易性症

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Shenyang Mental Health Center

Outpatient Medical Record

Card No.: 20220000000000    Name: panda         Gender: Female          Age: 26

Aug. 21, 2023 13:33 The patient consulted alone

Chief complaint: Almost 20 years of gender dysphoria

History of present illness: At the age of three the patient thought she was supposed to be a boy like her cousin. At age 6, 7 her aunt always looked at her breasts, which may have led to her being gender-conscious and hating her own construction. When the patient was 10 years old, parents took the patient to the mall to buy clothes and would choose men’s shoes. The patient insisted on a short haircut, and in middle school and high school, she lived in a dormitory and never went to the school’s girls’ bathroom. Gender was not emphasized much at school, and both boys and girls at school had short hair and wore the same uniforms. In the second year of junior high school, the patient wore a summer short-sleeved school T-shirt with boys’ style different from with girls’ style. Due to chest development, the patient had to start hunching and became introverted. In her first year of university, she talked to a boyfriend on the Internet, and the patient indicated from the onset that she was a boy at heart, but the boyfriend thought that the patient’s body was a girl, so he let the patient wear women’s clothes and keep her hair long. The patient took a leave of absence in her junior year because of the mental internal conflict. After breaking up with her boyfriend, the patient switched back to men’s clothes and cut her hair short, and her symptoms got better. In 2021, the patient was exposed to the concept of transgenderism, and in 2022, she explained the truth to her family, who expressed support. On May 10, 2023, the patient went to Shanghai Changhai Hospital for a flat chest surgery.

Past history: Previously health.

Personal history: Neutral personality before the disease

Family history: There was no positive family history of psychiatric abnormalities

Physical examination: No abnormalities

Mental examination: Consciousness, and orientation was intact. There were symptoms of anxiety and depression with less sleep, decreased appetite, and cognitive impairment. There was a sense of distress and self-awareness was intact.

Western medicine diagnosis: Transsexualism

Chinese medicine diagnosis:

Ecological investigation history: Examine for fever, dry cough, fatigue, decreased or loss of smell, taste, nasal congestion, runny nose, sore throat, conjunctivitis, myalgia, diarrhea, etc. (Yes□No ☑)

Auxiliary examination: HAMA: 13. May have anxiety (gender anxiety)   HAMD: 12. May have very mild depressive symptoms    MMPI: Anxiety depression 46.84%

LES: Total Life Event Stimulus was 50, which was above the upper limit of the normal range

SCL-90: 142, positive screen, SDSS: Have social functioning deficits

Treatment: Symptomatic treatment is recommended and medication should be taken according to the doctor’s advice

[A] Psychiatric class C scale assessment [MMPI] Total: 1 time; [A] Psychiatric class C scale assessment [SCL-90] Total: 1 time; [A] Psychiatric class A scale assessment [HAMA] Total: 1 time; [A] Psychiatric class A scale assessment [HAMD] Total: 1 time; [A] Psychiatric class B scale assessment [LES] Total: 1 time; [A] Psychiatric class B scale assessment [SDSS] Total: 1 time;

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