Patients with GID typically range from age 13 to 60 years, although some patients are referred as early as 4 years of age (Green 1974) and some as late as in their 70s (Docter 1985). Historically, these patients initially present with a request for cross-sex hormones (Benjamin 1953; Ihlenfeld 1973) or gender-related surgery (Benjamin 1955; Haire 1950; Hamburger et al. 1953; Worden and Marsh 1955), believing themselves to be “trapped” in the opposite-gender body. Male-to-female (MTF) transsexuals frequently compare their life histories to biographies published by transsexual people (Cossey 1991; C. Jorgensen 1967; Morris 1974; Richards 1983). In contrast, female-to-male (FTM) transsexuals have few well-known role models toward which to aspire (Martino 1977; Sullivan 1990).

Typical descriptions of male GID patients who present for treatment include an extensive history of cross-dressing that occurred infrequently in the preadolescent years, accelerated during and after puberty, and continued throughout adult life. Some male patients report occasionally attempting to suppress or rid themselves of their cross-gender feelings by destroying their female wardrobe and other aids for enhancing their female appearance, a practice known as “purging” (Benjamin 1954, 1967). Subsequently, they may attempt to eradicate their cross-gender feelings by excessive involvement in stereotypical male behavior, a phenomenon known as “flight into hypermasculinity” (G. R. Brown 1988a). These activities may include participating in “macho” sports like motorcycle racing and football and enlisting in the military to go to war or to become a specialized combat soldier. But these attempts to repress and suppress cross-gender feelings are generally unsuccessful and contribute to psychiatric comorbidities, as described below (see “Comorbid Axis I and II Diagnoses” subsection later in this chapter). Cross-gender feelings return, often stronger than ever. Many male patients present for their initial interview completely cross-dressed, appearing convincingly in the female role. Some have illicitly obtained hormones (usually in the form of birth-control pills) and undergone electrolysis, with both procedures having resulting in smoother complexions and significant breast development. Many have studied feminine gestures and have optimized their potential for speaking in feminine vocal registers. Some MTF transsexuals may seem to be compulsive in acquiring excessive cosmetic surgical procedures of various kinds in an effort either to feminize their bodies to pass as female or to more effectively eliminate masculine features.

Few FTM gender-dysphoric patients are able to obtain the desired steroids illegally, given that anabolic steroids (e.g., testosterone) are now more tightly controlled than estrogens and progesterone. Those on hormones prior to their first visit may be able to effect a natural permanent male vocal register, sport a beard or mustache, and dress convincingly as males (Lothstein 1983).

Most gender-dysphoric patients present with a psychosocial history that includes the following characteristics:

1. Childhood interest in cross-gender activities (i.e., for males, a preference for female playmates and games, including doll play; for females, a strong interest in rough-and-tumble play, sports, and war toys)
2. Childhood memories of painful rejection and taunting by peers
3. Limited friendships in adolescence and early adulthood
4. Unsatisfactory intimate and sexual relationships, often with a “forced” quality or with fantasies of being the anatomically other sex during sexual activity

Sexual partner attraction, which traditionally has focused on genitals exclusively, must be identified by distinguishing specific dimensions of sexual orientation, such as physical sexual activity, interpersonal affection, erotic fantasies, arousal cue response patterns (Coleman 1987; Hawkins 1982; Money 1986; Shively and De Cecco 1977; Siegelman 1981; Suppe 1984; Tripp 1975), motivation for overt sexual activity, source of arousal, and object choice (Hawkins 1982). MTF transsexuals may accurately describe themselves as lesbian if they are physically attracted to females. This is commonly reported, and some persons with this sexual arousal pattern may be understood as having autogynephilic eroticism (Blanchard 1989; Lawrence 1999). Clinically, no assumptions can be made about a patient’s sexual identity or role based on his or her gender identity. The entire range of sexual orientations may be present in gender-dysphoric persons, just as with gender-conforming adults. A “traditional” history of childhood gender identity problems is also not a prerequisite for the diagnosis of GID in adulthood (Person and Ovesey 1974), as many of these patients will report histories far different from that of the “classic transsexual” described by Stoller (1973).