Section 7. Mental Health Disorders

Chapter 104. Sexuality

Topics: Introduction | Gender Identity | Paraphilias

Gender Identity

Gender identity is how a person sees himself or herself, whether masculine, feminine, or somewhere in-between. Gender role is the objective, public presentation in our culture as masculine, feminine, or mixed. For most people, gender identity is consistent with gender role (as when a man has an inner sense of his masculinity and publicly acts in ways that support this feeling).

Gender identity is well established by early childhood (18 to 24 months of age). During childhood, boys come to know they are boys, and girls come to know they are girls. Children sometimes prefer activities considered to be more appropriate for the other sex. However, this does not mean that a young girl who likes to play baseball and wrestle, for example, has a gender identity problem, as long as she sees herself as, and is content with being, female. Similarly, a boy who plays with dolls and prefers cooking to sports or to rough types of play does not have a gender identity problem as long as he identifies himself as, and is comfortable with being, male.

Children born with genitals that are not clearly male or female (see Section 23, Chapter 265) usually do not have a gender identity problem if they are decisively reared as one sex or the other, even if they are raised in the gender role that is opposite their biologic sex pattern. There have been some highly publicized cases, however, in which this approach has failed.

Gender Identity Disorder and Transsexualism

People who experience a significant discrepancy between their anatomy and their inner sense of self as masculine, feminine, mixed, or neutral often have a gender identity disorder. The extreme form of gender identity disorder is called transsexualism.

People who are transsexuals believe that they are victims of a biologic accident and that they are cruelly imprisoned within a body incompatible with their gender identity. Most transsexuals are biologic males who identify themselves as females, usually early in childhood, and regard their genitals and masculine features with repugnance. Transsexualism appears to occur in about 1 of 30,000 males and 1 of 100,000 females.

Transsexuals may seek psychologic help, either to assist them in coping with the difficulties of living in a body that they do not feel comfortable with or to help them through a gender transition. Many transsexuals appear to be helped most by a combination of counseling, hormone therapy, electrolysis, and genital surgery.

Some transsexuals are satisfied with changing their gender role by working, living, and dressing in society as a member of the opposite sex, which may include obtaining identification (such as a driver's license) that reinforces their change in gender role. They may never seek to actually alter their anatomy in any way. Many of these people, who are sometimes referred to as "transgenderists," meet no criteria for a mental health disorder.

Other transsexuals, in addition to adopting the behavior, dress, and mannerisms of the opposite sex, also receive hormone treatments to change their secondary sex characteristics. In biologic males, use of the female hormone estrogen causes breast growth and other body changes, such as wasting of the genitals (genital atrophy) and the inability to maintain an erection. In biologic females, use of the male hormone testosterone causes such changes as the growth of facial hair, deepening of the voice, and changes in body odor.

Still other transsexuals seek to undergo sex reassignment surgery. For biologic males, this involves removal of the penis and testes and the creation of an artificial vagina. For biologic females, this involves removal of the breasts and the internal reproductive organs (uterus and ovaries), closure of the vagina, and creation of an artificial penis. For both sexes, surgery is preceded by use of the appropriate sex hormone (estrogen in male-to-female transformation, testosterone in female-to-male transformation).

Although transsexuals who undergo sex reassignment surgery are unable to have children, many are able to have quite satisfactory sexual relations. The ability to achieve orgasm is often retained after surgery, and some people report feeling comfortable sexually for the first time. However, few transsexuals endure the sex reassignment process for the sole purpose of being able to function sexually in the opposite sex. Confirmation of gender identity is the usual motivator.