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Amongst researchers, clinicians and TS themselves there is a lack of consensus regarding sexual orientation of those with GID. Again according to DSM. IV-TR, in F-M TS there is a predominant sexual attraction for females heterosexual and only a small minority refers sexual attraction for men Coleman et al. The feminine transsexual is of feminine biological gender, displays masculine social and gender roles, has masculine gender identification and usually heterosexual orientation occasionally he can be homo or bisexual.

The child s reactions are usually typical of the other gender. The term TS in exclusively applied to people with normal external genitals where discordance can only be applied to gender identity. The category of TS does not apply to individuals with undefined, or malformed, genitals, even if they have been educated as belonging to the wrong gender.

It is also pertinent to refer that according to Mead the concepts of masculinity and feminity are culture-bound variables, as are the gender roles deriving from those concepts. There are of course transsexual individuals in other cultures and these bear clear and distinctive characteristics shaped by their environment.

The TS phenomena cut across cultures, race, income levels and geographic regions Ramsey, The evolution of the very concept of transexuality enables us to observe the complex divergence of opinion and of unknown factors. Herein are referred theoretical cogitations, which however are not substantiated by scientific poor evidence.

The causes of TS have been examined from biological and psychological perspectives. It continues to be an arena of controversy largely colored by complex social and political strands making it a necessity for present dar clinicians to be aware of such a social context. Starting with recent research in the areas of animal behavior and evolution as well as genetic and brain dimorphism as yet more has left the land of hypothesis Saadeh, Nevertheless and gathering in all known data it would seem reasonable to assume that both biological and psychological factors somehow contribute to the development of TS, which would seem to be due to not just the cause but to a myriad of factors.

Biological Factors There is no single, clear evidence pointing to a biological cause for TS; nevertheless the investigations of biological causes continue to be investigated. From the beginning of the 90 s there has been considerable expansion on research of the biological mechanisms subjacent to psychossomal differentiation. Various hypothesis have been considered such as the interaction between brain development and sexual hormones or changes in chromosomes, molecular genetics, gene behavior, prenatal sexual hormones, pre natal maternal stress, maternal immunization, neurological processes, pheromones, anthropometric and neuroanatomical bases.

Some of the aforementioned dynamics have been studied in children and adults bearers of GID, in other subjects where the dependant. Abnormal development of perinatal endocrine levels an excess of androgens in the female sex and a deficiency of the same in the male; ii. The type of feedback as the response to luteinizing hormone LH after oestrogen stimulation; iii. Based on animal models, experimental research on sexual hormone impregnation of the brain lead the hypothesis of inadequate brain modification at pre-natal of perinatal stages Carrol, The importance of prenatal androgens in the developed of gender identity is pointed to in the adreno-genital syndrome and by androgen insensitivity as seen in the feminizing testis syndrome Brancroft, Such studies focus on the importance of parental hormonal balance Silveira Nunes, Dorner in 99, in his studies of hormone- dependent brain differentiation concludes that human sexual behaviour disturbances may be partly due to discordance between genetic sex and corresponding levels of sexual hormones at the moment of pre-natal brain differentiation.

Dorner in the same author further postulated that the necessary ingredient for male transexuality would be a pre-natal androgen deficiency, which would influence brain dimorphism, giving it female characteristics. However, further studies did. According to the same hypothesis androgen like hormones in greater quantities at prenatal phase could result in changes in the functional pattern of the female foetuses thereby facilitating on precipitating TS.

In this context the opposite could also happen; namely male foetuses undergoing neuro-functional changes due to the presence of feminizing hormones, which in turn would lead to the development, or facilitating of a feminine identity. Which is even more salient in the female brain; the author drew similar conclusions for male TS Dorner, Thus, according to Freitas women are feminine at neural and gonadal level, whilst the male TS are only feminine at the neural level. Again Dorner in 88, after examining the brain of human foetuses, demonstrated the existence of a critical period of neural sexual differentiation n humans directly recognisable at least in the pre-optic region of the hypothalamus that occurs and is complete between the fourth and the seventh month of gestation.

However these studies were not replicated by Goodman et al. As already mentions, hormonal influence during pre-natal phase may alter sexual development. The correlation between male hormones, brain development and differentiation and male and female behaviour has achieved frontline status in present day research Saadeh, However this hypothesis has yet needed to be proven Green, In most recent comparative studies the absence of the H-Y antigen in the male TS and its presence in the female TS reveal neither consistency nor specificity.

Electroencephalic disturbances or chromosomatic changes especially Klinefelter s syndrome may also be pointed to as biological markers of TS. However, these data provide quite a limited interest, since the great majority of transsexuals do not exhibit any changes at this somatic level Silveira Nunes, Anatomic studies trying to correlate the size of certain areas of the hypothalamus bed nucleus of the stria terminalis , between male transsexuals and women, have gathered some evidence.

Zhou, Hoffman, Gooren and Swaab in , performed a pertinent study on a determined brain region the hypothalamus, and they have concluded as being smaller in women than in men. In six male transsexuals, undergoing hormone therapy, they have shown a small hypothalamic region, similar to women. This result supports the hypothesis of an interaction between brain development and sexual hormones, as a path to gender identity In A sex difference in the human brain and its relation to transsexuality.

Nevertheless, these results should be carefully interpreted; the differences. As a consequence, the authors have concluded that, in transsexual patients, brain and genital differentiation goes in opposite directions and indicated the neurobiological basis of Gender Identity Disorder. Swaab, Chun, Kruijiver, Hofman and Ishunina refer that the differentiation of the hypothalamus occurs around four years of age, and it depends of genetic factors and also of prenatal hormones levels.

The same correlation between male behavior and androgens is also established by Gooren e Kruijiver Green highlights other indirect findings, still not conclusive, that have been suggested as biological markers. Rahman e Wilson, in , related the evidence, in homosexuals, of sexual hormones influence in sexual orientation, demonstrated through the analysis of the second and fourth hand fingers. Male and female homosexuals show a lower ratio between the second and the fourth finger when compared with heterosexuals. These data, according to the authors, bring evidence to the action of high doses of intra-uterine androgens.

In spite of its relation with sexual orientation, this genetic influence may be also related with the shaping of sexual identity in human beings Saadeh, Female transexuality in homozygous twins, although extremely rare, reveals the probable influence of genetics in the pathogenesis of this disorder. Others paths of research have pointed out the possible genetic basis for sexual identity. However, reports from clinical trials with discordant twins relatively to Gender Identity Disorder, have shown that genetic factors are not comprehensive in which the variation of cross gender behavior development Segal, Research has started to identify some independent dimensions, maybe biological, and based on children and adults characteristics with Gender Identity Disorder Gooren, , suggesting that it might have a biological basis.

There is little evidence to suggest that prenatal hormones play an important role on that level Meyer - Bahlburg, , since the great majority of these individuals are biologically normal. This has led some investigators to consider other alternatives that may affect the biological paths of psychosexual differentiation or to re-consider the prenatal hormonal theory in which hormones play a significant influence at brain level, but not genital.

In a global perspective, studies suggest that some genetic component, or other biological processes, may contribute to the development of Gender Identity Disorder American Psychological Association - APA, Psychological Factors Various psychosocial mechanisms thought to be associated to the genesis and maintenance of GID has been investigated.

Some have been shown to be incorrect, whilst. However, the emphasis has been very much on the complex psychosocial chain and the difficulties with the identification of the various processes and the understanding of their various impacts. For psychosocial factors to be considered as causes, it needs must be demonstrated that they influenced the emergence of a given crosssex behaviour in the first years of life.

If this should not be so, then such factors are best considered to be maintaining factors rather than predisposing. Thus various schools of thought have been salient regarding the influence of psychological factors on TS. It is neither a fantasy nor a different way of life.

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It is not a delusional idea as transsexuals has none of the clinical features of psychosis; it is not also a sexual perversion, but a disorder of identity: Contrary to these mentioned authors, others such as Kraft-Ebbing and Meyer consider that TS should be maintained in the category of the psychoses. Kraft-Ebbing in suggests that TS is a paranoid sexual metamorphosis, a psychosis characterized by the logical organization of delusional themes built upon false premises.

The delusion, a psychiatric disturbance defined by the persistence of ideas contrary to reality, is likewise the core belief in TS. Meyer postulates gender in dysphoria as a psychotic disturbance caused by grave intrapsychic conflicts. For Klotz the primordial cause, the very same that the courts demand that should be well defined, is that transsexuals are not delusional. They do not deny objective reality, knowing fully well that they possess a body in accordance with civil registry of gender, but consider that apparent reality is not in consonance with deep reality.

Notwithstanding that the majority of psychoanalysts consider TS to belong within the line of the perversions, there are paradoxical components. For Alby in 27, neurosis and perversion appear, in large measure, as mechanisms that enable to fight against castration anxiety. In TS that castration is asked for. Soccarides in maintains the classification of TS as a perversion and considers it to be a defence against an intense separation anxiety. Colona in 27 shares Alby s viewpoint, the transsexual s anguish is rooted before castration anxiety.

It is an archaic anguish of the same type as psychotic anguish, and in this context it may be considered as a psychotic prelude or as a defence against a global psychological drowning. Thus, transsexuality is an extremely profound aspect of depersonalization, although limited as to the infraction of exterior reality. Freud s theory relates to the quality of being a male and to masculinity as one of the principal and most natural of states, with both males and females considering being a female and femininity as less valuable Freud in , However the quality of maleness or femaleness is invaded by attributes of the other gender, so that innate bisexuality shall have consequences for both normal and abnormal development.

In boys, castration anxiety blocks what would otherwise be a tranquil path oriented towards masculinity and heterosexuality. They are thus forced to deal with their Oedipus conflict using techniques that avert the imagined castration. In girls the problems emerge from start and a fight to reach femininity will ensue. The way she deals with the. Anatomical differences allow for conflicts amongst boys, wherein the discovery of the creature without penis brings them nearer to the reality of the castration threat; in girls, the observing of the real penis accentuates its absence and consequent growth in jealousy.

Still yet in this context, men are better able than women to successfully overcome such barriers Stoller, Thus psychoanalytic theory is classically based on the innate bisexuality of human beings and strengthens the relationship between castration anxiety and the Oedipus complex in the development of masculinity and femininity Stoller, According to green TS could emerge from an excessive identification with the mother symbolic relationship. According to Money s model , in of the sequential development and gender identity differentiation, the necessary and complex integration of so many biological, psychological and social determinants must necessarily offer points of vulnerability of various kinds to the impact of pathogenic factors, themselves also of various kinds the behaviour of others may contribute to the establishment of identity and accordingly it can be expected that the style of treatment used by society, and more precisely by the parents, in educating the child, may assume a pathogenic influence Silveira Nunes, With the aim of illustrating the weight of socio-cultural factors, Money reports the case of two homozygotic male twins.

At the age of seven months and due to a surgical accident one of the boys had to undergo the amputation of his penis. Because of this the parents were advised to change the child s legal gender and to raise him as a girl. At 18 months the difference in both children s behaviour was already apparent, and around.

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This fact reveals the extraordinary modelling power of the environment on sexual dimorphism. In spite of the fact this had been the official version claimed by Money, reality proved to be quite different. Unlike what Money claimed to the world, the boy never got adapted to his new gender and this story better saying, this scientific fraud ended up in tragedy. Following a second sexual reassignment surgery, as an attempt to restore his original genetic gender, the boy committed suicide Albuquerque, In accordance with the Behaviourist Model, gender identity develops through processes of imprinting and conditioning.

When failures occur in these normal processes then gender dysphoria emerges. Quaglia suggests the existence of various causes which may lead to failures in the process of imprinting, leading thus to the emergence of TS: Numerical or structural changes in the sex chromosomes; ii. Poorly functioning foetal testicle; iii. Unusual stressing of the pregnant mother;. Intake of barbiturics or anti-androgenic substances by the pregnant mother during the critical period of brain imprinting; v. Tissue insensitivity to male hormones; vi.

Adverse environmental factors that would harm the boy s identification with the paternal figure, during infancy. In accordance with Money s theory , where he introduces biological factors either through hormones or cerebral sexual dimorphism , the author conceptualizes the existence of a critical period. Within this critical period, biological, psychodynamic as well as other variables such as parental expectations and educational styles influence the development of gender identity. Once this critical period is over the same factors cease to have any such influence.

Money in thus elaborates a triangular perspective: He thus constructed an analogy with the recognised critical period wherein genital differentiation occurs. Based on his own results Money braved the hypothesis that such a process as the acquisition and formation of gender identity could be compared with that of language acquisition Money, The same author also considered that around the age of fifteen months the elements of behaviour modulation needed for gender differentiation are already established.

Furthermore, through gender specific play activity, at the age of three years, the child confirms the awareness of her own gender identity Money, Based on clinical evidence it seems likely that transsexuality is established before the age of three years Stoller, ; Money, During this period, if not before, the child becomes amenable to the social phenotypes that typically differentiate between men and women and initiate a self-distinctive gender process Rabban, ; Paluszny et al. In accordance with the Cognitive Model, around the age of eleven years and coinciding with endocrine changes, gender identity is consolidated by the formation of logical thinking operations and abstract reasoning Gooren, The Social Learning Theories focus on the consolidation of the differentiation of stereotyped gender behaviours, which initiate after birth.

Sorensen and Hertoft emphasise TS as pathology of character. Using the two types of narcissistic characters described by Reich, the authors categorize male TS with a passive-feminine structure, and female TS with a phallic-narcissistic structure. TS with a given intra-psychic rigidity would bear an insecure sexual identity. The male TS would react to such a condition by emphasizing his passivity and assuming himself as a woman;. Other studies allusive to character pathology in TS, repeatedly refer to a borderline structure.

However, the fact that core gender identity is precociously established, from the age of eighteen to twenty four months, leads to the general acceptance that it is more easily pre-ordained than the possibly post-ordained character organization Silveira Nunes, According to Stoller the conviction of gender belonging is precocious, irreversible and essential. Gender identity represents the jointure of various elements, biological, biophysical, intra-psychic, parental and social, throughout the various stages of the individual s development.

Stoller in 27 integrates biological, ethological and psychoanalytic approaches, thus managing to elaborate a theory of aetiology stating: Thus, Stoller emphasises the existing symbiosis between the child and the parent of opposed gender. Gender identity is determined before the end of the second year and its development seems to occur in two timings: Symbiotic relationship with the mother, female and feminine proto feminine state; ii.

Elaboration of the gender identity within a separation process of the maternal symbiosis; this would be within a process of passive individualization in the girl, and active in the boy, who needs must disclaim his initial proto-femininity. The child is unable to learn where the mother ends and she herself begins, thus signing an excessive identification with the mother Silveira Nunes, Accordingly, Stoller refers that the parents of transsexual boys form a peculiar kind of couple: She would, herself would have had in childhood transsexual fantasies formed because of a repressed masculine behaviour in puberty, having to give way to the adoption of the feminine stereotypes, but without any real sexual benefit; the father is devalued and does not serve as an identification model.

For Stoller female TS is not equal to male TS, especially regarding the contribution of family dynamics. According to Silveira Nunes, , in female TS what emerges is a constellation practically inverse to that found in male TS, in as much as the mother is considered weak or depressed and the father as active or at times even brutal. Stoller points to a feminine mother who at the time of birth, or a little later in infancy, becomes separated, physically or psychologically , from her daughter, frequently because of an emotional illness, such as depression; and to a masculine father, who however is psychologically absent in at least two areas: Faced with such a family pattern the child not only fills the void left by the father, but also creates a sense of masculinity.

On the one hand, the little girl becomes a.


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Thus, the continuous repetition of this parental constellation, albeit without conflict, and then reproduced by others, reinforces the child s conviction of belonging to a certain gender. The determinism of female TS suggests to Stoller that the lack of a fusional relationship to the mother seems insufficient, and unconvincing to account for the little girl s systematic conditioning to masculinity, by the father. Neither is this a specific phenomenon to TS as it equally favours female homosexuality. Either consciously, or not, Stoller s belief is more or less implicit regarding sex the biological manifestation and gender the social and cultural manifestation.

A boy s feminine behaviour is based on the notion I know that I have a male sex, but in reality I am a girl, pointing to two different processes that of gender behaviour and gender identity awareness of, which will never be distinguished from each other, or voiced. Faure-Oppenheimer, For Stoller core gender identity is an irreversible conviction, which develops very precociously, without conflict, be it or not in accordance with biological gender, and remains fixed for life. According to Breton , Stoller went on to modify his own definition regarding the fixed nature of gender identity, core sexual identity in men is not totally immutable as previously and erroneously postulated.

Rather it always carries within itself the urgent need to regress to the original state of union with the mother. This latter conception seems more in consonance with the semiological variety encountered and also with the concepts of primary and secondary TS. As such TS is a pathological state, within the medical domain, as it is not a matter of choice. For Money causality in GID subdivides into genetic, pre-natal hormonal, post-natal social and post-puberty hormonal determinants, suggesting, there is no single cause for role identity nature in itself is not responsible, as neither is education or learning, singly.

All these factors act in synchrony, complementing each other. Even admitting a biological pre-disposition, which will affect the probability of a child adopting different degrees of typical versus atypical gender behaviour, it is also probable that many other factors will minimize or maximize the expression of the same. These other factors include parental response to cross-gender behaviour, the actual phenomology of the child s gender Martin et al, , and scans responses to the behavioural differentiation of crossed gender Rublo et al.

Those in favour of the diagnosis of GID, nevertheless argue against its definition as a mental disorder as this implies a diagnosis of the person as such, which provokes significant suffering and hampers functioning in various areas Fink, ; Spitzer, It is specifically argued that in itself GID is sufficiently handicapping even without social ostracism; it is made more so as all mental disorder diagnoses are stigmatizing. To take this argument to its logical conclusion would of course imply eliminating also all other diagnoses from the DSM.

On another, more pragmatic footing, but of extreme relevance, it needs must be pointed out that a diagnosis is essential for the provision of the necessary health care services. As Torres , points out, GID is not a mere social or existential problem; it is, rather, a health problem that necessitates health care resources for its treatment and diagnosis. There must be evidence of a strong and persistent cross-gender identification, which consists in the wish to, or in the insistence of belonging to, the other sex Criterion A. It is essential for this cross-gender identification to be more than a mere wishing to belong to the opposite sex because of perceived cultural advantages.

There must also be evidence of persistent discomfort with the person s own gender, or a sense of inadequacy with gender role Criterion B. The diagnosis is not made if the individual presents, simultaneously, a condition of physical intersex e. To make a diagnosis there must be clear evidence of clinically significant suffering or impairment in social, or professional functioning, or in other important areas of life Criterion D.

Appendix A In boys, cross-gender identification is manifest by a strong preoccupation with typically feminine activities. They may show preference for dressing in girl or women s clothes, or they may improvise such type of clothing using available items when the real thing is out of their reach. Towels, aprons or scarves are frequently used to represent long hair, or skirts.

There is a marked attraction for stereotyped feminine games and hobbies. They particularly like playing houses, drawing beautiful girls and princesses and watching television programmes or videos of their favourite female personages. Feminine stereotyped dolls are frequently the favourite toys; and their preferred games companions are girls. When playing house these boys take on female roles, frequently the mother and often are very preoccupied with images of female fantasies.

They avoid violent and competitive sports and show little interest in cars, trucks or non aggressive, but typically male toys. They may express the wish to become a girl, or assert that they will become. They may also insist on sitting to urinate and pretend not to have a penis, by squeezing it between their legs. More rarely, boys with GID may say that they find their penis and testicles repugnant and wish to remove them; they may assert that they wish to have, or indeed do have, a vagina.

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Girls with GID react strongly and negatively to the expectations of others e. Some may refuse to go to school, or social events, where such clothing has to be worn. They prefer boy s clothing and short hair, being frequently taken for boys, by strangers; they may even ask to be called by a male name.

Their imaginary heroes are frequently powerful male figures, such as Batman or Superman. These girls prefer boys as friends, sharing with them interest in sport, aggressive play and traditionally male games. They show scant interest in dolls, female clothing or typical activities.

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A girl with this type of disturbance may refuse to urinate sitting. She may claim to have developed, or to develop in the future, a penis, and refuse her breasts and menstruation. Sometimes such girls claim that they will be men when they grow-up. They also typically manifest a strong gender-crossed identity in their gender role, dreams and fantasies. Adults with GID are preoccupied with their desire to live as members of the opposite sex, which may be manifest by the intense need to adopt the other sex s social role and to change their appearance via hormonal and surgical procedures.

Individuals with this disturbance are not comfortable when observed by others, nor in functioning in society as a member of the sex by which they were designated at birth. In varying degrees they adopt the behaviour, clothing and mannerisms of the desired gender, whilst in private they may. Many try to be known, in public, as a member of the opposite sex. Through cross-dressing and hormonal treatment, plus electrolysis, in the case of men , many individuals with GID are successfully taken to belong to the opposite sex.

Their preference that their partners should neither see, nor touch, their genitals usually restrict the sexual activity of these people, with others of their biological gender. For some men who develop GID late in life, sometimes after marriage , sexual activity with their wives is accompanied by the fantasy that they are both lesbian lovers, or that the wife is a man, and he, himself, a woman.

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In adolescents, the clinical picture may be similar to the adult s, or to the child s, depending very much on the person s own level of development. Due to the typical defense mechanisms in place, it can be more difficult to make a precise diagnosis in the adolescent. These defenses may be even more intense if the adolescent is ambivalent as to the crossedgender identity, or if it is felt as unacceptable to the family. In such circumstances, the diagnosis of GID should be reserved for those who present a marked crossed-gender identification e.

Clarifying diagnoses in children and adolescents may require monitoring during a large time period. In individuals with GID, discomfort and impairment are manifest in various ways, throughout the life cycle. In young children distress is shown by the manifestation of unhappiness provoked by their biological sex. The preoccupation with crossed-gender desires frequently interferes with day-to-day activities.

In older children, the difficulty in. In both adolescents and adults the constant preoccupation with crossed-gender wishes frequently interferes in day-to-day life. Relationship difficulties are common and functioning at school, or work, may be compromised.

Accordingly, there is a need to codify the disturbance based on the person s present age. For sexually mature individuals the following specifications can be taken as the basis for the person s sexual orientation: Sexual attraction for men; ii. Sexual attraction for women; iii. Sexual attraction for both genders; iv. Appendix B These disorders are, according to the CID relatively uncommon and should not be confused with non conformity with stereotyped gender role behaviours, a. It is further recommended that the diagnosis should not be made if the individual has already reached puberty; furthermore the disorder must be present for more than six months to warrant the diagnosis.

Comparing the two classification systems, it is observed that the term transexuality and childhood sexual identity disturbance are organized in separate fashion. The Double Role Transvestism is also classified separately. In this classificatory system there is a clear steering away from the term transexualism and also a clear contemplation of the possibility that the person with GID may have sexual attraction for either, or both, sexes.

The Harry Benjamin International Gender Dysphoria Association s Standards of Care Another fundamental diagnostic reference is Guidelines for the care of Gender Identity Disorders, 6 th version , published by the Harry Benjamin International Gender Dysphoria Association presently known as the World Professional Association for Transgender Health WPATH , which in the introductory notes state very clearly that the aim of the Guidelines is to promote and coordinate consensus among international professional organizations regarding the features of, and the management of the psychiatric, psychological, medical and surgical treatments in gender identity disturbances.

Differential Diagnosis Beyond the aforementioned behavioural states which may be confused with transexuality, the specific gender ambiguities will be described The importance of the differential diagnosis cannot be overstated, when bearing in mind that the issuing surgery is irreversible. However, it is also true that the organic states of intersexuality, by virtue of their clinical features, do not usually present diagnostic difficulties.

Non conformity with typical gender role.

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In accordance with the DSM-IV-TR , the distinction between GID and gender role non-conformity lies in the depth and predominance of the cross gender desires, interests and activities. GID does not contemplate a child s non-conformity with stereotyped gender roles, as for example in the case of girls considered as tomboys, or boys with sissy behaviours. Rather, GID implies a profound disturbance of the person s sense of identity as to masculinity or femininity. It must not be applied to qualify the child who merely exhibits behaviour not in conformity with the cultural stereotypes of masculinity or femininity.

The diagnosis cannot be applied unless the full-blown syndrome is present, which needs must include discomfort and difficulties. According to the DSM-IV-TR , this condition occurs in heterosexual or bisexual men, for who cross-dressing has the purpose of provoking sexual arousal. Beyond transvestism, the majority of individuals with this condition do not refer a childhood history of cross gender behaviours. Men who meet diagnostic criteria for GID as well for fetishistic transvestism should receive both diagnoses.

If dysphoria is present in someone with fetishitic transvestism, but who does not meet criteria for GID, then the specification With Gender Dysphoria may be added. The subtype Gender Dysphoria allows for the clinician to note the presence of gender dysphoria as part of the fetishistic transvestism. In the schizophrenic psychoses, sometimes delusions of undergoing sex change are expressed; these are hallucinatory experiences of sex change. Breton considers that a filiation delusion is always subjacent to sexchange hallucinations, which, in turn, is always associated to full-blown personality and identity changes.

The insistence of belonging to the other gender, in GID sufferers, is not considered as a delusion, as such a belief invariably signifies that the person concerned feels as belonging to the other sex, but of course does not believe to be so.

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Nevertheless very rarely schizophrenia and GID may co-exist. However, suffering from a psychosis is considered as a formal contra-indication for sex-reassignment surgery. Turner s Syndrome implies the absence of the second feminine chromosome XO , wherein female hormones are not produced and gender identity is feminine.

Kleinfelter s Syndrome is characterized by a XXY genotype; the external genitalia, of male appearance, are usually small, with testicular atrophy due to low androgen production. People with this disorder are usually considered to be men. In True Hermaphoditism the individual presents at least one morphological contradiction, wherein gonadal tissue and the genitals are either discordant or opposing, as both female and male tissue are present, with XX or XY showing up in the chromatin.

Pseudohermaphroditism PH results because of endocrine or enzymatic deficiencies supra-renal hyperplasia in individuals with normal chromosomes. Thus, in Masculine PH at least one morphologically discordant feature is present, there is only male gonadal tissue and XY shows in the chromatin.

In this category, Breton includes the various forms of more unusual forms of gender dysphoria, such as transsexual crisis, depressive equivalents, genital dysmorphobia, impotence, the various types of marginal perversity, suggested transsexuality and masochism. Other Behavioural States Confused with Transsexuality There are other states in the human condition, of very diverse nature, but, nevertheless, often confused with transexuality. Homosexuality Filho and Pacheco define as homosexual somebody who has no desire whatsoever to change gender, and knowing to belong either to the male or female sex, seeks out another person of the same gender, with erotic purposes.

The authors state, when the male homosexual postures with feminine characteristics he does so as to better attract masculine men, even though he may have strong feminine traits in his personality. Albuquerque defines homosexuality as the preference for sexual behaviors, either real or in imagination, with people of the same gender, when the possibility of choice is available. Many homosexual men do not have female mannerisms, and there are effeminate men who are not homosexual.

Surely I cannot say that I have found the gene that determines sexual orientation I can only assert that the majority of homosexuals bear a mark in a very well defined zone of the chromosomes. It is likely, that in future the gene of sexual inclination, shall be found there Hamer,