Gender dysphoria

What is gender dysphoria?

'Gender identity' means the sex we most feel we are. For most people this is the sex they were assigned at birth as a result of the appearance of their genitals. However, for some people there is a mismatch between the sex they feel they are, and the sex they appear to be to other people.

Gender dysphoria is the term used by health professionals to describe profound distress when gender identity is in conflict with physical gender. Dysphoria means unhappiness. So 'gender dysphoria' describes the distress and problems which may be caused by gender identity issues.

Gender identity disorder is now an outdated term. It was gradually changed because the term wrongly suggests a mental illness.

It is not an illness to be transsexual, or to feel you should be another sex to the one you are born with. However, it can cause some problems and distress. You may wish to ask for medical help if you feel this way. You may need help coming to terms with the effect it has on your life. Or you may wish for help in changing your appearance to fit with the gender you feel is right for you. In order to access this care there has to be a medical term. Nowadays it is understood that being transsexual or transgender does not refer to illness - it refers to diversity. This is why the term 'gender dysphoria' is now used instead of the diagnosis 'gender identity disorder'.

Some more definitions

Gender is not simply being masculine or feminine. Gender refers to a personal sense of identity as masculine or feminine, and how you are seen by society. There is a range between masculine and feminine. Everyone should be accepted as an individual rather than a type.

Sex is also not simply being male or female. Although the great majority of people do adhere to being physically male or female, sexuality is about choice of sexual partner, and sexual identity ("straight", gay or lesbian, bisexual or asexual).

Cisgender: this is a term for people whose gender identity matches the gender that they were assigned at birth. Cis mean 'on the same side as', and is short for cisgender. Cisgender is the opposite of transgender.

Transsexual: a person who feels an overwhelming desire to make a physical change and live their life as a member of the opposite sex. Many transsexual people actively wish for and undergo an operation to change their sex.

Transgender or trans: although this is most often used to refer to people who wish to transition from male to female or vice versa, it can refer to a number of different gender experiences such as non-binary people and gender fluid people.

Non-binary (or genderqueer) is used for gender identities that are neither male nor female‍. Non-binary people may identify as an intermediate or a separate third gender, identify with more than one gender, no gender (agender), or have a fluctuating gender identity (genderfluid).

Trans woman/trans man: a trans woman is a person who has been assigned as a male at birth, but who later identifies as a woman. A trans man is a person who has been assigned as a female at birth, but later identifies as a male. These are terms used BEFORE a person has any sex-changing surgery, or makes any legal changes. After either of these events, they would normally refer to themselves as a woman or a man respectively.

Transvestite: a transvestite is a person who dresses in the clothing of the opposite sex. This usually refers to a man dressing as a woman. Transvestites do not necessarily wish for permanent changes to their sex or gender.

Sexual orientation is something separate from gender identity. It refers to the gender of a person to whom you are sexually attracted. A transsexual or trans person can be straight (heterosexual), gay (homosexual), attracted to both men and women (bisexual) or attracted to neither (asexual).

Patient picks for Other mental health problems

Mental health

Is maladaptive daydreaming a sign of mental illness?

We all daydream - and letting our thoughts drift into imagined scenarios and fantasies are a normal and healthy part of the human experience. But what about the dark side of daydreaming? We explore when this trait becomes harmful, and how this so-called maladaptive daydreaming is often linked to past trauma and mental illness.

by Amberley Davis

Mental health

Schizophrenia

Schizophrenia is a mental disorder. Symptoms include hearing, seeing, smelling or tasting things that are not real (hallucinations); false ideas (delusions); disordered thoughts and problems with feelings, behaviour and motivation. The cause is not clear. In many people symptoms come back (recur) or persist long-term but some people have just one episode of symptoms that lasts a few weeks. Treatment includes medication, talking treatments and social support.

by Dr Colin Tidy, MRCGP

Gender identity and the law

The Gender Recognition Act is a law in the UK which allows transsexual people to change their legal sex. In the UK, individuals may apply to the Gender Recognition Panel for a Gender Recognition Certificate. In order to obtain this certificate, you have to prove that you have been diagnosed with gender dysphoria. You also have to prove you have lived in your proposed gender for at least two years. You cannot be married at the time of applying. However, if you are married you may be able to obtain an 'Interim Gender Recognition Certificate'. You do not have to have had any sex-changing surgery in order to apply.

If you are given a Gender Recognition Certificate, you would then be referred to as a 'man' or a 'woman' and not a 'trans man' or a 'trans woman'.

At the time of this review, the UK government Gender Recognition Act 2004 is in the process of being updated..

The Equality Act of 2010 protects everyone from being discriminated against as a consequence of their sex, gender reassignment, age, race, disability, religion or any other personal characteristic.

How common is gender dysphoria?

It is difficult to know how common gender dysphoria is. The number of people who attend gender identity clinics is likely to be a small proportion of people who have sex or gender issues. Many will keep quiet about the way they feel, so the true numbers are difficult to count. It is thought that about one in a hundred people may have issues relating to their sex or gender.

What is the cause of gender dysphoria?

It is not known what causes gender dysphoria. It is likely to be a combination of a number of factors.

What are the problems associated with gender dysphoria?

Gender dysphoria is a feeling that you are not the sex that you were given at birth. It causes an intense wish to change. You may feel a wish to hide or get rid of characteristics which are typical of your assigned sex. For example, breasts or genitals or facial hair.

Gender dysphoria can make you feel very unhappy. Often other people do not understand your wish to be another sex, and this can cause difficulties in relationships with friends and family. It may cause stress, anxiety or depression. It may cause problems at work. Trying to suppress intense feelings can make you feel low, anxious and unsatisfied with your life.

Being transsexual, and wishing to be another sex, is NOT a mental illness. However, the problems associated with this can make you unwell.

Thinking about changing sex can be a very daunting, scary prospect. If you are considering this, there are lots of ways to obtain help and support, discussed below.

Can children have gender dysphoria?

Yes. Children and teenagers can have gender dysphoria. More often than not, this goes away as they go through puberty. Therefore, it is particularly important for children and teenagers to be supported and helped as they grow up. As time goes by, they will have a better idea of what their sexual identity will be in the long term. Some children who had gender dysphoria when very young grow up to be homosexual or bisexual rather than transsexual.

Some of the signs of possible gender dysphoria in children are:

• Wanting to dress in the clothes usually worn by the opposite sex.

• Wanting to play the types of games those of the opposite sex usually play.

• Wanting to play with the opposite sex more than their own.

• Saying they dislike their genitals or wish to get rid of them.

• Saying they are the opposite sex or saying they wish to be the opposite sex.

In many cultures the usual behaviour of each sex is quite stereotyped, and there is a lot of overlap. Not every girl who wants to dress in boys' clothes, or every boy who likes to play with dolls, is struggling with gender dysphoria.

Children who behave differently than their peers may be more likely to be bullied. They may be unhappy at school.

How do I find help if I have gender dysphoria?

There are lots of ways to obtain support and help if you have gender dysphoria. The first place to start is the huge amount of information which is available on the websites of support groups, including those listed in the Further Reading section at the end of this leaflet. There is lots of information about gender dysphoria and the support and treatments available. These groups can put you in touch with other people who have had similar feelings and problems. There is information and support for your family or friends as well, to help them understand what you are going through. All the types of issues you might be facing, or might have to face, are discussed.

Visiting your GP would be another good starting point. Your GP will want to know all about how you feel, and how long it has been going on. They will ask about exactly what type of help you want. If your feelings about your gender identity are causing you distress, or if you wish to change your sex, you would then be referred on to a specialist gender services clinic. If you prefer, your GP may refer you for counselling or talking therapy to help your mind get to grips with the way you feel. Professional help with sorting out the thoughts in your mind may then help you decide what you wish to do about them. Specialist gender identity clinics have the most experience with talking about these issues, however. You may or may not wish to have treatment to change your sex.

There are only a few specialist gender identity clinics in the country, but you can be referred to your nearest one. Gender identity clinics consist of lots of different specialists, because they offer lots of different treatments. You may need some or all of these. There may be surgeons, specialists in hormone treatments (endocrinologists), psychiatrists, people who specialise in support and talking treatments (psychotherapists, counsellors and psychologists), speech and language therapists, people who specialise in hair changes, nurses, social workers and occupational therapists.

Contact details for UK Gender Identity Clinics can be found in the NHS Gender Identity Clinics link in Further Reading below. There are also some private gender identity clinics in the UK, which you may choose to consider.

Children and adolescents up to the age of 18 are usually referred to the local Child and Adolescent Mental Health Service (CAMHS) in the first place. This is so they can have an assessment to see whether they do indeed have gender dysphoria. If so, they then have talking treatments (such as counselling and psychotherapy and family therapy). They may then be referred to the only specialist gender identity clinic in the UK for children and teenagers. This is based in London, in the Tavistock and Portman NHS Foundation Trust. This website has links to further information about referrals and treatments. This specialist clinic provides further help and support for this age group and often works with the whole family while the best way forward is planned. Sometimes children are given hormone treatments to delay puberty. This is to give them more time to consider their sexual identity. Some children will not have gender dysphoria that persists into adulthood.

What treatments are there for gender dysphoria?

There are a number of different treatments for gender dysphoria. You may wish for one or some or all of them. You may have them in turn, or all at the same time. This is a brief explanation of some of the treatments provided by the specialist clinics.

Psychological support

Counselling and psychotherapy are talking treatments. Professionals help you explore your feelings and help you understand yourself better. There may be a combination of individual and group-based options. You will be able to talk through the implications of changing sex on your life.

Hormone treatments to change gender

Our hormones help to give our bodies their male or female characteristics. They cause our bodies to grow hair in a male or female pattern. They affect where we lay down fat, which gives us a typically male or female shape. They affect our muscle development. They cause periods in women, and erections in men.

Therefore, when people wish to change sex, treatment is given to stop the production of their own hormones, and replace them with the type of hormones they want. So males who wish to become females have their male hormones (androgens) blocked, and they are given female hormones (oestrogen). The effects of this include bigger breasts, hips and bottoms and prevention of erections. If females wish to become males, their female hormones are blocked, and they are given a male hormone called testosterone. This causes a deeper voice, an enlarged clitoris, and more body hair. It also stops periods, and breasts become smaller. Some fat becomes muscle.

The medication which blocks your own hormones is called a gonadotrophin-releasing hormone (GnRH) analogue. It is often given as an injection every 4-12 weeks. Oestrogen hormones can be given as tablets, patches or a gel. Testosterone can be given as injections or a gel. (It is available in capsules but these are not recommended in this situation.)

Hormone treatment is not safe for everybody, and your specialist would check whether it is safe for you. If, for example, you have a history of blood clots (thrombosis) or heart disease or serious migraines, it may be too risky for you to have oestrogen treatment. If you have a history of breast cancer, cancer of the womb (uterus) or serious liver problems, it may not be safe for you to have testosterone treatment. If hormones are prescribed, you would have regular blood tests and physical check-ups to make sure they are not causing any harm.

Hormones may be the only treatment you need to live as the opposite sex. However, some people have hormone treatment and an operation as well.

Children with gender dysphoria may also be prescribed medication to block their own hormones. This is to stop them going past a certain stage of puberty. This gives them more time to consider their sexual identity. The block is reversible, so once the treatment is stopped, they will continue the changes of puberty as normal. Once they reach the age of 16 to 18, if they still have gender dysphoria, hormone treatments with oestrogen or testosterone may be a possibility. This would be decided with the gender development and identity specialists for children and adolescents. After 18, they would attend adult gender identity clinics.

Sex reassignment surgery

There are quite a number of different operations which may be done for people wishing to change their sex. These include:

• Genital changes for males wishing to become females. In this case, the penis and testicles are removed. Female genitals are fashioned in their place. A vagina, labia and clitoris can be created.

• Genital changes for females wishing to become males. In this case, the womb (uterus) is removed. Ovaries and the tubes which connect them to the womb (Fallopian tubes) may also be removed. A penis, scrotum and testicles are created, usually from skin taken from elsewhere. This is usually from the inner arm, or the skin on the lower part of the tummy (abdomen.) Alternatively a penis can be made from a female clitoris which has been enlarged with hormone treatment.

• Breast surgery. Males wishing to become females may wish for surgery to enlarge their breasts. Females wishing to become males may wish for their breasts to be removed (mastectomy).

• Facial surgery. Some males have operations to change the shape of their face to look more feminine.

• Voice surgery. Hormone treatment can cause a deeper voice for females becoming male. However, for men to have a higher-pitched, female-sounding voice, they may need voice therapy or an operation.

Speech and language therapy

Specialised speech and language therapists help you learn the voice and mannerisms of the gender you wish to be.

Hair treatments

Trans women may need help with hair removal. There are a number of ways this can be done. Laser and electrolysis treatments remove unwanted hair. These are usually done by beauty therapists or laser clinics, and may not be available on the NHS. They may also need help with wigs, or hair transplants.

Advice about fertility

One of the issues to think about when having sex-changing surgery is whether you want to have children. You cannot change the function of your reproductive organs like you can change what they look like. For example, having an organ that looks like a penis does not mean it will able to produce sperm and fertilise an egg. You may want to think about storing eggs or sperm for the future so that assisted reproduction techniques (like IVF) may be used to help create a child that is biologically similar to you.

Are there any risks or problems after treatment for gender dysphoria?

Most people who have had sex-changing treatment are happy with the results. Very few people regret making the change. Studies show people with gender dysphoria who have had sex-changing hormones and/or operations feel happier as a result. They are happier with the way they feel, the way they look, and the way they are able to have sex.

There can be problems following treatment, however, so it is very important to discuss these first with your specialist. This way you can make an informed decision, taking into account the risks and the benefits. All operations can in some cases have complications, and you should discuss these with your surgeon before going ahead. Hormone treatment also comes with some risks, and your doctor will discuss these with you. It is sensible to only take hormone treatment prescribed by your doctor, so you know that it is safe for you personally. Problems can mostly be prevented by having regular check-ups. These vary with the specific treatment but include physical checks (such as blood pressure) and blood tests. You can also keep your risks low by living a healthy lifestyle. This includes doing regular exercise, keeping your weight in a healthy range, and not smoking.

People who have gender dysphoria may be more likely to have depression, have suicidal thoughts and die from suicide. So it may be helpful to take up the counselling or talking treatments you are offered. If you find yourself feeling low, anxious or stressed, or wishing you were not alive, see your GP. They will be able to obtain help for you.

There are a lot of implications of sex reassignment surgery. Support groups, such as those listed in Further Reading below, have some helpful information which may be of aid in tackling this.

Dr Mary Lowth is an author or the original author of this leaflet.