Can You Be Trans*, Transgender, Genderqueer, Agender, Bigender, or Otherwise Gender Non-Conforming Without Being Dysphoric?

​I’ve read a couple of really good thought pieces on what it means to have a non-cisgender identity. And while it is far more common than not, the idea that dysphoria is a requirement Is totally shitty. Like there is a requirement of fundamental brokenness in your experience of your assigned gender before you are accepted for your true gender. A form of colonization of people with lived experience by the medical establishment.

I agree with that sentiment with 100% of my being. You know who you are. That is not for me as a clinician to decide. Individuals with lived experience have written about the no-dysphoria phenomenon, and you should read their pieces if you haven’t already. Sam Dylan Finch wrote a piece for Everyday Feminism. And this piece on FTM Magazine is an equally thoughtful and beautiful analysis of why dysphoria isn’t a requirement.

Then add to the mix this post by Zinnia Jones about her own experience with starting gender confirmation treatments without experiencing dysphoria…or so she thought. She started knowing that the aging process would likely cause physical changes that would trigger dysphoria in the future. But she also realized later that she did have symptoms of dysphoria that she didn’t well read at the time.

I absolutely agree with the idea that we need to de-stigmatize, de-medicalize, and de-colonize gender identity. But I think that Ms. Jones’ nuanced understanding of dysphoria is an important part of a conversation I endeavor to add to today.

 My role is that of a cisgender, ally clinician who serves to support individuals undergoing confirmatory treatment. In English, this means I’m one of the people in town who will write the letter that will allow individuals to receive gender confirmation treatments (hormone therapy and/or various surgical interventions).

Of course, the WPATH Standard of Care does not require a letter for many of these treatments, instead encouraging an informed consent dialogue with the treating professional. But all doctors have their own requirements, as do all insurance companies that provide coverage for confirmatory treatment.

In short, many docs and all insurance companies are going to require a diagnosis that establishes medical necessity. So whether you are seeking a letter or you are a clinician who is figuring out how to assign a diagnosis without breaking the law, this post is for you.
 
The Criteria for Diagnosing Gender Dysphoria

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) provides for one overarching diagnosis of gender dysphoria with separate specific criteria for children and for adolescents and adults. We are using the adolescent and adult criteria in this piece to keep things simple. Know that trans* children have very similar responses to gender mis-assignment, it just presents in more age-appropriate ways.
 
F64.0 [302.85] Gender Dysphoria in Adolescents and Adults

In adolescents and adults gender dysphoria diagnosis involves a difference between one’s experienced/expressed gender and assigned gender, and significant distress or problems functioning. It lasts at least six months and is shown by at least two of the following:
 

• A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics
• 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 the other gender
• A strong desire to be of the other gender
• A strong desire to be treated as the other gender
• A strong conviction that one has the typical feelings and reactions of the other gender

 
First of all, is Gender Dysphoria the only viable diagnostic option? The short answer is no. Your other options include:
 

• F64.8 [302.6] Other Specified Gender Dysphoria
• F64.9 [302.6] Unspecified Gender Dysphoria

 
Obviously, these are the same codes, just different interpretations. If it says “other specified” this could mean a multitude of things that a clinician would then elaborate on. This code is used when the dysphoria has not persisted more than 6 months, for example. It is also regularly used for individuals who have an intersex condition with accompanying dysphoria or for people who have a desire for a penectomy without wanting any other markers/characteristics of the female gender.
 
You could also make the argument that these are entirely appropriate codes for individuals who are trans* but do not experience dysphoria.

Above when I said the short answer is no? The longer answer is an insurance company will likely not accept one of these diagnosis for gender confirmation treatments. A doctor might. Though, if I sent this diagnosis in to one of the docs I work with in the area I would likely get a “Faith, WTF is this about?” text from them.

If I am forced to serve as a gatekeeper for someone else’s identity, the gender dysphoria diagnosis is the magic key for getting services.
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And this brings us back to the original question. If someone doesn’t endorse dysphoria are we fucking liars for using that diagnosis? And maybe it took me a minute to get to this point, but we need to look at how we operationalize clinical terminology when making these determinations. If we unpack the verbiage, I think we can come to terms with a diagnosis that fits a variety of lived experience without feeling that we are making a demeaning or unethical choice. And this is where I go into board supervisor and counselor educator mode. Bear with me.

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"You keep on  using that word. I do not think it means what you think it means." — Inigo Montoya

Let’s start with defining dysphoria as a state of unease or generalized dissatisfaction with life. It’s a mid-19th century term, coming from Greek word dusphoros meaning ‘hard to bear.’ This is a far different explication of dysphoria than we have been led to believe, isn’t it? It is more like Miss Clavell in the Madeline books by Ludwig Bemelmans who has a habit of saying “Something is not right!” Identity and assignment do not match, and I recognize this situation.

But hey, you’re saying. What about those few words from the DSM 5 that really change everything??? You know. The “significant distress or problems functioning” part. Are those five words forcing people into mis-diagnosis and forcing clinicians into a ethical conundrum?

After a lot of research and thinking about the issues, I have to say I don’t think so (though I am certainly open to and even welcome more dialogue on the topic).

And I came to this conclusion again through defining and unpacking the words being used. The common usage of the word distress has only vague similarities to the clinical definition of distress. And clinical definitions are what we are talking about here, after all, right?

Diagnoses are really intended for a pretty singular purpose: a shorthand conversation between treatment professionals about presentation, symptomology, life domain functioning, and treatment needs. I understand that we have weaponized and bastardized diagnoses to no end, which is a whole other conversation. But in the service of people, all the diagnosis is meant to represent is me (PhD) telling another doc (MD) that certain treatment protocols are appropriate for someone because there is something impacting their ability to be healthy and happy. And we are having a conversation between the two of us about how we can help fix that.

Back to a clinical definition of distress. The term “stress” has lost all logical meaning, hasn’t it? Everything is considered stressful nowadays. And it’s entirely probably that everything IS fucking stressful nowadays. But in a clinical sense, stress means an event that requires an output of resources.

Stress can be good (output of resources to create art, or run a race, or finish school) or it can be bad (coping with a car accident or an illness or being terminated from a job). Whether the situation is good or bad, we can hit a point where we run out of the resources that we need to cope with the situation.

And that is what distress is. The point of resource depletion. The point where we need support. Whether you are suffering enormous amounts of emotional pain over a mismatch between your gender and your birth assignment, or you are simply aware that it is incorrect and there are things that can be done to bring you into alignment, you could be said to be experiencing psychological distress. You’ve hit a point where you need resources. It isn’t something you can do on your own. It isn’t a term that identifies someone as tragically fucked up. It’s a term that treatment professionals understand to mean this person needs some help, and that’s your job. We have resources to assist in aligning a person’s gender with their physical body in ways that they can’t achieve on their own. And if we are operating with that intent, and the true spirit of what a diagnosis is designed to communicate, our work is accurate and ethical in both a legal and moral sense.
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I believe the move in the DSM V to category of Gender Dysphoria (instead of  DSM-IV’s Gender Identity Disorder) is an appropriate one. We are acknowledging a misalignment that may require resources to correct. We are acknowledging distress. Now let’ get to work.