Acta Med. Okayama, 2018
Vol. 72, No. 2, pp. 143‑151
CopyrightⒸ 2018 by Okayama University Medical School.

Original Article

http://escholarship.lib.okayama-u.ac.jp/amo/

Descriptive Study of Gender Dysphoria in Japanese Individuals
with Male-to-Female Gender Identity Disorder
Yoshie Shinoharaa＊ and Mikiya Nakatsukaa,baGraduate School of Health Sciences, Okayama University, bDepartment of Obstetrics and Gynecology and Gender Clinic,
Okayama University Hospital, Okayama 700-8558, Japan

We focus on Japanese individuals with gender identity disorder (GID), especially male-to-female (MTF) GID,
who have experienced difficulty in adapting to social life. We clarify what gender dysphoria is, and we examine
methods of intervention. Semi-structured interviews were conducted with 11 individuals with MTF-GID from
August 2015 to April 2017. We categorized the subjects’ experiences regarding dysphoria into the ‘Onset ofgender dysphoria,’ ‘Experience of feeling gender dysphoria,’ and ‘Changes due to receiving medical care.’ The
subjects reported experiencing great pain and distress because they did not fully understand that they wereexperiencing dysphoria and could not align their gender identity and their self-identity. All subjects described
their experiences of dysphoria as negative. Additionally, all said that the dysphoria was alleviated by a medical
intervention such as visiting a gender clinic, receiving a diagnosis and treatment, and changing their physicalsex to the sex congruent with their gender identity. The provision of information at the gender clinic and thephysical changes achieved by medical intervention exerted a positive effect both mentally and socially on thesubjects, who suffered various physical, mental and social problems.
Key words: gender identity disorder, gender dysphoria, gender identity, male to femaleA

gender identity disorder (GID) diagnosis involves
a marked incongruence between an individual’s
experienced/expressed gender and primary and/or secondary sex characteristics, a strong desire to be rid of
the primary and/or secondary sex characteristics, astrong desire for the primary and/or secondary sex
characteristics of the other gender, a strong desire to beof the other gender, a strong desire to be treated as theother gender, and/or a strong conviction that one has
the typical feelings and reactions of the other gender[1].
According to the guidelines of The Japanese Societyof Psychiatry and Neurology (JSPN), the current diagnosis and treatment of GID in Japan are as follows [2].
Received May 22, 2017 ; accepted November 24, 2017.
Corresponding author. Phone : +81-86-235-6895; Fax : +81-86-235-6895
E-mail : pd804vg1@s.okayama-u.ac.jp (Y. Shinohara)＊A psychiatrist with sufficient understanding and experience concerning GID performs a consultation, and the
diagnosis is confirmed by two psychiatrists. If the 2
psychiatrists do not agree, further examination by apsychiatrist is required. The individual’s upbringing,life history, and sexual behavior are inquired about
during counseling, and the status of gender dysphoria
is used to determine the gender identity. Subsequently,
the individual’s physical sex is determined by a urologist
or gynecologist and is confirmed in writing by the psychiatrist responsible for the diagnosis. Following adiagnosis by exclusion, GID is diagnosed when it isclear that the individual’s physical sex and gender identity do not match. In addition to psychiatric support,
physical treatment such as hormone therapy and sex
Conflict of Interest Disclosures: No potential conflict of interest relevantto this article was reported.

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reassignment surgery (SRS) can then be performed.
In 2013, amid an increasing awareness of GID insociety, the Diagnostic and Statistical Manual (DSM) of
Mental Disorders of the American Psychiatric Associa­
tion [1] adopted the diagnostic name “Gender dysphoria,” which corresponds to the previous diagnostic
name of GID. Previously, in the DSM-IV-TR (i.e., thefifth edition, text revision), the term “Cross-gender
identification” was used; however, the DSM-IV empha­
sized the inconsistency of the term “incongruence.” Thebasis of the diagnostic concept is to avoid conventionally used names such as “disorder” and the pathologization of the condition and to understand gender as being
diverse and not limited to the dualistic concepts of“male” and “female.” As the term GID continues to be
used in Japan, in the present study we use this term torefer to the transitional stage.
Many individuals with GID experience gender dysphoria from childhood [3]. Based on the results of asurvey report of consultees of gender clinics which hasprovided a GID clinical base in Japan, many individuals with GID began to feel gender dysphoria before
entering elementary school, and most felt gender dysphoria before puberty [4]. They reported feeling gender
dysphoria with respect to their own bodies and felt thatthey were different from others, commenting, forexample, “Am I strange?” “What would my parents
think if I told them?” or “I wish I had never been born”
as a result of decreased self-esteem [5]. Thus, many had
lived with a great deal of unease since childhood.
Children with male-to-female (MTF) gender dysphoria, in which the gender identity is female and thephysical sex is male, believe that they “definitely” do notwant their family members, their teacher, or school
nurse to know about their condition, and it is wellknown that in many cases, such children are unable toreveal the condition to anyone [6]. In addition, as secondary sexual characteristics develop, undesirable
physical characteristics related to sex become visible,
and individuals with gender dysphoria go throughpuberty with even greater distress. For individuals with
MTF gender dysphoria, changes in the body duringpuberty present difficulties in the social acceptance ofthe voice and appearance of the desired gender, [7] andthe changes create major problems in their adult social
lives. Moreover, among individuals with MTF gender
dysphoria in Japan, there are many cases in which theperson worries about public perception or the succes-

Acta Med. Okayama Vol. 72, No. 2sion of the family business and ends up marrying andhaving children [4]. For this reason, there are many
individuals who receive medical treatment to approach
their desired gender while experiencing isolation insociety, difficulty in living, and various stigmas [8].
Gender dysphoria is the root of the difficulties in thesocial lives of these individuals, but this can change
following medical intervention. However, after hormone therapy or SRS, gender dysphoria is not alleviated in all individuals even after changes in the body
have occurred. Kuiper and Cohen-Kettenis [9] reported
that some individuals experience a collapse of their previous self-image and body image as a result of undergoing hasty surgical treatment after being diagnosed with
GID. In addition, among individuals who have undergone SRS, there can be a sense of physical loss, andmany experience continued problems such as a lack ofunderstanding from family members, partners, andother people in their environment, and a sense of isolation. Simon et al. [10] indicated that individuals with
MTF gender dysphoria may face more difficulties
adapting than do individuals with female-to-male gender dysphoria, in which the gender identity is male but
the physical sex is female.
Cases of gender dysphoria are not uniform; thefeelings of each individual and the experiences associated with gender dysphoria are diverse. There may also
be differences depending on culture, religion, andother factors. The status of “gender dysphoria andaccompanying experiences” of individuals with GID in
Japan has not been elucidated to date. In the present
study, we focus on Japanese individuals with GID,
especially MTF, who experienced difficulty in adapting
to social life. We discuss the definition of gender dysphoria, and we examine the methods of intervention.

Subjects and Methods
Materials and methods.
Semi-structured interviews were conducted with 11 individuals with MTF
gender dysphoria from August 2015 to April 2017. The
subjects had already received a diagnosis of GID andwere receiving treatment (Table 1). An approx. 60-min
interview was held with each subject and we obtained
consent from each subject to record the interviews andtake field notes. We inquired about age, occupation,birthplace/environment, family background, education, and religion as background factors. We also asked

Gender Dysphoria in MTF-GID

April 2018
Table 1
Respondent

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Background of Respondents
Age

History of the Treatment

MarriedChild/Children

Interview Length1

Early 20ʼsHormone therapy

No

None

55 min2Late 30ʼsHorsmone therapy

No

None

63 min3Late 30ʼsHormone therapy, Phallectomy, Orchiectomy, Colpoplasty

No

None

85 min4

Early 30ʼsHormone therapy

No

None

48 min5

Early 30ʼsHormone therapy

No

None

43 min6Late 40ʼs

Hormone therapy

No

None

58 min7

Early 50ʼs

Hormone therapy

No

None

50 min8

Early 50ʼs

Hormone therapy

No

None

62 min9Late 50ʼs

Hormone therapy, Phallectomy, Orchiectomy, Colpoplasty

No

None

39 min10Late 50ʼs

Hormone therapy, Phallectomy, Orchiectomy, ColpoplastyYes

1

42 min11

Late 60ʼs

Hormone therapy, Phallectomy, Orchiectomy, ColpoplastyYes

3

36 minabout ‘gender dysphoria’ and ‘experiences concerning
their gender’ and encouraged the subjects to give freeresponses.
The interviews were recorded verbatim, and significant information was extracted while keeping the context in mind.
1. Data compression: We extracted a summary of
the significant points from the interviews, classified andorganized these points by comparing differences/common points using target words. We extracted subcategories, and further categorized the interview contents
by increasing the degree of abstraction.
2. Display of data: Concerning the relationships
between the categories obtained by the compression ofdata, we carefully considered the chronology of thenarratives related to gender dysphoria and performed aqualitative descriptive analysis.
Ethical considerations.
We explained the purpose and methods of the study to the subjects and provided a written description of the freedom to withdraw
from the study at any time, the subjects’ anonymity andthe protection of their personal information, the disclosure of data, and the data management. Writtenconsent was obtained from all subjects. The study wasapproved by the Institutional Review Board of the
Department of Nursing, Graduate School of Health
Sciences, Okayama University (Review no. D15-02).

Results
The subjects’ backgrounds. The mean ± standard
deviation [range] age of the 11 subjects was 39.9 ± 13.7
[21-65] years (Table 1). Their occupations included
unemployed, office worker, association staff member,medical welfare worker, part-time worker, and consultant sales representative. The interview duration was
49.5 ± 14.0 [36-85] min.
Category extraction and analysis results. Ourinterpretation of the subjects’ comments regarding dysphoria in light of the time sequence revealed 3 categories: ‘Onset of gender dysphoria,’ ‘Experience of feelinggender dysphoria’ and ‘Changes due to receiving medical care’ (Table 2).
Hereafter, each category is shown in square brackets[ ], subcategories are shown in angle brackets < >, andsome of the subjects’ statements are presented in “Arial
font” inside quotation marks.
1. Onset of gender dysphoria
Regarding the onset of gender dysphoria among the
subjects, our analysis revealed one category with threesubcategories, as follows.
[Uncertainty, confusion and disgust for one’s own
gender identity]
The subjects experienced a strange feeling along withincompatibility between their physical gender and theirgender identity. They made statements such as <I’mdifferent from the norm and am strange>, or had ques-146

Shinohara et al.

Table 2

Acta Med. Okayama Vol. 72, No. 2

Our classiﬁcation of the subjectsʼ statements about their discomfort regarding genderClassiﬁcation

Categories

SubcategoriesIʼm diﬀerent from the norm and am strange

Onset of gender dysphoria

Uncertainty, confusion and disgust for own
gender identity

Pain and distressre: physical gender

Is that really my gender?
Disgust for being categorized based on
physical gender
Distress or shock
Adolescent pains
Dysphoria felt through behavior or events

Experience of realizing dysphoria

Changes due to receiving medical care

Social experiences occurring as a result ofdysphoria

Negatively viewed by others
Feeling attraction to uniforms
Feeling uncomfortable when wearing
swimwear or changing clothes

Sense of conviction toward oneʼs own
gender identity arising from dysphoria

Being on the opposite side

Experiences of not being able to admit ones
dysphoria

Cannot tell anyone

Avoidance of restriction gained by collecting
information

Obtaining information

Mental stability after treatment

tions such as <Is that really my gender?>, and reported
harboring anxiety as children.
“I already felt discomfort with my gender when I wasin elementary school, feeling something different fromnormal people. When I was in a junior high school I
realized that my body shape was stranger than normal.”
In contrast, the subjects reported that in puberty
they asked themselves “Who am I?” in the process ofestablishing their identity rather than feeling dysphoria.
After beginning their careers, some worried <Is thisreally my gender?>.
“In my case, I really didn’t know who I was. I had
no room in mind to think about that.”“I led a normal school life as a male, but I found it
awkward after starting work, I mean I felt awkward
within myself.”
In addition, disgust at being forced to be a boy orgirl was expressed as <Disgust for being categorizedbased on physical gender>.

Wanting to live as another gender

Cannot tell parents

Feeling of stability
Softened the dysphoria
Regaining oneʼs true self

“When I was in a kindergarten, my very first memory was when I was maybe 3 or 4 years old.”“I felt extremely uncomfortable being categorized asa male in elementary school, junior high school andhigh school.”
The beginning of dysphoria was recognized as the
subjects noticed that their physical characteristics wereincompatible with their gender identity. This led to[Uncertainty, confusion and disgust for own gender
identity].
2. Experiences of feeling gender dysphoria
Our analysis showed four categories with 10 subcategories regarding the subjects’ experiences of feelinggender dysphoria.
1) Pain and distressre: physical gender.
The feelings of suffering and worrying that one’s
body is incompatible with one’s gender identity aredescribed as Pain and Distress. The experience of dysphoria greatly affects an individual mentally in the form

April 2018of <Distress or shock>. This experience is not limited toa certain period during childhood, puberty or adolescence, but rather can continue even after the individualis married and has a family, as was the case for some ofour subjects.
“It was just giving up, rather than feeling painful.
There was no choice. Society never thinks aboutanother possibility, so I can only say that I gave up.”
“I totally didn’t know how to have a sex. There wasno honeymoon night. I had to be taught. Months later,
our baby was born. It was a shock to acknowledge that
I was a man.”
We also observed a correlation with <Adolescentpain> regarding the stage at which the person who has
gender dysphoria does not know what measures should
be taken.
“About the time I entered junior high school, I
started to grow very tall. And boys’ voices change,
right? As I heard the voices of my friends changing, I
became scared. I kept resisting it, trying to make myvoice higher. I was convinced about my dysphoria.”“I think my position and the atmosphere at school
was a little different than my friends and others aroundme, it was close to be bullying.”“At that time, a man was expected to be masculine,
and a woman feminine, and there was no other idea.
When changes as secondary sexual characteristics
started to appear…while facing the dilemma and innerconflict, I felt a gap developing between myself andother men at the same time.”
2) Social experiences occurring as a result of dysphoria.
Dysphoria was observed not only from the mental
aspect but also from many life experiences. <Dysphoria
felt through behavior or events> and <Negatively
viewed by others> were described by the subjects.
Regarding <Dysphoria felt through behavior or events>,
one’s own gender identity could be reconfirmed by thegender of the object of one’s affection, and strongly
influenced dysphoria. One of the subjects described her
dysphoria from the experience of holding a woman’shand, and another subject described her dysphoria
from experiencing confusion when her object of affection was a woman.
“I feel dysphoria when seeing documents such as
election or prescription forms. On my hospital cardthey allowed me to write female (F), but the computer
displays M, I think payment is made with a male name,as well as at elections.”

Gender Dysphoria in MTF-GID

147“I tried to have a girlfriend just like everyone aroundme… a woman’s hand is soft, right? When I feel thatsoftness, I got irritated. Why is her hand so soft?”“My sexual orientation is only toward women. I
don’t like men, so it might be dysphoria.”“I was told my way of speaking or gestures were girly
and disgusting.”“Well, I thought that I may have been viewed as disgusting. Even if I said that I was female, maybe I would
be refuted. I didn’t have confidence in myself. I
couldn’t say that.”High school experiences related to uniforms andchanging clothes were also mentioned. The experienceof attraction to the girls’ uniforms was common, but noone related the same experience regarding the boys’
uniforms.
3) Feeling attraction to uniforms.
“There was a female senior with a black blazer. I was
attracted and even envied those clothes, it is a verystrong memory of my junior high school days.”“I was very attracted to women’s uniforms andwanted to wear one in junior high school and highschool.”4) Feeling uncomfortable when wearing swimwear orchanging clothes.
“When I entered the high school, the pool pump
was broken and it wasn’t repaired for the three years I
was in high school. So there was no swimming class, I
was very glad about that.”“The most embarrassing time was physical education, especially swimming. I really didn’t like it, so I
skipped school most of the time. Once I went swimming wearing girl’s swimwear and was scolded by a maleteacher.”5) Sense of conviction toward one’s own gender identity
arising from dysphoria.
When speaking about dysphoria, the subjects
described the feeling of <Being on the opposite side>and made statements such as, ‘I know my own physicalgender well, but I definitely don’t feel that way’. Daily
occurrences strengthened dysphoria due to feelings of<Being on the opposite side>. The subjects were convinced that they were different from their physical bodyand that this did not need to be pointed out by others or
by a diagnosis. They were <Wanting to live as anothergender>.
“I didn’t like the randoseru (Japanese school bag), its
use of colors. And elementary schools separate boys

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from girls, right? I didn’t like that either, like this side isfor boys, the other side is for girls. I thought I should
be on the other side.”“Maybe I felt something wrong when I was in an
upper grade of elementary school, at the health andphysical education class. Learning about the characteristics of the male and female bodies, I felt something,
like umm…, a discomfort. Like, I’m on the wrong
side.”“I wondered about the differences in my body. But
in my case, I was thinking why was such a strange
object added to me, because I was still a child. It never
happened but I kept wondering when it would be
removed or disappear. That period of time was fromelementary school to the beginning of junior highschool or so. Those feelings were especially strong
when I was in fifth grade, I often felt like I wanted to cut
it off when taking a bath, or something like that.”“It was a feeling that I wanted to be… a woman.”6) Experiences of not being able to admit one’s dysphoria.
Dysphoria is not a common experience, and anxiety
and uneasiness regarding how people the subjects considered important (such as family and friends) viewed
them, and feelings of guilt for making them worry,were listed as <Cannot tell anyone> and <Cannot tellparents>.
“I thought that I may look like a man. I didn’t havethe confidence in me, and I didn’t tell anyone.”“My father always told me ‘you’ re a man and theeldest son, behave like a man.’ I thought maybe I waswrong and that I should be like the man my father said,
always correcting myself.”
3. Changes due to receiving medical care.
Regarding the changes due to receiving medical carereported by the subjects, our analysis resulted in two
categories with four subcategories (Table 2).
1) Avoidance of restriction gained by collecting information.
Since the 1990s, the accumulation of a wide range of
information from the mass media and Internet andknowledge gained through interviews of other individuals with gender dysphoria has led to a decrease in dysphoria and sexual problems and pain, listed as<Obtaining information> and <Feeling of stability>.
“When I was a university student, I often noticed
when the topic was discussed on TV, or a transsexual or
gay bar was featured as a kind of a show. I could get to

Acta Med. Okayama Vol. 72, No. 2

know people in such positions, and became reallyinterested in them. I felt envy rather than disgust… I
think I was envious of their high degree of freedom, notfitting into the mold, not taking a side but staying in the
middle.”“A famous mental clinic was shown on TV. It was
famous to some extent, but I still didn’t know whichclinic I should go to.”“I buy clothes by mail order, change clothes in secretat night and go to secluded places by car. I can ease mymind, for example, by wearing a skirt under my work
clothes.”2) Mental stability after treatment.
By visiting a clinic, obtaining a diagnosis andundergoing a treatment course, our subjects’ sense ofdysphoria decreased and they reported that they could‘regain their true selves.’(1) Softened the dysphoria.
“In one word, I feel relieved. I always felt very
uncomfortable in elementary school, junior high schooland high school.”“I had only hormone therapy. I don’t feel dysphoria,
not since I started this life, maybe. My current workplace has accepted me as a female, but I haven’t comeout.”
“When considering one person, my mind and bodyare more balanced since the surgery has been completed. There is a little incompatibility, but it is stable.”(2) Regaining one’s true self.
“Dysphoria after the surgery… I feel like the real merather than a changed person. I am myself, after all.”“I have been told that my hands are like a woman’s,
so I was happy to become more feminine. I havebecome more myself. I haven’t done hair removal,
nothing. In the end, I thought my body is blessed.”

Discussion
Characteristics of the subjective experience of gender dysphoria.
1. Onset of gender dysphoria
Consistent with previous studies, the majority ofsubjects in the present study began to have gender dysphoria from early childhood or from elementary/juniorhigh school [6 , 11]. We compared the onset of gender
dysphoria by the age groups of the subjects, but noted
no differences.
During development from early childhood to ado-

April 2018

lescence, individuals acquire various physical and mental abilities as a result of interactions with their environment and society, and they form their own identity andbasic trust in others. During this period, individuals
with GID are often unable to talk about their sex or gender identity, and if they are able to talk about these
topics, they are characteristically unable to explain
themselves sufficiently. Children live with feelings suchas “I do not want to cause problems for my parents,” “I
do not want to be hated by my parents,” or “I do notwant to be looked at strangely by neighbors andfriends.” “Being in a situation where my sex is ambiguous” and “expressing gender dysphoria” led to fear andanxiety about the reactions of others, including family
members.
As a result of having gender dysphoria, individuals
feel different from their peers, and being unable toexpress this feeling decreases their self-esteem. This
status during the years from childhood to adolescence,
which form the foundation of personality, has a major
influence on the establishment of gender identity. As aresult, it appears that individuals with GID have“doubts, confusion, or loathing concerning sexual
identity” and cannot integrate their own sexual identity
into their ego identity, which increases the extreme
distress and difficulties that they feel.
2. The experience of feeling gender dysphoria
The experience of feeling gender dysphoria was
explained as a negative experience by all 11 of our subjects, although a difference in degree was noted. ‘Social
experiences arising from gender dysphoria’ were always
observed in ‘pain and suffering regarding physical sex’
and performing activities of daily living. There werealso conflicts between what the original self is in society
and in relationships with others. The World Profes­
sional Association for Transgender Health indicates thatstigmas related to gender dysphoria can be found inmany societies around the world [12], but events
involving interactions between people, which are essential for the formation of human relationships, are said
to vary from person to person.
Similar results were obtained in the present study;
according to their narratives, the subjects did not particularly feel gender dysphoria on a daily basis, but theyreported that they felt it for example when seeing theletters “M” and “F” in election-related documents, prescriptions, and so on. The subjects also had many negative experiences in terms of performing activities ofGender Dysphoria in MTF-GID

149

daily living, such as being on the receiving end of
uncomfortable looks or behaviors from others, andinternal pain or suffering related to their appearance(e.g., school uniforms). The stigma concerning gender
dysphoria has also spread to Japanese society. Genderroles are highly normative in Japan [13], and those who
do not conform to gender have no choice but to conceal
themselves, leading to a lack of opportunity to receive
appropriate care [14].
In the above-mentioned category ‘onset of gender
dysphoria,’ some of our subjects described experiencing a time of exploration in which they were unable tosolve sex-related problems by themselves. Such experiences led to ‘instinctive beliefs on gender identity arising from gender dysphoria.’ This is because GID can be
self-diagnosed, and it is the only disease for which
treatment methods can be selected [15].
Most individuals do not suffer confusion or doubt
about their own gender in activities of daily living.
Meanwhile, those with gender dysphoria feel that they
are not normal and consequently have “experiences ofbeing unable to reveal their gender dysphoria.” Asshown through the narratives of our subjects, individuals with gender dysphoria are constantly troubled about
their gender and experience unbearably strong helplessness, anger, and frustration. There were cases in which
the experience of feeling gender dysphoria was left
undealt with and suffering became intense as a result.
The subjects were unable to clearly explain this pain toothers, and a background factor for this was feelings ofreservation and regret of possibly bothering others,
especially their parents, by informing them about theirgender dysphoria, its influence on clothing and romantic relationships, and difficulties that they faced.
From the narratives of the subjects concerning theirpersonal history, diagnosis, and the treatment of gender dysphoria, it is clear that social changes at the present time period have had a great influence. If medical
institutions had existed decades ago to treat subjects
with strong gender dysphoria who are now in their 40s
and 50s, the recognition and understanding of family
members and society may have taken a different form.
Moreover, it can be inferred that children who grew up
in the period when the societal awareness of GID waspoor have experienced serious pain and suffering. The
conflict felt by not being able to fulfill the requiredsocial roles, i.e., “boys should act like boys and girls
should act like girls” was great. In addition, as noted in150

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the subjects’ narratives, while having gender dysphoria,
the subjects with MTF GID were expected to play amasculine role in the “family system” of Japan. The pain
and suffering associated with gender dysphoria cannot
be directly or easily removed; however, at present,
society as a whole is forming a foundation to accept
individuals with GID.
In 1997, the Japanese Society of Psychiatry and
Neurology’s Special Committee on Gender Identity
Disorder published the “Guidelines for Diagnosis andTreatment of Gender Identity Disorder (First Edition)”in “Reports and Recommendations on Gender Identity
Disorder.” Under these guidelines, GID is treated as atarget of medical treatment, and SRS is legally approved.
In 1998, SRS was first publicly performed in Japan at
Saitama Medical University. In 2004, the Act on Special
Cases in Handling Gender Status for Persons with
Gender Identity Disorder (partially amended in 2008)
came into force, and compared to the past, the medical
system has improved and legal rights are guaranteed.
Individuals with gender dysphoria are now frequently covered by the media, and it is expected thatfurther societal and medical progress may lead tochanges in individuals, families, and communities,
and as a result, there may be favorable changes in theperception of sexual minorities who have been likely toface preconceptions and prejudice. An age will comewhen individuals with MTF gender dysphoria who havesuppressed their own hopes can be saved from the distress and confusion caused by attitudes such as “menshould act manly” and “I must take up the family estatebecause I am the eldest son.”
However, in reality, individuals in Japan in certain
occupations expressing these characteristics on television are still ridiculed. This carries the risk of creating asituation in which individuals with GID are unable toescape preconceptions and prejudices. However, there
are also individuals with GID who are active in sports,
literature, and politics, for whom the societal changes
have been positive. Although they are active in a special
field, they experience further exposure by the media. It
is necessary that these public figures recognize that they
are asserting sexual diversity in response to conventional fixed concepts of gender.
3. Changes due to receiving medical careBy obtaining medical information and/or receiving
treatment, all 11 subjects said that they experienced
changes such as “amelioration of gender dysphoria” andActa Med. Okayama Vol. 72, No. 2“taking back their original selves” and became bothmentally and physically stable. Each subject received
treatment and was moving in a better direction compared to their previous experiences in life related togender. In our subjects with various physical, psychological, and social issues, the provision of various typesof information at a gender clinic and the physicalchanges due to medical intervention such as hormone
therapy and operative treatment had positive effects on
psychological/social aspects in all cases. Negative aspectsof medical intervention have been reported in previous
studies, but were not observed in the present study.
Japan has a long history of not providing medical
treatment for GID; at present, the extensive benefits ofmedical intervention have been confirmed, and individuals with GID have greater prospects. In manycases, changes due to hormone therapy and operative
treatment are expressed as psychological rather thanphysical changes. The fact that treatment does notremove physical obstacles but allows the individual toobtain mental stability is considered to be characteristicof GID.
Through the course of consultation, diagnosis, andtreatment at a gender clinic, our subjects reported thatthey could achieve both mental and physical balance,ameliorate gender dysphoria, and become the sex thatthey most identified with. These results are due not only
to the subjects’ ability to change their physical aspects/
appearance but also to being able to integrate their gender identity into their ego identity within their social
structure.
Limitations of this study and future tasks.
This
study focused on dysphoria in mostly subjects withmale-to-female GID; however, individuals withfemale-to-male GID may be as numerous, and there aredifferences in the characteristics or symptoms that eachindividual displays. Further analyses and examinationof the differences in experiences of individuals withFTM GID are needed. Our present findings indicatethat support is necessary for individuals with GID tolive with their chosen gender, considering their desire
to come out and/or have children, and focusing on thethoughts of their current gender and experience.
In conclusion, as a result of the description andanalysis of experiences of MTF persons with gender
dysphoria, the following points have been identified.
(1) The subjective experience of dysphoria could beclassified into the ‘Occurrence of dysphoria,’ theGender Dysphoria in MTF-GID

April 2018

‘Experience of realizing dysphoria’ and ‘Changes
brought by medical treatment’. (2) The ‘Occurrence ofdysphoria’ (in which the person does not fully understand him/herself as not normal) decreases an individual’s self-affirmation and strongly influences gender
identity during fundamental personality development.
The person suffers great pain and anguish, being unable
to integrate his/her self-identity and gender. (3) In the
category ‘Experience of realizing dysphoria,’ all subjects
related experiences of dysphoria as negative experiences. Just as a person cannot separate one’s mind fromhis body, one’s social gender is connected. Dysphoria
greatly influences one’s social life as well. In addition to
events personally experienced by the subjects, they also
experienced the glances, speech and actions of othersaround them and the inner pain which arises from matters such as appearance and school uniforms. (4) In‘Changes brought by medical treatments,’ the subjects
related that their dysphoria was alleviated and they
could gain their natural gender through the process ofvisiting a gender clinic, getting a diagnosis and treatment. This was the result not only of a change physically or by appearance, but due to creating and obtaining their own gender identity.

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Acknowledgments. We would like to thank all of the subjects forcooperating with this study.

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