Identification disorder and transsexualism: causes, symptoms, diagnosis, treatment

The breakdown of sexual identification is a state of persistent identification with the opposite sex, in which people believe that they are victims of biological error and are severely imprisoned in a body incompatible with their subjective perception of sex. People with very pronounced forms of sexual self-identification disorder are called transsexuals.

Actually, sexual identification is a subjective sense of belonging to any gender, i.e. The realization that "I am a man" or "I am a woman". Sexual identification is an internal sensation of masculinity or femininity. Tender role is an objective, external manifestation of the fact that a person is a man, a woman or a bisexual. In this case, a person speaks and behaves in such a way as to show others or himself how much he is a man or a woman. In most people, sexual identity and role coincide. In the disorder of sexual identity, however, there is a certain degree of inconsistency between the anatomical gender and sexual identity. This discrepancy is usually felt by transsexuals as complex, difficult, troubling and prolonged. The name of this condition "disorder" is associated with the distress often caused by it, this term should not be interpreted superficially. The goal of the treatment is to help the patient to adapt, rather than try to dissuade him from the sexual identification.

[1], [2], [3], [4], [5], [6], [7], [8]

The cause and pathophysiology of the disorder of identification and transsexualism

Although biological factors, such as the genetic component and the prenatal hormonal background, mainly determine gender identity, the formation of a confident, consistent gender identity and gender role is influenced by social factors such as the nature of the emotional bond between the parents and the relationship of each parent with the child .

When gender and upbringing are ambiguous (that is, in the case of genitalia of both sexes or in genetic syndromes that disrupt the appearance of the genitals, such as insensitivity to androgens), children may be unsure of their gender identities and roles, although the degree of significance of external factors remains controversial. However, if the gender designation and upbringing are unambiguous, even the presence of the genitals of both sexes does not violate the child's gender identity. In transsexuals, problems with sexual identification usually appear in early childhood. However, in most children with difficulties in sexual self-identification, transsexualism does not develop in adulthood.

Problems of sexual identification in children usually begin at the age of about 2 years. However, in some people, sexual identity disorder does not appear until adolescence. Children experiencing problems with sexual identification often prefer clothes of the opposite sex, insist that they are of a different sex, clearly and constantly want to participate in games and activities that are characteristic of the opposite sex, and have a negative attitude towards their sexual organs. For example, a little girl can insist that her penis will grow and she will become a boy, she can pee standing up. A boy can pee sitting and want to get rid of the penis and testicles. In most children, this disorder is not diagnosed until the age of 6-9 years - the age when the disorder is already becoming chronic.

Diagnosis of the disorder of identification and transsexualism

For the diagnosis of children, it is necessary to have both an identification with the opposite sex (the desire to be of a different sex or the belief that they belong to the other sex), and feelings of discomfort due to their gender or a significant discrepancy with their gender role. Identification with the opposite sex should not be a desire to obtain cultural advantages of the other sex. For example, a boy who says that he wants to be a girl to receive the special attention given to a younger sister is unlikely to have a sexual identity disorder. Behavior associated with the gender role is accounted for by a continuum of traditional masculinity or femininity, with increasing cultural pressure on people not corresponding to the traditional dichotomy of men and women. Western culture is more tolerant when little girls behave like rascals (usually not considered a sexual identity disorder) than to effeminate, effeminate behavior in boys. Many boys in role-playing games play girls or mothers, including trying on clothes of mothers or sisters. Typically, this behavior is part of normal development. Only in extreme cases, this behavior and the desire to be a person of the opposite sex associated with it persists. Most boys with a sexual identity disorder in childhood do not have this disorder in adulthood, but many are homosexual or bisexual.

Diagnosis in adults focuses on determining whether there is a pronounced distress or obvious violation in the social, professional or other important areas of functioning. Behavior that is characteristic of the other sex, such as dressing in clothes of the opposite sex, may not require any treatment if there is no accompanying psychological distress or malfunctioning, or if the person has physical signs of both sexes (ie congenital adrenal hyperplasia, genitalia of both sex, and a syndrome of insensitivity to androgens).

Rarely, there are cases when transsexualism is associated with the presence of genitalia of both sexes or genetic abnormalities (eg, Turner or Kleinfelter syndromes). Most transsexuals who require treatment are men who adopt female gender identity and with disgust are related to their genitals and signs of masculinity. They seek help mainly not for the purpose of receiving psychological help, but for the purpose of obtaining hormones and a surgical operation on the genitals, which will bring their appearance closer to their gender identity. The combination of psychotherapy, hormone administration and sex change surgery often heals patients.

Male-to-female transsexualism is often manifested for the first time in early childhood with participation in girls' games, fantasies about becoming a woman, avoidance of power and competing games, distress with physical changes in puberty, often with a requirement for adolescence of feminizing somatic treatment . Many transsexuals convincingly accept a public female role. Some of them are satisfied after they acquire effeminate appearance and will receive documents that indicate their belonging to the female sex (for example, the right to drive a vehicle), which helps them to work and live in society as a woman. Others experience problems, such as depression and suicidal behavior. The likelihood of a more stable adjustment can be increased by taking moderate doses of feminizing hormones (eg, ethinyl estradiol 0.1 mg once a day), electrolysis and other feminizing treatment. Many transsexuals require sex-change surgery. The decision about a surgical operation often causes significant social problems in the patient. In prospective studies, it is shown that operations on the genitals help selected transsexuals live happier and more productive, and this is true for highly motivated, properly diagnosed and treated transsexuals who have completed a 1- or 2-year experience of real life in the role of the opposite sex. Before surgery, patients usually need support in positioning themselves in the society, including gesticulation and gestures. Usually, it helps to participate in the respective support groups available in most major cities.

Transsexualism "from woman to man" is increasingly being considered in medical and psychiatric practice as amenable to treatment. Patients initially require mastectomy, followed by hysterectomy and ovariectomy. Androgenic hormones (eg, esterized testosterone 300-400 mg intramuscularly or equivalent doses of androgens transdermally or in the form of a gel), permanently administered, change the voice, cause the distribution of subcutaneous fat and muscle composition according to the male type, the growth of facial and body hair . Patients can insist on the formation of an artificial phallus (neo-phallus) from the skin transplanted from the forearm (phalloplasty) or the creation of a micropeniasis from fat tissues taken from a clitoris hypertrophied by testosterone. Operative treatment can help some patients to better adapt and receive satisfaction from life. Like transsexuals "from man to woman", such patients must meet the criteria of the International Association of gender dysphoria Harry Benjamin and live in the male gender role for at least 1 year. The anatomical results of surgical operations for the creation of neo-phallus are usually less satisfactory than the operations on creating the vagina in transsexuals "from man to woman". Complications are often observed, especially with procedures for lengthening the urethra in the neo-phallus.

[9], [10], [11], [12], [13], [14], [15]