Gender identity : better understanding for better support

Gender encompasses the social processes and relationships that serve to categorize humans. This categorization process is part of cognitive functions that allow our brain to conserve resources by simplifying the understanding of our environment. Throughout history and across cultures, an individual's gender has often been defined based on their sex.

However, sex and gender are two separate and very different concepts.

Sex is a biological concept. It ranges between two modes (male and female) and is constructed from many physiological factors: chromosomes, genes, hormone production, sexual organs, and secondary sexual characteristics, primarily. Therefore, there are many variations in the biological expression of sex.

Gender is a social and psychological concept that evolves within a broad spectrum. It mainly consists of four factors:

• Gender identity, which is a person's self-identification with one or more genders.
• Gender expression, which is how an individual modifies their presentation to align with their gender. This includes clothing, hairstyle, makeup, jewelry, name, and pronouns, etc.
• Body relationship, as the body one has may not correspond to the body associated with one's gender identity, causing significant distress.
• Relationships with gender roles, which are strongly influenced by culture and often play a role in the male-female binary.

An individual's gender is often assigned at birth based on their sex, but it is a part of identity that evolves significantly throughout life.

Some of these evolutions are socially expected. A young boy's gender expression will not be the same as during his adolescence, which will again be different from his gender expression in adulthood.

If an individual's gender identity and gender expression follow the gender assigned at birth (male or female), they are referred to as cisgender. Cisgender people are comfortable with this identity, and their evolution follows what is socially expected and accepted. However, for some people, there is a divergence between their gender identity and the gender assigned at birth. These individuals are referred to as transgender. The most well-known and represented form of transgender identity is binary transidentity: people assigned male at birth who transition to a female identity, and people assigned female at birth who transition to a male identity. However, there is a broader spectrum of gender identities between and beyond these two poles.

As we have seen, the concept of gender is constructed from many factors, and thus, all these variations make gender a spectral concept. It is very difficult to represent this gender spectrum, but here is a simplified version:

In this representation, shades of red are feminine, and shades of blue are masculine. Shades of pink and purple are therefore at the intersection of these two genders, in the realm of androgyny. Thus, even within this relatively binary aspect, we can observe an initial spectrum.

In this representation, however, there are colors that belong neither to the blue family nor to the red family. This pertains to non-binarity. Non-binary trans people do not identify with traditional genders and express their gender identity differently from the stereotypical expectations of men and women. This expression may be closer to traditional genders, as existing fashion is largely based on them, for example, but these identities remain outside this binary.

The last term represented in this image is "Agender" at the center, on the white. In this view of gender, the intensity of the color represents the intensity of identification with a gender. The more saturated the color, the stronger the identification. The paler the color, the weaker the identification. Some people do not identify with any gender or identify very weakly. The expression of a gender is of little importance to them, and how they are perceived is of little significance.

This diagram helps to understand in a visual way that gender is a matter of nuances, varying between individuals, most often in a gradient and rarely in a single color throughout life.

Thanks to a better understanding of transgender identity in recent years, it is no longer considered a mental disorder in major disease classification and diagnostic manuals. However, transgender identity can be a source of great suffering, particularly gender dysphoria. This is intense distress that occurs when gender expression does not match gender identity. Dysphoria can be triggered by body appearance, clothing style, the use of incorrect pronouns or name, and anything that reminds of the assigned gender at birth that does not correspond to the real gender.

The best way to alleviate dysphoria is, of course, transition. It can be medical, involving surgery, hormones, and vocal reeducation, but also social, involving clothing, using the chosen name, and appropriate pronouns. It is important to note that transition does not have to be medical and that sexual reassignment surgery is not necessary or desired by all transgender people. Dysphoria is one of the most significant factors in the high rates of suicide and suicide attempts among transgender people. It is therefore important to assess suicidal ideation in patients with severe gender dysphoria. In addition to supporting your transgender patients through their transition processes, offering them moments of gender affirmation helps alleviate dysphoria.

Using the correct name and pronouns (do not hesitate to ask if necessary) as well as offering techniques for managing emotions and distress, as transitions are often long processes. More generally, kindness, listening, and acceptance are key in caring for a transgender patient. Their identity is not to be questioned, nor their suffering. Their life is often filled with various degrees of violence, and the therapist should be a safe place for them to progress and alleviate their distress.