Gender Dysphoria and Gender Affirming Care
By: Zaine Roberts, ACPSY Master’s student class of 2024
Gender dysphoria and gender-affirming surgeries (GAS) have become the focal point of ire within sociopolitical contexts in recent years. Sociopolitical attacks against those that identify as transgender have witnessed a stark increase in laws preventing access to gender-affirming surgical intervention. Often, discourse promoting the passage of these laws focuses on preventing adolescents from accessing gender-affirming surgeries centered on “protecting kids” from sex reassignment surgery, often stoking the flames of misinformation and further alienating transgender people (Bockting et al., 2020).
Gender dysphoria is characterized by “a marked discrepancy between one’s birth-assigned sex and one’s gender identity and expression and is associated with immense bodily and emotional distress.” (American Psychiatric Association, 2013). It should be noted that previous definitions of gender dysphoria posited by the DSM-IV characterized gender dysphoria as a Gender Identity Disorder, showcased by a “strong and persistent cross-gender identification.” In adolescents, the DSM-IV notes that evidence for Gender Identity Disorder included preference for “cross-dressing” as the opposite sex, “strong preferences for cross-sex roles in make-believe play or fantasies, intense desire to participate in stereotypical games and pastimes of the other sex, etc” (American Psychiatric Association, 1994).
This is crucial to note as we can clarify the advancements regarding conceptualizations of both gender and sex in the years between the publication of the DSM-IV and DSM-V. It also exemplifies that while defining gender dysphoria, conceptualizations have shifted from experienced dysphoria as a disorder that needs to be cured, to a manifestation of personal and societal factors impacting the individual. However, it also magnifies the reality that someone experiencing gender dysphoria must have some form of diagnosis to receive insurance coverage and treatment for their experienced dysphoria.
Gender-affirming surgery includes a multitude of surgical interventions designed to support transgender individuals in aligning their physical characteristics with their aligned gender expression. While surgical interventions can involve reproductive organs, surgical interventions involve a variety of procedures including facial feminization surgery, hysterectomy, mastectomy, thyroplasty, and so on that allow the person’s physical characteristics to align with their gender identity (Hassan et al., 2021). Furthermore, guidelines have been set forth by organizations such as WPATH that detail components of ethical gender-affirming practice.
Gender dysphoria has been recorded throughout historical contexts, but differences in perception arise based on cultural contexts. For example, in many historical Indigenous oral traditions, two-spirit peoples were celebrated as having a unique closeness to “the creator” and thus they would take on important community and religious ceremony obligations (Angelin et al., 2020). The American Psychological Association (n.d.) defines two-spirit as “a person who takes on the gender identity of the opposed sex, with the approval of the culture,” however, it is important to note that because the two-spirit identity comprises such as wide berth of intersectionality with gender, sexuality, community, etc that they cannot be boiled down to this simple statement (Angelin et al., 2020).
Furthermore, longstanding religious beliefs including transgender people exists in many cultures. For example, in the Hindu religion, Lord Krishna’s willingness to take the form of a woman and wed Aravani to fulfil his obligation to spend his last night as a married man before his life was sacrificed gave rise to the Aravani, a group of transwomen who serve significant sociopolitical roles in their spiritual community. Additionally, Lord Rama granted the hijras (transgender individuals) that stayed with him during his banishment the power to confer blessings during marriage, childbirth, and inaugural functions (Srinivasan & Chandrasekaran, 2020).While some non-Western cultures celebrated transgender people, the concept of gender dysphoria was not recognized in the West until the end of the 19th century, while often being demonized as psychosis or hysteria. The creation of the first institute to study gender and sexual orientation was founded in 1930 during the beginning of the Nazi occupation. The Institut für Sexualwissenschaft, roughly translated to the Institute of Sex Research, was the first to provide gender-affirming surgeries recorded in the West. During the Nazi occupation of Germany, the institute was the first targeted book burning of the regime (Poteat et al., 2019).
Between the 1930s and the modern era, significant changes in the diagnosis and definition of gender dysphoria are prevalent in the literature (Coleman et al., 2023). The Western world would not see the first recognized recommendation for gender-affirming surgery until 1966 (Poteat et al., 2019). These advancements are facilitated by healthcare professionals recognizing the importance of gender affirming care and mark the transition from idea and speculation to ethical practice for gender-affirming surgery, as well as its impact on health outcomes.
Mental health outcomes are negatively affected when gender-affirming care is not taken into consideration when treating transgender individuals. Delays in gender-affirming care have been shown to decrease quality of life (Almazan & Keuroghlian, 2021). Denial of gender-affirming surgical intervention has revealed reports of attempted self-surgeries in the literature as people reach such extreme levels of distress that no other option appears available (Rotondi et al., 2013). Notably, delays in gender affirmation have been shown to increase the risk of suicidality in transgender populations exponentially, however, research has also shown a decrease in suicidal ideation post-surgical intervention (Almanzan & Keuroghlian, 2021).
Minority stress generation for transgender individuals has revealed intersectional dynamics both internally and externally. For example, proximal minority stressors may involve identity concealment, internalized stigma, internalized transphobia, and so on (Valentine & Shepherd, 2018). These can be particularly salient as abandonment and homelessness post “coming out” are prevalent causes of concern for transgender people (Fraser et al., 2019).
Distal minority stressors can include violence and danger associated with gender identity and expression (Valentine & Shepherd, 2018). When taking into consideration proximity to power and multiple minority status, it is necessary to note black transgender women have the least proximity to power, and thus, the highest potential for victimization in the population. The Transgender Homicide Tracker has shown that 68% of murders in the transgender population between 2017 and 2023 have been black women, while only 13% of the population is estimated to be black (Everytown For Gun Safety Support Fund, n.d,, Flores et al., 2022).
Clinical implications follow a complicated tightrope for clinicians as they navigate providing gender-affirming care in the current sociopolitical climate. Organizations such as WPATH provide guidelines for both effective gender-affirming care and surgical intervention. For example, a person must receive one year of mental healthcare for gender dysphoria before they can be cleared for gender-affirming surgery per WPATH guidelines (Coleman et al., 2022).
Research shows that gender-affirming care is necessary and an ethical imperative in the care of transgender individuals. This can be achieved by creating safe spaces in clinical practice such as providing gender neutral bathrooms, ensuring the use of gender affirming language, assessing personal bias regarding gender narratives, familiarizing yourself with recent laws affecting the population, etc. Equally, obtaining gender and sexuality training and improving your efficacy in providing a gender-affirming setting is paramount.
Importantly, and given sudden movements within the sociopolitical lens this information will swiftly be outdated, state legislations have moved quickly to ban gender-affirming care overall (Kraschel et al., 2022). While some state bans have been overturned, such as in Tennessee or Kentucky, 28 other states have been or are planning to pass bans on gender-affirming care, thus, clinicians are ethically bound to engage in social justice work to advocate against legislation that directly engages in actions that research has shown is detrimental to the lives of transgender individuals.
Resources, such as WPATH’s eighth edition can be accessed at their website at https://www.wpath.org/publications/soc” along with relevant research and resource availability. Equally, GLADD has resources for transgender organizations, crisis lines, research, and more at GLAAD, Transgender Resources“. Gender-affirming care can mean the difference between someone simply existing, falling into despair and hopelessness, or flourishing to achieve self-actualization. This sentiment is particularly salient for those that live in gender-unaffirming environments, and providing affirming care allows for the fundamental need for a space to be heard, validated, proud, and most importantly, safe.
Resources
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