lass="ws1">-
monal treatment for life (Blanchard, 1993; Cohen-Kettenis &
Gooren, 1999). Transsexual people desire to live and be ac-
cepted as a member of the gender opposite to that assigned at
birth (Hembree et al., 2009). The term Male-to-Female (MtF)
transsexual refers to a chromosomally male who identified on
the female gender; the term Female-to-Male (FtM) transsexual
means a chromosomally female person who identified on the
male gender. Gender dysphoria (GD) is a DSM-V diagnosis
that recently has been separated from Sexual Dysfunctions and
Paraphillic Disorders because persons experiencing gender dys-
phoria need a diagnostic term that protects their access to care
and will not be used against them in social, occupational or
legal areas. In DSM-IV-TR it is defined as:
A) A strong and persistent cross-gender identification, com-
bined with a persistent discomfort with one’s sex or sense of
inappropriateness in the role of that sex, causes clinically sig-
nificant distress.
B) Persistent discomfort with his or her sex or sense of inap-
propriateness in the role of that sex.
C) The disturbance is not concurrent with a physical intersex
condition.
D) The disturbance causes clinically significant distress or
impairment in social, occupational or other important areas of
functioning.
Usually the gender assigned at birth is that one correspond-
ing to the chromosomal information, but many exceptions hap-
pens considering only genetic data (Kandhelwal et al., 2010).
The reason why this criteria is still very used is because these
two parameters (chromosomes-gender) are practically always
correlated in an animal (Ngun et al., 2011). Recently, Australi-
an and after them German legislation, which went into effect on
Friday November 1st in 2013, were enacted in order to give
parents and children more time before making life-changing sex
reassignment decisions in cases of intersex genital characteris-
tics at birth. This will happen in German legislation having a
third option (blank for gender designation box in babies whose
gender is not clear at birth) only of their birth certificates, not
other legal registries such as passports, being possible to change
this blank designation later on to male or female or can be left
blank indefinitely (Stafford, 2013).
Only in 23% of cases (1/3 according to the DSM-V) does a
childhood gender problem leading to transsexuality in adult-
hood. With regard to sexual orientation, the most likely out-
come of childhood gender identity disorder is adult homosex-
uality or bisexuality. This population is served by clinicians
(Gender Teams) because they usually suffer from abuses and
on one-fourth of patients reported childhood maltreatment (Ban-
dini et al., 2011).
According to the onset time, transsexuality can be divided in
two different courses: early and late onset. In the early one, the
discomfort is present since the beginning of cross gender iden-
tification, between 2 and 4 years old. In late onset the cross
gender identification appears during puberty or adulthood, in a
more gradually way and being concurrent sometimes with
Transvestism Fetishism (DSM-IV-TR). It must be noted, how-
ever, that gender identity development is intrinsically pro-
grammed and there is no way of prevention for the disorder
(Looy & Bouma, 2005). On the other hand, some specific dif-
ferences in onset timing might be happening between sexes, for
Male-to-Female and Female-to-Male transsexuals (Lawrence,
2010).
There are still many confusions and doubts about what trans-
sexualism is in general population. The reason why might be
related to some mixed definitions or not boundaries well estab-
lished. For clarifying purposes, here we would like to explain
what is NOT transsexualism (Table 1) (as the extreme Gender
Dysforia form):
A) It is not an extreme form of homosexuality.
Although homosexuality is not included in the DSM any
more, some confusion it is still surrounding the two concepts:
gender dysphoria and gender orientation are two independent
processes in our brain. Neuroanatomical studies have shown
there are some brain regions located in the hypothalamus which
were related to sexual orientation in its volume—such as the
subdivision INAH3-(LeVay, 1991) and also to gender dyspho-
ria in its volume and number of neurons (Garcia-Falgueras &
Swaab, 2008). Other regions were related only to gender dys-
phoria in its intermediate values for volume and number of cells
INAH1—(Garcia-Falgueras et al., 2011) and the other region
in human hypothalamus were not different among man and
woman, nor related to sexual orientation or to gender dysphoria
INAH4(Allen et al., 1989; LeVay, 1991; Garcia-Falgueras
& Swaab, 2008; Garcia-Falgueras et al., 2011).
On the other hand, there are many reasons to logically con-
sider sexual orientation and gender dysphoria as different
processes in our brains. For instance, it is widely accepted,
since Kinsey’s scales, there are many grades in sexuality, de-
fined as a continuum from 0 to 6, from exclusive heterosexual
behavior to exclusive homosexual behavior. While for gender
dysphoria there are two categories (male to female and female
to male) although a third one can be also considered in cases of
gender indeterminacy at birth (Stafford, 2013). Hypothetically
those characteristics measured by different grades in scales
might be belonging to different specialization brain networks,
although they could share some components, such are those
related to sexual arousal or libido which are located in the b rain
in the insula, the inferior and middle frontal gyrus and the hy-
pothalamus as well (Hu et al., 2008), also incuding more cor-
tical areas such as the anterior cingulated cortex, the anterior
temporal cortex, and the ventral globus pallidus (Rauch et al.,
1999).
B) It is not a delusional disorde r, somatic type.
This is a primary disorder that is diagnosed when prominent
nonbizarre delusions coming from the own body (odors, mal-
formations, insects, etc.) are present for at least one month and
the symptoms criteria for Schizophrenia have never been met.
Hallucinations may be present but auditory or visual hallucina-
tions cannot be prominent. For the somatic type the delusions
are mainly related to physi cal defect, functions or general med-
ical condition (DSM-IV-TR). The exclusion criteria for Gender
Dysphoria might be:
1st) the prominent nonbizarre delusions are never related to
the gender, role or sex, but with some physical defect or general
A. GARCIA-FALGUERAS
OPEN ACCESS
162
Table 1.
Common aspects and main differences between Gender Dysphoria, homosexuality and some DSM disorders.
GENDER DYSPHORIA
COMMON
DIFFERENT
HOMOSEXUALITY
Coincidenc e 58% (Sm i t h et al., 2005)
Gender: cont inuum 3 levels
Orientation: continuum 6 levels
DELUSIONAL DISORDER, SOMATIC
Discomfort coming from the own body
1st
) the body dysmorphic disorder is about a real physical minor flaw (i.e.
acne) exaggerated to the extreme of causing deep impairment but it is not
related to gender, role or sex.
2
nd) In Gender Dysphoric pat i ents, afte r hor mones and surgical
intervention and rest or ation of c omfort bet ween body a nd gender, most
of cases dysphoria do not persist.
BODY DYSMORPHIC DISORDER
Discomfort coming from the own body
1
st) the prominent nonbizarre delusions are never related to the gender,
role or sex, but with some physical defect or general medical condition
and
2
nd) in Gender Dysphoric patients, after hormones and surgical
intervention and rest or ation of c omfort bet we
en body and gender, most
of cases dysphoria do not persist.
DISOCIATIVE IDENTITY DISORDER
Inequal personalities or identities.
1st
) in dissociative identity differe nt personalities are belonging to the
same gender.
2
nd) in dissociative identity memory problems are related.
3
rd) In Gender Dysphoric patients, after hormones and surgical
intervention and rest or ation of c omfort bet ween body a nd gender, most
of cases dysphoria do not persist.
BODY INTEGRITY IDENTITY
DISORDER
Coincidenc e 19% (First , 2005; Lawrence,
2006; First & Fisher, 2012)
1st) in Body Identity Integrity Disorder desires of amputations are related
to arms a nd l egs, not to genitals or breasts.
medical condition and
2nd) In Gender Dysphoric patients, after hormones and sur-
gical intervention and restoration of comfort between body and
gender, most of cases dysphoria do not persist.
C) It is not a body dysmorphic disorder
Body dysmorphic disorder is a secondary somatoform dis-
order marked by a preoccupation and perpetual negative
thoughts about their appearance with pain and discomfort. It is
based on a imagined or trivial defect in appearance (usually
related to skin, hair or nose) that causes clinically significant
distress or impairment in social, occupational or other impor-
tant areas of functioning. The exclusion criteria for Gender Dys-
phoria might be:
1st) the body dysmorphic disorder is about a real physical
minor flaw (i.e. acne) exaggerated to the extreme of causing
deep impairment but it is not related to gender, role or sex.
2nd) In Gender Dysphoric patients, after hormones and sur-
gical intervention and restoration of comfort between body and
gender, most of cases dysphoria do not persist.
D) It is not a dissociative identity disorder
DSM-IV-TR defines a dissociative disorder or multiple per-
sonality disorder as an extremely rare mental secondary disord-
er characterized by at least two distinct and relatively enduring
identities or dissociative personality states that alternatively
control a person’s behavior, accompanied by memory impair-
ments, lapsus and asymmetric amnesia. The exclusion criteria
for Gender Dysphoria might be:
1st) in dissociative identity different personalities are belong-
ing to the same gender.
2nd) in dissociative identity memory problems are related.
3rd) In Gender Dysphoric patients, after hormones and sur-
gical intervention and restoration of comfort between body and
gender, most of cases dysphoria do not persist.
E) It is not a Body Identity Integr i ty Disorder (BIID)
Currently BIID is not included in the International Statistical
Classification of Diseases 11th revision nor in the Diagnostic
and Statistical Manual of Mental Disorders IV or V. As such
this disorder is often not known to surgeons, neurologist and
psychiatrists.
Although both, the BIID and the transsexual desire of gona-
dectomy could be defined as a deep discomfort sensations that
causes clinically significant distress to the patient, in both dis-
orders patients recognize reality, meaning those discomfort
sensations are illusions, not delusions. In both cases, after sur-
gical restoration discomfort between body and gender or iden-
tity does not persist. Those people have in common that they
are preoccupied (defined as extreme or excessive concern) with
their body concept. That preoccupation causes clinically signifi-
cant distress (depressed mood, anxiety, shame) or impairment
in occupational or other important social areas. The distress
increases and intensifies the desire of changing their bodies.
The unique exclusion criteria for Gender Dysphoria might
be:
1st) in Body Identity Integrity Disorder desires of amputa-
tions are related to arms and legs, not to genitals or breasts.
Then, could be those diseases related someway in the brain?
Firstly described as apotemnophile (amputation lovers) by
Money et al. (1977) and most recently as Xenomelia (McGeogh
et al., 2011; Brugger et al., 2013), a holdover from sexological
research at Johns Hopkins in the 1970s, Body Integrity Identity
Disorder (BIID) is used to describe people who feel from an
early age that part of their body does not belong to them and
they want to get rid of it, no matter what the cost is. They do
not accept a particular limb as part of their body, even if it
there’s nothing wrong with its structure and function.
Neuroanatomically the BIID is characterized by an increased
excitability of the dorsal-horn neurons, a reduction of inhibitory
processes, and structural changes at the central nerve endings of
the primary sensory neurons, the interneurons and the projec-
tion neurons. This central sensitization is mediated by the
NMDA receptor and its transmitter is glutamate (Flor, 2002).
Thalamic stimulation and recordings in human amputees have
A. GARCIA-FALGUERAS
OPEN ACCESS
163
shown that reorganizational changes also occur at the thalamic
level and are closely related to the perception of phantom limbs
and phantom-limb pain. Tactile stimulation for undesired limbs
causes a different brain activity (van Dijk et al., 2013). It has
been suggested an absent memory process by a Hebbian learn-
ing mechanism for the limbs after amputation that could ex-
plain the weak phantom feelings (Ramachandram & Hirstein,
1998). After the amputation, a cortical reorganization via long-
range horizontal collateral pyramidal neurons through the
GABA releasing might be occurring adjacent to the deaffe-
rented areas (DeFelipe et al., 1986).
BIID patients usually report thinking about their perceived
appearance flaws for an average of 3 - 8 hours a day and about
one quarter report for more than 8 hours a day (Phillips et al.,
2010). In BIID different motivations for wanting an amputation
have been described and they usually report more than one
reason, although restoring identity is much more likely to be
reported as primary (First, 2005). This pathology is usually
strongly associated with high levels of social anxiety and some
obsessive compulsive behaviors (i.e. mirror checking) have
been described. Very poor functioning and high levels or rates
of depression, anxiety, social anxiety, anger/hostility, suicidali-
ty and other proxy measures of distress are usually described
(Phillips et al., 2010). There is a small subgroup of Gender
Dysphoric patients who also present with symptoms relevant to
BIID (Phillips et al., 2010) or BIID patients that present similar
symptoms that Gender Dysphoric (First, 2005; Lawrence, 2006;
First & Fisher, 2012).
The conviction that a lower leg or arm does not belong to
them develops at an early age, generally when patients are a
child, or sometimes as a young adult. A child with BIID will
cut figures out of newspapers, and then chop off the leg that
they want to have amputated themselves. Although very little
research has been done during development, several similarities
were found for body dysmorphic disorders (BDD) between
youth and adults (Phillips et al., 2010). Some patients have
these feeling increased progressively over his early adult years
and would intensify these feelings when they are under stress
(First, 2005). This leads to an overpowering desire for amputa-
tion. Only once their limbs have been amputated, they do feel
“complete”. Surgeons who carry out these requests run the risk
of being condemned for amputating a healthy limb. It seems
that two-thirds of those patients, who do ultimately manage to
have an amputation, damage their unwanted limb to the extent
that it has to be amputated. Sometimes this involves putting
their whole life in danger by putting a bullet through the knee-
cap, freezing the leg or using a saw to do the job themselves
and paradoxically they finally “feel c omplete” and with the only
regret of no having done it sooner. They can even get agitated,
extremely envious or even sexually arousal activated when they
see handicapped people who have to live without a leg or an arm,
and sometimes this is the moment that they first realize that this
is what they themselves wa nt (First , 2005; First & Fisher, 2012).
Often they will try to imitate the desired situation as close as
possible, for example by using an elastic bandage to bind a leg
against their buttocks, wearing wide trousers which hide the
lower part of the leg, folding up a trouser leg, walking with
crutches or using a wheelchair. Males are more likely affected
by BIID than females (Braam et al., 2006).
The connection with transsexuality is especially intriguing
due to the percentage (19 percent) of BIID patients who also
exhibit a gender identity problem and the high percentage of
homosexual and bisexual BIID patients (also 19 percent) (First,
2005; Lawrence, 2006). Comorbidity with depressive, anxiety
or somatoform disorders have been described (First, 2005). But
psychotherapy or pills do not generally change the minds of
those afflicted with the disorder, al though there is one report of
a BIID patient feeling less miserable after taking anti-depres-
sants and following cognitive behavioral therapy (Flor et al.,
2002). Later this patient told that, although it was nice to talk to
someone it did not change his desire for amputation at all .
A recent research on BIID and MRI have proved the tactile
stimulation for undesired limb is reduced in its brain activity,
involving the parietal lobe, suggesting the BIID might be cause
by altered integration or somatosensory and propioceptive
information (van Dijk et al., 2013). Curiously parital cortex has
been related to body scheme for perception of the self in my-
tical experiences (Beauregard & Paquette, 2006). There is evi-
dence that the parietal cortex is part of the neuronal systeme
implicated in the processing of visuospatial representation of
the body schema in the process of self/other distintion (Neggers
et al., 2006).
The BIID and the GD can be both e xpla ine d by a me cha nism
hard-wiring where the body image is represented innately into
the brain. It has been suggested the image of the sex organs of
transsexuals are “hard-wiredin the brain in a manner which is
opposite to that of their biological sex (Ramachandran &
McGeoch, 2007; Brang et al., 2008). This idea is based on the
fact that in transsexual population a different pattern of phan-
tom syndromes occurs after castration or breast extirpation
(Ramachandram & McGeogh, 2007; Brang et al., 2008). After
gonadectomy and breast removal, transsexual patients expe-
rience a phantom syndrome less frequently than the non-trans-
sexual population (Ramachandram & McGeoch, 2007). Around
60% of men who have to have their pennies amputated for
cancer will experience a phantom penis post-penectomy, but
only 30% of the post-operative male-to-female transsexuals
reported the incidence of a phantom penis. On the other hand
surprisingly the 62% of the female -to-male transsexual patients
reported having felt vivid phantom penises, including phantom
erections for many years. Moreover only the 10% of those fe-
male to male transsexual patients experienced phantom breast
sensations post-operatively (Ramachandram & McGeoch, 2008).
One important difference between GD and BIID persons is
the fact cortical reorganization might happen in different areas.
For BIID the motor parietal area is crucial, while for genitals
the location is more inside the brain, c lose to the foot represen-
tation in the Penfield homunculus (Ramachandram & Hirstein,
1998). In some cases (19%) these can be overlapped, but no so
often, making them different diseases. Exclusion diagnosis
have to be done for other identity disorders, such as the Body
Integrity Identity Disorder (BIID), because the connection with
transsexuality is especially intriguing in these cases due to the
percentage of BIID subjects (19%) (First, 2005; Lawrence,
2006) who also exhibit a gender dysphoric problem. In both
cases the satisfying patient’s demands for a surgical interven-
tion still remains the only way to improve their clinical condi-
tions and to avoid the onset of many other different and dra-
matic complications. Without any treatment the trouble might
became chronic without remission and with high suicides rates.
Psychology for Transsexuali sm
Sexual minorities are at a higher risk of maltreatment and
A. GARCIA-FALGUERAS
OPEN ACCESS
164
abuse (Corliss et al., 2002), together with their higher body
dissatisfaction and a worse lifetime mental health reported.
Maltreatment was defined in this study as an emotional abuse
and/or neglect, physical abuse and/or neglect and sexual abuse
(Bandini et al., 2011). However, an accurate mental health pro-
fessional diagnosis is usually recommended to be made for the
Gender Disorders (Hembree et al., 2009). Any treatment deci-
sions, even when reversible, mig ht always be tak en by a whole
clinical team after considering social and familiar circum-
stances (Kreukels & Cohen-Kettenis, 2011). Since the benefits
of clinical treatment for Gender Dysphoria are translated into a
reduction of social ostracism, the complexities of sex-reassign-
ment surgery, its biomedical treatment and the importance of
reducing family psychopathologies or stress when they are
present (Zucker et al., 2012) could be the clinical goals, toge-
ther with an accurate and precise diagnosis, which are per-
spective to be always considered and supported. For those rea-
sons a commitment of health in psychology/psychiatric and
physicians/endocrine professionals to collaborate in under-
standing and properly care treating these difficult diseases (Hem-
bree et al., 2009) would be required.
Acknowledgemen ts
I thank Prof. Dick F. Swaab for his help in research and Dr.
Jenneke Kruisbrink for her literature resource help.
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