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Identity disorder and transsexualism: causes, symptoms, diagnosis, treatment
Last reviewed: 05.07.2025
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Gender identity disorder is a condition of persistent self-identification with the opposite sex, in which people believe that they are victims of a biological error and are cruelly confined to a body incompatible with their subjective perception of gender. People with extreme forms of gender identity disorder are called transsexuals.
Gender identity itself is the subjective feeling of belonging to a particular gender, i.e. the awareness that “I am a man” or “I am a woman.” Gender identity is the internal feeling of masculinity or femininity. Gender role is the objective, external manifestation of the fact that a person is a man, a woman, or both. In this case, a person speaks and behaves in such a way as to show others or himself how much of a man or woman he is. In most people, gender identity and role coincide. In gender identity disorder, however, there is a certain degree of discrepancy between anatomical sex and gender identity. This discrepancy is usually experienced by transsexuals as difficult, severe, disturbing, and long-lasting. Calling this condition a “disorder” is due to the distress it often causes, and this term should not be interpreted superficially. The goal of treatment is to help the patient adapt, not to try to dissuade him from his gender identity.
[ Cause and pathophysiology of identity disorder and transsexualism
Although biological factors such as genetic makeup and prenatal hormonal levels largely determine gender identity, the development of a secure, consistent gender identity and gender role is influenced by social factors such as the nature of the emotional bond between parents and the relationship of each parent with the child.
When gender labeling and upbringing are ambiguous (i.e., when ambiguous genitalia are present or when genetic syndromes that alter genital appearance, such as androgen insensitivity, are present), children may be uncertain about their gender identity and role, although the degree to which external factors play a role is controversial. However, when gender labeling and upbringing are unambiguous, even ambiguous genitalia does not disrupt a child's gender identity. Transsexuals typically develop gender identity problems in early childhood. However, most children with gender identity difficulties do not develop transsexualism as adults.
Gender identity problems in children usually begin around age 2. However, some people do not develop gender identity disorder until adolescence. Children with gender identity problems often prefer to dress in the opposite gender, insist that they are the opposite gender, strongly and persistently want to engage in play and activities that are typical of the opposite sex, and have negative attitudes toward their genitals. For example, a little girl may insist that she will grow a penis and become a boy, and she may urinate while standing. A boy may urinate while sitting and want to get rid of his penis and testicles. Most children are not diagnosed with the disorder until they are 6 to 9 years old, an age when the disorder has become chronic.
Diagnosis of identity disorder and transsexualism
For a diagnosis to be made in children, there must be both cross-sex identification (a desire to be the other sex or a belief that they belong to the other sex) and discomfort with their gender or significant incongruence with their gender role. Cross-sex identification must not be a desire to obtain the cultural advantages of the other sex. For example, a boy who says he wants to be a girl in order to receive special attention from a younger sister is unlikely to have a gender identity disorder. Gender role behaviors fall along a continuum of traditional masculinity or femininity, with increasing cultural pressure for people who do not conform to the traditional male-female dichotomy. Western culture is more tolerant of tomboyish behavior in little girls (not usually considered a gender identity disorder) than of effeminate, feminine behavior in boys. Many boys engage in role-playing as girls or mothers, including trying on their mothers' or sisters' clothes. Typically, such behavior is part of normal development. Only in extreme cases does the behavior and the associated desire to be the opposite sex persist. Most boys with gender identity disorder in childhood do not have the disorder as adults, but many are homosexual or bisexual.
In adults, evaluation focuses on determining whether there is significant distress or impairment in social, occupational, or other important areas of functioning. Cross-sex behavior, such as cross-dressing, may not require any treatment if it occurs without accompanying psychological distress or impairment in functioning or if the individual has physical characteristics of both sexes (i.e., congenital adrenal hyperplasia, bisexual genitalia, androgen insensitivity syndrome).
Rarely, transsexualism is associated with the presence of ambidextrous genitalia or genetic abnormalities (such as Turner or Klinefelter syndromes). Most transsexuals who seek treatment are men who accept a female gender identity and who feel disgusted by their genitalia and masculinity. They seek help not primarily for psychological help but for hormones and genital surgery that will bring their appearance closer to their gender identity. A combination of psychotherapy, hormones, and sex reassignment surgery often cures patients.
Male-to-female transsexualism often first manifests itself in early childhood with participation in girl games, fantasies of becoming a woman, avoidance of power and competitive games, distress at the physical changes of puberty, and often a request for feminizing somatic treatments in adolescence. Many transsexuals convincingly accept the public female role. Some find satisfaction in acquiring a feminine appearance and obtaining documents indicating their female gender (e.g., a driver's license), which helps them work and live socially as a woman. Others experience problems such as depression and suicidal behavior. The likelihood of a more stable adjustment may be improved by moderate doses of feminizing hormones (e.g., ethinyl estradiol 0.1 mg once daily), electrolysis, and other feminizing treatments. Many transsexuals request sex reassignment surgery. The decision to have surgery often poses significant social problems for the patient. Prospective studies have shown that genital surgeries help selected transsexuals to live happier and more productive lives, and this is true for highly motivated, properly diagnosed and treated transsexuals who have completed 1 or 2 years of real-life experience in the opposite-sex role. Before surgery, patients usually need support in presenting themselves socially, including gesturing and voice modulation. Participation in appropriate support groups, which are available in most major cities, usually helps.
Female-to-male transsexualism is increasingly considered treatable in medical and psychiatric practice. Patients initially request mastectomy, then hysterectomy and oophorectomy. Androgenic hormones (e.g., esterified testosterone 300-400 mg intramuscularly or equivalent androgen doses transdermally or as a gel), administered continuously, alter the voice, cause a male-type distribution of subcutaneous fat and muscle build, and growth of facial and body hair. Patients may insist on the formation of an artificial phallus (neophallus) from skin grafted from the forearm (phalloplasty) or the creation of a micropenis from fatty tissue taken from the clitoris, hypertrophied by testosterone. Surgical treatment may help some patients to better adapt and experience satisfaction in life. Like male-to-female transsexuals, such patients must meet the Harry Benjamin International Gender Dysphoria Association criteria and live in the male gender role for at least 1 year. The anatomical results of neophallus surgery are usually less satisfactory than vaginal surgery in male-to-female transsexuals. Complications are common, especially with urethral elongation procedures in the neophallus.