XVI Harry Benjamin International Gender Dysphoria Association Symposium
17 - 21 August 1999, London

Reflections on "Transsexualism and Sex Reassignment" 1969 -1999

Gender Identity Disorder Comorbid with Dissociative Identity Disorder: Review of the Literature and Case Report

Brown, George R. M.D., Department of Psychiatry, James H. Quillen VA Medical Center, Johnson City, Tennessee, USA 37684; 423-926-1171, ext. 7709.

• Introduction
• Case Report
• Discussion

INTRODUCTION: Only several cases of the co-occurrence of dissociative identity disorder ("multiple personality disorder"; DID) and gender identity disorder (GID) in adults have been reported in the world literature based on a comprehensive search of English0language databases. Anecdotally, the author is aware of at least two other cases in the U.S., including one presented to the author at a case conference at the Menninger Clinic. There are undoubtedly others, some of whom have been diagnosed and those who remain to be. This presentation describes the literature on this topic, provides an in-depth case report not previously described in the literature, and raises important questions about referrals for sex reassignment surgery (SRS) in these situations.

CASE REPORT: "M" is a 45 y/o MW genetic male living full time as a female for 10 yrs. She was the victim of extensive physical and sexual abuse as a child, including being sold for heterosexual and homosexual prostitution by her father. She left her father to live in an orphanage after he slit her throat while he was intoxicated. She developed a series of alters beginning in childhood and is alleged to have 28 named alters in addition to the "host" (M). She joined the U.S. military as a male after being arrested for crossdressing. This flight into hypermasculinity resulted in the development of additional alters, however "he" was an expert marksman and was discharged honorably. Only 5 alters have been apparent during a year of psychotherapy and one hospitalization. 21 are described by the wife as female; 3/5 alters observed during treatment are male, although the host and main alter who are ‘out’ over 95% of the time are female. Both GID and DID dx’s have been confirmed by three separate evaluators over many years of observation. Dissociative Events Scale score was 34.3 when administered to the main personality (host). M passes effortlessly in the female gender role, has taken estrogen treatment for a decade, and has had breast augmentation surgery. Her voice passes as female, although male alters speak with deep male tones. She desires approval for SRS and when she has the money, plans to proceed. Both she and her wife view this as merely completing an already accomplished transition. She has had major difficulties with anesthesia in the past, resulting in violent dissociative events. Psychotherapy around affectively-laden issues has been hampered by the tendency to defensively dissociate, making exploration of SRS issues particularly difficult. There is no history of genital self-mutilation by any alters, or attempts at reversing any steps already taken in her gender transition. The host and main alters voice no ambivalence about having SRS. Male alters have not been accessible to discuss this issue.

DISCUSSION: DID can significantly complicate the psychiatric, medical, and surgical management of GID. At least two case reports are highly critical of referring DID patients for SRS due to negative postoperative psychiatric outcomes. No systematically collected data exist. Problems to consider include: variable compliance with treatment amongst alters, presence of both masculine and feminine alters, conflict between/among alters regarding GID management, potential post-operative psychiatric and medical complications, worsening of one or both disorders by either withholding or providing referral letters for SRS. As this combination of diagnoses is unlikely to be as rare as the literature would indicate, additional case reports or series should be published by gender researchers/clinicians to help guide clinical decision-making.