Gender identity disorder

Most children begin to identify themselves as either a boy or a girl between the ages of three and four years old. They engage in play that their family and friends connect with their gender; what psychologists call the 'gender role'. Some children continue to experiment with other games, but usually a combination of genetics and peer pressure brings this to an end. Some can seem to take longer than others to understand and embrace their gender role.

For a very small number, this passing uncertainty and discomfort, known as gender dysmorphia, can develop into gender identity disorder.

For some children social expectations lead to them conforming to their gender role, only to develop the self awareness to realise that they’re uncomfortable with their gender when they reach adolescence. This discomfort is always associated with profound feelings of disconnection with the sexual organs, a sense that they are somehow wrong.

A major difficulty with gender identity disorder is that it's a rare condition.

Estimates vary from one or two people in every 100,000 (an average size town) to about one person in every 12,000 (a small town). This means that people who have gender identity disorder can experience profound loneliness. It also makes research into why and how it occurs difficult. Added to this is the confusion that often arises in the minds of both healthcare professionals and the public about exactly what gender identity disorder is. To say that it’s a desire to be a member of the opposite sex is to underestimate the strength of emotion and impact it can have on a person’s life.

Diagnosing gender identity disorder

To get a diagnosis the person has to experience ‘persistent and intense distress’ about their gender. Given that this can be experienced from a very young age it can have a profound effect on emotional development. While their attempts to act in accordance with their preferred gender can lead to social stigma and bullying from peers, healthcare professionals can confuse the condition with other issues associated to the development of gender and sexuality, such as:

• Klinefelter’s syndrome, a disorder of the chromosomes.
• Transvestism or cross-dressing. Someone with gender identity disorder may well dress in the clothes of their preferred gender in an attempt to avoid the distress that they feel about their situation. However, most cross-dressers are usually quite happy with and secure in their gender, but derive pleasure from wearing the clothes of the opposite sex.
• Homosexuality, again most gay people are quite happy and secure in both their gender and sexuality.

It’s this last point that can cause the most confusion. Gender identity and sexuality are undoubtedly linked, and so issues about gender identity during childhood and adolescence can be a common experience among gay people growing up. But among that small group who continue to have gender identity disorder into adulthood, the question of their sexual orientation is irrelevant.

A person with gender identity disorder and a male body may feel attracted to women and pursue a gay lifestyle after gender reassignment, but they may be just as likely to be attracted to men and pursue a straight lifestyle after gender reassignment surgery. Whether the person is gay or not, before or after their gender reassignment surgery, is a redundant question.

The crucial factor that’s easily missed by healthcare professionals is the profound sense of discomfort that the person feels about their sexual organs.

This is a part of the body that most clearly and intimately defines who we are, yet for the person with gender identity disorder these organs can feel alien and completely unnatural. In some extreme cases this can lead to self-mutilation of these organs.

Gender reassignment surgery

In most cases, the person goes through the long and arduous process of gender reassignment by surgery. In the UK, the process on the NHS can take two to three years to complete.

The process begins by asking a general practitioner for a referral to the local mental health services for a psychological assessment. This is both to ensure that the request is not a symptom of a mental health problem, but also to acknowledge that people with gender identity disorder can experience a lot of distress and find the process of obtaining gender reassignment and then adjusting afterwards stressful. Often, two assessments made independently by different members of the team will ensure that a consistent view is formed before a referral is made to a gender identity clinic.

Given the rarity of gender identity disorder these clinics often cover very wide geographical areas and can be based a long way from the person’s home, which means a lot of travelling. Once they're under the care of the gender identity clinic, the person will usually start what's known as the 'real life test' - this means living in every way possible in the role of the gender to which the person wishes to be reassigned to. Often they may already have been doing this.

During this time the person usually starts to take hormones that trigger changes in the body that brings them closer to the look of the desired gender.

After a long journey both personally and with the health services, the person can finally have their reassignment surgery.

Often, this is not the end of the road. The genitals may have been reshaped, but there are often other aspects of the person’s body that may need further surgery later, such as breast augmentation or throat surgery to change the tone of the voice. For many people with gender identity disorder there’s no easy path. To not have the surgery means to live with great distress and unhappiness. However, to have surgery is also a long and difficult road.

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