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.