First, let's begin with: What is Gender Dysphoria?
When I ask this question in trainings with professionals and discussions with community members, answers usually fall somewhere around "my body not matching my gender identity." This is perhaps the most common understanding of Gender Dysphoria. Thanks to generations of advocates developing language, concepts, and educational material (such as the gingerbread person, "gender identity" vs "gender presentation," etc.), we have a better shared understanding of the experiences of trans and non-binary people.
This understanding of Gender Dysphoria is deeply true for many; however, it is not the only manifestation of gender dysphoria. The focus on a binary dissonance between the body and the mind is rooted in Western, medical pathology, which is why it is not surprising why many folks I have worked with from the Global South and East do not identify with Gender Dysphoria. In fact, many folks seeking gender-affirming care feel comfortable in their bodies in private, but hate how they are mistreated by others in public. Or, they feel comfortable with one part of their body, but not another. It is essential to distinguish between Gender Dysphoria as a diagnosis and pathology, and gender dysphoria as a more diverse spectrum of experiences and needs. By doing so, we honor all pathways for folks to explore their gender, manage and treat any Gender Dysphoria, and hopefully avoid seeking treatment that may not actually be the most effective or appropriate to truly address their needs.
In order to better understand experiences of gender dysphoria and how to effectively manage and treat it, I propose the Four Components of Gender Dysphoria:
Each component, in more depth:
1. Existential/Spiritual: A deep, holistic sense of who I am and who I am not.
“I know I’m a girl."
"I am not male or female."
“Something doesn’t feel right. I don’t fit in like I’m supposed to.”
2. Physical: My body.
“I am supposed to have breasts."
"I hate my hands. They’re too small and soft.”
3. Emotional: How I feel in relation to my gender presentation.
“I get depressed when I look in the mirror because I don’t look like how I know I’m supposed to look.”
"I feel happy when I wear my binder to flatten my chest."
4. Social/Cultural: How I feel and am effected by other people and larger systems.
“I hate when people call me ‘Sir.’ I get so anxious that people will think I’m a man, I don’t leave my house or use public restrooms.”
"I don't go to the doctor's office because I haven't changed my legal name or gender. I don't want the receptionist to call my dead name."
An individual's experience of gender dysphoria is a combination of existential/spiritual, emotional, physical and social factors.
Now, let's look at the most dominant and reinforced understanding of gender dysphoria - the disease and pathology.
To currently meet diagnostic criteria (1) for Gender Dysphoria in adults is to meet at least 2 of the following for at least 6 months:
A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics
A strong desire to be rid of one’s primary and/or secondary sex characteristics
A strong desire for the primary and/or secondary sex characteristics of the other gender
A strong desire to be of the other gender
A strong desire to be treated as the other gender
A strong conviction that one has the typical feelings and reactions of the other gender
You can read more about the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) here: https://www.psychiatry.org/patients-families/gender-dysphoria/what-is-gender-dysphoria
When we apply the 4 components of gender dysphoria, we see that the diagnostic criteria spans across all 4 components.
A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (physical)
A strong desire to be rid of one’s primary and/or secondary sex characteristics (physical)
A strong desire for the primary and/or secondary sex characteristics of the other gender (physical)
A strong desire to be of the other gender (existential/spiritual)
A strong desire to be treated as the other gender (social)
A strong conviction that one has the typical feelings and reactions of the other gender (existential/spiritual)
One of the main reasons why it is so difficult to comprehensively measure and track Gender Dysphoria, as well as accurately depict the effectiveness of treatments, is because we are typically tracking medical and clinical interventions for a state of distress that is not only medical and emotional, but existential/spiritual and social.
Now let's explore how a more holistic understanding of gender dysphoria can inform how we provide care for 3 fictional patients:
Patient 1: Holly
Holly is a 62 years old White trans woman. She obtained her Feminizing Mammoplasty (aka Breast Augmentation) and Vaginoplasty in Thailand approximately 30 years ago. Although Holly does not regret her surgeries, she continues to have significant Gender Dysphoria. She is now seeking psychotherapy to manage her on-going depressive and anxiety symptoms in relation to her Gender Dysphoria. Here is a portion of our conversation:
Holly: It took me an hour to get here on the bus and the kid across from me kept staring at me. It's not worth it!
Me: What's not worth it?
Holly: I don't know. I guess going outside. Everything. I was thinking of getting a Vaginoplasty revision, but I don't know if I can go through this again.
Me: Tell me more.
Holly: Most old girls like me, we have to manage, you know. We didn't have all the options that the girls have now.
Me: What do you think about the options now?
Holly: Well, back in the day, you had to work and save up all your money. It wasn't covered, and I wasn't about to do it in some back alley. It took me 20 years to save up money for my Vaginoplasty and Breasts. If someone had told me that I would still get treated like a tranny after all that, I probably would have saved myself the trouble!
Me: It sounds like a big source of your trouble is how others treat you.
Holly: Yes! That's ALL of the trouble. When I was younger, I didn't mind my penis and I had a little breast growth on hormones, but I thought if I could get bottom surgery and breasts, I'd finally be treated right. If I could be treated like the woman I am, I would take back my penis and give up my breasts in a heart beat.
Although Holly meets criteria for Gender Dysphoria and reports no regrets, she expresses how her surgeries did not meet expectations. Her Vaginoplasty and Feminizing Mammoplasty did not positively change how others treated her, which seems to be the primary source of her gender dysphoria - the social component. Considering that Holly continues to experience significant distress that impacts her daily functioning (social isolation, lack of motivation to pursue education or employment, depressive and anxiety symptoms, etc.), it can be argued that her Gender Dysphoria was not effectively treated with surgeries. However, this is a shallow and dangerous conclusion that can also be misused to restrict access to medically-necessary, gender-affirming surgery. I propose that it is not that gender-affirming surgeries did not effectively treat Holly's Gender Dysphoria, but that she perhaps would have benefited more from comprehensive education on her non-surgical and surgical options, as well as treatment planning around all components of her gender dysphoria.
Here is what it could have looked like:
Stage 1: Education on Non-Surgical and Surgical Options (Intake and Treatment Plan)
Stage 2: Non-Surgical Options
Stage 3: Surgical Option
Stage 4: Surgical Option, continued, if applicable
If we could go back in time to Holly's intake, Holly and her provider would collaboratively gain an intimate understanding of her gender dysphoria. What components of her gender dysphoria are the most pervasive and harmful in her daily life? What non-surgical treatment has she tried? How did it go? What surgical options might be best for her? They would eventually come up with a shared treatment plan, scaffolding various interventions to be mindful of her recovery and possible complications.
Holly would have appropriate time to integrate information and proposed treatment (e.g. if she had not started HRT yet, she could, and work with a Primary Care Provider to monitor her hormones and breast growth), as well as a space to reflect and explore if she would like to pursue a more intensive treatment (e.g. if she continues to experience clinically significant Gender Dysphoria after HRT, then perhaps she could access Feminizing Mammoplasty).
As providers, we are trained to do differential diagnosis and develop treatment plans. However, the current diagnostic criteria and insurance utilization management standards are inept in capturing the complexity of gender dyphoria. For example, strangers on the street don't easily see what is in between your legs, especially if you tuck, as painful and inconvenient as tucking can be. Vaginoplasty may not be the most effective gender affirming surgery for someone whose gender dysphoria stems primarily from how other's treat them, and not necessarily from their genitals. Other surgical options that may be more effective may be Feminizing Mammoplasty and/or Gender Affirming Facial Surgery.
Patient 2: Jade
Jade is a 17 years old, Vietnamese adolescent. He recently disclosed to his parents that he is trans and would like to pursue Subcutaneous Chest Mastectomy with Masculinizing Chest Contouring (aka "chest surgery"). Here is a portion of our conversation:
Jade: My family thinks trans is an American thing. I don't know the word for it in Vietnamese. I did not know I was trans until recently.
Me: Not everything knows they are trans or non binary right away. It sounds like navigating your family, culture and language has been a lot. That can shape your process.
Jade: I think it has. I found out about trans through the internet. I found photos of top surgery, got so excited, did research, and now I know I need it. My breasts are huge! I always wear baggy clothes to hide them, but you can still tell.
Me: That is hard. How do you think top surgery will change your life?
Jade: I will feel better in my body. I won't try to hide my body as much... I will be just happier. I won't have to hide in my room all the time. I don't even shower because I don't like being naked.
Me: That'll make a huge difference.
Jade: It will. Maybe I'll even join a sport or get a job somewhere when I'm older.
Me: What do you think won't change after top surgery?
Jade: ... Well, I guess I might still get "she," which sucks. My parents still call me their daughter. I need help with getting everyone on board with using "he." Maybe if I change my name, that will help.
With Jade, we see that his gender dysphoria stems from all 4 components with the physical component currently causing significant distress. We can create a holistic treatment plan for his gender dysphoria by approaching each component of his gender dysphoria as a pillar to be supported. For example, to support Jade's Existential/Spiritual gender euphoria, it is important to take into account developmental stages and understand that, like gender identity, gender dysphoria can be static for some and evolving for others. For example, Jay may not be interested in genital surgery now, but if he accesses HRT and SCM, he may experience an evolution in his gender dysphoria based on his socialization into male spaces and roles. Or, he may not. This is where building a solid foundation will be essential for Jade to be empowered to choose what kind of man he grows into. We can also support Jade's social gender euphoria by working with him and his support system (in this case, parents and school) to provide culturally responsive education regarding transition.
Patient 3: Tay
Tay is a 42 years old African American trans man. He had SCM 20 years ago. He is requesting Phalloplasty. Here is a portion of our conversation:
Tay: I thought I was finished with surgery after my chest, but after hearing that I can keep my vagina, I am interested. Honestly, I have always wanted a penis and vagina. I didn't tell anybody because I felt like a freak. I just didn't know I can have both.
Me: That's understandable. It is not commonly talked about, especially 10, 20 years ago. It is not your fault. Thank you for sharing this with me.
Tay: Surgeons will do it?
Me: It depends. The important thing is to meet insurance standards, be cleared, and communicate what you need with the surgeon. In order for me to provide supporting documentation, can you tell me more about how you knew you needed this surgery?
Tay: Well, I was born with a vagina. I never really minded it. I guess I'm lucky. I did hate my breasts though. I hated how they felt and how people stared at them. Once I got rid of them and started T, I started living my life. I've been pretty happy, honestly. I always imagine having a penis during sex. The reason I never went for Phalloplasty is because I enjoy using my vagina too, and not having a penis did not bother me enough to go through all that.
Me: What changed?
Tay: Well, I met someone who had Phalloplasty, but kept his vagina. I had no idea! They put his penis and balls in front of his vagina, if you know what I mean. You can't even tell from the front. He told me that he can use his penis and vagina. I got extremely excited and sad at the same time. I wouldn't go through this process if I didn't have to. It's a lot, I know that. But it's undeniable now. Now that I know, I can stop thinking about it, and I get sad whenever I think about not having a penis. Ignorance is bliss, I guess.
I included Tay as an example for numerous reasons: (1) to exemplify how gender dysphoria can evolve over time (2) gender dysphoria can be shaped by our surroundings, and (3) stress the importance of honoring variations of surgical combinations and genital surgeries. There are many non-binary folks who access gender affirming surgeries. This often triggers panic in providers and insurance, but I have faith this will change as we normalize all variations of gender affirming surgeries. In Tay's case, he is a trans man who has a very specific physical component of gender dysphoria - the lack of a penis, not the presence of a vagina. In other cases, an individual may seek a "feminizing" genital surgery, and "masculinizing" chest surgery. To avoid being distracted by the diversity of gender, I encourage providers, and community members as well, to focus on honest sources of distress, and less so on expectations of what transition is supposed to look like.
If you are experiencing or treating gender dysphoria, here is a list of possible treatments for various forms of gender dysphoria:
1. Existential/Spiritual:
- Psychotherapy (I am a fan of Narrative and Art Therapy for this specifically)
- Faith, Spirituality, or Religion
- Support Groups, including online
2. Physical
- Non-surgical (name change; pronoun change; diet and exercise for body shape; voice training; hairstyles; clothing; blockers; HRT; etc.)
- Surgical
3. Emotional
- Psychotherapy (I am a fan of Cognitive Behavioral Therapy and Dialectical Behavioral Therapy for depression, and anxiety, as well as movement and somatic therapy for trauma)
- Faith, Spirituality, or Religion
- Support Groups, including online
- Medication
4. Social/Cultural
- Policy Changes (trans specific housing, employment and education initiatives)
- Advocacy
- Education
- Psychotherapy (Acceptance, Commitment Therapy, specifically, if unable to change environment, or Motivational Interviewing if ambivalent about environment)
Let's return to Holly.
Holly spent her entire life managing her gender dysphoria, and yet, she continues to experience significant symptoms of gender dysphoria as a result of her environment continuing to marginalize and attack her. Without addressing the social and cultural components of gender dysphoria, we risk minimizing otherwise effective treatments. More importantly, we risk continuing to force trans and non-binary folks into a lower quality of life.
There are countless other Hollys. There are also generations of folks who were and are unable to access gender affirming surgeries.
The least invasive gender affirming surgeries cost $5,000+ out of pocket. Gender affirming genital surgeries cost $50,000+, each, with many being multi-stage. Add on adverse childhood events such as bullying, housing and employment discrimination, police harassment, and you can understand how those with the most severe Gender Dysphoria are debilitated. Even with legal coverage of medically-necessary, gender affirming surgeries, there are no restrictions on how many barriers can be placed before access. For example, if there are no competent licensed mental health providers or contracted surgeons in your area, you may have technical "access," but no real access. This is where movements among providers like the Gender Affirming Letter Access Project (GALAP) are organizing to remove barriers to care.
Who is responsible for addressing the social/cultural component of gender dysphoria?
The answer is us.
We all have a responsibility for building a more equitable world.
I have worked with many providers who are uncomfortable working with gender dysphoria. The most common reasons I get are that folks feel unqualified or overwhelmed. There is also a resistance to the reality that working with gender dysphoria often includes a high level of case management, such as support and referrals to legal and medical resources.
As medical and clinical providers, our scope of practice do direct us to treating the emotional and physical components of Gender Dysphoria - the diagnosis and pathology.
This is where the historical framework is important. We are experiencing trans and non-binary people, especially poor people and people of color, return to systems of are in attempt to access medically-necessary care. In the first years of my work in the San Francisco Department of Public Health, I served poor and uninsured adults seeking gender-affirming care. My average patient was older, the oldest being 74. As I worked over the years, the average age of patients slowly went down, as older folks who have been waiting their entire lives were able to access care, and younger folks were provided more education and access to gender-affirming care. It takes an incredible amount of time, energy, and resources to catch up for a history of lack of access. It is further complicated by restricted understandings of gender dysphoria and resources. Case management is a necessity in providing good care for trans and non-binary folks.
Where I see harm, often unintentional, is when we fail to set realistic expectations on the limitations of psychotherapy and medical interventions. This can look like a "White Knight" championing complete, unregulated access to gender-affirming care, bypassing obtaining informed consent. Unfortunately, this may ultimately serve the provider's sense of guilt as a gatekeeper, or ego as a champion, more than the long-term treatment of the patient. I have seen how post-operative disappointment can increase gender dysphoria. We just haven’t developed a language for it yet. Maybe in the DSM-VI, there can be a Gender Dysphoria scale (Mild, Moderate, Severe) or Gender Dysphoria, Type 1, and Type 2, to specifically name and treat increased gender dysphoria as a result of medical complications.
As providers, we need to approach treatment of gender dysphoria holistically. As a community, we also need to cultivate an honest understanding of what our gender dysphoria is, where it stems from, and what we can do about it.
For me, I began with the social component of my gender transition by changing my name and clothing. The next stage seemed to be the physical component, but I felt rushed. I felt like I was skipping a step. I had to incorporate spirituality into my gender transition. I am deeply grateful for this, because addressing my spiritual health has led me back to my biological family, my motherland, my native tongue, and a spiritual foundation that then supported me through the first few years of my physical transition. I now experience this life as a spirit who lived as a girl, and now gets to learn some different lessons as a man. My faith helps me tolerate the daily struggles I experience, because there is a greater purpose. This fluidity and openness works for me, but may not resonate or work for someone else.
There is no one way that gender dysphoria should look, and no one way to treat it. If we can honor every path and tailor each treatment for each individual and their environment, I think we are moving in the right direction.
This article was conceptualized and written based on my lived experience as a Licensed Clinical Social Worker of Vietnamese descent and transgender lived experience. Please honor my wisdom and labor by citing and referencing my holistic, clinical conceptualization of Gender Dysphoria. Thank you.