How does your dysphoria feel?
Dr. phil., born 1949; Psychological psychotherapist; Psychoanalyst; Professor of Sexual Sciences at the Medical Faculty of the University Medical Center Hamburg-Eppendorf, Institute for Sexual Research and Forensic Psychiatry, Martinistraße 52, 20246 Hamburg. [email protected]
introductionGender identity is addressed when there is uncertainty about gender identity, such as the presence of infertility ("Am I a real woman, a real man?"), Body and gender identity experience mismatch as in the case of the Transsexuality, or experience of identity in the presence of an ambiguous male or female body, as in the case of Intersex is up for discussion. In the second half of the 20th century, medicine and psychology had set themselves the goal of "healing", that is, preferably eliminating, abnormalities and deviations in the physical and psychological areas of the male or female gender. Children and adults should not only have a male or female body that is as unambiguous as possible, but also a stable male or female gender identity - and these should match. Thinking was determined by a binary concept of gender. 
When treating people whose body and gender experience do not correspond to one another, not only what a male, female or intersexual body is, but also what a male, female or ambiguous gender identity is. In most cases, however, there is no further definition of what is actually understood by the term gender identity, and the binary is not questioned. It must be taken into account that terms relating to psychosexual development are used inconsistently. 
In contrast to gender-typical behavior, which relates to behaviors frequently observed in one gender, gender-specific behavior which only occurs in one gender (e.g. breastfeeding a child), the term denotes Gender role since the 1950s, the entirety of the culturally expected, considered and assigned skills, interests, attitudes and behaviors of the respective gender. They are subject to change within and between cultures. Gender identity on the other hand, is the subjective feeling of a person to experience himself as a man or woman (or in between). This feeling can be found at all times and in all cultures. Under Gender role identity one understands the public manifestation of the gender identity of a certain person in a certain role behavior. It includes everything that a person says or does to demonstrate to others and / or themselves to what extent they feel they belong to one or the other gender. Sexual identity describes the subjective experience of a person as hetero-, homo-, bi- or asexual. The sexual preference describes what makes a person sexually aroused who sexual orientation the choice of partner. Mostly these correspond to the sexual identity. Predicting gender identity in various forms of intersexuality poses a particular problem. The distinction between gender role behavior and gender identity appears to be particularly important here. Atypical gender role behavior is certainly more common in people with various forms of intersexuality, but does not yet say anything about whether a person feels insecure or impaired in their gender identity as a man or woman. On the other hand, insecure gender identity does not automatically mean that a person wants to change their gender. A characteristic of people with intersexuality is that they are often ambiguous in their gender experience and, contrary to medical expectations, cannot be so easily "shaped", either in terms of appearance or gender identity. Under intersexuality or disorders of gender development (disorders of sex development (DSD)) a number of different phenomena are summarized in which the sex-determining and sex-differentiating characteristics of the body (chromosomes, genes, gonads, hormones, external genital organs and sexual characteristics) do not all correspond to the same sex.  The term "sexual development disorder" is criticized by those affected themselves. They prefer the terms "intersexuality" or "variants of gender development". These physical abnormalities can be accompanied by an irritation of the subjective sex experience from which the person suffers, a gender dysphoria. While people with transsexuality usually want to adapt the healthy male or female body to the subjectively experienced gender more or less, people with intersexuality were often assigned a gender in early childhood (gender allocation) and physically aligned (sex assignment). Linked to this was the hope of ensuring the development of an undisturbed gender identity corresponding to the adapted gender. 
When defining transsexuality, the question arises as to how far the desire for gender reassignment surgery (gender confirming surgery) or the fulfillment of this wish should be understood as a necessary and sufficient condition in order to be able to speak of transsexuality. Since gender reassignment operations are no longer a necessary prerequisite for a change in civil status, a clear decline or a delay in the attempt to achieve genital surgery can be observed, especially in older people. The term "transsexuality" is criticized by those who are of the opinion that it is more a question of identity or the body, but not a question of sexuality. So they prefer to speak of "trans identity" or "transgender". In the international medical classification system, neither the term “transsexuality” nor “transidentity” is used, but rather a gender identity disorder. Disorders of physical gender development or intersexuality have so far been an exclusion criterion for the award of the diagnosis disorder of gender identity / transsexuality. However, this does not mean that people with intersexuality cannot be insecure with regard to gender identity. Here, however, it is mostly an insecurity to be somehow different, and less the feeling or the desire to belong to the other gender that does not correspond to the body. International experts are currently discussing whether one should not drop the term transsexuality or gender identity disorder entirely and only speak of gender dysphoria when a person is suffering from uncertainty about their gender experience. In this case it is also justified to speak of a mental disorder. Gender dysphoria can occur in people with transsexuality as well as in people with intersexuality, but it is not observed in all. Transsexuality would no longer be a psychiatric diagnosis. 
The way in which a transsexual woman or a transsexual man is and how one should describe one's sexual orientation has also changed. The psychiatric diagnosis, but also the German legislation according to the Transsexual Act, regards a transsexual woman as a woman with a psychiatric diagnosis, the disorder of gender identity. In more recent usage, the term "transsexual woman" refers to a person who experiences himself as a woman, but was born with the external and internal physical and biological gender characteristics of a man, i.e. a man-to-woman transsexual.
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