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• becoming withdrawn or socially isolated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 the integrated care boards (ICBs) 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.

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

People with gender dysphoria may have a range of feelings and behaviours that show discomfort or distress.

The level of distress can be severe and affect all areas of their life.

Signs of gender dysphoria in children

A diagnosis of gender dysphoria in childhood is rare.

Most children who seem confused about their gender identity when young will not continue to feel the same way beyond puberty. Role playing is not unusual in young children.

However, ask a GP for advice if you are worried your child is showing signs of being depressed, anxious or withdrawn.

You might want to ask if these behaviours have been noticed at school before seeking advice from a GP.

Signs of gender dysphoria in teenagers and adults

If your feelings of gender dysphoria began in childhood, you may now have a much clearer sense of your gender identity and how you want to deal with it.

However, you may also find out that the feelings you had at a younger age disappear over time and you feel at ease with your biological sex.

Or you may find you identify as gay, lesbian or bisexual.

The way gender dysphoria affects teenagers and adults is different to children. You may feel:

• certain that your gender identity conflicts with your biological sex
• comfortable only when in the gender role of your preferred gender identity (may include non-binary)
• a strong desire to hide or be rid of physical signs of your biological sex, such as breasts or facial hair
• a strong dislike of the genitals of your biological sex

You may feel lonely or isolated from others. You may also face pressure from friends, classmates or workmates, or family to behave in a certain way. Or you may face bullying and harassment for being different.

Having or suppressing these feelings affects your emotional and psychological wellbeing.

If you're feeling depressed

Talk to friends and family if you feel able and see a GP as soon as possible or call NHS 111.

Or call Samaritans for free on 116 123 (24 hours a day) and talk through any issues you may have in total confidence. Alternatively, you can email jo@samaritans.org.

There are other mental health services you may find helpful.

Where to find help and support

You may have to wait some time for a referral for an assessment at a gender dysphoria clinic because of more people needing gender dysphoria services. However, there are things you can do to help.

For children and young people under 18

If your child or teenager is distressed, ask the GP to refer them to the local Children and Young People's Mental Health Service (CYPMHS). CYPMHS may be able to offer psychological support while they wait for their first appointment at the Gender Identity Development Service.

The school or college may be able to offer additional support.

For adults

While you're waiting for your first appointment at a gender dysphoria clinic (GDC), or waiting for treatment, there are several things you can do.

If you are struggling with your mental health, speak to your GP about getting support and treatment.

Quit smoking if you smoke

It's advisable to stop as smoking can increase the risks of side effects of hormone treatment and surgery. Get advice on stopping smoking.

Lose weight if you are overweight

Certain risks from cross-sex hormones are increased if you are overweight.

Do not self-medicate with hormones

You do not know what you're being sold and you could harm yourself without regular monitoring. Hormones may also affect your future fertility.

Use contraception if you are sexually active

Ask your GP or sexual health service for contraceptive methods to suit your needs.

The UK Faculty of Sexual and Reproductive Healthcare (FSRH) has a useful guide to contraception for transgender and non-binary people.

Live in your preferred gender (social transitioning)

For some, this is an important part of managing gender dysphoria at home, work and socially.

You would need to do this before you can have gender surgery. Gender dysphoria clinics need to know the changes you want to make in your social role will improve your life and be sustainable over time, so that they can help you with this process.

As part of social transitioning, most gender dysphoria clinics recommend you change your name by deed poll. You can do this for free and then use it to change your name on your passport and other personal documents, at your bank, work and at the GP surgery.

Treatment

Treatment for gender dysphoria aims to help people live the way they want to, in their preferred gender identity or as non-binary.

What this means will vary from person to person, and is different for children, young people and adults. Waiting times for referral and treatment are currently long.

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).

Your child or teenager will be seen by a multidisciplinary team including a:

• clinical psychologist
• child psychotherapist
• child and adolescent psychiatrist
• family therapist
• social worker

The team will carry out a detailed assessment, usually over 3 to 6 appointments over a period of several months.

Depending on the results of this assessment, the options for children and teenagers 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
• referral to a local Children and Young People's Mental Health Service for more serious emotional issues.
• a referral to a specialist hormone (endocrine) clinic for hormone blockers for children who meet strict criteria (at puberty)

Most treatments offered at this stage are psychological, rather than medical. This is because in many cases gender variant behaviour or feelings disappear as children reach puberty.

Hormone therapy in children and young people

Some young people with lasting signs of gender dysphoria and who meet strict criteria may be referred to a hormone specialist (consultant endocrinologist) to see if they can take hormone blockers as they reach puberty. This is in addition to psychological support.

Puberty blockers and cross-sex hormones

Puberty blockers (gonadotrophin-releasing hormone analogues) pause the physical changes of puberty, such as breast development or facial hair.

Little is known about the long-term side effects of hormone or puberty blockers in children with gender dysphoria.

Although this is a physically reversible treatment if stopped, it is not known what the psychological effects may be.

It's also not known whether hormone blockers affect the development of the teenage brain or children's bones. Side effects may also include hot flushes, fatigue and mood alterations.

From the age of 16, teenagers who've been on hormone blockers for at least 12 months may be given cross-sex hormones, also known as gender-affirming hormones.

These hormones cause some irreversible changes, such as:

• breast development (caused by taking oestrogen)
• breaking or deepening of the voice (caused by taking testosterone)

Long-term cross-sex hormone treatment may cause temporary or even permanent infertility.

However, as cross-sex hormones affect people differently, they should not be considered a reliable form of contraception.

There is some uncertainty about the risks of long-term cross-sex hormone treatment.

Transition to adult gender identity services

Young people aged 17 or older may be seen in an adult gender identity clinic.

By this age, a teenager and the clinic team may be more confident about confirming a diagnosis of gender dysphoria. If desired, steps can be taken to more permanent treatments that fit with the chosen gender identity or as non-binary.

Treatment for adults

Adults who think they may have gender dysphoria should be referred to a gender dysphoria clinic (GDC).

GDCs have a multidisciplinary team of healthcare professionals, who offer ongoing assessments, treatments, support and advice, including:

• psychological support, such as counselling
• cross-sex hormone therapy
• speech and language therapy (voice therapy) to help you sound more typical of your gender identity

For some people, support and advice from the clinic are all they need to feel comfortable with their gender identity. Others will need more extensive treatment.

Hormone therapy for adults

The aim of hormone therapy is to make you more comfortable with yourself, both in terms of physical appearance and how you feel. The hormones usually need to be taken for the rest of your life, even if you have gender surgery.

It's important to remember that hormone therapy is only one of the treatments for gender dysphoria. Others include voice therapy and psychological support. The decision to have hormone therapy will be taken after a discussion between you and your clinic team.

In general, people wanting masculinisation usually take testosterone and people after feminisation usually take oestrogen.

Both usually have the additional effect of suppressing the release of "unwanted" hormones from the testes or ovaries.

Whatever hormone therapy is used, it can take several months for hormone therapy to be effective, which can be frustrating.

It's also important to remember what it cannot change, such as your height or how wide or narrow your shoulders are.

The effectiveness of hormone therapy is also limited by factors unique to the individual (such as genetic factors) that cannot be overcome simply by adjusting the dose.

Risks of hormone therapy

There is some uncertainty about the risks of long-term cross-sex hormone treatment. The clinic will discuss these with you and the importance of regular monitoring blood tests with your GP.

The most common risks or side effects include:

• blood clots
• gallstones
• weight gain
• acne
• dyslipidaemia (abnormal levels of fat in the blood)
• elevated liver enzymes
• polycythaemia (high concentration of red blood cells)
• hair loss or balding (androgenic alopecia)

There are other risks if you're taking hormones bought over the internet or from unregulated sources. It's strongly recommended you avoid these.

Long-term cross-sex hormone treatment may also lead, eventually, to infertility, even if treatment is stopped.

The GP can help you with advice about gamete storage. This is the harvesting and storing of eggs or sperm for your future use.

Gamete storage is sometimes available on the NHS. It cannot be provided by the gender dysphoria clinic.

Read more about fertility preservation on the HFEA website.

Surgery for adults

Some people may decide to have surgery to permanently alter body parts associated with their biological sex.

Based on the recommendations of doctors at the gender dysphoria clinic, you will be referred to a surgeon outside the clinic who is an expert in this type of surgery.

In addition to you having socially transitioned to your preferred gender identity for at least a year before a referral is made for gender surgery, it is also advisable to:

• not smoke
• lose weight if you are overweight (BMI of 25 or over)
• have taken cross-sex hormones for some surgical procedures

It's also important that any long-term conditions, such as diabetes or high blood pressure are well controlled.

Surgery for trans men

Common chest procedures for trans men (trans-masculine people) include:

• removal of both breasts (bilateral mastectomy) and associated chest reconstruction
• nipple repositioning
• dermal implant and tattoo

Gender surgery for trans men includes:

• construction of a penis (phalloplasty or metoidioplasty)
• construction of a scrotum (scrotoplasty) and testicular implants
• a penile implant

Removal of the womb (hysterectomy) and the ovaries and fallopian tubes (salpingo-oophorectomy) may also be considered.

Surgery for trans women

Gender surgery for trans women includes:

• removal of the testes (orchidectomy)
• removal of the penis (penectomy)
• construction of a vagina (vaginoplasty)
• construction of a vulva (vulvoplasty)
• construction of a clitoris (clitoroplasty)

Breast implants for trans women (trans-feminine people) are not routinely available on the NHS.

Facial feminisation surgery and hair transplants are not routinely available on the NHS.

As with all surgical procedures there can be complications. Your surgeon should discuss the risks and limitations of surgery with you before you consent to the procedure.

Life after transition

Whether you've had hormone therapy alone or combined with surgery, the aim is that you no longer have gender dysphoria and feel at ease with your identity.

Your health needs are the same as anyone else's with a few exceptions:

• you'll need lifelong monitoring of your hormone levels by your GP
• you'll still need contraception if you are sexually active and have not yet had any gender surgery
• you'll need to let your optician and dentist know if you're on hormone therapy as this may affect your treatment
• you may not be called for screening tests as you've changed your name on medical records – ask your GP to notify you for cervical and breast screening if you're a trans man with a cervix or breast tissue
• trans-feminine people with breast tissue (and registered with a GP as female) are routinely invited for breast screening from the ages of 50 up to 71

Find out more about screening for trans and non-binary people on GOV.UK.