The differential diagnosis of gender identity conditions encompasses both physical and psychiatric considerations (Table 70-6). The nosological evolution of these conditions includes conceptual changes in DSM-IV from prior versions: independent placement of GID as a clinical syndrome; creation of a single, broad category of GID; elimination of the term transsexualism; and clarification of the relationship between gender identity and sexual orientation (Bradley et al. 1991; Pauly 1992). The inclusion of a clinical-significance criterion, as in all psychiatric diagnoses, makes it clear that not all persons with gender identity or role transposition merit a diagnostic label. The DSM-IV diagnostic criteria (American Psychiatric Association 1994) for GID are listed in

Table 70-7.

In the gender-dysphoric population, cross-dressers are the most prevalent, with comorbid psychopathology of an episodic or time-limited nature (Dixen et al. 1984). During stressful times in their lives, many transvestites will experience symptoms of acute gender dysphoria (Benjamin 1964b, 1966; Brown and Collier 1989; Wise and Meyer 1980c). This may coincide with periods of substantial losses (e.g., of jobs, wealth, loved ones) (Wise and Meyer 1980c). Although not displaying persistent gender dysphoria for the requisite 2 years (J. K. Meyer 1974; Wise 1982), transvestites’ psychosocial histories may be similar to those of transsexuals. The degree to which gender-dysphoric patients display symptoms may shift during their life span from fetishistic sexual behavior with cross-dressing to a predominant focus on gender dysphoria (i.e., a primary diagnosis of transvestism evolving to one of “secondary transsexualism”) (Docter 1988; Person and Ovesey 1974). Some researchers have reported that nearly all transsexualism is preceded by cross-dressing or accompanied by cross-gender fetishistic behavior (Hoenig and Kenna 1974). However, data from research conducted in the last 15-20 years in the United States (Person and Ovesey 1978; Wise and Meyer 1980b) and elsewhere (Blanchard et al. 1985; Buhrich 1981; Buhrich and McConaghy 1977a) do not support the universality of cross-gender fetishistic behavior or fetishistic cross-dressing as an antecedent to transsexualism.

Psychiatrists may be consulted regarding patients who have engaged in genital self-mutilation, including unilateral or bilateral autocastration (Brown and Philbrick 1996). The differential diagnosis associated with this extreme, life-threatening behavior is limited to psychotic disorders, gender identity disorders, delirium, and borderline personality disorder with significant gender confusion. Most patients who perform autocastration with full orientation and without psychotic symptoms are suffering from significant gender dysphoria and are seeking to decrease their testosterone levels through this desperate action. In addition to published case reports of non-inmates denied care (Rana and Johnson 1993), this behavior occurs in the incarcerated population as well as in those who have limited resources or have been denied treatment.