480 CHAPTER 11
Given how little is known about the neurological, psychological, and social fac-
tors that contribute to gender identity disorder, we cannot comment on the nature
of any feedback loops among them.Treating Gender Identity Disorder
Treatments for gender identity disorder can target neurological (and other biologi-
cal), psychological, or social factors.Targeting Neurological and Other Biological Factors:
Altered Appearance
One way for people with gender identity disorder to achieve greater congruence
between the gender they feel themselves to be and the sex of their bodies is to alter
some or all of their biological sexual characteristics. This sort of treatment may
involve taking hormones: In biological women, taking androgens (i.e., male sex
hormones) will lower the voice, stop menstruation, and begin facial hair growth.
In biological men, taking estrogen or progesterone (i.e., female sex hormones) will
enlarge breasts, and redistribute fat to the hips and buttocks.
Some people with gender identity disorder go a step further and have sex re-
assignment surgery, a procedure in which the genitals (and breasts, for biological
women) are surgically altered to appear like those of the other sex. Sex reassign-
ment surgery for biological males involves creating breasts and removing most of
the penis and testes and then creating a clitoris and vagina. For biological females,
surgery involves the removal of breasts, ovaries, and uterus and then creating a pe-
nis. Patients may also have subsequent surgeries to make their facial features more
similar to those of the other sex. These surgical treatments can be prohibitively
expensive, however.
Sex reassignment surgery is technically more effective for biological men than
for biological women, in part because it is diffi cult to create an artifi cial penis that
provides satisfactory sexual stimulation (Steiner, 1985). Regardless of biological
sex, however, most people who have gender identity disorder are satisfi ed with the
outcome of their sex reassignment surgery, despite possible diffi culty in attaining
orgasm (Cohen-Kettenis & Gooren, 1999; Smith et al., 2005). However, up to 10%
of people who have this surgery (depending on the study) later regret it (Landen
et al., 1998; Smith, Van Goozen, & Cohen-Kettenis, 2001). Factors associated
with a less positive outcome after surgery are having unsupportive family mem-
bers (Landen et al., 1998), having a comorbid psychological disorder (Bodlund &
Kullgren, 1996; Midence & Hargreaves, 1997; Smith et al., 2005), and being psy-
chologically unstable prior to the surgery (Smith et al., 2005).
In an effort to reduce the proportion of people who come to regret having
sex reassignment surgery, those contemplating it are usually carefully evaluated
beforehand regarding their emotional stability and their expectations of what
the surgery will accomplish. A careful diagnostic evaluation and a long period
of cross-dressing are required by most facilities before sex reassignment surgery
is done.Targeting Psychological Factors: Understanding the Choices
Treatment that targets psychological factors helps those with gender identity dis-
order not only to understand themselves and their situation but also to be aware
of their options and goals (regarding living publicly as the other sex); treatment
also provides information about medical and surgical options. Such treatment is
typically provided by mental health clinicians specially trained in diagnosing and
helping people with gender identity disorder. These clinicians also help patients
identify and obtain treatment for any other mental health concerns, such as de-
pression or anxiety (Carroll, 2000). For those who choose to live part-time orCaroline Cossey, born Barry Cossey, increasingly
felt during adolescence that although she had
a male body, she was a female inside. When 20
years old, after a couple of years of taking female
hormones and living as a woman, Cossey had sex
reassignment surgery and later became a model
and actress.Ian Spratt
Sex reassignment surgery
The procedure in which an individual’s
genitals (and breasts, for biological women)
are surgically altered to appear like those of
the other sex.P SN