Trans and gender diverse people

Your gender is whether you think of yourself as male, female or anything else. It may be the same as the sex assigned at birth, or it may be different.

When your gender is different from your sex assigned at birth, you may identify as being:

• transgender (trans) – you do not feel comfortable with traditional gender identities or behaviours that ‘match’ the sex assigned to you at birth
• gender diverse – you identify with a gender or genders outside of male or female.

Remember, your gender identity is what feels natural to you. You may know early in your life that you would feel more comfortable being the opposite gender or gender diverse, or you may take a long time to explore your gender.

Gender dysphoria

Many people don’t feel they fit the role and stereotypes for their gender. But some people also feel the sex of their body doesn’t feel right. When this mismatch causes severe distress, it is called gender dysphoria.

Gender dysphoria is a situation that may have symptoms (such as depression and anxiety) that need treatment, but it is not a mental illness.

It is not known how many people in Australia have gender dysphoria, due to hesitancy to disclose. But it is known that people who identify as trans or gender diverse have higher rates of discrimination, depression, suicide and attempted suicide, compared with the general population.

The feeling of living with a different gender identity to that assumed for you can occur at any point in life, although many trans and gender diverse people are aware of difference early in life.

Children may:

• be disgusted by their own genitals; feel detached from them as if they are not really a part of their body, or feel discomfort or have negative emotions attached to them
• feel rejected by their peers, and feel alone
• believe they will grow up to become another gender.

Adults may:

• cross-dress
• feel alone
• want to live as a person of another gender
• wish they didn’t have the sexual characteristics of the sex assigned at birth
• wish to change their genitals.

Both adults and children may:

• walk, talk or in other ways behave in a manner not considered typical of the sex assigned at birth
• have depression or anxiety
• withdraw from social interaction.

Options for changing your physical sex

You may want your body to match your gender identity. If so, you can choose to use hormone therapy or surgery. This decision is one that needs a lot of research, preparation and support.

For children, the decision is made with their parents. The process can be long and emotional.

Hormone therapy for children

If your child has gender dysphoria and they've reached puberty, they can be treated with gonadotrophin-releasing hormone (GnRH) analogues. These synthetic (human-made) hormones shut down the natural hormones that the body produces.

The idea is to stop the hormone-driven changes to the body in puberty. The hormone testosterone, for example, stimulates penis growth. And the hormone oestrogen, for example, stimulates breast growth.

If physical changes such as penis or breast growth can be delayed, then a child with gender dysphoria may feel less distressed by their body.

In other words, the delay helps them cope until they are old enough to look at options that adults can take.

If you are a parent of a child with gender dysphoria, be aware that:

• a child will be offered GnRH analogues only if they are in clear distress and strongly want to live as their gender identity
• the effects of this treatment are considered to be fully reversible, and the treatment can usually be stopped at any time
• you, your child and the care team need to make decisions together.

Hormone therapy for adults

As an adult, you can undergo hormone therapy (for as long as you want) to change your physical appearance to better match your gender identity:

• a trans man (a transgender person who identifies as male) or non-binary person (someone whose gender identity is not exclusively male or female) may take testosterone (masculinising hormones)
• a trans woman (transgender person who identifies as female) or non-binary person may take oestrogen (feminising hormones)
• a gender diverse or non-binary person might take testosterone or oestrogen.

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

If you're a trans woman, hormone therapy may lead to:

• your penis and testicles getting smaller
• less muscle
• more fat on your hips
• your breasts starting to form and slightly increasing in size
• less facial and body hair.

It will not change your voice. To make your voice higher, you will need voice therapy.

If you're a trans man, hormone therapy may lead to:

• more body and facial hair
• more muscle
• a small increase in the size of your clitoris
• your periods stopping
• a greater sex drive
• possibly a slightly deeper voice.

Social gender role transition (before surgery)

If you want gender affirmation surgery, you first need to live in your affirmed gender identity full time for at least a year. Called ‘social gender role transition’, this time will help you know for sure that permanent surgery is the right option.

Your care team will offer support during the process, as you go through a range of work, social and family experiences in your preferred gender role.

For some types of surgery – such as the removal of both breasts in trans men – you may need a shorter transition period before the operation.

Surgery

After your social gender role transition, and when you and your care team feel you're ready, you may decide to have surgery to permanently alter your sexual characteristics.

Below are the most common surgical options, but your care team and surgeon may offer other suggestions.

For trans men and non-binary people, surgery may involve:

• a bilateral mastectomy (removal of both breasts)
• a hysterectomy (removal of the womb)
• a salpingo-oophorectomy (removal of the fallopian tubes and ovaries)
• phalloplasty (construction of a penis from vaginal tissue and skin from the inner forearm or lower abdominal wall) or metoidioplasty (construction of a penis from the clitoris)
• scrotoplasty (construction of a scrotum) and testicular implants
• a penile implant (to create an erection).

The aim of phalloplasty or metoidioplasty is to create a functioning penis, so you can pass urine standing up and have a sexual sensation. More than one operation is usually needed.

For trans women and non-binary people, 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
• facial feminisation surgery (to make your face a more feminine shape).

Some trans women can't have a full vaginoplasty for medical reasons, or they may not want a functioning vagina. In such cases, they may choose to have a cosmetic vulvoplasty and clitoroplasty, plus the removal of the testes and penis.

A gender diverse person might choose one or more surgeries to affirm their gender identity, and help them to become more comfortable with their appearance, or gender presentation.

Sexual orientation

Once you change your physical sex, you may experience a change of sexual attraction That is, if you were attracted to women before surgery, you may be attracted to men after surgery (and the other way around), or your sexual attraction may stay the same.

Try not to worry about changing or not changing your sexual orientation. You first need to feel comfortable in your own body and live the gender identity that makes you happy.

Children and gender identity

It is common for children to behave and play (sometimes or often) in ways that society assumes typical of another gender. Some girls play with trucks rather than dolls, and some boys dress up with typically female clothing.

Some of these children will continue to identify as trans or gender diverse after they reach puberty. From then, nearly all trans or gender diverse adolescents continue as adults to identify as trans or gender diverse.

Most importantly, trans and gender diverse teenagers need care and support. They need people and services around them to help them understand their bodies and answer gender questions. They need information about their options for living with their gender identity, and they need an environment that is safe from abuse and discrimination. There is clear evidence of better mental health for trans and gender diverse teenagers who have parental, peer and family support.

Young trans and gender diverse people may also need medical treatment in early puberty for the best physical and mental health outcomes.

If your child is questioning their gender

If your child seems to be questioning their gender, you may feel worried or confused. Your child needs your support, however their gender identify unfolds. Be aware that:

• very young children commonly show an interest in clothes or toys associated with another gender
• older children also may identify with another gender, or say they want to be another gender
• children who do continue to experience gender variance will develop their gender identity in different ways. Some may feel they don't belong to any gender; others may, for example, want to dress in the clothes of another gender sometimes or all the time; some will feel they do not fit the male or female binary gender expectations and feel gender diverse or non-binary best describes their gender expression and identity
• young people who feel strong, ongoing discomfort about their gender may struggle at puberty when their body changes more obviously into a man or woman.

Whatever your child is feeling or saying about their gender, seek help if they are distressed, or if you are. More than anything, it is important to learn how to support your child and help keep them from self-harm, destructive behaviour or depression.

If your child is strongly identifying with another gender, it’s best to get help before puberty begins.

Mental health and trans and gender diverse people

Many trans or gender diverse people have happy, fulfilled lives and loving, safe relationships. However, there is also a higher risk of anxiety, depression, self-harm, eating disorders, sexual risk taking, substance abuse and suicide among trans and gender diverse people.

Australia’s first Trans Mental Health Study found that trans and gender diverse people experience very high levels of depression and anxiety. The reasons are twofold:

• First, you may experience emotional turmoil and physical discomfort when you identify as trans or gender diverse.
• Second, in affirming your gender identity you may confront harassment, discrimination, abuse, violence, rejection and exclusion.

In other words, the environments in which you live, work or study may create psychological stresses that leave you vulnerable to mental health conditions.

Trans and gender diverse people may have difficulty finding employment (or be under-employed) due to discrimination.

Where trans and gender diverse people face stigma in multiple areas (for example through their culture, their faith, working in the sex industry, experiencing intersex, or through cognitive and neurological differences, like autism spectrum disorder) the pressures they face may be exaggerated.

Young trans and gender people, for example, may experience bullying at school (including sexual and physical abuse). Trans and gender diverse adults may find it hard to achieve promotion or feel comfortable with colleagues if they are not supported at their workplace.

Where to get help

• Your GP (doctor)
• Switchboard Tel. 1800 184 527
• Equinox Gender Diverse Health Centre (03) 9416 2889
• Transgender Victoria Tel. (03) 9020 4642
• Minus18
• ReachOut – for a list of national and state-based support services for people who identify as transgender or transsexual
• Royal Children's Hospital – information about gender dysphoria and children