Dismantling Gender Dysphoria: A History in Waves

Gender dysphoria is a complex diagnosis with a controversial and sociopolitical history that cannot be ignored. It’s also a very recent concept that should not overshadow the full scope of gender diversity throughout the ages, or around the world. In retrospect, the diagnostic labels imposed on trans people reflect a biased attempt to measure or pathologize what cisgender people didn’t understand.

Yes, gender-diverse individuals experience unique forms of stress that are worth discussing, yet to do so effectively requires stripping away a lot of misunderstanding. To fully grasp the scope of gender dysphoria as an evolving framework, the past century can be broken down into five distinct waves: The Psychoanalytic Wave, The Transmedical Wave, the Transdiagnostic Wave, the Holistic Wave, and the Identity Wave. 

The Psychoanalytic Wave

The Psychoanalytic Wave of the 19th 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 Transmedical Wave

The Transmedical Wave of the mid-20th century focused on determining candidacy for medical treatment. While most psychiatrists were still trying to “correct psychopathology,” Christine Jorgensen’s transition in 1952 made the front page of the New York Daily News, bringing the possibility of sex reassignment into public awareness.

In 1966, endocrinologist and sexologist Harry Benjamin treated a client with hormone therapy. After yielding positive results, Benjamin was flooded with letters from people seeking the same. Attempting to conceptualize the array of people requesting hormones, Benjamin created the “Sex Orientation Scale,” ranging from fetishistic transvestite to true transvestite to transsexual (nonsurgical) to transsexual (moderate intensity) and transexual (high intensity). 

While the medical oath to “do no harm” was the positive intent behind this typology, it reinforced a gatekeeping model, situating the psychiatrist or physician in a seat of executive power.

However, when Norman Fisk and his colleagues began interviewing applicants in 1968, they quickly found that many had rehearsed their answers, having “availed themselves of the germane literature and…successfully prepared themselves to pass the initial screening.” So instead of trying to diagnose a person as a transsexual, Fisk and his colleagues observed a spectrum of what they called “Gender Dysphoria Syndrome.” 

They proposed a “mandatory period of trial cross-living on a 24-hour-a-day basis while receiving exogenous hormone treatment…for a minimum of 12 to 18 months, following a thorough reevaluation.” Access to treatment depended on “physical passability, vocational skills, overall psychic and emotional stability, past and present ego strengths, familial support, appreciation of core gender principles, absence of significant sociopathy, absence of psychotic symptoms and multiple or intensive neurotic symptoms (as manifested by impulsivity, poor judgement, deviousness, narcissism, manipulativeness, masochism, exhibitionism, and low self-esteem).” 

Problematically, this strict criterion didn’t fix anything—it just forced many to hide their mental health issues or conform to a transnormative treatment plan (or question their identity if they didn’t). It was already exhausting to perform masculinity or femininity to prove one was “trans enough” for treatment, but now one also had to be a model of sanity as well.  

The Harry Benjamin International Gender Dysphoria Association (HBIGDA) was founded in 1978, and a year later, it released its first Standard of Care (SOC). While these guidelines provided the best care practices known at the time, they were also the official hoops trans people had to jump through to transition.

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 Holistic Wave

The internet not only allowed gender-diverse people to connect, communicate, and advocate like never before, but it also gave researchers the ability to survey gender-diverse populations on a massive scale. Organizations like the Williams Institute and the National Center for Transgender Equality could pool tens of thousands of trans and non-binary people, corroborating what many in the community had been saying all along. 

First, the trans experience is not uniform, and there is a massive range of gender identities that socially and medically transition to varying degrees. Second, social acceptance increases the level of life satisfaction and overall well-being of gender-diverse people. Third, the minority distress gender-diverse people experience as a result of social intolerance is distinct from their relationship with their own gender identity.  

Recognizing how the environment impacts mental health, the Holistic Wave focused on allyship and social outreach, looking for ways to improve healthcare standards and provide resources to gender-diverse people. While LGBTQ+ advocates had been championing this for decades, the mental health community was finally on board. 

By viewing the client as a whole person impacted by overlapping relational, familial, political, cultural, and socioeconomic spheres, the Holistic Wave centered the need for social advocacy and a healthy community. The positive intent was to help the client improve their environment, yet clients often felt like it was solely on them to do so. Fair-weathered allyships and performative activism provided much lip service without any real social change. 

Furthermore, because cissexism intersects with sexism, racism, ethnocentrism, and classism, social change efforts require a paradigm shift on a much larger scale.  

In 2013 the APA released the DSM V, replacing Gender Identity Disorder with Gender Dysphoria (GD), characterized by at least two or more of the following over a span of six months:

  • A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or in young adolescents, the anticipated secondary sex characteristics)
  • A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or in young adolescents, a desire to prevent the development of the anticipated 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 (or some alternative gender different from one’s assigned gender)
  • A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender)
  • A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender)

The inclusion of “or some alternative gender” does make room for more diversity, and the focus is more on gender incongruence than a mental disorder. Yet, the definition of dysphoria itself is a feeling of dissatisfaction and unease. Advocates like the National LGBTQ Task Force point out that Gender Dysphoria, as described in the DSM 5, still operates under a disease framework, not an identity framework.

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. 

Alex Stitt, LMHC

Alex Stitt, LMHC

Writer & Contributing Expert

Alex Stitt is a nonbinary author, queer theorist, and licensed mental health counselor living in Hawaii. As a proud Queer Counselor, they work to educate professionals in the mental health field interested in working with LGBTQ+ populations. Their textbook, ACT for Gender Identity: The Comprehensive Guide, demonstrates how to apply Acceptance and Commitment Therapy to gender self-actualization.