“Being transsexual, transgender, or gender non-conforming is a matter of diversity, not pathology”. This statement is from The World Professional Association for Transgender Health (WPATH) Standards of Care, 2011 guidelines , which provide clinical guidance for health professionals and challenge medical classification that has long considered gender identity disorder, a term that has largely been replaced by gender dysphoria, to be a mental health problem.

As WPATH point out, “some people experience gender dysphoria at such a level that the distress meets criteria for a formal diagnosis that might be classified as a mental disorder.” However, gender dysphoria is not caused by psychopathology or mental illness, but is mainly an issue with identity. Misdiagnosis, or simply overlooking gender dysphoria is misleading, unhelpful, and harmful. Not only does it compound social stigma but it also misinforms the medical profession. Gender dysphoria is not a mental illness; however, internal biological conflicts—a yearning to live in the gender role dictated by the brain, not the genital sex, or phenotype—might lead to a mental health diagnosis.

The Tavistock and Portman's Gender Identity Development Service (London, UK) offers a specialist service to people aged 18 years or younger. There are an average of 55 UK referrals a month from a General Practitioner or from Child and Adolescent Mental Health Services, with a wait time of 18 weeks. Dr Bernadette Wren, consultant clinical psychologist at GIDS tells The Lancet Psychiatry that “a lot of the referred teenagers self-harm regularly, and a small number have tried to kill themselves”.

Many trans* people have chronic anxiety and depression, suicidal ideation, self-harm, agoraphobia, substance abuse, and feelings of low self-worth, detachment, and body dysmorphia. Dr Stuart Lorimer is a consultant psychiatrist working in the National Health Service (NHS) Gender Identity Clinic in Charing Cross (London, UK) and GenderCare (London, UK), a private practice of clinicians specialising in gender medicine. He believes that, mostly, psychological symptoms are relieved when the core gender concerns are addressed.

The organisation Gender Identity Research and Education Society ( GIRES ) is fiercely committed to trans* equality. GIRES aims to “improve substantially the circumstances in which gender non-conforming people live”. Its focus is on empowerment and advice, and educating corporations, schools , health providers, and policy makers to inform and change attitudes in health-care and education systems. GIRES founders, Bernard and Terry Reed, are passionate and tireless advocates: “We never say no,” Bernard explains. Priorities include providing online resources for General Practitioners and schools, in recognition of the huge gap in knowledge and the damaging effects this has on the trans* population. According to the Trans Mental Health Survey 2012 , 48% of trans* people under 26 years had attempted suicide, and 30% said they had done so in the past year, while 59% said they had at least considered doing so. This compares to about 6% in the same age group (Adult Psychiatry Morbidity Survey). “Trans* people are just ordinary people”, says Terry, but a minority that are marginalised and vulnerable to social exclusion. “We need to celebrate diversity not just tolerate it”.

The agonising wait for the first consultation at a Gender Identity Clinic (after the mandatory psychiatric assessment and referral) can take up to 1 year, and further delays often occur for hormone treatment and surgery (1–5 years), largely due to the very small number of gender specialised clinics in the UK . Consensus opinion identifies specific concerns: lack of trans* aware professionals, denial of treatment because of mental health problems, rigid criteria to meet for approval, denied access to the appropriate services, post-surgical complications, humiliation, and bullying. Lorimer says that he set up an independent practice because “I wanted to try and replicate what I saw as a model of good NHS practice within the private sector”, not to “poach” NHS patients, but to “move them on along NHS pathways in the longer term”. Diversity role model Leng Monty faced what he described as a “tennis match” between his General Practitioner and NHS psychiatric facilities—being referred though NHS pathways is often fraught with complications.

As well as hormone treatment and surgery, adapting to a gender role that has not been part of your social conditioning, with changes in cognitive and emotional functioning, brings its own set of challenges. Every trans* person experiences these to a lesser or greater degree, and individuality should not be overlooked—more focus on patient-centred care is needed.

Michelle Bridgeman, based in London, transitioned in an era when it was largely misunderstood. She is a counsellor specifically offering psychological support to children, their families, and anyone with gender concerns. “People are petrified about doing something about it” she says, identifying society as the problem and adding that she is “fed up with people who are supposed to be professionals not understanding”. She explains with the analogy, “you don't have to have had a stroke to deal with a stroke victim”.

Leah Davidson, at Pink Therapy , London, UK, states that there is little support offered to trans* identified people beyond hormone treatment and surgery. “Gender change and hormones mean that personality can change and the impact of this on relationships and partners who may not have chosen this is an issue”. After a protracted period of attempting to adopt a binary role in society, transitioning is a decision that many feel is their only recourse; however, acceptance from family, friends, and colleagues is often the hardest aspect, lack of which can, and does, result in the loss of important and lifelong relationships.

CliniQ is a sexual health and wellbeing service, with support around transitioning, relationships, sexuality, and gendercare pathways. Michelle, a CliniQ counsellor, says “the impact of transphobia and being misgendered can have a multiple layered negative intersection on every aspect of life.” Michelle is clear about what needs to be done: “Trans* awareness needs to be in the core curriculum of all health professional training.”

A community interest company set up in 2008, Gendered Intelligence (GI), offers a creative space for young people (under 25 years) to explore gender in various expressive arts workshops and projects. Jay Stewart tells The Lancet Psychiatry that the “current medical attitude is changing…our take at GI is to engage and play our part in shifting services, and to work with staff who are delivering those services.” Referring to the successful “ Who Am I ?” project at the Science Museum, Stewart says “science plays its part in distinguishing boys from girls, but science can also be used to empower us to express who we are”. Gender is dynamic he says, and this needs to be talked about.

Trans* awareness and acceptance needs greater visibility. However, disclosing one's identity is a personal choice. Journalist Juliet Jacques is open about her transgender history in blogs, such as My Transgender Journey published in The Guardian. She talks to The Lancet Psychiatry about supressing her transgender identity for years, first coming out as “gay” and a “cross-dresser”. When eventually she became Juliet, she had to cope with the psychological effects of “living as a woman” without hormones and treatment, which she says was “disastrous”. Her experience of a trans* phobic society kept her isolated and unable to form any meaningful relationships as a teenager. Juliet explains how “socially, I still feel like I'm in between male and female, and I do in my body as well”. The anxieties are still there, but “the all-consuming sense of it being fundamentally wrong for me has dissipated”.

Andie Davidson tells The Lancet Psychiatry that it is social conditioning that “makes gender incongruence destructive because it makes being transsexual a stigma and shameful.” She spent years in self-hating guilt, not knowing what was making her feel this way. Through transitioning she lost her marriage of 30 years—a tragic, but often inevitable consequence “simply for being me”. Being alone seems to be a reality for many trans* people. Abi Daniella Jay, living in a male role, discovered she was intersex late in her life, having felt “removed from so-called normal society” for as long as she can remember. Her transition cost her most of her family, her wife, and many friends. “Why should I be mocked or treated with disdain, as becoming Abi was never a premeditated act of betrayal,” she says. Samuel Hall faces ongoing transphobia from family members, alienation from his church community, and, a familiar narrative, being “ostracised in the workplace to the point of almost losing my career”. A society influenced by gender binary conventions can cultivate anger and fear and manifest in abuse and rejection. Samuel hopes for “a wider range of accessible mental health services, peer advocacy…and support hubs than signpost trans* people to services they might need”.

How important is it to talk to other trans* people who have lived through it? “Very important,” says Sonny Van Eden, co-author of Hertfordshire Transgender Health Needs Assessment 2013. Sonny has teamed up with mental health charity Viewpoint to address the lack of local services in his area and promote the right for equal access to health care for a hidden and underrepresented population. He sees a peer-support system as an exemplary model, but admits that implementation is not easy. Most trans* people seek out support groups that are trans* led. Sonny explains there is less of a sense of belonging to a community, but more a relief at meeting and talking to people who simply understand.

So what is out there for trans* people who cannot get their needs met from mainstream psychiatry? Although The Royal College of Psychiatry offers a CPD module by gender expert Professor Kevan Wylie, it is not a compulsory training requirement for UK psychiatrists. In 2012, a UK research partnership published the Trans Mental Health Survey, commissioned to explore how the process of transitioning (social or medical) affects mental health and wellbeing. This report highlighted a lack of appropriate health service provision (especially in regard to insufficient access to timely, good quality, and patient-centred NHS gender reassignment services).

Professor Melissa Hines (Director of the Hormones and Behaviour Research Lab at the University of Cambridge, UK), is a specialist in human gender development. She tells The Lancet Psychiatry “people assume that there is some inborn influence on gender identity variation, but no-one has been able to say what it is.” One fear, voiced by an anonymous contributor, is that unless specialist gender counselling is available outside of the assessment process, the fear of not being “trans” enough, or meeting the criteria guidelines, might result in withholding of treatment, and who has the right to decide this, the individual or the doctor? Nature delights in diversity, why can't human beings?

Trans* is an inclusive term that refers to all of the identities within the gender identity spectrum Tavistock and Portman Clinic see For thesee http://www.tavistockandportman.nhs.uk/care-and-treatment/information-parents-and-carers/our-clinical-services/gender-identity-development video on GIRES educational seminar with Thomson Reuters see For thes see https://www.youtube.com/watch?v=laPdcpZ7fUw&list=UUwIde9oejR6WpaVEa5zZ37w

Copyright © 2015 R Jeanette Martin/Demotix/Corbis

Article Info Publication History Identification DOI: https://doi.org/10.1016/S2215-0366(15)00022-X Copyright © 2015 Elsevier Ltd. All rights reserved. ScienceDirect Access this article on ScienceDirect