Case history

Case history #1

A 45-year-old man, dressed as a woman, requests a prescription for oestrogens and a rapid referral for gender reassignment surgery on the grounds of self-diagnosed transsexualism. He gives a history of lifelong cross-dressing, which became sexually exciting at puberty. The sexual excitement diminished in his 20s, to be replaced by a sense of relaxation and comfort when in a female role, described as being able to express his feminine side. He is married, but separated, and has 2 children. The sexual content of his marriage (never very great) diminished after their birth. He hid his cross-dressing from his wife until she discovered his female clothes and assumed that he was having an affair. Although initially tolerant of his cross-dressing, she became increasingly dissatisfied as he spent more time in a female role and suggested that they might live together as sisters. Moving away from his wife and children, he began to purchase oestrogens from the internet. He lived as a woman for all purposes aside from his work, where nothing was known of his female life outside. He began to feel increasingly unhappy in his male work life, feeling that he is only truly himself when living as a woman.

Case history #2

A 35-year-old woman requests treatment with androgens and a bilateral mastectomy. She looks masculine and is often taken to be a male somewhat younger than her chronological age. She gives a history of childhood tomboyism, and at secondary school was widely assumed to be lesbian. Declaring herself to be a lesbian in her late teens, she moved in lesbian social circles for some years and made relationships with women with some ease. These tended to founder after a few months because partners complained that, rather than being a masculine woman, she was more like a man. Although her libido was good and she was an attentive sexual partner, she could not bear attention being paid to her own female sexual characteristics, and the one-sided nature of the sexual relationship became, after a time, disturbing to her partners. Eventually she felt that her sense of masculinity could no longer be denied to herself and others, and decided to live as a man. She is desperate to halt her menstrual periods, seeking treatment with androgens to increase facial and body hair, and to lose her breasts.

Other presentations

The majority of born-male patients with gender dysphoria present with a background of initially fetishistic and subsequently dual role transvestism (cross-dressing). A smaller number give a history of earlier, very feminine homosexuality associated with a low libido and an ever-increasing sense of femaleness that drives them to live as a woman and to be viewed by others (including gay men) as a woman. Born-female patients almost all have a history of childhood masculine behaviour, and many have (for a while at least) been identified by themselves or others as masculine lesbian women. A small proportion of people of either biological sex present with pronounced gender dysphoria and cross-sex behaviour in childhood, even from their earliest years. They were often taken to be the opposite sex in childhood and very often experience sexual attraction to their own biological sex. However it is important to note that childhood gender dysphoria does not necessarily continue into adulthood.[1] A number of studies in both boys and girls with gender dysphoria suggest that persistence into adulthood occurs in 6% to 27% of children.[6][7][8][9][10][11]

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