Why "Gender dysphoria" Should Be Removed From the DSM: the Burden of Transphobia and Sexism
by Stefan Simanovich, LCSW
To me, the trans experience is about joy, freedom and transcendence, full of wisdom and resiliency. I do not see my trans identity as a weakness, wrong, abnormal or debilitating. It is me, who I am, and there is nothing wrong with me, my body, or my gender identity. I stand for healthcare rights and bodily autonomy for trans people in a healthcare system and society that chronically and historically has devalued and minimized the lives and struggles of trans people. This is because mental and medical healthcare that is trans-affirming saved my life, while transphobia and obtaining trans-affirming healthcare nearly took my life.
Pain, discomfort, and suffering come with life. We as humans can relate to this across body types, identities, and ways of being. Distress is a trauma response. Distress for trans people comes from being born in a world where we inherently do not belong from birth in a toxically rigid, gendered society on top of having to fight to just exist and live. Being trans is not a disorder, mental illness, pathology or a “misalignment”, a “wrong body” or sex. The distress is from consistently being told in so many ways you are wrong, unworthy, unlovable, and will be unable to live and whole and healthy life as a trans person. This includes being denied access to necessary mental and medical healthcare.
Gender is a core part of self and is felt, even without knowing. Third gender societies and people have existed across history and cultures. Trans people are not “new”; Gender dysphoria” is.
As recently as the 1980s the DSM-III categorized “transsexualism” as a mental disorder until it was replaced with “Gender identity disorder. ” In 2013 it was changed to “Gender dysphoria.” The term “Gender identity disorder”, many people in healthcare agreed, created pathology around ones’s identity, which was not indeed a disorder. The DSM, has in the past regarded homosexuality as a mental disorder by listing it in the DSM, so we must remember that this manual has historically been a stigmatizing and harmful manual that gave transphobes and homophobes a professional text in which to base their prejudice, embedded in erroneous gender science rooted in neurosexism. The DSM has historically pathologized and objectified trans people, despite attempting to restore dignity to trans people from “Gender identity disorder” by taking away the pathology of gender identity, the original diagnosis.
“Gender dysphoria” is a paradox because it has perpetuated harm. It has shaped how people and trans people view being trans, gender variant, overall emotional health, and gender itself. It is a limiting belief that blocks healing, while also preventing access to gender-affirming healthcare that is necessary and life saving. This is due to stringent guidelines, requiring “distress” as a condition necessary to receive care. Meanwhile this limited belief includes gender expectations correlated to biological sex that many people do not meet. The diagnosis enforces societal norms and expectations of gender assuming them to be true based on one's biology. Biological sex, the body, mind, and how we share ourselves with other through expression is an interconnected, lifetime, evolving process. It is not black or white either, as much as our brains want to compartmentalize everything to make sense of it.
“Dysphoria” has been normalized as being an internal source of distress coming from a “mind and body” disconnect/misalignment or “born one way, really another” mentality based on the belief that gender is biological sex and that there is a misalignment. It has also been interpreted as a mental health disorder, implicitly categorized as an illness by the DSM. The idea of “Gender dysphoria” has influenced the way people and society view trans people: weird, abnormal, traumatized, mentally ill, crazy, wrong, confused, other, or just a body. It’s the only language we are given in the trans community to describe the distress of being trans in this world and is used to justify one's worth in receiving medical intervention. It also enforces gender norms and expectations based on erroneous understandings of gender as related to embodiment, whole body health and biological sex.
I instead reframe the distress for trans people through a trauma-informed approach of “disembodiment trauma” or a core part of self being physiologically dis-associated from one’s self, body and others, coming from a lifetime of traumatic experiences that leave one feeling wrong and unworthy, covered in internalized shame, and thus incredibly trapped and hopeless. This comes from years of being unsafe, unseen, and unheard in an authentic way of being in one’s gender from birth. This is perpetuated through a healthcare system which enforces these wounds of self by engaging with trans people through frameworks like "dysphoria".
“Dysphoria” or distress of being trans, non-binary, or gender variant, in an incredibly gender binary and body shaming society, is very real. But it is not the body that is wrong or misaligned, it is society that is unable to accept trans people as people and gender variance as a regular human experience across body types; in a society that acknowledges only two genders correlated to biological sex and assumes so much based on how the body is perceived. Our bodies and genetic make up is a channel, mechanism, of energy and information flow, interconnected to our sense of self and how we share ourselves, through processing and making sense of it all.
Here at Transforward, I have spent thousands of thousands of hours (my entire career) working with trans and queer people across identities, backgrounds and ages. There are themes throughout my career and my life I have noted and attuned to as a trans person and mental health professional who is trauma-informed. I have sought to seek models and frameworks that are healing, not harmful. Models like “Gender dysphoria” only exacerbate the feeling of being wrong, unlovable, unworthy, and disconnected, an object. I can experience “dysphoria” for the rest of my life through the conditions of “Gender dysphoria” that normalizes a harsh gender binary society and tell me what my body "should" look like and who I "should" be. I have had "dysphoria" for my entire life and will continue to have it, if that is what we are describing as the trans experience and body.
Many trans people, like myself, come from complex trauma backgrounds, being rejected or unseen by family, or unsafe coming out, coupled with oppressive experiences like being banned or blocked from accessing affirming healthcare, feeling chronically unsafe in public, or not even able to use the public restroom (just a few examples). Many trans people have lacked exposure, language, or consciousness to describe their gender identity or distress/pain/confusion. This is due to not knowing a trans person growing up, and/or not having positive models of what it means and is to be transgender, much less access to gender-affirming care. Many trans people feel isolated and disconnected from society, community, and people. Many trans people experience discomfort, disgust, and hate themselves and their bodies for being trans. I have been here too. It nearly tears my heart out when a young trans person asserts they hate themselves and their body for being trans.
These lifetime experiences are often intersected with religious trauma, racism, fatphobia, ableism, violence, educational trauma, financial trauma, healthcare trauma as well as other forms of oppression that are all detrimental to socio-emotional health.
Many trans people are made to hide, be kept secret, remain invisible both unconsciously and consciously to just remain safe.
Embodiment (being “of the body”) requires that we feel seen, safe, and heard by others in our emotions, our expressions, and our identities, including one’s gender. Embodiment is socio-emotional-biological, mind, body, relational process that facilitates well-being through energy exchange. This is why a sense of belonging is so important and is a human need. If we do not have a sense of belonging, this can be enough to cause a person to take their own life. This is why access to medical healthcare that is trans-affirming is so important as well.
By allowing space for authenticity, embodiment, community, and healing through evidence based practices like EMDR Therapy, Internal Family Systems and other trauma-informed models people find harmony; alongside access to high quality medical healthcare appropriate for each individual’s medical transition needs, one that honors people's bodies, allows people to find health and well-being.
This means: a decrease in symptoms related to PTSD, dissociation, anxiety, mood instability, depression, adhd, chronic pain; a decrease in emotional distress related to feeling painfully alone, empty, isolated, disconnected, detached, restless, panic, overwhelm, suicidal.
Reprocessing trauma wounds using EMDR therapy, parts work, and other integrative models that are client-centered and trauma-informed, honoring one’s authentic self in one’s gender and body, is life transforming.
And people overall report less “dysphoria” or distress and sometimes stop using the word altogether, finding acceptance and ownership of a life, body, and identity that is theirs. This increases positive life choices, a sense of autonomy of one’s life, and a whole sense of self.
Despite your body type, size, shape, sex, gender, people are worthy of bodily autonomy, dignity, and access to health and well-being. And I believe having distress of one’s body should not be a condition to receiving gender-affirming healthcare, or to living your truth in a body that is yours no matter who you are or how you have been perceived. I believe that particularly people who do experience high amounts of distress related to one's gender identity and body, medical interventions should be available and affordable, without months and years of waiting, or barriers like receiving two letters from a mental health provider to get surgery or start hormones. THIS is distressing. These are medically necessary interventions for trans people that need it. “Gender dysphoria” adds distress by making the process distressing, terribly distressing. The near fact that one needs to wait to alleviate "distress" in and of itself is a paradox. On top of impending doom that I may one day lose or never have access to the medication I need (HRT) because of transphobia policy and hate.
End “Gender dysphoria” as a way of talking about trans people. Stop the use of phrases like “born in the wrong body.” By removing these harmful terms, we can expand access to trans healthcare and create a world where trans people belong.
My call to action is “Gender dysphoria” as a mental health diagnosis be removed from the DSM-IV. Trans, non-binary people, and gender variant people should receive access to medical healthcare through an integrative, preventative care approaches that respects and listens to trans people’s choices and body and are covered by insurance payers without the conditions of distress and the burden of transphobia. This includes an integrative medical team that is open, not rigid.
This includes changing our mindset and practices in facilities and institutions that affirm trans people; that trans people exist, creating gender neutral and gender affirming spaces across body types and identities across all systems. This also includes expanding access to low income (rural) communities and regions where many trans people lack exposure, language, and resources. And changing how we conceptualize gender in our society as a whole, one so entrenched in rigid gender norms that make it impossible to really see trans people.