Development of Transgender Identity and Gender Dysphoria

There are three elements to gender: biological sex, gender expression and gender identity. People are accustomed to recognising two genders male and female. Usually, by the age of three a child has formed a clear sense of their gender identity, most of the time their gender conforms to their biological sex. Society gradually programs the mind on how one should conform according to their birth sex. Transgender is an umbrella term used for people who have a sense of personal identity, gender expression or behaviour that does not conform to that typically associated with their sex at birth. Many transgender individuals seek further gender-affirming treatments which may include modifying their body to conform with their gender identity. Physical discomfort, psychological distress has been linked to be a major cause, both biological and psychological explanations have been examined through primary and secondary data.

Aim:

The aim of this research is to examine the factors that influence the development of a transgender identity.

Objectives:

1. To determine what gender dysphoria is.
2. To describe the biological and psychological perspectives of transgender identity.
3. To identify key stages of development.
4. Evaluate the treatment options for gender dysphoria.

Literature Review

According to an article by Ashby (2017) [online] Laurence Michael Dillon was the first transgender man in the United Kingdom to undergo a phalloplasty in 1949 (a doctor constructed a penis from scratch and grafted it onto his body) in May 1915 he was assigned female at birth and named Laura Maud. In 1946 Dillon wrote a book describing how transgender identity is innate and unaffected by psychotherapy. The book was called “A Study in Endocrinology and Ethics” and considered the first book about transgender identity and gender transitioning.

Dillon had long known that he was not a woman and felt more comfortable in men's clothing. In 1939 he sought treatment but at the time hormone masculinizing effects were poorly understood. In 1943 Dillon met with Dr.Gillies, a plastic surgeon who was one of the world's very few practitioners for plastic surgery. In his book he described how transgender was innate and should be treated medically. He wrote 'Where the mind cannot be made to fit the body, the body should be made to fit, approximately at any rate, to the mind.'

According to Chapman (2015) [online] the CNSNews.com advised that Dr. Paul R. McHugh believes that transgenderism is a mental disorder which merits treatment, he argues that sex change is biologically impossible and those who promote sexual reassignment surgery are collaborating with and promoting a mental disorder.

Pink News (2010) [online] report from 2000 to 2009 gender reassignment surgery rates have tripled. Surgery was performed on a total of 853 trans women and 12 trans men, costing the NHS around £10,000 on each case. The true number of transgender people is estimated to be much higher due to many people refraining from painful and complex surgery or are unable to access it. Batty (2004) [online] reports there is no robust scientific evidence that gender reassignment surgery is clinically effective. Large numbers of patients who have undergone surgery remain traumatised to the point of suicide. However, there is no conclusive evidence to suggest that increase in suicide rates are the result of gender reassignment surgeries or social stigma. Many researchers have lost track of former patients after transitioning, many of them have moved to a new place to re-start their lives under their newly formed identity or some have even committed suicide.

Hewett (2017) [online] explains in his article that for decades the non-conformity to birth assigned roles was diagnosed as a mental illness by the Diagnostic and Statistical Manual of Mental Disorders (DSM IV). It was later announced that in the DSM V (2013) “Gender Identity Disorder” (GID) has been replaced with the new term “Gender Dysphoria” which refers to the distress a person experiences because of their sex and gender they were assigned at birth. The term implies a temporary mental state rather than being labelled a disorder and helps remove the stigma faced by many transgender people.

Methodology

This research has gathered a small amount of primary data and include further secondary data to uncover the wider population identifying as transgender. It includes both qualitative and quantitative sources of data.

Primary data has been collected directly from the participants through interviews and used to analyse qualitative data. The questions consist of mostly open-ended questions with a semi-structured approach, subjective to enable a true valid picture. A snowball sampling method is used to recruit 3 trans-women within the Lancashire County based in North West of England, taking into consideration the difficulty in finding participants due to the very small population. The duration of the interviews were approximately 30mins and conducted in natural life settings to increase validity and help build trust and rapport, encouraging participants to open-up and be at ease. No discrimination was made in-terms of race, religion, sex, disability or social economic factors however, all participants involved were over the age of eighteen due to ethical issues surrounding consent. The strengths to using this method is the ability to recruit hidden population, the interviews can be quick and cheap to administer. Suitability to gather common, straightforward information but with the added ability to probe and clarify matters. The limitations to this method is that it is time consuming, the participants may lie to suit social desirability factors and the network of peers can lead to bias. Open-ended questions make it harder to quantify data as cannot be measured in numbers. The sample size is very small and unique therefore unable to generalise.

The practical issues faced are finding an adult transgender individual willing to participate in the research and finding mutual time agreement, cost of transportation and possible purchase of a Dictaphone. Ethical consideration will involve obtaining consent forms prior to the interview, participants to be briefed informed of their right to withdraw. A covert attitude where no deception is involved, participants to be guaranteed anonymity and confidentiality. Special care was taken to ensure participants were safeguarded from physical or psychological harm, interviews were held in a private area, questions were relative to the research and not too intrusive, participants debriefed informally after interview completion to ensure participant are kept comfortable and at ease. Theoretical issues with the interviews are based mainly upon the interpretivists approach. They prefer the use of data with high validity, which can be achieved through qualitative methods. By asking open ended questions a true picture of the subject will be encouraged. The semi-structured method allowed expansion to make generalisations about behaviour pattern which may be able to replicate. Positivist’s view this method lacks objectivity, reliability and fails to produce representative data that can be generalised to the wider population.

Secondary data was collected through internet sources and text books. This will include the research of real life history by other researchers and gathering statistics for quantitative data.

The strengths to using secondary data is the ease of access being able to study from home. It is cost effective due to not having to carry out thorough research. Books are genuine sources of data rating high in reliability, the vast amount of information available from the internet gives significant use for being able to compare both past and present data. The weakness of using secondary research is that it is time consuming and will need to ensure internet information is from trustworthy sources. Other people’s research which may not match the aims and objectives to be studied. Not having control over the quality of data, it could be out of date, inaccurate or biased.

Overall this research display’s a true insight into the journey of identifying as a transgender person by producing valid responses however, the results will not be able to generalise to the wider population of the transgender community due to having a very low sample size and biased method.

Results and Findings

To explain what gender dysphoria is.

Gender dysphoria refers to the discomfort or distress a person experiences due to the conflict between their assigned sex and their preferred gender identity. The results from the primary research interviews shows significant distress is caused due to participant’s gender identity not matching the biological sex they were born with. However, it also suggested that being transgender is not a mental illness the distress may be caused due to the social stereotypical factor. Donnelly (2015) reports rates have quadrupled in five years of children being referred to the NHS with gender confusion under the age of 10. The transgender community is incredibly diverse, there is a spectrum of terminologies under the transgender umbrella, ranging from those who cross-dress to transsexual people. The term also encompasses other gender variant people, including individuals who are androgynous and those who identify themselves as non-gendered. According to the Office of National Statistics (2009), the estimated figures for the trans community in the UK range from 65,000 (Johnson, 2001) to 300,000 (Gires, 2008).

Describe the biological and psychological perspectives of a transgender identity.

Russo (2016) [online] refers to Guillamon quotes: “Trans people have brains that are different from males and females, a unique kind of brain. It is simplistic to say that a female-to-male transgender person is a female trapped in a male body. It’s not because they have a male brain but a transsexual brain.” Behaviour and experience shape brain anatomy, so it may be impossible to say if these subtle differences are inborn. At birth an examination of the brain in impractical and inconclusive with current medical technology to distinguish the gender type which is a limitation. See brain differences in male and female (appendix pg 30) According to the NHS (2016) [online] gender dysphoria may be the result of congenital adrenal hyperplasia (CAH) when a high level of male hormones is produced in a female fetus which causes the genitals to become more male in appearance and in some cases, the baby may be thought to be biologically male when she is born.

Cardwell and Flanagan (2009) outline the view of psychologists who believe that the DSM diagnosis of gender dysphoria is a mental illness which may arise from childhood trauma or maladaptive upbringing. They refer to a case study of Coates et al (1991), a boy developing gender dysphoria which was a result of a defensive reaction to his mother’s depression following an abortion. They suggest that the trauma which occurred at the age of three (when a child is gender sensitive) may have led to a cross-gender fantasy as a means of resolving anxiety. This case study explains reasons in which an individual may develop gender dysphoria however, it ignores the role of biology, cannot be generalised and may not be reliable. Cardinal and Flanagan also report an opposing study of Cole et al (1997) of 435 individuals experiencing gender dysphoria and reported that the range of psychiatric conditions displayed was no greater than found in a ‘normal’ population. This suggests that gender dysphoria may not be related to trauma or pathological condition.

To identify key stages of development.

The biological explanation suggest that most transgender people are born with a pre-disposition to being transgender that was formed prenatally which directly drive’s development. According to Williams (2016) [online] there are three major factors in development; Chemical/Hormonal, Genetic and Environmental. Men and women have different brains according to size and proportion, these differences are small yet specific and identifiable. The brain of a transgender consistently matches the brain structure of their adopted gender and not the birth sex. These changes are understood to be caused due to chemical imbalances that causes the wrong hormones to be expressed prenatally and during the development of the brain. Although there is a growing consistent trend in these studies, the sample sizes are small due to the number of transgender person’s brain used for medical purposes and therefore difficult to generalise. He also conducted a study on animals to show how the cross of the wrong hormones leads to transgender issues during the brain development stage. The animal subsequently exhibited mating behaviours of the opposite sex even when the genitals match their genetic sex. The biological approach is valid and based on scientific findings, they predict behaviour according to heredity which is a strength. The limitations are that it is a reductionist, offers a few suggestions for the change in personality not considering thoughts and feelings. Primary research has shown significant impact on own identification during the early stages of puberty.

Evaluate the treatment options for gender dysphoria.

Various treatment methods can help manage this discontent including counselling and other mental health services, hormonal treatments, and surgery. Psychological interventions may help refrain from any physical treatments. Blood tests and medical checks are an important part of safe treatment. Treatment can begin in adolescent age with puberty blockers, these can buy time before a surge of unwanted hormones which can prevent physical changes such as breast development and facial hair.

Puberty blockers are completely reversible and can be stopped at any time, but they also contain risks including effecting long term including brain development, bone growth and fertility. Hormone therapy helps by changing the physical appearance into more of the adopted gender and therefore improves the feeling of oneself, such as estrogen for breast growth and testosterone for facial hair growth. They usually need to be taken indefinitely and the effects are irreversible. Some risks involved are weight gain, sleep apnea, blood clots and can also make trans men and trans women less fertile. Not all transgender people choose to have surgery, it can be costly and therefore unaffordable. Some people may not see surgery to be an important way to express their gender and some may not be discontent with their genitals. Surgery is usually performed in adulthood. A functioning vagina or penis can be created with an acceptable appearance allowing to pass urine and retain sexual sensation. NHS reports 96% satisfaction rate for genital reconstructive surgery, which suggests after surgery most trans men and trans women are happy with their new sex and feel more comfortable with their gender identity. Surgical interventions are irreversible and may require more than one operation to achieve satisfactory results. Risk of post-operative complications. Despite surgery trans men and women may still face prejudice and discrimination from society because of their condition. Primary research suggests that transgender individuals are well informed of their treatment options and overall seem to display a good level of satisfaction with medical intervention. Distress and discomfort of oneself has been experienced to a degree, however this could be the result of their physical appearance due to delays in treatment.

Discussion

Most transgender people know they are uncomfortable with their gender from an early stage. They usually convey strong persistent feeling of identifying as the opposite gender. Some people may come to realise later in life but even then, they have had early experiences of other gender nonconforming behaviours such as cross dressing.

Although the transgender communities have always existed throughout time, countries and different cultures there is very little mention of this type of population. In India trans women are recognised as “Hijra”, men raised as females in Samoa are called Fa'afafine. Historically, transgender identities were considered abnormal and unacceptable, this is probably the reason why Dillon fled to different towns and countries. There is still significant stigma and discrimination around being transgender in society, this may be the reason why many trans people suppress their feelings for so long resulting with delayed treatment and causing further distress.

The modification in the DSM indicates a significant development in the medical perception for transgender people, recognising that the conflict between birth, gender and identity does not necessarily suggest it is a mental disorder unless it causes the individual distress. From the primary data gathered it seems there is still ongoing debate from the transgender community about the diagnosis of “Gender Dysphoria” being recognised as a mental illness as per the views of Dr. Paul R. McHugh (2015) and therefore whether it should remain in the DSM V.

In 1949 when Dillon’s surgery was performed, the constructed penis was not fully functional. The main purpose was for him to pass as a man. The rapid increase in gender-reassignment surgeries reflect not only the growth in the transgender population but also determines its revolutionised surgical success. During primary data collection significant practical issues were faced in finding participants due to the very small transgender population. Blackburn College LGBTQ group were inactive due staff sickness, therefore, results solely relied upon referrals from key contacts. Considerable delays were experienced due to finding mutual time to conduct the interviews. Also, the samples collected were only from trans women resulted in bias. To repeat this research, the recommendation will be to change from snowball to quota sampling method, increase the sample size by recruiting from other LGBTQ groups and allow more time. This will ensure interviews are completed within time frame, the proportions of the sample in each category will be the same increasing representation and reducing bias.

Conclusion

Although transgender population is rare, the number of people being diagnosed with gender dysphoria is increasing due to growing awareness. In the UK access to free medical care has allowed more people to explore their gender options enabling the doctors to understand the need for transgender patients. Biological explanations provide a reasonable explanation to developing gender dysphoria however, there is very little evidence to form a conclusion. For future research, if women’s hormone levels are tested prenatally there could be a possibility to identify a development trend for becoming a transgender identity.