Transition and Detransition: Introducing some key ideas on sex and gender.

In every day speech sex and gender are sometimes used interchangeably and in some languages there is only one word to describe the two. However, the whole concept of gender dysphoria relies on understanding that there are differences between sex and gender. 

Sex refers to a person’s biology (i.e. their anatomy; skeleton, musculature, chromosomes, reproductive system and secondary sex characteristics). Over 99% of people are biologically male or female, there is no sex spectrum in the traditional sense of that word, though some people do suffer from disorders of sexual development. The vast majority of people with disorders of sexual development are also either male or female. 

Gender refers to the roles, behaviours, activities, and attributes that a given society considers appropriate for men and women [as defined by their biological sex]. ‘Masculine’ and ‘feminine’ are gender categories. Most, maybe all, people have a mix of masculine and feminine traits. Gender can therefore change both over time and between cultures. 

Gender non-conformity occurs when a person acts or presents differently from how their society expects them to, based on their sex. 

Gender Identity – some people believe that we all have an innate ‘gender identity’ – a deep sense or awareness of ourselves as either male, female or somewhere in between – which exists separately to biological sex and which can, on rare and extremely distressing occasions, differ from it. Other people do not believe that a specific gender identity exists that is distinct from other any other aspect of a person’s personality or identity. 

What is gender dysphoria?

Gender dysphoria is a diagnostic term used by the psychiatric and medical community to describe the distress experienced when someone feels that their gender identity does not match their biological sex.

People experiencing gender dysphoria report strong, persistent feelings of identification with a gender that differs from their sex, and associated discomfort with their sexed body. For a formal diagnosis to be made at present, the feelings have to cause significant distress or impairment to the person experiencing them.

What does it mean to be transgender?

Transgender is a term that can mean different things to different people. It is generally agreed that trans women are born with a male body but identify as female, trans men are born with a female body but identify as male, and non-binary people identify as neither male or female. People often use the shorter term ‘trans,’ to signify that someone identifies with a gender that is not the same as their biological sex. 

Transgender can be understood as;

  • i) someone is the sex/gender opposite or different to that they were born.
  • ii) someone believes they are the sex/gender opposite or different to that which they were born.
  • iii) someone is living as if their sex/gender is opposite or different to the sex which they were born.

Debates about which ways to understand the term and experiences are heated and controversial both within and outside of the transgender community. Some people feel that even having a discussion about what it means to be transgender is undermining the validity of the individual experience. These different definitions and beliefs inevitably lead to different ideas for how best to support people to manage gender related distress .

Options for Managing Gender Dysphoria

  • Social Interventions for Gender Dysphoria

People with gender dysphoria often desire to live in accordance with their gender identity and may experience a sense of relief when they present and express themselves in ways stereotypically associated with the sex with which they identify. This process is called socially transitioning. When people socially transition they invite others to refer and relate to their gender identity instead of the gender associated with their biological sex. 

  • Medical Interventions for Gender Dysphoria

Medical interventions have been increasingly available for people with gender dysphoria. The interventions usually aim to help people alter their body to make them more aligned with their gender identity. For example, cross sex hormones might help people who identify as trans men to grow beards, or trans women to develop breasts. Surgery can be used to alter the appearance of genitals or secondary sex characteristics. Puberty blockers have several purported purposes; they are sometimes used in an attempt to provide more time for a young person to make sense of their feelings without the distress they experience from pubertal body changes. In other situations, they are used to prevent a young person from going through puberty at all, so that the body has to be altered less in adulthood via surgery or the use of cross sex hormones (i.e. if someone who identifies as a trans man doesn’t go through their female puberty they would not need a mastectomy later on).

Therapeutic Approaches for Gender Dysphoria in Children and Young People

There have been a number of shifts in how the medical and psychiatric communities have tried to help patients with gender dysphoria over the past forty years or so. Initially, we had the Live in Your Own Skin model, which, having realised that gender dysphoria often dissipates after puberty, aimed to avoid young people going through any unnecessary social or medical interventions before hand. Active therapeutic interventions aimed to help people to be more comfortable identifying with the gender associated with their sex. Although the intervention helped the majority of young people, some people still experienced gender dysphoria after puberty and so needed further support and a different approach.

This approach therefore evolved into the Watchful Waiting model, which made no attempt to intervene with someone’s gender identity at all and took a supportive but hands off approach to their developing gender identity, allowing young people to socially transition, if necessary, as part of a process of self-guided exploration. A team in Holland started introducing puberty blockers as part of the watchful waiting approach, initially in an attempt to reduce distress and provide even more time and space for a young person to make sense of themselves before starting to experience the bodily changes that come with puberty.

More recently the approach has evolved again into the Affirmative Approach. This approach centres the young person as the expert on themselves and so allows/encourages anyone of any age with gender dysphoria to have access to either a social transition and/or a medical intervention, as age appropriate.

The Gender Exploratory approach has evolved over recent years alongside, and perhaps in response to, the affirmative approach. This approach is somewhat similar to the Live in Your Own Skin model but differs in that it argues for a more critical understanding of what gender is and what it means to be gender non-confirming. The gender exploratory approach does not see the necessity to alter one’s physical body or gender. Instead, gender exploration encourages therapeutic approaches to help people better understand the relationship they have to their gender and sex. This approach may also explore how they have come to understand themselves in a gendered way, to explore and  better understand the impact of any stigma associated with being gender non-conforming, and to consider ways to live in the body and society as they are. It is generally agnostic about the appropriateness or utility of medical interventions in adulthood, it will support it where appropriate. It is cautious about using medical interventions in children and young adults due to the complex bio-psycho-social developmental processes they are still undergoing. 

Changing Demographics

There have been a number of big changes in to the populations who experience gender dysphoria/ identify as transgender over the past decade or so. The changes include:

  • An unprecedented and exponential rise in people, publicly at least, identifying as transgender and requesting medical interventions
  • Greater awareness, and to some degree acceptance, that people can experience gender dysphoria or identify as transgender
  • More young people identifying as trans than ever before
  • Some people identifying as transgender without also experiencing dysphoria or distress
  • A ‘sex ratio change’ – there are now many more biological females experiencing gender dysphoria or identifying as trans. In the past there were more males.
  • More young people first experiencing gender dysphoria in adolescence, in the past the dysphoria usually began in childhood.
  • More people describing themselves as non-binary than ever before
  • More people socially transitioning (i.e. living and presenting themselves as the gender that they identify with) earlier in life and without professional support to do so
  • More people from across the age span accessing medical interventions
  • Younger people, on the brink of puberty (Tanner Stage 2), accessing medical interventions
  • Greater awareness that some people desist and detransition. 

We don’t yet know whether the population of people with gender dysphoria has stopped changing. It may still be in flux and it may continue changing in the years ahead. 

The Evidence Base

The evidence base for whether an intervention is effective in reducing the distress associated with gender dysphoria has always been poor. There were so few people seeking help for gender dysphoria in the past that studies often struggled to include enough participants to make them statistically powerful. Now that more people are identifying as trans, and/or seeking help for gender dysphoria, researchers are having to catch up. It is particularly difficult to research a clinical population that has changed as significantly as this one has. At the moment we do not know who is most likely to benefit from each intervention, whether interventions are damaging or come with side effects, or the effectiveness of any of the interventions over the longer term.