FROM THE NATIONAL HEALTH SERVICE OF WALES
Recently the question of GENDER DYSPHORIA arose on this blog.
Some readers were very compassionate and others were ignorant or intolerant.
1% of the population suffers from this condition in one way or another.
That is 600,000 people in the UK
And 50,000 on the island of Ireland.
We should all know about this condition which affects so many of our brothers and sisters.
We should all show COMPASSION, UNDERSTANDING and LOVING SUPPORT.
Remember: "BUT FOR THE GRACE OF GOD - THERE GO YOU".
Gender dysphoria is a condition where a person experiences discomfort or distress because there's a mismatch between their biological sex and gender identity. It's sometimes known as gender identity disorder (GID), gender incongruence or transgenderism.
Biological sex is assigned at birth, depending on the appearance of the genitals. Gender identity is the gender that a person "identifies" with or feels themselves to be.
While biological sex and gender identity are the same for most people, this isn't the case for everyone. For example, some people may have the anatomy of a man, but identify themselves as a woman, while others may not feel they're definitively either male or female.
This mismatch between sex and gender identity can lead to distressing and uncomfortable feelings that are called gender dysphoria. Gender dysphoria is a recognised medical condition, for which treatment is sometimes appropriate. It's not a mental illness.
Some people with gender dysphoria have a strong and persistent desire to live according to their gender identity, rather than their biological sex. These people are sometimes called transsexual or trans people. Some trans people have treatment to make their physical appearance more consistent with their gender identity.
Signs of gender dysphoria
The first signs of gender dysphoria can appear at a very young age. For example, a child may refuse to wear typical boys' or girls' clothes, or dislike taking part in typical boys' or girls' games and activities.
In most cases, this type of behaviour is just a normal part of growing up and will pass in time, but for those with gender dysphoria it continues through childhood and into adulthood.
Adults with gender dysphoria can feel trapped inside a body that doesn't match their gender identity.
They may feel so unhappy about conforming to societal expectations that they live according to their anatomical sex, rather than the gender they feel themselves to be.
They may also have a strong desire to change or get rid of physical signs of their biological sex, such as facial hair or breasts.
See your GP if you think you or your child may have gender dysphoria.
If necessary, they can refer you to a specialist Gender Identity Clinic (GIC). Staff at these clinics can carry out a personalised assessment and provide any support you need.
A diagnosis of gender dysphoria can usually be made after an in-depth assessment carried out by two or more specialists.
This may require several sessions, carried out a few months apart, and may involve discussions with people you are close to, such as members of your family or your partner.
The assessment will determine whether you have gender dysphoria and what your needs are, which could include:
- whether there's a clear mismatch between your biological sex and gender identity
- whether you have a strong desire to change your physical characteristics as a result of any mismatch
- how you're coping with any difficulties of a possible mismatch
- how your feelings and behaviours have developed over time
- what support you have, such as friends and family
The assessment may also involve a more general assessment of your physical and psychological health.
Treatment for gender dysphoria
If the results of an assessment suggest that you or your child have gender dysphoria, staff will work with you to come up with an individual treatment plan. This will include any psychological support you may need.
Treatment for gender dysphoria aims to help reduce or remove the distressing feelings of a mismatch between biological sex and gender identity.
This can mean different things for different people. For some people, it can mean dressing and living as their preferred gender.
For others, it can mean taking hormones or also having surgery to change their physical appearance.
Many trans people have treatment to change their body permanently, so they're more consistent with their gender identity, and the vast majority are satisfied with the eventual results.
What causes gender dysphoria?
Gender development is complex and there are many possible variations that cause a mismatch between a person’s biological sex and their gender identity, making the exact cause of gender dysphoria unclear.
Occasionally, the hormones that trigger the development of biological sex may not work properly on the brain, reproductive organs and genitals, causing differences between them. This may be caused by:
- additional hormones in the mother’s system – possibly as a result of taking medication
- the foetus’ insensitivity to the hormones, known as androgen insensitivity syndrome (AIS) – when this happens, gender dysphoria may be caused by hormones not working properly in the womb
Gender dysphoria may also be the result of other rare conditions, such as:
- congenital adrenal hyperplasia (CAH) – where a high level of male hormones are produced in a female foetus. This causes the genitals to become more male in appearance and, in some cases, the baby may be thought to be biologically male when she is born.
- intersex conditions – which cause babies to be born with the genitalia of both sexes (or ambiguous genitalia). Parents are recommended to wait until the child can choose their own gender identity before any surgery is carried out.
How common is gender dysphoria?
It's not known exactly how many people experience gender dysphoria, because many people with the condition never seek help.
A survey of 10,000 people undertaken in 2012 by the Equality and Human Rights Commission found that 1% of the population surveyed was gender variant, to some extent.
While gender dysphoria appears to be rare, the number of people being diagnosed with the condition is increasing, due to growing public awareness.
However, many people with gender dysphoria still face prejudice and misunderstanding.
Gender dysphoria is a complex condition that can be difficult to understand. Therefore, it helps to distinguish between the meanings of different gender-related terms:
- gender dysphoria – discomfort or distress caused by a mismatch between a person’s gender identity and their biological sex assigned at birth
- transsexualism – the desire to live and be accepted as a member of the opposite sex, usually accompanied by the wish to have treatment to make their physical appearance more consistent with their gender identity
- transvestism – where a person occasionally wears clothes typically associated with the opposite gender (cross-dressing) for a variety of reasons
- genderqueer – an umbrella term used to describe gender identities other than man and woman – for example, those who are both man and woman, or neither man nor woman, or moving between genders
Gender dysphoria isn't the same as transvestism or cross-dressing and isn't related to sexual orientation. People with the condition may identify as straight, gay, lesbian, bisexual or asexual, and this may change with treatment.
There are no physical symptoms of gender dysphoria, but people with the condition may experience and display a range of feelings and behaviours.
In many cases, a person with gender dysphoria begins to feel a mismatch between their biological sex and gender identity during early childhood. For others, this may not happen until adulthood.
Gender dysphoria behaviours in children can include:
- insisting they're of the opposite sex
- disliking or refusing to wear clothes that are typically worn by their sex and wanting to wear clothes typically worn by the opposite sex
- disliking or refusing to take part in activities and games that are typically associated with their sex, and wanting to take part in activities and games typically associated with the opposite sex
- preferring to play with children of the opposite biological sex
- disliking or refusing to pass urine as other members of their biological sex usually do – for example, a boy may want to sit down to pass urine and a girl may want to stand up
- insisting or hoping their genitals will change – for example, a boy may say he wants to be rid of his penis, and a girl may want to grow a penis
- feeling extreme distress at the physical changes of puberty
Children with gender dysphoria may display some, or all, of these behaviours. However, in many cases, behaviours such as these are just a part of childhood and don't necessarily mean your child has gender dysphoria.
For example, many girls behave in a way that can be described as "tomboyish", which is often seen as part of normal female development. It's also not uncommon for boys to roleplay as girls and to dress up in their mother's or sister's clothes. This is usually just a phase.
Most children who behave in these ways don't have gender dysphoria and don't become transsexuals. Only in rare cases does the behaviour persist into the teenage years and adulthood.
Teenagers and adults
If the feelings of gender dysphoria are still present by the time your child is a teenager or adult, it's likely that they're not just going through a phase.
If you're a teenager or an adult whose feelings of gender dysphoria begun in childhood, you may now have a much clearer sense of your gender identity and how you want to deal with it. Many people with strong feelings of gender dysphoria are fully transsexual during their teenage years.
The way gender dysphoria affects teenagers and adults is different to the way it affects children. If you're a teenager or adult with gender dysphoria, you may feel:
- without doubt that your gender identity is at odds with your biological sex
- comfortable only when in the gender role of your preferred gender identity
- a strong desire to hide or be rid of the physical signs of your sex, such as breasts, body hair or muscle definition
- a strong dislike for – and a strong desire to change or be rid of – the genitalia of your biological sex
Without appropriate help and support, some people may try to suppress their feelings and attempt to live the life of their biological sex. Ultimately, however, most people are unable to keep this up.
Having or suppressing these feelings is often very difficult to deal with and, as a result, many transsexuals and people with gender dysphoria experience depression, self-harm or suicidal thoughts.
Treatment for gender dysphoria aims to help people with the condition live the way they want to, in their preferred gender identity.
What this means will vary from person to person, and is different for children, young people and adults. Your specialist care team will work with you on a treatment plan that's tailored to your needs.
Treatment for children and young people
If your child is under 18 and thought to have gender dysphoria, they'll usually be referred to a specialist child and adolescent Gender Identity Clinic (GIC).
Staff at these clinics can carry out a detailed assessment of your child, to help them determine what support they need.
Depending on the results of this assessment, the options for children and young people with suspected gender dysphoria can include:
- family therapy
- individual child psychotherapy
- parental support or counselling
- group work for young people and their parents
- regular reviews to monitor gender identity development
- hormone therapy (see below)
Your child’s treatment should be arranged with a multi-disciplinary team (MDT). This is a group of different healthcare professionals working together, which may include specialists such as mental health professionals and paediatric endocrinologists (specialists in hormone conditions in children).
Most treatments offered at this stage are psychological, rather than medical or surgical. This is because the majority of children with suspected gender dysphoria don't have the condition once they reach puberty. Psychological support offers young people and their families a chance to discuss their thoughts and receive support to help them cope with the emotional distress of the condition, without rushing into more drastic treatments.
If your child has gender dysphoria and they've reached puberty, they could be treated with gonadotrophin-releasing hormone (GnRH) analogues. These are synthetic (man-made) hormones that suppress the hormones naturally produced by the body.
Some of the changes that take place during puberty are driven by hormones. For example, the hormone testosterone, which is produced by the testes in boys, helps stimulate penis growth.
GnRH analogues suppress the hormones produced by your child’s body. They also suppress puberty and can help delay potentially distressing physical changes caused by their body becoming even more like that of their biological sex, until they're old enough for the treatment options discussed below.
GnRH analogues will only be considered for your child if assessments have found they're experiencing clear distress and have a strong desire to live as their gender identity.
The effects of treatment with GnRH analogues are considered to be fully reversible, so treatment can usually be stopped at any time after a discussion between you, your child and your MDT.
Transition to adult services
Teenagers who are 17 years of age or older may be seen in an adult gender clinic. They are entitled to consent to their own treatment and follow the standard adult protocols.
By this age, doctors can be much more confident in making a diagnosis of gender dysphoria and, if desired, steps can be taken towards more permanent hormone or surgical treatments to alter your child’s body further, to fit with their gender identity.
Treatment for adults
Adults with gender dysphoria should be referred to a specialist adult GIC. As with specialist children and young people GICs, these clinics can offer ongoing assessments, treatments, support and advice, including:
- mental health support, such as counselling
- cross-sex hormone treatment (see below)
- speech and language therapy – to help alter your voice, to sound more typical of your gender identity
- hair removal treatments, particularly facial hair
- peer support groups, to meet other people with gender dysphoria
- relatives' support groups, for your family
For some people, support and advice from a clinic are all they need to feel comfortable in their gender identity. Others will need more extensive treatment, such as a full transition to the opposite sex. The amount of treatment you have is completely up to you.
Hormone therapy for adults means taking the hormones of your preferred gender:
- a trans man (female to male) will take testosterone (masculinising hormones)
- a trans woman (male to female) will take oestrogen (feminising hormones)
The aim of hormone therapy is to make you more comfortable with yourself, both in terms of physical appearance and how you feel. These hormones start the process of changing your body into one that is more female or more male, depending on your gender identity. They usually need to be taken indefinitely, even if you have genital reconstructive surgery.
Hormone therapy may be all the treatment you need to enable you to live with your gender dysphoria. The hormones may improve how you feel and mean that you don't need to start living in your preferred gender or have surgery.
Changes in trans women
If you're a trans woman, changes that you may notice from hormone therapy include:
- your penis and testicles getting smaller
- less muscle
- more fat on your hips
- your breasts becoming lumpy and increasing in size slightly
- less facial and body hair
Hormone therapy won't affect the voice of a trans woman. To make the voice higher, trans women will need voice therapy and, rarely, voice modifying surgery.
Changes in trans men
If you're a trans man, changes you may notice from hormone therapy include:
- more body and facial hair
- more muscle
- your clitoris (a small, sensitive part of the female genitals) getting bigger
- your periods stopping
- an increased sex drive (libido)
Your voice may also get slightly deeper, but it may not be as deep as other men’s voices.
There's some uncertainty about the possible risks of long-term masculinising and feminising hormone treatment. You should be made aware of the potential risks and the importance of regular monitoring before treatment begins.
Some of the potential problems most closely associated with hormone therapy include:
- blood clots
- weight gain
- hair loss from the scalp
- sleep apnoea – a condition that causes interrupted breathing during sleep
Hormone therapy will also make both trans men and trans women less fertile and, eventually, completely infertile. Your specialist should discuss the implications for fertility before starting treatment, and they may talk to you about the option of storing eggs or sperm (known as gamete storage) in case you want to have children in the future. However, this isn't likely to be available on the NHS.
There's no guarantee that fertility will return to normal if hormones are stopped.
While you're taking these hormones, you'll need to have regular check-ups, either at your GIC or your local GP surgery. You'll be assessed, to check for any signs of possible health problems and to find out if the hormone treatment is working.
If you don't think that hormone treatment is working, talk to the healthcare professionals who are treating you. If necessary, you can stop taking the hormones (although some changes are irreversible, such as a deeper voice in trans men and breast growth in trans women).
Alternatively, you may be frustrated with how long hormone therapy takes to produce results, as it will take a few months for some changes to develop. Hormones can't change the shape of your skeleton, such as how wide your shoulders or your hips are. It also can't change your height.
Hormones for gender dysphoria are also available from other sources, such as the internet, and it may be tempting to get them from here instead of through your clinic. However, hormones from other sources may not be licensed and safe. If you decide to use these hormones, let your doctors know so they can monitor you.
Social gender role transition
If you want to have genital reconstructive surgery, you'll usually first need to live in your preferred gender identity full time for at least a year. This is known as "social gender role transition" (previously known as "real life experience" or "RLE") and it will help in confirming whether permanent surgery is the right option.
You can start your social gender role transition as soon as you're ready, after discussing it with your care team, who can offer support throughout the process.
The length of the transition period recommended can vary, but it's usually one to two years. This will allow enough time for you to have a range of experiences in your preferred gender role, such as work, holidays and family events.
For some types of surgery, such as a bilateral mastectomy (removal of both breasts) in trans men, you may not need to complete the entire transition period before having the operation.
Once you've completed your social gender role transition and you and your care team feels you're ready, you may decide to have surgery to permanently alter your sex.
The most common options are discussed below, but you can talk to members of your team and the surgeon at your consultation about the full range available.
Trans man surgery
For trans men, surgery may involve:
- a bilateral mastectomy (removal of both breasts)
- a hysterectomy (removal of the womb)
- a salpingo-oophorectomy (removal of the fallopian tubes and ovaries)
- phalloplasty or metoidioplasty (construction of a penis)
- scrotoplasty (construction of a scrotum) and testicular implants
- a penile implant
A phalloplasty uses the existing vaginal tissue and skin taken from the inner forearm or lower abdominal wall to create a penis. A metoidioplasty involves creating a penis from the clitoris, which has been enlarged through hormone therapy.
The aim of this type of surgery is to create a functioning penis, which allows you to pass urine standing up and to retain sexual sensation. You'll usually need to have more than one operation to achieve this.
Trans woman surgery
For trans women, surgery may involve:
- an orchidectomy (removal of the testes)
- a penectomy (removal of the penis)
- vaginoplasty (construction of a vagina)
- vulvoplasty (construction of the vulva)
- clitoroplasty (construction of a clitoris with sensation)
- breast implants
- facial feminisation surgery (surgery to make your face a more feminine shape)
The vagina is usually created and lined with skin from the penis, with tissue from the scrotum (the sack that holds the testes) used to create the labia. The urethra (urine tube) is shortened and repositioned. In some cases, a piece of bowel may be used during a vaginoplasty if hormone therapy has caused the penis and scrotum to shrink a significant amount.
The aim of this type of surgery is to create a functioning vagina with an acceptable appearance and retained sexual sensation.
Some trans women can't have a full vaginoplasty for medical reasons, or they may not want to have a functioning vagina. In such cases, a cosmetic vulvoplasty and clitoroplasty is an option, as well as removing the testes and penis.
Life after surgery
After surgery, most transsexuals are happy with their new sex and feel comfortable with their gender identity. One review of a number of studies that were carried out over a 20-year period found that 96% of people who had genital reconstructive surgery were satisfied.
Despite high levels of personal satisfaction, people who have had genital reconstructive surgery may face prejudice or discrimination because of their condition. Treatment can sometimes leave people feeling:
- isolated, if they're not with people who understand what they're going through
- stressed about or afraid of not being accepted socially
- discriminated against at work
There are legal safeguards to protect against discrimination but other types of prejudice may be harder to deal with. If you're feeling anxious or depressed since having your treatment, speak to your GP or a healthcare professional at your clinic.
Once transition has been completed, it's possible for a trans man or woman to experience a change of sexual orientation. For example, a trans woman who was attracted to women before surgery may be attracted to men after surgery. However, this varies greatly from person to person, and the sexual orientation of many transsexuals doesn't change.
If you're a transsexual going through the process of transition, you may not know what your sexual preference will be until it's complete. However, try not to let this worry you. For many people, the issue of sexual orientation is secondary to the process of transition itself.
There are a number of laws and guidelines that protect transsexual people and outline how they should be treated by medical professionals.
Gender Recognition Act 2004
The Gender Recognition Act 2004 gives certain legal rights to trans men and women.
Under the Gender Recognition Act of 2004, trans men and women can:
- apply for and obtain a Gender Recognition Certificate to acknowledge their gender identity
- get a new birth certificate, driving licence and passport
- marry in their new gender
To apply for a Gender Recognition Certificate, you must be over 18.
The application process requires you to prove that:
- you have or have had gender dysphoria
- you have lived as your preferred gender for the last two years
- you intend to live permanently in your preferred gender