Disorders of gender identity: transsexualism

In this rare disorder, called transsexualism, the person has the conviction of being of the opposite sex to that indicated by the external genitalia. This is getting more and more common in Sydney. The person wishes to alter the external genitalia to resemble those of the opposite sex, and to live as a member of that sex. Most transsexuals are men; most women who cross-dress and imitate men are homosexual, not transsexual. In transsexuals, the conviction of being a woman usually dates from before puberty, but medical help is not requested until early adult life, when most transsexuals have begun to dress as women. Unlike transvestites (also called transvestitism is the practice of dressing and acting in a style or manner traditionally associated with the other sex.) they report no sexual arousal from cross dressing, and unlike the homosexuals who dress as women, they do not seek to attract people into a homosexual relationship.

Transsexual men may take a series of steps to become more like women. They practise female styles of speaking, gesturing, and walking, they remove body hair by electrolysis, they attempt to increase breast tissue by taking estrogen or by obtaining a surgical implant, and they may seek an operation to remove the male external genitalia and form an artificial ‘vagina’. Requests for such operations are often made in a determined and persistent way reflecting the person’s great distress, and may be accompanied by threats of suicide or self-mutilation if surgery is not provided. Since such threats are carried out occasionally with serious consequences, a specialist opinion should be obtained.

It might be thought that a logical treatment of transsexualism would be a psychological procedure to alter the person’s beliefs about his gender identity. No form of psychotherapy, however, has been shown to succeed in this aim. In any case, most transsexual patients reject this approach, hoping instead to alter their body to conform more closely to the gender they feel is theirs. In a few specialist centres operations with this purpose are carried out on selected patients (gender reassignment), and good results have been reported. However, there is no high quality evidence of the long-term effectiveness of the procedure.

Decisions about such treatment are therefore taken on an individual patient basis with thorough assessment, and are made jointly by an experienced psychiatrist and surgeon, in consultation with the general practitioner.