Cases That Test Your Skills

Gender dysphoria: ‘I’m a man, but…’

Current Psychiatry. 2006 December;5(12):107-114

References

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7. Hoenig J, Kenna JC. The nosolgical position of transsexualism. Arch Sex Behav 1974;3:273-87.

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9. Stein DJ, Hollander E. The spectrum of obsessive-compulsive related disorders. In: Hollander E, ed. The obsessive-compulsive related disorders. Washington, DC: American Psychiatric Publishing. In press.

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11. Quadland MC. Compulsive sexual behavior: definition of a problem and an approach to treatment. J Sex Marital Ther 1985;11:121-32.

12. Coleman E. Sexual compulsivity: definition, etiology, and treatment considerations. In: Coleman E, ed. Chemical dependency and intimacy dysfunction. New York: Haworth Press; 1988.

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14. Perilstein RD, Lipper S, Friedman LJ. Three cases of paraphilias responsive to fluoxetine treatment. J Clin Psychiatry 1991;52:169-70.

15. Blanchard R. Nonmonotonic relation of autogynephilia and heterosexual attraction. J Abnorm Psychol 1992;101:271-6.

16. Hirschfeld M. Sexual anomalies. New York: Emerson Books; 1948.

17. Kinsey AC, Pomeroy WB, Martin CE. Sexual behavior in the human male. Philadelphia: WB Saunders; 1948;636-59.

18. Kafka MP. Successful antidepressant treatment of nonparaphilic sexual addictions and paraphilias in men. J Clin Psychiatry 1991;52:60-5.

19. Marks IM, Mataix-Cols D. Four-year remission of transsexualism after comorbid obsessive-compulsive disorder improved with self-exposure therapy. Case report. Br J Psychiatry 1997;171:389-90.

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.

Autogynephilia may be a misdirected heterosexuality and is more prevalent among male-to-female transsexuals who are attracted to women, both sexes, or neither sex than among those attracted only to men.¹⁶

Gender identity fluidity. Clinicians have recorded fluidity in gender identity (sense of masculinity or femininity) and sexual orientation (the sex to which one is attracted). Sexologists have tried to create scales that gauge these changes.

The Kinsey Heterosexual-Homosexual Rating Scale¹⁷ is based on Kinsey’s theory that men are not strictly heterosexual or homosexual. Scores between 0 and 6 indicate some degree of both (Table).

The Benjamin Gender Disorientation Scale, which measures gender identity variations, recognizes variability of gender dysphoria expression and underscores the difficulty of classifying patients who—like Mr. C—present with varied symptoms. The scale is available at www.wpath.org.

I did not administer the Kinsey or Benjamin scales to Mr. C. Although his case shows how innate sense of masculinity or femininity can vary among patients with gender dysphoria, his presentation has been stable, albeit unusual.

Mr. C’s symptoms. Mr. C shows autogynephilic features. He lacks the schizoid’s emotional inertness and his gender presentation is static, though dramatic. He appears to meet criteria for GID and transvestism, autogynephilic variant.

Schizoid and other personality disorders are associated with unusual sexual fantasies. Mr. C lacks primary schizoid features, such as flattened affectivity and indifference to close relationships.

Table

Kinsey Heterosexual-Homosexual Rating Scale

Score	Indicates…
0	Exclusively heterosexual
1	Predominantly heterosexual, incidentally homosexual
2	Predominantly heterosexual, more than incidentally homosexual
3	Equally heterosexual and homosexual
4	Predominantly homosexual, more than incidentally heterosexual
5	Predominantly homosexual, incidentally heterosexual
6	Exclusively homosexual
Source: Reference 17. Reprinted by permission of The Kinsey Institute for Research in Sex, Gender, and Reproduction, Inc., Indiana University, Bloomington.

The author’s observations

Mr. C is a poor candidate for hormone therapy or gender reassignment surgery because of his circumscribed desire to live as a woman at home. Also, sexual gratification is his primary motivation for wanting to develop breasts.

Treating gender dysphoria

Serotonergic agents such as fluoxetine have shown effectiveness for treating paraphilias and nonparaphilic sexual addiction in case reports.^18,19

Behavioral techniques, however, might have a more definite impact on gender dysphoria. Marks¹⁹ reported a 4-year remission of transsexualism in a patient after comorbid OCD improved with self-exposure therapy.

Psychotherapy will not resolve gender identity disorder but can promote a stable lifestyle and improve the patient’s chances for success in relationships, education, work, and gender identity expression.²⁰ Psychotherapy can also help determine patients’ readiness for sexual reassignment surgery.

Treatment: learning to accept

I refer Mr. C back to his primary psychiatrist, who adds aripiprazole, 5 mg/d, to address grandiosity and hypomania that emerged months after my initial evaluation.

I also refer Mr. C to a gender disorder specialist for psychotherapy directed at examining his history, understanding his dilemmas, and identifying unrealistic ideas and maladaptive behaviors. The therapist has been teaching Mr. C coping skills and educating him on gender disorders and normal gender variations in activities and interests. He has been attending weekly sessions for 4 months.

To address his resentment over trying to look manly, I assure him that he doesn’t need to assume additional “masculine” behaviors and attitudes, and that his height and features make him appear masculine.

Related resources

World Professional Association for Transgender Health, formerly the Harry Benjamin International Gender Dysphoria Association (offers links to transgender resources, gender programs, and sexologists). www.hbigda.org.

Drug brand name

Divalproex sodium • Depakote
Fluoxetine • Prozac
Paroxetine • Paxil

Disclosures

Dr. Martin reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.