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  • Writer's pictureStefan Simanovich

The Paradox of “Gender dysphoria”:

a Trans-Embracing and Neurobiological Perspective

My body would never betray me, it is my body that has been betrayed.”

The system and rhetoric of “dysphoria” that we have normalized reinforces a lack of ownership of one’s body, one that says “who you are is wrong” and forces us to navigate a healthcare system that states in so many ways: you are unworthy of bodily autonomy and existing.

Our healthcare system and providers too often recommend or enforce guidelines for trans people that increase emotional distress and thus negatively impact health through the pathologization of a natural human phenomenon, gender variance. Gender varies across body types and expressions. Unfortunately even if you are not experiencing distress, it is a prerequisite to experience distress in order to qualify for necessary medical interventions that facilitate the embodiment of gender (mind, body, relational), a human experience.

Healthcare trauma:

Trauma from distressing experiences rooted in the lack of bodily autonomy and safety within healthcare institutions and interactions ,leave individuals feeling additionally traumatized while coping with existing trauma. This causes a chronic state of distrust between an individual and/or the healthcare community.

  • Increased emotional distress (in and out of office spaces).

  • Inauthentic exchanges in the office spaces due to fears and power dynamics.

  • Fear of being misunderstood/misperceived.

  • Post traumatic stress symptoms (panic, overwhelm, hypervigilance, self-harm) due to interactions that trigger old emotional wounds that already existed before walking into healthcare spaces.

This ripples in other directions in part because of the distrust between healthcare providers and service users. Additionally there is a lack of representation of social identities (trans people) within the healthcare system. Which can lead one to avoid healthcare altogether, resulting in the exacerbation of health issues.

Trans people experience disproportionate levels of healthcare trauma because of being misunderstood, objectified and devalued in healthcare spaces, institutions, and dialogue around the trans experience, gender identity and the body.

“Checkpoints” in the health care system meant to “observe” and “assess” the trans experience and one’s gender identity, too often leave one feeling implicitly that, “there must be something wrong with me, I’m different.”

Lack of bodily autonomy for trans people in healthcare:

In this way, the idea of “dysphoria” is paradoxical because it has shaped healthcare, society, and people’s perceptions about and how they interact with, treat, engage with and perceive trans people and trans bodies.

This has largely reinforced:

“There’s something wrong with me.” / sense of defectiveness

“My body is not mine.” / lack of ownership

“I cannot be myself and be loved.” / lack of belonging

“I am not enough.” / sense of worthlessness

Examples of Systemic Transphobia in Healthcare as a Result of “Gender dysphoria”:

  • Requirement of Letters of support accompanying a Gender dysphoria diagnosis.

  • Health care and mental health care providers working as “Gatekeepers” to receiving gender-affirming procedures.

  • Compartmentalization of the trans experience as separate, or of the mind and body disconnect that instills “you don’t know who you are.”

  • Prior authorization requirements for life-saving hormone replacement treatment from insurance companies.

  • The lack of government entities taking initiative in prioritizing trans health care and pioneering trans-affirming research.

  • Associating overall health with BMI and denying access to gender-affirming surgery.

  • Outright denial of coverage for life saving and gender-affirming procedures by insurance companies.

  • A lack of basic education among healthcare providers in regard to the transgender community that is based on real experiences and trans-affirming/trauma-informed research and frameworks; this includes basic education on a medical transition for a trans person and what that means.

  • Pathologization and institutionalization of trans people who disproportionately are hospitalized for emotional distress.

  • Requirement for trans people to work with a mental health therapist for extensive amounts of time.

  • Restrictions and regulations on medical interventions based on “how long” someone has been living in their self-proclaimed gender identity.

  • Requirements for “examples” of how someone does “not pass” as appropriate gender in public spaces as basis for medical necessity.

  • Doctor’s offices and facilities not having an option to be trans: in documentations, intake documents, history taking, gender marker, name.

Examples of Interpersonal Transphobia in Healthcare as a Result of “Gender dysphoria”:

  • Gender-affirming youth clinics implementing unnecessary psycho-emotional assessments to determine “mental readiness” for hormones, then denying access if a child is deemed emotionally unstable.

  • Unnecessary body examinations during routine doctor appointments.

  • The notion that life-expectancy would be lower for the trans people due to medical transitions or medical risks. *Life expectancy could be lower for particular trans communities due to chronic, acute psycho-emotional distress caused by social ostracization and oppression rather than any innate risk in medical transition. Hormone treatment that is appropriate for each individual is live saving, not life taking.

  • The idea and belief that there is a correlation between autism and “gender dysphoria”.

  • The belief that hormone replacement therapy is unanimously dangerous.

  • The belief that hormones alone directly impact mood stability and emotional states, or ability to express and process information without regard to one’s social environment.

  • The longstanding myth that people experiencing “Gender dysphoria” and/or identifying as trans do so because of a sexual trauma history.

  • The myth that trans people are trans or have “dysphoria” due to a trauma history and are simply “crazy” or “mentally unwell.”

  • Comparing cis people’s bodies and trans people’s bodies that can leave one vulnerable too “who I am is not enough” or “my body is not mine”.

  • Evaluations that “measure” someone’s gender or “trans-ness” based on stereotypical misunderstandings of gender and trans people, like assumptions of sex is correlated to gender identity and expression.

  • Offensive language such as, "genetic female" and "genetic male”.

  • Stating transphobic and sexist language in dialogue with a patient or client:

“You're just confused."

“You don't know that.”

“Promise me you won't start anything.”

"So down there you're still a woman?”

“Were you born in the wrong body?”

“Are you sure it isn’t your trauma?”

“It doesn’t look like you need top surgery.”

“Will you miss your…?”

“That is such a painful process, are you sure you want to do that?”

“Your life expectancy will be lower if…”

“Boys don’t have…” / “Boys have…” / “Girls are…”

“Girls don’t have…” / “Girls have…” / “Girls are…”

  • The trope that kids are too young to know who they are and “there’s no turning back” mentality enforced at the expense of a child’s authentic gender needs.

  • “De-transitioning” as a concept, equated with the trans experience.

Said in so many ways implicitly and explicitly by family, society, the government, media, healthcare institutions, strangers, public spaces, doctors, providers:

“There is something wrong with you, your body, you don’t know who you are, and who you really are inherently does not belong.”

With the erroneous conflation of gender with sex (including physical anatomy and sex characteristics) and the idea that there are only two genders (male and female) with rigid rules for existing in the human body of expression, this completely annihilates those of non-binary or fluid identities. And with the disparaging, inappropriate language that is used in the DSM like, “rid of”, there is a hyper focus on the body proper in understanding the trans experience and gender that perpetuates harm. Objectifying and dehumanizing an authentic sense of self reinforces disembodiment by claiming the body is wrong or not enough, forcing rigid gender norms/expectations and beliefs that are highly socialized and associated with the body. Those who engage in these practices, often find relief by pathologizing the individual versus challenging social standards that conflate gender to biological sex.

The language of gender dysphoria has created a system that pathologizes the trans experience and objectifies the trans body. This language is limiting and hinders one’s ability to view the trans experience and gender through a trauma-informed approach. Rigid gender norms and ingrained erroneous beliefs have been instilled in our social structures, including healthcare, limiting our ability to understand the trans experience through a humanizing and expansive framework of gender as a whole.

Trans people show us that gender is beyond what is perceived.

The current status quo of how trans people are discussed, engaged with, acknowledged, and treated in healthcare is largely transphobic due to the inherent dehumanization and objectification that happens in provider’s office spaces (sometimes even by well-meaning but uninformed providers), in healthcare facilities, research, conferences, classrooms and in the world of insurance payers.

“Gender Dysphoria”: a limited term used in the DSM-VI to put language to the distressing elements of the trans experience. Gender Dysphoria is a diagnosis in the DSM-VI, a mental health disorder, that is given to a trans person for access to healthcare. To be diagnosed with Gender dysphoria in adolescence and adulthood, someone must have experienced significant distress for at least six months due to at least two of the criteria listed in the DSM-VI: a) marked incongruence between your experienced and expressed gender and your primary or secondary sex characteristics b) strong desire to be rid of your primary or secondary sex characteristics c) strong desire for the primary or secondary sex characteristics of the other gender d) strong desire to be of the other gender f) strong desire to be treated as the other gender g) strong conviction that you have the typical feelings and reactions of the other gender.

In other words:

  • Distress created by mind and body disconnect.

  • Distress related to the body proper as related to sex characteristics, to “rid them” all together and/or to replace them with other parts.

  • Emphasis placed on desire to be the “other gender,” disregarding the validity of being transgender and further emphasizing that there are only two genders.

  • The criteria itself disregards the fluidity of gender as related to body types, and takes away the essence of gender on deeper levels.

  • There is an inherent tone of the body being wrong, different, undesirable, and disposable. This is from a history of pathologizing gender identity in the DSM.

The use of “strong conviction” inevitably leads to relying on a sense of trust of the other (“informed consent”), instilling the implicit belief that one is “unstable” or possibly could not know who they are, what is best for their body, and what is in their best interests. This is coming from an underlying concern that trans people, gender questioning/curious people, or people who assert that they experience “gender dysphoria” are “unwell.”

"It’s like the world wants us not to exist, and they have to kill us to do it."

"Negativity comes from outside, not within us, inside us is positive."

Gender development, or the embodiment of gender, for trans people is different because we have grown up in a world that only acknowledges two genders connected to two sexes (male and female).

Spectrum-based frameworks:

Refers to frameworks used to interpret and understand the human experience on a continuum of being at all times. In the context of gender and sexuality, spectrum-based frameworks are used to describe the embodiment of gender and sexual part of self as evolving and developing at all times according to mind, bodyand relational energy exchange across the lifetime.

The essence of someone in their core gender and sexuality does not change, it evolves and is embodied over the lifespan. It is unique for each individual.

The embodiment or lack thereof of these core parts of the self are what shape the development and thus expression of these parts of self.

I have come to perceive gender as something felt in the heart that is present from birth; simply knowing who you are, an identity of masculine and feminine energy that goes beyond what we can see. Gender identity is developed through the embodiment of a core gender part of self.

The heart is an organ, brain (heart-brain). The heart holds a sense of gender and this essence of knowing who we are.

Gender norms in our society, based on “biological sex” shape people’s socio-emotional development across the lifespan and one’s ability to live fully self-expressed and embodied in one’s core gender.

Embodiment is being “of the body” as an integrated self in a way that creates a sense of harmony between all parts of self and the body (nervous system). The embodied brain is the brain that is interconnected with the body as a whole (Siegel, 2012, AI-26).

Biological sex is not gender. There is an interconnection between sex, gender, sexuality, the body and our relational world that is evolving through growth and development over the lifetime. It is not rigid, correlated, or separated. They are interconnected in each individual’s own way.

This is why a medical transition and intervention is so necessary for some people. Rather than the body being wrong, the body knows what it needs.

Gender development:

Is the socio-emotional-biological development of a core gender part of self that is present from birth in its natural form, and develops through the embodiment of gender, in consciousness (conscious awareness), in feeling seen and heard by others over the course of someone’s life from birth which facilitates alignment with one’s body (being embodied). If one cannot be safe, seen, soothed, and secure in an authentic core gender expression, this can prevent the embodiment of gender. This includes necessary medical intervention for the body and a sense of belonging that facilitates a sense of, “I belong, there’s nothing wrong with me.”

The embodiment of gender is largely influenced by social factors, including gender norms/expectations, and associations to one’s body, and how someone’s body is perceived as related to these associations to one’s body.

Internalized transphobia

Internalized shame from external sources of transphobia that take the place of a core gender and cause someone to live in a survival/defensive way of being to protect oneself from further harm; a felt experience of gender is unable to be expressed because of the cloud of shame, creating a sense of “who I am is wrong”. This comes from a lifetime of being rejected in a core authentic way of being in one's gender, from socio-cultural trauma and attachment wounding.

I believe when gender is disembodied it is uniquely traumatizing over the lifetime if unacknowledged, unprocessed, and unseen due to the significance of “gender to the human experience and a gender binary society.

I do not believe that gender and sexuality are inherently distressing parts of the human experience in their natural forms of expression, identity, and embodiment. The body has become the enemy to trans people because society has told us that it is and that who we are does not exist.

There are limited frameworks that empower the trans experience and do not specifically target the adaptation of the trans body; frameworks that uplift the trans identity as a natural way of being that is expansive for each individual.

Rather than viewing the body as wrong, let’s start viewing the body as right. This is why medical healthcare is so important. The body knows.

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