How does gender dysphoria develop?

When it comes to the theory of gender identity, someone’s personality will interact with their inner sense of themselves, the ideas of gender they are exposed to from their social environment and their comfort with engaging in ‘gendered’ behaviours.

To understand how gender dysphoria develops one first needs to consider that a person’s gender identity is intertwined with many other facets of their personality. The development of an individual’s sense of self is a fundamental yet complicated process that can be a lifetime’s work. Doctors, nurses and therapists who study child development understand that this is a complex and fascinating field. The idea that people have a ‘true, authentic self’ can therefore be difficult to comprehend, as someone’s sense of self is multi-faceted and changes with time. People will usually react, respond and adapt to their environments as they develop. Their sense of self will also grow with experience, as they embody values and beliefs.

How individuals present themselves to others also becomes more sophisticated as people mature. They develop an understanding of various un-written social rules. For example, wearing a spiked leather vest, drinking alcohol, and singing loudly might be acceptable during a music gig or on the floor of a nightclub, but may not be received particularly well in a quiet corporate office or funeral parlour.

People are multifaceted. The idea that a person should have a single predominant aspect to their ‘true self’ reduces an individual’s variability. It might be more accurate to say that every person has ‘true selves.’ Therefore, many child development experts would say that advising people to become their ‘true, authentic self’ can be confusing and possibly distressing. Generally, this topic of personal identity is much more complex and nuanced than can be captured by conceptual reduction to a single ‘correct self’. 

The identities that a child develops will change as they move through the different stages of development from infant to child to adolescent, young adult, middle and old age. The influences they are subject to depend on multiple factors, leading to individual differences that make humans such a fascinatingly diverse group. Nature and nurture are both important, as is how nature affects nurture and vice versa, let alone when we consider the intergenerational role of epigenetics. Personality research has found that around 50% of four of the ‘big five’ traits (extraversion, neuroticism, conscientiousness and openness to experience) are inherited (Power and Pluess, 2015). The fifth trait (agreeableness) is much more influenced by the environment.

It can be difficult for parents who have children with very different personalities from each other, or different personalities to themselves, to understand their child’s ‘oddities’. For example, extravert parents may find their introvert child hard to fathom and may poke fun at them for their bookish behaviour, which can make the child miserable. This can be more difficult for a neurodiverse child growing up in a neurotypical family. 

Infants are wholly dependent on the adults caring for them. Their early sense of self is fragile, based on instincts. How their carers respond to them, by understanding their infantile communications and anticipating their needs, well before language even develops, will shape that child’s personality (as will their experiences in later life):

  • If the infant is hungry or cold, will someone pick them up when they cry? Or will they get ignored, or even shouted at? 
  • Will a parent experience visible joy watching their infant accomplish tasks such as sitting up, playing peek-a-boo, or saying their first words?
  • When the 2 year old child refuses to put their shoes on will they be labelled as ‘naughty’, or described as ‘resolute’? 
  • When the 3 year old girl plays with a truck, will this be encouraged, or will she be told it’s a boy’s toy? 
  • When the 4 year old boy wants to wear a dress, will he be laughed at or called a ‘poufter’, or will he be left to wear what he wants?
  • When the 5 year girl old loses her bookbag, will she be yelled at, or helped to remember where she might have left it?

The development of someone’s sense of self is a life’s work and is influenced by their environment. A person’s awareness and focus on their self depends on many factors. If someone is in dire straits, for example with domestic violence, sexual abuse, trauma, fleeing a war-torn country, or growing up in a hostile, chaotic and unpredictable environment, the focus and importance of their internal enquiry of who they are takes a back seat. In survival mode there are more pressing concerns.

As a person moves through the stages of development, from infant to adolescent to adult (and for some from parent to grandparent), their temperament might drive some fundamental personality traits. However, the individual will also use the feedback they receive from their environment (family, friends, teachers, work-colleagues etc), to co-construct their sense of self and their personality. This learning loop involves conscious and unconscious communications from other people around an individual. Therefore, when a parent says one thing, but actually believes something else, this ‘mixed-message’ may be picked up, creating a tension and conflict within the child. Classically, this might be the child who is told they are loved but is frequently and cruelly criticised (often for their ‘own good’).

An individual’s personality might be understood as related to how others view that person; and a person’s inner sense of self dependent on how that person views themselves (Nettle, 2009). Are they cooperative, or do they prefer to take the lead? Are they someone who loves making others laugh? Do they like things predictable and consistent, or would they take any opportunity to experience something new and different? Do they crave to be around people most of the time, or would they rather spend time on their own, and see people in small doses? Do they seek attention and admiration, or does the thought of performing to an audience make them cringe? Are they reliable or disorganised? Do they love learning lots of facts, or would they prefer creating abstract works of art? Are they aware of friends who are struggling and could do with some support, or do they believe every person is responsible for themselves? Are they sensitive to the emotions and needs of others, or do they find other people’s inner worlds a mystery? Are they prickly and a bit suspicious, or do they tend to ignore or forgive people’s foibles?

When it comes to the theory of gender identity, someone’s personality will interact with their inner sense of themselves, the ideas of gender they are exposed to from their social environment and their comfort with engaging in ‘gendered’ behaviours. Does a person present themselves using more stereotypical ‘masculine’ traits – loud, argumentative, powerful, controlling? Or do they see themselves as more stereotypically  ‘feminine’ – soft, compliant, ditzy, timid?

Many people will bristle and disagree with those gender descriptors, and seek to challenge restrictive stereotypes of women and men. Gender non-conformity is common: it is rare that a person can adhere consistently and completely to cultural caricatures of their sex. Descriptions of masculine and feminine traits vary across the world and over time. Gender will depend on the home someone is raised in, where they live, what culture they grow up in, and to what degree their society restricts the opportunities for members of each sex in terms of dictating how they ought to dress or behave. 

The development of identity is far from easy: people may feel discontent or uncomfortable with some aspect of themselves for any length of time, often until middle-age (ONS, no date), and frequently beyond. Adolescence is the time of most turmoil, where the psychological task of separating and individuating can become pretty all-consuming, and identities can shift quickly depending on many factors. 

An individual’s constant interaction with others around them can lead to consternation about how fellow humans ‘get them wrong’ and misunderstand that person (as everyone misunderstands each other, at least some of the time). This means that an individual’s internal world can be confusing. On the outside they try to present a stable and acceptable front that strives to be compatible with the world around them. Yet some of these same people may feel insecure or have unmet needs on the inside, regardless of how confident and self-assured they appear to others. Through adolescence and beyond people learn more about themselves, how they interact with others, and how others perceive them. They discover how complicated everyone is, how it’s easy to get another person wrong. It’s hard to expect others to truly understand someone else when most people find it difficult to understand themselves. Splitting off the idea of gender identity from all the other strands of development, in terms of its reliability and certainty at a young age, may thus be unhelpful. Conceptualising gender identity as permanent, innate and a somehow entirely separate component of a person’s self perception may try to simplify something that is more complicated. In doing so, clinicians may miss important aspects that affect these understandings. 

Gender dysphoria can arise when such confusing and complicated developmental processes get stuck, and the focus of attention becomes fixated on an inner sense that is difficult to define, and therefore to describe. The idea that people somehow know what their gender identity is (and that if they don’t, they should), is a new idea. This notion is one that many professionals are concerned about, as it seems an almost impossible task for their patients, let alone healthcare providers. This may explain the increasing number of labels (Abrams, 2019) that have come about to describe this inner essence. 

What clinicians do know is that the way people develop is wonderfully diverse. No one should feel they have to be put into a box, or that they should fit themselves into a box, especially during childhood and adolescence, when opportunities should be opening up rather than becoming more restrictive. This can be hard for the adolescent and their carers alike. Adolescence is a time for exploring and expressing different aspects of selfhood, and a time of risk-taking. Pushing back on society’s expectations for women and men may form part of that process: there is a long history of creative individuals who challenge gender roles and presentations. While defying social norms is not entirely risk-free, the UK has less rigid restriction on gender expression compared to other parts of the world.

References:

Abrams, M. (2019) 64 Terms That Describe Gender Identity and Expression, Healthline. Available at: https://www.healthline.com/health/different-genders

Nettle, D. (2009) Personality: What Makes You the Way You Are. Oxford University Press.

ONS (no date) Well-being, Office for National Statistics. Available at: https://www.ons.gov.uk/peoplepopulationandcommunity/wellbeing.

Power, R. A. and Pluess, M. (2015) ‘Heritability estimates of the Big Five personality traits based on common genetic variants’, Translational Psychiatry, 5(7), pp. e604–e604. doi: 10.1038/tp.2015.96.