Neil Van Der Merwe of South Africa sits on a hospital bed during preparations for a sex change operation at a hospital in Bangkok, Thailand. Van Der Merwe has lived as a man for the past five years.

Pornchai Kittiwongsakul/AFP/Getty Images

Diagnosis of Gender Identity Issues

When a transgender person wishes to have gender confirmation surgery, the process begins long before the procedures do. There are five steps to the process: diagnostic assessment, psychotherapy, real-life experience, hormone therapy and surgery.

The process begins when a person consults a mental health professional, who performs sessions of psychotherapy and formulates a diagnosis. To become a candidate for gender reassignment surgery, a person must first be diagnosed with Gender Identity Disorder (GID) or gender dysphoria. The International Classification of Diseases-10 (ICD-10) lists gender identity disorder as a disorder and the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-V) lists gender dysphoria.

Previously, the DSM-IV broke GIDs into several types: Gender Identity Disorder of Childhood, Gender Identity Disorder of Adolescence or Adulthood and Gender Identity Disorder Not Otherwise Specified. The revision to include gender dysphoria in the DSM-V was made to help ensure access to care while also attempting to reduce the stigma associated with gender identity struggles.

­Additionally, the ICD-10 provides five diagnosis types for GIDs:

  1. Transsexualism
  2. Dual-role Transvestism
  3. Gender Identity Disorder of Childhood
  4. Other Gender Identity Disorders
  5. Unspecified Gender Identity Disorder

According to the ICD-10, transsexuals are diagnosed when they have a desire to live as and be accepted as a member of the opposite sex, along with the desire to transform their bodies with gender reassignment surgery or hormone therapy. The person's gender identity must be persistent for at least two years, and the desire for gender change cannot be a symptom of another disorder or a chromosomal abnormality.

­Patients are diagnosed with dual-role transvestism when they have no desire for a permanent change to the opposite sex. Unspecified and Other GID diagnoses are often used to describe an intersex condition -- when an individual is born with ambiguous genitalia. Ambiguous genitalia is a rare birth defect where a child's genitals are not clearly male or female either because they are unformed, deformed or include aspects of both male and female genitalia.

Prospective candidates for gender reassignment surgery must work with a mental health professional for diagnosis. However, the mental health professional additionally provides counsel about treatment options and implications as well as therapy and education for the individual, his or her family and employers.

­After a diagnosis, there are three phases left for patients undergoing surgery:

  1. Hormone therapy
  2. Real-Life Experience, also known as the Real-Life Test
  3. Surgery to change genitalia and other sex characteristics

For some transmen (biologically born females transitioning to males), the phases may begin with hormone therapy but breast augmentation surgery to remove the breasts may come before the Real-Life Experience.

Now that we know how the diagnosis of gender identity disorders works, let's find out about treatment. Look at the next page to learn about hormone therapy, the Real-Life Experience and surgery.