Overview

Gender dysphoria is a term that describes a sense of unease that a person may have because of a mismatch between their biological sex and their gender identity.

This sense of unease or dissatisfaction may be so intense it can lead to depression and anxiety and have a harmful impact on daily life.

What is gender identity?

Gender identity refers to our sense of who we are and how we see and describe ourselves.

Most people identify as "male" or "female". These are sometimes called "binary" identities.

But some people feel their gender identity is different from their biological sex.

For example, some people may have male genitals and facial hair but do not identify as a male or feel masculine.

Some may have female genitals and breasts but do not identify as a female or feel feminine.

Some people do not define themselves as having a "binary" identity. For them the concept of gender is not relevant to their identity.

They may use different terms, such as agender, gender diverse, gender non-conforming, to describe their identity. However, as a group, they are often called "non-binary".

Gender dysphoria and gender identity

Many people with gender dysphoria have a strong, lasting desire to live a life that "matches" or expresses their gender identity. They do this by changing the way they look and behave.

Some people with gender dysphoria, but not all, may want to use hormones and sometimes surgery to express their gender identity.

Gender dysphoria is not a mental illness, but some people may develop mental health problems because of gender dysphoria.

Signs of gender dysphoria

People with gender dysphoria may have changed their appearance, their behaviour or their interests.

They may also show signs of discomfort or distress, including:

  • low self-esteem
  • becoming withdrawn or socially isolated
  • depression or anxiety
  • taking unnecessary risks
  • neglecting themselves

Children and gender identity

Children may show an interest in clothes or toys that society tells us are more often associated with the opposite gender. They may be unhappy with their physical sex characteristics.

However, this type of behaviour is reasonably common in childhood and is part of growing up. It does not mean that all children behaving this way have gender dysphoria or other gender identity issues.

A small number of children may feel lasting and severe distress, which gets worse as they get older. This often happens around puberty, when young people might feel that their physical appearance does not match their gender identity.

This feeling can continue into adulthood with some people having a strong desire to change parts of their physical appearance, such as facial hair or breasts.

How to get help

See a GP if you think you or your child may have gender dysphoria.

If the GP agrees, they can refer you to a gender dysphoria clinic (GDC) where you’ll be assessed by a specialist team.

You do not need to be assessed by a mental health service first, and the GP does not need prior approval from their Clinical Commissioning Group (CCG) responsible for local health services.

You can self-refer to a GDC, but a referral by the GP is best. This is because they can give the GDC your detailed medical history.

If you are already seeing a doctor or psychologist for other conditions, ask them if they can refer you to a GDC in Wales.

Waiting times

As there has been a huge increase in the number of people seeking a referral to a gender dysphoria clinic, waiting times can be long.

Treatment for gender dysphoria

After a detailed assessment to confirm the diagnosis of gender dysphoria and what it means for you, the GDC team will work with you on an agreed treatment plan.

If you are assessed as not having gender dysphoria, the GDC may recommend other forms of support to your GP.

Treatments provided by the GDC are intended to provide lasting relief from gender dysphoria. This can mean different things to different people.

For some people, treatment may just involve acceptance and affirmation or confirmation of their identity. For others, it may involve bigger changes, such as changes to their voice, hormone treatment or surgery.

What causes gender dysphoria?

The exact cause of gender dysphoria is unclear.

Gender development is complex and there are still things that are not known or fully understood.

Gender dysphoria is not related to sexual orientation. People with gender dysphoria may identify as straight, gay, lesbian or bisexual.

How common is gender dysphoria?

No one really knows because not all people who have a sense of unease about their identity, or already identify as gender diverse, need or ask for support from the NHS.

The number of people being referred and diagnosed with the condition has increased a lot over the last decade.

Signs

Where to find help and support

Treatment

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.

Hormone therapy

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

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.

Risks

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:

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.

Monitoring

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.

Surgery

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)
  • 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 (see guidelines for gender dysphoria), 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.

Sexual orientation

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.



The information on this page has been adapted by NHS Wales from original content supplied by NHS UK NHS website nhs.uk
Last Updated: 09/12/2020 13:36:04