In Japan, greater numbers of people with gender identity disorders (GID) are seeking professional help. The aim of our study is to show the clinical significance of classifying them into two subgroups when we address biological males with GID. From January 2001 to August 2009, 27 biological male patients with GID were consecutively examined at a university hospital in a major city in Japan. We formulated patients' own past history concerning their gender identity on the basis of their narratives presented in several interviews. The present study suggested that Japanese biological male patients with GID who have, since childhood, manifested a special longing for feminine clothes and behaviors, could be positioned as a "core group;" and, patients with an uncomfortable feeling about their own sex that did not appear until adolescence could be positioned as a "periphery group." As a result of psychotherapy in our samples, while the "core group" patients did not waver in their conviction that "I am a woman," the cross-gender identification eventually disappeared in the "periphery group." Identifying these two subgroups proved to be of great importance in deciding the management strategy for biological males with GID.
Keywords: gender identity disorder; transsexualism; core group; periphery group; subtypes
In recent years, studies on the causes of gender identity disorder (GID) have investigated aspects from the biological (Levin & DeFrank, 1988; Lobel, 1994; Ward, 1991) to the psychosocial (Lothstein, 1988; Zucker, Bradley, & Ipp, 1993), but findings have varied and no consistent conclusions have been reached. In Japan, since the guideline for the treatment of GID was published in 1997, greater numbers of people with this disorder are seeking professional help, and we have begun to see studies dealing with this disorder (Yamauchi, 2001). Various patterns at onset and sexual attraction in them were indicated (Furuhashi, 2008; Okabe, Sato, Matsumoto, Ido, Terada, & Kuroda, 2008). Thus, we cannot deal with them uniformly as a single-condition "GID." Clarification of what is occurring in these people is an urgent task to develop appropriate strategies for their treatment.
From our clinical experience in Japan, in typical biological male patients, a special longing for feminine clothes and behaviors already begins in childhood. Later, with the progression of their secondary sexual characteristics, they begin to feel discomfort with their own sex. There is also another group that only begins to experience discomfort with their own sex in adolescence, and this discomfort persists. Some people in this latter group come to have the desire to be of the other sex after adolescence. Such cases also satisfy diagnostic criteria for GID, as defined by the DSM-IV-TR. In these cases, however, the desire to be of the other sex is merely temporary.
At present, GID is thought to be incongruence between gender (self-awareness of one's own sex and gender role) and sex (biological sex; American Psychiatric Association [APA], 2010). The desire to be of the other sex (called cross-gender identification herewith) and discomfort with one's own sex must be present for a diagnosis of GID according to the DSM-IV-TR (APA, 2000). The following is a brief look at the history that led up to this definition.
Three divisions were introduced in the 1960s through 1970s: gender identity, gender role, and sexual orientation. This was due to the frequent clinical observation by Stoller of what is now called GID. Stoller (1968) thought that gender identity might be fixed by approximately 18 months of age from observations of children who had developed at variance from their own biological sex.
We should note that in the current of thought following Stoller, Fisk (1973) suggested a syndrome called "gender dysphoria." He considered that transsexualism and gender dysphoria were opposed to each other. According to Fisk's definition, sex reassignment surgery was indicated in cases of primary transsexualism, and gender dysphoria was secondary transsexualism. …