XVII Harry Benjamin International Gender Dysphoria Association Symposium
31 October - 4 November 2001, Galveston, Texas, U.S.A.

Sex Reassignment Surgery in a Patient with Gender Identity Disorder and Dissociative Identity Disorders: Report of a Successful Case

BROWN, GEORGE U.S.A.

Introduction: Few cases of the co-occurrence of gender identity disorder and dissociative identity disorder ("multiple personality disorder"; DID) have been reported in the world’s literature. There are no studies to guide the clinician who cares for these patients in applying the Standards of Care, especially in reference to the issues of eligibility and readiness for sex reassignment surgery. This case presentation describes ongoing multimodal treatment (now at 3.5 years) and the postoperative course of a patient with severe DID and GID who underwent SRS in July 2000.

Case Report: This case was initially presented at the XVI Symposium in London, England, in 1999. "M" has now been followed closely for 3.5 years and this presentation updates the case presentation to the current time. M is a 47 y/o married, white anatomically male transsexual who has been completely cross-living for over a decade. She has taken estrogens without incident for a decade as well, and has had an unwavering desire for SRS for over 25 years. Complicating her treatment has been the long-standing presence of severe DID, with an alleged 28 named alters in addition to the main personality (M) who generally presents for treatment at the beginning of each psychotherapy session. As many as 5 alters have been observed in a single session, but generally only 1-3 are apparent. Both diagnoses have been confirmed by three separate evaluators over the last 15 years. M also has a seizure disorder, for which she receives gabapentin and disability payments from a major airline after damaging a plane while having a seizure. Her history of severe physical, sexual and ritual abuse as a child has been detailed in the prior report. M and her wife (anatomic female) of 15 years both wanted her to obtain SRS, with or without approval from her psychiatrist. They were aware of the theoretical risk involved, especially related to her tendency to have a major dissociative reaction with anesthesia. They were also aware of the limited information available to guide medical decision-making. No male alters expressed ambivalence or opposition to SRS at any time during psychotherapeutic treatment.

After obtaining normal labs, the couple went to Asia for SRS. The surgeon and referring psychiatrist communicated by e-mail regarding the issues, both before and after M arrived at the surgical clinic. M and her wife worked out a plan for anesthesia, involving the strengths of two alters to manage the intraoperative and postoperative course. One alter has existed to manage physical pain; the other alter was employed to manage the altered mental status caused by pre-anesthesia medications and by "coming out" of general anesthesia after the operation. Through dissociation, the patient required no postoperative opioid pain medications and was ambulatory within a day. The couple remained in Asia for a two-week healing period and returned to the southeastern USA without incident. All dilation schedules were followed. Postoperative course was completely uneventful, with full satisfaction expressed in both the cosmetic and functional outcome of the neovagina. At no point in the continuation psychotherapy did any alter express regrets about having had SRS. GID became a background issue and eventually a "non-issue" in sessions. Progress on her DID was possible at this point, whereas no progress whatsoever on this diagnosis occurred prior to SRS. She experienced one psychiatric hospitalization 5 months after SRS related to overwhelming memories of childhood abuse and the integration of an alter who was the "repository" of these painful memories. GID was not related to the hospitalization. She continues to work toward symptom resolution and reaching a balance between the major alters and how much time "out" they each receive. She states repeatedly that she is happier than she has ever been in her life as a result of having had SRS. Her wife is also pleased with the changes in her spouse.

Discussion: DID is not a contraindication to either eligibility or readiness for SRS. Although psychotherapy is not "required" in the last two iterations of the SOC it seems prudent to consider this an essential part of the pre- and post-operative course for patients with DID. Communication with the surgeon is essential. This patient did not experience a brief "halo" period postoperatively and has had sustained relief from GID, enabling therapeutic progress to occur with her more disabling DID diagnosis.