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Home , Feminization (activity), Promiscuity, Transvestic fetishism

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CASES THAT TEST YOUR SKILLS In public, Mr. C is a “he-man.” In private, he wears , sees himself as a woman in sexual fantasies, and longs to develop . Can you detect his problem?

Gender dysphoria: ‘I’m a man, but ...’

Kari Ann Martin, MD ® Instructor of DepartmentDowden of psychiatry Health and psychology Media Mayo Clinic, Scottsdale, AZ CopyrightFor personal use only HISTORY: NORMAL ON PAPER tioned his 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 . . 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 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 is a . continued

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CASES THAT TEST YOUR SKILLS : ‘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 (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 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 . 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 . His onset transsexuals showed features of comorbid fourth has lasted 22 years and harbors transvestism and were sexually aroused by much affection and but little intercourse. female dress and behaviors. 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 . 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 , 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-

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tuates with affective excursions.4 O’Gorman,5 however, described a bipolar patient whose gender dysphoria was mitigated during manic episodes. How would you 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 , fetishism, , those of your colleagues , masochism/sadism, , and . gender identification and sense of inappropriate- Dividing transsexualism and pure trans- ness with being a man indicate GID. His recur- vestism 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. cannot be ignored. Nonparaphilic —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 , 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 continued

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CASES THAT TEST YOUR SKILLS Gender dysphoria: ‘I’m a man, but...’

• has engaged in heterosexual, homosexual, mood instability might affect his dysphoria. His sexual or abnormal sexual acts; ask about frequency and fantasies are mood-congruent and evoke no shame. preference Mr. C then states that he adamantly opposes • is married or has a girlfriend. If so, are they living outwardly as a woman, and fears that an getting along? How often do they have sex? overt sex change would destroy his marriage and • cross-dresses. Does his partner cross-dress other relationships. Even so, he desires hormone as well and, if so, do they cross-dress for sexual therapy and surgical implants so he can gratification or to identify with the opposite gen- more closely mimic physical womanhood and make der? Has this response changed over time? masturbation more pleasurable. He says he would Where and how often do they cross-dress? flatten his breasts with gauze while in public so he • is achieving sexual gratification. If so, how? can continue to look like a man. • has sexual fantasies involving breast-feed- Though comfortable with his sexual fantasies, ing, giving birth, or forced through Mr. C laments that presenting himself as an “alpha gender-changing surgeries or other means male” drains his psychic energy. • “tucks” his penis, urinates sitting down, or mimics other stereotypical feminine behavior. Which clinical condition most closely applies Also find out how long these behaviors have to Mr. C? persisted. Have they fluctuated? Have relationships, a) autogynephilia life stressors, or other factors influenced them? b) character pathology The answers will uncover a motivation c) gender identity fluidity behind these behaviors, which is key to diagno- sis. Sexual gratification as a motive suggests The author’s observations paraphilia, whereas a desire to live as a woman Mr. C meets criteria for GID and transvestism. points to transsexualism. Because of the myriad Some transvestites also meet criteria for autogy- presentations, multiple patient visits are neces- nephilia and report erotic arousal upon seeing sary for a specific diagnosis. oneself as a woman. Character pathology, specifi- cally sexual fantasies associated with schizoid DIAGNOSIS: ‘I ENJOY WOMANHOOD, BUT … ‘ personality, might also contribute to unusual gen- diagnose gender dysphoria, but because Mr. C’s der presentation. Sexologists also propose fluidity I mood is euthymic, I cannot discern how his in gender identification across populations and over a person’s life span. Autogynephilia—by which a man becomes sexu- ally aroused by imagining or seeing himself as a Want to know more? woman15—usually is associated with trans- See these related articles vestism. Autogynephiles often have sexual fan- www.currentpsychiatry.com tasies of possessing female anatomical structures, engaging in feminine behaviors, or performing female bodily functions such as lactation, men-  How to take a sexual history (without blushing) struation, or childbirth. AUGUST 2006 Autogynephilia may be a misdirected hetero- sexuality and is more prevalent among male-to- female transsexuals who are attracted to women, continued on page 113

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both sexes, or neither sex than among those Table 16 attracted only to men. Kinsey Heterosexual- Gender identity fluidity. Clinicians have recorded Homosexual Rating Scale fluidity in gender identity (sense of masculinity or femininity) and (the sex to Score Indicates … which one is attracted). Sexologists have tried to create scales that gauge these changes. 0 Exclusively heterosexual The Kinsey Heterosexual-Homosexual Rating 1 Predominantly heterosexual, Scale17 is based on Kinsey’s theory that men are not incidentally homosexual strictly heterosexual or homosexual. Scores between 2 Predominantly heterosexual, 0 and 6 indicate some degree of both (Table). more than incidentally homosexual The Benjamin Gender Disorientation Scale, 3 Equally heterosexual which measures gender identity variations, recog- and homosexual nizes variability of gender dysphoria expression 4 Predominantly homosexual, more and underscores the difficulty of classifying than incidentally heterosexual patients who—like Mr. C—present with varied 5 Predominantly homosexual, symptoms. The scale is available at www. incidentally heterosexual hbigda.org (see Related resources). 6 Exclusively homosexual I did not administer the Kinsey or Benjamin Source: Reference 17. Reprinted by permission of The Kinsey scales to Mr. C. Although his case shows how Institute for Research in Sex, Gender, and Reproduction, Inc., innate sense of masculinity or femininity can Indiana University, Bloomington. vary among patients with gender dysphoria, his presentation has been stable, albeit unusual. Mr. C’s symptoms. Mr. C shows autogynephilic cumscribed desire to live as a woman at home. features. He lacks the schizoid’s emotional inert- Also, sexual gratification is his primary motiva- ness and his gender presentation is static, though tion for wanting to develop breasts. dramatic. He appears to meet criteria for GID TREATING GENDER DYSPHORIA and transvestism, autogynephilic variant. Serotonergic agents such as fluoxetine have Schizoid and other personality disorders are shown effectiveness for treating paraphilias and associated with unusual sexual fantasies. Mr. C nonparaphilic sexual addiction in case reports.18,19 lacks primary schizoid features, such as flattened Behavioral techniques, however, might have affectivity and indifference to close relationships. a more definite impact on gender dysphoria. Marks19 reported a 4-year remission of transsexu- I would refer Mr. C for hormone treatment alism in a patient after comorbid OCD improved and breast implantation: with self-exposure therapy. a) now Psychotherapy will not resolve gender identi- b) after extensive psychosocial treatment ty disorder but can promote a stable lifestyle and c) I would not recommend these treatments improve the patient’s chances for success in rela- tionships, education, work, and gender identity The author’s observations expression.20 Psychotherapy can also help deter- Mr. C is a poor candidate for hormone therapy or mine patients’ readiness for sexual reassignment gender reassignment surgery because of his cir- surgery. continued

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TREATMENT: LEARNING TO ACCEPT refer Mr. C back to his primary psychiatrist, Related resources I  World Professional Association for Health, formerly who adds aripiprazole, 5 mg/d, to address the Harry Benjamin International Gender Dysphoria Association grandiosity and hypomania that emerged months (offers links to transgender resources, gender programs, and sexologists). www.hbigda.org. after my initial evaluation. I also refer Mr. C to a gender disorder special- DRUG BRAND NAME ist for psychotherapy directed at examining his his- Divalproex sodium • Depakote Fluoxetine • Prozac tory, understanding his dilemmas, and identifying Paroxetine • Paxil unrealistic ideas and maladaptive behaviors. The therapist has been teaching Mr. C coping skills and DISCLOSURES educating him on gender disorders and normal gen- Dr. Martin reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products. der variations in activities and interests. He has been attending weekly sessions for 4 months. 6. Diagnostic and statistical manual of mental disorders, 4th ed, text rev. To address his resentment over trying to look Washington DC: American Psychiatric Association; 2000:566-76. manly, I assure him that he doesn’t need to 7. Hoenig J, Kenna JC. The nosolgical position of transsexualism. assume additional “masculine” behaviors and atti- Arch Sex Behav 1974;3:273-87. tudes, and that his height and features make him 8. Jenike MA. Obsessive-compulsive and related disorders: a hidden epidemic. N Engl J Med 1989;24;321:539-41. appear masculine. 9. Stein DJ, Hollander E. The spectrum of obsessive-compulsive related disorders. In: Hollander E, ed. The obsessive-compulsive References related disorders. Washington, DC: American Psychiatric 1. Mental and behavioral disorders, diagnostic criteria for research. In: Publishing. In press. The ICD-10 classification of mental and behavioural disorders: diagnos- 10. Hollander E. Serotonergic drugs and the treatment of disorders tic criteria for research. Geneva: World Health Organization; 1993. related to obsessive-compulsive disorder. In: Pato MT, Zohar J, eds. 2. Caldwell C, Keshavan MS. Schizophrenia with secondary Current treatments of obsessive-compulsive disorder. Washington, transsexualism. Can J Psychiatry 1991;36:300-1. DC: American Psychiatric Publishing; 1991:173-92. 3. Hyde C, Kenna JC. A male MZ twin pair, concordant for 11. Quadland MC. Compulsive sexual behavior: definition of a transsexualism, discordant for schizophrenia. Acta Psychiatr Scand problem and an approach to treatment. J Sex Marital Ther 1985; 1977;56:265-75. 11:121-32. 12. Coleman E. Sexual compulsivity: definition, etiology, and treat- 4. Habermeyer E, Kamps I, Kawohl W. A case of bipolar psychosis ment considerations. In: Coleman E, ed. Chemical dependency and and transsexualism. Psychopathology 2003;36:168-70. intimacy dysfunction. New York: Haworth Press; 1988. 5. O’Gorman EC. The effect of psychosis on gender identity. Br J 13. Anthony DT, Hollander E. Sexual compulsions. In: Hollander E, Psychiatry 1980;136:314-5. ed. The obsessive-compulsive related disorders. Washington, DC: American Psychiatric Publishing. In press. 14. Perilstein RD, Lipper S, Friedman LJ. Three cases of paraphilias responsive to fluoxetine treatment. J Clin Psychiatry 1991;52:169-70. Diagnosing sexual identity disorders is 15. Blanchard R. Nonmonotonic relation of autogynephilia and heterosexual attraction. J Abnorm Psychol 1992;101:271-6. difficult. Distinctions between 16. Hirschfeld M. Sexual anomalies. New York: Emerson Books; 1948. transvestism and transsexualism are 17. Kinsey AC, Pomeroy WB, Martin CE. Sexual behavior in the often arbitrary, and patients show male. Philadelphia: WB Saunders; 1948;636-59. behaviors suggesting multiple gender 18. Kafka MP. Successful antidepressant treatment of nonparaphilic sexual addictions and paraphilias in men. J Clin Psychiatry 1991; identity disorders. Until a more specific 52:60-5. diagnosis can be teased out over 19. Marks IM, Mataix-Cols D. Four-year remission of transsexualism after comorbid obsessive-compulsive disorder improved with self- multiple visits, an inclusive diagnosis of exposure therapy. Case report. Br J Psychiatry 1997;171:389-90. gender dysphoria better serves patients. 20. Harry Benjamin International Gender Dysphoria Association’s Standards of Care for Gender Identity Disorders. Int J Transgenderism 2001; 5(1). Available at: http:// www.symposion.com/ijt/index.htm. Accessed November 3, 2006. Bottom Line

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