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CP_1206_CASES.Final 11/14/06 12:40 PM Page 107 Current p SYCHIATRY CASES THAT TEST YOUR SKILLS In public, Mr. C is a “he-man.” In private, he wears lingerie, sees himself as a woman in sexual fantasies, and longs to develop breasts. Can you detect his problem? Gender dysphoria: ‘I’m a man, but ...’ Kari Ann Martin, MD ® Instructor of psychiatry DepartmentDowden of psychiatry Health and psychology Media Mayo Clinic, Scottsdale, AZ CopyrightFor personal use only HISTORY: NORMAL ON PAPER tioned his sexual identity in early childhood, when r. C, age 65, presents to an endocrinologist he sometimes dressed in his mother’s clothes for M complaining of hot flashes and low libido. play. As an adult, he mostly cross-dresses in lin- Initial testing shows low male testosterone, but a gerie; he wears a woman’s tank top in public once repeat test shows normal levels. No medical cause or twice weekly underneath his polo dress shirt. is found for his symptoms. Fifteen years ago, he suffered anorexia and bulimia “My testosterone might be normal on paper,” while trying to look as svelte as a woman. Mr. C tells the endocrinologist, “but I’m not. I think At 6 feet, 2 inches with good muscle tone and I’m a woman.” short, wavy black hair, Mr. C looks strikingly mascu- Mr. C requests referral to a female psychiatrist line. Now retired, he served in the Air Force and because he feels more comfortable discussing sex- later worked as a commercial pilot and in construc- ual issues with a woman. The endocrinologist refers tion. In private, however, he prefers gardening and him to me for evaluation. cooking over sports and cars. Over 7 years, Mr. C’s other psychiatrist—a Mr. C is married but seldom has sexual inter- man—has been treating him for obsessive-compul- course with women. He gains sexual fulfillment by sive disorder (OCD), anxiety disorder, and bipolar visualizing himself as a woman having sex with disorder type II. Mr. C takes paroxetine, 60 mg/d, for other women or with himself as a man. He denies depressive symptoms and was taking divalproex, interest in male-male sex. 1,500 mg/d, to stabilize his mood. He recently The patient has been masturbating since age 5, stopped divalproex because it was causing nausea mostly by rubbing his scrotum against a swing set and sedation. pole he still keeps in his utility shed. He often tucks During our initial visit, Mr. C says he’s “through his penis to mimic female genitalia and makes pretending to be a man.” He says he first ques- believe his rectum is a vagina. continued VOL. 5, NO. 12 / DECEMBER 2006 107 For mass reproduction, content licensing and permissions contact Dowden Health Media. CP_1206_CASES.Final 11/14/06 12:40 PM Page 108 CASES THAT TEST YOUR SKILLS Gender dysphoria: ‘I’m a man, but...’ Box The author’s observations Gender dysphoria encompasses I suspect gender dysphoria, which describes a these sexual identity disorders heterogeneous group of persons who express varying degrees of distress with their anatomic • Transsexualism sex and sometimes desire secondary opposite- • Pure transvestism (having a firm gender gender sexual characteristics (Box). identity but becoming sexually aroused by Sexual identity in gender dysphoria is often cross-dressing) fluid. Symptoms might suggest transvestism, • Dual-role transvestism (cross-dressing then evolve to transsexualism. Recognizing this solely to experience temporary heterogeneity and fluidity is crucial to diagnosis membership in the opposite sex) and treatment. • Stress-related cross-dressing Primary transsexualism. The term “transsexual- • Men who desire penectomy or castration ism” describes persons who want to live and be but no other gender-reassignment accepted within the opposite sex.1 The transsexu- interventions al identity persists for ≥ 2 years and is not caused • Congenital intersex conditions, such as by another mental disorder or intersexed condi- hermaphrodism tion. Fetishism is classically absent and cross- dressing is not sexually gratifying. Most transsex- uals want surgical and hormone treatment to Mr. C’s sexual identity and intimacy problems make their bodies as congruent as possible with destroyed three marriages. His first two lasted 6 the preferred sex. months and 2 years; the third ended after 10 years In 1994, DSM-IV recognized that some late- when his then-wife accused him of being gay. His onset transsexuals showed features of comorbid fourth marriage has lasted 22 years and harbors transvestism and were sexually aroused by much affection and foreplay but little intercourse. female dress and behaviors. Gender identity dis- Mr. C’s Mini-Mental State Examination score of order (GID) replaced the term “transsexualism” 30 indicates no underlying dementia. He shows sta- and includes these individuals. A secondary ble affect with no evidence of derailment, paranoia, diagnosis of transvestism is applied. thought blocking, or auditory hallucinations. Secondary transsexualism. Case reports2 describe Medical examination results are normal. psychosis-induced transsexual desires in patients Negative urine toxicology screen rules out sub- with schizophrenia. Gender dysphoria improved stance abuse, and negative rapid plasma reagin as their schizophrenia symptoms lessened. rules out syphilis. Testosterone is not rechecked The relationship between transsexualism because levels were normal 2 days before. and schizophrenia has been debated. Hyde and Kenna3 view transsexualism as a schizophrenia spectrum disorder, whereas sexologists consider Mr. C’s symptoms suggest: transsexualism and schizophrenia distinct syn- a) pure transvestism dromes that can occur simultaneously. b) primary transsexualism (gender identity Affective disorders might also alter content- disorder of adulthood) ment with gender role, but the relationship is c) transsexualism secondary to psychosis unclear. Case reports of patients with bipolar dis- d) sexual obsession and compulsion of OCD order suggest that gender dysphoria intensity fluc- 108 Current VOL. 5, NO. 12 / DECEMBER 2006 p SYCHIATRY CP_1206_CASES.Final 11/14/06 12:40 PM Page 109 Current p SYCHIATRY tuates with affective excursions.4 O’Gorman,5 however, described a bipolar patient whose gender dysphoria was mitigated during manic episodes. How would you Paraphilias are sexual disorders with recur- handle this case? rent intense urges and fantasies that do not follow normative arousal patterns and can diminish 6 Visit www.currentpsychiatry.com capacity for sexual intimacy. Manifestations to input your answers and compare them with include exhibitionism, fetishism, frotteurism, those of your colleagues pedophilia, masochism/sadism, voyeurism, and transvestic fetishism. gender identification and sense of inappropriate- Dividing transsexualism and pure trans- ness with being a man indicate GID. His recur- vestism paraphilia into discrete categories is sim- rent sexual urges and fantasies and impaired plistic, as transvestites can develop secondary capacity for sexual intimacy suggest a paraphilia components of transsexualism. Hoenig and or transvestism. Kenna7 assert that transsexualism—though not an The significance of Mr. C’s comorbid bipolar anomalous erotic preference—is almost always disorder and OCD is unclear. Both appeared preceded by transvestism or accompanied by controlled, but the potential for mania-induced cross-gender fetishism. hypersexuality cannot be ignored. Nonparaphilic sexual addiction—included in DSM-IV-TR as sexual disorder not otherwise specified—describes culturally acceptable sexual DIAGNOSING GENDER DYSPHORIA interests and behaviors that are frequent or A thorough medical, psychiatric, and sexual his- intense enough to reduce capacity for sexual tory can reveal sexual identity symptoms’ source. intimacy. Such behaviors include compulsive Consider a medical cause. Your medical workup masturbation, repetitive promiscuity, and depen- may include a genital exam to check for irregu- dence on anonymous sexual encounters. larities such as hermaphrodism that can com- An addiction model conceptualizes para- pound questions of sexual identity, and kary- philia as a form of pleasure seeking that has otyping to probe chromosomal anomalies, such become habitual and self-destructive. Treatment as mosaicism or chimerism. involves directing patients to 12-step groups pat- Consider schizophrenia or bipolar disorder, as terned after Alcoholics Anonymous. mania or psychosis can cause aberrant sexual Other models place paraphilias and related behavior. In gender-dysphoric patients with disorders within the OCD spectrum.8-13 Persons either disorder, treating the psychiatric comorbid- with OCD often are obsessed with sexual con- ity might alleviate the dysphoria. Watch for fluc- tent and might grapple with religious and moral tuations in gender dysphoria intensity when you concerns about sexual issues. They typically con- treat other psychopathologies. sider their symptoms intrusive or senseless. Take a thorough sexual history. Being matter-of- Selective serotonin reuptake inhibitors—the fact while discussing unusual sexual acts will standard medication for OCD—might alleviate help the patient “open up” about his sexual prob- paraphilia, but results are mixed.14 lems. Ask him if he: Mr. C’s symptoms. Mr. C shows features of GID • showed gender-atypical behavior as a child, and transvestism. His strong, persistent cross- which can predict transsexualism or homosexuality continued VOL. 5, NO. 12 / DECEMBER 2006 109 CP_1206_CASES.FinalREV 11/15/06 1:32 PM Page 110 CASES THAT TEST YOUR SKILLS Gender
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