Transsexualism: syndrome or symptom?

An ontology-based review of transgender literature: Revealing a history of medicalization and pathologization

OBJECTIVES

To evaluate the linguistic changes of transgender-related resources prior to 1999 to create a comprehensive dataset of resources using an ontology-derived search system, laying a framework for ontology-based reviews to be used in informatics.

METHODS

We analyzed 77 bibliographies and 11 databases for transgender resources published prior to 31 December 1999. We used 858 variants of the term "transgender" to identify resources. Individual sources were tagged by subject matter and major conceptual terminology usage. We evaluated the accuracy of a Gender, Sex, and Sexual Orientation (GSSO) ontology-based mechanism on tagging relevant literature searches.

RESULTS

We identified 3,058 sources in 19 languages. Primary subjects covered included surgery, psychology, psychiatry, endocrinology, and sexology. The GSSO-based tagging mechanism correctly tagged 97.7% of MEDLINE resources as transgender-related.

DISCUSSION

The GSSO-based tagging mechanism was more effective than keyword-specific elucidations of terminologically complex literature and was just as effective at manual identification of subjects discussed within resources. Diverse language relating to transgender persons can be identified using the GSSO, which can also be used for structured literature review based on subject matter thus improving research in the area.

Transsexualism in a Klinefelter male: a case report

We report a Klinefelter male who presents requesting gender reassignment surgery. There may be a predisposition to gender dysphoria in Klinefelter's Syndrome, and in the case we describe, the perception of his symptoms as being of biological origin coupled with the unavailability of gender reassignment surgery in the Republic of Ireland has had a negative therapeutic effect.

Hormone and genetic study in male to female transsexual patients

BACKGROUND

Data of the literature demonstrated controversial results of a correlation between transsexualism and genetic mutations.

AIM

To evaluate the hormone and gene profile of male-female (M-F) transsexual.

SUBJECTS AND METHODS

Thirty M-F transsexuals aged 24-39. Seventeen had already undergone sex reassignment surgery, 13 were awaiting. All subjects had been undergoing estrogen and antiandrogen therapy. We studied hormones of the hypothalamus- pituitary-testicular axis, thyroid and adrenal profile, GH basal and after GHRH stimulation, IGF-I. The gene study analyzed SRY, AR, DAX1, SOX9, AZF region of the Y chromosome.

RESULTS

Pre-surgery subjects had elevated PRL, reduced testosterone and gonadotropins. Post-surgery subjects showed reduced androgens, a marked increase in LH and FSH and normal PRL. Cortisol and ACTH were similar to reference values in pre- and post-surgery patients. There was a marked increase in the baseline and post-stimulation GH values in 6 of the 13 pre-surgery patients, peaking at T15. IGF-I was similar to reference values in both groups except for one post-surgery patient, whose level was below the normal range. There were no polymorphisms in the amplified gene region for SOX9, and a single nucleotide synonimous polymorphism for DAX1. No statistically significant differences were seen in the mean of CAG repeats between controls and transsexual subjects. SRY gene was present in all subjects. Qualitative analysis of the AZFa, AZFb, and AZFc regions did not reveal any microdeletions in any subject.

CONCLUSIONS

This gender disorder does not seem to be associated with any molecular mutations of some of the main genes involved in sexual differentiation.

Sexual orientation versus age of onset as bases for typologies (subtypes) for gender identity disorder in adolescents and adults

The most widely used and influential typologies for transsexualism and gender identity disorder (GID) in adolescents and adults employ either sexual orientation or age of onset of GID-related symptoms as bases for categorization. This review compares these two typological approaches, with the goal of determining which one should be employed for the diagnosis of GID in Adolescents or Adults (or its successor diagnosis) in the forthcoming revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM). Typologies based on sexual orientation and age of onset of GID-related symptoms are roughly comparable in ease and reliability of subtype assignment. Typologies based on sexual orientation, however, employ subtypes that are less ambiguous and better suited to objective confirmation and that offer more concise, comprehensive clinical description. Typologies based on sexual orientation are also superior in their ability to predict treatment-related outcomes and comorbid psychopathology and to facilitate research. Commonly expressed objections to typologies based on sexual orientation are unpersuasive when examined closely. The DSM should continue to employ subtypes based on sexual orientation for the diagnosis of GID in Adolescents or Adults or its successor diagnosis.

Clinical characteristics of a total cohort of female and male applicants for sex reassignment: a descriptive study

The objective of this study was to compare the features of female-to-male transsexuals (F-M) with those of male-to-female transsexuals (M-F) in the cohort of all applicants for sex reassignment over a 20-year period. In an observational, cross-sectional design the cohort was retrospectively identified, consisting of all 233 subjects who applied for sex reassignment in Sweden during the period 1972-1992. The cohort was subdivided into the groups M-F (n=134) and F-M (n=99), and the two groups were compared. M-F were older when applying for sex reassignment surgery than F-M, and more often had a history of marriage and children than their F-M counterparts. M-F also had more heterosexual experience. F-M, on the other hand, more frequently exhibited cross-gender behaviour in childhood than did M-F transsexuals. The present and previous studies strongly support the view that transsexualism manifests itself differently in males and females. Various models for understanding these differences are discussed.

Prevalence, incidence and sex ratio of transsexualism

Frequency figures for transsexualism, concerning incidence, prevalence and sex ratio calculated in the 1960s and 1970s, were compared with recent reports. The incidence figures remained constant over time, whereas the prevalence figures tended to increase during the review period. The incidence was found to be of the same magnitude in men and women, while the corresponding ratio for prevalence figures was 3:1. It is suggested that men seeking sex reassignment represent a more heterogeneous group than women, and that the reported male predominance to date is due to a lack of categorical studies of primary/ genuine transsexualism. It would appear that genuine transsexualism is, on the whole, insensitive to societal changes. The fundamental disturbance underlying this psychosexual identity disorder is suggested to be neurobiological in origin.

Cross-gender identity in transvestites and male transsexuals

A self-theory of transvestism and secondary transsexuality in which gender identity is a major self subsystem has been advanced in previous research. Within this framework transsexuals and transvestites were compared on a number of developmental characteristics. While early-onset transsexuals (n = 103) were dominantly female, both late-onset transsexuals (n = 52) and transvestites (n = 36) showed much more feminine behavior than expected. This was interpreted as a sign that they were already developing a feminine gender identity in their early years. Implications for this theory were discussed: (i) The assumption of two gender identity subsystems (a masculine and a feminine) in any human being, which can have any relative strength; (ii) the incorporation of the concept of expression of an identity subsystem, which can be unconditional or conditional (i.e., expression of aspects of the self only if certain conditions are fulfilled) and which has the function of self-seeking. Two continua are proposed. One ranges from a strong feminine gender identity subsystem that is unconditionally expressed to weak unexpressed femininity. The second ranges from a strong and unconditionally expressed masculinity to a weak masculinity. Male-to-female transsexuals (and "normal" females) are characterized by a strong unconditionally expressed feminine gender identity in combination with a weak unexpressed masculinity. Transvestism is a position in between in which both masculinity and femininity are conditionally expressed.

Clinical features of patients attending a gender-identity clinic

Of 106 patients attending a gender-identity clinic, 73% satisfied DSM-III criteria for transsexualism. These DSM-III positives had a significantly younger age of onset and were less likely to experience sexual arousal with cross-dressing than those who did not satisfy DSM-III criteria. They were also significantly more likely to fulfil a definition of 'core transsexualism'. 'Core transsexualism' may represent a subgroup within DSM-III criteria for transsexualism and its defining features in this study were an early age of onset, low sexual activity, lack of sexual arousal with cross-dressing and homosexual orientation. Of the whole sample, 23% were referred for gender reassignment surgery, of whom 100% were DSM-III positive and 60% were 'core transsexuals'.

Aspects of psychiatric symptoms at different stages in the treatment of transsexualism

Three groups of male transsexuals at different stages of the treatment process were examined and shown to match retrospectively in actuarial and psychiatric data. Transsexuals who were on a waiting list for surgery showed lower neurotic scores on the Crown-Crisp Experiential Index than those at the assessment stage of clinic attendance, while post-operative transsexuals obtained scores lower than either of the other groups. Transsexuals during the assessment stage of treatment obtained the lowest scores on items in the Bem Sex Role Inventory that define stereotypical masculine characteristics and the highest scores on items that define stereotypical feminine characteristics, in relation to the other two groups.