1.Introduction

---

This case report describes a 59-year-old trans man, who is currently undergoing treatment at the Outpatient Sexual Medicine Clinic of the Department of Gynecology and Obstetrics. Although born as a biological female, his parents registered him as a male at birth (for unknown reasons) and he was educated as a boy. To date, he has undergone a bilateral mastectomy, receives androgen therapy, and has a strong desire for genital surgery.
Gender dysphoria is a rare condition with a prevalence of 0.001%to 0.002% in the general population [1]. A trans person has incongruence between gender identity and body phenotype. This causes great suffering and often motivates the person to seek hormone treatment and surgery so that the body corresponds to the gender identity.
This case report describes what happened to a person whose biological sex was female, but was educated as a male by his parents, and also describes the patient's own feelings about his condition. The patient expressed his desire to tell his history to the scientific community and provided written informed consent.

2. Case Report

---

A psychologist (MRL) interviewed David in 2012 using an open interview style, which started with triggering questions: “How did you learn about your transsexual condition? How do you feel about your condition?” The answers were recorded for later analysis, based on a theoretical framework provided by previous studies on this topic. Some parts of the interview were selected to show the feelings of the patient about his condition.
David is a 59-year-old patient. Although born as a biological female, for unknown reasons his parents registered him as a male and he was educated as a boy. David reported that his parents wanted to have a male baby because all their other children were girls. He has a masculine appearance but normal female genitalia. He cannot inform about his genitalia appearance at birth as his parents have never told him anything about his genitalia.
When he was about 6 to 7 years old, while swimming with some boys, he realized that his genitals were different from the other boys, but forgot about this for a long time. At age 8, he had poliomyelitis that rendered him paralyzed from the waist down and he has since needed a wheelchair for mobility. This illness prevented him from walking because of neuromotor alterations, although he still experienced pain and erotic sensations. At age 8, his parents took him to an orphanage- a catholic institution presided by nuns, telling him that there he would see an expert physician. However, he does not remember being taken to a medical care unit, and his parents never returned to see him. In fact, in the orphanage he had only basic care and religious support. He therefore remained atthe orphanage from age 8 to 11 years and lost contact with his family for three years.
David said that he was raised as a boy and treated as such, even by his relatives. During the three years of living in the orphanage, David was recognized as a woman by nuns and his colleagues. As he took care of himself alone he prevented himself of exposing his genitals. However, as his breasts developed and after the onset of menstruation, he realized that he was born with a female body, causing extreme distress; It was very difficult for me when my female characteristics developed ... I did not have any way to hide them ... it got worse ... I used to avoid crowded places ... I was alone!” In fact he felt as if he was a man with a woman´s body. He never shared his condition with anyone. He started school when he was 12 years-old, and was always afraid of being discovered as a boy with a small penis. So he left school when he was 13, and studied alone at home.
At age 11, David's older sister helped him find his family, but the court did not allow him to come home. However, at the urging of his family, he returned home at the age of 11 to live with his family.
At age 15, David fell in love with a girl, but avoided approaching her using his disability as an excuse. “I felt desire for that girl, do you understand? I wanted to kiss her, make love to her… but I never had the courage to declare my love … I didn‟t know how she would react - I didn‟t know if she could see that there was something wrong with me.”Later, he had his first sexual experience with her. David told her about his history at the orphanage and about his illness. She was very affectionate and said she would like to stay with him. She was his real first love. Since then, David started daydreaming about looking for work, having his own home, and having children. He married this girl in a Catholic church when he was 20 years-old. Their sex life was restricted to caresses because he told his wife that he was born with a defect in his genitalia that prevented him but not sex…she did not know anything about my genitalia … she could not imagine that I am a man without a penis”. However, during sexual activity, he experienced erotic sensations such as sexual desire, arousal, and lubrication, and became conscious that he could not have a true sexual relationship because he lacked a penis. This motivated him to look for phalloplastic surgery.
Over time, the couple adopted 10 homeless children, and the community where they lived helped them to support their children. Later, David and his wife started a non-governmental organization for homeless children and could provide a better support to them. His family (wife and children) did not know anything about his transsexual condition. They divorced a few years later because his wife wanted to have a biological child.“My wife started to ask for a biological son ... I gave her excuses by using the problem with my legs as an excuse to avoid intimacy ....but she insisted … she wanted to have sex because she wanted to have biological children … and she left me.” The 10 children lived with him, with help from the local community.
David reported that he always felt he was a male and thought he was born with a small penis. When he was 50 years-old, he was watching a television program about trans people and realized that he could have genital surgery. This led him to search for medical treatment for genital surgery and mastectomy; “I avoided social activities for fear that people would start to perceive my abnormality ...He felt ashamed over the possibility that the doctors and nurses would consider him a liar. I underwent a double mastectomy with nobody knowing about it ... I find excuses and I carry on …”.Later, he underwent hormone therapy and sought genital surgery for sexual inadequacy.
David became more anxious as he grew older, and feared that if he became ill his children would discover his condition. Thus, he expresses an urgent need for sex genital surgery; “I need my dignity ... I cannot imagine that my children might think that I lied to them my whole life ... I need this treatment so that I may die with dignity ... the thing I most fear is the possibility of dying and losing all that I accomplished and taught my children.”
“I need surgery not to have sex, but just because I want to die with dignity ... I can´t imagine my children and others discovering after my death that I have female genitalia … I lived lying, my life, my life is a lie!” David has been trying to solve his problem for many years by hiding his female body, and acting as a man; “As time passes, the possibility that I will fall ill or even die and that my children will have to take care of me ...of my body ... is very frightening ... to imagine that they will know that I lied my entire life … I need this surgery to be able to die with dignity….“I may have a physical condition showing that I am a woman ... but my name is David and I was raised as such and I am currently looking to have a male physical condition.”
At the age of 58, David experienced genital bleeding and presented to our clinic for treatment. He did not show any formal prescription for androgen therapy and gave confusing information on when he started hormone therapy. At the time he attended our service, he had stopped androgen therapy for five months. He was using intramuscular (IM) testosterone cypionate(200 mg, 4 times per month). The clinical exam showed male characteristics, including facial hair and a deep voice. The genitalia were typically female, with a clitoris of the usual size and a vagina that was 9 cm long and normal width.
Abdominal ultrasound showed an endometrium that was 9 cm thick, and a hysteroscopy showed endometrial thickening with a regular surface. An anatomo pathological exam showed simple endometrial hyperplasia. The laboratory tests showed dehydroepiandrosterone sulfate (83 µg/dL), 17-alpha-OH-progesterone (47 ng/dL), and female levels of testosterone (73 ng/dL). Karyotyping indicated the female sex (XX). This suggests that David had normal genitalia at birth. The hospital anxiety and depression scale (HAD) used to assess the risk of anxiety and depression [2] showed high scores for both disorders (HAD-A scored 19, and HAD-D scored 14). David was diagnosed with gender dysphoria according to DSM-V[3] as he identified himself as being male and regarded himself as lucky to have received a masculine name; “I was given the male name of David, and I was raised as such … I definitely am not a woman. When I was born I had a „small comma‟ (referring to the clitoris) instead of a normal penis. The doctors told me that my mother was sure that I was a boy. I was lucky to have been baptized as a boy without going through the embarrassment of having a female name.” “I spent my whole life waiting for treatment and looking for help to change my body ... I spent day after day, waiting for it! I want to have sex genital surgery ... I had a mastectomy ... alone ... I have never been open about my sexual condition to anyone ...”scale (HAD) used to assess the risk of anxiety and depression [2] showed high scores for both disorders (HAD-A scored 19, and HAD-D scored 14). David was diagnosed with gender dysphoria according to DSM-V[3] as he identified himself as being male and regarded himself as lucky to have received a masculine name; “I was given the male name of David, and I was raised as such … I definitely am not a woman. When I was born I had a „small comma‟ (referring to the clitoris) instead of a normal penis. The doctors told me that my mother was sure that I was a boy. I was lucky to have been baptized as a boy without going through the embarrassment of having a female name.” “I spent my whole life waiting for treatment and looking for help to change my body ... I spent day after day, waiting for it! I want to have sex genital surgery ... I had a mastectomy ... alone ... I have never been open about my sexual condition to anyone ...”scale (HAD) used to assess the risk of anxiety and depression [2] showed high scores for both disorders (HAD-A scored 19, and HAD-D scored 14). David was diagnosed with gender dysphoria according to DSM-V[3] as he identified himself as being male and regarded himself as lucky to have received a masculine name; “I was given the male name of David, and I was raised as such … I definitely am not a woman. When I was born I had a „small comma‟ (referring to the clitoris) instead of a normal penis. The doctors told me that my mother was sure that I was a boy. I was lucky to have been baptized as a boy without going through the embarrassment of having a female name.” “I spent my whole life waiting for treatment and looking for help to change my body ... I spent day after day, waiting for it! I want to have sex genital surgery ... I had a mastectomy ... alone ... I have never been open about my sexual condition to anyone ...”
The medical procedures included progesterone (medroxyprogesterone acetate) plus androgen therapy with testosterone cypionate (200mg IM each 15 days). A psychiatric examination was used to assess his mental condition and confirmed that he had anxiety. Thus, the patient was referred to a psychologist for psychotherapy. During the therapeutic process, the patient was encouraged to reflect on his female genitalia and the possible negative influence on his self-esteem. He was informed about coping and anxiety-reducing strategies, and was encouraged to communicate better with his relatives. The possibility of genital surgery was discussed, together with his expectations. He was also told about the possible risks of genital surgery and hormone therapy.
The medical procedures included progesterone (medroxyprogesterone acetate) plus androgen therapy with testosterone cypionate (200mg IM each 15 days). A psychiatric examination was used to assess his mental condition and confirmed that he had anxiety. Thus, the patient was referred to a psychologist for psychotherapy. During the therapeutic process, the patient was encouraged to reflect on his female genitalia and the possible negative influence on his self-esteem. He was informed about coping and anxiety-reducing strategies, and was encouraged to communicate better with his relatives. The possibility of genital surgery was discussed, together with his expectations. He was also told about the possible risks of genital surgery and hormone therapy.
The medical procedures included progesterone (medroxyprogesterone acetate) plus androgen therapy with testosterone cypionate (200mg IM each 15 days). A psychiatric examination was used to assess his mental condition and confirmed that he had anxiety. Thus, the patient was referred to a psychologist for psychotherapy. During the therapeutic process, the patient was encouraged to reflect on his female genitalia and the possible negative influence on his self-esteem. He was informed about coping and anxiety-reducing strategies, and was encouraged to communicate better with his relatives. The possibility of genital surgery was discussed, together with his expectations. He was also told about the possible risks of genital surgery and hormone therapy.

3. Discussion

---

The present case report shows the multiple physical, psychological, social, and medical characteristics of a patient with gender dysphoria. We could not assess any official information on the history of David at the orphanage or medical records. Thus, all data presented in this case report were obtained by interview with the patient. The lack of medical records on the genital and psychological condition of David may have led to some misunderstandings or misinformation on his childhood and adolescence. However, his reflections of his own feelings provide important information on what happened to him. Thus, the main contribution of this case report is to highlight the dilemmas experienced by trans people, including his suffering and the level of stress experienced by such an individual who lives this condition.
David said that he felt himself to be a boy as early as he can remember and he can´t understand why his body was like of a woman. Indeed, many trans people report that they always felt they were boys since childhood [4]. The fact that he did not show signs of altered genitalia, the lack of recognition of his biologic gender by his parents and family may have influenced his perception and feelings regarding his gender. The patient has identified himself as of the opposite sex for as long as he can remember. This early perception of gender identity has been reported previously [5]. Thus, his male identity involved the construction of a masculine personal image so deeply rooted in his personality that he regards himself as lucky to have received a masculine name[4]. Currently, the gender norms are imposed during childhood in order to ensure that behavior and genitalia are construct male and female bodies in agreement with the genitals within a binary system [6]. This entire process may occur even before a child becomes aware of the existence of social rules. This was easier for David, because he has a document from the Civil Registry showing that he was registered as male.
David scored high for anxiety and depression. His suffering is clear when he states that he feels like a child, with no sexuality, rights, love, or dignity. In David´s history there are many factors that may impair mental health: his parents abandoned him, he has traits of low self-esteem and negative feelings about his genitals, which he considered abnormal and ugly, and he is always worried about hiding his genital. In fact, early study showed that one third of trans people suffer from anxiety, depression and social anxiety disorder[7], as well as significantly greater general psychopathology, lower self-esteem, and experienced greater transphobia and interpersonal problems [8].
The lack of information in the pre- and post-natal environment, of David, together with the lack of data about his childhood and infant psychological condition, prevented to identification the factors that contributed to his trans condition. Nevertheless, this case report may allow health professionals to assess the suffering associated with this condition, and such knowledge may be useful for formulating the establishment of public policies to support trans patients. However, it is important to highlight that this is a retrospective report. Emotional and possible feeling of shame during physician and psychological interview, as well as anxiety with the possibility of physical exam may have distorted the real history of David.
Finally, this case report is limited in that information on David´s disability related to poliomyelitis as well as his life in the orphanage are lacking. Also, this is a retrospective report, and thus emotional and some feeling of shame during physician interview, as well as anxiety with the possibility of physical exam may distorted the real history. However, this study shows that enhancement of the quality of life of trans individuals requires assessments of their medical, psychological, and social conditions. Appropriate approaches are needed for them, as well as methods to determine the sexual expectations of each patient and his/her level of motivation regarding the therapeutic process[9], including analyses of their psychological condition, followed by effective support [10]. Surgical treatment is performed not only to construct a new sex organ that agrees with the patient’s gender identity, but to offer patients the opportunity to have a healthy sexual/affective/family/social life [[11], [12]]. A person’s identity is not simply defined biologically, but also historically.

4. Conclusion

---

This case report shows the psychological vulnerability of a trans man, as revealed by his feelings, lack of self-esteem, fears, and high scores of anxiety and depression expressed by David.

References

---

1. Roberto, L.G., Issues in diagnosis and treatment of transsexualism. Arch Sex Behav, 1983. 12(5): p. 445-73.
2. Zigmond, A.S. and R.P. Snaith, The hospital anxiety and depression scale. Acta Psychiatr Scand, 1983. 67(6): p. 361-70.
3. Association, T.A.P., Diagnostic and Statistical Manual of Mental Disorders, 5th Edition: DSM-5 5th Edition. 5th ed. 2013: American Psychiatric Association.
4. Wallien, M.S. and P.T. Cohen-Kettenis, Psychosexual outcome of gender-dysphoric children. J Am Acad Child Adolesc Psychiatry, 2008. 47(12): p. 1413-23.
5. Harrison, S.I., A.C. Cain, and E. Benedek, The childhood of a transsexual. Arch Gen Psychiatry, 1968. 19(1): p. 28-37.
6. Weinraub, M., et al., The development of sex role stereotypes in the third year: relationships to gender labeling, gender identity, sex-typed toy preference, and family characteristics. Child Dev, 1984. 55(4): p. 1493-503.
7. Bergero-Miguel, T., et al., Gender Dysphoria and Social Anxiety: An Exploratory Study in Spain. J Sex Med, 2016.
8. Arcelus, J., et al., Risk Factors for Non-Suicidal Self-Injury Among Trans Youth. J Sex Med, 2016. 13(3): p. 402-12.
9. Bouman, W.P., A.L. de Vries, and G. T'Sjoen, Gender Dysphoria and Gender Incongruence: An evolving inter-disciplinary field. Int Rev Psychiatry, 2016. 28(1): p. 1-4.
10. Powell, D.M., K.D. Newman, and J. Randolph, A proposed classification of vaginal anomalies and their surgical correction. J Pediatr Surg, 1995. 30(2): p. 271-5; discussion 275-6.
11. Costantino, A., et al., A prospective study on sexual function and mood in female-to-male transsexuals during testosterone administration and after sex reassignment surgery. J Sex Marital Ther, 2013. 39(4): p. 321-35.
12. Johansson, A., et al., A five-year follow-up study of Swedish adults with gender identity disorder. Arch Sex Behav, 2010. 39(6): p. 1429-37.