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Transgender Issues and Genital Reassignment

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Gender Dysphoria

Most adult transsexual individuals remember that their gender discomfort started early in life, well before puberty. Usually, their sense of belonging to the other sex but being trapped in the wrong body has been a tormenting experience. By definition, there should be no evidence of disorders of sexual differentiation. Hormonal and surgical interventions have far-reaching consequences, and are only indicated after comprehensive psychological assessment has concluded that sex reassignment will bring relief to an individual suffering from gender dysphoria and that the subject is ready to transition to the new sex. 

When able, the transgender individual should live in the desired gender role as much as possible to help determine the success and the goals of the gender transition. In some cases, hormonal therapy may be sufficient to alleviate the symptoms of gender dysphoria and surgical therapy may not be required. In other cases, hormonal therapy may only partially relieve the gender dysphoric symptoms and surgical therapies are required. An unsuccessful social transition may raise questions regarding the diagnosis of gender dysphoria and the readiness and eligibility for more irreversible therapies.

Children with gender dysphoria increasingly come to the attention of mental health providers. Prospective and retrospective follow-up studies suggest that gender dysphoria during childhood persists into adolescence/adulthood in only a minority of children (approximately 15 percent).

Other influences — It is not known if the mechanism controlling sexual differentiation of the human brain is exclusively hormonally determined. From clinical observations in patients with a disorder of sex development or cross-sex hormone exposure during pregnancy, the evidence for a hormonal mechanism alone is not convincing. Postnatal rearing is likely to be a significant factor in the development of gender identity; this is no longer irreconcilable with the concept of a biological substrate for gender identity, since early life experiences can shape subsequent brain anatomy and function.

Some infants with one gonadal sex are born with the external genitalia of the other. Follow-up studies of these children show that sex of assignment is an important but not the sole prognosticator of future gender identity and role. It had also been thought that gender identity becomes largely fixed around the age of three years. Clinical experience shows, however, that this is not universally the case.

Individuals with disorders of sex development may transition to the other sex, which may occur well beyond the age of three years. It happens mainly in subjects with a degree of prenatal androgen (testosterone) exposure, such as steroid 5-alpha-reductase 2 deficiency and 17beta-hydroxysteroid dehydrogenase deficiency. These individuals may develop a male gender identity at puberty, after having been originally assigned to the female sex on the basis of the appearance of their female-looking genitalia.

The initial assessment of a patient for transsexualism is based on psychodiagnostic instruments and is generally done by a mental health professional. Two diagnostic classification systems, Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) and International Classification of Diseases 10 (ICD-10), have diagnostic guidelines for transsexualism and gender dysphoria.

Core components of the DSM-5 diagnosis of gender dysphoria include long-standing discomfort with assigned gender and interference with social, school, or other areas of function.

Diagnostic criteria — The current criteria for transsexualism include:

●The desire to live and be accepted as a member of the opposite sex, usually accompanied by the wish to make their body as congruent as possible with the preferred sex through surgery and hormone treatments.

●The presence of the transsexual identity persistently for at least two years.

●The absence of another mental disorder or a genetic, intersex, or chromosomal abnormality.

The diagnosis of transsexualism must first be made before considering hormone and surgical reassignment therapy. In addition, it is essential to identify any comorbid psychiatric diagnosis that may require treatment before considering hormone therapy.

Most cases of transsexual identity are diagnosed in adulthood, but increasingly children and adolescents with gender dysphoria present for diagnosis and treatment.

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