Case presentation:
Sisters M.K and F.K are 17-year-old twins. The second pair twin sister;
F.K had got divorced recently and attended to our clinic for psychiatric
evaluation. She was deeply uncomfortable with her gender to the point
that she was disgusted by her first name and had request for Sex
Reassignment Surgery (SRS). Furthermore, she liked to act the same as
men whether in talking in a masculine manner or wearing men cloths. She
was interested in having friendships with males. Instead she was
sexually attracted to females. She declares her desire to have a male
gender has nothing to do with benefits or grants a man could have in the
society. And the only reason she wants to be a man is about her
experienced gender which is male identity. She had had cross-gender
behaviors since her early childhood (at the age of 3). She would have
preferred playing with boys and joining them in the games for boys, like
playing football. She used to demand for having hair styles of the
opposite sex and since the age of nine she began liking her female
cousin very much and having sexual relationship with. She avoided the
obligation to sit with girls in the same classroom at school. Going
through puberty, it was very problematic for her and her menstrual cycle
were lasting for sixteen days. Her parental rearing and behavior were
never masculine and sometime to emphasize on an appropriate feminine
attitude they would ridicule her. She then had suicidal idea but for the
sake of her mother she did not have any plan or act accordingly.
She got married at the age of 15; had hatred feeling for her husband and
disliked the sexual relationship with him. After her parents knew about
their daughter problematic behavior, they attended to psychiatrist and
Gender Dysphoria revealed as the diagnosis for her. Finally after two
years of marriage she got divorced.
She was a baby of unintended pregnancy from 15-year-old mother and she
was result of caesarian section delivery within 8th months of
gestational age. She has a 4-year-old brother and she mentions that
something is always missing in her life. She loves her parents, but no
love for her husband; she had a history of depression and suicidal idea
and now is working as a waitress in a restaurant.
In mental state examination, thought content was not delusional and
there were no other thought disorders including thought form or
perceptional disorders. As a result schizophrenia and somatic delusion
of transsexualism were rule out.
Intelligence Quotient (IQ) were within normal range. When compared to
her twin sister; M.K looked thinner with more feminine appearance. She
(the first pair twin sister) also had the same desire to change her
gender to opposite sex but this tendency were more intense with more
distress in F.K sister. M.K also disliked to be a girl and had a request
for SRS. Her IQ and education were similar to the second pair without
any mental problem. Although twins had concordant desire regarding their
gender identity, their temperament features found to be completely
discordant. F.K was a kind of rigid and introverted person while M.K was
a flexible and sociable one.
However, in both twin sisters, the physical examination confirmed normal
uterus, ovaries and external genitals. Female Secondary sex
characteristics were also evident. Skull radiography, adrenal and
genitalia sonography were normal and the karyotype chromosomal analysis
for both were “46 XX”. Psychological tests with different
questionnaire including Freiburger Personality Inventory Beck Depression
Inventory (BDI); State-Trait Anxiety Inventory showed slightly elevated
depressive tendency without any other psychiatric disorders.
Hormonal studies; Testestrone, free testestrone, E2 stradiol, sexual
hormone binding globulin, FSH, LH, cortisol, 17- hydroxyl progesterone
before and after ACTH stimulating test were within normal range.
Molecular genetic analysis with 15 microsatellite for confirming
monozygotic showed % ? Probability.