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.
Gender dysphoria encompasses these sexual identity disorders
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.- Transsexualism
- Pure transvestism (having a firm gender identity but becoming sexually aroused by cross-dressing)
- Dual-role transvestism (cross-dressing solely to experience temporary membership in the opposite sex)
- Stress-related cross-dressing
- Men who desire penectomy or castration but no other gender-reassignment interventions
- Congenital intersex conditions, such as hermaphrodism
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.