Key points are not available for this paper at this time.
Gender identity refers to one's basic conviction of belonging to one of the sexes. However, rather than conforming to the binary concepts of physical sex (male versus female), psychological gender identity (man versus woman), and social gender role (masculine versus feminine), human gender identity is experienced along a continuum from complete mental agreement between body image and gender to the extreme conflict between physical sex and psychosocial gender identification known as transsexualism. The term gender dysphoric describes a heterogeneous group of individuals who experience some degree of discrepancy between gender identity and physical sex. The pioneer of transsexology, Harry Benjamin, 1 divided male gender dysphoric persons into three groups according to the severity of the dysphoria. First, there are those with a low degree of gender dysphoria, who merely want to cross-dress and be socially accepted as women. They are transvestites who accept their anatomic gender but feel constrained and anxious unless they are free to express gender behaviors associated with the other sex. When allowed to cross-dress, transvestites usually demand no therapy for emotional comfort. For patients with a high degree of gender dysphoria, the quest for full hormonal and surgical sex reassignment is vital because they actually feel "trapped" in an anatomically wrong body. These patients are genuinely transsexual, and "cross-dressing is an insufficient help, as aspirin for a brain tumor headache would be."1 Rather than referring to "transsexuality," the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders refers to Gender Identity Disorder. For individuals suffering from an intermediate degree of gender dysphoria, mere cross-dressing does not suffice to restore or maintain emotional balance. Some physical changes (e.g., breast development), but not all of the anatomic features of the other sex, are requirements for easing the dysphoria. 1 Gender Identity Disorder Not Otherwise Specified (GIDNOS) is the classification category included in the Diagnostic and Statistical Manual of Mental Disorders for coding the intermediate degree of gender dysphoria that is not classifiable as transsexuality or transvestitism. GIDNOS is analogous to nontranssexual gender dysphoria or nontranssexual transgender behavior, 'transgender' being the umbrella term referring to a diverse group of individuals who cross or transcend culturally defined categories of gender in some way or another. 2 Examples of persons with GIDNOS include persistent preoccupation with castration or penectomy without a desire to acquire the sex characteristics of the other sex. Alternatively, a person with GIDNOS may desire some of the anatomy of the other sex (such as breasts or lack of breasts) in addition to its gender behaviors, but not the genitals of the other sex. Giving in to such desires would result in male transgenderists having breasts and a penis, female transgenderists with vaginas but no breasts, or even "intersexed" or "bisexed" individuals with both a penis and a vagina. Even though transsexualism is recognized as a serious and not uncommon gender identity disorder that may be medically treated, the nontranssexual intermediate form of gender identity disorder has not received much medical, let alone surgical, review. A general professional discussion on the possible indications for, and limitations of, treatment for GIDNOS is needed to establish the admissibility and practicability of such treatment. Accepting the Transgender Concept—A Shift of Paradigm In the 1960s and 1970s, the term gender dysphoria became widely used to refer to the transsexuals' basic conviction of being a mem- ber of the opposite sex. A male-to-female transsexual was characterized as feeling like a member of the female sex trapped in a male body and by being either asexual or desiring a "relation with a normal male as female."1 Because the focus of sex reassignment was to help transsexuals to fully cross over, with the added expectation that postoperative transsexuals would identify as heterosexuals, therapy conformed to the binary concepts of sex and gender identity and role. 2 Although gender confirming treatment followed this paradigm in the first decade of services, it was soon realized that many transsexuals did not identify as heterosexual postoperatively. In 1987, the term transgenderist was coined to refer to genetic male individuals who transcend the gender barrier to live full-time as women without undergoing sex reassignment surgery. A growing number of individuals who completed sex reassignment short of genital surgery, and increasing numbers of postoperative transsexuals, began to question the binary concept of sex and gender. This transformation in thinking gave birth to today's transgender movement, which is most outspoken in the United States. It blurred the distinction between transsexual and transvestite so prevalent in the 1970s and 1980s to make room for a continuum of gender variance. Currently, the transgender movement includes cross-dressers or transvestites, female and male impersonators, drag queens and kings, transgenderists and bigender persons (who identify as both man and woman), as well as transsexuals who have undergone or desire to undergo sex reassignment therapy. This transgender coming-out is at the heart of a psychosocial paradigm shift challenging the sexual and gender dichotomy. 2 The traditional paradigm conforming to binary conceptualizations of sex and gender gives gender dysphoric persons three options. They can try to contain their dysphoria and adjust to the role congruent with their natal sex; they can lead a double life by compartmentalizing both a male and a female identity; or they can cross over completely through the process of sex reassignment. However, these options render the unique characteristics and needs of the nontranssexual gender dysphoric person invisible, and as a result of the paradigm shift, there is a growing pressure on gender teams to no longer aim exclusively to assess whether clients are true transsexuals ready for complete sex reassignment. Options for identity management are required to be no longer limited to adjustment in either the male or the female gender role, and to also include the possibility of affirming an "in-between" transgender identity. 2 Prevalence of Transsexual and Nontranssexual Gender Dysphoria No census data on the prevalence of GIDNOS are available. The Gender Team of the Academisch Ziekenhuis Vrije Universiteit in Amsterdam serves about 100 new gender dysphorics each year, totaling well over 1500 since its inception in 1975. This makes this institution the main provider of transgender-specific health services in The Netherlands, drawing patients from other states in and outside Europe as well. Although the Diagnostic and Statistical Manual of Mental Disorders suggests that 1 per 30,000 male adults and 1 per 100,000 female adults seek sex reassignment surgery, the prevalence of transsexualism in The Netherlands is estimated to be 1 per 11,900 for men and 1 per 30,400 for women. The difference between the numbers of intake and numbers of reassignment in Amsterdam became larger as of 1989 and, like the higher prevalence of transsexualism in The Netherlands, this may be in part explained by subjects with milder forms of gender dysphoria coming for consultation. It is very likely that GIDNOS has been treated by the Amsterdam Gender Team without being distinguished as such. Of 352 female-to-male patients treated hormonally by the Amsterdam Gender Team until 1995, only 138 underwent mastectomy and phalloplasty; 169 others had a mastectomy but no phalloplasty. Even though some female-to-male patients will only undergo mastectomy because the available phalloplastic techniques are still considered inadequate, we should recognize that some nontranssexual gender dysphoric persons are among these patients. They do not crave further treatment but rather they make use of part of the treatment modalities more readily available to transsexuals for maintaining their emotional balance. The fact that Pauly 3 found many female-to-male transsexuals "amazingly" successful in establishing a relationship with a spouse without having undergone phalloplasty may well have indicated that even his series already included female patients with GIDNOS who were not interested in a complete sex change. Likewise, a small group of male patients with GIDNOS inadequately diagnosed and treated as male-to-female transsexuals will undergo only part of the sex reassignment therapy. The data on 1049 male-to-female patients treated hormonally by our Gender Team indicate that 76% underwent surgery. This leaves 24% with some degree of breast development from estrogen treatment, in combination with the nonoperated penis. Of the 795 operated male-to-female patients, 22 underwent only an augmentation mammaplasty. In the United States, the transgender communities in Minneapolis/St. Paul, New York, and San Francisco have been on the forefront of transgender coming-out. 2 Approximately 750 transsexuals, 2000 cross-dressers, and 300 drag queens/kings and (fe)male impersonators are estimated to reside in Minnesota, a state with a large transgender population. 2 The prevalence of all gender identity disorders has even been regarded to be at least 10 times higher than that of transsexualism. Still, the prevalence of GIDNOS may be overrated in the United States inasmuch as the considerable costs of hormonal and surgical gender confirmation may prohibit patients to undergo full therapy. Like those who refrain from surgery because of its limitations, transsexuals unable to undergo full treatment because of physical, mental, or financial restrictions should not be considered as having GIDNOS. Differential Diagnosis in Gender Dysphoria—Gender Identity Disorder or GIDNOS? Although Benjamin 1 felt that the request for a complete surgical sex conversion is typical only for the transsexual and that this can actually serve as a definition, he and others found that an overlapping and blurring of the three types of gender dysphoria he described is certainly frequent. Moreover, gender identities may fluctuate, and individuals change their identification and the labels they use to describe themselves over time and depending on the situation in which they find themselves. 2,4 Gender dysphoric individuals with a primary diagnosis of transvestitism may, later in life, be considered "secondary transsexuals" on the basis of a reported disappearance of fetishistic involvement with cross-dressing and fixation of gender dysphoria as the predominant, persistent symptomatology. 1,2 Such later-onset transsexuals are recognized to have more fluctuating degrees of cross-gender identification and to be more ambivalent about sex-reassignment surgery. Many patients are well read on the literature of transsexualism, and their level of knowledge frequently surpasses that of the general behavior therapist. The evaluating psychologist or psychiatrist may naively accept the sophisticated history provided and erroneously conclude that the patient seems to be correct in the self-diagnosis of transsexualism. Diagnosis of gender dysphoria and its establishment as the unique drive to undergo sex reassignment therapy is essential, as it may, for example, be financially attractive for sex workers to have both a penis and breasts. As is true in Gender Identity Disorder or transsexuality, GIDNOS should be differentiated from mental illnesses such as schizophrenia or dissociative personality disorders, manic depression psychosis, and obsessive-compulsive disorder, as well as from body image disorders such as severe anorexia nervosa. For these reasons, a surgeon must lean on the expertise of a specialized behavior scientist, and, until general expertise is built up, treatment of patients with GIDNOS should be restricted to professionals working in close relation to experienced gender teams. 5 A Medical Problem? In 1910, Magnus Hirschfeld wrote Die Transvestiten. 6 This founder of sexology medicalized gender dysphoric behavior in an attempt to counter the strong societal rejection and condemnation of sexual variance. He conceptualized transvestism as an inborn anomaly and called for compassion and acceptance. For many persons with gender dysphoria, it is much more acceptable to suffer from a medical and possibly correctable condition than it is to be a "social leper" with the moral stigmas that accrue to the other rather poorly treatable afflictions. 5 On the other hand, the medicalization of gender dysphoria is a subject of growing tension between providers and consumers. 2 One may rightly defend the view that transgender behavior should be de-medicalized for the same reasons that homosexuality was de-medicalized, and that it should be protected against arbitrary discrimination for the same reasons that ethnic origin and religion are not permissible bases for discrimination. 7 Still, the question as to whether gender dysphoria should or should not be medicalized and viewed as a disorder matters little in that the problems posed demand knowledge of human biology, endocrinology, psychological development, and psychodynamics, as well as surgery in certain cases. Moreover, only meticulous diagnosis and follow-up of nontranssexual gender dysphoric persons by specialized gender teams will indicate the possible merits of the difficult decision to treat transgenderists. Any form of gender dysphoria is, therefore, a proper and legitimate field of concern for the medical profession. 8 Transgenderists have a stigmatized identity that is often met with ignorance, rejection, harassment, and assault. This, in combination with the lack of positive role models, motivates many to stay "in the closet" or to lead a double life. Such forced suppression of transgender feelings may lead to shame, low self-esteem, isolation, anxiety, depression, substance abuse, and compulsive sexual behavior, all of which are legitimate indications for psychiatric treatment. 2 Those who do come out as transgender may face job discrimination and economic vulnerability, which lead some to turn to "survival sex" in the sex industry. Stigmatization and disenfranchisement add to the risks of contracting sexually transmitted diseases and erratic use of hormones, which in turn can cause mood swings that may prompt additional risky, acting-out behaviors involving sex or needles. Like the transsexuals before them, persons with GIDNOS may be compelled to obtain hormones on the black market and to undergo surgery in the hands of inadequately trained surgeons and outside of reputable gender clinics. It is proposed that GIDNOS is a serious and very real health problem for patients so afflicted, and that despite its controversial and unsettling aspects, the condition warrants attention and awareness from physicians and behavior scientists. Only a reputed gender team may be able to counter the predictable criticism of colleagues and laymen who do not yet understand the problems of persons with nontranssexual gender dysphoria or the reasons why respectable doctors are willing to give in to their "whim." This way, the possible negative spin-off of the treatment of nontranssexual gender dysphoric patients on the general acceptance of true transsexualism may be contained. Affirmation of a spectrum of transgender identities as part of prevention education by the medical profession will alleviate the pressure to physically conform to a binary conceptualization of gender and may, hence, play an important role in the prevention of risk behavior. 2 A Surgical Problem? Initially, transvestism and transsexuality were viewed by many as perverse or deviant, and psychoanalytical and behavior therapy aimed to resolve the alleged underlying psychodynamic conflict or recondition and reduce cross-gender behavior. By and large, these therapies have failed, and this has led to the realization that the only beneficial therapeutical approach for the properly selected transsexual patient is hormonal and surgical gender confirming treatment. Nontranssexual gender dysphoric persons do not seek to change sex completely. Instead, an intersexed or bisexed state with characteristics of both sexes, or an asexual state with neither male nor female sex characteristics, is strived for. Passing as a member of the other sex is not the criterion for treatment, whereas achievement of personal comfort and well-being are. Because transgender identities and their requirements are so diverse, therapy may or may not include changes in primary or secondary sex characteristics. Hormone therapy does not necessarily have to be followed by sex reassignment surgery; it is a valid option in and of itself. Likewise, limited surgery instead of hormonal therapy may be indicated as part of a client-centered approach. 2 This would require a major adaption of the surgeon's viewpoint because patients would no longer be required to be "true transsexuals" to qualify for surgery. Even as early as 1974, Laub and Fisk 5 indicated that transsexuals are not the only group that can benefit from gender confirming operations. Plastic surgeons have realized that it is more important to correct the patient's sense of deformity or self-image than to correct an external or objective deformity; certainly, the gender dysphoric patient is a case in point. We are used to seeing even minor physical alterations produce profound and lasting improvement in the self-esteem and functioning of patients. 9 As such, surgery for patients with GIDNOS may be considered as an ultimate form of aesthetic surgery. Still, we must not turn too quickly to surgery as the solution for all gender identity problems. No surgeon should engage in cross-identity procedures without the aid of a gender team to evaluate each prospective patient in detail over a sufficient length of time, as well as to establish whether or not hormonal treatment or surgical alteration will offer significant relief for patients with GIDNOS. 9 Quo Vadis? We are learning from nontranssexual gender dysphoric patients that gender is not simply binary and that their identities are not always static. Identity and behavior are often unexpectedly incongruent with conventional assumptions. Rather than optimally changing the patient from one normal physical appearance to that of the opposite sex, GIDNOS requires us to construct or remove normal primary and secondary sex characteristics to create some sort of bisexed, intersexed, or asexual phenotype, thereby transcending the binary concepts of sex and gender. 2 To change a person's anatomic sex is a repugnant concept. Morally and instinctively, it is difficult enough for a surgeon to consider, for example, genital amputation and castration in a physically healthy subject. 5 Still, Hamburger 10 concluded that in dealing with the severe gender dysphoric patient, "one feels it a duty to appeal to the medical profession and to the responsible legislature: do your utmost to ease the existence of these fellow-men who are deprived the possibilities of a harmonious and happy life—through no fault of their own." As it was, and still is, true for transsexualism, a basic understanding of the pathogenesis, clinical variations, psychodynamics, and treatment of transgenderism has "little chance to develop until a professional climate is established that is free of emotional reflex and willing to confront the issues."9 Again, doctors must be willing to accept the criticisms not only of many laymen, but also of conscientious colleagues. Restraints against the creation of a bisexed or asexual status will result from religious taboos and cultural strictures against any attitudes or life forms that are deemed unnatural. In 1910, Hirschfeld 6 expressed his feeling that "we have no right to condemn people we cannot heal, whom we cannot even help. We do not have the right to judge persons because their peculiarities are strange to us, incomprehensible, perhaps even unpleasant. We would look down on soldiers who thought less of their wounded comrade." History repeats itself, albeit on a different level. Again, "we are called upon so to reconstruct our schemes of right and wrong, of good and evil, that nothing which aids a human soul in his path through life should ever be deemed a weakness or a vice" (quoted from Havelock Ellis by Sir Martin Roth). 8 We must not forget that the personal and human needs of the individual patient with any gender identity disorder constitute the only justifiable indications for treatment—surgical or otherwise. 9 The Ellis argument is a cogent one, but the real question centers on whether or not practicing an alternative lifestyle does indeed help the human soul in its path through life or whether those who have deviant forms of sexual or gender behavior are foredoomed to suffer frustrations of different kinds. In more restrictive societies, gender dysphoric individuals will pine away or take on their existing gender role because no other possibilities are open to them. 8 In a more permissive environment, the possibility of a resolution for their problems through psychosocial, hormonal, or surgical treatment is more likely to arise as an idea and to evolve into an emulation. Acknowledgments The authors are grateful to Professor Eli Coleman, Ph.D., and Walter O. Bockting, Ph.D., from the Department of Family Practice and Community Health at the University of Minnesota Medical School, for their guidance and inspiration.
Hage et al. (Wed,) studied this question.