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Wednesday November 26, 2008
THE DOCTOR SAYSBy DR MILTON LUM
While the causes of gender identity disorders are still disputed, one thing is certain – these patients need care and compassion, rather than discrimination.
A PERSON’S sex is defined, at the time of birth or soon after, by an inspection of the external genital organs (or anatomical sex).
The term “gender identity” refers to the person’s feelings as to whether he or she is male or female. “Gender role” describes how people publicly express themselves in their clothing, appearance, conversation, body language and behaviour.
A person with gender identity disorder (GID) has a marked discordance between his or her anatomical sex and gender identity. The person has cross-gender identification, with a desire to live and be accepted as a member of the opposite sex. In short, one who is identified as a male may feel like and act like a female, and vice versa. The common descriptive terms used are effeminate men and “butch” women.
It is important to distinguish gender identity from sexual orientation – which is the sex that one is attracted to – such as heterosexual, homosexual or bisexual. The proportion of the latter in people with GID is not different from those who do not have GID.
Data from Europe reports that one in 30,000 adult males and one in 100,000 adult females seek sexual reassignment surgery due to GID. There is no published data on the prevalence of GID in Malaysia. However, Zulhizzam’s study of GID among male students in selected public institutions of higher learning in the Klang Valley provides some insight. Sixty-eight cases and 175 controls responded to self-administered questionnaires. Of the GID cases, 55 (80.9%) were Malays and 13 (19.1%) were non-Malays. Their characteristics included persistent cross gender roles in social or play activities (58 or 85.3%); spoke or attempted female speech (51 or 70.6%); displayed feminine-like body and limb movements (48 or 70.6%) and insisted on being treated or accepted as female (35 or 51.5%).
Some were disgusted with their own genitals and were willing to get rid of it (13 or 19.1%) and some had attempted to change their sexual characteristics by taking female hormones (13 or 19.1%). What is of concern is that high risk sexual behaviour was increased in GID cases (52.9%) as compared to controls (16.4%), with homosexuality, the most common sexual practice.
Although the causes of GID are still the subject of debate, there is evidence to suggest that the basis is neurobiological. Some believe that the physical and mental health of the affected person’s mother when pregnant plays a role in the genesis of GID. Others believe that there is an altered reaction between the foetal brain and the sex hormones in early pregnancy. Differences have also been found in the brains of male-to-female transsexuals.
GID has also been attributed to developmental problems in early childhood. Adults with GID have reported differences in child-rearing practices as compared to those without GID. Male-to-female transsexuals reported that their fathers were less warm, more rejecting, and controlled excessively. Female-to-male transsexuals reported that both parents were more rejecting and less emotionally warm, but their mothers were more overprotective.
GID is recognised as a medical problem. The various types of GID, according to the World Health Organisation classification are listed below.
Transsexualism is defined as “a desire to live and be accepted as a member of the opposite sex, usually accompanied by a sense of discomfort with, or inappropriateness of, one’s anatomic sex, and the wish to have surgery and hormonal treatment to make one’s body as congruent as possible with one’s preferred sex.”
Dual-role transvestism is defined as “the wearing of clothes of the opposite sex for part of the individual’s existence in order to enjoy the temporary experience of membership of the opposite sex, but without any desire for a more permanent sex change or associated surgical reassignment, and without sexual excitement accompanying the cross-dressing.”
Gender identity disorder of childhood is defined as “a disorder, usually first manifested during early childhood (and always well before puberty), characterised by a persistent and intense distress about assigned sex, together with a desire or insistence to be the other sex.
The diagnosis requires a profound disturbance of the normal gender identity; mere tomboyishness in girls or girlish behaviour in boys is not sufficient. Gender identity disorders in individuals who have reached or are entering puberty should not be classified here but as psychological and behavioural disorders associated with sexual development and orientation.”
The diagnosis of GID is complex as the phenomenon is not homogenous. The diagnostic criteria for GID (transsexualism) include strong and persistent cross-gender identification that extends beyond a desire for perceived advantages stated in the preceding paragraph.
GID in children is defined by four or more of the following characteristics: a desire to be the other sex; preference for cross-sex roles in play or preference for cross-dressing; persistent fantasies of being the other sex; intense desire to participate in stereotypical games and pastimes of the other sex; and strong preference for playmates of the other sex.
Boys loathe their penis or testes and rough play, believe their genitals will disappear, and reject male toys. Girls reject urinating in the sitting position, stress that they will grow a penis and do not want to grow breasts or menstruate, and dislike feminine clothes.
Adolescents and adults may experience the following: desire to be the other sex; frequent passing as the other sex; desire to live or be treated as the other sex; has the typical feelings and reactions of the opposite sex; and persistent discomfort with his or her sex or sense of inappropriateness in the gender role of that sex. Adolescents and adults may be preoccupied with getting rid of their sexual characteristics, and may believe that they were born with the wrong sex.
People with GID have significant distress or impairment in social, occupational, or other areas of functioning. There is a range of treatment options available, such as hormone therapy and sex reassignment surgery, for which the patient will be given counselling. Psychotherapy is essential as it will help in decisions about progression to hormone and surgical therapy.
Sex reassignment surgery (SRS) may be considered when the doctors supervising treatment are convinced of compliance with strict eligibility criteria. The surgical procedures for female-to-male SRS include removing breasts, the uterus and ovaries, and the construction of a penis and scrotum.
The surgical procedures for male-to-female SRS are removal of the penis and testes, construction of a vagina, breast augmentation, reshaping of the nose and throat and facial remodelling.
Not everyone requires or is suited for SRS. The factors contributing to satisfaction include young age, strong family and social support, and successful surgery.
There is considerable social stigma attached to GID. This is sad as those affected need multi-disciplinary medical assistance. Society needs to be less judgmental and more caring and compassionate. This will go a long way in helping those who are in a situation that is not of their making.
Dr Milton Lum is chairperson of the Commonwealth Medical Trust. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with.
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