Medical Psychological Aspects of Transgender

Medical. There is no known medical reason for GID. Suggested possibilities include possible in utero hormonal effects that create a vulnerability or propensity that is then exacerbated by subsequent environmental factors. Some argue that there are morphological changes in the corpus callosum, but evidence is ambivalent (some studies say yes, others say no, some find it inconclusive). Some argue that other areas of the brain are altered. In particular, one study by Zhou, Hofman, Gooren, and Swaab (1997) argues that the central subdivision of the bed nucleus of the stria terminalis (BSTc) in transgen-dered individuals does, in fact, have features of the contragender brain structure. However, these results are based upon post-mortem analyses of a very small sample of transgender brains. Additionally, there are androgenic factors such as partial androgen insensitivity syndrome (PAIS), Turner's syndrome, or congenital adrenal hyperplasia (CAH) that may or may not play into the biomedical mix.

Psychological. Axis II disorders such as schizophrenia can play a part in a person's self-perception and therefore need to be ruled out, along with environmental factors such as drug abuse, depression, etc. Depression does not rule out GID as a diagnosis, but needs to be considered within the GID diagnostic context. Multiple personality disorder issues must be resolved, so that all the different personalities agree on the sex change procedures. Axis III disorders are also critical and need to be rigorously addressed before GID diagnostic assignment. A recent study from Scandinavia (Haraldsen & Dahl, 2000) has demonstrated that transsexual persons selected for sex reassignment show a relatively low level of self-rated psychopathology before and after treatment.

Significant pressure to remove GID from DSM is currently mounting. In order to understand the reasoning behind this pressure, let us examine the current diagnostic criteria for GID.

Diagnostic Criteria (DSM IV-TR). GID is diagnosed via four criteria that must be met:

1. Evidence of a strong and persistent cross-gender identification (the desire to be or insistence that one is the other sex. The identification must not merely be a desire for perceived cultural advantages of being the other sex).

(a) Repeated stated desire to be, or insistence that he or she, is the other sex.

(b) In boys, preference for cross-dressing or simulating female attire; in girls, insistence on wearing only stereotypic masculine clothing.

(c) Persistent preferences for cross-sex roles in make-believe play or persistent fantasies of being the other sex.

(d) Intense desire to participate in the stereotypic games and pastimes of the other sex.

(e) Strong preference for playmates of the other sex.

2. There must be evidence of persistent discomfort about one's assigned sex or a sense of inappropriateness in the gender role of that sex.

(a) In boys we see assertions that penis or testes are disgusting and will disappear or assertion that it would be better not to have a penis, or aversion towards rough-and-tumble play and rejection of male stereotypical toys, games, and activities.

(b) In girls, we see rejection of urinating in a sitting position, assertion that she has or will grow a penis, or assertion that she does not want to grow breasts or menstruate, or marked aversion toward normative feminine clothing.

(c) In adolescents and adults the disturbance is manifested by symptoms such as preoccupation with getting rid of primary and secondary sex characteristics (requests for hormones, surgery, or other relief-based procedures), or the belief that he or she was born the wrong sex (born in the wrong body).

3. Intersex conditions and metabolic conditions such as PAIS or CAH rule out GID as a diagnosis.

4. To make the diagnosis there must be evidence of clinically significant distress or impairment in social, occupational, or other important areas of functioning.

A detailed discussion of the pros and cons of the DSM IV-TR GID diagnosis can be found at the website of the Harry Benjamin International Gender Dysphoria Association (HBIGDA) (http://www.hbigda.org), along with the current standards of care document. In the upcoming sections, we present a discussion of transgen-der and transsexuality in a number of countries as reported by researchers from those countries.

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