Wider understanding of trans people’s struggles needed to address complex issues: Local case report

10 Jan 2022

Wider understanding of trans people’s struggles needed to address complex issues: Local case report

10 Jan 2022

BY Ruwan Laknath Jayakody Since both internal and external transphobia could force trans individuals to live a life they do not enjoy, a wider understanding of the unique struggles of each trans individual is needed in order to address their complex issues successfully. This observation was made by P. Ginige (attached to the University of Peradeniya’s Medical Faculty’s Psychiatry Department) and H.K.K.I. de Alwis (attached to the Peradeniya Teaching Hospital’s Psychiatry Unit) in a brief report on “A challenging case of transsexualism” which exemplified the diagnostic difficulties in this field, particularly when there are comorbid challenging personality traits and mental health disorders involved, and which was published in the Sri Lanka Journal of Psychiatry 12 (2) in December 2021. According to the International Statistical Classification of Diseases and Related Health Problems 10th Revision Classification of Mental and Behavioural Disorders, the term “transsexualism” is used when an individual seeks or has undergone a social transition from the birth sex to the preferred sex, usually involving treatment with hormones or surgery. It is, Ginige and de Alwis pointed out, a condition that lies within the diverse spectrum of gender dysphoria, the current management of which is based mainly on guidelines prepared on expert consensus rather than a robust evidence base. Therefore, Ginige and de Alwis presented a case which exemplifies how transsexualism demands a deeper and wider understanding, given the complexities of its presentations. Case report A 39-year-old married businessman presented, expressing the need to become a woman. He reported that he had wished to be of the female sex from the age of 10 years. He had behaved and felt like a boy until then. He had thereafter increasingly started living in a female role, for which he was bullied by his friends and scorned by his family, mainly his father. He became distressed due to this, and tried to “be a man” as per the wish of his father, by bodybuilding and taking male hormones in his 20s. He had several sexual relationships with boys in the school, where he was the submissive partner. The sexual activities were limited to kissing, stroking, and fondling. He felt emotionally close to his partners and felt lonely when they left him for female partners. He started a relationship with a 16-year-old girl at the age of 19 and married her after a courtship of five years. It was an open marriage, with both having separate sexual partners of their own. He denied having group sex. He and his wife engaged in vaginal sexual intercourse with him as the male partner. He had an adequate erection and he also engaged his wife to penetrate his anus with a prosthetic penis for sexual pleasure. He denied practicing anal intercourse as the male penetrating partner in his homosexual relationships. He reported having periods of feeling sad, worthless, and inactive, intermittently throughout his life. He said that though he engaged in sex with his wife and casual male partners, he did it with no desire, and that he always felt guilty following the sexual acts. There had been times when he had felt suicidal, but he had never attempted to harm himself. He had stopped engaging in sexual activities for the past one-and-a-half years, due to the lack of desire. He had been using an over-the-counter oestrogen medication for seven to eight months. His wife had commenced a stable relationship with another man during this time. He decided to separate from her and started living independently over the past six months, which had been against the wish of his wife, who had wanted them to remain together. He had felt increasingly sad when he saw transgender people and a few months after the separation from his wife, he had presented to the relevant services for treatment. He had a pattern of the harmful use of alcohol. By nature, he was an impulsive and hot tempered character who would get easily frustrated. On examination, he was a pleasant man, who looked like a male with only mild stereotypical feminine gestures and body language. His mood was depressed. He expressed a strong desire to become a woman, but did not answer the question as to whether he would request a transition if he was still in a relationship with his wife. He was suffering from moderate depression, and was preoccupied about not being able to fulfil his desire to be a woman. His wife claimed that he had always been a male. She said that she was not aware that he wanted to change his sex, and expressed great distress over his wish. It was decided to assess him in greater detail before starting the transition, at which he became very angry and was verbally abusive towards his wife and one of the researchers of this study (Ginige). A continuous flow of text messages to the clinic’s WhatsApp number, expressing his sadness, distress, disgust and anger for not being able to start the transition, with intermittent threats to kill himself, followed. Ginige and de Alwis had responded acknowledging his distress and frustration, offering support and were able to engage him again. It was decided to obtain a second opinion regarding his diagnosis and this was explained to him in a clear and non-threatening manner. He agreed at first, but subsequently again became verbally abusive towards the clinicians and refused to engage. It was decided to direct him to another psychiatrist for support, as the therapeutic relationship was adversely affected. According to Ginige and de Alwis, while he fulfilled the criteria for transsexualism, there were however grey areas that made them question his gender dysphoria. He was not an adolescent whose gender identity was still being formed but an adult close to 40 years. He reportedly did not have any stereotypical feminine behaviour during very early childhood. His homosexual activities started around early adolescence, and he started experiencing gender dysphoria parallel to these encounters. Gender, as K. Zucker, A. Lawrence and B. Kreukels explained in “Gender dysphoria in adults” is a fluid construct and psychosocial factors influence the expression of gender identity. His relationship with boys when his gender identity was being formed, Ginige and de Alwis argued, might have played a role in his gender dysphoria. Yet, per G. Heylens, E. Elaut, B.P.C. Kreukels, M.C.S. Paap, S. Cerwenka, H. Richter-Appelt, P.T. Cohen-Kettenis, I.R. Haraldsen and G.D. Cuypere’s “Psychiatric characteristics in transsexual individuals: Multi centre study in four European countries”, every adolescent who experiences homosexual activities does not develop gender dysphoria. His borderline personality traits, per D. Bosnjak, T. Sabo and P. Makaric’s “Gender identity disorder or a symptom of borderline disorder – A case report”, may have influenced his gender identity. The ongoing, undetected and untreated depression may also, Ginige and de Alwis explained, markedly influence the clinical picture. Though he expressed a desire to become a woman, Ginige and de Alwis questioned whether he would seek to change his sex if his wife did not commence another relationship. It is possible, Ginige and de Alwis added, that he did not want to lose the emotional stability he felt with his wife by changing to the desired sex. Sexual orientation and gender identity are, Ginige and de Alwis pointed out, affected by grief and depression. Depression needs to be treated, Ginige and de Alwis observed, in order to commence the gender transition process. Overall, per Ginige and de Alwis, he appeared to be a transwoman with bisexual orientation. If you or someone you know would like to seek help and/or counselling, the following places may be able to assist you: Sri Lanka Sumithrayo: (011) 2 682 535 EQUAL GROUND: (011) 2 075 121 / (011) 4 334 279 Shanthi Maargam: 071 7 639 898 Courage Compassion Commitment (CCC) Foundation: 1333

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Wider understanding of trans people’s struggles needed to address complex issues: Local case report

Wider understanding of trans people’s struggles needed to address complex issues: Local case report

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