“Gender dysphoria: ‘I’m a man, but…,’” offers an excellent overview of gender identity disorder (Current Psychiatry, December 2006).
However, in my 10 plus years as medical director in a clinic specializing in gender disorders, I’d be sure to ask Mr. C, “Why are you coming to us now?” I would want to know why he brought the problem to the endocrinologist at that time and why he wants to see a psychiatrist after struggling with gender identity for so many years. These answers might help confirm the diagnosis and guide treatment, but the author never addresses this issue.
I question the statement, “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.” Given he is 65 and happily married, a limited change might be satisfactory. Moreover, using hormones often enhances transsexuals’ mental well-being.
I’m not sure what to make of his later emerging hypomania. Was it present when he first sought help? Has the aripiprazole prescribed by the primary psychiatrist lessened his gender concerns? If so, then the primary transsexualism diagnosis is questionable and hormone therapy is not indicated.
H. Steven Moffic, MD
Professor of psychiatry and behavioral medicine
Medical College of Wisconsin
Milwaukee
Dr. Martin responds
There are no easy answers when treating these individuals, and much depends on the clinician’s comfort level with the stated problem. I agree that, for many, hormones can improve their well-being. For Mr. C, however, the transvestism seemed to be the overriding factor, and I did not feel comfortable prescribing hormones for a paraphilia after one consultation. I referred the patient to a gender therapist to explore the issue further.
Dr. Moffic’s question regarding why the patient is seeking treatment late in life is a worthy one. When I asked Mr. C he could only say he was finally comfortable bringing the problem out in the open.
Mr. C’s gender issues did not subside with aripiprazole, and the intensity of his gender concerns showed no clear relationship to his underlying cycling disorder. No symptoms of mania were evident when I first met with him.
Kari Ann Martin, MD
Instructor of psychiatry
Department of psychiatry and psychology
Mayo Clinic
Scottsdale, AZ