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Friedemann Pfäfflin,
Ulm University, Germany

Walter O. Bockting,
University of Minnesota, USA

Eli Coleman,
University of Minnesota, USA

Richard Ekins,
University of Ulster at Coleraine, UK

Dave King,
University of Liverpool, UK

Managing Editor:
Noelle N Gray,
University of Minnesota, USA

Editorial Assistant:
Erin Pellett,
University of Minnesota, USA

Editorial Board


book Historic Papers


© Copyright

Published by
Symposion Publishing

ISSN 1434-4599

Volume 2, Number 2, April - June 1998


Transgenderism and Dissociative Identity Disorder - A Case Study

By Bonnie R. Saks

Citation: Saks Bonnie M. (1998) Transgenderism and Dissociative Identity Disorder - A Case Study. IJT 2,2, http://www.symposion.com/ijt/ijtc0404.htm


This paper focuses on the process of assessing gender issues. Dissociation and Dissociative Identity Disorder are discussed.

A case of dissociative identity disorder presenting as gender dysphoria is presented. This individual, who was sexually traumatized as a little girl, had seven surgeries to complete gender reassignment before treating clinicians recognized that there were multiple male and female ego states. Psychological testing and treatment recommendations are suggested so that integration can be achieved or at least consensus of ego states can be reached before GRS surgery is done.



In the field of sexology, histories of sexual abuse are frequent. When the abuse has been severe and at an early age, dissociation may be used as a mechanism of defense to cope with overwhelming and continuous emotional assaults. In some cases this dissociation defense leads to development of separate ego states or alter personality states which are not co-conscious of other ego states. These "alters" may be male or female, of various ages and different perceived appearances. They may be persecutors or protectors of other alters which they do not usually perceive as being part of the same body or person. The research of this phenomenon has led to inclusion of Dissociation and specifically Dissociative Identity Disorder (300.14) in DSM IV.

The prevalence of people with this condition is not known but is probably more common than formerly thought. Alter personalities have different mannerisms and different moods, often different handwritings, different food preferences, different clothes preferences and different gender preferences. The frequency of dissociate identity disorder patients requesting gender reassignment is also not known, but there are a few cases reported in the literature. Both Pearl Schwartz and Holly Devor decribed cases of female to male transsexuals. The following case study refers also to a female to male patient, and has quite similar clinical characteristics.

Case Study

Mike (name changed) is a fifty-five year old who gave the following history:

The patient was born female to a mother who was a famous show person. The father died shortly after her birth. The mother gave the little girl to another very well known family to raise.

The patient now relates that she (as a female child) was severely sexually abused throughout childhood. She says the adopted father would rape her and the step-mother gave her enemas for punishment. When she was nine years old, she confided in a teacher whom she says "got fired for trying to help her." She felt since the adopted parents were so prominent and powerful in the community, there was no hope for rescue.

The patient remembers dissociating since age six. She knew that she lost time and sometimes found herself in the boys' line instead of the girls' line at school. The patient knew there were male alter personality states who were good in ice hockey and other activities. At age 11 her biological mother took her back. She was aware of the time lapses but said it was easy to hide them. "If you acted funny, well, people thought you were a show person." There were seven or eight personalities then, 32 or 33 now.

Two male alters, John and Mike, began to dominate. The patient cross-dressed for 11 years most of the time. There were simultaneously existing female alters, one who designed jewelry.

The patient went to a gender dysphoria clinic in Jacksonville, Florida, where she withheld information about dissociating. Mike and John passed all the tests. Surgeries were done in 1975, 1976 and 1977. In 1986 the patient married a Swiss woman. He subsequently developed diabetes and had a nervous breakdown in 1988 and again in 1989. It was during this last hospitalization that the patient was finally diagnosed DID with psychological testing though it was suspected by his therapist one year before.

He now keeps a calendar of time, tries to be more aware and co-conscious with other alters.

He is on disability for diabetes and knee replacement, is dating a woman who was also sexually abused, and is in therapy.

Two of the 32 male alters are Mike and John and two female alters are Michelle and Jackie. Michelle has a very feminine voice and is mildly suicidal. Jackie is eight years old, has a childlike voice, and likes to play with Barbie Dolls.

Discussion and Conclusions

Dissociative identity disorder may be quite difficult to detect, since in both this case and the previously reported cases the alters wishing surgery were very dominant and intent on keeping the others away in order to have the surgery.

However rare or common this type of case may be, it may behoove the mental health professional seeing transgender individuals to include dissociative disorders in their differential diagnosis.

Perhaps routinely and certainly if there is any evidence of memory lapses or dissociation, established psychological tests such as the SCID-D designed by Marlene Steinberg at Yale or the DES (Dissociative Experiences Scale) should be given to establish a diagnosis.

If not requiring integration of alters before gender reassignment surgery is done, at the very least there should be informed consent or consensus of all (known) alters before GRS surgery.


Carlson, EB and Putnam, FW. An Update on the Dissociative Experiences Scale, Dissociation Vol. 6, p. 16-27, 1993.

Devor, Holly, Transsexualism, Dissociation, and Child Abuse: An Initial Discussion based on Nonclinical Data. Journal of Psychology and Human Sexuality, Vol. 6(3), p. 49-72, 1994.

Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, American Psychiatric Association, Washington, DC, Copyright 1994, p. 477-491

Ross, Colin et. al.. Epidemiology of Multiple Personality Disorder, Psychiatric Clinics of North America 14, p. 503-517, 1991.

Schwartz, Pearl, A Case of Concurrent Multiple Personality Disorder and Transsexualism, Dissociation, Vol.1, No.2 June 1988, p. 48 - 51.

Steinberg, Marlene, Structured Clinical Interview For DSM-IV, Dissociative Disorders American Psychiatric Press, 1993. Copyright 1985

Please submit requests for information to:
Bonnie R. Saks, MD
Bonnie R. Saks, M.D. and Associates
Clinical Associate Professor of Psychiatry
University of South Florida
3333 West Kennedy Blvd. Suite. 106
Tampa, Florida 33609
Telephone: (813) 354-9444
Fax: (813) 354-9436
e-mail: BRS331@AOL.com