Transgender patient with ovarian dysgerminoma in medical history

Summary Purpose of Investigation: Recognition of transgender individuals is increasing and so should physicians’ knowledge concerning the appropriate management to ensure the best possible care for these patients. Materials and Methods: Comprehensive case study with guidelines analysis. Results: The case of a 17-year-old female patient is presented. The patient had a previous medical history of left adnexectomy and chemotherapy due to an ovarian dysgerminoma yolk sac tumor. The current problem relates to gender identity formation disorders. The patient requires continuation of multidisciplinary examination, and is under the care of doctors and psychologists. The problem is not only gynecological. Conclusion: This patient’s case indicates that psychosexual development may be neglected over oncological history of ovarian malignancy.

Diagnostic criteria for individual types of gender identity disorders according to ICD 10: I) transsexualism (F64.0) has three criteria: a desire to live and be accepted as a member of the opposite sex, usually accompanied by a wish to have surgery and hormonal treatment to make one's body as congruent as possible with one's preferred sex.The transsexual identity has been continuously present for at least two years.The disorder is not a symptom of another mental disorder or genetic, intersex, or chromosomal abnormalities.II) Dual-role transvestism (F64.1) has three criteria: 1) The person wears clothes of the opposite sex for pleasure (in order to enjoy the temporary experience) of membership of the opposite sex, 2) The cross-dressing is not accompanied by sexual excitement (the cross-dressing is not sexually motivated), and 3) the person does not desire to reassign the other sex surgically (no wish for a permanent sex change).III) Gender identity disorder of childhood (F64.2): the disorder is usually first manifested during early child-hood (and always before puberty).It is characterized by a persistent and intense distress about assigned sex, together with a desire to be of the other sex.There is a persistent preoccupation with the dress and activities of the opposite sex and the rejection of the individual's own sex.The diagnosis requires the identification of a profound disturbance of the normal gender identity; mere tomboyishness in girls or girlish behaviour in boys is not sufficient.This disorder in individuals who have reached or are entering puberty should not be classified here but in F66 [1].
F66 Psychological and behavioural disorders associated with sexual development and orientation: note, sexual orientation by itself is not to be regarded as a disorder.
F66.0 Sexual maturation disorder: the patient suffers from uncertainty about his or her gender identity or sexual orientation, which causes anxiety or depression [2,3].

Case Report
A female OU patient aged 17 years visited the Puberty Gynaecology and Sexology Unit of the Gynaecology Clinic, Perinatology and Gynaecology Chair of the Medical University in Poznań with her mother in relation to the sensation of being male.She had been choosing typical boy games and clothes since early childhood [2,4].
The patient underwent adnexectomy and chemotherapy of germ cell tumour as a child at the Paediatrics Institute of the Medical University in Poznań.Histopathology results indicated dysgerminoma and yolk sac tumour [5,6].
The patient moves and clothes in manners characteristic of boys of her age.She attends a state middle school.As she reported, the fact that she was different was tolerated well by her peers and teachers, which was confirmed by her mother and is a good sign for psychosocial aspects.It should be noted that she flattens her mammary glands at the 4 th stage of development with a piece of cloth, modulates her voice to be deeper to mimic boys, and as opposed to other girls her age, she is not concerned about acne, hirsutism, or overweight.The patient had menarche at the age of 12 and reported slight cycle deviations once a month.
The patient was referred to the Gynaecology Clinic, Perinatology and Gynaecology Chair of the Poznań University of Medical Sciences in on 12 October 2016 for karyotyping (46XX), laboratory tests, including hormone tests, ultrasound, and psychological consultation.
Ultrasound: uterus body 4.3 cm AP 3.5 cm, linear endometrium, the right ovary of correct size and structure with follicles up to 8 mm of diameter, and the left ovary removed (as mentioned above) [4].Several weeks after the hospitalization, the patient reported great abdominal pain caused by incorrect diet.She was checked at an A&E unit, where a small cyst was found on the right ovary.At the Puberty Gynecology and Sexology Unit, a post-rupture status of right functional change was found.Ca125 5.21 and HE 4 4.2 tests were performed.
The patient is under gynecological, sexological, and oncological observation.The patient was referred to the national transsexualism consultant.Until that day, the patient is being monitored by a psychologist-sexologist, and writing a retrospective diary starting in early childhood about her behaviour: games, clothes, etc. related to her gender identity disorder, which is an important diagnostic tool in sexology.

Discussion
The gender identity disorder of childhood F64.2 is usually first manifested during early childhood (and always before puberty).It is characterized by a persistent and intense distress about the assigned sex, together with a desire to be of the other sex [2,3].In the case of this particular patient, her childhood psychosexual issues were not the focal point of her parents' attention due to her oncological history.Gender identity disorders cause a persistent preoccupation with the dress and activities of the opposite sex and the rejection of the individual's own sex.Diagnosis requires the identification of a profound disturbance of the normal gender identity; mere tomboyishness in girls or girlish behaviour in boys is not sufficient.It is not only an issue of female gynecology [2,3,7].
Gender identity disorders should not be diagnosed in individuals who have reached or are entering puberty and a thorough medical and psychological investigation should be performed.Genetic, hormone, endocrinology, and psychiatric tests are important [2,3,7].

Conclusions
As the social recognition of transgender individuals is increasing, so should the knowledge of the physicians concerning the appropriate management to ensure the best possible care for these patients.However, healthcare professionals in many countries the lack standards, knowledge, and comfort sufficient for clinical management of transgender and gender non-conforming patients.The patient's gender identity was happily accepted by her environment.Still, medical professionals must be aware of the higher prevalence of violence and rejection towards transgender youth.The provision of non-judgmental and youth-friendly healthcare services is crucial for ensuring the highest quality of care.It is necessary to provide patients with gender identity disorders with broad diagnosis and an individual approach [2][3][4][5][6].