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Gender Identity

Gender Dysphoria History

Louise D.
Gender Dysphoria
Dr.James Barry (1789/1795-1865)

Gender dysphoria is by no means a new concept, contrary to popular belief. In fact, the concept might date as far back as 1503 BC when a queen of Egypt dressed and lived mainly as a man throughout her reign. By 30BC a Jewish philosopher by the name of Philo wrote about gender dysphoria.

There are unconfirmed tales of a Pope by the name of John Anglicus who was actually physically female. Charlotte Clarke was one of the first confirmed cases of a transgender individual which came to light when she published her memoir in 1755.

In 1769, the Californian Indian cultural third gender of the joyas is discovered and recorded. In 1865, an esteemed military surgeon by the name of Dr. James Barry dies and it is discovered that he has female primary sex characteristics. He has been passing as a male since 1809.

By 1912 some of the first rudimentary and incomplete sex reassignment surgeries for female-to-male patients are performed in Berlin.

In the 1920s a formal classification for gender dysphoria is made by a surgeon who performed some of the first recorded male-to-female genital surgery procedures. He claimed to have done so only to ease concerns that the patients might otherwise self-mutilate.

In the 1930s more published articles are appearing. In 1931 the first recorded complete surgery is performed. The same year that Lili Elbe died of complications following an attempt the year before.

In 1933 Nazis burn important anthologies related to sexology research. Due to the rise of Nazi Germany, research in this area slows significantly.

In 1944, ten years later, Dr Harold Gillies performs surgery on Michael Dillon. It is a fundamental advancement for FTM surgical procedures.

1949 – Sees hormone therapy provided to transgender individuals.

1952 – Sees a New York Daily News article about the sex reassignment surgery of Christine Jorgensen. She was accepted by her parents (her father even had a house built for her), joined a Lutheran church with a fiance, but was not able to marry him because her birth certificate listed her as male.

Gender Dysphoria
Christine Jorgensen

1968 –  The DSM-III includes its first failed attempt at gender identity disorders (in this case specifically aimed at homosexuality).

1970s – Sees an increase in private surgeons performing SRS on transgender patients.

1972 – The American Medical Association officially lists SRS as a treatment for gender dysphoria.

1973 – Norman Fisk coins the term ‘Gender Dysphoria Syndrome’.

1979 – Sees the birth of the World Professional association for transgender health.

1980s – Transsexualism is in the DSM-III and is renamed Gender Identity Disorder in the DSM-IV.

1992 – Press For Change is born.

1998 – Sees the first transgender character on TV in Coronation Street.

1999 – Focus of gender dysphoria moves further from psychology and more into medicine.

Since then there has been an even bigger social movement in support of the transgender population, which continues to grow and evolve as society moves forward.

Gender Dysphoria

Gender Dysphoria in Health Care

It seems like gender dysphoria first became a health care concern around the early 1900s, and this is also when attempts at treatments began. Although crude and rudimentary in the beginning there seems to have been a huge surge in refinement in the last 50 or so years, as is the case with most medical procedures.

The late 1960s and throughout the 1970s was the pinnacle of concern by mental health professionals over gender dysphoria, but more recent years have seen a complete shift away from attempts to make gender issues diagnosable mental health disorders. Although this was not necessarily a malicious attempt, it did pave the way for some very problematic situations for the transgender community.

A major criticism of history related to gender dysphoria falls within the fact that most history over the last 100 to 150 years has focused on two factors: Firstly, trying to find a cause for gender dysphoria with either the parent or the child, and secondly, treating hypotheses on the basis that gender dysphoria is a problem that requires a solution or cure. These two factors, either in isolation or collaboration have resulted in some dangerous paths that mental health professionals have found themselves following.

Luckily the recent shift away from psychiatric interventions related to ‘curing’ gender identity issues and rather placing focus on treating psychiatric comorbidity has had a largely positive effect on the current situation. Gender affirming hormone therapy for gender identity issues is now the norm for transgender health, and it is no longer seen as a psychological disorder, but rather something more than that which can cause psychological distress if not addressed properly.

Gender Identity

The normalizing of human sexuality and medical care for addressing gender expression issues has made gender transition much simpler and easier to come by in the modern world. But as we well know, it was not always this way.

Issues related to gender identity tend to appear very early on in life, and a major source of stress can be the development of secondary sex characteristics during puberty. For example, things like breast growth, increased body hair and deepening of the voice, all of which can easily be addressed with hormone therapy. Hormone therapy is a very good way to suppress natural male and female hormones by administering carefully calculated doses of alternative hormones.

Although there tends to be an increased risk of high blood pressure with hormone therapy, it needs to be weighed against the increased risk of suicide or severe psychological distress related to not addressing gender dysphoria.

Gender Identity Disorder

We have come a long way from when Gender Identity Disorder was a mental disorder, which was not that long ago, to where we are today. Mental health professionals today understand that gender identity issues are not mental disorders, and any anxiety or dysphoria associated with gender identity can be addressed with gender reassignment surgery and hormone therapy.

A Gender Identity Disorder diagnosis is no longer made today, although gender dysphoria can still be diagnosed it is usually done to allow for hormone therapy to begin and is monitored to make sure that support interventions are being successfully implemented.

Sexual Orientation

Attempts to classify any sexual orientation as a mental health condition have been entirely abandoned and are now actively contraindicated by mental health professional associations. Social support is widespread and transgender people are actively seen as valued members of society. However, there is still widespread bias and discrimination in most societies. While social support is more readily available and much of gender identity has been normalized there is still much room for improvement when it comes to transgender equality and the rights of transgender people.

Sexual orientation is not the same as what is experienced by gender-nonconforming people. There is a difference between what we are attracted to in other people and the identified gender we feel within ourselves. Any person from any sexual orientation can experience gender incongruence, but the two are not mutually exclusive.

Gender Affirming Hormone Therapy

Usually, the first step in addressing dysphoria associated with sex assigned at birth is to explore the implementation of a hormone regimen to begin physical changes to secondary sex characteristics so that a patient’s gender identity is more congruent with their preferred gender identity.

While gender-affirming hormone therapy is an integral part of transgender health and it mainly addresses secondary sex characteristics, it is the first step towards eventual gender-affirming surgery.

As mentioned earlier, the implementation of a hormone regimen can usually be done as early as some time before puberty. But there are still many benefits to starting hormone therapy later in life as well.

You will necessarily have to already be on hormone therapy before discussions about surgical procedures can begin. As it stands, more and more health insurance providers are also starting to cover hormone therapy to affect things like breast development. Facilitating desired physical changes in transgender youth ends up being a protective factor again psychiatric comorbidities later down the line.

Gender Affirming Surgery

For a long time consultation with a mental health professional was a prerequisite before any psychical transition surgeries could be discussed to address gender incongruence in gender-nonconforming people. Recently, however, it is no longer such a strict requirement.

Hormonal and surgical treatments are advancing all the time and transgender youth are pushing this advancement further along with adult transgender people. More and more people are able to alter their sex assigned at birth when their gender identity differs so that their physical bodies can better match their identified gender.

There are a great many surgical options available to transgender individuals. Anything from breast augmentation surgery to genital surgeries is being performed daily around the world, and it all works together with sustained hormone therapy.

Transgender Health

Sadly, even with all the advancements made transgender populations are still at higher risk of mental illness and struggle to find mental health care due to a number of reasons that work together to disadvantage the population.

While hormone therapy addresses important things like breast development, facial hair growth, and body hair growth it can have a negative effect on emotions and might need to be adjusted several times before an ideal dose can be found that works well for the individual. Hormone therapy is a thing that requires sensitive calibration which varies from one individual to the next.

Many people who identify as transgender can also struggle with mood disorders or even sexual orientation. They also can experience distress at things that are considered ‘normal physical changes’ within their bodies. While things like laser hair removal and other rudimentary treatments can help alleviate distress, we still need to make sure that transgender people receive the mental health care that they need. Hormone therapy on its own is not enough and many benefits greatly from counseling.

It, of course, helps to receive therapy from someone who knows how hormone therapy works and who can talk about a physical transition, sexual function after surgery and other issues like decreased libido due to gender incongruence.

What is very promising in this regard is what organizations like the American Psychiatric Association actively urge support and equality for transgender populations. This, in itself, has increased access to hormone therapy significantly.

Transition Timelines

Firstly we need to make it clear that SRS is generally not performed on children, even though children can be allowed to start hormone therapy under certain circumstances.

SRS can be performed in adolescents under very specific circumstances but is generally not very common. It is very common for hormone therapy to start in adolescence and continue indefinitely. Hormone therapy is what ‘sets the scene’ for surgery, so there will be a minimum time period that you will have had to be receiving hormone therapy before surgery is considered.

The biggest factors in delays of transition timelines are usually attributed to financial barriers or there simply not being enough qualified surgeons to meet the demand.

There are also several supporting documentation that surgeons require before attempting surgery. These can take a while to obtain and while this can be frustrating the venture is supported by the World Professional Association For Transgender Health. There might even be a minimum time requirement for both psychological counseling and hormone therapy.

One of the earliest official steps you will take is a social transition, where you will live as your preferred gender for a period of time. Preferably full-time.

The ideal timeline for hormone therapy sees the most changes optimizing by 2 years on hormone therapy, with the final changes finalizing within 5 years of starting hormone therapy.

The full timeline is greatly depending on the individual, however, the process will likely be similar for everyone. Social transition happens first, then hormone therapy and counseling. There is then a preparation period before surgery. Top surgery usually happens first. Recovery takes, on average, a maximum of 2 years. Hormone therapy continues during this time.

You will then need to continue living with only top surgery for a period of time while on hormone therapy before discussion for further surgery will begin if you wish to undergo any further surgery. Remember there is always a possibility for a need for additional surgeries.

The timeline for bottom surgeries is similar and often requires more preparation and several surgeries to complete. Initial recovery periods range from 6-8 weeks, but most bottom surgeries then have an optimization period during which more internal healing occurs. You will continue with hormone therapy even after completing the surgical components of the transition.

Any attempt at the surgery will need to adhere to World Professional Association for Transgender Health guidelines.

Gender Dysphoria

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