Gender Dysphoria in a Mother and Son: A Report of Two Cases Referred to Legal Medicine Office of Iran

Case Reports

Case 1: M., a 16-year-old, an assigned male at birth, who studies at grade 11 came to Psychiatric department of Tehran Legal Medicine. His chief complaint was “What I am is not consistent with my body”. The client was first child of the family and had a brother. He stated that he has had such feeling since he has been 5-6 years old. He would prefer to play often the stereotyped “girlish” games and dress like a girl when he was 5 or 6 years old. He preferred to play with girls and quickly developed a liking to stereotypical girlish games like doll games, playing by one leg and guest game (special girlish plays in Iran). He grew up in a traditional family that did not know about the nature of gender problems, and he had to suffer constant humiliation and feeling of inferiority, especially by his classmates at school. Although his mother had understood his feelings, his father felt ashamed of his appearance and behavior. He told to the psychiatrist that he cannot justify himself and explain the problem to his family members. In these cases, the cultural impact on understanding the issue is undeniable.

He said that he has learned about his problem recently and realized that he could request for SRS. He has thought that he is homosexual at first, but he has suppressed this feeling, since he has believed that “it is a great sin”. His parents had seen his girlish behaviors since childhood. He experienced puberty while he was 13 and since then he has had sexual desire to men. In fact, he had never felt any real attraction toward the female sex. During early adolescence; he was attracted to one of his male classmates and has felt disappointment while he has found out that he has a girlfriend. After several years and during the course of therapeutic interventions in specialized psychiatric settings, his father accepted his son’s problem. His father emphasized that his son was interested to dance like girls (notice that in Iranian culture boys do not usually dance or behave like girls). He added that his son has been interested to girlish games, to put on girls clothes, and interested to girls sports since early childhood. He reported that his son had been lifting his eyebrows, (it is not common in Iranian culture) but he had not been concerned with that before. He knew the nature of gender dysphoria and that he would not be able to get pregnant after sexual reassignment surgery even in the best possible conditions. The psychiatrist spent more time to explain the good and bad consequences of the surgery and to appreciate the nature and quality of sexual relationship that he may have in the future.

He reported that he likes to put women’s dress, participate in female gatherings, having permission to make up in home and practicing dance. He was interested to designing women’s dresses, female hair styling, housekeeping tasks and fine artistic works. During treatment sessions he started to put girlish clothes regularly and was very satisfied with that. He reported that he is more relaxed in women’s dress and people’s look does not bother him. He stated that his family accepted him as a girl and he decided to make SRS as soon as possible. His intention for SRS was “to resolve the conflict between his mind and his body” since he feel that “I am a prisoner in a wrong body”. Mental status examination revealed dysphoric mood, helplessness, over-valued ideas about her sexual identity and mild anxiety symptoms. During first session, his father used to try to describe his child as a normal boy, although during treatment sessions he had stated that he has paid more attention to his child behaviors recently, and realized that he has “girlish morale and characteristics”.

The results of karyotype and sexual hormone tests were in normal range and consistent with his assigned gender as a male. Patient showed high scores in masculinity-femininity (Mf) scale of Minnesota Multiphasic Personality Inventory (MMPI) implying lack of traditional masculine role and interests.

He attended in the Psychiatric Council of Legal Medicine Office, and was examined by a group of expert psychiatrists. After a long discussion, they agreed with the sex reassignment surgery.

Case 2: Ms. F, a 38-year-old, an assigned female at birth, mother of case 1, was referred to Psychiatric department of LMO. Her complaint was: “I am not a woman. I am a complete man. I feel I am trapped in a wrong body”. She was born in a village in western provinces of Iran. She was a housewife, 7th child of a low socioeconomic family and had completed 5 years of education. She had lost her mother when she was 7. She was married twice and reported has been mandated to marriage both times. She stated that she had not perceived herself as a woman at all and had never put make up so far. She had chosen a male name for her and reacts to that name. She reported a strong desire to be a male from her childhood. She would prefer to dress like a boy, and play often the known “boyish” games other boys. Her family has been forcing her to put on girl clothes but she hated that. After puberty, she has had sexual attraction towards same-sex and has had sexual experiences with other girls. She said that her family had mandated her to marry with a young man when she was 16, but she ran away from her husband home after 1 week. The family of her first husband has agreed to divorce, because she had not accepted to come back. After divorce, she left her birthplace and came to Tehran with one of her brothers to find a job at 17 years old. She worked in small factories for a while. She reported bitter experiences to have an independent life as a woman because of financial constraints and need to social support, in Tehran. At the same time, she has regularly practiced karate in a female-specific club and has been attracted to her female coach. She stated that she used to buy flowers for her coach every day and after a while she told her that “I love you like a man and want to be with you.” The karate coach has said that I am going to marry with a normal man and this made her disappointed. She reported that she began to smoke cigarette when she heard a negative answer from her coach.

She had to marry again, and she said to her second husband that “I will live with you as a friend.” She knew that her sexual orientation has always been toward males, but she used to think that her sense of masculinity would decrease after marriage. She was in severe distress all the time and finally attempted suicide thorough hanging herself, but her husband succeeded to save her life.

She has been very reluctant to do housekeeping tasks at home, but was not interested to have sex with her husband, and this led to severe marital conflicts. Their sexual relationships were completely discontinued after 2 years of their marriage.

She spoke to her children about her situation and thought that they, particularly her older child, are able to understand her. She said that I explained to my children that “I am still your parent but my role will change.” She stated that “I am an adult and experienced the life, marriage and raising my children. My insistence on surgery is not an impulsive decision. I really feel that I am a prisoner of my body and I am looking for freedom. I will certainly have surgery even if only one day of my life is remained. I am ready to endure any pain and discomfort so that I can live with my true identity and my name.” in further evaluations we realized that there is no family history of psychiatric disorder, except for the gender identity disorder in her son. At counseling sessions, she and her husband mutually agreed to divorce. After divorce, she wore men’s clothes and was very happy and satisfied. She thought that she is a male partner who can love a woman. She used to feel that her life is not worthy because She had the feeling that she is really a man who trapped in a wrong body. Mental status examination revealed no psychiatric disorder. She was hopeful, energetic and assertive. The results of the karyotype and sex hormone tests were within normal range and in line with the gender determined as a woman. MMPI revealed high scores in Mf scale that suggests serious doubts about traditional feminine roles. The BEM gender Role Inventory showed a higher normal masculinity and normal limit femininity scores.