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You may have seen recent news stories on gender-related topics. In fact, in recent years, there’s been an explosion of interest in the topic with arguments cropping up in politics as well as in the media. From Nicola Sturgeon (former First Minister of Scotland and leader of the Scottish National Party) and J K Rowling (celebrated author of the Harry Potter series of novels) to Sharron Davies (English competitive swimmer in the Olympics and Commonwealth Games), nearly everyone is joining in.
As a result of the growth in the discussion about gender, it is important to understand what gender and therefore gender dysphoria is. Gender dysphoria is a recognised medical condition. Research has shown that about 1 in 14,700 adult males and 1 in 38,000 adult females have gender dysphoria.
What is gender dysphoria?
Before we begin to understand gender dysphoria, we first need to look at the definition of sex, gender and gender identity as all play a role in a person’s experience of gender dysphoria. The words ‘sex’ and ‘gender’ are often used interchangeably in everyday life. Nevertheless, they are two very different concepts.
What is sex?
Sex refers to the physiological and biological differences between males, females and a very small percentage of intersex people as determined by their anatomy. This is produced by their chromosomes, hormones and the interactions between them. In the UK, a baby’s sex is noted at birth on their birth certificate as either male or female. Gender is different from sex but interacts with it.
What is gender?
The World Health Organisation defines gender as:
“the characteristics of women, men, girls and boys that are socially constructed.”
It goes on to specify that this includes the behaviours, the norms and the roles associated with being a man, woman, girl or boy, as well as the relationships with each other. The WHO states that, because gender is a social construct, gender “varies from society to society and can change over time”. It’s hierarchical, producing “inequalities” that also intersect with other economic and social inequalities.
The UK government also falls on the same lines with its definition of gender, regarding it as:
“A social construction relating to behaviours and attributes based on labels of masculinity and femininity.”
What is gender identity?
Gender identity is a more recent concept than sex and gender although the term was first coined by Robert Stoller in 1964. Both gender and sex are related to gender identity but are also resolutely different from it.
A person’s gender identity is said to reflect a person’s individual and internally felt experience of gender. Some people may feel that this does not align with their physiology and biological sex. Gender identity is typically self-identified.
Dysphoria is the opposite of euphoria. That is, it’s a mental state where a person has a deep sense of dissatisfaction and unease. It is not necessarily a mental health diagnosis but is often regarded as a symptom of mental illnesses like anxiety, depression and stress.
As such, gender dysphoria is a deep feeling of distress and discomfort in people who believe that their gender identity is different from their biological sex. Gender dysphoria focuses on the discomfort felt as the main problem rather than a person’s identity.
A gender dysphoria diagnosis is included in the DSM-5 – the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association. It is a diagnosis that was created to support those with gender dysphoria to have access to effective healthcare and treatment.
Gender dysphoria and trans-identifying people
Gender dysphoria is something that transgender people may experience at some point in their lives. However, some transgender people do not experience gender dysphoria even if they do not pursue medical intervention.
Along these lines, it is reported that the number of people with gender dysphoria is actually much smaller than the number of people who identify as trans. In the UK, there are about 650,000 trans people, equating to about 1 in 100.
Gender dysphoria is currently one of the requirements for people to legally change their gender with a Gender Recognition Certificate. Since the Act came into force, 4,910 trans people have been issued with a certificate.
What causes gender dysphoria?
The causes of gender dysphoria are not currently known but it is believed that pre-natal hormonal influences, environmental factors and a person’s genes are all thought to be involved.
In adults, the onset of gender dysphoria is typical in early to mid-adulthood.
There are two typical ways in which gender dysphoria usually develops in adults:
- The first way is common in late adolescence or early adulthood when there is a continuation of dysphoria that began in childhood or early adolescence.
- The second is where the more obvious signs of gender dysphoria and cross-gender identity develop later and much more gradually. Typically they present in early to mid-adulthood.
Signs of gender dysphoria
The signs and symptoms of gender dysphoria are very individual. Essentially, dysphoria is presented as an intense discomfort between a person’s perception of their gender identity and their biological sex.
The difference may be presented in the following ways:
- An intense dislike or discomfort with the genitals or secondary sex characteristics such as facial hair, voice or breast size. For younger people, it includes the fear of secondary sex characteristics developing during puberty.
- A desire to remove genitals or secondary sex characteristics or, in pre-pubescent children, a desire to prevent their development.
- A desire to have the genitals and secondary sex characteristics of the opposite sex.
- A desire to be or be treated in the same way as the opposite sex.
- A fervent belief that they have the typical feelings associated with another gender or sex.
Aside from those specific signs of gender dysphoria, it can also present as distress in other situations affecting how you function in school, work or social situations.
Gender dysphoria often typically arises when a person approaches puberty. Puberty is a time when young people try to work out who they are and begin to explore their sexual feelings. However, sometimes, gender dysphoria does not appear until much later in life.
For gender dysphoria to be classed as a diagnosable condition, the signs must have been present for at least six months. Having said that, gender dysphoria does fluctuate. A person may experience periods of it at various stages in their life and they may have times when they no longer experience it.
Gender dysphoria in children
In children, gender dysphoria may be expressed by a child wanting to dress as the opposite sex or play with toys that are more typically associated with the other gender. They may also take on role-play roles that are usually associated with the opposite gender.
However, it is important to explain that exploring all types of toys and clothing is also a common part of childhood development. Wearing clothes or playing with toys normally associated with another gender does not mean that the child is experiencing gender dysphoria.
Children may express dislike of their genitals, ask to remove them or ask questions about why their genitals are different to other children’s. Again, this is most often a developmental stage that is fairly common among children and is associated with curiosity.
Likewise, children may request to be called a different name or to express that they wish to be the opposite sex. Young children are naturally curious and are working out social norms and expectations that are often deeply ingrained in society with regard to gender. A diagnosis of gender dysphoria in a young child is extremely uncommon and nearly all children who express such thoughts grow up to be perfectly comfortable with their sex and gender.
Gender dysphoria in adults
The signs and symptoms of gender dysphoria in adults are generally similar to those already discussed. Aside from these, signs of gender dysphoria in adults often start as being very private and may be uncovered by those closest to them before they are disclosed.
- Having or wearing items of clothing that are usually associated with the opposite gender.
- Grooming activities concerning hairstyles, body hair and wearing make-up that are atypical.
- Cross-dressing and trying to pass as the opposite sex.
- Pre-occupation with secondary sex characteristics.
- Breast binding in females.
- Internet history or history of posting and/or reading online content associated with gender dysphoria.
- Behaving differently.
- Adopting different mannerisms.
- Suicidal feelings.
- Anxiety disorders.
- Low self-esteem.
- Social isolation.
- Substance misuse.
In both children and adults, a diagnosis of gender dysphoria is only given if there is clinically significant distress associated with it that has persisted for six months.
How common is gender dysphoria?
The DSM-5 states that for biological/natal males, between 0.005% and 0.014%, go on to be diagnosed with gender dysphoria. For biological/natal females, the figures are between 0.002% and 0.003%. These estimates, however, are based on those who actively seek treatment for their gender dysphoria, so these rates are considered to be a gross underestimation.
The NHS states that from 2018 to 2019, 8,000 people were referred to adult gender dysphoria services in England alone.
Dealing with gender dysphoria
Those with gender dysphoria struggle with how society views them combined with how they feel both mentally and physically. For many people, simply dressing and behaving as they wish is enough for them to feel more at ease with their gender identity.
It is well reported that many trans-identifying people do not have gender dysphoria and are content with their ‘authentic self’ and therefore do not pursue a medical diagnosis. For others, having a medical diagnosis is something that they wish to pursue.
It is important for those struggling to deal with gender dysphoria to seek appropriate support. Those who do not access adequate help may be more prone to suffering from depression, anxiety, low self-esteem and suicidal ideation. Some sources say that in one study, 48% of gender dysphoric people reported having suicidal thoughts with 24% saying they had already attempted suicide on at least one occasion.
Diagnosis of gender dysphoria
In children, cross-gender activities and interests often peak between the ages of 2 and 4 years old. Many parents of children who are later discovered to be gender dysphoric often report historic cross-gender interests. For young children expressing gender dysphoria, only a small number continue to have symptoms when they reach adulthood.
Those children who continue with their feelings of distress are often referred for medical support around the time they are reaching the later years of primary school.
This is typically when their differences begin to become more of a challenge and it is not considered by their parents to be “just a phase”.
For children who are suspected to have gender dysphoria, visiting the GP is usually the first port of call. If the GP agrees with the potential diagnosis of gender dysphoria, he/she may refer the child to a gender dysphoria clinic where the child will be assessed by specialists. Children and young people are usually referred to the Gender Identity Development Service as it is specifically for this age group.
The child will be seen by a multidisciplinary team that includes a clinical psychologist, a child psychotherapist, a children’s and adolescent psychiatrist, a family therapist and a social worker. There is an assessment process that takes place over three to six appointments over the course of several months. The results of the assessments will determine what path the child takes next.
Many people wonder if they need to be assessed by mental health services first but this is often not the case unless mental health difficulties and a significant risk of mental health deterioration are identified.
Treatment for gender dysphoria
For those who have been diagnosed with gender dysphoria, their treatment is largely concerned with treating their distress over their condition rather than challenging the way they feel about their gender.
Treating children with gender dysphoria
For children, the treatments offered at this stage are psychological rather than medical. This is because children and adolescents often express gender-variant feelings and behaviours that change or even disappear as they reach puberty. Talking therapies with specialised psychologists or psychiatrists often play a key role in helping children with gender dysphoria.
In recent years, there has been an extremely controversial use of puberty blockers in children that pause the child’s physical changes associated with puberty such as growing facial hair in males or growing breasts in females.
Despite some organisations advising that this treatment is reversible, there is very little known about the effects of such medications on children, especially regarding the psychological effects associated with stopping the drugs.
Aside from this, not enough is known about how hormone blockers affect teenage brain development or the development of children’s growing bones. There are also the associated side effects of fatigue, mood alterations and hot flushes.
It is reported that the Gender Identity Development Service at Tavistock and Portman NHS Trust in London will close later in 2023 after a report accused it of rushing children onto puberty blockers. The treatment pathways will now be located at local hospitals that will provide holistic care that has strong links to mental health services.
Treating adults with gender dysphoria
For some gender non-conforming adults, their treatment becomes more about bringing their physical appearance more in line with how they believe they feel inside. They may choose a different name, ask people to refer to them by different pronouns or change the way they dress and present in society. For many people, this is enough of a transition to alleviate their dysphoric feelings associated with their gender.
Other trans-identifying people may wish to pursue other options to help them deal with their dysphoria. This includes seeking cross-sex hormones and surgery.
After assessments, adults diagnosed with gender dysphoria may be offered hormone therapy. The aim of this therapy is supposedly to make the trans-identifying person feel more comfortable within their body in terms of their physical appearance. The hormones will need to be taken for the rest of a person’s life, even if they opt for surgery.
For those who want to appear more masculine, testosterone is the drug of choice. For those desiring femininity, oestrogen is prescribed. Both of these drugs also suppress the release of the body’s natural sex hormones. It takes many months for hormone therapy to be effective, which frustrates many trans-identifying people.
For many gender dysphoric people, hormone therapy is a sufficient treatment for them to feel less distress with their gender identity.
However, there are risks with hormone therapy that include:
- Blood clots.
- Weight gain.
- Elevated liver enzymes.
- Dyslipidaemia (abnormal fat levels in the blood).
- Polycythaemia (a high concentration of red blood cells).
- Balding or hair loss.
- Infertility in long-term use.
Some gender dysphoric adults decide to have surgery to alter their bodies permanently to align their bodies physically with their perceived internal gender identity.
Surgery for trans-identifying females:
- Removing the breasts and chest reconstruction.
- Dermal implants and tattoos.
- Nipple repositioning.
- Phalloplasty or metoidioplasty – the construction of a ‘penis’.
- Scrotoplasty – the construction of a ‘scrotum’ with testicular implants.
- A penile implant.
- Sometimes, a hysterectomy (removing the womb) and salpingo-oophorectomy (removing the ovaries and fallopian tubes) may also occur.
Surgery for trans-identifying males:
- Orchidectomy (removing the testicles).
- Penectomy (removing the penis).
- Vaginoplasty (constructing a ‘vagina’).
- Vulvoplasty (constructing a ‘vulva’).
- Clitoroplasty (constructing a ‘clitoris’).
- Breast implants.
- Facial feminisation surgery.
- Hair transplants.
It is worth noting that not all of these surgical procedures would be funded by the NHS.
After medical transition
Gender dysphoric individuals who have been medically treated for their condition by way of hormones and/or surgery will likely need life-long monitoring. They may also require contraception if they have not had surgery that would otherwise prevent it.
Additionally, it’s important for those who have transitioned to still attend their GP for sex-based screening such as cervical screening, breast screening and prostate examination as appropriate when required.