Gender Dysphoria and Transgender Issues

Gender Dysphoria and disorders of sexual development (DSD), also known as “intersex,” are not the same thing, although of course people with DSD can also experience complex and challenging emotions around their condition and their sense of a gender identity.

When someone has a DSD they are usually born with an ambiguous physical appearance that, in the days before modern chromosomal testing, sometimes made it difficult for doctors and parents to distinguish the child’s sex. The term “gender assigned at birth” originates in medical thinking about DSD, as in the past clinicians would often make a “best guess” and then advise parents to raise their child accordingly, and sometimes they also performed surgeries intended to make the child resemble one or other sex more closely. Today, however, even in the case of children born with ambiguous genitals, in most countries modern testing quickly reveals what sex they are.

People with Gender Dysphoria, conversely, usually have no physical anomalies that make it difficult to distinguish their sex. Instead, while they generally have bodies that are typical for their biological sex, they experience a profound sense of disconnect between their physical reality and their deeply-held, personal feelings about gender and identity. Since 2013, Gender Dysphoria has been officially recognised as a psychiatric condition.

No. Most people who are same-sex attracted – lesbians and gay men – or who are bisexual do not also have Gender Dysphoria, while people with Gender Dysphoria might be attracted to individuals who are the same sex as themselves, or to the opposite sex, or both – just like everyone else.

Sexual arousal in men is complex, involving interactions between hormones, emotions or feelings, and the physical architecture of the reproductive organs, including nerves, muscles, and blood vessels. When there is an issue with the brain and with the emotions the man is feeling, Erectile Dysfunction can be triggered or exacerbated.

Clearly, when someone with Gender Dysphoria requires psychological support, they need to encounter a safe, inclusive environment in which they will be listened to and feel accepted.

In recent years, relating to concerns about conversion therapy – a discredited practice that attempts to “deprogram” people experiencing same-sex attraction – some therapists have been reluctant to provide therapy for people with Gender Dysphoria, lest they be accused of trying to “convert” them. However, growing evidence suggests that, unlike same-sex attraction, which is a normal variant of human sexual attraction and behaviour, issues with gender dysphoria are often linked to childhood experiences, including neglect and physical or sexual abuse. People with Gender Dysphoria also have higher than average rates of alcohol and substance abuse, mental illness – including depression, schizophrenia, and mood and personality disorders – and suicidal ideation. They are also much more likely than average to be neuro-atypical, with conditions including autism and Asperger’s syndrome. It is, however, important to note that there are also people with Gender Dysphoria who do not report any past trauma, and have no known comorbidities.

In order to understand the story of the patient with Gender Dysphoria, they and their therapist will need to talk about their past experience, including when they started to feel uncomfortable with their sex, and whether they have experienced trauma and/or any psychiatric issues in the past.

Even today, many women and men who feel that they are “atypical” in terms of their gender presentation – mode of dress, mannerisms, and interests – can feel criticised or out of place, leading to distress. Many people with Gender Dysphoria describe having had interests and habits as children that they feel were seen as inappropriate for their physical sex, and sometimes describe parents who were critical of these behaviours, and even punished them or restricted their access to toys and other things considered inappropriate. It is important to reassure them – and indeed the parents of children perceived as “atypical” – that there is absolutely nothing wrong with boys whose interests are perceived as “feminine” or girls whose interests are perceived as “masculine.” Similarly, among adults, having interests and preferences that are typically considered to “belong to” the other sex should be celebrated as part of the diversity of life, rather than used to imply that “real” men or “real” women should always behave in a certain way. In therapy, these stereotypes can be challenged in a constructive manner.

The World Professional Association for Transgender Health (WPATH) recognises that psychotherapy is a useful, helpful way to support people with Gender Dysphoria and that it can change their lives for the better, including in the absence of hormone-based medical therapy or gender affirmation surgery.

However, because people with Gender Dysphoria often express a strong sense of discomfort with their physical bodies, in particular their primary and secondary sex characteristics (genitals, breasts, body hair, and so on), they may feel attracted to the idea of having surgery and/or taking cross-sex hormones to change their bodies until they feel more comfortable with them.

While surgical and hormonal treatments have become increasingly common in recent years, they should both be approached with caution. Anyone considering going down this path needs to be aware of the many physical and psychological health risks associated with these interventions. A therapist working with a pre-surgical client can explore with them – in a safe, compassionate, and inclusive way – whether their expectations that everything will be better after surgery are realistic. With any type of plastic or cosmetic surgery, even something relatively minor, such as a “nose job” or breast augmentation, there is a risk that the patient may be projecting all of their anxieties onto the body part that causes them distress. While often in the months immediately following surgery there can be an initial sense of euphoria, frequently as time passes and this euphoria recedes, the same psychological issues are still there, and will continue to be a problem as long as they remain untreated.

All of this applies also in the case of surgery intended to replicate the appearance of opposite-sex genitals or secondary sex characteristics, while these treatments also have extremely high rates of complication and even failure, including incontinence, chronic or repeated infections, and fistulae, or openings between the neo-vagina and the rectum, causing the seepage of faecal matter. Therefore, we consider it very important for anyone contemplating a treatment of this sort to engage with a suitably trained, compassionate therapist who can help them to figure out if this approach really is the best thing for them, and whether their expectations for what life will be like after surgery are realistic. As part of this process, it may be useful to explore whether minor surgical or cosmetic procedures – such as hair removal – would be sufficient to alleviate feelings of gender dysphoria, as the potential for severe side-effects is much lower.

Individuals who have already had surgery to change their physical appearance may also benefit from therapy. Managing a surgically-altered body can require ongoing procedures, such as dilation of the surgically-created neovagina in transwomen, which can be onerous, painful, and stressful. The loss of fertility, which can follow a more radical, medicalised approach to transition, may seem unimportant at the time of the surgery, only to become more of an issue later on, and many people also experience a loss of sexual function that can become difficult to live with. It is important to have appropriate psychological supports in place to aid the person through the post-surgical period and beyond.

Not everyone who experiences Gender Dysphoria expresses a desire to have surgery to change the appearance of their body. Some people who report even strong feelings of Gender Dysphoria also state that they wish to retain their physical appearance, often – but not always – while expressing their feelings relating to gender through dress, make-up, and other non-invasive modes.

In cases of gender dysphoria, whether or not the individual in question decides to transition, family and/or group therapy may be indicated. For example, consider the following scenarios:

• A man in his forties who has lived with varying degrees of gender dysphoria all his life has decided to transition, including having radical surgery to reconfigure his genital area. He has been married to a woman for nearly twenty years, and they have three children together. He now identifies as a lesbian and hopes that, post-transition, the marriage will continue. His wife, however, is struggling with the changes. She loves her husband and while she is trying to be supportive, she does not consider herself to be a lesbian. Whatever happens, they will still have to figure out a way to co-parent together in an atmosphere of mutual respect. Family therapy in a safe, inclusive, and questioning environment should help them to find a way forward, together or apart.
• A young woman from a very traditional, conservative religious background has struggled with gender dysphoria since early childhood. She has always found her parents’ expectations for her behaviour challenging, and has been same-sex attracted since adolescence. Now that she has left home, she is struggling to understand whether her longing to be seen as a man means that she has a transgender identity, or stems from the fact that she has never liked the version of womanhood promoted in her family. While she would certainly benefit from individual therapy, group therapy may also be useful, as she would be able to discuss all of these issues with others having similar dilemmas. Family therapy with her family of origin would certainly be useful if her parents and siblings consent.
• A transwoman who was hopeful that issues with distress and self-esteem would improve post-surgery finds that, while levels of satisfaction with a changed physical appearance are quite good, other areas of life have not changed as much as was hoped for. Engaging with peers in group therapy in a safe, welcoming therapeutic environment helps with practical support and understanding that is not always available in the wider world.

Everyone is different, so there is no one-size-fits-all approach to therapy for people with gender dysphoria or transgender identities, but in general it is important to remember that nobody lives in a vacuum. When one person in a family, friendship group, or other social unit experiences gender dysphoria or decides to transition, this can impact on the dynamic of the group. Depending on their individual circumstances, and whether or not their loved ones consent to therapy, some form of family or group therapy can be very useful for a cohort that often struggles with social isolation and being accepted. For those who have issues with substance abuse, in parallel with access to other forms of therapy, therapeutic interventions designed to change this damaging behaviour are also indicated.

This complex area of psychology and care is extremely sensitive, and can be a challenging field to work in, amid ongoing research and cultural flashpoints. In this context, an empathy-centred approach is essential to support the individual with Gender Dysphoria and their often complex needs. If you experience Gender Dysphoria and feel that therapy would be helpful, there are many options that we can explore together.

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Zucker KJ (October 2017). “Epidemiology of gender dysphoria and transgender identity,” Sexual Health, 14 (5): 404–411. Link