# Motivation and emotion/Book/2019/Gender transformation motivation

* Multimedia presentation (3 min)

## Overview

Gender transformation is the changing of one’s assigned gender to their desired gender. This is also known as changing from the gender you are born with to one you feel you were born to be. Gender transformation has been present since 1922, when Magnus Hirschfeld offered one of his patients the ability to change into their desired gender (Khan, 2019). Motivators of gender transformation include the disorder gender dysphoria. This was added to the DSM-V to account for those who believe they were born into the wrong body.
Theories that emphasise the motivation one may have to change genders, and how this could affect their well-being for the better, include Gender-Role-Conflict (GRC) theory, and Maslow’s hierarchy of needs theory. There are also many aspects that may discourage one from achieving their desired gender. These include the financial cost of transformation, including gender confirmation surgery and hormone treatments. There is also the physical and mental cost of gender transformation, and also the discrimination one may face from those outside the LGBTQI+ community.

## Gender transformation

Gender transformation refers to the process of changing from one’s assigned gender (the gender you are born with) to one’s desired gender in which you feel you resonate with more. In the DSM-V, there are many different terms and definitions relating to gender transformation:
* Sex: refers to the physical/biological sex organs you are born with. This includes a penis for men, and a vagina and breasts for women.
* Gender: refers to the label society gives you. This can include male, female, girl, boy man and woman. This does not always refer to the gender you are born with, as you may have been born a female, but feel as though you resonate with being a male more, regardless of your sex organs. Some may also not label themselves as any gender, regardless of their sexual organs.
* Gender assignment: refers to the societal label of gender you are born with. This includes the labels of male or female.
* Transgender: refers to an individual who persistently identifies with a gender that is not their assigned gender and does not resonate with their sex organs.
* Transsexual: refers to an individual who has undergone a physical/social transition from one gender to another. This can involve an undergoing of cross-sex hormone treatment and gender confirmation surgery.
* (Diagnostic and statistical manual of mental disorders, 5th Edition)

## The history of gender transformation

Gender transformation started becoming a possibility due to the work of Magnus Hirschfeld (see Figure 1), a German physician and sexologist. In 1918 he coined the term transvestite, and used the term as his basis of consideration for sex changing therapies (Khan, 2016). He was one of the first people to offer one of his patients a sex change through sex confirmation surgery (Khan, 2019). More can be read about him and his work on Magnus Hirschfeld.
Homosexuality was diagnosed as a psychiatric illness in the Diagnostic Statistic Manual (DSM) up until 1973, and even after that, conditions containing homosexual traits were not entirely removed from the DSM until 1987 (Beredjick, 2012). Gender dysphoria, which is the psychological condition given to many who are transgender, was added to the DSM-III originally as Gender Identity Disorder, and was then changed to gender dysphoria in the DSM-V (Zucker, 2010).

## What motivates gender transformation?

It is important to clarify what is meant by gender transformation. When you think of gender transformation, many think of the partaking of gender confirmation surgery to change one’s gender, however, surgery is not the only way in which some transgender individuals gain their desired gender. For some, partaking in hormone replacement therapies are beneficial enough. These include feminising hormone therapies, which are for male-to-female transformations and increase the levels of estrogen and decrease testosterone (Transgender Care, 2019). For female-to-male therapies, there are masculinising hormone therapies which increase testosterone and decrease estrogen (Transgender Care, 2019). For other individuals, the simple changing of labels and names are enough to feel as if they have made the change from female to male. This includes being referenced with the correct pronoun such as ‘he’ or ‘she’, as well as changing their name to a ‘gender specific’ name. This can increase their feeling of being accepted as the gender they desire. There are a few different reasons and theories as to what may motivate one to first feel as if they were born into the wrong body, as well as what may motivate them to fully engage with their desired gender.

### Gender dysphoria

Gender dysphoria was added to the DSM-III, originally as Gender Identity Disorder (Zucker, 2010). It was then changed to gender dysphoria in the DSM-IV-TR (Zucker, 2010). Gender dysphoria refers to the distress that may accompany the incongruence between one's desired gender and one's assigned gender. For example, if an individual is born as a male, but feels as if they are meant to be a female, or vice-versa.
One will be diagnosed with gender dysphoria if they are experiencing the distress for at least 6 months, and must experience 6 of the following:
* A strong need to be the desired gender or an insistence that one is another gender
* A strong preference for cross dressing or wearing the desired gender’s typical clothing, and a strong resistance for wearing the assigned gender’s clothing
* A strong preference for cross-gender roles in make-believe play or fantasy play
* A strong preference for the toys, games, or activities stereotypically used or en­gaged in by the other gender
* A strong preference for friendships of the other gender
* A strong resistance of one’s assigned gender’s toys, games and activities. For example, for assigned males, a disinterest in rough-and-tumble games
* A strong dislike of one’s assigned sexual anatomy
* A strong desire for the primary and/or secondary sex characteristics that match one’s desired gender
* (Diagnostic and statistical manual of mental disorders, 5th Edition)
Not all indi­viduals will experience distress as a result of such incongruence, but will experience the distress if the desired interventions by means of hormones and/or surgery are not available.
There is no specific age for the onset of gender dysphoria or feelings of confusion and conflict about ones assigned gender. While many think of adults and those over the age of 18 when discussing transgender individuals, gender dysphoria can be found in individuals under the age of 18. While the actual act of transformation is not made available to children under the age of 16 for hormonal therapies, and under the age of 18 for surgical treatments, there is an understanding that children can feel that they were born in the wrong body or of the wrong gender (Zucker, 2010). However, there is very small research on the effects of diagnosing such a young child with gender dysphoria, and what mental and physical effects it can have on a prepubescent child’s health. One study conducted focused on the mental health of transgender children who are supported from a young age about their internal conflicts between their assigned and desired gender, showed that their levels of anxiety and depression are limited during peak developmental periods (Olso, Durwood, DeMeules & McLaughlin, 2016). This can demonstrate that supporting all children that feel this conflict can be beneficial and will allow them to grow up feeling accepted and loved compared to those children who are not allowed to express their feelings about the gender dysphoria they are experiencing. To find out more, visit transgender youth.

### Theories

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#### Maslow's hierarchy of needs

Maslow’s hierarchy of needs is a great demonstration of how and why individuals are motivated to engage in gender transformation. Maslow stated that individuals are motivated to achieve certain needs they have. When one need is fulfilled, a person then seeks to fulfil the next one and so on (McLeod, 2007). However, certain needs cannot be fulfilled without other needs first being met.
This is a motivational theory within psychology that focuses on 5 main 'needs' that must be met throughout life. There are five stages to this model, which can then be divided into basic needs and growth needs. This theory is often depicted in a pyramid, with basic level needs at the bottom, psychological needs in the middle, and self-fulfilment needs on top (McLeod, 2007).
Referring to Figure 2, the five stages are physiological, safety, social, esteem and self-actualisation. Physiological refers to any biological needs such as food, water, shelter, warmth, sleep and sex. The safety stage refers to security of body, employment, resources, mortality, family, health and property. The belonging/love stage refers to having relationships with family, friends, as well as experiencing sexual intimacy. The fourth stage, esteem, refers to one’s self-esteem, confidence, achievement, respect for others and respect by others. The fifth and final stage is self-actualisation. This refers to realising personal potential, self-fulfilment, seeking personal growth and peak experiences (Mcleod, 2018).
One cannot meet all five stages of needs without the lower stages being met first. For example, if an individual is not satisfied in their belonging and love stage, they will not be able to fully meet the self-esteem or self-actualisation stage.
This relates highly to the conflict that one faces when dealing with gender dysphoria, as it demonstrates how individuals who are not able to surrender to the feelings of their desired gender, are not reaching their fullest potential both physically and mentally. Many of the stages display an area that many transgender individuals cannot achieve without becoming their desired gender. For example, in the safety stage, while security of body may mean in a physical sense, transgender individuals may not feel security in their assigned gender body. Therefore, they are unable to move up to the next stage of needs. The Esteem and Self-actualisation stages would not be able to be achieved until transformation has begun, as the individual may not have any self-esteem due to feeling so uncomfortable in their assigned body, and self-actualisation involves self-fulfilment, which again, will not be achieved until they experience their desired gender.
Maslow’s hierarchy of needs demonstrates how one may be motivated to transform to their desired gender, as one will never reach their full potential or gain all the required needs to live a happy and full life, without feeling like themselves. Gender transformation may be the final step one needs in order to live a well-rounded and happy life.

#### Gender-Role-Conflict theory

Gender-Role-Conflict (GRC) theory is a framework that demonstrates how GRC occurs when an individual experiences negative consequences from overly restricting gender roles and situations (Wester, McDonough, White, Vogel & Taylor, 2010). This can be applied to transgender individuals as it may demonstrate the stress that is caused due to a mix of gender dysphoria and GRC demanding them to embrace their assigned gender, rather than allowing them to experience their desired gender.
GRC theory explains that there are five stages involved in the process from transitioning from one gender to another. While this is a stage model, it is neither progressive nor inclusive. Meaning that not necessarily all transgender individuals will go through these exact stages, and those that do progress through the stages may not do so in this exact order (Wester, McDonough, White, Vogel & Taylor, 2010).
* Stage 1: Awareness – This stage is referenced as the state of coming to terms with an internal sense of feeling different, and the realisation that one may be different from others. In other terms, transgender individuals are becoming aware that they as an individual do not fit into societal expectations for their assigned gender.
* Stage 2: Seeking information – This stage results in finding information about the way one is feeling through external sources, rather than trying to determine it on their own. This includes the negative and positive outcomes to fully accepting their true self and displaying the desired gender to society.
* Stage 3: Exploration – This stage involves the individual exploring what meaning their transgenderism has in their life. This can include the adoption of a label that resonates with their desired gender, such as changing their name to a desired gender specific name and being asked to be called the correct pronouns (e.g. him to her, or she to he). This stage typically results in a resolution of conflict caused by gender dysphoria, and will often begin the process of determining how to reach their inner desires of their gender. However, this stage also offers some challenges and many individuals do not see themselves as either male or female, as they feel one way but look another. This will often have the effect on individuals wanting to jump straight into transformation treatments such as surgery or hormonal supplements.
* Stage 4: Disclosure – This stage refers to informing one’s friends, family and social circles of one’s transgender identity. This can often be the most challenging stage of all because the fear of not being accepted is very much made aware to the individual.
* Stage 5: Integration – This stage focuses on how the individual will engage in transgender transformation, whether this be surgery, medical intervention or just behavioural, and the post-transitional resolution of gender dysphoria.
* (Wester, McDonough, White, Vogel & Taylor, 2010)
This demonstrates the stages that a transgender individual goes through until they accept that gender transformation is what will benefit them both physically and mentally. These stages are very emotional and overwhelming to experience, and therefore knowing that transformation is what can limit the amount of conflict occurring within them, they will often become more motivated to engage in transformation, regardless of whether this is surgical, hormonal or just simply by label.

## What discourages gender transformation?

While there are many theories that explain the reasoning behind what motivates someone to engage in gender transformation, it is also beneficial to explore what could potentially discourage someone from engaging in gender transformation. This could include the financial, physical and mental costs of transformation as well as the discrimination that is faced when part of the LGBTQI+ community.

### Cost of transformation

For some transgender patients, as mentioned above, they consider themselves to have gone through gender transformation by a change of labels and/or hormone replacement therapy. However, for some, it is also the physical look of their body that they require to have changed to match their desired gender in order to fully feel as if they are experiencing themselves for who they feel they were born to be. This means undergoing gender confirmation surgery.
Gender confirmation surgery (originally named sex reassignment surgery) refers to all surgical procedures that a patient can receive in order to resemble the appearance of the opposite gender(Selvaggi & Bellringer, 2011).This is including vaginoplasty (for male-to-female transformations; the reconstruction of external male genitalia to female genitalia), a metoidioplasty (for female-to-male surgeries; the reconstruction of external female genitalia to male genitalia), or a phalloplasty (for female-to-male transformations; reconstruction of external female genitalia as well as a hysterectomy) (Bottom Surgery, 2019). For many this can resolve the conflict of gender dysphoria and help them reach their desired gender. However, it is not always financially viable for an individual to have the surgery, and can also have psychological and physical effects on an individual.
For vaginoplasty, the cost is somewhere between $10,000-$30,000. For either a metoidioplasty or a phalloplasty, is anywhere from $6,000-$30,000 (for a metoidioplasty) or 50,000-$150,000 (for a phalloplasty) (Bottom Surgery, 2019). These costs include the surgery itself, hospital accommodation, anaesthesiologist fees, psychological counselling required prior to the surgery, as well as hormone replacement therapy. For many individuals, to be able to finance such a surgery is unrealistic and unobtainable and can be why many transgender individuals do not always opt for this option, and are content with just hormone supplements. However, for those that do wish for the surgery in the hopes of ending their gender dysphoria, it is often unlikely one will be able to afford one.
When looking at the cost of transformation, this does not always mean financial cost. There are many health risks that come with having such a major surgery such as gender confirmation surgery. Bleeding, infections and blood clots all are risks one faces when making the decision to receive this surgery (Gender confirmation surgery, 2019). Some patients have also found issues in going to the toilet or sexual pleasure after surgery (Selvaggi & Bellringer, 2011). Gender confirmation surgery is also almost impossible to reverse, so one must live with the chosen gender (Gijs & Brewaeys, 2007). While the majority of individuals do feel a resolution of their gender dysphoria after surgery, there are those that do not feel a sense of resolved conflict, and therefore makes the decision on how to move forward with their transformation even more difficult (Gender confirmation surgery, 2019).

### LGBTQI+ community discrimination

The major discrimination shown towards the Lesbian Gay Bisexual Transgender Queer Intersex community by many homophobic and transphobic individuals is extensive. The act of completely changing your gender from your assigned gender to your desired gender is an act considered to be unnatural to some people, due to either religious views, or simply just prejudice against the unknown (Human rights campaign, 2019). In 2018, almost 400 transgender individuals were killed by either shootings, stabbings or beatings (Elks, 2018). This number may not be representative of how many transgender individuals have faced discrimination and may not show the true number of deaths and/or attacks due to transphobia.
Regardless, it is well known that all individuals from the LGBTQI+ community will face discrimination, not only from strangers but also, for many, from their own family and friends. While the LGBTQI+ community is a lot more accepted today than it was decades ago, there are still many that hold the opinion that what goes on in the LGBTQI+ community is unacceptable and dangerous. The fear of knowing that they may not be accepted by others, or that by being outspoken about their transition could cause them physical pain and maybe even death, which may discourage one from speaking out about their feelings let alone making the major gender transformation change.

## Conclusion

Gender transformation is an ever-changing experience with many different aspects, both emotional, physical and financial. Theories such as Maslow’s hierarchy of needs and gender-role-conflict theory highlight the stages individuals with Gender Dysphoria go through before they reach the decision to engage in gender transformation. This transformation may include gender confirmation surgery, hormone replacement therapy, or the changing of societal labels.
Their motivation may vary due to aspects such as the financial, physical and mental cost of transformation as well as the unnecessary discrimination that one may face during the transformation process.
More research is needed in the follow up after major surgeries and hormone treatments, and how transgender individuals feel after the change is finally made, as it would benefit those that are motivated to change as they would have all the information needed to decide whether gender transformation is required for them or not.