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Understanding gender dysphoria
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This booklet is no longer available in printed format due to limited demand. You are therefore welcome to print the text below for personal or professional use.
What is gender identity?
What is gender dysphoria?
How common is gender dysphoria?
What are the causes?
What are the signs of gender dysphoria?
Is it the same as being homosexual or a transvestite?
What is gender reassignment?
What does male to female gender reassignment involve?
What does female to male gender reassignment involve?
How will gender reassignment surgery affect me legally and socially?
Useful organisations
Useful websites
Further reading
‘I told my mum I thought I was really a girl. She told me, don’t be silly, you’ll grow out of it.’
‘All my friends thought I was just one of the lads. I couldn’t tell them how I was really feeling. The only way I could survive was to pretend. I was living a lie.’
‘I couldn’t pretend any longer. I was feeling so depressed and frustrated, so I decided to take a risk and tell my family I was a transsexual. At first they didn’t believe me; they thought I was joking. Once they got over the initial shock, they have beenunderstanding and supportive.’
When a baby is born, the first thing most people ask is: ‘Is it a boy or a girl?’ Most people never question the gender they are assigned at birth, but for some people, it is the most important question they can ask. This booklet explains how and why people may feel they belong to the wrong gender, and looks at the options they have for dealing with it.
What is gender identity?
The term ‘gender’ refers to the differences between men and women that are social rather than biological. It’s generally assumed that someone’s gender follows on from his or her biological sex. The assumptions made about someone’s gender at birth hugely influence everybody’s expectations of how that person will grow up to be as a man or as a woman. These two paths have very different sets of expectations and behaviours, which are thought of as appropriate to that gender. But these vary between different societies and cultures, and some cultures even accept the idea of a third gender, which lies somewhere between male and female.
‘Gender identity’ means how someone categorises themselves as male or female. Children develop their sense of gender identity at a very early age – usually by the age of two. At this age, most children begin to make some sort of verbal distinction between words such as ‘boy’ and ‘girl’ or ‘mummy’ and ‘daddy’. From then on, a process of ‘gender-role learning’ occurs, during which a child’s behaviour is continually matched against a set of standards shared by parents, teachers and other children. Problems can arise when a child’s perception of their own identity doesn’t match up with other people’s perceptions of them.
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What is gender dysphoria?
Gender dysphoria, also known as ‘gender identity disorder’, is a medical term for anxiety, confusion or discomfort about birth gender. Those who feel they have been born into the wrong gender are often aware there is ‘something wrong’ early in childhood. Because society places great emphasis on sexual and gender classification, and on gender-appropriate behaviour, such a child will feel very different from their peers, and uncertain about their identity.
This feeling of being the wrong gender may come and go over the years, but it creeps into all aspects of life. Milder forms of gender dysphoria can mean occasional feelings of belonging to the opposite sex, and may cause people to dress as the opposite sex once in a while (see Cross dressing). For others, anxiety about being ‘in the wrong body’ can be the major driving force in their lives, leading them to seek gender reassignment, commonly known as a sex-change (see below). Others question the rigidity of gender roles, and seek to establish a ‘transgender’ identity.
People with gender dysphoria are often afraid to express their feelings publicly, because they fear being rejected or because they feel guilty or ashamed. They can develop anxiety problems, which deepen over time, and this can lead to long-term depression. Some people may even consider or attempt suicide, as a result.
Diagnosis
To diagnose gender identity disorder, according to the DSM-IV (the commonly used diagnostic manual), there has to be evidence of a strong and persistent ‘cross-gender identification’, meaning the person wants to be, or is insistent that they already belong to the opposite sex. They must be persistently uncomfortable in their current gender role, and feel that it is quite inappropriate to them. It is not about wanting to get some cultural advantages out of changing sex: there has to be evidence of clinically significant distress, or damage to important aspects of the person’s life to diagnose gender identity disorder.
Also, the diagnosis would not necessarily be made if someone has one of the rare physical ‘intersex’ conditions, such as, androgen insensitivity syndrome or congenital adrenal hyperplasia, where the person has some of the physical characteristics of the other sex; and likewise for hermaphrodites (people born with both male and female sexual organs). However, when these physical conditions occur, it may mean that at birth the wrong gender is assigned and, if that is the case, the person may experience gender dysphoria like anyone else.
Transsexualism
A transsexual is a man or woman who has a lifelong feeling of being trapped in the wrong body. The sense of belonging to the opposite sex is so strong, they feel that the only way to achieve peace is to change their body to match their mind. Some go through the process of living in their chosen gender role, with the help of hormones, eventually leading to gender reassignment surgery. Others seek counselling or therapy to help them to cope with their confusion or discomfort.
Cross-dressing
Some young people and adults with gender dysphoria problems have an enduring desire to dress as the opposite sex. Some of them simply fantasise about it, but others put it into practice. This is not something they do because it’s sexually exciting, nor is there any desire to change their bodies to make them more feminine or masculine.
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How common is gender dysphoria?
There’s no recent research on this, but referrals to gender clinics suggest that approximately one in 30,000 men and one in 100,000 women seek gender reassignment surgery. However, the Gender Identity Research and Education Society (GIRES) estimates that there are about 15,000 people in the UK receiving some form of medical help for gender dysphoria, which is about one in 4,000 of the whole population.
More men than women experience gender dysphoria, (two or three men for every one woman). Boys with gender dysphoria outnumber girls by approximately five to one.
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What are the causes?
Little is known about the causes. One theory is that changes in the brain before birth cause certain parts of it to develop the opposite pattern to their sex. Significant proportions of male transsexuals have abnormally low levels of HY antigen. HY assists in the masculinising effect of the Y chromosome in men. Work done in the Netherlands also suggests that the problem arises in the hypothalamus in the brain. This is involved in the early development of sexual differences within the brain, and controls the production of sex hormones throughout life.
Others believe that experiences, especially in early childhood, affect the outward expressions of gender behaviour. People learn early on in life how to behave appropriately for their gender, and society places great store by this. People who don’t conform may be reprimanded and even shunned. The problems arise, therefore, from society’s attitude rather than in the person. The fact that psychiatry labels people as having a ‘disorder’ because they find they can’t ‘fit in’ with sexual stereotypes is a case in point.
Transsexuals have normal male (XY) or female (XX) chromosomes for their sex. There are no identifiable physical characteristics for gender dysphoria, and there is no ‘test’ for the condition.
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What are the signs of gender dysphoria?
Childhood
Boys may show a marked interest in traditionally feminine activities. They may prefer dressing in girls’ or women’s clothes. A boy who openly admits wanting to be a girl is likely to be ‘corrected’, made fun of or told off severely. He is expected to grow out of it quickly. A girl who wants to be a boy and expresses this is less likely to invite such criticism. She may be labelled as a tomboy, but is still expected to grow out of it.
Often, children do grow out of gender dysphoria. Only a small number of children continue to feel the same way in later adolescence. Some families are better than others at accepting their children’s behaviour. Some children live openly in their chosen gender role, but have to endure the taunts of their peers as well as pressure from their parents. Others cope by hiding their feelings and learning to play the gender role assigned to them, meanwhile going deeper into a private world of cross-gender fantasy and desire.
Adolescence
At this stage in life, coping with gender dysphoria becomes far more complex, and different pressures are brought to bear on the different genders. With puberty, hormones start to trigger body changes. A higher level of testosterone in a boy leads to a deeper voice, beard growth and more body hair. Girls grow breasts and start their periods. This can all be highly distressing and confusing to young people with gender dysphoria.
To relieve their anxieties, boys may combine excessive masturbation with secret cross-dressing. Often, they will start to behave in stereotypically male fashion to hide their secret desire to be female. Girls may start wearing loose, baggy and neutral clothes to hide their bodies.
Early adulthood
Most people who have grown up with gender dysphoria show less openly cross-gender behaviour as time goes on, because of their parent’s interventions or pressure from their peers. By early adulthood, about three quarters of boys who had a childhood history of gender dysphoria may think of themselves as homosexual or bisexual. They no longer have feelings of belonging to the wrong gender.
However, many young adults continue to experience gender dysphoria. They may try to rid themselves of their ever-increasing gender anxiety in various ways. They may get married and have children, in the hope that this will help, or simply to hide their feelings from others. Some seek professional help, often to ask for gender reassignment.
Later adulthood
Later adulthood can be a very difficult time. Years of trying to overcome a deep-rooted desire and coping with anxiety can lead to depression. For some, the pressure is so great that they attempt suicide. Many re-assess their lifestyle when they come to later life. Some seek professional help; others start cross-dressing more frequently, in private.
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Is it the same as being homosexual or a transvestite?
Gender identity is quite distinct from a person’s sexual orientation. People with gender dysphoria can be homosexual, bisexual or heterosexual. For example, some male-to-female transsexuals may be attracted to women and consider themselves lesbians. Someone with gender dysphoria, may try out transvestite or homosexual behaviour, but not necessarily consider themselves as transvestite or homosexual. Anyone can go through a period of sexual experimentation, and people with gender dysphoria are no exception.
Transvestism
A transvestite, or transvestic fetishist, will dress as a member of the opposite sex and will often get sexual excitement from it. Transvestism is quite different from transsexualism and other forms of gender dysphoria. Transvestites don’t feel that they belong to the opposite sex or alienated from their own bodies or sexual organs.
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What is gender reassignment?
Gender reassignment is a long process. Although people’s chromosomes and reproductive identity can’t be altered, long-term hormone treatment and surgery should allow them the physical appearance and some of the sexual functions of the opposite sex. However, after surgery, they will lose the ability to have children. A psychiatrist, GP or social worker can refer people wanting to have gender reassignment surgery to a recognised gender identity clinic. An evaluation for treatment will be based on a detailed history of a person’s childhood development through to puberty and afterwards. The clinic will want to know about a person’s medical and personal history, current circumstances and general stability. There may be further psychological assessments to clear up any unanswered questions.
Gender reassignment is not the right solution for everyone. It needs thinking about very carefully, and the clinic will actively pursue any possible alternatives to it. Staff may well encourage people to pursue less drastic possibilities, after an initial assessment. These might include pursuing their chosen lifestyle without surgical intervention, or getting other forms of support, such as counselling or self-help groups.
Recognised gender identity clinics generally follow the guidelines and standards set out by the World Professional Association for Transgender Health (WPATH, formerly known as the Harry Benjamin International Gender Dysphoria Association).
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What does male to female gender reassignment involve?
For a man wishing to become a woman, treatment would mean taking female hormones for at least one year before any irreversible surgery would take place. The hormones reduce body hair, cause breast development, and generally make the body shape and skin texture more feminine. The person would also have to live as a woman, full-time, for a minimum of one year before any surgery can be authorised. During this period, some transsexuals may choose to have facial hair removed by electrolysis, may undergo cosmetic surgery to make their face more feminine, or learn to raise the pitch of their voice. When a patient feels ready, they may apply for medical approval of reassignment surgery. The clinical team will review the patient’s progress to see how well they’ve adapted to their new role, and depending on the results of this evaluation, surgery may then be approved.
Gender reassignment involves major surgery. Under general anaesthetic, the testicles and erectile tissue of the penis are removed. An artificial vagina is then created and lined with the skin of the penis, where the nerves and blood vessels remain largely intact. Tissue from the scrotum is then used to create the labia, and the urethra is shortened and repositioned appropriately.
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What does female to male gender reassignment involve?
For a woman wanting to become a man, taking the male hormone testosterone leads to beard growth and muscle development. On the whole, these changes can’t be reversed later. As early as six months into this programme, it may be possible to have a mastectomy (breast removal). This makes it much easier for the person to appear as a man in public. After at least a year of hormone treatment, the ovaries and uterus are removed.
For many female to male transsexuals, this is as far as they will go with surgery. Going further is more complex, costly and difficult to achieve. For those who do continue, phalloplasty (penis construction) and testicle implants are available. It’s also possible to create a male urethra and to move the clitoris to the head of the penis.
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How will gender reassignment surgery affect me legally and socially?
There’s no doubt that transsexuals and others with gender dysphoria face discrimination from society in general. In 1997, British transsexuals won the right to sue employers for harassment and discrimination following gender reassignment. The Employment Appeal Tribunal said that such bias violates the Sex Discrimination Act.
The European Court of Justice has ruled that discrimination because of gender reassignment is ‘sex discrimination’ under the Equal Treatment Directive. Regulations clarified the law about gender reassignment. People can formally change their names on official documents, such as driving licences, passports and National Insurance documents. Guidance on these regulations covers discrimination at work (including good practice for people in single-sex occupations), sick leave taken while having reassignment surgery, and ways of accommodating an employee’s transition to the new gender (for example, dress codes and use of single sex facilities, including toilets). (For more information about these regulations, see Press for Change under Useful organisations.)
The Gender Recognition Act 2004 allows transsexual people to apply to a Gender Recognition Panel for full legal recognition of their changed gender identity, which is confirmed by the issue of a gender recognition certificate. If a person is married, they will receive an interim certificate and their marriage must be dissolved or annulled before they can receive a full certificate.
A copy of the certificate must be sent to the appropriate Registrar General (for England and Wales, for Scotland, or for Northern Ireland) who will keep a Gender Recognition Register which cannot be searched by the public. The person’s acquired gender will then be recognised for legal purposes. A new birth certificate can be issued which gives the new gender without disclosing the gender change.
However, the recognition will not be retrospective for acts done (such as crimes) or events occurring before the change was recorded. The Act does not provide for any new protection against discrimination, under the Sex Discrimination Act, on the grounds of being a registered transsexual person, but certain sections of the Sex Discrimination Act 1975 are amended by the Gender Recognition Act. (See the websites of the Gender Trust and Gender Identity Research and Education Society GIRES), under Useful organisations for more information.)
The family, friends and colleagues of transsexuals respond in many different ways. Some transsexuals face a great deal of hostility and rejection, while many have found acceptance and support, even to the point of retaining the same job throughout their transformation. Most people find the reactions are generally more positive than they may have feared. How you present the news may have great bearing on how others receive it. Counselling on this and other issues should be available as part of the professional treatment provided. GIRES has recently produced information on transgender issues for the Department of Health, aimed at families and medical staff as well as transgendered people. (See Useful organisations.)
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Useful organisations
The Beaumont Society
27 Old Gloucester Street, London WC1N 3XX
infoline (24 Hr): 01582 412 220
helpline: 07000 287 878
web: www.beaumontsociety.org.uk
FTM Network
BM Network, London WC1N 3XX
tel. 0161 432 1915
web: www.ftm.org.uk
For female to male transgender and transsexual people
Gender Identity Clinic
Charing Cross Hospital, 179-183, Fulham Palace Road, London, W6 8QZ
tel. 020 7386 1262, 020 8483 2800 or 020 8483 2801
Gender Identity Research and Education Society (GIRES)
Melverley, The Warren, Ashtead, Surrey KT21 2SP
tel: 01372 801 554
web: www.gires.org.uk
Information for the general public on the issues surrounding gender identity and transsexualism.
The Gender Trust
Community Base, 113 Queens Road, Brighton BN1 3XG
tel. 01273 234 024 national helpline: 0845 231 0505
web: www.gendertrust.org.uk
Help and information for those with gender issues, and training for employers
Gendys Network
BM Gendys, London WC1N 3XX
web: www.gender.org.uk/gendys
Networks, help and information for transsexuals and intersexed people
Mermaids
BM Mermaids, London WC1N 3XX
helpline: 07020 935 066
web: www.mermaids.freeuk.com
Information and support for children and teenagers with gender identity issues, and their families and carers
The Northern Concord
PO Box 258, Manchester M60 1LN
web: www.northernconcord.org.uk
For cross-dressers
Press For Change
BM Network, London WC1N 3XX
web: www.pfc.org.uk
Campaigns for equality and rights for gender diverse people
Seahorse Society
BM Seahorse, London WC1N 3XX
email: Seahorse.Society@btinternet.com
web: www.btinternet.com/~seahorse.society
Transliving International
TLI, P.O. Box 3, Basildon, Essex SS13 3WA
helpline: 01268 583 761
web: www.transliving.co.uk
Useful websites
www.dh.gov.uk
See the ‘Publications’ section for two publications that GIRES has written: Transgender experiences – information and support for trans people, their families and healthcare staff and A guide to hormone therapy for trans people
http://genderxchange.co.uk
Website of James Bellringer, a male to female gender reassignment surgeon based at Charing Cross Hospital
www.transgenderzone.com
Includes details of psychiatrists, psychologists and surgeons for referrals
www.wpath.org
The World Professional Association for Transgender Health
Further reading
Climbing out of depression: a practical guide for sufferers S. Atkinson (Lion Publishing 1993)
Confidence works: learn to be your own life coach G McMahon (Sheldon Press 2001)
How to accept yourself, Dr W Dryden (Sheldon Press, 1999)
How to assert yourself (Mind 2006)
How to cope with doubts about your sexual identity (Mind 2007)
How to cope with loneliness (Mind 2007)
How to cope with panic attacks (Mind 2006)
How to cope with suicidal feelings (Mind 2007)
How to improve your mental wellbeing (Mind 2007
How to increase your self-esteem (Mind 2007)
How to look after yourself (Mind 2007)
How to stop worrying (Mind 2006)
Making sense of cognitive behaviour therapy (Mind 2007)
Making sense of counselling (Mind 2008)
The Mind guide to managing stress (Mind 2006)
Mind troubleshooters: stress (Mind 2006)
Mind troubleshooters: panic attacks (Mind 2007)
Overcoming low self-esteem: a self-help guide using cognitive behavioural techniques M Fennell (Robinson 1999)
Understanding anxiety (Mind 2008)
Understanding depression (Mind 2007)
Understanding the psychological effects of street drugs (Mind 2007)
Understanding talking treatments (Mind 2005)
For a catalogue of publications that can be purchased from Mind, send a request with your address details to: publications@mind.org.uk or call 0844 444 4448.
Visit the online shop to see details of all the publications stocked.
This booklet was written by George Stewart and revised by Katherine Darton
First published by Mind 1998. Revised edition © Mind 2008
ISBN 9781874690702
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