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In this discussion, I will refer to E in the female rather than shifting back and forth between he and she or using the awkward he/she. In my clinical practice I address my patients in the gender they request or the gender in which they present themselves.
Upon initial presentation to treatment, E was a presumed genetic male in her twenties who was requesting female hormone therapy and sexual reassignment surgery. What was particularly unique about E's request was the desire to have both male and female organs, a state labeled “she-male” in the gender community and seen in full form (breasts, penis, vulva, and vagina) in pornographic films.
In addition to noting this unusual gender request, the therapist notes that E had a “subtle thought disturbance,” “minor neologisms,” and “lack of integration and cohesion in his thought processes.” Quotes from the patient vividly demonstrate her fragmented inner state, and this fragmentation correctly became the focus of E's treatment. The authors comment that “Both disorganization and fragmentation in thought processes and identity are often seen in cases where there have been early trauma and disruptions in the developing sense of self” (p. 136). A question to be considered is what relation has E's thought disorder to her gender identity?
The authors point out that E had no early memory of a wish to be female, and this is not uncommon. The adult ego-dystonic