The essence of transsexualism is still not completely clear. Finding out its pathogenesis is not only of fundamental, but also of practical interest, since only with a full understanding of this problem it will be possible to conduct differential diagnostics with clinically similar conditions, as well as to search for and develop methods of treatment, social rehabilitation and rehabilitation.
Some authors adhere to a biological concept (genetic, etc.), others give crucial importance in the formation of transsexualism to psychosocial factors. Despite the polarity of views regarding the etiology of transsexualism, attempts to interpret its pathogenesis from a purely psychiatric standpoint are now completely abandoned. The treatment of transsexualism by “psychiatric methods” using high doses of neuroleptics, lithium preparations, convulsive and insulin-comatose therapy, and psychotherapy methods proved to be ineffective.
Identifying the origins of transsexualism in early childhood, developmental features, independence from parenting and environment, rigidity of the clinical picture, and resistance to therapy allow one to presumably assess transsexualism as an endogenous (constitutional) personality anomaly.
In search of a biological substrate that creates an endogenous-constitutional predisposition to transsexualism, drew attention to the real fact of the existence of sexual differentiation of the brain.
According the formation of sexual identification occurs in the first 3 years of a child’s life.
Lateralization of cerebral functions in female transsexualism does not actually differ from those given in the group of healthy men. This suggests that one of the morphofunctional components of transsexualism is in a certain way associated with the violation (inversion) of sexual dimorphism in the lateralization of brain functions.
Recently, much attention has been paid to the study of genetic and endocrine factors that can create prerequisites for the development of transsexualism.
G. S. Vasilchenko (1983) believes that a full-fledged process of differentiation of the brain in men requires compliance with many conditions, such as the concentration of embryonic androgen, the period and duration of its impact, and the absence of estrogen. Violation of any of these factors can lead to impairments in the differentiation of the corresponding brain structures.
A promising method at the present time is to study the cellular receptors of sex hormones and their functioning. Sex hormones play a crucial role in the differentiation of the genitals. Much attention is paid to the study of their impact on prenatal sexual differentiation of brain structures.
Showed that in lower mammals sexual behavior is regulated by the central nervous system, which “matures” prenatally or during the first days of life, hormonally -sensitive period. The CNS “male-type” bookmark occurs when there is a significant amount of androgens in this period, while the development of the CNS “by the female type” – with an insufficient number of androgens or receptors and enzymes participating in their
transformations. According to the researchers, these hormonal effects depend neither on the chromosome set, nor on the structure of the gonads.
Thus, the differentiation of the external genitalia occurs under the action of dihydrotestosterone, a testosterone metabolite, and sexual differentiation of the brain depends on the processes of flavoring testosterone into estradiol.
According to these authors, the differentiation of the external genitalia precedes the sexual differentiation of the brain. These data make it possible to explain the discrepancy between the sexual differentiation of the brain and the genitals in terms of the corresponding enzymatic and hormonal disorders.
Showed that the level of sex hormones and neurotransmitters during critical periods of child development determines sexual identification and psychosexual orientation. He believes that the genetic prerequisite for the development of female transsexualism is the insufficiency of 21-hydroxylase in the mother or fetus, caused by prenatal stress, the frequency of which is much higher in both female and male transsexualism compared to the general population.
But how, then, to explain the emergence of M / G-transsexualism? Why not all patients with the viril form of congenital dysfunction of the adrenal cortex (with a karyotype of 46, XX) violated sexual identification?
Congenital dysfunction of the adrenal cortex is a genetically determined disease, which is expressed in the lack of enzyme systems that provide hormone synthesis in the adrenal cortex . This is a group of diseases that is heterogeneous in the clinical picture, among which we can distinguish those that occur with the viril pattern (21-hydroxylase and 11-UZ-hydroxylase deficiency) due to increased production of androgens. The adrenal glands of the fetus (with viril forms of congenital dysfunction of the adrenal cortex) initially function inadequately large numbers of androgens, which in girls leads to congenital virilization of the external genitalia of varying severity (penis-like clitoris, urogenital sinus, scrotal large labia).
There are frequent cases when genotypic girls (with a karyotype of 46, XX) with congenital dysfunction of the adrenal cortex at birth mistakenly establish the male civilian sex, but with timely diagnosis and early treatment of the disease in childhood, patients feel in their biological (female) field. And even if the male civilian sex was initially mistakenly established, changing it to the female one is painless. In the future, these patients create families, give birth to children. Yes, we have cases of late treatment, when patients with the viril form of congenital dysfunction of the adrenal cortex, having a karyotype of 46, XX and living in the male field, do not want to change sex and refuse to carry out treatment, but these cases are rare and mostly refusal to change sex is due to social reasons believe that the gender change in the majority of patients with a 21-hydroxylase defect, in accordance with functional and physiological possibilities, proceeds quite favorably, which indicates the difficulty of comparing this pathology with transsexualism.
Thus, the etiology and pathogenesis of transsexualism has not yet been definitively established, however, due to the high risk of suicide, the only way to resolve conflicts related to the inconsistency of biological and of a passport floor with a mental floor in transsexuals, is hormonal and surgical treatment aimed at changing the anatomical and passport sex.