Gender Identity Disorder of Adulthood Clinical Presentation

Patients with GID typically range from age 13 to 60 years, although some patients are referred as early as 4 years of age (Green 1974) and some as late as in their 70s (Docter 1985). Historically, these patients initially present with a request for cross-sex hormones (Benjamin 1953; Ihlenfeld 1973) or gender-related surgery (Benjamin 1955; Haire 1950; Hamburger et al. 1953; Worden and Marsh 1955), believing themselves to be "trapped" in the opposite-gender body. Male-to-female (MTF) transsexuals frequently compare their life histories to biographies published by transsexual people (Cossey 1991; C. Jorgensen 1967; Morris 1974; Richards 1983). In contrast, female-to-male (FTM) transsexuals have few well-known role models toward which to aspire (Martino 1977; Sullivan 1990).

Typical descriptions of male GID patients who present for treatment include an extensive history of cross-dressing that occurred infrequently in the preadolescent years, accelerated during and after puberty, and continued throughout adult life. Some male patients report occasionally attempting to suppress or rid themselves of their cross-gender feelings by destroying their female wardrobe and other aids for enhancing their female appearance, a practice known as "purging" (Benjamin 1954, 1967). Subsequently, they may attempt to eradicate their cross-gender feelings by excessive involvement in stereotypical male behavior, a phenomenon known as "flight into hypermasculinity" (G. R. Brown 1988a). These activities may include participating in "macho" sports like motorcycle racing and football and enlisting in the military to go to war or to become a specialized combat soldier. But these attempts to repress and suppress cross-gender feelings are generally unsuccessful and contribute to psychiatric comorbidities, as described below (see "Comorbid Axis I and II Diagnoses" subsection later in this chapter). Cross-gender feelings return, often stronger than ever. Many male patients present for their initial interview completely cross-dressed, appearing convincingly in the female role. Some have illicitly obtained hormones (usually in the form of birth-control pills) and undergone electrolysis, with both procedures having resulting in smoother complexions and significant breast development. Many have studied feminine gestures and have optimized their potential for speaking in feminine vocal registers. Some MTF transsexuals may seem to be compulsive in acquiring excessive cosmetic surgical procedures of various kinds in an effort either to feminize their bodies to pass as female or to more effectively eliminate masculine features.

Few FTM gender-dysphoric patients are able to obtain the desired steroids illegally, given that anabolic steroids (e.g., testosterone) are now more tightly controlled than estrogens and progesterone. Those on hormones prior to their first visit may be able to effect a natural permanent male vocal register, sport a beard or mustache, and dress convincingly as males (Lothstein 1983).