Transition is a term that is used to describe the process that individuals typically experiencing gender dysphoria go through to reach their desired social role, and/or physicality; there is no single definition of transition as the term is based on the unique requirements of each individual.
A diagnosis of gender dysphoria that is congruent with the diagnostic criteria of a recognised 'gender identity disorder' is the typical prerequisite for the treatment of persistent gender dysphoria in those countries which offer such services. Healthcare professionals typically reference either the Diagnostic and Statistical Manual of Mental Disorders (DSM) or the International Classification of Diseases (ICD) in order to confirm a diagnosis of gender dysphoria.
Before the 1960s few countries offered safe, legal medical options for people experiencing gender dysphoria and many criminalized gender-nonconforming behaviours or mandated unproven psychiatric treatments. In response to this problem, the Harry Benjamin International Gender Dysphoria Association now known as the World Professional Association for Transgender Healthcare (WPATH) authored one of the earliest sets of clinical guidelines for the express purpose of ensuring "lasting personal comfort with the gendered self in order to maximize overall psychological well-being and self-fulfilment". The WPATH 'Standards of Care' are the most widespread clinical guidelines used by professionals working with transsexual, transgender, or gender variant people, and have undergone several revisions since its initial publication. Traditionally these guidelines have been structured in relation to the Transsexualism diagnosis and as such have presented a dilemma for non-transsexual individuals who have been unable to meet the eligibility criteria for medical treatment.
In 'Archives of Sexual Behaviour (Volume 16), "Heterosexual and homosexual gender dysphoria"' (1987), Dr Ray Blanchard (who served on the DSM-IV Subcommittee on Gender Identity Disorders) wrote, "(there is a) well-recognized tendency of applicants for sex reassignment surgery to distort their histories in the direction of 'classic' transsexualism in an effort to gain approval for such surgery".
Gender dysphoria vs. gender identity disorder
Main article: Gender dysphoria
The diagnosis of 'Transsexualism' was introduced in the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) compiled by the American Psychiatric Association (APA) in 1980 for individuals who had experienced a minimum of two years of continuous interest in reconstructing their sex-physicality and assigned gendered identity. The criteria of the diagnosis focused on individuals whose identities resembled a male-to-female (MTF) or female-to-male (FTM) paradigm. Others experiencing gender dysphoria, but whose identities did not fit the MTF/FTM paradigms could be diagnosed with 'Adulthood Nontranssexual Type', or 'Gender Identity Disorder: Not Otherwise Specified' (GIDNOS). In 1994 the DSM-IV committee replaced the transsexual diagnosis; for individuals with MTF/FTM type identities a diagnosis of 'Gender Identity Disorder' (GID) would be applied instead. The diagnostic criteria of GIDNOS was left undefined, bar that the diagnosis be given to those whose 'gender identity disorder' cannot be defined within a MTF or FTM paradigm. Though a gender dysphoric nonbinary individual may use the term 'transsexual' to describe themselves, they are not considered to be transsexual within a clinical context.
The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was published in May 2013 which replaced the gender identity disorders with Gender Dysphoria. "The new revisions for the Gender Dysphoria diagnosis in the DSM-5 are mostly positive. However they do not go nearly far enough. The change in title from Gender Identity Disorder (intended by its authors to mean “disordered” gender identity) to Gender Dysphoria (from a Greek root for distress) is a significant step forward. It represents a historic shift from gender identities that differ from birth assignment to distress with gender assignment and associated sex characteristics as the focus of the problem to be treated... In another positive change, the Gender Dysphoria category has been moved from the Sexual Disorders chapter of the DSM to a new chapter of its own. Non-binary queer-spectrum identities and expression are now acknowledged in the diagnostic criteria... However, the fundamental problem remains that the need for medical transition treatment is still classed as a mental disorder. In the diagnostic criteria, desire for transition care is itself cast as symptomatic of mental illness, unfortunately reinforcing gender-reparative psychotherapies which suppress expression of this “desire” into the closet. The diagnostic criteria still contradict transition and still describe transition itself as symptomatic of mental illness. The criteria for children retain much of the archaic sexist language of the DSM-IV-TR that psychopathologizes gender nonconformity. Moreover, children who have happily socially transitioned are maligned by misgendering language in the new diagnosis. More troubling is false-positive diagnosis for those who have happily completed transition. Thus, the GD diagnosis, and its controversial post-transition specifier, continue to contradict the proven efficacy of medical transition treatments. This contradiction may be used to support gender conversion/reparative psychotherapies – practices described as no longer ethical in the current WPATH Standards of Care".
Non-binary healthcare (UK)
Main article: Non-binary healthcare (UK)
Historically, eligibility criteria for medical treatment has presented a barrier for nonbinary individuals, specifically the 'real life test' (RLT) component which was later renamed the 'real life experience' (RLE). The website of the London NHS gender identity clinic states, "There is a two year Real Life Experience (RLE) of living in the reassigned gender role at the GIC for people who want to have genital reconstruction surgery (GRS). This is dated from the start of full-time gender role transition after which they can be assessed for referral for GRS. The RLE includes at least a year in some form of agreed occupational activities." Nonbinary individuals requesting genital reconstruction surgery (GRS) are generally unable to satisfy clinicians in relation to the RLE criteria as there is little social or legal recognition of the nonbinary demographic. On the 1st December 2010, the University of Cambridge Centre for Gender Studies hosted the final public forum in its series on gender and radical biomedical advances, “Transitioning gender: the challenges of radical technologies”, in association with the Guardian and supported by Cambridge University Press. One of the speakers was Dr Richard Green, former research director and consultant psychiatrist of the London NHS gender identity clinic, who referenced “third gender or no-gender person(s)” seeking surgery to “remove breasts or male genitalia” and calls this a “medical dilemma for physicians because there’s no real life experience. Its either surgery, or not”.
“...Young people are eligible for treatment in the adult NHS clinics (once they are 18 years old) or by private practitioners (from 16 years old)”.
Changing your name
Main article: Names
In most societies, a personal name is a fundamental component of social identity. The naming of infants by humans throughout history has typically followed local cultural traditions which have emphasised familial connections, also commonly inferring that the owner of a given name is either 'male' or 'female'. Many individuals go on to adopt an alternative to their birth-name, or replace it altogether; individuals experiencing gender dysphoria may regard such an act as constituting the whole, or part, of their transition.
Changing one's name within an everyday social context can be as simple as informing others of your choice, however in societies with a complex legal system (or equivalent) there can be conditions that place limitations on the individuals right to self determination which can be especially problematic for nonbinary individuals. For example, in Germany the Standesamt (Office of Vital Statistics) typically refuses to recognise in German civil registration law names that are gender-ambiguous; a given name must indicate that the owner is either 'male' or 'female'.
State of address
Main article: Gender neutral titles
Many societies formally recognise various states of address (commonly referred to as ones 'title'), which in many instances indicate a 'male' or 'female' identity; such as 'Mr' in the English vocabulary, 'Madame' in French, and so on. Many individuals changing their name as part of their transition also change their state of address, or attempt to remove such references from their personal identity documentation altogether.
Some individuals adopt a gender neutral title such as 'Mx', 'Misc', or 'Pr'. For the most part, gender neutral titles without qualification/career connotations are not recognised by the general public or businesses/organisations. Activists and supporters are working toward awareness and acceptance of alternative titles. For some nonbinary folk, being referred to with a gendered title can trigger gender dysphoria.
Main article: Pronouns
Pronouns are a part of language used to refer to someone or something without using proper nouns. Proper nouns are the names for things - for example, "Pat" for a person or "Husky Tower" for a downtown building. The most common use of pronouns in the singular of the English language for people is gendered - for example, he/him/his for men and she/her/her for women. However, there is an increasing demand for singular gender neutral pronouns, such as they/them/their in the singular or the Spivak set, ey/em/eir.
Changing your presentation
Main article: Non-binary presentation and expression
Some nonbinary individuals intentionally present an androgynous or gender neutral personal aesthetic by removing, replacing, or blending gender cues in their general presentation. For many, adopting such a personal aesthetic can ease the symptoms of gender dysphoria, while others may be motivated primarily by a desire to make a political statement; each individual typically has their own unique reasons for adopting any particular 'look'. However, it is no more true to state that 'all nonbinary individuals want to appear androgynous' than it is to state that 'all women want to appear feminine'. Though they may not apply binary-gender stereotyping to their own presentation, some nonbinary individuals seek a personal aesthetic that is considered by their own culture as being variously congruent with binary stereotypes, the affected nonbinary individual may then experience gender dysphoria triggered by the resulting cognitive dissonance.
Public reactions to individuals whose presentation, for whatever reason(s), appears to challenge binary-gender stereotypes varies widely. While there are a number of individuals who are known internationally and celebrated specifically for having such an appearance (such as Ruby Rose), most individuals receive negative reactions for challenging binary-gender stereotypes, so safety is a concern for many nonbinary individuals attempting to transition to a socially visible nonbinary status.
Changing your voice
Main article: Voice and speech
Many societies (human and otherwise) recognise certain rages of vocal communication as being typically 'masculine' or 'feminine', consequently a given individuals own vocal range can trigger a feeling of gender dysphoria in that individual and they may try to alter their vocal range, or 'voice', as a result.
There are several factors which contribute to how a voice is interpreted with regards to gender, and these factors vary between societies. The most commonly recognised of these factors is pitch, which can undergo a dramatic transformation during ones lifetime due to the physical changes associated with puberty or endocrine therapy, for instance. Several studies have identified a gender-ambiguous average pitch at 155-187Hz, a feminine average pitch at 220Hz, and a masculine average pitch at 120Hz.
Changing your legal identity
Main article: Legal gender
The majority of contemporary national legal systems operate according to a standard wherein each citizen must be registered as either 'male' or 'female', however an actual definition of those terms may be lacking in legislation. For example in Britain the terms 'male' and 'female' are not mentioned in registration law, the individual is solely referred to as either 'person' or 'the child' although there are some gendered references such as 'mother', 'father', etc. However, the terms (male or female) are usually required to be visible on personal identity documentation which is necessary to access many essential public services.
India recognises one of its trans demographics (Hijra) in law, giving them a status besides 'male' and 'female' in legal documentation, however as the rest of the legal system is designed to accommodate only 'male' and 'female' citizenship the Hijras' legal recognition can at times prevent affected individuals from enjoying the equality their legal status was originally intended to secure.
- Adler et al 2006, Andrews 1999, Gelfer et al 2000, Spencer 1998, Wolfe et al 1990