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Problems in management of a transvestite with multiple sclerosis
BRIEF
NOTE Problenas
in Management of a Transvestite with Multiple Sclerosis
By J.
TttOMAS
UNGERLEIDEI~, M . D .
T
HE ROLE of psychological factors in multiple sclerosis has frequently been noted. This psychic component has, at various times, been described as a p r e c i p i t a n t / as an exacerbating f a c t o r , -° a n d a s p o s s i b l y e t i o l o g i c , a T h e p o s s i b i l i t y h a s a l s o b e e n c o n s i d e r e d t h a t t h e a s s o c i a t i o n is a c o i n c i d e n c e . 4 O n e r e p o r t s t a t e s " ' . . . i n m u l t i p l e s c l e r o s i s [ t h e r e is] . . . a g r e e m e n t among authors o n l y t h a t m e n t a l c h a n g e s a r e f r e q u e n t . T h e r e is p r o f o u n d d i s a g r e e m e n t as to t h e , i r n a t u r e a n d c a u s e . "'n The mental changes described in multiple sclerosis include conversion hyster i a a n d e m o t i o n a l i m m a t u r i t y , :~ a f f e c t i v e d e r a n g e m e n t - d e p r e s s i o n s and, rarely, e u p h o r i a , '~ m o r b i d a n x i e t y a n d p s y c h o s e x u a l immaturity, 4 and behavior difficulties with antisocia| and psychotic trends. 6 Psychologic symptoms ascribed to cerebral pathology in multiple sclerosis include sexual impotence and org a n i c s y n d r o m e s , n s u c h as f o r c e d l a u g h i n g a n d c r y i n g a s p a r t o f t h e s y n d r o l a ~ e of pseudol~ulbar palsy. ~ The occurrence of this illness in conjunction with transvestitism, however, is r a r e . I h a v e n o t b e e n a b l e t o f i n d s u c h a c a s e r e p o r t e d i n t h e l i t e r a t u r e , altho,.~gh m a l e e x h i b i t i o n i s m a n d f e m a l e h o m o s . e x u a l i t y h a v e b e e n e n c o u n t e r e d in a s s o c i a t i o n w i t h m u l t i p l e s c l e r o s i s . 4 T h i s c a s e is r e p o r t e d t o d e s c r i b e s o m e of the difficu]tes involved in the management of a transvestite with multiple sclerosis. No attempt has been made to decide which symptoms are functional and which are due to the organic process.
C A S E RE'PONT
Present Illness T h e p a t i e n t is a thirty-two year old m a r r i e d w h i t e male w h o was referred to the psychiatric o u t p a t i e n t facility* following confession of his transvestitism to his private physician. T h e p a t i e n t was well until a p p r o x i m a t e l y one year before the psychiatric referral, at w h i c h t i m e h e n o t e d d e c r e a s e d desire for intercourse a n d i m p a i r e d ability to p e r f o r m sexually. Several m o n t h s later he l)~:gan to d e v e l o p diplopia, weakness a n d n u m b hess in all extremities, a n d sa~l~jective as well as objective vertigo. H e was hospitalized for evaluation b y a n e u r o s u r g e o n and was f o u n d to h a v e ptosis, n y s t a g m u s , optic disk pallor, ataxia of all extremities, a s y m m e t r i c d e e p t e n d o n reflexes and bilateral Babinski responses, a n d an a b n o r m a l colloidal gold reaction in t h e eerebrosl)inal fluid. T h e diagnosis of m u l t i p l e sclerosis ~vas n m d e . W h e n the p a t i e n t was so i n f o r m e d , he p r o m p t l y w-rote a thirteen p a g e letter to his physician confessing his transvestitism. In the letter h e stated his belief t h a t t h e m~ltiple sclerosis was caused by his l~erversion a n d that psychiatric t r e a t m e n t o f t h e latter w o u l d cure t h e organic illness. H e expressed dissatisfaction w i t h his "'small c h i n " a n d his "'small penis" a n d revealed his u r g e to b e c a s t r a t e d a n d b e c o m e a w o m a n . H e wr¢~te that lie h a d m a r r i e d his w i f e seven years ago only to p r e v e n t h e r from revealing his transvestite activities a n d h e d e s c r i b e d his o v e r t homosexual relations d u r i n g h i g h school a n d i n t e r m i t t e n t l y thereafter. * T h e Psychiatric Clinic, University Hospitals, Cleveland, Ohio.
CO,',XPI~EHENSIVE PSYCHIA'rnY, VOL. 3, No. 2 ( A P m L ) , 1962
NOTE Problenas
in Management of a Transvestite with Multiple Sclerosis
By J.
TttOMAS
UNGERLEIDEI~, M . D .
T
HE ROLE of psychological factors in multiple sclerosis has frequently been noted. This psychic component has, at various times, been described as a p r e c i p i t a n t / as an exacerbating f a c t o r , -° a n d a s p o s s i b l y e t i o l o g i c , a T h e p o s s i b i l i t y h a s a l s o b e e n c o n s i d e r e d t h a t t h e a s s o c i a t i o n is a c o i n c i d e n c e . 4 O n e r e p o r t s t a t e s " ' . . . i n m u l t i p l e s c l e r o s i s [ t h e r e is] . . . a g r e e m e n t among authors o n l y t h a t m e n t a l c h a n g e s a r e f r e q u e n t . T h e r e is p r o f o u n d d i s a g r e e m e n t as to t h e , i r n a t u r e a n d c a u s e . "'n The mental changes described in multiple sclerosis include conversion hyster i a a n d e m o t i o n a l i m m a t u r i t y , :~ a f f e c t i v e d e r a n g e m e n t - d e p r e s s i o n s and, rarely, e u p h o r i a , '~ m o r b i d a n x i e t y a n d p s y c h o s e x u a l immaturity, 4 and behavior difficulties with antisocia| and psychotic trends. 6 Psychologic symptoms ascribed to cerebral pathology in multiple sclerosis include sexual impotence and org a n i c s y n d r o m e s , n s u c h as f o r c e d l a u g h i n g a n d c r y i n g a s p a r t o f t h e s y n d r o l a ~ e of pseudol~ulbar palsy. ~ The occurrence of this illness in conjunction with transvestitism, however, is r a r e . I h a v e n o t b e e n a b l e t o f i n d s u c h a c a s e r e p o r t e d i n t h e l i t e r a t u r e , altho,.~gh m a l e e x h i b i t i o n i s m a n d f e m a l e h o m o s . e x u a l i t y h a v e b e e n e n c o u n t e r e d in a s s o c i a t i o n w i t h m u l t i p l e s c l e r o s i s . 4 T h i s c a s e is r e p o r t e d t o d e s c r i b e s o m e of the difficu]tes involved in the management of a transvestite with multiple sclerosis. No attempt has been made to decide which symptoms are functional and which are due to the organic process.
C A S E RE'PONT
Present Illness T h e p a t i e n t is a thirty-two year old m a r r i e d w h i t e male w h o was referred to the psychiatric o u t p a t i e n t facility* following confession of his transvestitism to his private physician. T h e p a t i e n t was well until a p p r o x i m a t e l y one year before the psychiatric referral, at w h i c h t i m e h e n o t e d d e c r e a s e d desire for intercourse a n d i m p a i r e d ability to p e r f o r m sexually. Several m o n t h s later he l)~:gan to d e v e l o p diplopia, weakness a n d n u m b hess in all extremities, a n d sa~l~jective as well as objective vertigo. H e was hospitalized for evaluation b y a n e u r o s u r g e o n and was f o u n d to h a v e ptosis, n y s t a g m u s , optic disk pallor, ataxia of all extremities, a s y m m e t r i c d e e p t e n d o n reflexes and bilateral Babinski responses, a n d an a b n o r m a l colloidal gold reaction in t h e eerebrosl)inal fluid. T h e diagnosis of m u l t i p l e sclerosis ~vas n m d e . W h e n the p a t i e n t was so i n f o r m e d , he p r o m p t l y w-rote a thirteen p a g e letter to his physician confessing his transvestitism. In the letter h e stated his belief t h a t t h e m~ltiple sclerosis was caused by his l~erversion a n d that psychiatric t r e a t m e n t o f t h e latter w o u l d cure t h e organic illness. H e expressed dissatisfaction w i t h his "'small c h i n " a n d his "'small penis" a n d revealed his u r g e to b e c a s t r a t e d a n d b e c o m e a w o m a n . H e wr¢~te that lie h a d m a r r i e d his w i f e seven years ago only to p r e v e n t h e r from revealing his transvestite activities a n d h e d e s c r i b e d his o v e r t homosexual relations d u r i n g h i g h school a n d i n t e r m i t t e n t l y thereafter. * T h e Psychiatric Clinic, University Hospitals, Cleveland, Ohio.
CO,',XPI~EHENSIVE PSYCHIA'rnY, VOL. 3, No. 2 ( A P m L ) , 1962