Gender dysphoria, also called gender identity disorder (GID) or transgenderism, is a condition characterised by a strong dissatisfaction with one’s own gender and a desire to live as a member of the opposite gender. For example, a boy may wish to dress-up and follow the mannerisms of a girl. It can be differentiated from homosexuality in that it is more of an identification with the opposite sex than sexual attraction towards the same sex.
Gender development is a complex process. Hormones play a major role in the determination of gender in terms of both the structure of sexual organs as well as its functioning. Many aspects of sexual development also involve the brain and how it responds to the sex hormones. The interplay of hormones in relation to the normal development of the sexual organs, their functions and the overall sexual behaviour are critical to the general differentiation of the sexes.
The exact cause of this condition is not known, though hormonal influences in the womb are suspected to be involved. The response of the brain and reproductive organs to sex hormones may not function normally, leading to disparity in the physical and behavioural characteristics. This may be caused by additional hormones due to certain medications that a mother takes. Gender dysphoria may also be associated with certain conditions such as:
- Androgen insensitivity syndrome (AIS): foetus is insensitive to the hormones
- Congenital adrenal hyperplasia (CAH): female foetus produces high levels of male hormones
- Intersex conditions: presence of genitalia of both male and female sexes
Gender dysphoria can cause severe anxiety, depression and distress. This dissatisfaction can interfere with the activities of daily living such as school, work or social interactions.
There are no specific symptoms of gender dysphoria, but those with the condition display specific feelings and behaviour. Children insist that they belong to the opposite sex. They may refuse to wear clothes typically worn by their sex and insist on wearing clothes belonging to the opposite sex. They may choose games and activities associated with the opposite sex rather than their own, and prefer the company of the opposite sex. The act of passing urine may also be similar to the opposite sex. For instance, a boy may prefer to pass urine while sitting down. They may be disgusted with their genitalia and become extremely distressed with the onset of puberty. They may believe they will grow up to become members of the opposite sex.
The signs and symptoms of gender dissatisfaction should persist for at least 2 years for a diagnosis of gender dysphoria to be made. An in-depth psychiatric evaluation involving several sessions every few months with family members and friends can help confirm on the diagnosis.
Without appropriate care and support, the individual may try to suppress their feelings and live according to their biological sex. This can lead to other mental health disorders such as anxiety, depression, mood disorders, schizophrenia, eating disorders, substance abuse and suicidal tendencies.
Treatment is not aimed at changing how you feel about your gender, but to help deal with the distress that is associated with this condition.
Treatment options for gender dysphoria may include:
- Psychological counselling: This will help you deal with stress caused by the condition in a positive way. It may include family education and counselling as well.
- Pharmacotherapy: Drug treatment may be required for severe anxiety, depression and personality disorders.
- Hormonal therapy: You may be prescribed hormones that would suppress sexual changes associated with puberty and/or those that would develop sexual characteristics of the gender that you desire to be identified with. You will be advised about the benefits and negatives of these hormones before prescribing them. Male-to-female conversions would require female hormones to suppress male sexual characteristics and initiate the development of breasts, wider hips, increased body fat and decreased musculature, reduction in the size the of penis, and less facial and body hair. A female-to-male conversion would require testosterone (male hormone) to increase facial and body hair, reduce breast size, cease menstruation, enlarge clitoris, increase muscle development and sexual drive.
- Behavioural therapy: This involves support groups and suggestions on dressing habits in preferred gender roles.
- Speech therapy: This involves voice modulation to enable you to sound like the identified sex.
- Surgery: This can vary from complete sex-reassignment to specific changes that reflect your desired sexual orientation.
- Female-to-male conversions: Surgical treatment may involve the removal of the breasts (mastectomy), uterus, fallopian tubes and ovaries. Construction of a penis using vaginal tissue and skin from the forearm (phalloplasty) or using a clitoris enlarged through hormone therapy (metoidioplasty).
- Male-to-female conversions: Surgical treatment may involve the removal of the testes and penis, construction of a vagina from tissues of the penis (vaginoplasty) and feminising facial surgery. Urethral reconstruction may be required so that it lies within the vagina. The vulva and labia may be created using scrotal skin.
In certain cases, psychotherapy by itself fails to provide lasting benefits, requiring gender re-assignment surgery.
Prior to surgery, you may be required to have a real life experience (RLE), and live as a person of the identified sex for a while.
In the postoperative period you may have to be isolated for proper healing and fear of not being accepted.
After complete recovery from surgery, you can expect to have a biological body that is more in line with the identified gender.
Depending on the type of surgical procedure undertaken you may expect to be off work for a variable period of time until fully recovered. It would take years to achieve a complete reconstruction.
With early intervention of treatment, and full support from family and society, hormonal therapy and surgery can not only bring about a complete gender transformation towards the gender that you prefer but also provide satisfactory emotional and social wellbeing.
Treatments costs vary depending on the treatment option and the length of treatment, and can be discussed prior to initiation of treatment.
There has been extensive research regarding gender dysphoria. Some studies include:
- Chen M, Fuqua J, Eugster EA. Reply to: Zucker et al., "Comment on Chen, Fuqua, and Eugster's (2016) 'Characteristics of Referrals for Gender Dysphoria Over a 13-Year Period'". J Adolesc Health. 2016 Jun;58(6):694.
- Chen M, Fuqua J, Eugster EA. Characteristics of Referrals for Gender Dysphoria Over a 13-Year Period. J Adolesc Health. 2016 Mar;58(3):369-71.