In the clinical assessment of patients, all aspects of sexual identity, sexual role, and sexual behaviors should be approached as variables independent of gender identity and role. One of the problems with research in sexual identity formation is that gender role behavior is often seen as a direct measure of gender identity. It is quite common, however, for a person to engage in cross-gender behavior and not have an inner feeling of being the opposite gender. In addition, using words such as homosexual or heterosexual to describe attraction in GID confuses reference points (anatomic sex or subjective gender identity) and may be offensive to members of these groups and others (Bradley et al. 1991; Pauly 1990). Empathic failures with gender-dysphoric persons are guaranteed if the evaluating mental health professional insists on using anatomy rather than psychology as the reference point for pronoun selection (Brown 1990a). It is most appropriate simply to ask the patient what she or he prefers to be called.

To understand a patient’s psychosexual and psychosocial development en route to an accurate diagnosis and treatment plan, the clinician must obtain in the initial diagnostic interviews a complete sexual history. Commonly, the diagnostic interview is extended over three or more sessions (Brown et al. 1990a). The Sex History Inventory (Pomeroy et al. 1982), developed from the original Kinsey Interview Schedule (Kinsey et al. 1948, 1953), is one tool for conducting the initial interview. This lengthy, multisectioned, comprehensive interview guide focuses on basic life data (e.g., age, education, religious observance, occupation, family history) as well as those areas in a sexual and gender history that influence development (e.g., anatomy [desired body changes, sexual partners], dreams to orgasm, sexually transmitted disease exposure and treatment, adolescent sex play [with females and males, in both peers and adults], erotic arousal stimuli, sexual fantasies, self-masturbatory patterns [frequencies, techniques, onset to date], petting, coitus [postpubertal, premarital, marital, extramarital], group sex, fetishes, cross-dressing, exhibitionism, voyeurism, pedophilia, cross-gender identity feelings and imagery, suicide attempts or self-mutilation, paraphilia, sexual assault, incidental prostitution, incidental homosexual experience, homosexual prostitution).

Individuals with extensive homosexual histories, as well as people involved in the commercial sex industry, have a lifestyle, a vocabulary, and a way of looking at their environment that are unique to their experience. This population is at elevated risk for engaging in behaviors likely to lead to sexually transmitted diseases (Bockting et al. 1998). Sexual history-taking should take this into account. Many gender-dysphoric individuals without employment skills may resort to this dangerous work for survival. In addition, these patients are greatly in need of large sums of money to pay for the medical, psychiatric, and surgical care gender dysphoria treatment entails.

In assessing variations in gender identity disorders, a complete life history of each of the key factors in

Table 70-8 should be considered.

Although many patients themselves are confused and concerned about the symptoms and manifestations of their condition and the various descriptive labels they have heard used, it is the psychotherapist who must understand, evaluate, guide, and facilitate patients in making appropriate and intelligent choices for both their gender transition experience and their total psychosocial adjustment (Schaefer and Wheeler 1995).