Gender dysphoria

Ever since medical doctors and psychologists started to develop gender affirmative care in the 1950s and -60s, the field has been dominated by controversies regarding the diagnostic criteria for such treatment. The diagnostic criteria were initially conservative. The person was expected to suffer from “extreme gender dysphoria” (De Cuypere 2016). Back in the 1950s and -60s, it was common with psychotherapy, often referred to as reparative therapy, aimed to change the person’s gender identity in accordance with the sex assigned at birth. However, for some people, the gender dysphoria was so pronounced that it was considered to be more helpful to change body instead of mind. From the very beginning, the debate has implicitly rested upon a dualistic view on body-mind.

Gender dysphoria as a concept

Gender dysphoria refers to the mismatch between gender identity and birth-assigned sex. The concept was coined by the psychiatrist Norman M. Fisk in the early 1970s (Fisk 1974). According to Fisk, the medical doctor and pioneer within sex reassignment treatment, Harry Benjamin, operationalized transsexualism as a necessary diagnosis in order to be elected for sex reassignment operation. This was in the early 1950s. In order to be diagnosed as transsexual, the person was required to have a life-long and consistent behaviour that was either effeminate or masculine and a deep conviction of being a member of “the opposite sex”. The criteria were strict and not very flexible. According to Fisk, the reason why Benjamin and his colleagues set up these requirements was primum non nocere: the professional oath of physicians stating that primarily, they should do no harm.

In 1968, Fisk and his colleagues at Stanford University Medical Centre, one of the first clinics to implement systematically a program for gender affirmative care, embarked upon a research project. They learned from in-depth interviews with patients that applied for treatment that many of them deviated from the “classical transsexual type”. What struck Fisk the most was in fact that for many, the biggest source to gender dysphoria was strict norms regarding how women and men should behave, and not necessarily the body in itself. Fisk therefore suggested that gender dysphoria should be conceptualized as a spectrum of gender related distress. In this way, he launched himself into a controversial debate, that would last for decades, regarding the nature of gender dysphoria and gender diversity.

Gender dysphoria and gender diversity

Some people with gender dysphoria are in need of medical treatment aimed to adjust the body more in accordance with identity, and seek medical care. For others, it is sufficient with non-medical interventions, such as clothing, hair and make-up. Some people with gender dysphoria identify as transgender. This is an umbrella term for people who identify differently from birth assigned sex. However, not everyone with gender dysphoria identify within the transgender umbrella. Since 2013, gender dysphoria has been the name of the diagnosis that before was referred to as gender identity disorder (DSM-5). In the rest of the world, the diagnostic label is gender incongruence (ICD-11).

Read more about The ICD-11 Classification of Mental and Behavioural Disorders. See also Diagnostic and Statistical Manual of Mental Disorders.

An outside perspective

For decades, an aim within clinical research on gender dysphoria has been to discover predictors that can identify those who will benefit from gender affirmative care. In many ways, this kind of research has had an “outside perspective”. The aim has been to identify different aspects of gender dysphoria that can predict whether medical care is needed on an individual level. Clinicians have implicitly had a medical and essentialist perspective of gender dysphoria. This has, in the next round, had consequences for how the phenomenon has been framed in a clinical context. The therapeutic aim has been to discover the core characteristics of gender dysphoria, in order to conceptualize it as a medical disorder. Thus, both researchers and clinicians have been searching for the kernel of gender dysphoria, separated from social and cultural noise.

Framing gender dysphoria as a medical condition has perhaps been important in order to legitimize invasive hormonal and surgical interventions both among medical personnel and health insurance companies. However, if one operates within a medical perspective, it is easy to oversee contextual aspects such as gender norms, social marginalization and cultural symbols, and how this influences on the individual person’s subjective experiences of gender dysphoria.

An inside perspective

In my project, I aim to embrace an “inside perspective” on gender dysphoria. I explore how teenagers referred to the Norwegian national treatment unit for gender incongruence at Oslo University Hospital experience gender dysphoria and how they themselves describe it. In other words, I focus on each young person’s unique experience of mismatch between gender identity and birth-assigned sex. As a clinical psychologist, it falls naturally for me to have a phenomenological and interpretative approach to the topic.

Read the article Balancing in the margins of gender: exploring psychologists’ meaning-making in their work with gender non-conforming youth seeking puberty suppression. Read also the MA-thesis Balancing in the margins of gender. How clinical psychologists relate to puberty suppression when working with gender variant youth.

This question has become more and more important the last twenty years, because of the increasing number of young people that are referred to gender affirmative care for treatment of gender dysphoria. This development is international (Kaltiala-Heino, Bergman, Työläjärvi & Frisén 2018). The last decades, puberty suppression has become an accepted intervention for children and youth with gender dysphoria (Wren 2014). The clinical aim for these early interventions is to buy time for exploration of how to handle gender dysphoria. Similar to the clinical work with adults, the rationale is that the medical interventions are aimed to decrease the subjective experiences of mismatch between gender identity and birth assigned sex. At the same time, activists, academics and clinicians disagree when it comes to what constitutes good treatment, and to what degree health personnel are expected to contribute with their opinion.

Feminist grounded, with a liberating and normative ambition

In addition to a psychological and phenomenological perspective, I ground my research within a feminist tradition. This implies that I pay attention to how gender as a social and cultural phenomenon is related to subjective experiences of gender dysphoria: Within Western societies, people are expected to identity with one’s birth-assigned sex, and act to express oneself accordingly. At the same time, historical research has given us many accounts of how people throughout time and place have challenged gender norms and established diverse ways of organizing one’s life. Thus, historically, it is not a new phenomenon that people feel discomfort with birth-assigned sex (Stryker 2017).

In this way, my research project has a liberating and normative ambition: I do not want to describe the situation of young people with gender dysphoria as disconnected from the context they live in. Instead, I hope to demonstrate how gender dysphoria is a phenomenon that is deeply embedded within our culture. In this way, I aim to provide knowledge that can assist both health personnel and activists to better understand how gender dysphoria is experienced, so that we as a society in the long run can create a world that is more gender inclusive.

Read about the research project Gender dysphoria in adolescents, as well as the research project Kjønnsdysfori blant ungdom.