Understanding the Nuance of the Gender Dysphoria Diagnosis

The inclusion of the Gender Dysphoria diagnosis within the DSM-V is a controversial topic in the spheres of psychological practice and academia. The term "disorder" has been criticized for stigmatizing gender nonconformity and implying that its nature is inherently pathological. Rather than focusing on the emotional distress individuals might experience due to gender

incongruence or societal stigma, the diagnosis has been implicated in reinforcing harmful stereotypes and creating barriers to affirming care.

Transgender activists, clinicians, and scholars have challenged the stigmatization of trans identities, advocating for a diagnosis that preserves access to medical care without labeling identity as pathological. Additionally, research has increasingly demonstrated that being transgender is not inherently indicative of psychopathology, while recognizing that some form of diagnosis unfortunately remains necessary for access to gender-affirming medical care (e.g., hormones, surgery) under current insurance and health systems.

So, What is Gender Dysphoria?

According to the DSM-V, gender dysphoria refers to “the distress that may accompany the incongruence between one’s experiences or expressed gender and one’s assigned gender.”

This marked incongruence between one’s experienced/expressed gender and assigned gender must last at least 6 months and must be associated with clinically significant distress or impairment to meet diagnostic criteria.

Within the historical canon of the DSM, the Gender Dysphoria diagnosis was seen as an improvement from the Gender Identity Disorder that appeared in the DSM-3 and DSM-4. Proponents of this change acknowledged that being transgender is not a mental illness and recognized the distress (dysphoria) that may arise from social stigma, discrimination, or lack of affirmation, rather than identity itself. In order to facilitate access to care, the DSM-V retained a gender related diagnosis to allow access to medical transition support through insurance and the US healthcare systems, and emphasized individualized care focused on alleviating distress rather than enforcing binary gender conformity.

Socio-Historical-Political Factors

One problem with the Gender Dysphoria diagnosis is that it functions to gatekeep medical care. To access gender affirming health care, many trans people are required to seek a Gender Dysphoria Diagnosis, and the medicalization of a social construct like gender pressures individuals to present their experiences in ways that conform to clinical jargon and requirements.

Nonbinary, genderfluid, and culturally specific gender identities (such as Wakashu in Japanese culture and Hijras in South Asia) are excluded from this clinical model. Importantly, this diagnosis plays a vital role in issues with insurance. One of the main reasons for seeking a Gender Dysphoria diagnosis is to allow insurance coverage for gender affirming treatments.

This creates a paradox: individuals must be diagnosed with a mental health condition to receive life-saving affirmative care, simultaneously contributing to social stigma surrounding trans and gender expansive identities. Ultimately, this serves to delay and limit access for individuals without adequate healthcare or access to affirming mental health providers, and may lead to individuals being subject to external scrutiny under which they must “prove” their gender under a cyclically perpetuated gender binary.

The Nuances of Trans and Gender Expansive Experience

Many scholars conceptualize gender dysphoria as a primarily relational issue rather than a

medical issue. They hold the perspective that it’s not that one feels bad in one’s gender because something is inherently “off” in the brain, but rather issues related to one’s gender derive from how others react and respond, and how one moves through a world that pathologizes and stigmatizes gender nonconformity.

An alternative view offered by scholar and activist Judith Butler (1990) holds that gender is not a fixed biological trait but a performance shaped by social expectations and norms. Under this framework, gender dysphoria is less about an inherent mismatch between gender and body, and more about an individual's experience of being forced to conform to societal gender roles that feel inauthentic or uncomfortable.

Manifestations of Stigma

The stigma associated with gender nonconformity has real-life impacts on those who exist outside the prescribed gender binary. Data collected by the Trevor Project from 2020-2022 shows that 46% of transgender and nonbinary young people seriously considered attempting suicide in the past year. Additionally, 45% of transgender and nonbinary young people reported that they or their family have considered moving to a different state because of LGBTQ+-related politics and law, and 65% of transgender and nonbinary young people reported that they have felt discriminated against in the past year due to their gender identity.

Conversely, LGBTQ+ young people who reported living in very accepting communities attempted suicide at less than half the rate of those who reported living in very unaccepting communities. Transgender and nonbinary young people who had access to gender-affirming clothing, gender-neutral bathrooms at school, and had their pronouns respected by the people they live with had lower rates of attempting suicide compared to those who did not. These figures show the crucial impact of social attitudes and support on the well-being of trans and gender expansive youth.

So Where Do We Go From Here?

It is crucial for mental health professionals working with trans and gender expansive individuals to understand the complexity of their clients’ unique socio-historical positionalities. In working with this community, competent care must include an understanding of the current and historical structures that stigmatize and pathologize gender nonconforming individuals, especially those within the healthcare field. Therapists must seek to understand their clients’ journey with their gender identity over time, in their own words and understanding, and how that journey has been impacted by their unique positionalities.

Furthermore, the goals of therapy should include helping the client cope with gender related stress while enhancing their autonomy and agency in making gender affirming decisions. As clinicians, we occupy a gatekeeping role in access to healthcare for this population–a responsibility that requires a multilevel, nuanced understanding and person-centered approach that is resolute in pursuing care that aligns with our clients’ best interests.

Sources:

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Publishing.

American Psychiatric Association. (n.d.). What is gender dysphoria? American Psychiatric

Association.

https://www.psychiatry.org/patients-families/gender-dysphoria/what-is-gender-dysphoria

Butler, J. (1990). Gender trouble. Routledge.

The Trevor Project. (2022). 2022 U.S. National Survey on LGBTQ Youth Mental Health:

Introduction. The Trevor Project. https://www.thetrevorproject.org/survey-2022/#intro