Gender, identity, support

The editor of TRANS, psychiatrist Dr AZ Hakeem, believes it may never be possible to settle on language that is universally accepted or endorsed. His bold new guide endeavours to make support needs related to gender and identity more commonly understood among a wider community.

People living with a sense of unhappiness or confusion with their own sex and gender often need support unless and until there is a resolution and sometimes beyond. Professionals make this distinction: sex is the biological sex that one is born with (in terms of anatomy and chromosomes); gender is a social division. You are intersex if you are not entirely physically male or female and have a body that does not neatly fit into this binary category. Unhappiness with our sex or gender can lead us to question whether the sex we belong to matches the gender which we identify with. In psychiatry, this is known as gender dysphoria.

What is it like to feel unhappy with your sex or gender?

There are number of classic misunderstandings in relation to gender dysphoria. People with a gender dysphoria are not all the same, each is an individual.

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I have been offering specialist clinical services to people with gender dysphoria for the past 18 years and it is clear that gender dysphoria is a very broad spectrum of conditions.

People with gender dysphoria do not all identify with the opposite sex to their birth sex.

Some people with a gender dysphoria do identify with the opposite sex to their biological sex at birth, whereas others may identify with no particular sex, or with an indeterminate gender which does not fall within a binary male/female system. These people may refer to themselves as having a non-binary gender identity and do not comfortably identify with either male or female genders.

Common misconceptions

My patients have shown me that gender dysphoria can arise at any age. Often, people are born without a gender dysphoria, but later become unhappy, confused or dissatisfied with their identity. Then, following a period of increasing confusion and/or unhappiness with their gender, they develop an increasing gender dysphoria, prior to then identifying with a gender identity which they may wish to pursue. It may or may not be accompanied by the wish to make physical changes to their body.

What support is available?

When people think of gender dysphoria, they usually think of people 'wanting to have a sex change'. Search online for services and treatments for gender dysphoria and you’ll primarily find references to hormones and surgery. If your gender identity is quite fixed, then relatively permanent physical treatments such as hormones, or wholly permanent treatment such as surgery, may be fine. But if your gender identity is non-binary or is more fluid, or is changeable over time, then physical permanent interventions are not suitable. For people with such atypical gender presentations, mental health support in the form of counselling and therapy may be far more helpful, psychologically.

The understanding of gender dysphoria is outside the remit of any undergraduate medical training and general psychotherapy trainings, and is poorly understood by many professionals. As such, it is outsourced and delegated to a much smaller group of specialist clinicians. Most are specialists in physical treatments of prescribing hormones, or performing gender reassignment surgery.

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For over a decade I ran a specialist psychotherapy service within the NHS which acted as a tertiary referral service for the whole of the UK. During this time I was the only Consultant Psychiatrist in the UK’s NHS specialising in psychotherapeutic assessment of people with a gender dysphoria, specialising on those with more atypical non-binary gender identity presentations, for whom physical treatments such as hormones and surgery were not going to be useful options.

Specialist psychotherapy for people living with a sense of unhappiness or confusion with their own sex and gender should involve examining what it means to be any gender and dismantle any unhelpful assumptions or rigid ways of perceiving or understanding gender. Often when one breaks down the rigid internally perceived framework of gender then one experiences more freedom to express one’s gender, without feeling tormented about “not fitting in”.

As a psychiatrist and psychotherapist, my hope is that services for people with gender dysphoria should have a greater emphasis on exploratory talking therapies for people who comfortably identify with neither male nor female genders. If your gender identity is more fixed, then permanent physical treatments can be affirming.

The ultimate aim is to help people get to grips with something potentially quite complex in an easy to understand way.

Dr AZ Hakeem is the editor of TRANS, a consultant psychiatrist, and a visiting professor in applied psychiatry and applied psychotherapy.