Evidence-Based Reviews

Transsexualism: Clinical guide to gender identity disorder

Current Psychiatry. 2007 February;6(2):81-91

Treatment needs include psychiatric comorbidities.

References

1. Laden M, Walinder J, Lundstrom B. Prevalence, incidence and sex ratio of transsexualism. Acta Psychiatr Scand 1996;93(4):221-3.

2. Diagnostic and statistical manual of mental disorders, 4th ed, text rev. Washington, DC: American Psychiatric Association; 2000.

3. World Health Organization (WHO). The ICD-10 classification of mental and behavioural disorders: diagnostic criteria for research. Geneva; 1993.

4. Rachlin K. Transgender individuals’ experiences of psychotherapy. Int J Transgender 2002;6-1.

5. Pfäfflin F, Junge A. Thirty years of international follow-up studies after sex reassignment surgery: a comprehensive review, 1961-1991. Dusseldorf: Symposium Publishing; 1998.

6. Zhou JN, Hofman MA, Gooren LJ, Swaab DF. A sex difference in the human brain and its relation to transsexuality. Nature 1995;378(6552):68-70.

7. Coates S, Pearson ES. Extreme boyhood femininity: isolated behavior or pervasive disorder? J Am Acad Child Psychiatry 1985;24(6):702-9.

8. Zucker KJ. Associated psychopathology in children with gender identity disorders. In: DiCeglie D, Freedman D, eds. A stranger in my own body: atypical gender identity development and mental health. London: Karnac Books; 1998.

9. Hepp U, Kramer B, Schnyder U, et al. Psychiatric comorbidity in gender identity disorder. J Psychosom Res 2005;58(3):259-61.

10. Cole S, Denny D, Eyler A, Samons S. Issues in transgender. In: Szuchman L, Muscarella F, eds. Psychological perspective on human sexuality. New York: John Wiley; 2000.

11. Jones B, Hill M. Mental health issues in lesbian, gay, bisexual, and transgender communities. Rev Psychol 2002;21:15-31.

12. Harry Benjamin international gender association standards of care for gender identity disorders, 6th version. Minneapolis, MN: The Harry Benjamin International Gender Dysphoria Association; 2001.

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19. Van de Poll ME, Van Goozen SHM. Hypothalamic involvement in sexuality and hostility: comparative psychologic aspects. In: Swaab DF, Mirmiran M, Ravid R, Van Leeuwen FW, eds. The human hypothalamus in health and disease, progress in research. Amsterdam: Elsevier; 1992;343-61.

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21. Spinder J, Spijkstra JJ, Gooren LJ, Burger CW. Pulsatile luteinizing hormone release and ovarian steroid levels in female-to-male transsexuals compared to heterosexual women. Psychoneuroendocrinology 1989;14(1-2):97-102.

22. Slabbekoorn D, Van Goozen S, Gooren L, Cohen-Kettenis P. Effects of cross-sex hormone treatment on emotionality in transsexuals. Int J Transgender [serial online] 2001;5(3). Available at: http://www.symposion.com/ijt/ijtvo05no03_02.htm. Accessed January 11, 2007.

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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: