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Gender identity and gender expression
'Gender identity' is generally defined as the inner sense of whether one experiences oneself as a man, a woman, or something else. 'Gender expression' is the outward presentation through clothing, behaviour and appearance. Both terms are used extensively in contemporary policy documents and care guidelines, but it is worth bearing in mind that they are concepts, not objectively measurable quantities. The prevailing picture – that every person has an inner 'gender identity' separate from the body – is a theoretical premise, not a scientifically established fact.
What is gender identity?
'Gender identity' refers to a reported inner experience. For the overwhelming majority of people – usually called 'cisgender' in this terminology – that experience matches their sex. A smaller group experiences a discrepancy and may identify as transgender, non-binary, genderfluid or agender. The terminology has expanded considerably in a short time; at the time of the DSM-IV (1994) most of these categories barely existed.
The causes of such a discrepancy have not been clarified. There is no 'gender gene', no blood test, no brain scan that can establish 'gender identity'. Studies reporting brain differences between transgender and cisgender people are small, methodologically weak and have not been replicated; they also overlap strongly with the effects of hormone use. The Cass Review (2024) concluded that the evidence for an unambiguous biological basis of trans identity is limited. What is clear is that the number of young people – particularly girls – identifying as transgender or non-binary has risen explosively since around 2010. There is growing attention for social-contagion hypotheses such as rapid-onset gender dysphoria and the role of peer and internet influences.
In children showing gender-variant behaviour, classic follow-up research (Steensma et al. 2013; earlier studies by Zucker and colleagues) shows that, left undisturbed, 60–90% develop along a cisgender trajectory later in life, often in combination with a homosexual orientation. This phenomenon, desistance, is central to the criticism of early medical 'affirmation': affirming a trans identity in a child can disrupt this natural course.
What is gender expression?
Gender expression is a far less controversial concept: it simply describes how someone dresses, behaves and presents themselves. That this does not strictly follow sex is a banality – men with long hair, women in work overalls, children with gender-crossing preferences exist and always have. What is contested in the current debate is the step in which a deviating gender expression is interpreted as evidence for an underlying deviating 'gender identity' – an interpretation that in many cases does not stand up.
Gender expression is strongly culture- and time-dependent. What counts as 'masculine' or 'feminine' shifts continuously; this argues more for cultural flexibility than for the existence of a fixed inner gender core.
The distinction between identity, expression and orientation
Identity, expression and sexual orientation are strictly separated in current terminology. That is logical in theory but less clear-cut in practice: many boys who later turn out to be gay show feminine gender-expressive behaviour in childhood (and vice versa). A too-quick 'gender-affirmative' interpretation of such behaviour threatens to medicalise gay youth – a concern expressed explicitly in Iran but also in Western contexts, by both LGB organisations and clinicians such as Susan Bradley.
Gender identity and mental health
Young people who identify as transgender have above-average rates of co-morbid mental-health problems: autism (substantially overrepresented), depression, anxiety, eating disorders, trauma. Whether gender dysphoria is cause, effect or symptom in these cases is often unclear. The Cass Review pointed out that at the British Tavistock clinic this comorbidity was frequently glossed over so patients could move on to medical pathways, while psychotherapeutic exploration scarcely took place. See: Cass Review (2024) and the page Cass Review.
The much-cited suicidality figures – used in the 'transition or suicide' rhetoric – are empirically untenable as an argument for medical intervention. Research after the closure of the GIDS clinic showed that suicide among young people on the waiting list was extremely rare; the Cass Review called the use of suicide rhetoric harmful and unsupported.