October 26, 2020

Are all transgender people gender dysphoric?

No, the headline is not another variant of the “you cannot be trans if you are not gender dysphoric” meme, often used by transmedicalists and transgender separatists who think they more trans than other trans people.

The headline rather refers to our understanding of the term “gender dysphoric”.

Could it be that the “you have to be dysphoric to be trans” statement is based on a misunderstanding of the term “gender dysphoric”?

Over at CDL Carah Maisie (who is herself a transgender woman) makes this argument on the basis of an analysis of the DSM-5 “gender dysphoria” diagnosis. Her argument is inspired by an article written by Jocelyn Badgley.

The DSM-5 manual and its criteria for being gender dysphoric

The DSM-5 is the current edition of the American psychiatric manual. “Gender dypsphoria” is not seen as a mental illness in the manual, but it is included all the same to ensure that trans people get access to health services and proper insurance.

Carah and Jocelyn list the various criteria that indicate gender dysphoria in the DSM-5, and some of them do indeed refer to a mind/body misalignment:
  • 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 another gender
But these are not the only criteria. Others refer to social and societal dysphoria:
  • A strong desire to be of another gender
  • A strong desire to be treated as another gender

And there is also one referring to gender stereotypes:
  • A strong conviction that one has the typical feelings and reactions of the other gender

You do not need body dysphoria to be gender dysphoric

Carah writes:
Note, only two of these conditions need be met for a formal diagnosis. You may notice that only two of these comprise the physical body. It is perfectly valid for a trans person to be experiencing Gender Dysphoria without actually hating any part of their body, or wanting to change any part of their body. Physical Dysphoria is only one fraction of the many ways that lead to being trans.

So, it is literally impossible for a person to identify as trans and not experience gender dysphoria.
You can read Carah’s analysis here.

You will find the DSM-5 text here. 

I think Carah and Jocelyn are spot on as far as the deconstruction of the DSM-5 is concerned. You do not need anatomic dysphoria to be diagnosed with gender dysphoria.

Indeed, the manual stresses that “In adults with gender dysphoria, the discrepancy between experienced gender and physical sex characteristics is often, but not always, accompanied by a desire to be rid of primary and/or secondary sex characteristics and/or a strong desire to acquire some primary and/or secondary sex characteristics of the other gender.” (My emphasis)

You could argue that there would still be some kind of dysphoria, though  – in the sense of a sense of discomfort coming from not being able to live as your target gender.

Does transgender mean the same as transsexual?

But there is one complication. The DSM-5 distinguishes between “transgender” and “transsexual”. “Transgender” is used as a broad umbrella term for gender variance:
Transgender refers to the broad spectrum of individuals who transiently or persistently identify with a gender different from their natal gender.
This definition is broad enough to include gender nonconforming people who feel at home in their assigned gender.

As I read the DSM-5 the term “gender dysphoria” seems more to correspond to the medical term “transsexual”, defined in the manual in this way:
Transsexual denotes an individual who seeks, or has undergone, a social transition from male to female or female to male, which in many, but not all, cases also involves a somatic transition by cross-sex hormone treatment and genital surgery (sex reassignment surgery).
Not all transgender people are transsexual. Some of the confusion regarding dysphoria is caused by people interpreting “transgender” in a very narrow way, i.e. as to mean the same as the old fashioned term “transsexual”.

The fact remains though: You do not need to be alienated from your body to be diagnosed as gender dysphoric as far as the DSM-5 goes.

Do we need to follow the DSM?

Do we need to accept the definitions of the DSM-5? 

No, we do not. The international WHO ICD-11 manual does not talk about "gender dysphoria" at all. Instead that manual uses the term "gender incongruence," which is defined as follows:

Gender Incongruence of Adolescence and Adulthood is characterised by a marked and persistent incongruence between an individual´s experienced 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 experienced 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 experienced gender. The diagnosis cannot be assigned prior the onset of puberty. Gender variant behaviour and preferences alone are not a basis for assigning the diagnosis. (My emphasis)

You could read this definition as support to the idea that you need some kind of body dysphoria to be transgender, but you would be wrong. 

The fact is that the manual does not say anything about being transgender, because being transgender is no longer considered a mental illness and therefore does not belong in a health manual. 

The manual does not try to diagnose or define  the identities of trans people. Instead it is looking at one possible effect of being trans– an effect that may require medical intervention. Indeed, the only reason gender incongruence is included at all is that health systems require a diagnosis in order to provide the medical services some trans people need, and those services are often addressing the body. 

If you read the text carefully, however, you will see that you do not need to suffer from body dysphoria to be diagnosed with gender incongruence. 

That being said, trans people have no reason to accept the texts of health manuals just because they are written by doctors and scientists. Trans people are the ultimate experts on trans issues, not doctors.  And keep in mind that it isn't that long ago that the same manuals classified trans people as mentally ill, suffering from disorders.  

Indeed, some trans people argue that we should stop using such medical terms altogether, and no longer allow health professionals to have any say in the debate about transgender lives. There are good arguments for this, but I am afraid that as long as health services are required, there will be a need for some kind of agreement.

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