DISORDERS USUALLY FIRST EVIDENT IN INFANCY, CHILDHOOD OR ADOLESCENCE Pg. 74 Section 302.50 TRANSSEXUALISM

The essential features of this disorder are a persistent discomfort and sense of inappropriateness about one's assigned sex in a person who has reached puberty. In addition, there is persistent preoccupation, for at least two years, with getting rid of one's primary and secondary sex characteristics and acquiring the sex characteristics of the other sex. Therefore, the diagnosis is not made if the disturb ance is limited to brief periods of stress. Invariably there is the wish to live as a member of the other sex. In the rare cases in which physical intersexuality or a genetic abnormality is present, such a condition should be noted on Axis III.

People with this disorder usually complain that they are uncomfortable wearing the clothes of their assigned sex and therefore dress in clothes of the other sex. Often they engage in activities that in our culture tend to be associated with the other sex. These people often find their genitals repugnant, which may lead to persistent requests for sex reassignment by hormonal and surgical means.

To varying degrees, the behavior, dress, and mannerisms become those of the other sex. With cross-dressing and hormonal treatment (and for males, electrolysis), some males and some females with the disorder will appear relatively indistinguishable from members of the other sex. However, even after sex reassignment, many people still have some physical features of their originally assigned sex that the alert observer can recognize.

Cross-culturally, the Hijra of India and the corresponding group in Burma may have conditions that, according to this manual, would be diagnosed as male-to-female Transsexualism. The Hijra, however, tra ditionally undergo castration, not hormonal and surgical feminization (creation of a vagina).

ASSOCIATED FEATURES
Generally there is a moderate to severe coexisting personality disturbance. Frequently the person experiences considerable anxiety and depression, which he or she may attribute to the inability to live in the role of the desired sex.

COURSE
Without treatment, the course of the disorder is chronic, but cases wht apparently spontaneous remission do occur. The long-term outcome of combined psychiatric, hormonal, and surgical sex reassignment treatment is not well known. Many people function better for years after such treatment, but a number of cases in which re-reassignment has been desired have also been reported.

People who have female-to-male Transsexualism appear to represent a more homogeneous group than those who have male-to-female Trans sexualism in that they are more likely to have a history of homosexuality and a more stable course, with or without treatment.

AGE AT ONSET
People who develop Transsexualism almost invariably report having had a gender identity problem in childhood. Some assert that they were secretly aware of their gender problem, but that it was not evident to their family and friends. Although onset of the full syndrome is most often in late adolescence or early adult life, in some cases the disorder has a later onset.

IMPAIRMENT AND COMPLICATIONS.
Frequently, social and occupational functioning are markedly impaired, partly because of associated psychopathology and partly because of problems encountered in attempting to live in the desired gender role. Depression is common, and can lead to suicide attempts. In rare instances, males may mutilate their genitals.

PREDISPOSING FACTORS
Extensive, pervasive childhood femininity in a boy or childhood masculinity in a girl increases the likelihood of Transsexualism. It seems usually to develop within the context of a disturbed relation ship with one or both parents. Some cases of Gender Identity Disorder of Adolescence or Adulthood, Nontranssexual Type, evolve into Trans sexualism.

PREVALENCE.
The estimated prevalence is one per 30,000 for males and one per 100,000 for females.  

SEX RATIO
Males seed help at clinics specializing in the treatment of this disorder more commonly than do females. The ratio varies from as high as 8:1 to as low as 1:1.

FAMILIAL PATTERN
No Information.

DIFFERENTIAL DIAGNOSIS.
Some people with disturbed gender identity may, in isolated periods of stress, wish to belong to the other sex and to be rid of their own genetals. In such cases a diagnosis of Gender Identity Disorder Not Otherwise Specified should be considered, since the diagnosis of Transsexualism is made only when the disturbance has been continuous for at least two years. In Schisophrenia there may be delusions of belonging to the other sex, but this is rare. The insistence by a person with Transssexualism that he or she is of the other sex is, strictly speaking, not a delusion, since what is invariably meant is that the person "feels like" a member of the other sex rather than truly believes that he or she "is" a member of the other sex. In very rare cases, however Schizophrenia and Transsexualism may coexist.

In both Transvestic Fetishism and Gender Identity Disorder of Adolescence or Adulthood, Nontranssexual Type, there may be cross- dressing. But unless these disorders evolve into Transsexualism, there is no wish to be rid of one's own genetals.

TYPES
The disorder is subdivided according to the history of sexual orientation, as asexual, homosexual (towards one's own sex), hetero sexual (toward opposite sex), or unspecified. In the first, "asexual", the person reports never having had strong sexual feelings. Often there is an additional history of little or no sexual activity or pleasure derived from the genitals. In the second group, "Homo sexual", a predominantly homosexual arousal pattern preceding the onset of the Transsexualism is acknowledged, although often such people deny that the orientation is homosexual because of their conviction that they are "really" the other sex. In the third group, "heterosexual", the person claims to have had a heterosexual orientation.

DIAGNOSTIC CRITERIA FOR 302.50 TRANSSEXUALISM

A) Persistent discomfort and sense of inappropriateness about one's assigned sex.

B) Persistent preoccupation for at least two years with getting rid of one's primary and secondary sex characteristics and acquiring the sex characteristics of the other sex.

C) The person has reached puberty.

(Specify history of sexual orientation: asexual, homosexual, heterosexual, unspecified.)

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GENDER IDENTITY DISORDER OF ADOLESCENCE OR ADULTHOOD, NONTRANSSEXUAL TYPE (GIDAANT) - SECTION 302.85 - Page 76.

The essential features of this disorder are a persistent or recurrent discomfort and sense of inappropriateness about one's assigned sex, and persistent or recurrent cross-dressing in the role of the other sex, either in fantasy or in actuality, in a person who has reached puberty. This disorder differs from Transvestic Fetishism in that the cross-dressing is not for the purpose of sexual excitement; it differs from Transsexualism in that there is no persistent preoccupation (for at least two years) with getting rid of one's primary and secondary sex characteristics and acquiring the sex characteristics of the other sex.

Some people with this disorder once had Transvestic Fetishism, but no longer experience sexual arousal with cross-dressing. Other people with this disorder are homosexuals who cross-dress. This disorder is common among female impersonators.

Cross-dressing phenomena range from occasional solitary wearing of female clothes to extensive feminine identification in males and masculine identification in females, and involvement in a transvestic subculture. More than one article of clothing of the other sex is involved, and the person may dress entirely as a member of the opposite sex. The degree to which the cross-dressed person appears as a member of the other sex varies, depending on mannerism, body habitus, and cross-dressing skill. When not cross-dressed, the person usually appears as an unremarkable member of his or her assigned sex.

ASSOCIATED FEATURES.
Anxiety and depression are common, but are often attenuated when the person is cross-dressing.

AGE AT ONSET AND COURSE.
Age at onset and course are variable. In most cases before puberty there was a history of some or all of the features of Gender Identity Disorder of Childhood. However by definition, GIDAANT is diagnosed only once puberty has been reached. The initial experience may involve partial or total cross-dressing; when it is partial, it often progresses to total. Cross-dressing, although intermittent in the beginning, often becomes more frequent, and may become habitual. A small number of people with GIDAANT, as the years pass, want to dress and live permanently as the other sex, and the disorder may evolve into Transsexualism.

IMPAIRMENT.
Unless there is another diagnosis in addition to GIDAANT, the impairment is generally restricted to conflicts with family members and other people regarding the cross-dressing.

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SEXUAL DISORDERS pg 288 Section 302.30 TRANSVESTIC FETISHISM

The essential feature of this disorder is recurrent, intense, sexual urges and sexually arousing fantasies, of at least six months' duration, involving cross-dressing. The person has acted on these urges, or is markedly distressed by them. Usually the person keeps a collection of women's clothes that he intermittently uses to cross-dress when alone. While cross-dressed, he usually masturbates and *imagines other males' being attracted to him as a woman in his female attire *

This disorder has been described only in heterosexual males. The diagnosis is not made in cases in which the disturbance has evolved into Gender Identity Disorder of Adolescence or Adulthood, Nontranssexual Type, or Transsexualism.

Transvestic phenomena range from occasional solitary wearing of female clothes to extensive involvement in a transvestic subculture. Some men wear a single item of women's apparel (e.g., underwear or hoisery) under their masculine attire. When more than one article of women's clothing are involved, the man may wear makeup and dress entirely as a woman.

The degree to which the cross-dressed person appears to be a woman varies, depending on mannerisms, body habitus, and cross- dressing skill. When not cross-dressed, he is usually unremarkably masculine. Although the basic preference is heterosexual, rarely has the person had sexual experience with several women, and he may have engaged in occasional homosexual acts.

An associated feature may be the presence of Sexual Masochism.

AGE AT ONSET AND COURSE.
The disorder typically begins with cross-dressing in childhood or early adolescence. In many cases the cross-dressing is not done in public until adulthood. The initial experience may involve partial or total cross-dressing; when it is partial, it often progresses to complete cross-dressing. A favored article of clothing may become erotic in itself and may be used habitually, first in masturbation, and later in intercourse.

In some people sexual arousal by clothing tends to disappear, although the cross-dressing continues as an antidote to anxiety. In such cases the diagnosis should be changed to Gender Identity Disorder of Adolescence or Adulthood, Nontranssexual Type. A small number of people with Transvestic Fetishism, as the years pass, want to dress and live permanently as women, and desire surgical or hormonal sex reassignment. In such cases the diagnosis should be changed to Transsexualism.

PREDISPOSING FACTORS.
According to the folklore of people with this condition, "petticoat punishment", the punishment of humiliating a boy by dressing him in the clothes of a girl, is common in the history of those who later develop this disorder.

DIFFERENTIAL DIAGNOSIS.
Cross-dressing for the relief of tension or gender discomfort may be done without directly causing sexual excitement. This should not be diagnosed as Transvestic Fetishism; the diagnosis of Gender Identity Disorder of Adolescence or Adulthood, Non-transsexual Type should be considered. In male homosexuality there may be occasional cross- dressing to attract another male or to masquerade in theatrical fashion as a female. However, the act of cross-dressing does not cause sexual arousal. In female impersonators, unless Transvestic Fetishism is also involved, the act of cross-dressing does not cause sexual arousal, and interference with the cross-dressing does not result in intense frustration.

In Transsexualism there is persistent discomfort and a sense of inappropriateness about one's assigned sex and preoccupation with getting rid of one's primary and secondary sex characteristics and acquiring the sex characteristics of the other sex. No sexual excitement is associated with the cross-dressing. The person with Transvestic Fetishism considers himself to be basically male, whereas the originally anatomically male Transsexual has a female sexual identity. In the rare instances in which Transvestic Fetishism evolves into Transsexualism, the diagnosis of Transvestic Fetishism is changed to Transsexualism.

Fetishism is not diagnosed when sexual arousal by nonhuman objects is limited to articles of female clothing used in cross- dressing. In Sexual Masochism (Not associated with Transvestic Fetishism) the person may desire to be forced to cross-dress because of its humiliating associations, but the garments themselves do not cause sexual arousal.

DIAGNOSTIC CRITERIA FOR 302.30 TRANSVESTIC FETISHISM:
1) Over a period of at least six months, in a heterosexual male, recurrent intense sexual urges and sexually arousing fantasies involving cross-dressing.

B) The person has acted on these urges, or is markedly distressed by them.