Saturday, 17 March 2018

ABC's of the DSM-V: G is for Gender Dysphoria

The discussion around gender and sexuality has started to move away from being a taboo, becoming a slightly more acknowledged topic. That’s not to say that acceptance and understanding are prevalent – far from it – but the first steps have been taken and people are starting to have more discussions, opening the door to understanding what gender and sexuality are.

In this post I’ll be discussing gender dysphoria and how it affects identity, sexuality and the wellbeing of an individual. As a cisgender woman I can’t speak from a personal perspective, but I can comment on the psychological and biological aspects of GD and let others use this as a platform for their voices and experiences.

Stef Sanjati. Credit
We have come a long way in regards to studying GD and related disorders in such a short time, which can be seen in a change in attitudes towards gender in recent years. This change can also be seen in research – sociological and sociocultural differences have caused a shift in how many natal women (female at birth) have been referred in to gender clinics due to GD. Prior to 2006, natal males were more commonly referred to gender clinics, whereas between 2006 – 2013 there was a shift, favouring more natal women (Aitken et al., 2015). Over the last 10+ years women’s freedom, liberation and rights have been pushed to the forefront – in the UK alone, there have been changes to the law regarding female welfare such as the Female Genital Mutilation Act 2003, The Equality Act 2006, The Forced Marriage Act 2007, and more notably the No More Page 3 campaign. These changes are only a small example of how women have started to come forward regarding their own rights, pushing forward against the way the patriarchy has pushed us into a corner and told us how to be, changing attitudes, which may have played a role in allowing natal women to feel more comfortable coming forward regarding their own gender identity. 

But first, lets talk about the basics – What is GD? When you’re born, you are assigned a gender as a result of your sex. There are 2 sexes, XX and XY – there is a misconception that the chromosomes are exclusively linked to a specific gender (XX with female and XY with male) – this isn’t true. Scientifically, these chromosomes are called XX and XY, not male or female – those are labels that we've made up for gender identity; something completely different to sex. The sex chromosomes determine what organs you have, what hormones you have, how much of each hormone you have, all that biological stuff. Gender is something we as humans have chosen to define what the outcome of those biological aspects make you – it’s a label: it is NOT a biological entity on its own, it’s a psychological state that happens as a result of those chromosomes. Because of the way the sex chromosomes manifest in humans, it has illustrated a pattern which is why we label those with XX chromosomes as being female and those with XY being male – most people with XX show a consistent pattern of characteristics that we would call female (breasts, high estrogen, low testosterone) and the same with male (testicles, high testosterone, etc). Due to the fact that each set of chromosomes is associated with a specific gender, we as humans expect each person with certain sex organs to fit that box – So we expect those with XX organs to be feminine, look a certain way, behave a certain way, have certain characteristics that we associate with them having XX chromosomes – still with me? Good.

GD happens when someone is assigned a gender due to their chromosomes, but feels that their assigned gender doesn’t match with their psychological state, resulting in distress and discomfort in their own bodies. It can manifest as low self esteem, depression, anxiety and even self harm, causing someone with GD to try and do anything they can to match the gender they feel psychologically and high levels of anxiety and dysmorphia occurring when its unsuccessful or perceived unsuccessful ("I don't look male 

Stef Sanjati, a popular youtuber who has been documenting her transitioning journey over the last few years has a great way of explaining dysphoria:
 “Dysphoria is like an extreme discomfort in your body, based on gendered things.”
I also got the chance to speak to a friend who has experienced dysphoria and listen to their experiences of it (not every experience is the same and doesn’t make anyone’s gender identity more or less valid, it’s a very personal thing and so each experience will not be the same). Assigned female at birth, River* experienced gender dysphoria from a young age and described it as being “always paired with anxiety and shame. Shame for wanting something impossible.” That feeling of shame and anxiety is common in those with GD, with depression and anxiety being highly comorbid (Holt, Skagerberg & Dunsford, 2014).

Stef Sanjati. Credit
So what is it that causes GD? There is a common misconception that it has a lot to do with sexual organs, however studies have found it’s more to do with aspects that are outwardly apparent on first glance – facial features, figure, the way one walks or talks etc. Sexual organs can play a role in GD of course, but much of the body dissatisfaction is less to do with genital dissatisfaction and more to do with characteristics which influence gender recognition. For trans women that was mostly related to voice and hair, whereas in trans men it was muscularity and posture. As a person, you want your insides to match your outside, and in River’s case it was a struggle because to them “it felt like nothing more than dress up. It made sense, but it still wasn’t what I wanted. […] I wanted to be a guy, not a butch lesbian. […] I couldn’t get the outside to change the way I wanted to. […] I was so deeply jealous of androgynous people who could just pass any day of the week they felt like.” The key element to GD is looks, because it’s your looks that defines how you’re perceived in regards to gender. Stef Sanjati highlights this in her Dysphoria video
 “I saw my arms, in the window and I just thought I looked so huge and muscular, and I’m trying really hard to empower myself with my muscularity […] it is very difficult, and a lot of other girl’s experience this too. Especially female athletes because it’s not the image of what women are supposed to be. It’s a gendered thing, women are supposed to be lean, not buff, […] and women that are muscular are considered manly, masculine, ugly, unattractive, Hulk’s, like all this stuff. Obviously, that is not the case, but it is what is in my head and it’s been what’s been force-fed to me as a child. Muscular women are a no-no and I am one of them now and it’s difficult to unlearn that hatred of myself.”

There is a belief that GD is a case of simply dressing up but as stated before it goes beyond that. A literature review found that those with GD attending trans health care services have a higher risk of psychiatric conditions such as depression and anxiety, but they improve following treatment which could include hormone replacement therapy (HRT) or surgery (Dhejne et al., 2016); leading to a change in outward appearance and lessening the effects of dysphoria. These treatments come with risks, ones that can harm their body and yet the dysphoria causes such distress that it can lead a person to decide that changing their biology is the only way, showing just how serious it can be. There is a high prevalence of suicidality in those with GD/trans individuals, something that has been showing up more and more in local media lately. 

Treatment is usually a case of referral to gender clinics or related services, which can result in either talking therapies or HRT, which can eventually lead to surgery, whether its gender reassignment or facial feminization or brazillian butt lifts! (The latter 2 of which Stef Sanjati has had and has documented extensively if you want to have a look!) Sometimes people don't feel they require treatment, and it's simply a case of changing their looks and style, something androgynous people are seen to do since they have the capability to change their looks and be what's considered "passable" (being perceived as cisgender based on looks/social cues).

For those that feel that they may be a little bit of both - unsure of which gender role they fit into, one day they may feel like they identify as male and another day female, this is known as being genderfluid, and the opposite end being non-binary, where you don't feel like you belong in any category and simply are taking a step OUT of the designated labels (The umbrella term being genderqueer for both). There has been a lot of controversy and negative comments towards people who are genderfluid - being called ridiculous and "too PC" and other derogatory comments, but coming from a psychological perspective there is nothing ridiculous about it. The outrage and feelings that people feel about others who have no effect on their own lives are unjustified and silly. 

Ruby Rose: A well known genderfluid celebrity. Credit
Being genderfluid is a result of feeling like you may fit into one category which may be your natal gender - not suffering any dysphoria - and another day having dysphoria and feeling like you are your non-natal gender. The fluidity aspect comes from accepting that the dysphoria isn't there every day and there is a possibility that you may be fine with your assigned gender sometimes, accepting each day as it comes and just trying to fit into each gender identity depending on how you feel. One of the points made by people who seem to disagree is that it's simply playing dress up, because they choose to identify as their natal gender on occasion - however the dysphoria is there for some: there is a distressing aspect there and it exists, and it is something very real as we've discussed. For others it is simply a form of expression - a type of gender expression. For those who are genderfluid they may not feel dysphoria but may feel like it is a part of their identity - something explained by Courtney Act recently on celebrity big brother.

Courtney Act, a popular genderfluid celebrity/drag queen. Credit
Sexuality is something that causes confusion when talking about gender dysphoria because it's something that you can easily figure out if you are certain in your gender, but when talking about someone that may not identify as the gender they were assigned at birth such as natal female, it becomes a question of straightness when being attracted to males. In the end sexuality is something fluid, and if you're attracted to someone regardless of their gender then does it matter what your sexuality is? You may consider yourself straight when you fall in love with a woman, and only find out later that they identify as male and choose to continue the relationship because the attraction is still there, does that make you straight? Well, you're technically in a homosexual relationship but that may not define your future relationships - you may have only "straight" relationships after that. In the end it doesn't matter because sexuality is fluid, there are no clear cut lines, and that's okay, and the sexuality of someone you don't know makes no difference to you, so intrusive questions are generally unwelcomed and should be thought about before being made. Regarding GD, sexuality can be confusing and can add to the general distressing nature of GD which is why it plays into such a huge role in identity - sexuality is a big component of your identity and when several components are being questioned then you can imagine how stressful it can be.

There is still a lot of resistance towards gender identity, especially towards those that don't fit into the boxes that have been assigned already (male/female). Anyone that identifies as being on the outside, or both, have a lot of resistance and are always justifying how they feel: I'd like to remind everyone that just because it doesn't fit into your idea of what gender you feel they should be, that does not give you the right to be rude, whether it's making derogatory comments or try to humiliate them for being who they are. If it isn't affecting you then zip your lip because it wont bring you any good and will only lead to upset and heartache on the other end. It's a sad state of affairs when you have to remind adults to be kind to one another, but that's the world we live in and that's why dysphoria and gender are such difficult topics to discuss.

Be kind to one another and remember, gender isn't the only thing that defines you and everyone around you, if you disagree with someone's gender identity then don't focus on it - it's not causing you any harm (confusion is not harm). Try to understand, be kind, you may learn something and gain a friend.

* Not their real name.

Aitken, M., Steensma, T. D., Blanchard, R., VanderLaan, D. P., Wood, H., Fuentes, A., ... & Leef, J. H. (2015). Evidence for an altered sex ratio in clinic‐referred adolescents with gender dysphoria. The journal of sexual medicine12(3), 756-763.
Van de Grift, T. C., Cohen-Kettenis, P. T., Elaut, E., De Cuypere, G. R. E. T. A., Richter-Appelt, H., Haraldsen, I. R., & Kreukels, B. P. (2016). A network analysis of body satisfaction of people with gender dysphoria. Body image17, 184-190.
Zucker, K. J., Lawrence, A. A., & Kreukels, B. P. (2016). Gender dysphoria in adults. Annual Review of Clinical Psychology12, 217-247.
Dhejne, C., Van Vlerken, R., Heylens, G., & Arcelus, J. (2016). Mental health and gender dysphoria: a review of the literature. International Review of Psychiatry28(1), 44-57.

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