Gender Identity Disorders (GID)

Gender Identity Disorders (GID) • Developed by Gendercare Gender Clinic Copyright Gendercare(2001-2005) • Dr.Torres,MS,PhD. • Harry Benjamin International Gender Dysphoria Association-HBIGDA member • You may use this presentation, if you mention Gendercare as its origin, with no changes in its content.

This presentation was developed by Dr.Torres,PhD and Gendercare staff, based on 4 years of work evaluating and treating GID`s (2001/2005); • This presentation also is based upon Torres & Jurberg published papers on Scientia Sexualis, from Universidade Gama Filho, RJ-Brazil (2000/2001); Torres papers on GID Journal editions (2003/2004), and Martha Freitas book “Meu Sexo Real”, Editora Vozes, Brazil, (1998).

A woman with a heart (brain, identity) of a man, or a FtM man that feels with an odd body? What is today the best way to define someone`s sex and gender? The genitals, or the heart?

Where we may find our Identity? • Not in our feet. If we loose them, we loose not our identity. • Not in our nose, also; • Not in between our legs, too! • Probably in our heart? No!... we may change our heart, and our identity will continue the same! • Probably in our brain? Yes! But where in our brain? • Possibly in our cortex? No! Damasio show we may loose alot of our cortex and the identity will remain there! • So, where? • In our brain, near the central control of our life... because our identity ends, when our life ends...

What GID`s surely are not • GID`s are not an option, a question of taste or any peculiar situation that happens naturally as a simple diversity of the normality; • GID`s are not derived from a homosexual kind of sexual orientation; • GID`s are not necessarily a kind of mental disease, nor any kind of split from reality; • GID`s are not the consequence of no moral behavior.

Homosexual sexual orientation is by definition, the way someone loves other people. Sexual orientation is always a relation problem, and never a problem inside someone. GID`s are problems inside yourself, a split and discord inside you, about your aspects and parts of you. They are evidently different problems, with different causes and consequences. • Sexual orientation (heterosexual, homosexual, bisexual, asexual, pansexual) never is a medical question, but GID`s are medical questions. • GID`s may have any sexual orientation. • The mix up of so different phenomena brings for both communities (GLB and GID`s) alot of problems and generates alot of caricature situations. • So it is very interesting to split radically those two situations, to understand better both.

GID`s had nothing to do with religious and moral problems. There is alot of wretch people without GID , and there are lots of GID`s that are honorable people; • Noone, being a man, would like to be a woman, and vice versa, because no one likes to be discriminated and suffer alot; • GID`s do not escape from reality.... They escape the pre established reality others considered the best for them.... And family and society and authorities have not the right to define any absolute reality. • Biology today show the genital tissue is not an absolute criteria to define sexual and gender reality; • Psychiatric tests show, most times, the GID`s have no mental problems, and are very inteligent, most of the time.

What are GID`s • The ICD-10th from the WHO says GID`s are health problems, and surely they are, and they are classified in ICD-10th as F.64: • F.64.0 e F.64.2........ Transexualism; • F.64.1...................... Cross Dressing; • F.64.8...................... Trangenderism & others (GIDNOS). • GID`s are a kind of health problems, and need a good diagnosis, treatment and cure (GIDNOS means Gender Identity Disorder Not Specified)

GID`s and GIDNOS are health problems and need health care, even if they are not, necessarily, mental diseases. We know GID`s and most kinds of GIDNOS have two possible and most common ethiologies: • Congenital phetus formation problems and/or • Some hard and strong PTSD due to very early traumas, mainly mother rejection and father abuse and/or violence. • All GID and GIDNOS (almost all) are victims, from nature, families or society.

F.64.0 e F.64.2 (Transexualism)-Gendercare ethiology theory • All we feel, we feel through the operation of our brain, and our brain has alot of different systems and different parts that work to do different jobs. • To feel a boy or a girl, to develop a gender identity is a question of brain, and today we know, in all primates, includding man, the basal brain is congenitally differentiated as a male or as a female basal brain, due to genes and hormones. • Thru two different ways and during different times, the genital and the basal brain`s tissues have their gender differentiation. The genitals have their differentiation through more simple endocrine and genetical processes and the basal brain have that differentiation due to very complex genetic and endocrine processes. • Due to those complex differences, the discord of gender between tissues in the genitals and in the basal brain may happen.

Genital Tissues Gonads thru the action of SRY gene; External genitals thru the efficient action of DHT-dihydrotestosterone over the androgen receptor (AR), forming the phallus. Problems on the production of DHT, or over the action of DHT start intersex cases. Basal Neural Tissues Dozens of genes take a part on that process, because alot RNAm is produced in those tissues during gender differentiation; Testosterone-T is the main endocrine agent, directly over AR ou thru aromatization acting over ER. Those basal brain differentiation processes are much more complex than the genital tissue process. They need alot of T, and are independent from DHT. Tissues sexual masculinization

A little bit more about genes and hormones... • DHT action over AR is 4 times stronger than T action; • T action is much more complex than DHT action. AR and ER may be activated by T, but only AR may be activated by DHT. That T complex action on the brain happens only during gestation, on primates includding man, and on the basal brain and not in the brain cortical area. The basal tissues are mainly the hypothalamus, limbic system, amygdalas and stria terminalis. Those are the main basal systems related to the generation of our gender identity. • Cortical regions of the brain, later, after birth, will be masculinized by some DHT action, but not T. • Very few genes are important for gonads and genital differentiation, but alot of them are important for brain gender differentiation, mainly basal tissues. • A woman`s female brain will be totally female, in the basal and cortical brain. And vice versa for a man. • The brain for a MtF woman, will be basal female and probably will have a male cortex, and vice versa for FtM men.

Continuing the ethiology... • The emotional state of the mother may interfere also on that neural differentiation process. Stressed mothers have their imune system debilitated, and that fact interferes on T action and production. So, the emotional of the mother interferes with the endocrine system of the phetus, and may disturb the basal brain differentiation. • The Gender Discord between the basal brain (that generates the gender identity) and the genitals (that our society think is the only biological system that interferes on sex and gender), may happen. That is the main ethiology for transsexual F.64.0 and F.64.2 GID`s. • But our clinic and therapeutic experience shows sometimes very hard traumas, and very early traumas, may also happen, or may be the most important cause sometimes for transsexual situations. When that happens, a PTSD may be the most important cause for those GID and some GIDNOS conditions. Those traumas and PTSD may develop the desire to be someone new, even considering sex and gender; • It is important to consider, PTSD situations always show some signs, a congenital discord do not show. It is much more probable to have a patient with related mental disorders in PTSD stimulated GID`s than those without those traumas.

This look like a Chaos... • Deterministic processes (as the genetic and endocrine described), when there are very small disturb in the beginning may generate chaotic results and consequences. • Gender identity is the result of a possibly chaotic deterministic process, due to genetic and endocrine processes on different body tissues. At least 54 genes, some complex ones, are participating on those processes! • So, small differences and mutations on some genes, as the androgen receptor AR for example, may generate alot of what we could say chaotic deterministic situations. Imagine the 54 genes together, what may happen, includding the emotional state of mothers during gestation, and endocrine complex factors...

For example: Androgen Insensitivity Syndromes- AIS • There are mainly 3 kinds of typical AIS syndromes: • Complete Androgen Insensitivity Syndrome-CAIS • Partial Androgen Insensitivity Syndrome – PAIS • Mild or Minimum Androgen Insensitivity Syndrome- MAIS • CAIS generates always a specific kind of syndrome, we named in the past times as testicular feminization syndrome; • PAIS generates some intersex cases, and possible GIDNOS situations as a consequence of bad treatment and diagnosis of those intersex children; • MAIS may generate GID mainly of the F.64.0 or F.64.2 cases. • Obviously the GIDNOS and GID ethiology is not limited to those possible AIS situations.

In the beginning of gestation, all were XY (100% maleness in the Y axis). During genital differentiation there is a diversity of possible situations of intersex, due to PAIS. Also CAIS and MAIS situations may happen. The neural basal differentiation also may happen in a very spread of situations. Practically it is as a chaotic situation and could happen due to the complexity of the factors involved during gestation.

In the beginning, all were XY. Later, during genital differentiation, due probably to a PAIS condition, all had intersex genital formation, but nearly male, almost all. Even in that situation, we may not be sure about gender identity, because some female brains may happen, generating a female gender identity. The Chaos again.... No previsibility is certain...

In the beginning all were XY. During the genital differentiation, due to CAIS or PAIS, the genitals looked like more female than male. May we be sure about the gender identities? Surely not. Probably they are female, but only probably.... All the cases I show here are real ones.

Important consequences of that knowledge 1.Someone may have male genitals and be a XY, and develop a female gender identity, and vice versa. That is the main ethiology for transsex. 2. It is very dangerous to make sex assignment surgeries in intersex babies and small children. The best way is to wait the child freely manifests its gender identity, and only after a good examination, for example from Gendercare experts in gender identity evaluation, to decide what reassignment surgery it will be the best option. 3.Most parents think the “sex” determined by ultrasonography during gestation is enough to know the sex and gender of the child. That may be a mistake, because we may not know the basal brain of the child, that is forming in the later part of gestation. 4.We thought knowing the chromossomes, gonads and genitals we would know all about sex and gender of someone.... really, knowing only those aspects, we know almost nothing...

About Gendercare GID and GIDNOS diagnostic • To know if someone may have a GID or GIDNOS, WE MAY NOT SEE THE PATIENT. • Why? • Because the external appearance of the patient may work as a trap for the therapist, even the most experienced ones. We intend to diagnose discords between heart/brain/mind/gender identity and genitals and not clothes, make up and appearance. • Someone may fake very easily the GID appearance, even not really being a GID, and on the other side, most GID`s have not the appearance they would like to have. • We intend to evaluate basal brains that generate the gender identity, and not how people appear socially only. • So, the best method to evaluate GID and GIDNOS is through the Web.

The First Step • We need an anamnesis, a deep one. Most part of GID and GIDNOS patients are people that have scares of deep early experiences of life. • We developed an anamnesis method thru emails. • A perfect confidential method, bacause the story of the patient, our questions, our comments and its answers will remain only in my personal computer (Dr.Torres) and in the patient`s computer. Never we will show those data, not to physicians, nor to psychologists or psychiatrists, nor surgeons. • Our main effort in the anamnesis step is to discover signs of congenital gender discord and early traumas, with PTSD signs.

The Second Step • After the anamnesis, the patient may answer the unexpected femininity (for MtF`s) or masculinity (for FtM`s) tests developed by Gendercare (MFX and FMX tests respectively) • We evaluate 4 scales: • Masculinity/Femininity Scale; • Gender Disforia Scale; • Sexual Orientation Scale; • Sexual Action Scale.

In those scales evaluation we consider the results related to the age of the patient, and we may analise the evolution dynamics of the formation of gender identity, and sexual orientation. • We may evaluate if the unexpected femininity or masculinity is well structured or not, and with the anamnesis we may conclude about signs of different GID and GIDNOS possibilities. • Those tests may establish a differential diagnosis for transsex, transgenderism and crossdressing. • Any future referral letter for that patient will follow with that test report as an annex, for local clinicians, endocrinologists, psychologists, psychiatrists or surgeons

The Third Step • After the gender identity test, we need to know if the patient has no mental problems. We use, as most GID evaluators do, the MMPI for that purpose. • We observed after alot of evaluations, mainly when the GID or GIDNOS is due to a PTSD, sometimes the MMPI show some related problems. • Almost always there are signs of depression. • Almost never we see signs of BAD. • Mainly in PTSD GID generated, sometimes we see signs of disorders developed as a consequence of the GID or GIDNOS. • The main cause of those possible related disorders are derived from family and society exclusion.

In the worsest situations, we always suggest a local psychiatric follow up for those related disorders, mainly when we see also signs of PTSD. • Critical mental situations always are related to GID`s or GIDNOS derived from PTSD. • With that analysis we end our GID evaluation. If the result shows a F.64.0 or F.64.2 condition (transsex), or F.64.8 GIDNOS we may say as a transgender condition, we may start the transition and HRT. • Cross dressing diagnosis lead to a particular kind of therapy (F.64.1) that will be specific for each patient condition.

At the x axis we have MMPI scales.The scales order here is:L,F and K validation scales, one zero value, and later Hs, D, Hy, Pd, Mf, Pa, OCD, Sc, BAD, Si clinical scales. The y axis show T values.

Transsex and Transgender treatment • After we end the diagnosis evaluation, and the transsex or transgender condition is confirmed, we may start the treatment, with transition and HRT. • First of all we will need some pictures from the client – face, hair, body – in swimming clothes, to know the body and its necessities for good transition. • MtF transition will include – beard elimination, body poils elimination, hair vitalization, suggestions for FFS-face feminization surgeries, HRT-hormone therapy to develop secondary body characteristics, as breasts and a new fat distribution, all with a complete health care monitoring for the liver, circulation, prolactine, etc.. • We make the complete follow up of transition and HRT, even we may orient the local physicians. • FtM`s transition – We suggest controlled HRT, we prepare the patient for the best mastectomy, and other surgeries, etc..

When the patient needs any psychiatric follow up, we suggest a local expert to help those possible conditions. • Even if a local psychiatric follow up is needed due to any related mental disorder, we start transition and HRT when we know that will be the best way for the patient. In those situations, we have a very near follow up for transition, to see the reaction of the patient for that treatment. If we see any sign of problems, we stop the treatment immediately.

Transsex SRS –sex reassignment surgeries(F.64.0 e F.64.2 only) • MtF surgeries: • There exists a very good Brazilin technique (Dr.Jurado, Dr.Cury), mainly for mature people, when that is the ideal technique; • For the others, we suggest the Thai surgeons (Dr.Suporn, Dr.Preecha, Dr.Kamol e Dr.Saram). • American, Canadian and European surgeons are also very good, but much more expensive. • FtM surgeries: • We always suggest metoidioplasty; • There are very good surgeons in the world, USA (Dr.Peter Raphael, Dr.Meltzer), Canada (Dr.Brassard) and Belgium (Dr.Monstrey), for example.

The good SRS • Most SRS MtF and FtM surgeons think their surgeries are very good. • Most of them say, one week after SRS that the surgery was a success. • What Gendercare would like to say to those surgeons is... The good SRS we know only six months after surgery... • Because only after a perfect post op follow up, and a very careful follow up of the dilation on MtF SRS, for example, we may be sure it will be really functional. • Some SRS MtF are very beautiful from the outside... But has no minimum deepness to have a normal sexual life, due to lack of skin grafs, or lack of efficient instructions after SRS. • The good SRS we know after 6 months...

May we say transsex has a cure? • When I was in the XVth World Sexology Congress in Paris, in 2001, a French doctor said.... There is no cure for transsex. • I may not agree with him. • Today we may in most of cases, correct the bodies, even genitals, for the inner reality of the heart (the brain, the mind, the identity). From 16 yo to more than 70 yo, that is possible today, mainly for MtF`s (but soon for FtM`s too, surely). • Until 2001 almost all people thought, as the French doctor, it would be impossible to cure transsex situations. But today we know alot of situations have an almost perfect cure. • What has no cure, and probably never will have, are the psychic scars the ignorance and prejudice of authorities do in patients and victims. Human stupidity, sometimes has no limits. Even after a perfect correction, and a complete harmony between body and heart, some say... That is not a cure. The stupidity, most of the times, have no cure. • A transsexual that may live in complete harmony after maturity, will have so much psychical scars, that those scars will not have a cure, even when the GID had one.Her body is cured.... Genitals and brain are in harmony.... But the scars are there. • The earlier the evaluation and correction, the better, to limit psychic scars. That is the good way for GID cure.

The Transsex Cure • As soon as we can, we need to diagnose the GID child. • Parents need to observe the children, and if any GID sign be perceived, the best solution will be to contact Gendercare or any other GID service. • We may start the GID diagnose for children, at 5 yo, to have a complete diagnosis when the child has 10 yo. To achieve that goal, we developed in Gendercare our Game tests to diagnose GID children thru the Web. • At Holland, Belgium and Germany GID children diagnosis are commom, with very good results, for years. • After the diagnosis we may start transition and HRT from 10 yo to 14 yo. • At 16 yo we may have SRS (MtF-Thailand; FtM- Holland, Belgium, Germany, and at 18 yo, USA and Canada)

The SRS quality need to be almost perfect for GID children... As the Thai surgeries MtF... Today we have no perfect FtM solution... • Soon after SRS, with the least burocracy possible, the GID child needs new reassigned papers and social status. • From now on, with full existential and social harmony, feeling as a cured person, the child will be as productive as any other person in society. • Dr.Peggy Cohen Kettenis,PhD, from Holland and a HBIGDA director, says she has alot of successes treating GID children that way, with no failure, for years! • GID surely has a complete cure, when the children receive the professional health care they deserve. I may not say the same for Crossdressing and some GIDNOS situations, as transgenderism. • Transgenderism and most crossdressing situations have no complete cure... But in those cases, really who needs treatment and cure is our society, full of ignorance and aggressivity against the different.

The heart is the best way to define sex and gender today. • Gendercare proposes that new paradigm, from now on, in medicine, psychology, includding the law. • What we have between our legs need to be in harmony with what we have in our heart. That is the only way to have gender health in our society. • That paradigm will be the way for all GID and GIDNOS to live in peace and in harmony. • To live in inner harmony to have the possibility to be happy and live in peace, is a human right. • The End

PS:Dear English Speaking Friend • We are Brazilians, and our language is Portuguese. • Our Portuguese is reasonably good, but our English surely is very bad and poor. • Forgive us for our bad English translation of that presentation. • If you could help us with the English, tell us thru our contact page, please. • Thank you.

Gender Identity Disorders (GID)