Introduction:
A person with gender dysphoria experiences anxiety, uncertainty or persistently uncomfortable feelings about their birth gender.

They feel that they have a gender identity that is different from their anatomical sex. This may lead to a fear of expressing their feelings and a fear of rejection, which may lead to deep anxiety, leading to chronic depression and possibly attempted suicide.

Sometimes a person, with gender dysphoria, undergoes hormone and surgical treatment to physically change their sex. This is called transsexualism.

It is often reported that approximately 1 in 30,000 adult genetic males and 1 in 100,000 genetic females seek to change their sex. However these figures are now generally accepted to be far too low.

Positive publicity has meant that many more people feel that they can now express their transsexual feelings.

The Gender Recognition Act 2004 came into force on 4 April 2005. The law now recognises a change of gender ('the acquired gender') as being a person's gender for all legal purposes.

If the person who has changed gender has an entry in a UK birth register, they are entitled to have a new entry showing their acquired gender. They are also entitled to have a new birth certificate reflecting their aquired gender.

Symptoms:
In childhood, boys may show an interest in traditionally feminine activities and girls may display tomboy behaviour; they may express a desire to be the opposite sex.

A few of these children continue to have these feelings into adolescence, however most boys and girls with gender identity uncertainty outgrow their wish to change sex and gender. In a few cases these feelings continue and so the physical effects of puberty can be very distressing and confusing.

Young adults with gender dysphoria may try to relieve increasing feelings of gender anxiety by getting married and trying to live in their birth sex. They may try counselling or therapy to help them cope with their confusion and discomfort. Others will seek gender reassignment surgery.

Gender identity is quite separate from sexual orientation (whether someone is attracted to men or women). People with gender dysphoria may be heterosexual, homosexual or bisexual. Sexual orientation can however change after hormone and surgical treatment. For example a male to female transsexual person attracted to woman prior to surgery may find they are attracted to men after surgery.

Transvestism is also quite distinct from gender dysphoria. Transvestites are people who get sexual or emotional pleasure from wearing the clothing of the opposite sex. They are content with their gender identity but enjoy the fantasy of pretending to be a member of the opposite sex.

Causes:
Little is known about the cause of gender dysphoria.

There has been some research claiming to show that male and female brains show some difference in structure and that people with gender dysphoria have brains structured like those of their psychological rather than physical sex. This suggests the cause occurs during the development of the brain while in the womb, however the research is inconclusive.

Research has also shown that a significant proportion of male transsexuals have abnormally low levels of HY antigen (This is present in the cells of males but not in the cells of females).

Many believe gender dysphoria is caused by hormonal alteration of the nervous system of developing foetus.

Diagnosis:
A G.P. or psychiatrist will refer a person thought to have gender dysphoria to a Gender Dysphoria Clinic.

A detailed history of gender development in childhood and puberty will be documented. Also, details of current life circumstances and general stability are noted. Psychological assessments will be undertaken. There must be evidence of clinically significant long-term anxiety, distress and impairment in social and occupational functioning for a firm diagnosis to be made.

The diagnosis is not made when there is a genetic abnormality or concurrent intersex condition (congenital disorders that cause the person to display physical attributes of the opposite sex), such as androgen insensitivity syndrome or congenital adrenal hyperplasia.

Delusional conditions, such as schizophrenia also have to be ruled out when making a diagnosis.

Treatment:
Once referred to a gender dysphoria clinic, alternatives to sex reassignment are considered. Counselling is offered to the individual about the range of treatment options and their implications.

Many people will choose to live as the sex they are psychologically. This can involve counselling, speech therapy, electrolysis (removal of facial hair) or hormone treatments. Hormone treatments can play an important role in the anatomical and psychological gender transition process for properly selected adults with gender identity disorders.

Sex reassignment surgery, commonly known as a sex-change operation, is given to people who are convinced that they are of the wrong anatomical sex. Such people are said to be transsexual. The transsexual person completes a detailed psychiatric and psychological evaluation to ensure that the desire is genuine and permanent and has been present for at least two years.

For a male becoming female, female hormones are taken orally to produce changes in the secondary sex characteristics, such as body hair reduction and breast development. Electrolysis and cosmetic surgery may be undertaken. The person is also required to live as a female for a minimum of one year before surgery is authorized.

If surgery is approved, the testes and erectile tissue of the penis are removed under general anaesthetic. An artificial vagina is created and lined with skin from the penis. Tissue from the scrotum (the sack that contains the testes) is then used create the labia, and the urethra (urine tube) is shortened and positioned in the female location.

For the female to male patient, the process is similar. The male hormone, testosterone, is taken by injection or patch. It produces largely irreversibly effects of beard growth and masculine muscle development, as well as a deepening of the voice. A mastectomy may then follow and the ovaries and uterus may be surgically removed. Penis construction, artificial testes implants and operations to create a male urethra and relocation of the clitoris to the head of the penis are available but the surgery is complex and costly.

The vast majority of transsexual people experience a successful outcome in terms of subjective well-being, preservation of bodily attractiveness and sexual function. (See also: Treatment NHS, Treatment private)