Transgenderism

History and Terminology
Epidemiology
Etiology
Diagnosis
Treatment
Future Directions
Internet Resources

Album cover for Christine Jorgensen Reveals (1958)

Goal

At the completion of this module, the participant will understand the diagnosis and elements of treatment of transgenderism and Gender Identity Disorder (GID).

Objectives

In order to reach this goal, the participant will have:

knowledge of current theoretical and epidemiological information about transsexualism;
knowledge of current understanding of etiology of GID;
ability to effectively apply DSM IV criteria for GID;
knowledge of current treatment options for GID including psychotherapeutic, hormonal and surgical interventions.

Pre-Test

History and Terminology

Our character, the manner in which we feel, our entire temperament is not masculine, it is feminine. We only act male. We play the male just as an actress plays a man on stage. . . . It is impossible for us to transform our female instinct into a male instinct. --Karl Heinrich Ulrichs

Karl Heinrich Ulrichs (1864) was describing the sexual temperament of himself and similar men he named "Urnings." He characterized these individuals as having "a female psyche caught in a male body" and an erotic attraction exclusively to men. Subsequently, he recognized that there were also "sexually inverted" women. Although he wrote as a lawyer battling Prussian antisodomy laws, his evidence for the naturalness of this condition was drawn from biomedicine. Indeed, in the second half of the nineteenth century, European forensic doctors and neuropsychiatrists became increasingly interested in the "sexual perversions": conditions that had previously been in the jurisdiction of moralists and lawyers. Indeed, Victorian physicians first described "sexual inversion" (1869), "exhibitionism" (1877), "homosexuality" (1880), "amorous fetishism" (1887), "sadism and masochism" (1890), and "heterosexuality" (referring to "inclination to both sexes") (1892). Ulrichs's condition was subsumed under the diagnosis of inversion or homosexuality, although the element of cross-dressing became an independent focus of attention after sexologist Magnus Hirschfeld coined the term "transvestite" in 1910.

Although Freud (1905) made a critical distinction between sexual aim (one's preferred sexual behavior) and sexual object (the entity with which one engages sexually), he did not examine the matter of sexual identity. Any deviation from "normal" gendered behavior, dress, anatomy, or sexual activity implied a wholesale disorder of sex--frequently referred to as "psychosexual hermaphroditism." Even though Hirschfeld had coined the term "transsexual" in 1923, homosexuality, transvestitism, and cross-gendered self-identification were regularly collapsed together in the medical literature. For example, the first two patients who underwent complete "genital transformation surgery" from male to female in 1931 were diagnosed as "homosexual transvestites" and the surgery was performed to "complete" their cross-dressing. Even Christine Jorgensen (whose sex change surgery brought transsexualism to broad public attention in 1952) was originally diagnosed with "genuine transvestitism."

In the 1950's, John Money and his colleagues at the Johns Hopkins made the distinction between gender role (behavior that is typically masculine or feminine) and gender identity (self-identification as male or female) in arguing for early surgical sex assignment of hermaphroditic children.

Endocrinologist Harry Benjamin's seminal publications in the 1950s and 1960s were most important in disseminating the diagnosis of transsexualism. It was included in the DSM-III along with psychosexual disorders. However, in DSM-III-R , Transsexualism was included among the Gender Identity Disorders First Evident in Childhood or Adolescence. The essential features of these is an "incongruence between assigned sex... and gender identity," and resultant gender dysphoria or discomfort about one's assigned sex and sexual body. DSM-IV groups Gender Identity Disorder with Sexual Dysfunctions and Paraphilias (the fetishes). Homosexuality, which had been included among the Sexual Deviations in DSM-II , was deleted from the DSM in 1973 after considerable controversy in the American Psychiatric Association (Bayer 1987).

Epidemiology

The best epidemiological data on transsexualism come from the United Kingdom, the Netherlands, and Denmark where sex reassignment treatment is largely centralized. Dutch studies suggest a prevalence of adult transsexualism of 1 male-to-female (MTF) transsexual in 11,900 males and 1 female-to-male (FTM) in 30,400 females. The broader category of cross-gendered behavior is more difficult to estimate; however, in children it has been reported as high as 10-16 percent.

Early estimates of sex ratio suggested a preponderance of MTFs over FTMs. However, with greater subcultural and professional awareness of FTMs, a sex ratio of 4 MTF: 1 FTM or even parity has been suggested in certain countries.

Etiology

Early theories emphasized developmental psychodynamic factors. Robert Stoller suggested that FTMs had been ugly, non-cuddly babies whose stereotypically feminine and usually depressed mother had not received sufficient psychological support from a masculine but distant father. The daughter was unconsciously encouraged to play the husband-substitute to both comfort the ailing mother and gain her inadequate affection. Stoller theorized that the MTF transsexual attracted to men had been an especially cute boy with an overly seductive mother whose excessive bodily contact with the child led to his overidentification with the mother and a female gender identity. The Mahlerian theory of Ethel Person and Lionel Ovesey emphasized the MTF child's separation-individuation anxiety producing a fantasy of symbiotic fusion with the mother which the transsexual tries to resolve by surgically becoming his mother.

Genetic, gonadal, genital, and hormonal studies of transsexuals have failed to produce consistent results that explain the etiology of the condition (as has been the case with homosexuality). Currently, the dominant biological paradigm is that some genetic or in utero sex hormone alteration influences sexually dimorphic regions of the brain to develop in a cross-gendered manner. Zhou, Hofman, Gooren, and Swaab (1995), for example, found evidence that the volume of the central subdivision of the bed nucleus of the stria terminalis (BSTc) was "female sized" (i.e., smaller) in a group of six MTF transsexuals compared to heterosexual or homosexual men. They argue that this was independent of the administration of hormones in adulthood or of sexual orientation. However, these findings remain to be replicated.

Richard Green hypothesizes that "homosexual gender identity disorder" (i.e., MTFs sexually attracted to men, and FTMs attracted to women) is etiologically related to homosexuality (without GID). This is based on retrospective phenomenological similarities: a high percentage of adult homosexuals recall gender-atypical behaviors in childhood similar to that of children with GID. Furthermore, in one longitudinal, prospective study of cross-gendered boys, the majority developed homosexual or bisexual identities in adulthood without GID, and only one was transsexual. These studies are complicated by recall bias and changing nosology.

Ray Blanchard has suggested an etiological association between transvestic fetishism and "nonhomosexual gender identity disorders" (i.e., FTMs sexually attracted to men, both men and women, or neither, and MTFs attracted to women, both men and women, or neither). This is based on retrospective studies of transvestic male fetishists and MTFs where Blanchard has identified a common element of "autogynephilia"--which Blanchard defines as a man's eroticization of himself as being or dressing as a female.

Diagnosis

The DSM-IV has two major diagnostic criteria for Gender Identity Disorder in children, adolescents, and adults. First, there must be persistent and strong cross-gender identification . Second, there must be gender dysphoria : disidentification and discomfort with the assigned or birth gender. Cross-gender identification is determined by stage appropriate symptoms. In children there may be the insistence or fantasy of being the other sex, gender-atypical dress, play, and roles, and preference for opposite sex playmates. In adults, there is passing as the desired sex and insistence on having the psyche of that sex. Persistent gender dysphoria is manifested by the feeling of having been born the wrong sex. There is discomfort with the genitals and secondary sexual traits, and a preoccupation with eliminating or transforming them. In children there is aversion to gender-typical play, clothes, and roles.

The exclusionary criterion is that the disturbance cannot be concurrent with an intersex or hermaphroditic condition. As with other disorders in the DSM , the disturbance must cause clinically significant distress and functional impairment. The ICD-10 adds the additional exclusion criteria that the disorder is not a symptom of another mental disorder such as schizophrenia. It also includes a separate diagnosis of Dual-role Transvestitism characterized by non-erotic cross-dressing and absence of a desire for permanent sex reassignment.

The diagnosis is coded for GID in children versus adolescents or adults. Furthermore, sexual attraction--to males, females, both or neither--is specified. This avoids the confusion of labeling the patient homosexual or heterosexual based on born sex versus their self-identified sex.

Finally, GID should also be distinguished from homosexuality. A significant percent of gender-atypical boys will grow up to be homosexual and not transsexual. In certain cultures (particularly East Asian) where male homosexuality is not tolerated except in extremely gender-inverted manifestations, transsexualism may be the only acceptable adjustment for same-sex erotism. Therefore, cultural meanings of gender and sexuality must be carefully examined during evaluation and treatment of individuals with gender dysphoria.

Treatment

The Harry Benjamin International Gender Dysphoria Association (HBIGDA) first published its standards of care (SOC) for transsexualism in 1979. The fifth version (1998) outlines the organization's consensus concerning the psychiatric, psychological, medical, and surgical management of GID. The HBIGDA was instrumental in legitimizing the diagnosis of transsexualism and its treatment with a three part approach of psychotherapy, hormones, and sex reassignment surgery (SRS). It establishes minimal time and "real-life experience" criteria for access to hormone and surgical interventions. The real-life experience consists of successful public "passing" as the desired gender. This can be demonstrated, for example, by maintenance of employment, studies or volunteer work, a legal change of name, or statements from family, friends, or colleagues that the patient functions well in the desired gender. The current SOC do not prescribe a fixed package of sex reassignment therapy, but establish as the treatment goal an individualized plan of psychotherapeutic, hormonal, and surgical therapies to help the person with GID to achieve " lasting personal comfort with the gendered self in order to maximize overall psychological well-being and self-fulfillment ."

The role of the mental health professional is first in accurately diagnosing GID and any co-morbid psychiatric conditions. The therapist should inform the patient of the range of therapeutic options and help patients examine their sense of their gender and their expectations of therapy. The current SOC recommends a minimum of three months of therapy before the therapist considers recommending a patient for hormone therapy. Then the therapist should liaison with the medical and surgical colleagues involved in sex reassignment. One letter of recommendation from a mental health professional is required for initiating hormone therapy and two letters are required for surgery.

In the case of children with GID, the SOC recommends careful diagnostic evaluation of the child's gender identity and behavior, developmental history, and family dynamics. Treatment may involve a variety of individual and family modalities in order to improve the child's home, school, and social adjustment, as well as treatment of other psychopathology.

Earlier behavioral therapy approaches to gender-atypical boys were aimed at preventing adult transsexualism and homosexuality. These seem to have failed in the latter: no therapeutic intervention has been consistently shown to permanently alter sexual orientation. A better goal of therapy is to help the child and parents develop more flexible ideas of gender role and identity that help the child be happier with who he or she is. The SOC discourages hormonal or surgical sex reassignment treatment in children.

Recommendations for the treatment of adolescents with GID are similar, however, the SOC cautiously allows for first phase hormonal treatment in carefully evaluated adolescents. This involves amenorrhea-inducing doses of androgens, progestins, or LHRH agonists in girls, or antiandrogen or LHRH agonists in boys. Second phase hormones (i.e., higher doses of estrogenic or androgenic hormones which induce permanent changes) should be deferred till age 16. Real life experience in the desired gender may also be started.

Before initiating hormone therapy in adults, the SOC recommends a minimum of three months of psychotherapy and three months real life experience, as well as a consolidation of gender identity and stabilization of other mental health problems. The requirements for sex reassignment surgery are another twelve months of successful real-life experience, gender consolidation, and continuous hormone therapy, along with thorough education about the costs, complications, and post-operative care of SRS.

For male-to-female transsexuals the surgical interventions include orchiectomy, penectomy, vaginoplasty, and breast augmentation. Patients may also elect to undergo vocal cord surgery, depilatory treatments, thyroid cartilage reduction, rhinoplasty, and other cosmetic procedures to achieve their desired bodily femininity.

Female-to-male transsexuals may be satisfied with results of hormone therapy: clitoromegaly, amenorrhea, facial and axial hair growth, increased libido. Surgical interventions include breast reduction, hysterectomy, bilateral salpingo-oophorectomy, labial fusion with testicular implants, and metoidioplasty (anterior mobilization of the enlarged clitoris, allowing it to function as a phallus). Although phalloplasty techniques have improved significantly, the procedure is expensive, not very cosmetically or functionally successful, and prone to post-operative complications; therefore, few FTMs chose it.

Psychotherapy should explore familial, school, and societal mistreatment, and the possibility of physical and sexual abuse. Adolescents with GID are often marginalized, drop out of school, or run away from home. Many gravitate to large cities with transgender subcultures where they may rely on sex work and/or suffer from chronic un- or under-employment. As with other youths and adults in these situtations, mood and anxiety disorders are more frequent along with comorbid alcohol and substance abuse. Given how common trauma and poor childhood attachments are for individuals with GID, Axis II disorders must also be carefully considered. However, studies of non-patient transsexuals indicate that transdengered individuals can demonstrate normal psychological adjustment.

Future Directions

With the development of trangender social and advocacy groups in the 1990s, the diagnosis of GID has become controversial (Stryker 1998). Some transgender activists have argued that GID, like the former diagnosis of homosexuality, unduly pathologizes a normal variant of human gender and sexuality, and that it is familial and societal rejection that produces gender dysphoria. They claim that the treatment of GID has often been aimed at curing transsexualism or homosexuality, rather than helping transgendered individuals achieve individual gender satisfaction.

Much work remains to be done to characterize the phenomenology of gender and the biological and developmental basis of transgenderism. The appropriate treatment of transsexualism has been well established thanks to the HBIGDA Standards of Care. However, it is becoming increasingly clear that there is a much broader range of trangendered conditions; therefore, treatment must be tailor-made through a careful and empathic exploration of an individual patient's gender and sexuality conceptualizations, ideals, and goals.

Post-Test

Internet Resources

Benjamin, Harry. 1966. The Transsexual Phenomenon.

Sex Change Indigo Pages: links to a variety of resources for trangendered individuals (medical centers, support groups, other web sites)

FTM International: primarily for female-to-male transgendered people

International Foundation for Gender Education: has links and address for resources around the world

International Journal of Transsexualism

Harry Benjamin International Gender Dysphoria Association. (Feb. 2001). Standards of Care For Gender Identity Disorders (Sixth Version).

References

Bayer, R. 1987. Homosexuality and American Psychiatry: The Politics of Diagnosis. Princeton: Princeton University Press.

Benjamin, H. 1966. The Transsexual Phenomenon. New York: Julian Press.

Blanchard, R. 1993. Varieties of autogynephilia and their relationship to gender dysphoria. Arch Sex Behav 22:241.

Blanchard, R, Collins, PI.. 1993. Men with sexual interest in transvestites, transsexuals, and she-males. J Nervous Mental Dis 181:570-5.

Brown, GR, Wise, TN, Costa, PT, Jr, Herbst, JH, Fagan, PJ, Schmidt, CW, Jr. 1996. Personality characteristics and sexual functioning of 188 cross-dressing men. J Nervous Mental Dis 184(5):265-73.

Cohen, L, de Ruiter, C, Ringelberg, H, Cohen-Kettenis, PT. 1997. Psychological functioning of adolescent transsexuals: personality and psychopathology. J Clin Psychology 53(2):187-96.

Eldh, J., Berg, A., Gustafsson, M. 1997 Long-term follow up after sex reassignment surgery. Scan J Plastic and Reconst Surg and Hand Surg 31(1):39-45.

Freud, S. [1905]. Three Essays on the Theory of Sexuality . New York: Norton.

Futterweit, W. 1998. Endocrine therapy of transsexualism and potential complications of long-term treatment. Arch Sex Behav 27:209.

Green, R. 1987. The "Sissy Boy Syndrome" and the Development of Homosexuality . New Haven: Yale University Press.

Green, R. 1994. Atypical psychosexual development. In Child and Adolescent Psychiatry , ed. M Rutter, L Hersov, E Taylor. London: Blackwell Scientific.

Person, E. and Ovesey, L. 1974. The transsexual syndrome in males. I. Primary transsexualism. Am J Psychother 28:4.

Rehman, J, Lazer, S, Benet, AE, Schaefer, LC, Melman, A. 1999 . The reported sex and surgery satisfactions of 28 postoperative male-to-female transsexual patients. Arch Sex Behav 28(1):71-89.

Rosario, V. 1996. "Trans [Homo] Sexuality? Double Inversion, Psychiatric Confusion, and Hetero-Hegemony." In Queer Studies: A Lesbian, Bisexual, Gay, Transsexual Anthology, ed. B. Beemyn and M. Eliason, 35-51. New York: New York University Press.

Stoller, R.J. 1975. Sex and Gender , vol. 2, The Transsexual Experiment . New York: Aronson.

Stryker, S. (ed.). 1998. The Transgender Issue. GLQ 4(2).

Tsoi, W.F., Kok, L.P., Yeo, K.L., Ratnam, S.S. 1995. Follow-up study of female transsexuals. Annals Acad Med, Singapore 24(5):664-7.

Ulrichs, K.H. [1864-79] 1994. Forschungen über das Räthsel der mannmännlichen Liebe. Trans. M. A. Lombardi-Nash as The Riddle of "Man-Manly" Love: The Pioneering Work on Male Homosexuality. Buffalo, N.Y.: Prometheus.

Zhou J.-N., Hofman, M.A., Gooren, L.J., Swaab, D.F. 1995. A sex difference in the human brain and its relation to transsexuality. Nature 378: 68-70.

Zucker, K., Green, R. 1993. Psychological and familial aspects of gender identity disorder. In Sexual and Gender Identity Disorders, ed. A. Yates. Child and Adolescent Psychiatric Clinics of North America. Philadelphia: WB Saunders.