Male Prison Inmates With Gender Dysphoria: When Is Sex Reassignment Surgery Appropriate?

Gender dysphoria (GD), a feeling of persistent discomfort with one's biologic sex or assigned gender, is estimated to be more prevalent in male prison inmates than in nonincarcerated males; there may be 3000-4000 male inmates with GD in prisons in the United States. An increasing number of U.S. prison systems now offer gender dysphoric inmates diagnostic evaluation, psychotherapy, cross-sex hormone therapy, and opportunities, albeit limited, to enact their preferred gender role. Sex reassignment surgery (SRS), however, has not been offered to inmates except in response to litigation. In the first case of its kind, the California Department of Corrections and Rehabilitation recently agreed to provide SRS to an inmate and developed policy guidelines for its future provision. In other recent cases, U.S. courts have ruled that male inmates with GD are entitled to SRS when it is medically necessary. Although these decisions may facilitate the provision of SRS to inmates in the future, many U.S. prison systems will probably remain reluctant to offer SRS unless legally compelled to do so. In this review, we address the medical necessity of SRS for male inmates with GD. We also discuss eligibility criteria and the practical considerations involved in providing SRS to inmates. We conclude by offering recommendations for physicians, mental health professionals, and prison administrators, designed to facilitate provision of SRS to inmates with GD in a manner that provides humane treatment, maximizes the likelihood of successful outcomes, minimizes risk of regret, and generates data that can help inform future decisions.

Gender Dysphoria in Adults.

Gender dysphoria (GD), a term that denotes persistent discomfort with one's biologic sex or assigned gender, replaced the diagnosis of gender identity disorder in the Diagnostic and Statistical Manual of Mental Disorders in 2013. Subtypes of GD in adults, defined by sexual orientation and age of onset, have been described; these display different developmental trajectories and prognoses. Prevalence studies conclude that fewer than 1 in 10,000 adult natal males and 1 in 30,000 adult natal females experience GD, but such estimates vary widely. GD in adults is associated with an elevated prevalence of comorbid psychopathology, especially mood disorders, anxiety disorders, and suicidality. Causal mechanisms in GD are incompletely understood, but genetic, neurodevelopmental, and psychosocial factors probably all contribute. Treatment of GD in adults, although largely standardized, is likely to evolve in response to the increasing diversity of persons seeking treatment, demands for greater client autonomy, and improved understanding of the benefits and limitations of current treatment modalities.

Autogynephilia: an underappreciated paraphilia.

Autogynephilia is defined as a male's propensity to be sexually aroused by the thought of himself as a female. It is the paraphilia that is theorized to underlie transvestism and some forms of male-to-female (MtF) transsexualism. Autogynephilia encompasses sexual arousal with cross-dressing and cross-gender expression that does not involve women's clothing per se. The concept of autogynephilia defines a typology of MtF transsexualism and offers a theory of motivation for one type of MtF transsexualism. Autogynephilia resembles a sexual orientation in that it involves elements of idealization and attachment as well as erotic desire. Nearly 3% of men in Western countries may experience autogynephilia; its most severe manifestation, MtF transsexualism, is rare but increasing in prevalence. Some theorists and clinicians reject the transsexual typology and theory of motivation derived from autogynephilia; their objections suggest a need for additional research. The concept of autogynephilia can assist clinicians in understanding some otherwise puzzling manifestations of nonhomosexual MtF transsexualism. Autogynephilia exemplifies an unusual paraphilic category called 'erotic target identity inversions', in which men desire to impersonate or turn their bodies into facsimiles of the persons or things to which they are sexually attracted.

Sexual orientation versus age of onset as bases for typologies (subtypes) for gender identity disorder in adolescents and adults.

The most widely used and influential typologies for transsexualism and gender identity disorder (GID) in adolescents and adults employ either sexual orientation or age of onset of GID-related symptoms as bases for categorization. This review compares these two typological approaches, with the goal of determining which one should be employed for the diagnosis of GID in Adolescents or Adults (or its successor diagnosis) in the forthcoming revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM). Typologies based on sexual orientation and age of onset of GID-related symptoms are roughly comparable in ease and reliability of subtype assignment. Typologies based on sexual orientation, however, employ subtypes that are less ambiguous and better suited to objective confirmation and that offer more concise, comprehensive clinical description. Typologies based on sexual orientation are also superior in their ability to predict treatment-related outcomes and comorbid psychopathology and to facilitate research. Commonly expressed objections to typologies based on sexual orientation are unpersuasive when examined closely. The DSM should continue to employ subtypes based on sexual orientation for the diagnosis of GID in Adolescents or Adults or its successor diagnosis.

Societal individualism predicts prevalence of nonhomosexual orientation in male-to-female transsexualism.

There are two distinct subtypes of male-to-female (MtF) transsexuals: homosexual and nonhomosexual. The relative prevalence of these two subtypes varies dramatically between countries, but no explanation of this variability has yet been proposed. This study examined the hypothesis that the prevalence of nonhomosexual MtF transsexualism, relative to homosexual MtF transsexualism, would be higher in individualistic countries than in collectivistic countries. I analyzed data from 22 studies of MtF transsexualism, conducted in 16 countries, examining the association between percentage of nonhomosexual participants and Hofstede's (Culture's consequences: Comparing values, behaviors, institutions, and organizations across nations, 2001) Individualism Index (IDV). IDV accounted for 77% of observed variance in the percentage of nonhomosexual MtF participants (r = 0.88, p < .0001). Controlling for differences in national wealth and in Hofstede's other indices of societal values (Power Distance, Uncertainty Avoidance, and Masculinity) did not significantly change the ability of IDV to account for variance in the percentage of nonhomosexual participants. The factors that contribute to the observed association between societal individualism and the relative prevalence of nonhomosexual MtF transsexualism remain to be determined, but a greater tolerance within individualistic countries for socially disruptive gender transitions by nonhomosexual gender dysphoric men, and the availability within many collectivistic countries of socially approved transgender roles for pervasively feminine homosexual gender dysphoric men, are plausible contributors.

Erotic target location errors: an underappreciated paraphilic dimension.

Based on studies of heterosexual male fetishists, transvestites, and transsexuals, Blanchard (1991) proposed the existence of a hitherto unrecognized paraphilic dimension, erotic target location errors (ETLEs), involving the erroneous location of erotic targets in the environment. ETLEs can involve preferential attention to a peripheral or inessential part of an erotic target, manifesting as fetishism, or mislocation of an erotic target in one's own body, manifesting as the desire to impersonate or become a facsimile of the erotic target (e.g., transvestism or transsexualism). Despite its potential clinical and heuristic value, the concept that ETLEs define a paraphilic dimension is underappreciated. This review summarizes the studies leading to the concept of ETLEs and describes how ETLEs are believed to manifest in men whose preferred erotic targets are women, children, men, amputees, plush animals, and real animals. This review also describes ETLEs in women; discusses possible etiologies of ETLEs; considers the implications of the ETLE concept for psychoanalytic theories of transvestism and male-to-female transsexualism, as well as for the forthcoming revision of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition; suggests reasons why the concept of ETLEs has been underappreciated; and describes what might result if the concept were more widely appreciated.

Anatomic autoandrophilia in an adult male.

Some men are sexually aroused by impersonating the individuals to whom they are sexually attracted, or by permanently changing their bodies to become facsimiles of such individuals. Blanchard (J Sex Marital Ther 17:235-251, 1991) suggested that these paraphilic sexual interests, along with fetishism, represented erotic target location errors, i.e., developmental errors in locating erotic targets in the environment. Because the desire to impersonate or become a facsimile of the kind of person to whom one is attracted can have significant implications for identity, Freund and Blanchard (Br J Psychiatry 162:558-563, 1993) coined the term erotic target identity inversion to describe this type of erotic target location error. The best-known examples of erotic target identity inversions occur in men who are sexually attracted to women and who are also sexually aroused by the idea of impersonating or becoming women; these paraphilic interests manifest as transvestic fetishism and as one type of male-to-female transsexualism. Analogous erotic target identity inversions have been described in men who are sexually attracted to children and to female amputees. In theory, erotic target identity inversions should also occur in men who are sexually attracted to men. There have been no unambiguous descriptions, however, of men who are sexually attracted to men and also sexually aroused by the idea of changing their bodies to become more sexually attractive men. This report describes such a man, whose paraphilic interest would appropriately be called anatomic autoandrophilia. The demonstration that anatomic autoandrophilia exists in men is consistent with the theory that erotic target location errors constitute an independent paraphilic dimension.