Sex identity and gender identity

Sex identity, the assigned sex at birth, often correlates to the peripheral genital presentation, vagina for females and penis for males. Usually, this is in conjunction with the sex chromosomes, XX for females and XY for males. However, abnormalities can arise leading to the spectrum of sex and intersex individuals.¹ Sex identity does not ascribe to the individual’s feelings but rather indicates their biological makeup.

Gender identity is what an individual identifies with based on their internal feelings and social/ cultural environment. People who identify with their assigned sex are cisgender (same gender), and people who do not identify with their assigned sex are transgender (different gender).²

Gender lies on a spectrum. Often people identify at the poles, either male or female, including transgender males and females, but there is space in between the binaries. Some people within this gap are cis-, some are trans-, and this also encompasses non-binary identification, gender fluidity and more. There is a whole list of possibilities between the binaries that spell out each individual's unique experiences and feelings. Gender identity may stretch beyond the binaries depending on the individual, such as agender identities.³

Gender identity does not relate to gender expression, which is how somebody outwardly expresses themselves, but is not how they identify internally.²

Gender identity is influenced by societal standards of different genders and the associated feelings. Transgender people don’t emotionally or mentally associate with their assigned sex and associate somewhere else along the gender spectrum. It is an internal feeling associated with their sense of self and their emotional processes within a demographic.^2,3

Transgender people have been present throughout history. The ‘kathoey’ (Thailand) and ‘hijra’ (India) people have existed for centuries, and North American Indigenous tribes have had third-gender roles and gender fluidity in their cultures. Japanese, British, Indonesian, American and more accounts of possible transgender people, gender dysphoria, and additional gender presentations and roles have been present within our societies for much of history. The feeling of gender dysphoria is not new and it isn’t going away.

Gender dysphoria: what is it?

DSM-5 defines gender dysphoria as a “marked incongruence between one’s experienced/ expressed gender and their assigned gender, lasting at least 6 months”. The criteria for gender dysphoria are different for children vs adolescents and adults, primarily due to the ability to self-reflect and communicate feelings of distress and changes.

In adults and adolescents, dysphoria is usually marked by

• A strong desire to change or be rid of sex characteristics, primary or secondary
• An incongruence with the current sex characteristics and expressed gender
• A desire to be and to be treated as another gender than the assigned one.

In children, dysphoria is marked by:

• A strong desire to be another gender or insisting that they are another gender
• Cross-dressing and disliking wearing typical clothing of their assigned gender along with cross-gender roles in fantasy play/ games
• Preference for playing with the opposite gender and with toys typical of the opposite gender alongside  rejection of toys of their assigned gender
• A strong desire to change their sex characteristics

However, it should be noted that children may wish to cross-dress and/or play with the opposing gender and not have dysphoria but simply a preference.

To meet the criterion for either age group, there must also be significant clinical distress and functional impairments within social and occupational areas of life related to their gender. Distress can come in the form of depression and anxiety, social isolation, and neglecting health.

Gender dysphoria does not have to be present in all transgender people but this is most often the case. If you want a diagnosis of gender dysphoria, you should speak to your GP or therapist.⁴

Challenges

Gender dysphoria can cause a host of mental illnesses. Being uncomfortable in your skin is a disheartening experience that can lead to various mental health issues.⁵

There is also an increased suicide rate due to the dysphoric feeling and associated mental illnesses along with other challenges that contribute to suicidal feelings. Very frequently, these feelings tend to diminish as gender-affirming care is given.⁶

There are severe levels of stigmatisation from a personal/ community level up to a political/nationwide level. Transgender people are frequently used as scapegoats for far-right political tactics in modern politics and due to this, people around them, both known and unknown, are discriminatory in both personal and professional lives. Transpeople are frequently the victims of hate crimes ranging from bullying and harassment to murder.⁷ It is important for trans people to have safe social groups.

Treatment and management

Gender affirming care

Gender-affirming care is the best treatment people with gender dysphoria can receive. Gender-affirming care encompasses all steps taken to help a person feel comfortable within their body and gender identity, from cisgender to transgender individuals.⁸

It is important to note that not all trans people undergo gender-affirming care and that many undergo some aspects and not others. This does not retract them of their gender identity or gender presentation, it is simply their personal choice.⁶

Gender-affirming care includes:

Hormone replacement therapy

By taking hormones, – testosterone for males and progesterone and oestrogen for women – you can promote certain physiological features to help presentation as the desired gender, ranging from breast tissue growth to increased facial hair to the redistribution of fat stores around the body. Hormone therapy is often the most important step in a transgender person’s journey and amends many of the symptoms of gender dysphoria, aside from primary sexual characteristics. This treatment is not usually allowed until a certain age threshold is reached and so it is only used for older adolescents and adults.

Adolescents can also be prescribed puberty blockers, halting the effects of puberty on their assigned sex. These blockers do not induce the opposite characteristics and are reversible.

Gender-affirming surgery

This is common in both trans- and cisgender people to help with physical presentation. It includes plastic surgery such as facial restructure as well as hair transplants. Surgeries may seem drastic but are normal procedures that help adults feel at home within themselves. These procedures are much more common in adults who go through all the stages of puberty and wish to reverse some of the changes.

Surgery may include ‘top surgery’ to remove the breasts or, to add breast implants, and ‘bottom surgery’, usually the final part of a person’s transition, where they reconstruct the primary sex characteristics to fit that of the opposite gender.

Medical affirmations are not recommended for (prepubescent) children at all and instead focus is on social and psychological affirmations until children are of age.

Exercises and voice training

Various exercises can help with attaining the physique people desire to amend any gender dysphoria or anxieties. Following specific training routines and focusing on certain body parts can help shape someone’s body and allow them to present themselves however they’d like. Voice training is a method used to be able to communicate comfortably with a higher or lower tone, often associated with masculine or feminine voices. Testosterone can often lower someone’s voice but the same is not true for female hormones.

Other forms of care

Facial hair removal, as well as hair removal in other hairy areas, is common using laser hair surgery. 

Genital tucking or packing helps with perceptions for the individual and others, as well as chest binding for those with breasts using tape or a binder.

Psychological support

Support from their circles and therapists/ doctors provides a great deal of comfort to a trans individual. Even before any type of gender-affirming care, being called and known as your gender identity helps a person’s mental health and feeling of safety.⁵

This is done by adopting a person’s pronouns and any new name they choose to be known by. Supporting changes in outward gender expression such as makeup, haircuts, clothing etc. are all helpful in supporting a person’s transition.⁵

A therapist can help a trans person come to terms with who they are and guide them through difficult times as well as help them with their feelings of dysphoria that are often present. While this does not change outward perceptions, it can help change internal perceptions and thus make an individual more comfortable with who they are at any stage of their life, transgender or not.⁵

Legal recognition

Being legally recognised as the gender a person identifies with is helpful towards the perception of a person in various environments and helps a transgender person to be recognised by various businesses and services as their gender.

It prevents them from being called the wrong name and gender in many different environments and helps to prevent gender dysphoria as more people and institutions perceive these individuals as who they are.

Summary

Gender dysphoria among transgender individuals is a serious disorder that can result in debilitating mental health issues that last a lifetime.

Transgender people and gender dysphoria can be seen throughout history, and now support and care for trans people is more effective than ever, both medically and socially. By receiving the correct support and therapies for their gender identity, a trans person can amend their dysphoria and be recognised as themselves, both externally and internally.

Gender dysphoria is not something which should be stigmatised or shunned but rather something which should be treated and accepted. Legislation to remove trans people is rooted in bigotry and aims to remove what it means to exist as who they are.