This post was written by a WoLF member who is a licensed psychotherapist with 30 years of experience in the mental health field. It applies solely to individuals who have a recognized psychiatric condition, though we note that the majority of current gender identity laws make no reference to any mental health condition, and do not require that individuals have received a psychiatric diagnosis in order to assert a transgender identity.

When we talk about gender activism and women’s and girls’ rights, it’s easy to forget that we may also be talking about clinical issues.

Transgenderism is related to a psychiatric diagnosis called Gender Dysphoria (formerly called Gender Identity Disorder, in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition). It has not been established to be an innate identity, unlike homosexuality, which was removed from the DSM in 1973. 

The presence of a psychiatric disorder indicates a need for treatment. But, the causes of Gender Dysphoria are not understood, and therefore, it is difficult to identify the best treatment for the condition. 

Persons who have a financial interest in promoting medical and surgical transitions, such as doctors who perform or prescribe these treatments, or psychotherapists who have developed a side job in writing approval letters for surgery, are not reliable sources of information on the best treatment for someone with Gender Dysphoria. Only someone with no ulterior motive, who is also an experienced and ethical clinician, can perform a bias-free assessment. 

Persons who identify as transgender should be evaluated for the numerous conditions that involve identity disturbance and/or discomfort with one’s body. These include Dissociative Identity Disorder, Body Dysmorphia, and Borderline Personality Disorder. They should also be evaluated for Autism Spectrum Disorder, as an association has been found between autism and Gender Dysphoria.  They should also be evaluated for internalized homophobia, internalized misogyny, and other socially-driven sources of self-hatred and body hatred.

None of these clinical conditions and responses to oppression, any one of which could present with symptoms of Gender Dysphoria, are treated with hormones or surgeries according to any recognized standard of care. Borderline Personality Disorder cannot be accurately diagnosed until adulthood because of the normal fluctuations of identity during adolescence. 

The foundational ethics and methods of psychotherapy give insight into how both clinicians and society could approach the struggles of transgender persons. These clinical traditions hold that an objective and scientific stance toward the patient’s symptoms, a perspective of intellectual curiosity, and an attitude of compassion toward the patient are the gold standard for care. Compassion toward the patient is not equivalent to agreeing with whatever the patient says. Rather, basic theories of psychotherapy hold that we should help patients understand themselves and their emotions. This usually includes helping the patient explore the development of his or her personality from early childhood on. Identity is conceptualized as originating in both “nature” and “nurture.” In other words, both genetics and the social environment play a role. 

Is it possible that some individuals may have developed such a persistent and intractable Gender Dysphoria that only living in accordance with their belief that they are the opposite sex offers relief? It’s possible. However, only after a comprehensive assessment of the adult, fully developed person, and a course of exploratory psychotherapy to clarify the roots of identity development, would it be ethical to suggest such an option.