Case history
Case history #1
A 45-year-old transgender person, who is birth-assigned as male, requests a prescription for estrogens and a rapid referral for gender reassignment surgery. She identifies as a transgender woman, and uses the pronouns "she/her." She is dressed as a woman, and gives a lifelong history of lifelong cross-dressing, which became sexually exciting at puberty. The sexual excitement diminished in her 20s, to be replaced by a sense of relaxation and comfort when in a female role, described as being able to express her feminine side. She is married to a woman, but separated, and together they have 2 children. The sexual content of their marriage (never very great) diminished after their birth. She hid her cross-dressing from her wife until she discovered her female clothes and assumed that she was having an affair. Although initially accepting of her dressing in female clothes, her wife became increasingly dissatisfied as she spent more time in a female role and suggested that they might live together as sisters. Moving away from her wife and children, she began to purchase estrogens from the internet. She lived as a woman for all purposes aside from at work, where nothing was known of her female life outside work. She began to feel increasingly unhappy in her male work life, feeling that she was only truly herself when living as a woman.
Case history #2
A 35-year-old transgender person, who is birth-assigned as female, requests treatment with androgens and a bilateral mastectomy. He identifies as a transgender man, and uses the pronouns "he/him." He looks masculine and is often taken to be a male somewhat younger than his chronological age. He gives a history of being a "tomboy" as a child, and at high school he was widely assumed to be lesbian. Declaring himself to be a lesbian in his late teens, he moved in lesbian social circles for some years and made relationships with women with some ease. These tended to founder after a few months because partners complained that, rather than being a masculine woman, he was more like a man. Although his libido was good and he was an attentive sexual partner, he could not bear attention being paid to his own (female) sexual characteristics, and the one-sided nature of the sexual relationship became, after a time, disturbing to his partners. Eventually he felt that his sense of masculinity could no longer be denied, and he decided to live as a man. He is desperate to halt his menstrual periods, seeking treatment with androgens to increase facial and body hair, and to lose his breasts.
Other presentations
The majority of birth-assigned male people with gender incongruence/dysphoria (i.e., transgender women) present with a background of cross-dressing. A smaller number give a history of earlier, very feminine homosexuality associated with a low libido and an ever-increasing sense of femaleness that drove them to live as a woman and to be viewed by others (including gay men) as a woman. Birth-assigned female transgender people (i.e., transgender men) very often have a history of childhood masculine behavior, and many have (for a while at least) been identified by themselves or others as masculine lesbian women.
A small proportion of people of either birth-assigned sex present with pronounced gender incongruence or gender dysphoria in childhood, even from their earliest years. They were often taken to be members of the other sex in childhood and very often experienced sexual attraction to others with the same birth-assigned sex. However it is important to note that childhood gender incongruence or gender dysphoria does not necessarily continue into adulthood.[4] A number of studies in prepubescent children with gender dysphoria/incongruence suggest that persistence into adulthood occurs in 12% to 27% of children.[7][8][9]
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