Dismantling Gender Dysphoria: A History in Waves

The Psychoanalytic Wave

The Psychoanalytic Wave of the 19^th century was preoccupied with causation. Fascinated by unique case studies, analysts extrapolated theories about same-sex attraction and what they considered cross-sexed behavior. 

In 1869, the German psychiatrist Karl Friedrich Otto Westphal observed what he called “conträre sexual empfinding” or contrary sexual feeling. Michel Foucault would later attribute this as the start of pathologizing homosexuality, yet it also turned scrutiny towards feminine men and masculine women. Even sexologist Richard Von Krafft-Ebing described cross-dressing as a “paranoid sexual metamorphosis.”

In 1906, Karl M. Baer, a young Jewish social worker, became the first person to have sex reassignment surgery with the help of Magnus Hirschfield. After being arrested and tortured by the Nazis in 1937, Karl escaped to Israel, where he lived the rest of his life as an accountant. As for Magnus Hirschfeld, his Institut für Sexualwissenschaft (Institute for Sex Research), was raided in 1933, leading to the incineration of over 20,000 books and journals. 

The LGBTQ+ community largely regards this as a Library of Alexandria moment since the understanding and humanization of sexual and gender minorities was set back by decades.

The Transdiagnostic Wave

Reliant on case studies and snowball samples, the Transdiagnostic Wave of the late 20th century focused on improving mental health. The prevailing data showed that gender-diverse people were disproportionately at risk regarding anxiety, depression, PTSD, substance abuse, suicidal ideation, and self-harm. Unfortunately, the literature was still steeped in cisnormative bias.

In 1980, the American Psychiatric Association published the DSM III, which presented Transsexualism as a diagnosis for the first time. It also used the term “Gender Identity Disorder (GID)” to differentiate GID/Children Transsexualism, GID/Adolescence, and Adult Non-transsexual Type, and GID/Not Otherwise Specified.

Throughout the 80s and 90s, trans activists argued that Transsexualism, as a diagnosis, was just a way of pathologizing trans identity. This led to a revision in 1994 when the DSM IV replaced Transsexualism with GID in Adolescents and Adults. 

Outside of the U.S., the tenth edition of the World Health Organization’s (WHO) International Classification of Diseases (ICD-10) retained Transsexualism as a subsection of GID.

At that time, those who needed hormones or surgery were caught in a Catch-22 whereby they still had to “play the part” to receive treatment. An example of this includes the three British trans women who won a landmark case in 1998. They effectively argued that the National Health Service (NHS) should provide trans people treatment because they had sworn to care for “persons suffering an illness.” While this was a progressive step towards gender affirmative care in the U.K., it still operated under the premise that gender diversity is “a mental illness.”

In 2001, HBIGDA rolled out its sixth SOC for Gender Identity Disorders, introducing the criteria needed for therapists to write letters of recommendation for surgery. It also introduced the Real Life Experience (RLE), requiring trans people who desired hormones or surgery to first live publicly as their “desired gender.” 

For those who were already doing so, this was not a problem, but the RLE was heavily criticized because it did not adequately consider the client’s level of social support or physical safety. The Transdiagnostic Wave placed too much responsibility on the individual to safeguard their well-being from hostile and intolerant environments and then barred them from care when they showed psychological distress.

In 2006 HBIGDA changed its name to the World Professional Association for Transgender Health (WPATH) to emphasize health and well-being over gender dysphoria.

The Identity Wave

Currently, there is a small but growing movement of licensed mental health professionals who are attentive to gender-diverse voices, as well as counselors who are gender-diverse themselves. 

This Identity Wave focuses on each client’s lived experience, instead of assuming all gender-diverse people will fit one stage model of development, or cookie cutter treatment plan. Just as there are many unique experiences of gender, so too are there many routes to self-actualization, self-affirmation, and self-empowerment. Understanding this, researchers are starting to conceptualize how multifaceted gender identity development is instead of overgeneralizing results, “othering” trans identities, and maintaining the false binary between cisgender people and everybody else.

In 2018, WHO released the ICD-11, introducing Gender Incongruence, characterized by a “persistent incongruence between an individual’s experience gender and the assigned sex, which often leads to a desire to transition, in order to live and be accepted as a person of the experience gender, through hormonal treatment, surgery, or other health care services to make the individual’s body align, as much as desired and to the extent possible, with the experience gender.” 

Not only is this description open to a wide array of genders, but it was also moved from “mental and behavioral disorders” to “conditions related to sexual health.” In other words, gender incongruence is not a disorder, but a condition that some people may experience in life.

Following suit in 2022, WPATH released version eight of their SOC, abandoning the language of gender dysphoria in favor of gender incongruence. The criteria for adults seeking hormones reads as follows:

• Gender incongruence is marked and sustained;
• Meets diagnostic criteria for gender incongruence prior to gender-affirming hormone treatment in regions where a diagnosis is necessary to access healthcare;
• Demonstrates capacity to consent for the specific gender-affirming hormone treatment;
• Other possible causes of apparent gender incongruence have been identified and excluded;
• Mental health and physical conditions that could negatively impact the outcome of treatment have been assessed, with risks and benefits discussed;
• Understands the effect of gender-affirming hormone treatment on reproduction and they have explored reproductive options.

The criteria for adults seeking surgery reads as follows:

• Gender incongruence is marked and sustained;
• Meets diagnostic criteria for gender incongruence prior to gender-affirming surgical intervention in regions where a diagnosis is necessary to access healthcare;
• Demonstrates capacity to consent for the specific gender-affirming surgical intervention;
• Understands the effect of gender-affirming surgical intervention on reproduction and they have explored reproductive options;
• Other possible causes of apparent gender incongruence have been identified and excluded;
• Mental health and physical conditions that could negatively impact the outcome of gender-affirming surgical intervention have been assessed, with risks and benefits have been discussed;
• Stable on their gender-affirming hormonal treatment regime (which may include at least six months of hormone treatment or a longer period if required to achieve the desired surgical result, unless hormone therapy is either not desired or is medically contraindicated).

While a level of gatekeeping still remains, the shift towards gender incongruence goes a long way to destigmatize trans and nonbinary people.

So what will become of gender dysphoria as a diagnosis? Will the next DSM discard it as an outdated relic, or will it be reclassified? 

Members of the trans community often remind people that not everyone who’s trans has gender dysphoria. Yet some people do experience an intense level of social, physical, and mental distress pertaining to their gender, that goes beyond incongruity. 

Perhaps gender dysphoria needs to be dismantled to specify anxiety induced by minority stress, internalized transphobia, grief for anatomy one’s missing, or discomfort for anatomy one has. Regardless, it’s imperative not to frame these issues as mental health disorders, just as it’s imperative to grant people their own body autonomy.