Managing body dysphoria and puberty-related pressures

Body dysphoria is a term used to describe the experience of discomfort or distress that a trans or gender diverse person might feel because there is a mismatch between the sex assigned at birth on the basis of genital appearance (usually male or female), and the gender identity (usually boy or girl). Not all trans or gender diverse people experience body dysphoria, but many do.

Whilst on the waiting list to the Gender Identity Development Service (GIDS), Oonagh worries that GIDS gives a lot of weight to body dysphoria as a requirement to be trans.

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Wed been waiting, cause a lot of people go to the system a bit later and it’s all a bit of a worrying time, because the children at sort of started puberty and things like that, whereas she said time was on our side. We can make sure that any intervention is at a time, timely point. She was reassuring. But she said, you know, you just have to, cause this is watch, watch and wait approach that they have. I mean my worry is that [name of participant’s child] doesnt really display dysphoria. And my worry is that because she doesnt display dysphoria about her body that theyre gonna see that as some sort of indication that she’s not trans. To me, I’m giving it the benefit of the doubt, everything’s pointing to the fact she is trans but she doesnt necessarily have to have dysphoria to be trans. But I worry that the GIDS system seems to think that you have to be really, really in traumatic, trauma about your body to be trans.

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Parents we spoke to talked about how their trans, or gender diverse children felt about their bodies. Many spoke about feelings of discomfort and distress that their children experienced and how puberty accelerated feelings of body dysphoria for their children. Alongside getting psychological support, there were practical things that helped with body dysphoria.
Parents discussed practical strategies they or their children had found useful for managing feelings of body dysphoria for instance, in those assigned female at birth:
  • Binding to reduce the appearance of breasts;
  • Packing to give appearance of a penis;
  • Contraceptive pill to stop periods.
Some adult trans and gender diverse people choose to have surgery to alter their bodies. This is only an option for those over the age of 16. No genital surgeries are done until adulthood 18 or older, however, a 16 year old might have chest surgery. You can read more about parents talking about surgery here. You can also read more about Jan’s experience of her daughter having facial feminisation surgery below.
Hormone blockers were a very common and a very important way to manage puberty that parents discussed. Parents of young adults also talked about gender affirming hormone therapy.

Body dysphoria and puberty related pressure

In our interviews, younger children were less likely to experience distress relating to their body, even though some were aware of the differences between boys’ and girls’ bodies. For example, talking about her son around the age of four Georgina observed that he used to ask her when he could go to the doctors and ‘get his boy bits, his boys bum.’ Some parents of younger children worried that the way their child will feel about her body in the future will be negatively impacted by society’s ‘expectations of what a body should look like for a certain gender.’

Interview 1 worried that the existing healthcare model could contribute to feelings of dysphoria for her daughter, leaving no room for being a girl with a different type of body.

So, like if my child would be happy without hormones, I would see that as a better option than if she’s happy with hormones, because, you know, less medical – sounds good to me. But Id like her to have a conversation with someone who will say, girls have all kinds of bodies and you can be a girl and have you know, a deep voice or you know. But the state of the clinicians is they don’t wanna have that conversation. They wanna have the, Are you sure you don’t wanna be a boy? You know, and that conversation to her would be so loaded and harmful that I think that would even close down her even thinking about whether she could be a girl with a different type of body. And we havent got to that point yet. But I don’t feel like even the conversations that she could be having are gonna be worthwhile in the system if theyre coming from a place of cisnormative expectations of what a body should look like for a certain gender.

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Puberty related changes such as starting periods, facial and body hair, growth of breasts, deepening of the voice, changes to facial features etc., were often a huge source of discomfort for young trans and gender diverse people. The uncertainty or anticipation of puberty even before any changes occurred also caused worry and stress for the young person. Georgina reflected that her teenage son didn’t like his body and that he didn’t like ‘what’s going to happen at puberty.’ She emphasised that ‘luckily so far there’s nothing to make him look feminine, because puberty has started. It’s just that it’s in the form of hairiness first, which is lucky for him.’
Bodily changes during puberty could seem sudden. Elijah said about his child that puberty had hit ‘like a rock.’ When puberty started, Teresa’s daughter ‘was getting taller, her voice was breaking. She started to grow a beard. Testosterone was just raging.’ The family decided to access private care to stop some of the changes.
For some young people body dysphoria contributed to depression and anxiety.

Having a female sounding voice has caused anxiety for Ross’s child, who won’t talk to people on the phone.

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Nearly all of them are suffering depression and suffering anxiety certainly for mine, still telephone conversations, they cant do telephone, because theyve got a female voice. They sound like a female when they talk on the telephone. So then the person on the other end of the telephone will miss-gender them, because they sound female. I know that is gonna change with the testosterone. It will have an effect and their voice will hopefully get much deeper and then theyll start using the telephone. But that’s an issue at the moment is, they refuse to do anything on the telephone. Theyll send emails, they will send text. But they wont talk on telephone, because their voice sounds female.

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Talking about their bodies and puberty can be difficult for young people, in particular when they find the changes that are happening distressing.

Talking about bodily changes in early puberty could be challenging, and Georgina used a tick box exercise to help her son express his wishes.

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And then we tried to talk about that with my son, that there is this issue, it was like: alright, that’s okay, how is this making you feel? Do you, are you bothered or are you not bothered and [participant’s child’s name] he said he wasnt bothered, which didnt help his case [laughs] but he said it, to be a people pleaser and I know that and the guy should have asked the deeper question. He should have carried on and he didnt and it annoys me cause I know which questions to ask to get the answers and I know how to do it. And I did suggest a few different ways of doing that, because [participant’s child’s name] finds verbalising, you know, saying the words hurts him. Does that make sense?

Mmm
So the same, he I, Ive done tick boxes for him in the past. Ive put, you know: Puberty’s coming. These are the things that are gonna happen, which ones do you want And he ticks all the boy ones and then the girls ones and he scribbles them out, really strongly, you know. But it hurts him to say the word boobs when it’s referred to him. Does that make sense?

So he cant verbalise it, especially to somebody he doesnt know very well. So to expect him to do that is difficult.

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Parents whose children had not yet entered puberty sometimes worried about how the experience of puberty would be for their trans, or gender diverse children. For those waiting to start hormone blockers there could be additional concerns about how far into puberty their son or daughter would be before the treatment started.

For Mel waiting for hormone blockers felt almost like a time bomb. She also worried about her stepdaughter not going through puberty at the same time and in the same way as her peers.

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But yeah, now it’s been agreed that she can have hormone blockers. We’ve gotta wait for the last possible moment in terms of her showing symptoms of, not symptoms, I guess, you know, sort of displaying. Showing, you know, sort of traits of going through puberty. I feel like that must be, for me, it feels like waiting for a time-bomb, almost. And waiting for it. And I find myself sort of looking not looking at her, but like I’ve noticed she’s got a slight darkening of the top lip. And what that’s gonna be like for her having to wait until the last moment and then get treatment. How will it be for her and her peers.

What it means to then not necessarily be going through puberty in the same way that your peers are? I worry about how she will empathise or how she will cope when her, especially with her sister and her mother when her sister starts having periods and she can’t have them. I do worry about that. And will that cause any resentment.

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Managing body dysphoria: binding, packing, the contraceptive pill and surgery

Parents we spoke to talked about things that helped their children with body dysphoria. Some of the things they discussed were going on a contraceptive pill to stop periods, binding and packing, and surgery.
Binding refers to compressing breast tissue to flatten the chest in those assigned female. The type of materials and methods used for binding vary. Binding can alleviate the dysphoria related to having breasts that trans men can experience. Lesley said about her son: ‘he’s got a few binders and that helps him feel less dysphoric.’ Ross said that for his child, who was ‘so far through puberty’, with a fully developed chest, wearing the binder was ‘the only option.’
Leigh, Lesley and Kate all talked about the importance of binders for their sons. Kate also discussed how to choose the right binder and how to use it safely. Lesley said she found out about binders from Mermaids and from reading about experiences of adult who were trans men online. She felt that for her son, CAMHS recommendations not to bind when he was an inpatient were unhelpful, as she felt binding was ‘crucial’ for reducing her son’s body dysphoria. Leigh said her foster son ‘will not leave the house unless he has a binder on.’ But binding also could have its challenges and frustrations: Ross said although using binders was helpful for later puberty, it’s ‘not healthy and its not been great’.

Binders made Kate’s son feel better. She also had some advice on how to wear them safely.

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So, unfortunately for him, he started his periods very early at 10. So, he’s been, you know, for a long, long time he going through puberty. And he developed his breasts very early as well. With the whole binding thing, it, you know, it was clear that he was uncomfortable and didn’t want to look that way. So, he was trying to find sports bras that would be, would minimise his chest and so on. And I broached the subject of whether he wanted to use a binder. At that point, he was still adamant that he wasn’t trans. And he like, Ah, Mm, yeah I could. But I’m not trans, mum, I promise I’m not trans. And so we went ahead and used the binder. And that that’s fine. He wears those all the time other than when he’s at home and he’s, when he gets home from school he tends to get into like comfy things like pyjamas and an old T-Shirt. He’ll sometimes still keep it on then. But, later on the day, he’ll sort of take that off. I’m probably not as strict as I should be about how long you’re supposed to keep them on for and so on. But, if there are other people around, he’ll always have it on. He’ll never—so, if we stay other than my mum, we go and stay with my mum and he’ll be, he doesn’t mind that. But if there are other people staying as well or other family, then he’ll always have his binder on now. Holidays are a bit of a problem in that, how do you go swimming and how do you do those sorts of things. He doesn’t really like that anymore. So, he has a binder that he can wear swimming and with a rash vest, so that it you know. But it’s not comfortable for him. So, we tried that this year and I don’t think we’ll necessarily be doing that again. And yeah, with the pill he’s only just started the pill but I think it will just be better for him that he has some control over that and knows when it’s gonna happen. And, obviously, hopefully, will, you know, decrease the, you know, the discomfort and the constant reminder that, you know, this is happening to him. So, yeah, he’s started that and I think he didn’t really push for that that much. But I think he is pleased that he’s doing that now.

How did you learn on all the stuff about the binders and how to use and when to use it and all that?

So, I started looking when he started dressing more as a boy and cos it started slow. He’d have a few boy’s things. And then quite just gender-neutral. But then when he would only like get stuff that was made for boys I sort of started looking and the holiday, not this time when he has been binding, but the time before, I was trying to look for swimming costumes for holidays that would be more modest and less, cos, you know, most swimming costumes are trying to show everybody’s, flaunt everybody’s features. And I just knew that that wasn’t comfortable for him. So, I was trying to find things and I found some kind of more, I think I started looking for tomboy. He was never a tomboy at all. But I thought, you know, tomboy like swimming or something. So, I just found stuff on the, on the internet. And then I found a site for binders and they were really good, actually, cos they were really responsible and had like good information on there and so on. And as I noticed, some of those kind of websites which are for which are providing something for people from that community tend to have a bit more information there and point you in the right direction, so you kind of go off and, and find a bit more out. So, when he started binding, I was a bit stricter about well you can only wear this for this time and you mustn’t but actually it just makes him, we get decent ones so that it shouldn’t make him, you know, so it’s as comfortable as possible for him. And just so that he, I know that it makes him feel better to wear it. So, actually, although it might not be, you are only supposed to have them on only for a certain period of time. I’d rather he was comfortable and psychologically comfortable. So I don’t tend to nag him too much now.

So just for other people who might be thinking about binding what kind of information do you have about how a person should wear it?

So, there was, so I think they shouldn’t wear them when they’re exercising, which is a bit of a problem with swimming. So, yeah, shouldn’t wear them exercising. It should only really be on for eight hours. And the best ones, the ones that kind of do up at the sides and not glued, cos they tend to crush more than sort of squash. So, they, there I think there is quite a bit of information out there. But it is, unfortunately, one of those things where it seems to be, you know, you have to pay a bit more to get something that is better for them, rather than gonna do any sort of damage.

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Leigh talks about her foster son feeling very self-conscious about his chest and binding being uncomfortable in hot weather.

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He has unfortunately got his mum’s genes, so his chest is at least D cup and it was a D cup at eleven and a half and twelve. So, now he is on hormone blockers that has stopped the growth. But it’s there. So he has no option other than to have surgery post eighteen. If that’s what his choice is. If he was my birth child, maybe he could have stopped growing at a B cup or you know, an A cup if hed got there quicker. He wouldn’t have had to have such severe surgery in the future. So him being a foster child has helped in many ways. But then, for him it’s also been a hindrance in that it’s, he’s having to live daily, binding daily. He will not leave the house unless he has a binder on. He will not leave his bedroom unless he has a binder on. And in this weather thirty degrees heat, you know, being binding and wearing coats and jackets, because he still feels like everybody can see his chest, you know.

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Packing refers to wearing padding or a penis shaped object in the front of the pants or underwear to give the appearance of having a penis.

Lesley talked about her son’s dysphoria around periods, binding and packing. She said binding and packing made her son feel better about his body.

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It used to be around, partly it used to be around periods and this huge distress he used to have every month when he had his period. Partly it’s about his breasts. And wearing binders and things like that, so he’s got a few binders that help him and that helps him feel, feel less dysphoric. There’s all sorts of bits around his genitalia and stuff like that and things that and the genitalia, the genitalia that he has the genitalia that he doesn’t have. His perception that penises are much bigger than they actually are [Laughs]. He has a couple of packers one which I bought him, which I think is probably a realistic size for a teenage boy. And one which he chose which is, from my perspective, completely unrealistic in size. It makes him feel better. But, well that sort of thing helps.

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Getting the contraceptive pill prescribed to stop periods can help young people assigned female, identifying as boys/ men deal with feelings of body dysphoria brought about by menstruation. However, not all pills are equally suitable and some might have unwanted side effects. For example, Lesley felt that although her son’s GP was very helpful and offered to put him on the pill, the pill itself ‘made things a bit worse for a while.’ Choosing the right contraceptive pill could help.

Ross suggested the contraceptive pill to manage his child’s periods. He said the GP was very supportive and found a pill that was low in oestrogen.

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Certainly one of probably one of the bigger issues was contraceptive pill to stop periods, because that was a really, really big issue [Gender Identity Development Service] had previously offered hormone blockers, but that was at the point when mum was going to the meetings and mum fiercely went against blockers. So then [Gender Identity Development Service] never ever mentioned it again until my child was eighteen and pretty much out the other side of puberty. So they did suffer through puberty. I suggested to our GP that they go on contraceptive pill, not for contraceptive purposes but to manage the hormones up and down and the menstrual cycle, which our very, very supportive GP looked into and prescribed the pill that was very, very, very low oestrogen where most contraceptive pills were much higher, which gave us a lot of confidence in our GP, the fact that they went out of their way to look, initially they didnt. Initially they just gave a stock standard pill. But after maybe a month they said that theyd looked into it and researched it and found that there was a high oestrogen level and realised that that wasnt conducive with a trans person, so changed the pill. So the pill theyre on now is not very good on contraception, but it’s got zero oestrogen. So it’s really good for trans.

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A few parents and carers with children over the age of 16 had considered how surgery might address changes brought about by puberty. Chest reconstruction is only available to people who are 16 or older for genital surgery they must be 18 or older (see Resources).
Jan said her daughter’s receding hairline and prominent masculine facial features were a concern for her daughter and that she was ‘very keen for facial feminisation surgery.’ The family decided to pay for the surgery privately. Ali thought it was a shame that laser facial hair removal wasn’t available on the NHS for young trans women. Other parents spoke about their young person getting gender affirming surgery on the NHS. You can find out more about gender affirming surgery here.

Hormone therapy

Hormone therapy in young people, gender affirming hormone treatment to masculinise with testosterone or feminise with oestrogen, is, where possible, preceded by hormone blockers in...