Gender dysphoria

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Last Medical Review: April 1, 2020
Medically Reviewed by Dr. Elisabeth Vincent Hamelin
Gender dysphoria (April 1, 2020)
Home With Your Gender (April 1, 2020)

Gender dysphoria is when you feel that your body does not match your gender identity and that it means suffering for you.

Those with gender dysphoria can receive treatment to feel better. It is called gender-affirming treatment. The purpose of the treatment is to adapt the body as far as possible to your gender identity.

Contents

Symptoms

It is always individual what suffering means. It may be that you are feeling mentally ill and, for example, have problems such as depression, anxiety, abuse or eating disorders. It can also mean that you cannot participate in everyday life the way you want. You may have difficulty being naked or exchanging with others. It can then be more difficult, for example, to go and work out, visit the bathhouse or have sex.

It can also be about how others see and name you. That you have a name that does not fit your gender identity, that others use the wrong pronoun and do not see you as the one you yourself feel you are. Pronouns are words that are used instead of the names of a person, such as he, she or them.

How much gender dysphoria you have is individual and everyone experiences it in different ways. Some experience it all the time, others in some situations.

What can I do for myself?

There are many things you can do yourself to reduce your gender dysphoria or endure when it’s difficult. Here are some of them.

  • You can choose to use the pronoun that suits you and ask others to use it
  • You can change your name by making an application to the American Tax Agency. If you are under 18, the custodian’s approval is required. You can add, swap, and delete first names, and you can swap multiple times if you want. It costs SEK 250 to change your first name. Read more about changing the first name of the American Tax Agency.
  • You can use clothes and other gender expressions to change your appearance.
  • You can use a bra and put in silicone inserts to enlarge the breasts.
  • To make it look like you have a penis, you can use a packer. It is a silicone penis that you can have in your underwear.
  • You can use a sports top if you want to make the breasts flatter. Some also use a binder.

Thinking about one’s gender identity can sometimes feel lonely. Then it can help to try to find people with similar experiences. There are associations where you can meet other transgender people. You can also get in touch with others and discuss things related to trans in different groups on the internet.

Where can I get help?

Contact a youth clinic, doctor, curator or psychologist at the health center, school or student health care center, or a psychiatric clinic if you want to discuss with someone in the care about your gender identity. In some county councils there are also special HBTQ receptions.

You need to do an investigation on an investigation team to find out what treatments are possible for you. You don’t need to be sure how to identify yourself or if you need gender-affirming treatment to get an investigation.

To start an investigation you need a referral. It can be written by a person in the health care, for example, a health center, psychiatry, student health, youth reception or by a psychotherapist, priest or equivalent. You can also sometimes submit a self-referral. It differs between the different investigation teams if you can submit a self-referral or who you need to get a referral from. Contact the reception where you want to make your inquiry if you are unsure of how to get a referral and start an inquiry.

Investigation team for those over 18 years of age

In some county councils that do not have an investigation team, there may be a coordinator who can advise you. See what applies where you live on your county council’s website.

Seek care if you are mentally ill

If you are feeling mentally ill, contact a health care center or psychiatric outpatient clinic. You can contact many receptions by logging in.

Call telephone number 911 if you want medical advice and help with where to seek care.

Investigations

The investigation is done so that you get the best treatment possible based on your needs. The purpose of the investigation is to identify and try to understand your experience of gender dysphoria and what the causes are. During the investigation, we also investigate if there are other things you may need help with. You can also discuss gender-affirming treatment and what kind of treatment you may need. You can tell us what you expect from the treatment.

The investigations are conducted in different ways at different locations in the country

You can seek care at any health center or open specialist clinic you want throughout the country.

Investigation if you are under 18 years of age

For those under the age of 18, the investigation is conducted in much the same way as for adults, but you need the consent of your guardian. A guardian must also participate in the investigation.

You get to meet an investigation team

You get to meet a psychiatrist, psychologist, sociologist and sometimes an endocrinologist or gynecologist. They make separate assessments. The investigation team will investigate with you if you have gender dysphoria. You also go through what you need for treatment. A guardian must be with you if you are under 18 years of age.

The investigation team investigates if there are other things you also need help with in order to be able to carry out the treatment and get the best results possible. For example, there may be a mental or physical illness or practical issues, such as finances or housing that need to be resolved. If at the same time you feel mentally ill, there is no obstacle to getting an investigation or a diagnosis, but you may need other help as well.

The investigation team can provide information to your relatives

It often makes it easier to have support from one’s surroundings in a gender-affirming treatment. Therefore, it may be good for your relatives, such as parents of siblings, or other people you see as your relatives, to meet with the investigative team to get the information they need in order for them to be a good support for you.

How long does the investigation take?

How long it takes before you can start an investigation and how long the investigation itself takes varies. The investigation usually takes between four months to two years, but it can also take longer than that. The investigation time is affected by how far you have come in your process when you seek care and different routines on the different investigation teams in the country. The investigations follow the National Board of Health’s knowledge support for Care in Gender Dysphoria.

Certain parts of the treatment may be allowed to begin with the investigation.

When the investigation is complete

In USA, three diagnoses are used for gender dysphoria:

  • transsexualism
  • gender identity disorder without further specification
  • other gender identity disorder.

All three diagnoses can provide the opportunity for gender-affirming treatment.

When the investigation is complete and you have received your diagnosis, the investigation team, in consultation with you, writes the referrals needed for your treatment. They follow and support you during the process of changing your body. In cases where you wish to change legal gender or undergo sex-affirming genital surgery, they will also assist you with an application to the National Board of Health and Welfare’s Legal Council.

You and the investigation team may find that you do not want to proceed with the investigation and treatment. You may also find that there are other causes for your complaints. In this case, the investigation team will help you get the help you need from other parts of the care.

It is important that all decisions come to maturity for a while and are thoroughly thought through as they affect many aspects of your life throughout your future.

If you and the investigation team disagree, you have the opportunity to get a so-called second opinion, a second assessment by another team.

You should be able to understand the information

In order for you to be involved in your care and treatment, it is important that you understand the information you receive from the healthcare staff. Ask questions if you don’t understand. For example, you should get information about treatment options and how long you may have to wait for care and treatment.

Children should also be involved in their care. The older the child, the more important it is.

You have the opportunity to get help from an interpreter if you do not speak English. You also have the opportunity to get help from an interpreter if you have a hearing loss.

If you need tools, you should get information about what is available and how to get it.

Treatment

Gender-affirming medical treatment can begin if you have been diagnosed with gender dysphoria and come to the conclusion that you want to be treated. The treatment aims to reduce the gender dysphoria and the suffering it brings to you. The goal is to be able to live as you are.

What is needed to change legal gender or undergo sex-affirming genital surgery?

It is the National Board of Health and Welfare’s Legal Council that handles applications to change legal gender and get permission to undergo gender-affirming treatment. There are four criteria that you must meet before you can change legal gender or undergo sex-affirming abdominal surgery. This is how the criteria are formulated according to the law.

  • You then experience for a long time that you belong to the second gender.
  • You then act for a time in accordance with this gender identity.
  • You must presume to live in this gender identity in the future as well.
  • You have turned eighteen years old and are registered in Sweden.

The Judicial Council interprets the law’s criteria as having lived as the gender you feel as in all contexts for at least one year. It is often called real life or social transit. You should also have been in contact with the investigative team, or other gender dysphoria care, for an extended period of time. Exactly how long may vary but you should expect two years. You who want to change your legal gender or undergo genital surgery must submit an application to the National Board of Health and Welfare. You don’t have to operate the genital area to change your legal gender but if you want to operate the genital area you must also change the legal gender.

The investigation team will assist you with the application and that certificates needed are submitted with the application. When your application is approved, your legal gender changes and you get a new social security number after about a week. You then need to inform the care so you can get calls and recipes in your new social security number. The investigation team informs you of other instances that you need to inform. You can appeal the decision or apply again if your application is not approved. Talk to your investigation team about how to do it.

How much do the treatments cost?

The treatments are counted as medical care and are included in the high-cost protection for health care and the high-cost protection for medicines.

Treatment without surgery

During the investigation, you should get information about the different treatments and how they can improve your gender dysphoria. The investigation team then decides with you which treatments will be good for you.

Aid

The county councils and municipalities are to offer aids to people with gender dysphoria. It is different in different county councils what tools you can get and what they cost.

In some county councils, if you want to get a custom made penis prosthesis you can choose how the penis should look like. Sometimes you can instead get a packer, which is an already manufactured penis.

In some county councils you may get a binder that will make the chest flatter if you want.

You who need can get wigs or hair replacements as an aid, for example if you are bothered by hair loss.

Hormone treatment

Before starting hormone therapy, the therapist will ask you if you want to save sperm or eggs in order to possibly have children that you are genetically related to in the future.

The purpose of hormone therapy is to change the body to better match your gender identity. You can either get masculinizing treatment with testosterone or feminize with estrogen. Estrogen is often combined with medicines that reduce testosterone.

You can sometimes get help to stop menstruation or inhibit erections even before you start your hormone therapy.

Protect yourself from pregnancy if needed.

During hormone therapy, one can usually not get pregnant. Use a pregnancy protection if you have sex in a way that can lead to a pregnancy and want to be absolutely sure that there is no conception.

All are affected differently by hormone therapy

Most physical changes occur during the first two years of hormone therapy. This applies to both testosterone and estrogen. How much the body changes and exactly how long it takes can vary greatly from person to person.

Some want the hormones to affect the body as much as possible and continue to take hormones throughout their lives. Others just want some changes and may then take hormones for a shorter period.

Puberty can be paused with hormone blockers

You who are under 18 and have not reached puberty when you get your diagnosis may get hormone blockers. Hormone blockers prevent puberty. When you turn 16, you can start with the hormones you want and get a puberty trend that matches your gender.

The hormones are available in various forms

You can get the hormones like a patch, gel or a syringe. Hormones given by syringe last for a long time, while it is easier to adjust the dose with a patch or gel. You and the therapist together decide which method is best for you.

Treatment with testosterone

Testosterone treatment can affect the body in several ways:

  • Your period will end.
  • It will be easier to build muscle.
  • Your clitoris is getting bigger.
  • You get less subcutaneous fat on the hips and lower abdomen.
  • Your voice gets darker.
  • You get increased body hair and beard, while the hair on the head thins out.
  • You can get more acne during a transitional period.

Testosterone does not affect your leg body, your body length or the size of your hands and feet. If you stop taking testosterone, most of the changes will go back. What does not go back are the voice changes and the clitoral enlargement you have had. Also, if you have increased beard growth and body hair, it does not completely disappear when you stop taking testosterone.

Estrogen treatment

Estrogen treatment can affect the body in several ways:

  • Your breasts are growing.
  • You get more subcutaneous fat on the hips and lower abdomen.
  • Your skin becomes softer.
  • Your testicles will be smaller.
  • Your sperm production will decrease.
  • It will be more difficult to get a stand.

Estrogen does not affect your leg body, your body length or the size of your hands and feet. Your voice and hair growth on your face is not affected by estrogen either. The hair growth on the body may decrease slightly.

Voice therapy in a speech therapist

Estrogen does not affect the voice, and therefore you who take the estrogen are offered voice treatment by a speech therapist. The speech therapist provides advice and treatment so that you can raise your voice and be perceived as more feminine.

Testosterone often darkens the voice, but you get voice therapy from a speech therapist if you need it.

Hair removal

Antitestosterone and estrogen help reduce body hair. It can thin out facial hair but not completely remove the hair. Hair removal with diathermy or laser is therefore included in the sex-confirmatory treatment. Different county councils have different rules for when you can begin hair removal and what parts of the body are included. You can get information about what applies in the county council where you are registered by the investigation team.

Treatment with surgery

Any vocal cord surgery and sex-affirming abdominal surgery can only take place once you have received permission from the National Board of Health and Welfare’s Legal Council. The other gender-affirming surgery can occur when your investigation is complete and you have been diagnosed.

The investigation team sends a referral for the operations you have agreed on. The plastic surgeon or ear-nose-throat specialist makes an individual assessment and provides advice and information on which surgeries are possible for you. Then you make a decision together on what to do. It is important that you feel well informed about what is possible to achieve with an operation and what is not going so that you can make a good decision for you.

The order in which the operations take place is individual. Some procedures are almost always performed at one and the same time, while others are performed in several steps. Contact the plastic surgery clinic that you have been referred to for information on how long the waiting times are for a consultation and for the surgery itself.

Feminizing surgery before changing legal gender

  • The front part of the larynx, the Adam’s apple can be reduced to create a more feminine look.
  • You may be given the opportunity to have a breast enlargement if the breasts have not developed sufficiently after about a year of hormone therapy. It may also be appropriate to have a breast enlargement if you cannot be treated with estrogen.

Feminizing surgery after changing legal gender

  • You can undergo sex-affirming surgery of the genital area to get a sheath, clitoris and pubic lips.
  • If your voice has not become brighter by voice processing, vocal cord surgery may sometimes be necessary.
  • According to the Social Board’s knowledge support, feminizing facial surgery can be included in some cases. Currently, feminizing facial surgery is not performed in Sweden.

Masculinizing surgery before changing legal gender:

  • The breasts can be operated away so you get a more masculine chest. Often, the size and placement of the nipples need to be adjusted. It is common to need more than one operation to achieve the desired result.
  • For those with very wide hips, it may be possible to get liposuction on the hips and thighs to get a more masculine appearance.

Masculinizing surgery after changing legal gender:

  • You can undergo sex-affirming surgery of the genital area. Then you can, for example, remove the uterus, ovaries, fallopian tubes and sheath. There are also ways to construct a penis for those who want it.

Health checks after gender affirming medical treatment

You are no longer called to the gender-based screenings that are done within the county council if you change legal gender, even though there is still a medical need for it.

This means that if you have a male social security number and a uterus pin, you need to search for it yourself.

The risk of breast cancer does not completely disappear when you remove the breasts, as the surgeon leaves some breast tissue for aesthetic reasons. You need to remember to do a check about every two years. You can contact a health care center when it’s time.

You who have changed the legal gender of a woman will be called mammography like other women. It is important that you go for these checks.

For prostate cancer, there is no national screening, however you can take blood tests to screen for prostate cancer. You who have been attributed to male sex at birth and have operated on the abdomen still have your prostate. Discuss with a doctor when it is appropriate to have blood tests.

You can save germ cells if you want to be able to have children with whom you are genetically related

If you want to be able to have children that you are genetically related to in the future, you must save germ cells, sperm or eggs. The healthcare staff will inform you of your opportunities to do so. Then the sperm or eggs can be used in a test tube fertilization.

You who have not started your hormone therapy can save the sperm or eggs before starting treatment.

You who are treated with hormones can stop your hormone therapy to regain sperm production or ovulation. It varies from person to person how long it takes and how fertile you become.

The law limits how you can use the germ cells

There are limitations in the legal conditions for assisted conception. According to the law, only eggs or sperm may be donated. If the eggs are fertilized when they are frozen, they may only be used in the relationship that was relevant at the time of fertilization.

The germ cells are stored for a long time in different county councils

How long sperm and unfertilized eggs can be stored is different in different county councils and regions. Several county councils have the routine to save sperm until you turn 55 years old. Frozen unfertilized eggs are stored in several county councils until you turn 45 years old. Fertilized eggs may be stored for a maximum of five years.

You can read more about trans and parenting on the HBTQ-Families website.

You who want to have a female abdomen

There are several interventions that make the abdomen more feminine. Both testicles and penis can be removed. You can also create a vagina. Vaginoplasty often refers to several surgical procedures that can be performed in one or two steps. A vulva is created, which consists of the vagina, the ventricle, the clitoris and the inner and outer pubic lips. The clitoris is made by the penis solo and usually has the ability to orgasm. The surgeon makes the urethra shorter and creates a new urethra. Skin from the scrotum and the skin around the scrotum is used to construct the inner and outer labia.

The operations are done on one or two different occasions. First, the vagina, pubic lips and clitoris are created. After three to six months, pubic lips are corrected and a surgeon creates a coat over the clitoris.

The new vagina is called neovagina or vagina or vagina obtained.

Rod Training

You need to take care of your neovagina with pole training. Rod training means that you insert a rod into the vagina. First you use a small thin stick and then you use larger variants.

You need to practice the pole every day so that the vagina does not contract or shorten. Once the vagina has healed, you need to continue with your spell training daily throughout your life. You can replace the vocal training with vaginal intercourse or use a dildo in the vagina when masturbating.

To think about before surgery

Complications can always occur during an operation and it usually hurts afterwards. Some of the gender-affirming surgeries produce visible scars. Talk to the plastic surgeon who will perform your surgeries to find out what complications this can mean for you.

You who want to have a male abdomen

There are two different ways to create a penis. One is metoidoplasty, the other is falloplasty. With scrap plastic you can also create a purse.

Metoidioplastik

Metoidoplasty is an operation where the clitoris is raised to create a penis. Ollon and shaft of the clitoris are straightened and made visible. Then a urethra is constructed, the penis thickens and the penis shaft is covered with skin from the inner labia. In metoidoplasty, all steps in the penis structure are done at the same time.

A prerequisite for metoidoplasty is that the clitoris is enlarged enough by the testosterone treatment.

Metoidoplasty is also called metaplasty. The new penis is sometimes called neopenis or metapenis.

Falloplastik

Falloplasty is an operation where the surgeon creates a penis with skin from the forearm or thigh. A new urethra is constructed and the clitoris is placed at the lower part of the penis shaft. After three to six months, you are called on a return visit to the doctor to plan for a second operation. Then you have an erection and testicular prosthesis if you want it. The surgeon also creates an ulcer on the penis.

The new penis is sometimes called neopenis or fallopenis.

Skrotalplastik

A purse can be created by the surgeon inserting testicular prostheses of silicone into the outer labia. Shy lips are adjusted to create more volume. The scrotum is placed above or around the vaginal opening.

It is called creating a neo-scrotum or neo-scrotum.

To remove the uterus, ovaries and vagina

You can also choose to have the uterus and ovaries removed. It is possible to remove the ovaries and uterus without having to do penis surgery.

If you want to remove the vagina, this is often done in conjunction with other genital confirmatory operations.

What is life like then?

Most people who have received gender-affirming treatment feel that life feels better and easier in several ways afterwards. It can be anything from your mental state to your sexual health or your ability to work. A sex-affirming treatment changes your body to better match your gender identity, but of course does not solve all the problems. It is important that you get help if you have other problems.

There are few people who regret the treatment. If you do, there is support available.

Your sexuality can be affected

Sexuality can be affected in different ways by gender dysphoria and a gender affirming treatment. Some people feel that it is easier to have sex when treatment has begun, as they feel more comfortable with their body.

Sex is different important for different people, and it can also vary during different periods of life.

Be clear about whether there are things you don’t want the person you have sex with. You can also tell if there are things you would like them to do or say.

Sometimes sex can be easier by changing what words you use on different parts of the body, so that it feels more affirming to you in your gender identity.

Sex during hormone therapy

Some experience increased sex drive when treated with hormones, both testosterone and estrogen. Partly it may be due to the hormones, partly because you may start to feel more comfortable with your body. For others, sex drive may decrease or not change at all.

Estrogen can cause feeling in the nipples to increase. If you are taking estrogen and have not undergone an abdominal surgery, you may find that the midsection becomes more sensitive to touch. Testosterone blockers and estrogen therapy lower the level of testosterone. This can make the penis not as hard as before. If you do not want that effect, you can discuss it with your endocrinologist, who may try to adjust the hormone treatment so that it does not.

Testosterone causes clitoris to grow and many people feel that clitoris becomes more sensitive. You can use a locally-acting estrogen cream that makes the vagina less dry if you have trouble with reduced lubrication. Testosterone can also make a congenital sheath less extensible. Then sexually transmitted diseases can be transmitted more easily and you can get fungal infections. Take it gently in the beginning and use a lot of lubricant if you want to use the vagina when you have sex.

Breast and chest surgery change the feeling

Chest or chest surgery can affect the feeling in different ways. It is only about a year after the last surgery that it is possible to determine how sensitive your nipples and wounds will be in the future.

Sex after abdominal surgery

Wait to have sex where your genitals are involved until your body heals if you have undergone a genital surgery. The surgeon operating you can tell you how long to wait.

Metapenists can often stand by themselves but can be a little less harsh. Fallopian tubes cannot. However, it is possible to have rods implanted one year after the operation. The rods make it possible to have enclosing or penetrating sex with the fallo penis.

You who have received a vagina will also receive a clitoris made by the penis. It has generally retained erogenous feeling. You who have a metapenis have a full erogenous feeling in it, assuming it is created by the clitoris. For those with a fallopian tube, the clitoris is retained in the base of the fallopian tube and it has erogenous feel.

How can I talk to my relatives about my gender dysphoria ?

It can be a great thing to tell of their relatives about their gender identity and any gender affirmative therapy. Maybe have you been alone with your thoughts long. Or so have you been open with your relatives about your gender identity, and they have been supportive.

It is understandable if you feel you nervous before to tell to your relatives. Maybe are you afraid of that not be understood, to be rejected or anything else.

That is not to say how your relatives going to react when you tell about your gender identity. For many, it feels like a relief to finally be able to tell, no matter how the surroundings react. Perhaps noticing you that any relationship gets deeper as you can tell, because you do not have to have a big secret from you. It can happen that your relatives also feel a great relief over that you tell and explain how you feel.

One tip is to first tell of someone who you feel you safe in order to then tell for many people when it feels right for you.

During the investigation, can you get hints on how you can tell for the environment. Investigation teams offer also talks with related parties.  It might be nice to someone else explain and can answer the questions that your relatives may have.

Advice to related parties

Maybe are you happy to be your relatives have been told to you about their gender identity, or so it feels, it is difficult. You have the right to feel as you feel and no feelings are wrong or strange. But even if you do not can understand the sense of that being transgender, can you respect and acknowledge your kindreds gender identity.

Think of that even if it seems difficult or awkward for you, so is it probably more difficult for the person who says.

What can I do as a family member of that help ?

There are many things you can do for the ease of your relatives, and for your self. That you read on this text is a good beginning.

Try to not make gender identity to a problem. To be transgender can be very straightforward, or to and with the solution of a problem.

You can help and support through to ask your relatives what Cohen wants to be called. Use the new name and the correct pronoun, it wants to say, he, she, hen, that or something else that the person prefers. It can also be important that you remind second if that is the correct name and pronouns.

Ask please your relatives about the hen wants that you help to with something for example to tell the second or hen would do it himself.

You as a relative can receive support

If the person undergoing the investigation agrees, you are called to the investigation team for an information call. In the majority of teams can you also offered more conversation with a counselor or participating in a kin group if you need it.

Keep in mind that it is that perhaps feels new and unfamiliar now, will that become a part of everyday life of the time.

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