Transsexualism
The essential features of this disorder
are a persistent discomfort and sense of
inappropriateness about one's assigned sex in
a person who has reached puberty. In
addition, there is persistent preoccupation,
for at least two years, with getting rid of
one's primary and secondary sex
characteristics and acquiring the sex
characteristics of the other sex. Therefore,
the diagnosis is not made if the disturbance
is limited to brief periods of stress.
Invariably there is the wish to live as a
member of the other sex. In the rare cases in
which physical intersexuality or a genetic
abnormality is present.
People with this disorder usually complain
that they are uncomfortable wearing the
clothes of their assigned sex and therefore
dress in clothes of the other sex. Often they
engage in activities that in our culture tend
to be associated with the other sex. These
people often find their genitals repugnant,
which may lead to persistent requests for sex
reassignment by hormonal and surgical means.
To varying degrees, the behavior, dress, and
mannerisms become those of the other sex.
With cross-dressing and hormonal treatment
(and for males, electrolysis), some males and
some females with the disorder will appear
relatively indistinguishable from members of
the other sex. However, even after sex
reassignment, many people still have some
physical features of their originally
assigned sex that the alert observer can
recognize.
Cross-culturally, the Hijra of India and the
corresponding group in Burma may have
conditions that, according to this manual,
would be diagnosed as male-to-female
Transsexualism. The Hijra, however,
traditionally undergo castration, not
hormonal and surgical feminization (creation
of a vagina).
Associated features. Generally
there is a moderate to severe coexisting
personaIity disturbance. Frequently the
person experiences considerable anxiety and
depression, which he or she may attribute to
the inability to live in the role of the
desired sex.
Course. Without treatment,
the course of the disorder is chronic, but
cases with apparently spontaneous remission
do occur. The long-term outcome of combined
psychiatric, hormonal, and surgical
sex-reassignment treatment is not well known.
Many people function better for years after
such treatment, but a number of cases in
which re-reassignment has been desired have
also been reported.
People who have female-to-male Transsexualism
appear to represent a more homogeneous group
than those who have male-to-female
Transsexualism in that they are more likely
to have a history of homosexuality and a more
stable course, with or without treatment.
Age at onset. People who develop
Transsexualism almost invariably report
having had a gender identity problem in
childhood Some assert that they were secretly
aware of their gender problem, but that it
was not evident to their family and friends.
Although onset of the full syndrome is most
often in late adolescence or early adult
life, in some cases the disorder has a later
onset.
Impairment and complications. Frequently,
social and occupational functioning are
markedly impaired, partly because of
associated psychopathology and partly because
of problems encountered in attempting to live
in the desired gender role. Depression is
common, and can lead to suicide attempts. ln
rare instances, males may mutilate their
genitals.
Predisposing factors. Extensive,
pervasive childhood femininity in a boy or
childhood masculinity in a girl increases the
likelihood of Transsexualism. It seems
usually to develop within the context of a
disturbed relationship with one or both
parents. Some cases of Gender ldentity
Disorder of Adolescence or Adulthood,
Nontranssexual Type, evolve into
Transsexualism.
Prevalence. The estimated
prevalence is one per 30,000 for males and
one per 100,000 for females.
Sex ratio. Males seek help
at clinics specializing in the treatment of
this disorder more commonly than do females.
The ratio varies from as high as 8.1 to as
low as 1:1.
Familial pattern. No
information.
Differential diagnosis. Some
people with disturbed gender identity may, in
isolated periods of stress, wish to belong to
the other sex and to be rid of their own
genitals ln such cases a diagnosis of Gender
Identity Disorder Not Otherwise Specified
should be considered, since the diagnosis of
Transsexualism is made only when the
disturbance has been continuous for at least
two years. In Schizophrenia there may be
delusions of belonging to the other sex, but
this is rare. The Insistence by a person with
Transsexualism that he or she is of the other
sex is, strictly speaking, not a delusion,
since what is invariably meant is that the
person feels like a member of the other sex
rather than truly believes that he or she is
a member of the other sex. ln very rare cases
however, Schizophrenia and Transsexualism may
coexist.
In both Transvestic Fetishism and Gender
Identity Disorder of Adolescence or
Adulthood, Nontranssexual Type, there may be
cross-dressing. But unless these disorders
evolve into Transsexualism, there is no wish
to be rid of one's own genitals.
Types. The disorder is
subdivided according to the history of sexual
orientation, as asexual, homosexual (toward
same sex), heterosexual (toward opposite
sex), or unspecified. In the first,
"asexual," the person reports never
having had strong sexual feelings. Often
there is an additional history of little or
no sexual activity or pleasure derived from
the genitals. In the second group,
"homosexual," a predominantly
homosexual arousal pattern preceding the
onset of the Transsexualism is acknowledged,
although often such people deny that the
orientation is homosexual because of their
conviction that they are "really"
of the other sex. ln the third group,
"heterosexual," the person claims
to have had a heterosexual orientation.
A. Persistent discomfort and
sense of inappropriateness about one's
assigned sex.
B. Persistent preoccupation
for at least two years with getting rid of
one's primary and secondary sex
characteristics and acquiring the sex
characteristics of the other sex.
C. The person has reached
puberty.
Specify history of sexual
orientation: asexual, homosexual,
heterosexual, or Unspecified.
Gender
Identity Disorder of Adolescence or
Adulthood,
Nontranssexual Type (GIDAANT)
The essential features of this disorder
are a persistent or recurrent discomfort and
sense of inappropriateness about one's
assigned sex, and persistent or recurrent
cross-dressing in the role of the other sex,
either in fantasy or in actuality, in a
person who has reached puberty. This disorder
differs from Transvestic Fetishism in that
the cross-dressing is not for the purpose of
sexual excitement; it differs from
Transsexualism in that there is no persistent
preoccupation (for at least two years) with
getting rid of one's primary and secondary
sex characteristics and acquiring the sex
characteristics of the other sex.
Some people with this disorder once had I
transvestic Fetishism, but no longer
experience sexual arousal with cross
dressing. Other people with this disorder are
homosexuals who cross-dress. This disorder is
common among female impersonators.
Cross-dressing phenomena range from
occasional solitary wearing of female clothes
to extensive feminine identification in males
and masculine identification in females, and
involvement in a transvestic subculture. More
than one article of clothing of the other sex
is involved, and the person may dress
entirely as a member of the opposite sex. The
degree to which the cross-dressed person
appears as a member of the other sex varies,
depending on mannerisms, body habitues, and
cross-dressing skill. When not cross-dressed,
the person usually appears as an unremarkable
member of his or her assigned sex.
Associated features. Anxiety
and depression are common, but are often
attenuated when the person is cross-dressing.
Age at onset and course. Age
at onset and course are variable In most
cases, before puberty there was a history of
some or all of the features of Gender
Identity Disorder of Childhood. However, by
definition, GIDAANT is diagnosed only once
puberty has been reached. The initial
experience may involve partial or total
cross-dressing; when it is partial, it often
progresses to total. Cross-dressing, although
intermittent in the beginning, often becomes
more frequent, and may become habitual. A
small number of people with GlDAANT, as the
years pass, want to dress and live
permanently as the other sex, and the
disorder may evolve into Transsexualism.
Impairment. Unless there is
another diagnosis in addition to GIDAANT, the
impairment is generally restricted to
conflicts with family members and other
people regarding the cross-dressing.
Complications. The major
complication is Transsexualism.
Predisposing factors. As
noted above, both Gender Identity Disorder of
Childhood and Transvestic Fetishism sometimes
evolve into GIDAANT
Prevalence. Although its
prevalence is unknown, the disorder is
probably more common than Transsexualism.
Sex ratio. The disorder is
more common in males.
Familial pattern. No
information.
Differential diagnosis. In
Transvestic Fetishism, the cross-dressing is
for the purpose of sexual excitement. In
Transsexualism, there is a persistent (for
more than two years) wish to get rid of one's
primary and secondary sex characteristics and
acquire the sex characteristics of the other
sex. In those rare instances in which a
person with GIDAANT develops Transsexualism,
the diagnosis of GIDAANT is changed
accordingly.
Subtypes. The disorder is
subdivided according to the history of sexual
orientation, as asexual, homosexual (toward
same sex), heterosexual (toward opposite sex)
or unspecified. In the first,
"asexual," the person reports never
having had strong sexual feelings. Often
there is an additional history of little or
no sexual activity or pleasure derived from
the genitals. In the second group,
homosexuaI," a predominantly homosexual
arousal pattern preceding the onset of the
GIDAANT is acknowledged. In the third group,
"heterosexual," the person claims
to have had a heterosexual orientation.
Diagnostic Criteria for Gender
Identity Disorder of Adolescence,
Nontranssexual Type (GIDAANT)
A. Persistent or recurrent
discomfort and sense of inappropriateness
about one's assigned sex.
B. Persistent or recurrent
cross-dressing in the role of the other sex,
either in fantasy or actuality, but not for
the purpose of sexual excitement (as in
Transvestic Fetishism).
C. No persistent
preoccupation (for at least two years) with
getting rid of one's primary and secondary
sex characteristics and acquiring the sex
characteristics of the other sex (as in
Transsexualism).
D. The person has reached
puberty.
Specify history of sexual
orientation: asexual, homosexual1
heterosexual, or Unspecified.
Gender
Identity Disorder Not Otherwise Specified
Disorders in gender identity that are not
classifiable as a specific Gender identity
Disorder.
Examples:
- children with persistent
cross-dressing without the other
criteria for Gender identity Disorder
of Childhood
- adults with transient, stress related
cross dressing behavior
- adults with the clinical features of
Transsexualism of less than two
years' duration
- people who have a persistent
preoccupation with castration or
peotomy with-out a desire to acquire
the sex characteristics of the other
sex
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