-Mental State Examination score of 30 indicates no underlying dementia. He shows stable affect with no evidence of derailment, paranoia, thought blocking, or auditory hallucinations.

Medical examination results are normal. Negative urine toxicology screen rules out substance abuse, and negative rapid plasma reagin rules out syphilis. Testosterone is not rechecked because levels were normal 2 days before.

The author’s observations

I suspect gender dysphoria, which describes a heterogeneous group of persons who express varying degrees of distress with their anatomic sex and sometimes desire secondary opposite-gender sexual characteristics (Box).

Sexual identity in gender dysphoria is often fluid. Symptoms might suggest transvestism, then evolve to transsexualism. Recognizing this heterogeneity and fluidity is crucial to diagnosis and treatment.

Primary transsexualism. The term “transsexualism” describes persons who want to live and be accepted within the opposite sex.¹ The transsexual identity persists for ≥ 2 years and is not caused by another mental disorder or intersexed condition. Fetishism is classically absent and cross-dressing is not sexually gratifying. Most transsexuals want surgical and hormone treatment to make their bodies as congruent as possible with the preferred sex.

In 1994, DSM-IV recognized that some late-onset transsexuals showed features of comorbid transvestism and were sexually aroused by female dress and behaviors. Gender identity disorder (GID) replaced the term “transsexualism” and includes these individuals. A secondary diagnosis of transvestism is applied.

Secondary transsexualism. Case reports² describe psychosis-induced transsexual desires in patients with schizophrenia. Gender dysphoria improved as their schizophrenia symptoms lessened.

The relationship between transsexualism and schizophrenia has been debated. Hyde and Kenna³ view transsexualism as a schizophrenia spectrum disorder, whereas sexologists consider transsexualism and schizophrenia distinct syndromes that can occur simultaneously.

Affective disorders might also alter contentment with gender role, but the relationship is unclear. Case reports of patients with bipolar disorder suggest that gender dysphoria intensity fluctuates with affective excursions.⁴ O’Gorman,⁵ however, described a bipolar patient whose gender dysphoria was mitigated during manic episodes.

 

Paraphilias are sexual disorders with recurrent intense urges and fantasies that do not follow normative arousal patterns and can diminish capacity for sexual intimacy.⁶ Manifestations include exhibitionism, fetishism, frotteurism, pedophilia, masochism/sadism, voyeurism, and transvestic fetishism.

Dividing transsexualism and pure transvestism paraphilia into discrete categories is simplistic, as transvestites can develop secondary components of transsexualism. Hoenig and Kenna⁷ assert that transsexualism—though not an anomalous erotic preference—is almost always preceded by transvestism or accompanied by cross-gender fetishism.

Nonparaphilic sexual addiction—included in DSM-IV-TR as sexual disorder not otherwise specified—describes culturally acceptable sexual interests and behaviors that are frequent or intense enough to reduce capacity for sexual intimacy. Such behaviors include compulsive masturbation, repetitive promiscuity, and dependence on anonymous sexual encounters.

An addiction model conceptualizes paraphilia as a form of pleasure seeking that has become habitual and self-destructive. Treatment involves directing patients to 12-step groups patterned after Alcoholics Anonymous.

Other models place paraphilias and related disorders within the OCD spectrum.^8-13 Persons with OCD often are obsessed with sexual content and might grapple with religious and moral concerns about sexual issues. They typically consider their symptoms intrusive or senseless. Selective serotonin reuptake inhibitors—the standard medication for OCD—might alleviate paraphilia, but results are mixed.¹⁴

Mr. C’s symptoms. Mr. C shows features of GID and transvestism. His strong, persistent cross-gender identification and sense of inappropriateness with being a man indicate GID. His recurrent sexual urges and fantasies and impaired capacity for sexual intimacy suggest a paraphilia or transvestism.

The significance of Mr. C’s comorbid bipolar disorder and OCD is unclear. Both appeared controlled, but the potential for mania-induced hypersexuality cannot be ignored.

Diagnosing gender dysphoria

A thorough medical, psychiatric, and sexual history can reveal sexual identity symptoms’ source.

Consider a medical cause. Your medical workup may include a genital exam to check for irregularities such as hermaphrodism that can compound questions of sexual identity, and karyotyping to probe chromosomal anomalies, such as mosaicism or chimerism.

Consider schizophrenia or bipolar disorder, as mania or psychosis can cause aberrant sexual behavior. In gender-dysphoric patients with either disorder, treating the psychiatric comorbidity might alleviate the dysphoria. Watch for fluctuations in gender dysphoria intensity when you treat other psychopathologies.

Take a thorough sexual history. Being matter-of-fact while discussing unusual sexual acts will help the patient “open up” about his sexual problems. Ask him if he:

• showed gender-atypical behavior as a child, which can predict transsexualism or homosexuality has engaged in heterosexual, homosexual, or abnormal sexual acts; ask about frequency and preference
  
• is married or has a girlfriend. If so, are they getting along? How often do they have sex?
  
• cross-dresses. Does his partner cross-dress as well and, if so, do they cross-dress for sexual gratification or to identify with the opposite gender? Has this response changed over time? Where and how often do they cross-dress?
  
• is achieving sexual gratification. If so, how?
  
• has sexual fantasies involving breast-feeding, giving birth, or forced feminization through gender-changing surgeries or other means
  
• “tucks” his penis, urinates sitting down, or mimics other stereotypical feminine behavior.
  

Also find out how long these behaviors have persisted. Have they fluctuated? Have relationships, life stressors, or other factors influenced them?

The answers will uncover a motivation behind these behaviors, which is key to diagnosis. Sexual gratification as a motive suggests paraphilia, whereas a desire to live as a woman points to transsexualism. Because of the myriad presentations, multiple patient visits are necessary for a specific diagnosis.

Diagnosis: ‘i enjoy womanhood, but…’

I diagnose gender dysphoria, but because Mr. C’s mood is euthymic, I cannot discern how his mood instability might affect his dysphoria. His sexual fantasies are mood-congruent and evoke no shame.

Mr. C then states that he adamantly opposes living outwardly as a woman, and fears that an overt sex change would destroy his marriage and other relationships. Even so, he desires hormone therapy and surgical breast implants so he can more closely mimic physical womanhood and make masturbation more pleasurable. He says he would flatten his breasts with gauze while in public so he can continue to look like a man.

Though comfortable with his sexual fantasies, Mr. C laments that presenting himself as an “alpha male” drains his psychic energy.

The author’s observations

Mr. C meets criteria for GID and transvestism. Some transvestites also meet criteria for autogynephilia and report erotic arousal upon seeing oneself as a woman. Character pathology, specifically sexual fantasies associated with schizoid personality, might also contribute to unusual gender presentation. Sexologists also propose fluidity in gender identification across populations and over a person’s life span.

Autogynephilia—by which a man becomes sexually aroused by imagining or seeing himself as a woman¹⁵—usually is associated with transvestism. Autogynephiles often have sexual fantasies of possessing female anatomical structures, engaging in feminine behaviors, or performing female bodily functions such as lactation, menstruation, or childbirth.

 

Autogynephilia may be a misdirected heterosexuality and is more prevalent among male-to-female transsexuals who are attracted to women, both sexes, or neither sex than among those attracted only to men.¹⁶

Gender identity fluidity. Clinicians have recorded fluidity in gender identity (sense of masculinity or femininity) and sexual orientation (the sex to which one is attracted). Sexologists have tried to create scales that gauge these changes.

The Kinsey Heterosexual-Homosexual Rating Scale¹⁷ is based on Kinsey’s theory that men are not strictly heterosexual or homosexual. Scores between 0 and 6 indicate some degree of both (Table).

The Benjamin Gender Disorientation Scale, which measures gender identity variations, recognizes variability of gender dysphoria expression and underscores the difficulty of classifying patients who—like Mr. C—present with varied symptoms. The scale is available at www.wpath.org.

I did not administer the Kinsey or Benjamin scales to Mr. C. Although his case shows how innate sense of masculinity or femininity can vary among patients with gender dysphoria, his presentation has been stable, albeit unusual.

Mr. C’s symptoms. Mr. C shows autogynephilic features. He lacks the schizoid’s emotional inertness and his gender presentation is static, though dramatic. He appears to meet criteria for GID and transvestism, autogynephilic variant.

Schizoid and other personality disorders are associated with unusual sexual fantasies. Mr. C lacks primary schizoid features, such as flattened affectivity and indifference to close relationships.

Table

Kinsey Heterosexual-Homosexual Rating Scale

Score	Indicates…
0	Exclusively heterosexual
1	Predominantly heterosexual, incidentally homosexual
2	Predominantly heterosexual, more than incidentally homosexual
3	Equally heterosexual and homosexual
4	Predominantly homosexual, more than incidentally heterosexual
5	Predominantly homosexual, incidentally heterosexual
6	Exclusively homosexual
Source: Reference 17. Reprinted by permission of The Kinsey Institute for Research in Sex, Gender, and Reproduction, Inc., Indiana University, Bloomington.

The author’s observations

Mr. C is a poor candidate for hormone therapy or gender reassignment surgery because of his circumscribed desire to live as a woman at home. Also, sexual gratification is his primary motivation for wanting to develop breasts.

Treating gender dysphoria

Serotonergic agents such as fluoxetine have shown effectiveness for treating paraphilias and nonparaphilic sexual addiction in case reports.^18,19

Behavioral techniques, however, might have a more definite impact on gender dysphoria. Marks¹⁹ reported a 4-year remission of transsexualism in a patient after comorbid OCD improved with self-exposure therapy.

Psychotherapy will not resolve gender identity disorder but can promote a stable lifestyle and improve the patient’s chances for success in relationships, education, work, and gender identity expression.²⁰ Psychotherapy can also help determine patients’ readiness for sexual reassignment surgery.

Treatment: learning to accept

I refer Mr. C back to his primary psychiatrist, who adds aripiprazole, 5 mg/d, to address grandiosity and hypomania that emerged months after my initial evaluation.

I also refer Mr. C to a gender disorder specialist for psychotherapy directed at examining his history, understanding his dilemmas, and identifying unrealistic ideas and maladaptive behaviors. The therapist has been teaching Mr. C coping skills and educating him on gender disorders and normal gender variations in activities and interests. He has been attending weekly sessions for 4 months.

To address his resentment over trying to look manly, I assure him that he doesn’t need to assume additional “masculine” behaviors and attitudes, and that his height and features make him appear masculine.

Related resources

• World Professional Association for Transgender Health, formerly the Harry Benjamin International Gender Dysphoria Association (offers links to transgender resources, gender programs, and sexologists). www.hbigda.org.
  

Drug brand name

• Divalproex sodium • Depakote
  
• Fluoxetine • Prozac
  
• Paroxetine • Paxil
  

Disclosures

Dr. Martin reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.