Gender dysphoria

13/07/2011

Gender dysphoria is the distress experienced by those whose gender identity feels at odds with aspects of their birth body.

This can be experienced as physical discomfort and psychological and emotional distress. Social factors are often key in the experience of gender dysphoria.

Biological sex is assigned at birth, depending on the appearance of the genitals. Gender identity is the gender that a person identifies with or feels themselves to be.

Gender identity

People who have long-lasting and extreme gender dysphoria are known as transsexuals.

While biological sex and gender identity are the same for most people, this isn't the case for everyone. For example, some people may have the body of a man, but identify themselves as a woman. Others may not feel they're either male or female.

This mismatch between sex and gender identity can lead to distressing and uncomfortable feelings that are called gender dysphoria. Gender dysphoria is a recognised medical diagnosis, for which intervention is sometimes appropriate. It is not a mental illness.

Some people with gender dysphoria have a strong desire to live according to their gender identity, rather than their biological sex.

Trans terms

Trans people can identify in a variety of terms including Trans, Transsexual, Male/Female, Non-Binary etc .

Some trans people have interventions to make their physical appearance more consistent with their gender identity.

How common is gender dysphoria?

Gender dysphoria is rare. The number of people presenting to services and being diagnosed with it is increasing due to growing public awareness.

Although awareness has increased over recent years, many people with gender dysphoria still face prejudice and misunderstanding.

The prevalence of transgender people in Ireland is difficult to estimate as there is currently no official collection of this data.

It is estimated that 1 in 4,000 people are receiving medical interventions for gender dysphoria. However, there may be many more people with the condition who have yet to seek help. The number of people seeking access to services is steadily increasing. However, not every transgender person wants or needs medical services or interventions.

Gender terminology

Gender dysphoria is complex and can be difficult to understand. It helps to distinguish between the meanings of different gender-related terms.

Gender dysphoria

Discomfort or distress caused by a mismatch between a person’s gender identity and their biological sex assigned at birth

Transsexualism

The desire to live and be accepted as a member of the opposite sex. Usually accompanied by the wish to have treatment to make their physical appearance more consistent with their gender identity

Transvestism

Where a person occasionally wears clothes typically associated with the opposite gender (cross-dressing) for a variety of reasons.

Non-binary

An umbrella term for gender identities that fall outside the gender binary of male or female. This includes individuals whose gender identity is neither exclusively male nor female, a combination of male and female or between or beyond genders.

Similar to the usage of transgender, people under the non-binary umbrella may describe themselves using one or more of a wide variety of terms. See definition of Androgynous, Gender Fluid, Genderqueer, Gender variant.

Gender dysphoria isn't the same as transvestism or cross-dressing. Gender identity and sexual identity are separate issues. People with gender dysphoria may identify as straight, gay, lesbian, bisexual, asexual or pansexual, and this may change with intervention.

Defining gender gysphoria

Gender dysphoria is a complex variant of human behaviour. People who have gender dysphoria may believe that they were born into the wrong body. They often prefer to live as a member of the opposite sex. 

Some transgender people desire to live and be accepted as a member of the opposite sex. Some seek to alter their sex using hormone treatment and surgery.

A person who seeks to undergo, is undergoing or has undergone surgery to alter their sex may be known as:

  • a trans man (female to male)
  • a trans woman (male to female)

13/07/2011

The first signs of gender dysphoria can appear at a very young age. For example, a child may refuse to wear typical boys' or girls' clothes. They might also dislike taking part in typical boys' or girls' games and activities.

In most cases, this type of behaviour is just part of growing up and will pass in time. But for those with gender dysphoria, it continues through childhood and into adulthood.

People with gender dysphoria can feel trapped inside a body that doesn't match their gender identity.

They may feel so unhappy about conforming to societal expectations that they live according to their anatomical sex, rather than the gender they feel themselves to be.

They may also have a strong desire to change or get rid of physical signs of their biological sex, such as facial hair or breasts.

Physical signs

There are no physical signs, but people with gender dysphoria may experience and display a range of feelings and behaviours.

In many cases, a person with gender dysphoria begins to feel a mismatch between their biological sex and gender identity during early childhood. For others, this may not happen until puberty, adolescence or adulthood.

Children with gender dysphoria

Gender dysphoria behaviours in children can include:

  • insisting they're of the opposite sex
  • disliking or refusing to wear clothes that are typically worn by their sex
  • wanting to wear clothes typically worn by the opposite sex
  • disliking or refusing to take part in activities and games that are typically associated with their sex
  • wanting to take part in activities and games typically associated with the opposite sex
  • preferring to play with children of the opposite biological sex
  • disliking or refusing to pass urine as other members of their biological sex usually do
  • insisting or hoping their genitals will change
  • feeling extreme distress at the physical changes of puberty

Children with gender dysphoria may display some, or all, of these behaviours. Behaviours such as these can be part of childhood and don't necessarily mean your child has gender dysphoria. Many girls behave in a way that can be described as tomboyish, which is often seen as part of normal female development. It's also not uncommon for boys to role play as girls and dress up in their mother's or sister's clothes. This is usually just a phase.

Most children who behave in these ways don't have gender dysphoria. Only in rare cases does the behaviour continue into the teenage years and adulthood.

Teenagers and adults

The feelings of gender dysphoria might still be there when your child is a teenager or adult. If so, it's likely that they're not just going through a phase.

If you are a teenager or an adult whose feelings of gender dysphoria began in childhood, you may now have a much clearer sense of your gender identity and how you want to deal with it.

The way gender dysphoria affects teenagers and adults is different to the way it affects children. If you're a teenager or adult with gender dysphoria, you may feel:

  • without doubt that your gender identity is at odds with your biological sex
  • comfortable only when in your preferred gender identity
  • a strong desire to hide or be rid of the physical signs of your sex
  • a strong dislike for – and a strong desire to change or be rid of – the genitalia of your biological sex

Without help and support, some may try to suppress their feelings and try to live the life of their biological sex. But most people are unable to keep this up.

Suppressing these feelings is often very difficult to deal with. As a result, some people with gender dysphoria experience depression, self-harm or suicidal thoughts. It is important to access mental health care in these instances.

13/07/2011

The exact cause of gender dysphoria is unknown and there is much debate over the possible causes of gender dysphoria.

Causes of gender dysphoria most likely involve a number of different factors. Recent studies have suggested that there may be biological causes associated with the development of gender identity before birth.

More research is needed before the causes of gender dysphoria can be fully understood.

Typical gender development

Much of the crucial gender development that determines your gender identity happens in the womb. To understand how gender identity can be affected by development in the womb, it is necessary to know how it normally works.

Your sex is determined by chromosomes. Chromosomes are the parts of a cell that contain genes (units of genetic material that determine your characteristics). You have two sex chromosomes: one from your mother and one from your father.

During early pregnancy, all unborn babies are female because only the female sex chromosome (the X chromosome) that is inherited from the mother is active. At the eighth week of gestation, the sex chromosome that is inherited from the father becomes active, which can be either an X chromosome (female) or a Y chromosome (male).

If the sex chromosome that is inherited from the father is X, the unborn baby (foetus) will continue to develop as female with a surge of female hormones. The female hormones work in harmony on the brain, gonads (sex organs), genitals and reproductive organs, so that the sex and gender are both female.

If the sex chromosome that is inherited from the father is Y, the foetus will go on to develop as male. The Y chromosome causes a surge of testosterone and other male hormones, which initiates the development of male characteristics, such as testes. The testosterone and other hormones work in harmony on the brain, gonads (sex organs) and genitals, so that the sex and gender are both male.

Therefore, in most cases, a female baby has XX chromosomes and a male baby has XY chromosomes.

Changes to gender development

Gender development is complex and there are many possible variations that can cause confusion between a person's sex, and gender identity. Some examples of the possible variations are outlined below. However, it is important to remember that these are not yet fully understood.

Malfunctioning hormones

In rare cases, the hormones that trigger the development of sex and gender may not work properly on the brain, gonads and genitals, causing variations between them. For example, the sex (as determined physically by the gonads and genitals) could be male, while the gender (as determined by the brain) could be female.

This could be caused by additional hormones in the mother's system or by the foetus's insensitivity to the hormones, known as androgen insensitivity syndrome (AIS). In this way, gender dysphoria may be caused by hormones not working properly within the womb.

Other rare conditions

Other rare conditions, such as congenital adrenal hyperplasia (CAH), and intersex conditions (also known as hermaphroditism) may also result in gender dysphoria.

In CAH, a female foetus's adrenal glands (two small, triangular-shaped glands located above the kidneys) cause a high level of male hormones to be produced. This enlarges the female genitals. In some cases, they may be so enlarged that the baby is thought to be male when she is born.

Intersex conditions cause babies to be born with the genitalia of both sexes (or ambiguous genitalia). In such cases, it was recommended that the child's parents should choose which gender to bring up their child. However, it is now thought to be better to wait until the child can choose their own gender identity before any surgery is carried out to confirm it.

13/07/2011

If you think that you or your child may have gender dysphoria, ask your GP about a referral.

There are strict criteria for diagnosing gender dysphoria, which are different for children and adults. Due to the fact that gender dysphoria is complex, a comprehensive assessment is carried out. This considers more than the diagnostic criteria. Each case of gender dysphoria is unique and should be treated as such.

Criteria for children

To be diagnosed with gender dysphoria, a child should experience the following for at least 6 months:

1. Want to be the same sex
Repeatedly insist they want to be the opposite sex, or they are the opposite sex, and behave as the opposite sex. This must not be just because they want the supposed advantages of being the opposite sex.

2. Dislike of certain clothes
Dislike or refuse to wear clothes typically worn by their sex and insist on wearing clothes typically worn by the opposite sex. Or show dislike or unhappiness with their genitalia and insist that it will change into that of the opposite sex. For example, refusing to pass urine as members of their sex usually do.

3. Puberty
Have not yet reached puberty.

Criteria for teenagers and adults

To be diagnosed with gender dysphoria, a teenager or adult should:

1. Feel they are the wrong sex
Feel persistently and strongly that they are the wrong sex and feel a strong identification with the opposite sex

2. Feel discomfort in their sex
Feel discomfort in their sex and its gender role and strongly dislike and wish to be rid of the physical characteristics of their sex, such as breasts, facial and body hair and genitalia

3. Physical attributes
Not have a condition that causes them to display physical attributes of the opposite sex (although this is being increasingly questioned)

4. Experience distress
Experience impairment at home, school, socially or in occupational areas of life due to the level of distress from dysphoria

5. Experience anxiety
Experience long-term anxiety, distress and impairment in social and occupational areas of life due to their condition

Assessment

As well as these criteria, a diagnosis of gender dysphoria will depend on a full and highly personalised assessment of the teenager or adults gender identity.

Your gender development in childhood and puberty will be assessed, or your child's gender development in earlier childhood.

The level of cross-gender identification or gender fluidity will be considered. Other relevant aspects of life will be explored.. The assessment may indicate a need for intervention to address co-occurring medical, psychological or social issues identified which need to be addressed.

13/07/2011

Treatment for gender dysphoria aims to help people with the condition live the way they want to in their preferred gender identity. What this means will vary from person to person, and some people will need more treatment than others.

Once you or your child has been diagnosed with gender dysphoria, different treatments can be considered. Counselling (a talking therapy) should be offered to you or your child about the range of available treatment options and their implications.

The various treatments for children and adults with gender dysphoria are detailed below.

Treatment for children

If your child is under 18 years of age, they should be referred to a specialist child and adolescent psychiatrist. These clinics can offer ongoing assessment for children with gender dysphoria, and specialised treatment and support for children and their families. Your child will be fully assessed before any treatment begins.

Your child's treatment should be arranged with a multi-disciplinary team (MDT), a team of different healthcare professionals working together. Your child's MDT may include:

  • a mental health professional, who is trained in dealing with gender dysphoria in children and teenagers
  • a paediatric endocrinologist, a specialist in hormone conditions in children

Children before puberty

If your child is diagnosed with gender dysphoria before they reach puberty (when a child progresses into a sexually developed adult), they will not receive endocrine treatment. Endocrine treatment is treatment with hormones (powerful chemicals). It is the first step to developing the physical signs of your preferred gender.

Guidelines from the Endocrine Society in the UK do not recommend endocrine treatment for young children because a diagnosis of transsexualism cannot be made before a child has reached puberty. Transsexualism is a life-long and extreme form of gender dysphoria, when someone seeks to change their sex.

The Endocrine Society found that 75-80% of children who were diagnosed with gender dysphoria before they reached puberty did not have the condition after puberty. Therefore, endocrine treatment is not recommended until after puberty, when a diagnosis of gender dysphoria can be confirmed.

Children up to 16

If your child has been diagnosed with transexualism and they have reached puberty, they may be treated with gonadotrophin-releasing hormone (GnRH) analogues. These are synthetic (manmade) hormones that suppress the hormones naturally produced by your body.

The recommendation for endocrine treatment must come from a mental health professional, and they must continue to be part of your child's ongoing care. An endocrinologist (a specialist in hormonal conditions) must also confirm your child's diagnosis.

Puberty is divided into stages. These are called Tanner stages, named after James Mourilyan Tanner who first identified them. GnRH analogues may be suitable for children who have reached Tanner stage two, which means a number of physical changes have taken place, such as pubic hair starting to grow. In girls, this is around 11 years of age and in boys it is around 12 years of age.

Some of the changes that take place during puberty are driven by hormones. For example, the hormone testosterone, which is produced by the testes in boys, helps stimulate the development of the penis. As GnRH analogues suppress the hormones that are produced by your child's body, they also suppress puberty.  

GnRH analogues can be taken until your child reaches 16 years of age, after which cross-sex hormones can be taken (see below). 

Children over 16

If your child has been taking GnRH analogues for several years and are still diagnosed as transsexual, they may be offered cross-sex hormones. These can alter your child's body further to fit with their gender identity. The effects of these hormones are only partially reversible, so they are not offered to children who are under 16 years of age.

Once your child reaches adulthood at 18 years of age, they can begin the process of gender confirmation surgery, which will change their gender irreversibly (also known as transition). Not all children who experience gender dysphoria will go on to transition. In fact, the number of children who go on to become transsexuals is very small.

For more information about cross-sex hormone treatment and gender confirmation surgery, see the section below about treatment for adults.

The amount of treatment that your child has will depend on how strong and long-lasting their feelings of gender dysphoria are. However, all children and their families should be offered counselling and support through their gender identity clinic.

Treatment for adults

Adults who have been diagnosed with gender dysphoria and transsexuals should be referred to a specialist gender identity psychiatrist. They can offer ongoing assessment for people with gender dysphoria. They can also provide support and advice about living in your preferred gender role, including:

  • mental health support
  • hormone treatment
  • ways to dress in your preferred gender role
  • ways to behave in your preferred gender role 
  • language and speech therapy
  • hair removal treatments
  • peer support groups to meet other people with gender dysphoria
  • relatives' support groups for your family

For some people, support and advice from a clinic are all they need to feel comfortable in their gender identity. However, others will need more extensive treatment, such as a full transition from one sex to the other. The amount and extent of treatment you have is completely up to you.

Once you have been referred to a gender identity clinic, it is likely that you will have another full assessment, for a period of approximately three months. This will usually be with the input of a psychiatrist (a doctor who treats mental and emotional health conditions). This assessment is necessary to confirm your diagnosis and, if you want to have hormone therapy, means that you can take the necessary health tests first.

Cross-sex hormone therapy

Cross-sex hormone therapy means taking the hormones of your preferred gender:

  • a trans man (female becoming a male) will take testosterone
  • a trans woman (male becoming a female) will take oestrogen

The aim of hormone therapy is to make you more comfortable with yourself, both in your physical appearance and how you feel psychologically (mentally). These hormones start the process of changing your body into one that is more female or more male, depending on your gender identity.

Hormone therapy may be all the treatment you need to live with your gender dysphoria. The hormones may improve how you feel and mean that you do not need to start living in your preferred gender or have surgery.

Trans woman

If you are a trans woman, some of the changes that you may notice from hormone therapy include:

  • your penis and testicles may get smaller
  • you may have less muscle
  • you may have more fat on your hips
  • your breasts may become lumpy and may increase in size slightly
  • you may have less facial and body hair

Hormone therapy will not affect the voice of a trans woman. To make the voice higher, trans women will need vocal therapy and possibly vocal cord or trachea (windpipe) surgery. Hormone therapy may make it harder to get an erection and have an orgasm.

Trans man

If you are a trans man, some of the changes that you may notice from hormone therapy include:

  • you may have more body and facial hair
  • you may have more muscle
  • your clitoris (a small, sensitive part of the female genitals) may get bigger
  • your periods may stop
  • you may have an increased sex drive (libido)

Hormone therapy can also cause baldness and acne in trans men. Your voice may get slightly deeper, but it will not be as deep as other men's voices.

Monitoring

While you are taking these hormones, you will need to go for regular check-ups at your gender identity clinic. You will be assessed to find out whether the hormone treatment is benefiting you, as some people may find the effects of hormone treatment unpleasant.

If you do not think that hormone treatment is right for you, discuss it with the healthcare professionals who are treating you. If necessary, you can stop taking the hormones, although some changes are irreversible such as:

  • a deeper voice in trans men
  • breast growth in trans women

Alternatively, you may be frustrated with how long hormone therapy takes to produce results, as it can take a few months for some changes to develop. Hormones cannot change the shape of your skeleton, for example how wide your shoulders or your hips are. It also cannot change your height.

Hormones for gender dysphoria are also available from other sources, such as the internet, and it may be tempting to get them from here instead of through your clinic. However, hormones from other sources may not be licensed and, therefore, may not be safe. If you decide to use these hormones, let your clinic know so that they can monitor you.

Real life experience (RLE)

If you want to have gender confirmation surgery, you will first need to live in your preferred gender identity full time for at least a year. This is known as real life experience (RLE) and will help confirm that permanent surgery is the right decision.

Once your hormone treatment is under way, you can start as soon as you are ready with the support of your clinic. The length of RLE varies from person to person, but is usually between one and two years.

You may have various other surgical treatments during your RLE to prepare for full transition surgery, including:

  • mastectomy (removal of the breasts) for trans men
  • mammoplasty (cosmetic breast surgery) for trans women
  • feminising facial surgery for trans women

Trans women should continue with hormone therapy for at least 18 months before having a mammoplasty to ensure that the treatment has had the maximum effect on the development of the breasts.

Gender confirmation surgery

Once you have completed your RLE and you and your multi-disciplinary team (MDT) feel that you are ready, you may decide to have surgery to permanently alter your sex.

Trans man surgery

For trans men, surgery may involve:

  • a hysterectomy (removal of the womb)
  • a salpingo-oophorectomy (removal of the fallopian tubes and ovaries)
  • construction of a penis using a phalloplasty or a metoidioplasty

A phalloplasty uses the existing vaginal tissue and skin taken from the inner forearm to create a penis. A metoidioplasty involves creating a penis from the clitoris, which has been enlarged through hormone therapy.

The aim of this type of surgery is to create a functioning penis, which allows you to pass urine standing up and to retain sexual sensation. You may need to have more than one operation to achieve this.

Trans woman surgery

For trans women, surgery may involve:

  • an orchidectomy (removal of the testes)
  • a penectomy (removal of the penis)
  • construction of a vagina from the leftover tissue of the penis (known as a vaginoplasty)

The vagina is created and lined with skin from the penis, and tissue from the scrotum (the sack that holds the testes) is used to create the labia. The urethra (urine tube) is shortened and repositioned. The aim of this type of surgery is to create a functioning vagina with an acceptable appearance and retained sexual sensation.

After surgery

After surgery, the vast majority of transsexuals are happy with their new sex and feel comfortable with their gender identity. One review of a number of studies that were carried out over the last 20 years found that 96% of people who had gender reassignment surgery were satisfied. However, some of these studies may not have been of high quality.

Following gender confirmation surgery, one possible complication is that people may face prejudice or discrimination because of their condition. Treatment can sometimes leave people feeling:

  • isolated if they are not with people who understand what they are going through
  • stressed about or afraid of not being accepted socially
  • discriminated against at work

Sexual orientation

Once transition has been completed, it is possible for a trans man or woman to experience a change of sexual orientation. For example, a trans woman who was attracted to women before surgery may be attracted to men after surgery. However, this varies greatly from person to person, and the sexual orientation of many transsexuals does not change after transition.

If you are a transsexual going through the process of transition, you may not know what your sexual preference will be until it is complete. However, try not to let this worry you. For many people, the issue of sexual orientation is secondary to the process of transition itself.

Gender
In this article, gender refers to the feeling of being either male or female.

Gender dysphoria
A condition that describes the feeling of being trapped in a body of the wrong sex.

Gender identity
Gender identity is your personal sense of knowing which gender you belong to, or the way that you see yourself.

Hormones
Hormones are groups of powerful chemicals that are produced by the body and have a wide range of effects.

Ovaries
The ovaries are two small, round organs in the female reproductive system that release an egg every month.

Sex
In this article, sex refers to male or female, the biological sex that you were born with.

Testicles (testes)
The testicles are part of the male reproductive system. They produce sperm and are located within the scrotum (a loose bag of skin) hanging down behind the penis.

Transsexual
A transsexual is someone with an extreme and long-term case of gender dysphoria, who seeks to alter their biological sex to match their gender identity.

Vagina
The vagina is a tube of muscle that runs from the cervix (the opening of the womb) to the vulva (the external sexual organs).

Womb
The uterus (or womb) is a hollow, pear-shaped organ in a woman where a baby grows during pregnancy.

13/12/2017

Treatment for gender dysphoria aims to help people become content with their gender identity. This can mean different things for different people. For some people it can mean dressing and living as their preferred gender. For others, it can mean taking hormones that change their physical appearance. Some transgender people seek to have surgery to permanently alter their biological sex.

The aim of intervention

Interventions aim to help people with the condition live the way they want to, in their preferred gender identity.

What this means will vary from person to person, and is different for children, young people and adults. Your team will work with you on an individualised plan tailored to identify your needs.

The HSE is currently developing a transgender model of care to improve services for people with gender dysphoria. The information here relates to the current system and will be subject to change over time.

Social transition

For genital reconstructive surgery, you'll usually need to live in your preferred gender identity full time for at least a year. This is known as social transition (real life experience or RLE). It will help confirm if permanent surgery is the right option.

You can start your social transition as soon as you're ready, after discussing it with your medical professional. They can offer support throughout the process.

The recommended length of the transition period can vary, but it's usually 1 to 2 years. This will allow time for a range of experiences in your preferred gender identity, for example, holidays and family events.

You may not need to complete the entire transition period before having the operation. For example, for surgery such as a bilateral mastectomy (removal of both breasts) in trans men.

Intervention for pubertal children

The child and the family should talk to their GP. In some instances, the GP may make a referral to the CAMHS (Child and Adolescent Mental Health Service) team.

The GP may also:

  • refer to TransParenCI, a national transgender family support group
  • refer to TENI, the national support group for Transgender People
  • provide ongoing monitoring of the child’s situation.

CAMHS

Some CAMHS teams only accept referrals if significant co-morbid mental health concerns are present

If CAMHS do not accept the referral, they may be able to signpost to other local services which might be more appropriate in the first.

Once an adolescent has been accepted by a CAMHS service, the family of the young person can apply to the Treatment Abroad Scheme (TAS). This can lead to specialist input from the Gender Identity Development Service, Tavistock and Portman NHS Trust.

Intervention for adults

For a diagnosis of gender dysphoria, talk to your GP.

The GP may refer you to your local community mental health team for support and a diagnosis. You will need an assessment if you want to start hormone suppressants in Ireland.

The GP may also refer you to a consultant endocrinologist in Dublin. A diagnosis of gender dysphoria is required by the endocrine services in order to begin hormone treatment. Referrals to both the community mental health services and the Endocrinology services are recommended.

The GP may also refer you to the local acute hospital for a DEXA scan. This will examine baseline bone density before the first endocrinology appointment. This report must accompany the patient when they attend their first endocrinology appointment.

You will need to have a full blood check (including FSH/LSH) before you attend your first endocrinology appointment.

Transition support

If you are unsure about transitioning or do not want to transition, but you want some support, the GP may:

  • refer you for psychotherapy or counselling to explore your gender identity or expression
  • refer you to a local transgender support group
  • begin ongoing monitoring of your situation

Psychotherapy or counselling

If you are experiencing anxiety due to reactions from family and friends, your GP might recommend psychotherapy or counselling.

If you have a medical card, the GP may recommend the HSE Counselling in Primary Care (CIPC).

You can also request a referral to local HSE Speech and Language services.

13/12/2017

There are two types of hormone intervention:

  1. puberty suppressing hormones, sometimes known as blockers or hormone blockers
  2. cross-sex hormones, oestrogen or testosterone

Puberty suppressing hormones may be prescribed to pause puberty and allow further time for exploration of gender identity.

Hormone therapy for adults means taking the hormones of your preferred gender:

  • a trans man (female to male) will take testosterone (masculinising hormones)
  • a trans woman (male to female) will take oestrogen (feminising hormones)

The aim of hormone therapy is to make you more comfortable with yourself. In your physical appearance and how you feel.

These hormones start the process of changing your body into one that is more female or more male. They usually need to be taken indefinitely, even if you have genital reconstructive surgery.

Some people are satisfied with the effects of hormones and do not wish to pursue other interventions.

Changes in trans women

If you're a trans woman, changes that you may notice from hormone therapy include:

  • your penis and testicles getting smaller
  • less muscle
  • more fat on your hips
  • your breasts becoming lumpy and increasing in size slightly
  • less facial and body hair

Hormone therapy won't affect the voice of a trans woman. To make the voice higher, trans women will need speech and language therapy and, rarely, voice modifying surgery.

Changes in trans men

If you're a trans man, changes you may notice from hormone therapy include:

  • more body and facial hair
  • more muscle
  • your clitoris (a small, sensitive part of the female genitals) getting bigger
  • your periods stopping
  • an increased sex drive (libido)

Your voice may also get slightly deeper, but it may not be as deep as other men’s voices.

Monitoring

While you're taking these hormones, you'll need to have regular physical health checks. Ongoing psychological assessment is also advised. You'll be assessed, to check for any signs of possible health problems and to find out if the hormone treatment is working.

If you don't think that hormone treatment is working, talk to the healthcare professionals who are treating you. If necessary, you can stop taking the hormones (although some changes are irreversible, such as a deeper voice in trans men and breast growth in trans women).

You may be frustrated with how long hormone therapy takes to produce results. It will take a few months for some changes to develop. Hormones can't change the shape of your skeleton, such as how wide your shoulders or your hips are. It also can't change your height.

Hormones for gender dysphoria are also available from other sources, such as the internet. It may be tempting to get them from here instead of from a medical doctor in Ireland. However, hormones from other sources may not be licensed and the incorrect dose may be taken. This can lead to significant side effects. If you decide to use these hormones, let your doctors know so they can monitor you.

13/12/2017

You may decide to have surgery to permanently alter your sex. You should only do this if you've completed your social transition and you and your care team feels you're ready.

The most common options are discussed below. You can talk to members of your team and the surgeon at your consultation about the full range available.

Trans man surgery

For trans men, surgery may involve:

  • a bilateral mastectomy (removal of both breasts, also known as ‘top-surgery’)
  • a hysterectomy (removal of the womb)
  • a salpingo-oophorectomy (removal of the fallopian tubes and ovaries)
  • phalloplasty or metoidioplasty (construction of a penis)
  • scrotoplasty (construction of a scrotum) and testicular implants
  • a penile implant

A phalloplasty uses the existing vaginal tissue and skin taken from the inner forearm or lower abdominal wall to create a penis. A metoidioplasty involves creating a penis from the clitoris, which has been enlarged through hormone therapy.

The aim of this type of surgery is to create a functioning penis, which allows you to pass urine standing up and to retain sexual sensation. You'll usually need to have more than one operation to achieve this.

Trans woman surgery

For trans women, surgery may involve:

  • an orchidectomy (removal of the testes)
  • a penectomy (removal of the penis)
  • vaginoplasty (construction of a vagina)
  • vulvoplasty (construction of the vulva)
  • clitoroplasty (construction of a clitoris with sensation)
  • breast implants

The vagina is usually created and lined with skin from the penis, with tissue from the scrotum (the sack that holds the testes) used to create the labia. The urethra (urine tube) is shortened and repositioned. A piece of bowel may be used if hormone therapy has caused the penis and scrotum to shrink.

The surgery aims to create a functioning vagina with an acceptable appearance and retained sexual sensation.

Some trans women can't have a full vaginoplasty for medical reasons, or may not want to have a functioning vagina. In such cases, a cosmetic vulvoplasty and clitoroplasty is an option, as well as removing the testes and penis.

After surgery

After surgery, most trans women and men are happy with their new sex and feel comfortable with their gender identity. One review of a number of studies that were carried out over a 20-year period found that 96% of people who had genital reconstructive surgery were satisfied.

Despite high levels of personal satisfaction, people who have had genital reconstructive surgery may face prejudice or discrimination because of their condition.

Intervention can sometimes leave people feeling:

  • isolated, if they're not with people who understand what they're going through
  • stressed about or afraid of not being accepted socially
  • discriminated against at work

There are legal safeguards to protect against discrimination, but other types of prejudice may be harder to deal with. If you're feeling anxious or depressed since having your intervention, speak to your GP or a healthcare professional at your clinic.

Sexual orientation

Once transition has been completed, it's possible for a trans man or woman to experience a change of sexual orientation. For example, a trans woman who was attracted to women before surgery may be attracted to men after surgery. However, this varies greatly from person to person and the sexual orientation of many trans people doesn't change.

Gender dysphoria isn't the same as transvestism or cross-dressing and isn't related to sexual orientation. People with gender dysphoria may identify as straight, gay, lesbian, bisexual or asexual, and this may change with intervention. However, try not to let this worry you. For many people, the issue of sexual orientation is secondary to the process of transition itself.

Content provided by NHS Choices www.nhs.uk and adapted for Ireland by the Health A-Z.

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