The Best Way to Treat Gender Dysphoria

When Bruce Jenner revealed to Diane Sawyer and the world that he was, “for all intents and purposes…a woman,” the revelation sparked a nationwide conversation about gender. Jenner, beloved by American sports fans since the 1970s, is neither homosexual nor effeminate. What does it mean for Jenner to be transgender? 

“My brain is much more female than it is male. It’s hard for people to understand that, but that’s what my soul is.” Jenner described what psychologists call gender dysphoria, a mismatch between biological sex and gender identity.

What is Gender Dysphoria?

When we are born, the doctor glances at our genitalia, declares us male or female, and we are bound by that identity for life. As Helen, a transgender woman from London points out in one of her online essays, “[gender] is the most primary piece of information people use to determine how to react to you, judge you, even see you.” Some people do not identify themselves as the gender that matches their anatomy. A person may have the physical characteristics of a woman, but identify wholeheartedly as a man, or may not feel strongly identified with either gender. These feelings often arise at a young age (18 months for Helen), and can be very confusing for a child in a world that neatly divides everything from toys to bedding according to gender. 

What Causes Gender Dysphoria?

The short answer is that we don’t know. According to the UK’s National Health Service, “Gender dysphoria was traditionally thought to be a psychiatric condition, with its causes believed to originate in the mind. However, more recent studies have suggested that gender dysphoria is biological and caused by the development of gender identity before birth.” In other words, gender dysphoria is not a mental illness. Or, as the World Professional Association for Transgender Health puts it, “Being transsexual, transgender, or gender-nonconforming is a matter of diversity, not pathology.”

According to  Brock McCalmon of New York City, who often speaks on the topic of gender identity, “As a trans person I’ve come to understand that I was not ‘born in the wrong body.’ I was born in a body that society does not understand. Once we start to challenge our ideas about that, I believe trans and gender non-conforming people will truly be able to live without fear of harm, rejection, shame, and a lifetime of misunderstanding. “ 

It is that rejection, shame and misunderstanding that trans people need help with, more than their gender identity. Says McCalmon, “We KNOW what our gender is but body dysphoria, that is a real thing. People don’t understand our bodies.”

Gender Dysphoria in the DSM

“Though I was happy to see the DSM-V change their language from Gender Identity disorder to Gender Dysphoria, I have qualms with this diagnosis, as well.” says McCalmon. “What I’ve learned as a trans person and an active member of the trans community, as an activist and advocate, is that very rarely do we have any ‘dysphoria’ about our gender. Our gender is usually our most solid identity.”

The inclusion of gender dysphoria in the DSM-V is somewhat controversial, due to a history of casting alternative gender expression as mental illness. Although some wanted the term removed from the psychiatric lexicon, it has remained as a potential diagnosis because transsexual and transgendered individuals often experience distress as they come to terms with their gender identities. Keeping the term in the DSM means physical and mental health services can be offered to transgender individuals who need support and relief.

Helen describes that distress eloquently. “…gender identity isn’t a conscious state, it cannot be counseled, neither is it an emotion. It’s located below instinct, it’s not how or what you do, it’s just you. Or in my case, not_you…If anybody had ever asked me the one part where feeling the ‘wrong’ gender hurt, I would have unhesitatingly pointed to the very spot in my brain where the amygdala resides…Until puberty, the angst was distant and vague. But once male hormones flowed in earnest, it was like being poisoned. Not a sharp pain, just an overwhelming sense of wrongness, drip-dripping inside my head all the time; like Chinese water torture slowly driving me mad. Sometimes I could ignore it, at other times it was the only thing  of which I was aware. You can hope it goes away, occasionally convince yourself that it has, but it never does.”

Treatment for Gender Dysphoria

Since people with gender dysphoria are “of sound mind,” they are able to direct their own decisions about treatment. Some, like Bruce Jenner, choose to “transition,” or make hormonal and surgical changes to their bodies to bring them into alignment with their identities. 

However, not everyone whose gender identity doesn’t match their physical body chooses to transition. A St. Louis trans person who chooses to remain anonymous talks about the pressure to transition that sometimes comes from within the trans community. “Just because one doesn’t choose to transition doesn’t mean that the issue has gone away…choosing not to transition is completely valid for some.” Gender, for many people, is more of a continuum than two sides of a coin. It is possible to live in the middle of that continuum, or even to remain fluid and express one’s gender differently from day to day, or even to live with as little gendered expression as possible.

In general, treatment means helping individuals deal with whatever internal and external stresses they face as they make decisions about how to live in a way that feels like an honest expression of gender for them.

McCalmon hopes that societal perceptions of gender will evolve to embrace more of a continuum of gender. “I think the best thing we can do when it comes to treating any sort of gender or body dysphoria, is to challenge our ideas of what it is to be a man or woman.  We have to let go of the idea of penis = Man, vagina = Woman.  Gender is much more vast than biological sex.”