www.elsevier.es/rmuanl
REVIEW
ARTICLE
Gender
dysphoria:
An
overview
N.C.
Capetillo-Ventura
∗,
S.I.
Jalil-Pérez,
K.
Motilla-Negrete
PsychiatricDepartmentofthe‘‘Dr.JoséE.González’’UniversityHospitaloftheAutonomousUniversityofNuevoLeón,Mexico
Received31March2014;accepted3June2014 Availableonline6February2015
KEYWORDS
Genderdysphoria; Transsexualism; Genderidentity disorder; Multidisciplinary treatment
Abstract Gender dysphoria, gender identity disorder or transsexualism is a psychological
conditionthatrequirescareandmultiplehealthprofessionals;endocrinologists,surgeonsand psychiatristsarejustsomeoftheprofessionalsneededtoaddressthesesituations.The follow-ingarticleisasummaryofwhattranssexualitymeans,itshistoryandtreatment,asmoreand morepeoplerequestourserviceswithatherapeuticapproach.
©2014UniversidadAutónomadeNuevoLeón.PublishedbyMassonDoymaMéxicoS.A.Allrights reserved.
Introduction
Gender identity defines the extent to which each person identifiesthemselvesasmale,femaleor acombinationof thetwo.Itistheinternalreference,builtovertime,which allows individuals toorganize a sense of self andbehave sociallyaccording tothe perception of theirown sexand gender.Genderidentitydeterminesthewaypeople experi-encetheirgenderandcontributestotheirsenseofidentity, singularityandofbelonging.1
Gender identity disorder is defined as the inconsis-tency between physical phenotype and gender. In other words,self-identificationasamanorawoman.Experiencing
∗Corresponding author at: Departamento de Psiquiatría del HospitalUniversitario‘‘Dr.JoséEleuterioGonzález’’,delaUANL Monterrey,NuevoLeón,Ave.FranciscoI.MaderoyGonzalitosSN, Col.MitrasCentro,C.P.64460,Mexico.Tel.:+528183480585.
E-mailaddress:dranellycv@hotmail.com (N.C.Capetillo-Ventura).
thisinconsistency isknownasgender dysphoria.Themost extremeform,wherepeopleadapttheirphenotypetomake itconsistentwiththeirgenderidentity,throughtheuseof hormonesandbyundergoingsurgery,iscalled transsexual-ism.Individualswhoexperiencethisconditionarereferred toastrans, thatis trans men (womanto man)and trans women(mantowoman).2,3
Stoller4established,inSexandGenderVol.1,the
distinc-tionbetweenanatomicalandphysiologicalsex,beingaman orwomanandgenderidentitythatmasculinityand feminin-itycombinein anindividual.Hedefinedtranssexualismas ‘‘theconvictionofabiologicallynormalsubjectof belong-ingtotheoppositesex’’.Inanadult,nowadaysthisbelief comeswithademandforendocrinologicalsurgeryinorder tomodifytheiranatomicalappearancetothatofthe oppo-sitesex.4Becerra5alsoexpressesthisideainhisdefinition
oftranssexualism.Hepointsoutthatthereisaconvictionof transsexualstobelongtotheoppositesex,withaconstant dissatisfactionof their ownprimary andsecondary sexual characters,withadeepsenseofrejectionandanexpressed desiretosurgicallychangethem.5
http://dx.doi.org/10.1016/j.rmu.2014.06.001
In general, they refer to transsexuals as women who feel‘‘trapped’’inaman’sbody,andviceversa.Regarding diagnosticclassifications,startingwiththeFeighneretal. criteria,theyconsiderthatoneofthefivenecessary crite-riatomakeatranssexualismdiagnosisisthestrong desire tophysicallyresembletheopposite sexthroughany avail-ablemeans: forexample,howtodress,conductpatterns, hormonetherapyandsurgery.6
Transsexualspresentasexualorientationwithinthesame rangeofpossibilitiesasheterosexuals, inother words, by thesamesexortheoppositesex,bothorneither.Another classification of transsexualism is the one proposed by Gooren,7 Herman-Jeglinska8 andLandén9 whomakea
dis-tinction between early or primaryand late or secondary. Theyexplainthatwithinearlyorprimarytranssexualisman inconformityisnoticeablefromanearlyage,effeminateor masculinebehaviorduringtheirchildhood,aversionfortheir bodies,asenseofbelongingtotheoppositesex,no fluctua-tionsingenderdysphoriaandsame-sexsexualattraction.On theotherhand,lateorsecondarytranssexualsdetecttheir conditionapproximatelyafter35yearsof age,throughout theirlivestheyhavehadtransvesticepisodes,andthereis ahighprobabilityforthemtofeelregretfulaftertheir gen-derreassignmentsurgery,theirsexualorientationfluctuates from heterosexuals to bisexuals, occasional homosexuals andhomosexuals.7---9
History
Transsexualism is not a new phenomenon. It has existed for many years and in different cultures. In 1869, West-phaldescribed a phenomenon hecalled ‘‘conträre sexual empfinding’’ which included some aspects of transsex-ualism. Later, in 1916, Marcuse described a type of psychosexual inversion which led toward sex change. In 1931, Abraham referred to the first patient who had an anatomic sex change performed. In 1894, Krafft-Ebing describedawayofdressingaccordingtotheoppositesex, whichhecalled‘‘paranoidsexualmetamorphosis’’.In1966, HarryBenjaminmadetheterm‘‘transsexual’’popular,and in 1969, John Money coined the concept ‘‘Gender Reass-ignment’’,withtheintentionofincludingdifferentstates wherethebasiccharacteristicisanalterationofsexual iden-tityandgender.Moneysuggestedtheconceptofgendermaps orgenderschemeswhichencompassmasculinity,femininity andandrogenic codes in the brain. These maps wouldbe establishedearlyinlifeandwouldbehighlyinfluencedby hormonesduringpregnancy.Finally,in1989,RayBlanchard suggestedtheterm‘‘autogynephilia’’asthepropensityto besexuallyactivethinkingofoneself(aman)asawoman. Thisdefinitionsuggests,fromapsychopathological perspec-tive,apossiblealterationordeeppsychologicalvariationof thesenseofidentity,inbodyidentification(genital)aswell asmentalidentity(theideaofone’sgender).10
American endocrinologist Harry Benjamin compiled observationsabouttranssexualismandtheresultsofmedical interventionsinhisbook‘‘Thetranssexualphenomenon’’.11
The term ‘‘gender dysphoria syndrome’’ wasproposed in 1973, which includes transsexualism in addition to other gender identity disorders. Gender dysphoria is used to describetheresultingdissatisfactionoftheconflictbetween
gender identity and assignedsex. In 1980, transsexualism appeared asadiagnosisintheDSMIII (Diagnosticand Sta-tistical Manual of MentalDisorders, third edition). In the followingrevisionofthismanual(DSMIV)in1994,theterm transsexualismwasabandoned,beingreplacedbytheterm gender identity disorder (GID) to describe those subjects who show a strong identification to the opposite gender and a constant dissatisfaction with their anatomical sex. In the DSM-V,the term gender identity disorder hasbeen replacedby theterm gender dysphoria.The International Classification ofDiseases, tenthedition (ICD10) mentions five different forms of GID, using, once again, the term transsexualism to refer to one of these forms. In 1979 theHarryBenjaminInternationalGenderDysphoria Associa-tion(HBIGDA)wasfounded,approvingguidelineswhichare reviewed periodicallyandwork asguidancefor GIDs. The lastreviewwasin2001.
Epidemiology
Studiesoftheepidemiologyoftranssexualismarescarceor nullinmostcountries.12,13 Thebestestimateofthe
preva-lenceofGIDortranssexualismcomesfromEurope,witha prevalenceof1in30,000menand1in100,000women.The majorityofclinicalcentersreportthreetofivemalepatients foreveryfemalepatient.14
InMexicothereislimitedepidemiologicaldataon trans-sexualism. There is evidence, unsupported by scientific research,suggestingthepossibilityofanevenhigher preva-lence:(1) sometimes previously unknown gender problem diagnoses are made when treating patients with anxiety, depression, bipolar affective disorder, conduct disorders, drugabuse,identitydissociativedisorders,borderline per-sonalitydisorders,diversesexualdisorders,andintersexual conditions;(2)itis possiblethatsomemaletransvestites, cross-dressers,transgender,andmaleandfemale homosex-uals,whodonot showupfor treatment, have someform ofgenderidentitydisorder;(3)theintensityofthegender identitydisorderinsomepeoplevaries;(4)gendervariation amongpeoplewithfemininebodiesisusuallycomparatively invisibletosociety,especiallyprofessionalsandscientists.
Etiology
There are several biological proposals that attempt to explain gender dysphoria conditions and homosexuality, rangingfromgeneticlevelsandprenatalalterations,tohigh hormonelevelsandexternalfactorslikestress.15
Inregardtocerebraldifferences,ithasbeenknownfor sometimenowthatsomestructuresaredifferentbetween menandwomen,thusspecialattentionhasbeenplacedon these structures in people with gender dysphoria. Differ-entstudieshavebeenconductedtoobservethecentralbed nucleus ofthestriaterminalis,whichisinvolved insexual dimorphismfunctions,includingaggressiveconduct,sexual conduct,andthesecretionofgonadotropins,whicharealso affectedbygonadalsteroids.2
numericrangeandtheoppositeoccurswithtransW---Mwho aresimilartomen.16Inotherwords,size,innervationtype
andneuronnumberagreewithgenderandnotwithgenetic sex. Unfortunately, this differencemanifests during early adulthood, which meansthat thisnucleus cannot beused forearlygenderdysphoriadiagnoses.17
Various authors concludethat the factorswhich affect genderduringearlydevelopmentareprenatalhormonesand thecomponentsthatchangethesehormonelevels.Whilean influenceingeneticfactorsmustbepresent,aninfluenceby postnatalsocialfactorshasnotbeen established.Inmice, masculinizationofthedevelopingbrainisduetoestrogens formedbytestosteronearomatization.Inthesexual differ-entiation of human brains, direct effects of testosterone seem to beof great importance. Aclear example of this issubjectswithmutationsinandrogenreceptors,estrogen receptorsoraromatase.18
The periodwhere the human hypothalamus’ structural sexualdifferentiationoccursisbetween4yearsofageand adulthood,muchlaterthanitisusuallypresumed.However, theendofsexualdifferentiationmaybebasedonprocesses alreadyprogrammedinthemiddle ofpregnancyor during theneonatalperiod.17---20
Peoplehavetriedtoexplainitsetiologyindifferentways. Forexample,SigmundFreudbelievedthatgender identity problemsweretheresultsofconflictsexperiencedby chil-dren in the Oedipal triangle. These problems are fueled by real family developments as well as the child’s fan-tasies. Everything that interferes withthe love the child feelstoward his/herparentofthe oppositesex, andwith his/heridentificationwiththeparentwhosharesthesame sexalso interferes with normal gender identity.14 Gender
identityisanorganizingnucleusofthepersonality.20
Rodriguez Lamarque reports the evaluation and treat-mentof9menandagirlwithgenderidentitydisorderand observeshowthe parents’personality disorderspositively affected their marital dysfunction. This, combined with theirpersonalitypathologies,wasadeterminant contribu-tion (not the only one) in the genesis of their children’s genderidentitydisorders.21
Diagnosis
Inordertomakeaprecisegenderdysphoriadiagnosis,we usetheICD10criteria,aswellastheDSM-Vcriteria.
ICD-10definestranssexualismasthedesiretoliveandbe acceptedasamemberoftheoppositesex,whichisusually accompaniedbyfeelingsofdiscomfortordisagreementwith theirownanatomicsex,aswellasthedesiretoundergo sur-gicaland/orhormonetreatmentsothattheirbodiesmatch as much as possible with the preferred sex. In order to diagnose it, transsexual identity must have been present constantlyforatleasttwoyearsandnotbeasymptomof anothermentaldisorder,likeschizophrenia,orsecondaryto anyintersexual,geneticorsexualchromosomeanomalies.
Ontheotherhandsexualidentitydisorderinchildhoodis definedasadisorderwhichmanifestsclinicallyforthefirst time during early childhood (always long before puberty) characterizedbyanintenseandpersistentdiscomfortdue to the person’s own sex, along with the desire (or insis-tence)ofbelongingtotheoppositesex.Thereisaconstant
concernabouttheoppositesex’sclothesandactivitiesora rejectiontowardtheperson’sownsex.Thesedisordersare believedtoberelatively rareand shouldnotbeconfused witha lack ofaccordancewiththe sociallyaccepted sex-ualrole,whichismuchmorefrequent.Adiagnosisofsexual identitydisorderduringchildhoodrequiresadeepalteration inthenormalsenseofmasculinityorfemininity.Simple mas-culinizationofhabitsingirlsoreffeminationinboysisnot enough.Diagnosiscannotbemadewhentheindividualhas reachedpuberty.22
However,DSMV’sdiagnosticcriteriaaredividedinto gen-derdysphoriainchildrenandgenderdysphoriainteenagers and adults. Gender dysphoria in children is defined as a stronginconsistencybetweenthesexonefeelsorexpresses andtheoneassigned,withdurationofatleastsixmonths, whichmanifest inatleastsixofthefollowing characteris-tics:
• Astrongdesiretobelongtotheoppositesexoran
insis-tencethatheorshebelongstotheoppositesex(orfrom analternativesexdifferentfromtheoneassigned).
• In boys (assigned sex), a strong preference for
transvestism, or for simulating feminine attire; in girls (assignedsex)astrongpreferencefordressingonlyin typ-icallymasculineclothesandastrongresistancetowearing typicallyfeminineclothes.
• Astrongandpersistencepreferencetoplaytheopposite
sex’sroleorfantasiesaboutbelongingtotheoppositesex.
• A strong preference for the toys, games and activities
customarilyusedorpracticedbytheoppositesex.
• Astrongpreferenceforplaymatesoftheoppositesex. • Inboys(assignedsex),astrongrejectiontotypically
mas-culine toys, games and activities, as well as a strong avoidancetoroughplay;ingirls(assignedsex),astrong rejectionoftoys,gamesandactivitieswhicharetypically feminine.
• A strong discontent with the individual’s own sexual
anatomy.
• Astrong desiretohavethe primaryandsecondary
sex-ualcharacteristicscorrespondingtothesextheindividual feels.
Theproblemisassociatedwithaclinicallysignificant dis-comfortordeteriorationinsocial,schooland/orotherareas importanttofunctioning.
Ingenderdysphoriainteenagersandadultsthereisalso astronginconsistencybetweenthesextheindividualfeels andexpressesandtheoneassigned,withadurationofat leastsixmonths,manifestedbyatleasttwoofthefollowing characteristics:
• A strong inconsistency between the sex the individual
feels or expressesand his or her primaryor secondary sexualcharacteristics(orinyoungteenagers,visible sec-ondarysexualcharacteristics).
• A strong desire to detach from their own primary or
• Astrongdesiretopossessprimaryandsecondarysexual
characteristicscorrespondingtotheoppositesex.
• Astrongdesiretobelongtotheoppositesex(oran
alter-nativesexdifferentfromtheoneassigned).
• Astrongdesiretobetreatedasanindividualofthe
oppo-site sex (or an alternative sex different from the one assigned).
• Astrongconvictionthatonepossessesfeelingsand
reac-tions typical of the opposite sex (or an alternative sex differentfromtheoneassigned).
The problem isalso associatedwitha clinically signifi-cantdiscomfortordeteriorationinsocial,workand/orother areasimportanttofunctioning.23
However, the psychiatric evaluation must include a comorbiditystudy inordertogivea propertreatment, as describedlater.
Treatment
The effectiveness of any pharmacological treatment to reduce the desire to change sexes has not been proven. When sexual dysphoria is severe and untreatable, sexual reassignmentmaybethebestsolution.24
Psychotherapywiththeobjectiveof‘‘curing’’ transsexu-alism,inordertogetthepatienttoacceptoneselfasaman ora woman,isuseless withthecurrentlyavailable meth-ods.The transsexualmindcannot bechangedintoafalse gender orientation.Everyattempt therethathas been to dosohasfailed.Thetranssexualmindcannotadjusttothe body,thusitislogicalandjustifieddoingtheoppositeand tryingtoadjustthebodytothemind.Besidespsychological orientation,thishelphasbeengiventhroughtwodifferent therapeuticmeans:hormonemedicationandsurgery.
Apsychiatricevaluationmustprecedeallgender reass-ignmentsurgicalprocedures,inordertoestablishnotonly thepossible existence ofpsychosis, but alsoa reasonable degreeofintelligenceandemotionalstability(Fig.1).11
Nowadays the internationally accepted medical treat-ment protocols to treat these people includes sexual reassignmentsurgery,providedthatthepatientmeets cer-taineligibilityanddisposition criteria.The mostaccepted protocolfor the sex-reassignmentprocessis basedonthe standardsproposed during the eighties bythe Harry Ben-jamin International Gender Dysphoria Association, which recommends a therapeutic triad (psychological, hormonal and surgical), determining specific eligibility criteria and additionalformsobligingthefulfillmentoftherapeuticand surgicaltherapies.11---25Thisassociationhaschangednames
andiscurrentlyknownastheWorldProfessionalAssociation forTransgenderHealth(WPATH).
Aftera GID diagnosis, thepsychotherapist’s focus gen-erallyincludesthreeelementsorstages(sometimescalled triadtherapy): a life experiencein thedesired role, hor-monesofthedesiredgenderandasurgerytochangegenitals andothersexualfeatures.
Mentalhealthprofessionalswhotreatpeoplewithgender identitydisordersareexpectedtoundertakemanyofthese responsibilities:
Yes
Treatment Treatment
Symptom of a mental disorder
Psychiatric evaluation
Intellectual
discapacity Comorbidities
Recommendations of available treatments
Urology, Surgery, Endocrinology and others
Refer to the mental health professional for:
No
Patient with gender dysphoria
No Yes
To begin tripartite therapy
Psychotherapy (if required)
Hormone treatment
Surgery
Figure1 TICflowchart.
• Accuratelydiagnose thepatient’s genderidentity
disor-der.
• Accuratelydiagnoseanycomorbidpsychiatricconditions
andperformappropriatetreatment.
• Advisethepatientregardingtheavailablerangeof
treat-mentsandtheirconsequences.
• Providepsychotherapy.
• Evaluatethepatient’s eligibilityand suitabilityfor
hor-moneandsurgicaltherapies.
• Makeformal referralsto colleagues(doctors, surgeons,
etc.)
• Describethepatient’srelevanthistoryinareferral
cer-tificate.
• Bepartofagroup ofprofessionalsinterestedingender
identitydisorders.
• Educaterelatives,employersandinstitutionsabout
gen-deridentitydisorders.
• Make oneself available to the patients for follow-up
treatments.26
trial-and-error approach depending on their affordability onthemarket.Similarsituationshavebeenfoundinother studies,27---29reflectingtheproblemsthatthesepatientshave
in ordertoobtain hormonetreatments inpublichospitals in and out of Spain, consequently increasing the risk of complications.30 Despitethefactthattherearenosimilar
studiesinMexico,weshouldtakethedataintoaccountgiven therisksthatself-medicationinvolves.
It is alsointeresting topoint outthe need for integral andintegratedmedicalattentioninthepublichealth ser-vicesfor peoplewithgenderidentitydisorders.Beingable toguaranteethistypeoftherapywillbefinancedbypublic health,31inadditiontoprovidingpropertreatment,willend
theagonytranssexualsgothroughwhensearchingillegally forthe mostdiversetreatments,whichendangernotonly theirmentalhealthbuttheirlives.Thisconstantsearchfor solutionshasfavoredthemarginalityandstigmatizationof transsexuals.26---31
GID patients must be treated by a multidisciplinary team:thepsychiatristor psychologist isthe firstonewho usually sees them, and if the patient goes to see the endocrinologist, he/she should refer the patient to the psychiatrist/psychologist.Theseprofessionalsshare respon-sibilities in the decision to begin hormone and surgical treatment,along withthe physicianwhoprescribes them. Hormonetreatmentoftenalleviatesanxietyanddepression inpatientswithouttheneedofrecurringtoadditional med-ication.Theexistenceofanotherpsychopathologydoesnot excludesurgery,butitmaydelayit.31
Conclusions
Whilegender dysphoriaisafrequent diagnosisin our pro-fessionalandsocialfield,thereislittleresearchaboutthe subjectandthereisalackofpreciseinformationaboutthe prevalenceofthisdiagnosisinMexico.Inaddition,thereisa lackofguidelinestoapproachthesepatients.Thissituation causes the treatment to be performed in a partial man-ner,withouttakingintoaccountthattheproperapproach includes atleast acouple ofhealth professionalswhoare inchargeof guiding,informingandassessingthepatient’s physicalandpsychologicalcondition.
It is our duty as health professionals to promote a multidisciplinary approachwhich allows gender dysphoria patientstoimprovetheirqualityoflifeanddecreasetheir presentsymptomatology.
Conflict
of
interest
Theauthorshavenoconflictsofinteresttodeclare.
References
1.ActasdeunaReunióndeConsultaconvocadapor:Organización Panamericanade la Salud (OPS) Organización Mundial de la Salud(OMS)EncolaboraciónconlaAsociaciónMundialde Sex-ología(WAS)Celebradaen:AntiguaGuatemala,Guatemala19 al22demayode2000.
2.Allen LS, Gorski RA. Sex difference in the bed nucleus of the striaterminalis of the human brain. J Comp Neurol. 1990;302:697---706.
3.BatesDJ. Locatingthetranssexualnarrativeinthegendered landscape.NewZealand:TheUniversityofWaikato;2002.p. 437.
4.StollerRJ.Sexandgender.I.NuevaYork:Karnak;1968. 5.Becerra A. Transexualidad. La búsqueda de una identidad.
Madrid:DíazdeSantos;2003.
6.FeighnerJP,RobinsE,GuzeS,etal.Diagnosticcriteriaforuse inpsychiatricresearch.ArchGenPsychiatry.1972;26:57---63. 7.GoorenL.Thebiologyofhumanpsychosexualdifferentiation.
HormBehav.2006;50:589---601.
8.Herman-JeglinskaA,GrabowskaA,DulkoS.Masculinity, femin-ityandtranssexualism.ArchSexBehav.2002;31:527---34. 9.LandénM,WalinderJ,LundströmB.Clinicalcharacteristicsofa
totalcohortoffemaleandmaleapplicantsforsexreassignment: adescriptivestudy.ActaPsychiatrScand.1998;97:189---94. 10.GastóFerrerC.Transexualidad.Aspectoshistóricosy
concep-tuales.CuadMedPsicosom.2006:78.
11.HarryBenjaminMD.Thetranssexualphenomenon.NuevaYork: TheJulianPress,Inc.Publishers;1966.
12.Michel A, Mormont C, Legros JJ. A psycho-endocrinological overview of transsexualism. Eur J Endocrinol. 2001;145: 365---76.
13.Landén M, Wälinder J, Lundström B. Prevalence, incidence and sex ratio of transsexualism. Acta Psychiatr Scand. 1996;93:221---3.
14.Sadock B, Sadock V. Sinopsis de psiquiatría. Décimaedición. Philadelphia: Wolters Kluwer/Lippincott Williams &Wilkins; 2009.
15.OrozcoG,Ostrosky-SolísF,SalinR,etal.Basesbiológicasde la orientaciónsexual: un estudio de lasemociones en tran-sexuales.RevNeuropsicolNeuropsiquiatrNeurocienc.2009;9: 9---24.
16.KruijverFP,ZhouJN,PoolCW,etal.Male-to-female transsex-ualshave femaleneuronnumbersinalimbicnucleus.JClin EndocrinolMetabol.2000;85:2034---41.
17.ChungWC,DeVriesGJ,SwaabDF.Sexualdifferentiationofthe bednucleusofthestriaterminalisinhumansmayextendinto adulthood.JNeurosci.2002;22:1027---33.
18.SwaabDF.Thehumanhypothalamus.Basicandclinicalaspects. PartI.Nucleiofthehypothalamus.PartII:Neuropathologyof thehypothalamusandadjacentbrainstructure.In:Handbook ofClinicalNeurology.Amsterdam:Elsevier;2003---2004. 19.Zhou JN, Hofman MA, Gooren LJG, et al. A sex difference
inthehumanbrainanditsrelationtotranssexuality.Nature. 1995;378:68---70.
20.KernbergP,WeinerAS,BardensteinKK.Personalitydisordersin childrenandadolescents.NewYork:BasicBooks;2000. 21.RodríguezMI.Trastornosdelaidentidaddegéneroenlani˜nez.
PerinatolReprodHum.2001;15:52---9.
22.CIE 10. Trastornos mentales y del comportamiento. Madrid: Meditor;1994.
23.American Psychiatric Association. Diagnostic and statistical manualofmentaldisorders.5thed.Arlington, VA:American PsychiatricPublishing;2013.
24.The Harry Benjamin International GenderDysphoria Associa-tion. Thestandardsofcare forgenderidentitydisorders(6a version).Minneapolis:HBIGDA;2000.
25.FernándezM,García-VegaE.Variablesclínicaseneltrastorno deidentidaddegénero.Psicothema.2012;24:555---60. 26.EstevaI,GiraldoF,BergeroT,etal.Evaluaciónendocrinológica
ytratamientohormonaldelatransexualidadenlaUnidadde TrastornosdeIdentidaddeGénerodeAndalucía(Málaga).Cir PlástIberolatinoam.2001;27:273---80.
27.GómezGilE.Laatenciónalatransexualidadporlaunidadde saludmentaldelHospitalClínicde Barcelonaen losúltimos a˜nos.CuadMedPsicosomPsiquiatrEnlace.2006;78:55---64. 28.Blanchard R,Clemmensen LH, SteinerBW. Heterosexual and
29.Becerra A, de Luis Román DA, Piédrola G. Morbilidad en pacientestransexualesconautotratamientohormonalparael cambiodesexo.MedClín.1999;113:484---7.
30.GordonEB.Transsexualhealing:medicalfundingofsex reass-ignmentsurgery.ArchSexBehav.1991;20:61---74.
