3.4 Supporting clients who receive a gender dysphoria diagnosis
In the UK, a psychiatric diagnosis of ‘gender dysphoria’ (DSM-5, 2013) is necessary to access trans-related healthcare or a Gender Recognition Certificate (GRC) which provides legal recognition of gender. That a psychiatric diagnosis is required to access gender-affirming medical treatment is something that has been strongly argued to be both invalid and stigmatising of trans people (Ashley, 2021; Davy and Toze, 2018; Inch, 2016; Campbell et al., 2015; Suess et al., 2014; Drescher et al., 2012). The phenomenon of ‘gender euphoria’ – a feeling of congruence, rightness and wellbeing, related to gender affirmation, is also now being discussed as a more positive reason to facilitate transition (Beischel et al., 2021).
Therapists, might find themselves supporting trans people waiting for, attending, or after attending an NHS Gender Identity Clinic. In the ICTA study, while some participants had positive experiences of diagnosis, many more found the process of diagnosis added to their mental health burden. To find out more about this try the next activity.
Activity 3.5: The impact of diagnosis for ICTA participants
Match the quotes with the impact of waiting.
Two lists follow, match one item from the first with one item from the second. Each item can only be matched once. There are 4 items in each list.
Questioning during diagnostic process is experienced as intrusive
Repetition of questions is experienced as feeling doubted
Questions experienced as aggressive
Diagnostic process experienced as having to prove they are trans
Match each of the previous list items with an item from the following list:
a.‘It was an interview, it was a chat but obviously the questions were designed to find out am I seriously transgendered or am I just somebody that wants some, just likes putting a frock on once every, you know. Am I serious about this? Am I going to, is it flavour of the month? I’m transgendered today and I’m something else tomorrow?’
b.‘She was asking the same questions in a different way. Not entirely but, each time… I assumed it was because she wanted to check that my story stayed the same over a period of time. You know, I was describing the same symptoms, the same experiences, the same feelings when asked in different ways.’
c.‘At the beginning, they want to know everything. They want to know all about your masturbatory history and all that kind of stuff. That was deeply humiliating. That happened in the first two sessions that I had there before they put me onto the doctor to start me on hormones and stuff. I mean I don’t have a problem talking about this kind of stuff now, but it felt very invasive at the time.’
d.‘It was like coming at me really hard, questioning me, asking me why I’m doing, asking why questions, which are quite challenging questions to ask, and much more aggressive questioning than any of my previous experiences… I looked at it afterwards and I thought to myself what they’re doing is they are identifying your commitment shall we say. That’s what I felt they were doing, is identifying your commitment to doing what you’re doing by being very challenging.’
- 1 = c,
- 2 = b,
- 3 = d,
- 4 = a
Discussion
Across the ICTA data, a common theme was that the process of a gender dysphoria diagnosis was experienced as having to prove their trans identity to a hostile, typically cis clinician. Negative experience of trans-affirming care is also reported in other UK-based research e.g. White et al., 2023; Wright et al., 2021). This echoes a wider theme in our culture – the pervasive doubting of the validity of trans identities (Bettcher’s ‘denial of authenticity’, 2009) and is an example of a microaggression (Freeman and Stewart, 2019). As discussed earlier, microaggressions create a mental health burden.
Lesson
Understand that the experience of transitioning – including the experience of accessing gender-affirming medical treatment – often involves experience of discrimination and may evoke significant psychological distress – further reasons to seek psychological therapy.
3.3 Patrick’s experience of waiting