The diagnosis and care of transsexual children and adolescents: a pediatric endocrinologists' perspective

The normally developed child whose gender identity and anatomic sex disagree is referred to as a transgendered child, or as used subsequently in this text, a transsexual. The ramifications of this disagreement include a high risk of psychiatric conflict and maladjustment, for both the individuals themselves and their families. Despite the efforts of researchers to systematically study this group of children, many fundamental questions remain. In many respects, those lingering questions are shared by patients with physical intersex who have been cared for by pediatric endocrinologists. In intersex and transsexual patients, the medical community, although sincerely interested, remains wary to intervene in ways that may lead to further inconsistency between anatomic sex and adult gender identity. A perspective on the problems of differentiating permanent from transient gender identity, some thoughts on the most appropriate management of the transsexual child/adolescent as well as remaining questions are discussed. Both the flexible and therefore potentially misleading gender identity in children and the medical communities' pledge to first do no harm (primum non nocere) have regrettably fostered disharmony between gender disordered patients, their families, and the practitioners who want to help them.

Gender identity disorder: general overview and surgical treatment for vaginoplasty in male-to-female transsexuals

LEARNING OBJECTIVES

After studying this article, the participant should be able to discuss: 1. The terminology related to male-to-female gender dysphoria. 2. The different theories regarding cause, epidemiology, and treatment of gender dysphoria. 3. The surgical goals of sex reassignment surgery in male-to-female transsexualism. 4. The surgical techniques available for sex reassignment surgery in male-to-female transsexualism.

BACKGROUND

Gender identity disorder (previously "transsexualism") is the term used for individuals who show a strong and persistent cross-gender identification and a persistent discomfort with their anatomical sex, as manifested by a preoccupation with getting rid of one's sex characteristics, or the belief of being born in the wrong sex. Since 1978, the Harry Benjamin International Gender Dysphoria Association (in honor of Dr. Harry Benjamin, one of the first physicians who made many clinicians aware of the potential benefits of sex reassignment surgery) has played a major role in the research and treatment of gender identity disorder, publishing the Standards of Care for Gender Dysphoric Persons.

METHODS

The authors performed an overview of the terminology related to male-to-female gender identity disorder; the different theories regarding cause, epidemiology, and treatment; the goals expected; and the surgical technique available for sex reassignment surgery in male-to-female transsexualism.

RESULTS

Surgical techniques available for sex reassignment surgery in male-to-female transsexualism, with advantages and disadvantages offered by each technique, are reviewed. Other feminizing nongenital operative interventions are also examined.

CONCLUSIONS

This review describes recent etiopathogenetic theories and actual guidelines on the treatment of the gender identity disorder in male-to-female transsexuals; the penile-scrotal skin flap technique is considered the state of the art for vaginoplasty in male-to-female transsexuals, whereas other techniques (rectosigmoid flap, local flaps, and isolated skin grafts) should be considered only in secondary cases. As techniques in vaginoplasty become more refined, more emphasis is being placed on aesthetic outcomes by both surgeons and patients.

Was the gender identity disorder of childhood diagnosis introduced into DSM-III as a backdoor maneuver to replace homosexuality? A historical note

Over the years, the DSM diagnosis of gender identity disorder (and its predecessors gender identity disorder of childhood [GIDC] and transsexualism) has attracted controversy as a mental disorder, for its diagnostic criteria, as a target of therapeutic intervention, and for its relationship to a homosexual sexual orientation. Another point of controversy is the claim that the diagnosis of GIDC was introduced into the DSM-III in 1980 as a kind of "backdoor maneuver" to replace homosexuality, which was deleted from the DSM-II in 1973. In this article, we challenge this historical interpretation and provide an alternative account of how the GIDC diagnosis (and transsexualism) became part of psychiatric nosology in the DSM-III. We argue that GIDC was included as a psychiatric diagnosis because it met the generally accepted criteria used by the framers of DSM-IIIfor inclusion (for example, clinical utility, acceptability to clinicians of various theoretical persuasions, and an empirical database to propose explicit diagnostic criteria that could be tested for reliability and validity). In this respect, the entry of GIDC into the psychiatric nomenclature was guided by the reliance on "expert consensus" (research clinicians)--the same mechanism that led to the introduction of many new psychiatric diagnoses, including those for which systematic field trials were not available when the DSM-III was published.

[Selected aspects of diagnosis and treatment of transsexualism in Poland]

Transsexualism is a form of sexual identity disorder. In this disorder sexual identification psychological level is inadequate to biological level. One man out of 30000 and one woman out of 100000 ones is transsexual. The etiology of transsexualism has not been known yet. The treatment is complex and a cooperation of the specialist team is necessary. An operation is a second step after the diagnosis of transsexualism (psychological, psychiatric and sexological), hormonal therapy end Real Life Test. Follow-up therapy with the psychologist and supportive therapeutic group is extremely important after the operation.

Psychiatric comorbidity of gender identity disorders: a survey among Dutch psychiatrists

OBJECTIVE

In the Netherlands, it is considered good medical practice to offer patients with gender identity disorder the option to undergo hormonal and surgical sex reassignment therapy. A liberalization of treatment guidelines now allows for such treatment to be started at puberty or prepuberty. The question arises as to what extent gender identity disorder can be reliably distinguished from a cross-gender identification that is secondary to other psychiatric disorders.

METHOD

The authors sent survey questionnaires to 382 board-certified Dutch psychiatrists regarding their experiences with diagnosing and treating patients with gender identity disorder.

RESULTS

One hundred eighty-six psychiatrists responded to the survey. These respondents reported on 584 patients with cross-gender identification. In 225 patients (39%), gender identity disorder was regarded as the primary diagnosis. For the remaining 359 patients (61%), cross-gender identification was comorbid with other psychiatric disorders. In 270 (75%) of these 359 patients, cross-gender identification was interpreted as an epiphenomenon of other psychiatric illnesses, notably personality, mood, dissociative, and psychotic disorders.

CONCLUSIONS

These data suggest that there is little consensus, at least among Dutch psychiatrists, about diagnostic features of gender identity disorder or about the minimum age at which sex reassignment therapy is a safe option. Therapy options proposed to patients with gender identity disorder appear to depend on personal preferences of psychiatrists. These results underline the need for more specific diagnostic rules in this area.

A case of bipolar psychosis and transsexualism

A case of bipolar disorder and transsexualism is reported and discussed. The case report shows the problematic nature of the distinction between transsexualism and psychosis-induced transsexual desires. If there is a true comorbidity of these disorders, a subtly differentiated process to guide medical expert opinion and therapy is necessary.

[Transexual gender identity disorders: diagnostic and legal issues]

The current classification systems (ICD-10, DSM-IV), epidemiology, symptoms and diagnostic features of gender identity disorders are discussed. In the best interest of the patients, and in view of the legal situation, treatment has to follow set "standards of care". The necessity of a psychotherapeutically guided real life test, lasting at least 1 year before somatic treatment can begin, is again pointed out.

Dissociative disorders and traumatic childhood experiences in transsexuals

In this first prevalence study of dissociative symptoms and different forms of childhood experiences among transsexuals, 41 transsexuals and 115 psychiatric inpatients were compared by means of the Interview for Dissociative Disorders (SCID-D-R), the Dissociative Experiences Scale (DES), and the Childhood Trauma Questionnaire (CTQ). The total score for the dissociative symptoms revealed no significant differences between the transsexuals and the psychiatric inpatients. However, the higher DES score among transsexuals compared with a normal population was found to be due largely to one item. A surprisingly high prevalence of emotional maltreatment was recorded. The results suggest that both the DES and the SCID-D-R have limited validity as instruments for screening and diagnosing dissociative disorders in transsexuals. Psychiatrists should be mindful of the possible existence of dissociative disorders in transsexual patients. Further investigations are needed to clarify the effects of traumatic childhood experiences on sexual identity in transsexuals and to throw more light on the phenomenological correlation between transsexualism and dissociative identity, using taxometric analyses.

Endocrinologic treatment of gender identity disorders

OBJECTIVE

To review the diagnosis, therapeutic options, and potential complications of treatment of transsexualism.

METHODS

We summarize the appropriate initial assessment and the current guidelines for hormonal and surgical treatment of patients with transsexualism.

RESULTS

The cardinal feature of transsexualism is the permanent feeling of gender dysphoria. As part of the treatment of this condition, patients may seek medical and surgical therapies to change their physical appearance to match their internal gender identity. Cross-sex hormone therapy is a key medical management and is often prescribed in consultation with an endocrinologist. Patients should participate in a period of psychotherapy before such hormonal therapy is initiated. Medical therapies for transsexualism are associated with potentially serious complications, such as thromboembolism related to estrogen treatment and testosterone-induced hepatotoxicity. Patients should be carefully selected for therapy with use of the current management guidelines published by the Harry Benjamin International Gender Dysphoria Association.

CONCLUSION

Physicians caring for patients with transsexualism should have a general knowledge about the diagnosis, available treatment, and monitoring for complications of hormonal therapy. Ongoing research and education are necessary for improvement in the health care of these patients.

Masculinity, femininity, and transsexualism

This study examined the relationship between sex role and gender identity in a Polish transsexual population where, unlike in Western countries, male-to-female (MF) transsexualism is much less common than female-to-male (FM) transsexualism. One hundred and three FM (82 primary, 21 secondary) and 29 MF (16 primary, 13 secondary) transsexuals plus 135 control males (CM) and 303 control females (CF) completed a Sex Role Inventory, which measures sex-role identification, that is, the degree to which one self-identifies with masculine and feminine characteristics. Data obtained from primary transsexuals revealed that, on a femininity scale, MF transsexuals scores exceeded not only CM but also CF. On a masculinity scale, MF transsexuals rated themselves significantly lower than CM, but at a level comparable to CF. The comparison of FM transsexuals and controls showed that, on a masculinity scale, transsexuals scored higher than CF but were not different from CM. On the femininity scale, FM transsexuals rated themselves in between the two control groups: lower than CF but slightly higher than CM. The relations of secondary transsexuals' scores to CF and CM scores, on both masculine and feminine scales, were in the same direction as the primary transsexuals' scores. Secondary transsexuals rated themselves very similarly to their primary counterparts (the exception was a much higher score of MF-primary transsexuals than MF-secondary transsexuals on the femininity scale). Our study revealed that transsexualism does not imply a simple inversion of sex-role patterns: transsexuals differ not only from nontranssexual individuals of the same anatomical sex but also from those of the opposite sex. Moreover, MF transsexualism is not a mirror image of FM transsexualism: it constitutes a more extreme condition in the identification with feminine versus masculine personality traits. These differences seem to be universal for different countries and regions. The diagnostic value of our findings is discussed.

[Treatment follow-up of transsexual patients. A catamnestic study]

In a retrospective study, 33 transsexual patients, 22 male-to-female transsexual (MF-TS), and 11 female-to-male transsexuals (FM-TS), were interviewed 53-121 months after their first referral to the psychiatric department of a university hospital. Social integration proved to be satisfactory and relatively stable. Twenty-five patients had gone through surgical sex reassignment, while 29 were currently undergoing hormonal treatment. Regarding the course of treatment, the FM-TS were a more homogeneous group than the MF-TS group. Overall, physical and psychosocial well-being was satisfactory. Psychometric measures yielded remarkably normal values, with some pathological findings regarding personality traits. In the majority of patients, self- and observer-rating appraisals of gender-specific physical appearance were equally positive. The results suggest a three-step procedure for the treatment of transsexual patients, as is practiced in other centers within German speaking continental Europe.

[Was Snow White a transsexual?]

The Rorschach Ink Blot test is considered to be an essential analytical instrument when studying the personalities of individuals presenting identity disorders, in particular, in the context of a sex change request. Nevertheless, there exist less than 20 studies of transsexualism utilising the Rorschach since the creation of this diagnostic category in 1953. This research has mostly concerned itself with relations between psychopathology and transsexualism. Practically non-existent are studies investigating the psychological conditions that permit, shape or induce sex change requests in individuals. Transsexuals request the removal of their genitals through mutilation surgery, which can be seen as subjects literally crying out to be castrated. This request is all the more surprising given that castration, in psychoanalytic terms, is considered to be the most severe punishment that an individual (woman or man) can be threatened with. Therefore, we asked ourselves which psychic conditions could motivate such as request. Based on any earlier study where answers (some explicit, others symbolic) given by sex-change applicants tested on the Rorschach were analysed, results seemed to suggest a counter-phobic attitude underlying sex-reassignment requests (28). According to these hypotheses, the fear of castration (banal as such) can only be overcome through the active search for castration itself. In opting for castration, the transsexual puts an end to the states of anxious waiting that are dominated by feelings of the incertitude and unpredictability of an eventual castration. Once obtained, the threat it constituted disappears, and with it so does the fear. Thus, by taking this active and voluntary step, the subject is no longer exposed to an imminent danger in a passive manner. This in itself creates a great feeling of relief, if not of actual pleasure in the subject (28). In this article, we postulated in a purely speculative manner, the existence of one or several modalities in the transsexual dynamics. Nevertheless, one can ask oneself about the possibility of a request based on a desire rather than on a defense, or even on the existence of a defensive process diametrically opposed to the counter-phobic attitude and which, instead of actively provoking the dreaded reality, would privilege its avoidance and the search of passivity. This latter hypothesis has the advantage of being rather easy to explore with the Rorschach because, according to Exner, the predominance of passive compared to active human movement responses (which he terms the Snow White Syndrome) indicates the propensity to escape into passive fantasies and the tendency to avoid the initiative for behaviour or decision-making, if other people can do it in the subject's place (12). Our results largely confirmed the hypothesis of the existence of an opposite mechanism, as a third of subjects (n = 26) presented Snow White Syndrome. According to Exner, these transsexuals are typically characterized by hiding into a world of make believe, avoiding all responsibility, as well as any decision-making. This passivity in our Snow White Syndrome group was all the more remarkable in that, on the whole, it infiltrated into all the movement responses and seemed to define a rigid style of thinking and mental elaboration, in addition to a suggestive content of passivity. However, this condition cannot be associated with a general lack of dynamism or energy. In fact, the treatment of information, which provides data concerning the motivation to treat a stimulus field of the stimulus--whether this concerns the capture (L) of the stimulus or the elaboration (DQ+) of the response--displayed a sufficient amount of motivation. Furthermore, internal resources (EA) were considerable and were brought into play whenever it was necessary to adopt a behaviour or make a decision. Furthermore, based on these Rorschach findings, we note that in transsexuals with Snow White Syndrome, there is a stereotyped tendency to shy away from difficulties by seeking refuge in realistic representations (but that lack in variety), which could be materialized by actions, but where the initiative is delegated to others. These transsexuals appear to shy away from the difficulties of life by seeking refuge into a world of fantasy, which they fill with the representations borrowed from reality (rather than fantasy) and consequently that are liable to be transposed, if necessary, back into reality. Therefore, one can better understand why they shun away from the deceiving reality that their physical sex represents, into the satisfying dream where they possess the genitals of the opposite sex, that is, a perfectly real organ, no longer the result of the subject's fantasy world.

A psycho-endocrinological overview of transsexualism

The technical possibility of surgical sex change has opened up a debate concerning the legitimacy and utility of carrying out such an intervention at the request of the transsexual. Diagnostic, psychological, medical and ethical arguments have been brought forth, both for and against. Nonetheless, anatomical transformation by surgical means has currently become a practice as the frequency of serious gender identity disorders is constantly progressing. After a brief introduction, the present paper will consider typological, aetiological and epidemiological aspects of transsexualism. Treatment of the sex change applicant is then defined and discussed in terms of psychological, psychiatric, endocrinological and surgical aspects. Finally, the question of post-operation follow-up will be examined.

[Done is done--and gone is gone. Sex reassignment is presently the best cure for transsexuals]

Sweden was the first country to legislate on sex reassignment procedures in 1972. Patients with gender dysphoria are in Sweden referred to one of six university clinics specialised in the field; all surgery, however, is centralised to the Karolinska Hospital in Stockholm. The aetiological strivings regarding transsexualism have to date been inconclusive; however, several lines of evidence speak in favour of an early biological influence on gender identity. The vast majority of studies addressing outcome have provided convincing evidence for the benefit of sex reassignment surgery in carefully selected cases. The current article summarises the state of the art regarding work-up and treatment of transsexuals.

The gender identity disorder in the DSM-IV classification: a critical evaluation

OBJECTIVE

The DSM-IV classification in its definition and description of the gender identity disorder omits a number of diagnostically significant features. This paper attempts to correct the deficiencies.

METHOD

The text under the headings: 'Diagnostic features', 'Specifiers', 'Associated disorders', 'Laboratory findings', 'Prevalence', 'Course' and 'Differential diagnosis' is subjected to a detailed scrutiny, using the author's experience as consultant psychiatrist to the Monash University Gender Dysphoria Clinic over a period of 25 years as source and background. Results of two studies of male-to-female and female-to-male transsexuals are given in the Table.

RESULTS

DSM-IV criteria are augmented and the symptomatology focused. The existing gaps in the delineation of specifiers and associated features are closed by providing additional clinical material. The description of the course and the differential diagnosis are enriched.

CONCLUSIONS

Although the critical analysis of the DSM-IV classification of the gender identity disorder has shown the manual to be adequate, it nevertheless has shortcomings which may impede exact diagnosis.

Symptom profiles of gender dysphoric patients of transsexual type compared to patients with personality disorders and healthy adults

OBJECTIVE

Gender dysphoric patients of transsexual type (TS) have been considered to have severe psychopathology. However, these notions have a weak empirical documentation.

METHOD

TS patients (n = 86), patients with personality disorder (PD, n = 98) and adult healthy controls (HC, n = 1068) were compared by means of the Symptom Checklist 90 (SCL-90). All patients were diagnosed by structured interviews (Axis I, II and V of DSM-III-R/IV). PD patients were further characterized according to the LEAD-standard.

RESULTS

TS patients scored significantly lower than PD patients on the Global Symptom Index and all SCL-90 subscales. Although the TS group generally scored slightly higher than the HC group, all scores were within the normal range.

CONCLUSION

TS patients selected for sex reassignment showed a relatively low level of self-rated psychopathology before and after treatment. This finding casts doubt on the view that transsexualism is a severe mental disorder.

[Treatment of young transsexuals in the Netherlands]

For more than ten years transsexual adolescents have been diagnosed and treated psychologically at the department of Child and Adolescent Psychiatry, University Medical Centre in Utrecht, the Netherlands. The medical part of the treatment takes place at the Academic Hospital of the Free University of Amsterdam. Diagnosis is done in two phases: the first diagnostic phase and the 'real life test'. In this second phase the ability to live in the opposite gender role is tested. Gender dysphoric non-transsexual adolescents are offered psychological or psychiatric interventions. For transsexual adolescents with the express wish to undergo a sex change two types of hormones are prescribed. First, hormones which halt the own pubertal development, then cross-sex hormones with irreversible effects. Surgery for adolescents is not different from surgery for adults. Although the cause of transsexuality is probably impaired sexual differentiation at cerebral level, it appears that the risk of unjustified treatment is higher when the treatment is administered at an early age than in adults; justified treatment, however, has better results when it is administered at an early age.

[Assessment and treatment of transsexualism]

Transsexualism, a gender identity disorder, is manifested by a strong and persistent cross-gender identification and the desire to adapt the body to the preferred sex by hormonal and surgical sex reassignment. The etiology of gender identity disorder is not known. Treatment takes place gradually in phases in a interdisciplinary setting (psychiatry, endocrinology, gynecology and surgery). In Switzerland, in contrast to other European countries, there is no special legislation to regulate the change of the name and personal status.

[Transsexualism. Definition, classifications, symptomatology of the phenomenon]

The main objective of this paper is to show different definitions and classifications of transsexualism, as well as changing the diagnostic criteria of this phenomenon according to DSM-III, DSM-III-R, DSM-IV, ICD-10.

Transsexualism: a review of etiology, diagnosis and treatment

Transsexualism is considered to be the extreme end of the spectrum of gender identity disorders characterized by, among other things, a pursuit of sex reassignment surgery (SRS). The origins of transsexualism are still largely unclear. A first indication of anatomic brain differences between transsexuals and nontranssexuals has been found. Also, certain parental (rearing) factors seem to be associated with transsexualism. Some contradictory findings regarding etiology, psychopathology and success of SRS seem to be related to the fact that certain subtypes of transsexuals follow different developmental routes. The observations that psychotherapy is not helpful in altering a crystallized cross-gender identity and that certain transsexuals do not show severe psychopathology has led clinicians to adopt sex reassignment as a treatment option. In many countries, transsexuals are now treated according to the Standards of Care of the Harry Benjamin International Gender Dysphoria Association, a professional organization in the field of transsexualism. Research on postoperative functioning of transsexuals does not allow for unequivocal conclusions, but there is little doubt that sex reassignment substantially alleviates the suffering of transsexuals. However, SRS is no panacea. Psychotherapy may be needed to help transsexuals in adapting to the new situation or in dealing with issues that could not be addressed before treatment.

Effects of sex steroid hormones on regional fat depots as assessed by magnetic resonance imaging in transsexuals

We investigated prospectively the effect of sex steroids on regional fat depots and thigh muscle mass in adult transsexuals. Ethinyl estradiol in combination with cyproterone acetate, a progestational antiandrogen, was given to 20 male-to-female (M-F) transsexuals, and parenteral testosterone esters were given to 17 female-to-male (F-M) transsexuals. Before and after 12 mo of cross-sex hormone administration, several anthropometric measurements (weight, skinfolds, body circumferences, and bioimpedance) were performed, and transverse magnetic resonance images were obtained at the level of the abdomen, hip, and thigh to quantify fat depots (subcutaneous and visceral) and muscle areas. We observed that treatment with ethinyl estradiol in M-F transsexuals induced a significant increase in all subcutaneous fat depots, with a lesser but proportional and significant increase in the visceral fat depot and a decrease in thigh muscle area. Testosterone administration in F-M transsexuals markedly increased thigh muscle area, reduced subcutaneous fat deposition at all levels measured, but slightly increased the visceral fat area. We conclude that sex steroid hormones are important determinants of the sex-specific localization of body fat.

Prediction of outcome in transsexualism by means of the Defense Mechanism Test and multivariate modeling: a pilot study

To elaborate the predictive value of the projective method using the Defense Mechanism Test in a 5-yr. follow-up study of 16 transsexuals, all subjects were approved for sex reassignment surgery and had completed the baseline assessments and the 5-yr. follow-up evaluation. Furthermore, we intended to create an outcome model based on the test data for prior patients wherein new consecutive applicants for sex change could be tested to predict the outcome in individual cases. Outcomes after five years showed that 62% of the transsexuals were judged as improved in a variety of areas of psychosocial functioning, 19% were unchanged, and 19% were worsened. Firstly, the analysis of the test data confirmed differences between the improved transsexuals and those who were not. Secondly, sex differences were found, with female-to-male transsexuals having a better outcome and being more homogeneous than their male counterparts. Thirdly, there was good correspondence in prediction of outcome between the model based on the Defense Mechanism Test and a clinical judgment made by a psychiatrist for two new applicants for sex reassignment surgery. It appears the Defense Mechanism Test has a predictive ability for patients with gender-identity disorder.

[Standards for treatment and expert opinion on transsexuals. The German Society for Sexual Research, The Academy of Sexual medicine and the Society for Sexual Science]

Over the last two-and-a-half years a committee of experts, consisting of members of the three leading German sexology associations, developed guidelines for treating and assessing transsexuals. Their purpose is to improve the care for patients with sex identity disorders and to ensure that such care is of uniform quality to avoid erroneous decisions to the disadvantage of those affected. The guidelines are set out in full.

Birth order in girls with gender identity disorder

This study examined the birth order of girls with gender identity disorder (N = 22). Each proband was matched to 3-7 clinical control girls for age at assessment and number of siblings (the mode number of controls per proband was 7) (total N = 147). The number of older brothers, older sisters, younger brothers, and younger sisters was recorded. Slater's birth order index showed that the probands were significantly more likely to be early born than were the controls. A modified Slater's index also compared the birth order of the probands and the controls only to their brothers (when they had one or more) and only to their sisters (when they had one or more). Compared to the controls, the probands were born early compared to their sisters, but not to their brothers. These findings are the inverse of two previous studies of boys with gender identity disorder, who were later born relative to clinical control boys, an effect that appeared to be accounted for primarily by being born later relative to older brothers, but not to older sisters.

[Psychiatric evaluation in accordance with the transsexualism regulation. An experience-based plea for guidelines and against arbitrary bias]

Today patients want to change their Christian names not so much for social support but in order to obtain sex change operations. For this reason among others we caution against casual and careless evaluations and plead for conscientiousness and thoroughness. The spectrum of 16 evaluation cases in the year 1995 is presented. Following this and looking for guiding principles, the most important aspects are discussed: the dilatable frame of the written law, the examiner's diagnostic process, the duty of being well informed, reconstruction of development as the first goal of examination, real-life self-testing and therapy, the obligation to report one's own findings, change of Christian name and indication of operation, evaluation for gender changing, problems of the judge-expert relationship and of future development.

[Transsexualism. Current status of research and clinical practice]

In the past decades the cultural and social status of transsexuals has changed considerably. They have established their own organizations, obtained legal rights and access to health insurance services. The professional point of view has changed as well considerably. Very different personality structures, developmental courses and sexual preferences are described. As differential diagnoses homosexual and transvestitic developments, psychoses, early-onset personality disorders, adolescence crises, culturally induced gender dysphorias, and intersexual disorders have primarily to be considered. In therapy, the old confrontation psychotherapy vs. surgery has widely been relinquished. Patient's age is nowadays much lower. Sex ratio in Germany is approaching for the first time 1:1. So far worldwide a preponderance of biologically male transsexuals is reported. The total number of adult transsexuals in Germany is estimated 2000-4000.

[Change in gender identity in male pseudohermaphroditism. Differential diagnosis of transsexualism and intersexuality]

Gender identity change in intersexual patients is rare. We report on the transsexual development of a patient with male pseudohermaphroditism. The case report emphasizes the importance of a thorough differential diagnosis.

Gender identity disorder in a girl with autism--a case report

A girl with high functioning autism who developed transsexualism is described. The literature to date has, to the authors' knowledge, not documented any similar case. The diagnosis of a coexisting psychiatric disorder in transsexualism has implications for the evaluation, prognosis, and appropriate management of the patient. The question of a possible relationship between autism and transsexualism and whether there is a predisposition to gender dysphoria in autism, is discussed.

[The transsexualism syndrome: clinical aspects and therapeutic prospects]

The prevalence rate of transsexualism varies from 1 to 50,000, to 1 to 100,000. Although it remains an infrequent affliction, transsexualism generates usually major suffering and may be responsible of many complications like suicide, self-mutilations, affective disorders and social disabilities. Since the first descriptions of Esquirol in the nineteenth, the medical community has always been questioned on medical, legal, social or ethical aspects of transsexualism. The aetiology of the trouble is still unknown. In the absence of biological marker, the syndrome of transsexualism can be defined only with clinical criteria. The main differential diagnosis are sexual ambiguities and psychotic disorders. For the specialists, satisfying the patients demand of a surgical and social reassignment still remains the only way to improve their clinical condition and avoid the onset of many dramatic complications. Without any treatment, the evolution of the trouble is chronic, without remission. Longitudinal studies of transsexual patients with a five year follow-up demonstrated subjective improvement in two thirds of the patients and don't find either higher rates of suicides nor psychotic decompensations after surgery and hormonotherapy. Clinical and neuropsychological studies of sexually differentiated cognitive abilities of transsexual patients, before and after hormonotherapy, could allow us in improving the understanding of sexual differences of the brain.

[Delusional "pseudotranssexualism" in schizophrenic psychosis]

The case of a 32-year old man suffering from a 10-year course of schizophrenia is presented. The man's delusions include the conviction of being of the opposite sex and thus, he applied for an operational correction of his gender according to the law of transsexualism. Based on the evident problems arising from this case, the differential diagnosis of genuine transsexualism is discussed.

[Validation of the FKB-20 as scale for the detection of body image distortions in psychosomatic patients]

The study examines the validity of a body image questionnaire (FKB-20) assessing body image disturbances in a clinical sample (n = 405 outpatients of a psychosomatic clinic) and two non-clinical samples (n = 141 medical students and n = 208 sports students). The criterion group was constituted by 98 patients of the clinical sample with diagnosed body image disturbances (anorexia, transsexualism, hypochondriac symptoms). The validity coefficients were 0.56-0.65. The sensitivity of the questionnaire was 82-90%, the specificity 90-97%, and the total mistake rate was 8-10%. The FKB-20 proves to have good validity and can be used for the diagnosis of body image disturbances.

The successful treatment of a gender dysphoric patient with pimozide

OBJECTIVE

The case is reported of a gender dysphoric patient who responded successfully to pharmacotherapy with pimozide.

CLINICAL PICTURE

An adult male patient with a borderline learning disability presented with cross-dressing and a strong wish to undergo a sex change.

TREATMENT

Supportive psychotherapy and pharmacotherapy with pimozide was tried.

OUTCOME

There was an excellent response to pimozide 2 mg daily, with a cessation of both cross-dressing and the wish for sex reassignment. When, after 1 year, the dose was reduced to 1 mg daily, there was a rapid return of the cross-dressing and the wish for sex reassignment. An increase in the dose again led to a remission which has been maintained since then.

CONCLUSION

Pharmacotherapy with pimozide should be considered in cases of doubtful gender dysphoria.

[Psychiatric aspects of transsexualism]

Transsexualism is a mental disease in which gender identity goes contrary to corporal reality. Diagnostic is purely clinical and needs a prolonged observation. The actual experience concerning about 700 cases allow us to consider that one quarter of patients should get sexual conversion.

Transsexualism--general outcome and prognostic factors: a five-year follow-up study of nineteen transsexuals in the process of changing sex

Nineteen transsexuals, approved for sex reassignement, were followed-up after 5 years. Outcome was evaluated as changes in seven areas of social, psychological, and psychiatric functioning. At baseline the patients were evaluated according to axis I, II, V (DSM-III-R), SCID screen, SASB (Structural Analysis of Social Behavior), and DMT (Defense Mechanism Test). At follow-up all but 1 were treated with contrary sex hormones, 12 had completed sex reassignment surgery, and 3 females were waiting for phalloplasty. One male transsexual regretted the decision to change sex and had quit the process. Two transsexuals had still not had any surgery due to older age or ambivalence. Overall, 68% (n = 13) had improved in at least two areas of functioning. In 3 cases (16%) outcome were judged as unsatisfactory and one of those regarded sex change as a failure. Another 3 patients were mainly unchanged after 5 years. Female transsexuals had a slightly better outcome, especially concerning establishing and maintaining partnerships and improvement in socio-economic status compared to male transsexuals. Baseline factors associated with negative outcome (unchanged or worsened) were presence of a personality disorder and high number of fulfilled axis II criteria. SCID screen assessments had high prognostic power. Negative self-image, according to SASB, predicted a negative outcome, whereas DMT variables were not correlated to outcome.

[The place of endocrinology in the management of transsexualism]

Transsexualism is not a sexual perversion but rather a gender identity disorder. The patient claim for his personal and public image and condition. The diagnosis problems arise from the lack of clinical, biological or hormonal typical signs. The pathogenesis is unclear but works in progress suggest somatic alterations. These alterations might be pre or perinatal hormonal changes and/or alterations in cerebral structures involved in sexual differentiation. Transsexualism is not a treatable disease using currently available treatments. Only hormonal and surgical treatments with sex reassignment might answer to the patient's request and improve his mental condition. Hormonal treatment might only prescribed after a consensus statement of about the sex reassignment of the patient and under medical follow-up. An early and strict medical follow-up of the patients by a multi specialist medical team is required and have to warrant the etic aspects. This is mostly important for the approval for sex reassignment from the authorities.

Personality characteristics and sexual functioning of 188 cross-dressing men

The literature on cross-dressing men has been primarily limited to self-identified patients at psychiatric clinics who are in distress. To understand the personality trait characteristics and sexual functioning of nonpatient cross-dressers, 188 non-treatment-seeking male cross-dressers completed the NEO Personality Inventory (NEO-PI) and the Derogatis Sexual Functioning Inventory (DSFI). Respondents were classified as transvestites (TV; N = 83), transgenderists (TG; N = 61), or transsexuals (TS; N = 44) based on self-report and the nature of their cross-gender activities (e.g., use of female hormones, desire for sex reassignment, and amount of time spent in female role). These diagnostic groups did not differ on the five broad personality domains of the NEO-PI, but TS men scored higher than TV and TG men on the Aesthetics facet scale of Openness to Experience (O). In terms of the DSFI scales, TS men reported lower sexual drive than TV and TG men, and TS and TG men exhibited greater psychiatric symptoms and feminine gender role, and poorer body image than TV men. Upon exclusion of a group of 49 respondents who previously sought treatment for psychological problems, no significant differences emerged among the three diagnostic groups on the NEO-PI domain and facet scales. Consideration of the DSFI scales showed that TS men experienced less sexual drive, more psychiatric symptoms, and a greater feminine gender role than TV or TG men. This study suggests that cross-dressers not seen for clinical reasons are virtually indistinguishable from non-cross-dressing men using a measure of personality traits, a sexual functioning inventory, and measures of psychological distress. These results emphasize the importance of using clinical significance criteria as required by DSM-IV guidelines before diagnosing men who cross-dress with an axis I disorder.

Unveiling the mystique of gender dysphoria syndrome

There are common myths surrounding the condition of gender dysphoria and individuals seeking therapy. The diagnosis of gender dysphoria syndrome is applied to individuals who feel ill at ease with their biological body and either seek hormonal reassignment therapy or hormonal therapy and sex reassignment surgery. The author discusses standards of care, diagnostic criteria, physiological and psychological changes incurred through hormonal therapy are introduced as well as surgical techniques. By assisting individuals with gender dysphoria syndrome to enhance the integration of their new gender role into their self-identity, nurses are in an excellent position to facilitate improvements in their overall health status as well.

Gender Dysphoria Update

Concepts of sexuality and gender identity are undergoing re-examination in society. Recent media attention has intensified interest in the area, although reliable information is sometimes lacking. Gender dysphoria, and its extreme form, transsexualism, frequently brings sufferers into contact with psychiatric, social, and mental health professionals, and surgical caregivers. Treatment of these patients often represents a challenge on many levels. Some guidelines for this care are outlined.

Multistep treatment concept of transsexual patients

Here we present a pragmatic multistep approach for the treatment of transsexual patients. The importance of an individually designed cross-gender hormone replacement therapy embedded in a multidisciplinary treatment concept, provided by psychiatrists, endocrinologists and surgeons, is demonstrated. Following this concept outcome of therapy has been improved in the last years. Over the last 5 years we have gained substantial experience in the cross-gender hormone treatment of transsexual patients. By continuous follow-up examinations and therapy adjustment the risk of side effects accompanying this therapy has been significantly minimized. This report is designed as a guideline to the clinical endocrinologist for the handling and treatment of transsexual patients.