men and women standing side by side

Perhaps it is easier to say what gender is not – it is not sex, and the two words should never be confused as meaning the same thing. Many people interchange the terms gender and sex, believing them to be the same, and this leads to confusion for many and distress to others for whom the difference is a significant issue in their lives.

Sex is the biological description of a thing, be it plant or animal, and is based on DNA, chromosomes, hormones and the resultant anatomy. Sex therefore cannot be changed at a biological level, although the outward appearance of a person can be altered by medical interventions, as in the case of what used to be known as Sex Reassignment Surgery. Terminology constantly changes and better descriptions include Gender Confirmation Surgery, Gender Affirmation Surgery or perhaps Genital Reconstruction Surgery as, after all, that it what actually happens.

Gender, on the other hand, is predominantly a social construct and, dependent upon where in the world you live, can mean different things to different people. We have to accept, though, that gender is determined, in the first instance, by a person’s biological sex and outward appearance at birth. This means that a baby with a penis is assigned male at birth and is expected to grow up to be a man and behave in a way that society expects a man to be. Similarly, a baby with a vagina is assigned female at birth and is expected to grow up to be a woman and to behave as society expects a woman to be. It is therefore widely accepted that gender is a learned behaviour – we watch our parents and other adults during childhood and copy them.

However, gender is not all about learned behaviour; there is also a biological element which is understood to occur during development of the foetus. All foetuses start life as female because it is initially only the female sex chromosome, which is inherited from the mother, that is active. After the eighth week of pregnancy the chromosome from the father becomes active. An X-chromosome will allow the foetus to continue its female development; a Y-chromosome will cause the foetus to develop as a male.

This process is known as differentiation and occurs in two distinct stages:

  • Physical differentiation – development of gonads and secondary sexual features
  • Brain differentiation – development of the brain and neurological connections.

Differentiation may be influenced for example by stress in the mother during pregnancy, which may then influence hormonal release at strategic times during foetal development. For example: it is possible for a foetus to develop a male physicality following activation of the Y chromosome but, because of stress or other influences at significant times, the neurological differentiation process can be affected, thereby leaving the neurological characteristics to continue development along their original female path.   Alternatively, the differentiation could be interrupted such that a female body develops male neurological characteristics. Please note that this is a very much simplified explanation of what is a very complex process with many factors which may or may not influence the final outcome.

Research supports the influence of both sociological learned behaviour and differentiation in the establishment of gender identity, although specific details are still very much under debate. These processes give rise to the awareness of self and, subsequently, to the gender identity that a person believes themselves to have. There are truly many variables associated with gender identity and there are increasing numbers of individuals who feel that their gender identity is different to that which was assigned at birth and that they no longer fit within the generally accepted binary ideal of the culture within which they live.

It is the expectation of society, then, that determines gender and appropriate behaviour, although this may vary widely from one group or society to another. Clearly the man’s gender role in western society is very different to that expected of a man from the Kalahari Desert, for example. In both cases the biological sex remains the same, but the expected behaviour and role within society differ considerably.

It is hardly surprising, therefore, that people become confused by what they don’t understand, as we move away from the long-standing binary notion of man and woman. The concept that gender is fluid, and that there is a multiplicity of genders across the spectrum between the two extremes of male and female, is difficult for some to embrace. The ability to express one’s gender in any fashion one wishes is known as being non-binary or genderqueer and is the underpinning concept of gender diversity. A person can identify how they wish, whether that is as male, female, both, neither or in fact anything that feels appropriate for them. For some their gender is fluid and can change depending upon how they feel at any particular time. The ‘queer’ in genderqueer has the original meaning of being unusual, rather than the derogatory inflection that has been applied since the early 1900’s, particularly in relation to gay men.

We are in a time of change, when a younger, more rebellious generation no longer wishes to be bound by the older and more conservative ideals of what gender is and of how people should be expected to conform and behave. The deliberate use of ‘queer’, in defiance of the pejorative application of the word by older generations, only makes their behaviour harder to accept as being just the natural progression of a new generation.

Gender, therefore, is not a straightforward concept which can be explained simply. It is complex and it is fluid, constantly changing for many as they move through their lives. When meeting someone whose outward presentation is ambiguous and whose mannerisms are not obviously masculine or feminine, we are well-advised to be polite enough to ask how the person wishes to be gendered. The answer may surprise: the person may simply say ‘he’ or ‘she’; but they could equally respond with one of a whole range of alternate gender pronouns such as ‘they’ (as a singular pronoun), ze, zie or ey. The list continues to grow.

However, despite the wide variety of self-identified gender options which appear to be available, there is a group of people for whom the binary concept of gender remains very important, namely trans men and trans women.  A trans man is someone who was born female but feels that his gender identity is male. Similarly, a trans woman was assigned male at birth but feels her gender identity is female. These people often suffer deep unhappiness (or dysphoria) as they struggle to accept the gender role they were assigned at birth; they frequently feel they cannot continue to live that way.

There are two terms which need to be understood when talking about gender dysphoria and those whom it affects. The first is cisgendered, (pronounced sisgendered). Cis is from Latin and means ‘to be on the same side’. This is applied to people whose gender assigned at birth matches their biological sex. Being ‘cis’ has nothing to do with sexuality and so it is quite feasible to be a cisgendered lesbian for example. Trans, on the other hand, means ‘to cross’ or ‘on the other side of’ and applies to people for whom their gender, assigned at birth and based on biological sexual features, does not correspond to how they feel. Many trans women and men experience deep psychological distress or dysphoria when they feel forced by the norms of society to conform to a gender role which they feel is wrong for them.

For many trans-identifying people therefore, the concept of the ‘old fashioned’ gender binary is important as they very specifically wish to change from male to female or vice versa; many are not interested in a ‘half-way house’ of a vaguer gender definition. It is important to them to be recognised as the woman or man they feel themselves to be. Some, of course, can and do find a place between the two extremes within which to settle and live a contented life.

There is a long-standing belief that being trans is a mental health disease. This is not the case. The Diagnostic and Statistical Manual of Mental Disorders Edition 5, published by the American Psychological Association, is used internationally as the document of record for identifying mental health issues. The Manual no longer identifies a gender identity disorder but instead defines it as gender dysphoria. The previous use of ‘disorder’ was seen as pathologising the condition (representing it as a disease). The term gender dysphoria takes away the assumption that it is a disease, in an attempt to destigmatise the diagnosis. Gender Dysphoria is defined as: “an anxiety, uncertainty or persistently uncomfortable feelings experienced by an individual about their assigned gender which is in conflict with their internal gender identity.”

Many people with this condition do indeed have mental health issues such as depression or anxiety, but these can occur as a result of how society treats trans-identifying people rather than from the condition itself. Trying to conform to the gender role assigned to them at birth leads many to marry and have families, for instance, as a means of proving to themselves and others that they can ‘fit in’. High rates of self-harm and suicide are a direct result of the inability to successfully integrate into a society which does not accept. Waiting lists for medical and psychological support just add to the ills trans people deal with on a daily basis.

Paradoxically, significant numbers of young men, who feel they should have been women, turn to ‘macho’ careers in the military, the police, or heavy industry, for instance, in the hope of dispelling their ‘wrong’ feelings. “I wanted to knock some sense into myself,” is a not uncommon phrase from those who give up the struggle and eventually seek to transition.

It is also a common misconception that all trans people have ‘sex change surgery’. This is not the case and many find that they can live contentedly in their acquired gender role, whatever that may be, without the need for medication or surgical interventions. For example, in 2015/16 statistics from Charing Cross Gender Identity Clinic showed that only 60% of trans women receiving treatment went on to have genital reconstructive surgery.

Gender diversity is an emotive topic which receives significant exposure in the press and in social media. It is a subject many find difficult to grasp. There are some who feel that being trans is not a ‘proper’ illness; others think that offering surgical intervention is wrong and is a form of self-mutilation; and some see it as a waste of NHS resources. This heated debate is further fueled by the rise in numbers of young children who are coming forward, often with the support of their parents, to seek help dealing with their gender identity.

The focus of health care engagement is alleviating the distress. The goal of treatment for trans people is to improve their quality of life by facilitating their transition to a physical state that more closely represents their sense of themselves; that may or may not include hormone treatments or surgery.

Trans, non-binary and gender-variant people are individuals who have a different sense of self when compared to the majority of society who are cisgendered. Mockery, discrimination or abuse of these people is just as much an infringement of their human rights as it would be for any other minority group. In less than a lifetime public understanding of, and attitudes towards, those suffering gender dysphoria have improved markedly; it is to be hoped that the progress continues.

The recently published Second Memorandum of Understanding against Conversion Therapy acknowledges that no one gender identification is preferable to another. As therapists we must be aware of this when working with clients and ensure that we do not inadvertently (or deliberately) direct a client to pursue one gender identification in preference to another. This would be seen to convert the clients’ perspective and to work in a reparative manner which is now acknowledged to be unethical and harmful. Caution and appropriate training are needed to work in this field (and also that of sexual and relationship diversity), to be able to provide a client with the support, and in some cases perhaps education, about gender and sexual diversity and the many variations that exist in society today.

The Second Memorandum of Understanding against Conversion Therapy can be found on professional websites and is relevant to the medical, psychological, counselling and therapeutic professions within the UK who are signatories. Information can also be found on many sites that are allies to and supporters of gender and sexual diversity. This document extends the existing professional stance against conversion therapy for sexual diversity to now be inclusive of gender diversity. The details of the memorandum can be found here.