Last week, Ohio Gov. Mike DeWine, a Republican, vetoed a measure that would have barred minors from receiving harmful transgender interventions such as puberty blockers and wrong-sex hormones. Amid intense backlash, he’s since tried to run damage control, signing an executive order on Friday that bans only trans surgeries for minors. We hope Ohio Republicans still override DeWine’s veto.
There’s more going on behind the scenes of the medical establishment, however, especially as it relates to the “gender dysphoria” diagnosis. Gender dysphoria must be addressed in conjunction with contributing factors, such as adverse childhood experiences, but instead licensed clinicians rush children toward life-altering medical interventions.
If you pay any attention to the conversation surrounding so-called gender identity, you might be led to believe sex is not real and that its binary nature is a created concept that can be altered to align with a person’s psychological beliefs about his or her sex. Such is the thinking that undergirds gender dysphoria, a condition listed in the Diagnostic Statistical Manual for Mental Disorders, Fifth Edition (DSM). The diagnostic criteria hold that gender dysphoria is “a marked incongruence with one’s experienced/expressed gender and assigned gender.”
The key to the gender dysphoria diagnosis hinges on the presence of distress. If a person experiences marked distress about being identified as transgender, that distress can be labeled a disorder. If a person does not experience marked distress, advocates hold that person’s transgender identity ought to be considered normal.
In 2013, the gender dysphoria diagnosis was changed to include this understanding to normalize what was previously considered a disorder. Since then, the conceptualization of gender dysphoria has become muddled. It is no longer clear that there can be a therapeutic goal of helping people shed the delusion that they can truly live as a sex other than what is written in their genetic code.
When responding to all the changes made to the DSM in 2013, it is fair to ask: If the medical working groups and other professional organizations’ goal in changing the diagnosis was to destigmatize the condition, then why not completely remove the diagnosis from the DSM?
You can find one answer to this question in how the American medical system is structured. Our medical system does not allow for insurance reimbursement without a diagnostic code. When it comes to gender dysphoria, it would seem the diagnosis is often not being given for the purpose of remedying the root causes of mental distress. Instead, the diagnosis is increasingly being used as a vehicle for payment to change one’s physiological appearance.
If this were not the case, we would see the mental health profession researching and embracing other clinical modalities that are known to help with psychological needs common among those who claim a transgender identity. Currently, the only “treatment” endorsed and propagated by these professional and medical boards is so-called gender-affirming care, which is actually medically assisted self-harm. Gender-affirming care is a one-track approach swaddled in a dogmatic ideology, and it shuns any other approach that does not entail denying biological realities.
Diagnosis is just as vital to the “treatment” process as getting insurance to pay for it because it precedes the development of an intervention. In most instances, a clinician has the latitude to give a provisional diagnosis and, if necessary, pivot to a better-suited diagnosis and intervention once time and ongoing assessment have more accurately revealed the nature of the problem. This is not the case with a gender dysphoria diagnosis. The therapeutic and public community alike have been told that the gender dysphoric condition can be remedied only by altering or excommunicating parts of the body so that people can appear outwardly more like what they feel internally. This invasive physiological intervention has been billed as life-saving care, and backing away from such a course of action has been posited as unethical.
One of the authors, Walt Heyer, was diagnosed with gender dysphoria and given hormones and surgery only to discover, like the vast majority of regretters and detransitioners have, that the misuse of the gender dysphoria diagnostic term enacts painful personal consequences.
The Authority of the DSM
In all the discussions on the transgender topic, there is rarely any consideration given to the question of the gender dysphoria diagnosis’ legitimacy. For context, questioning the authority of the DSM is not a newly explored topic. This question has been the source of a long-standing debate among psychiatrists, mental health professionals, and theorists who use the DSM to diagnose other mental disorders. This debate arises out of concern that giving diagnostic labels reduces human experience and suffering into overly simplistic categories that can limit treating the whole person.
For example, borderline personality disorder has been recognized by clinicians and researchers as a diagnosis often disproportionately attributed to women and not men. This is likely due to several factors; one is that the symptoms characteristic of this disorder fit well with some of the stereotypical qualities of emotional expression found to be more prominent in females than males. Therefore, it is conceivable that inaccurate diagnoses can occur based on social norms rather than sound diagnostics, which are followed by appropriate treatment plans.
Diagnoses can help with medical communication and treatment planning, but these are not static concepts that pigeonhole people into a way of acting, thinking, and behaving unto their last dying breath. Before scrapping the whole DSM, we should take stock of the fact that there are diagnoses based on well-formed ideas with solid research studies and clinical observations. Ultimately, these must be held in concert with a recognition that human beings are complex and have unique experiences that are not always accurately depicted by lists of symptoms found in the DSM.
We are not arguing to eliminate the DSM; however, we are raising questions about the use and overuse of the gender dysphoria diagnosis. The misuse of this diagnostic term is not without consequences.
Include Other Possible Factors
Instead of rushing into surgical and chemical interventions, what if the gender dysphoria diagnosis were reconceptualized to include other possible contributing factors to the distress (adverse childhood experiences, neurological disorders, etc.)? This approach would necessitate a thorough and ongoing evaluation of a person and his or her life experiences that have formed the presenting gender distress, a stark difference from the current conceptualization that promotes a haphazard, catch-all approach to diagnostics.
For example, it is well-documented that adverse childhood events contribute to many types of mental disorders and distress. This term refers to a range of negative and highly stressful experiences a child may experience firsthand or as a witness, such as physical neglect, parental separation or divorce, living in a household in which domestic violence occurs, or living in a household with an alcoholic. These negative experiences have the potential to alter the brain, where the most basic human needs originate and a person’s identity is formed.
In one large-scale study, transgender-identifying youth reported having other mental health diagnoses that were present before the onset of transgender belief. This study compared more than 1,300 transgender-believing youth with age-matched peers from three large pediatric practices in California and Georgia. The findings showed psychological disorders such as anxiety, depression, and attention deficit disorders were several times higher than the peer group. Suicidal ideation was up to 54 times higher, and self-harm was up to 144 times higher.
Other studies of transgender-identified individuals have also reported a high frequency of childhood emotional and physical neglect and abuse. These findings merit diagnostic conceptualization and treatment plans that lend themselves to addressing comorbidities.
We believe the terms of a gender dysphoria diagnosis must be viewed in conjunction with contributing factors, such as adverse childhood experiences. Unfortunately, this is not the predominant approach among the preponderance of licensed clinicians.
