Lots of Kids Have Real & Diagnosable Gender Dysphoria, But That's Not the Same as Being Trans

And That's Why Across-the-Board Affirmation and Transition Is a Failing Treatment Approach

If I could wave a magic wand and clear up one misconception that keeps popping up in discussions about gender, it would be this:

Many people equate having “true” gender dysphoria with “being trans.” They will, for example, speak sympathetically of the rare people who truly have gender dysphoria and who therefore really need to transition, in contrast to some group whom they perceive not to have true gender dysphoria, such as today’s adolescents and young adults.

Abigail Shrier and Jesse Singal are two examples of high-visibility people who do this. Please understand: My respect for and gratitude toward both of them is immeasurable. Shrier and Singal have both taken a lot of heat for their opinions, but it hasn’t stopped them from sharing what they’ve discovered, even when it’s not politically popular. They’ve both had more of a positive impact than I—an anonymous writer with a couple thousand subscribers—can ever hope to have.* So please don’t misinterpret this as minimizing the enormous good they’ve done.

But — on this one point, where they frequently equate “real gender dysphoria” and “being trans,” they’ve fallen a bit short, and here’s the obvious reason why that’s counterproductive:

If we don’t fully understand what gender dysphoria is, we can’t address it — and it is a very real problem in today’s adolescents and young adults. We also run the risk of looking foolish (or making ourselves an easy target of criticism from the gender-medicine community) if we make the claim that many of today’s kids don’t really have it.

No. They do.

It’s just that “having real gender dysphoria” is not the same as “being trans.”

When we talk about social contagion, let’s understand: The thing that is being passed from kid to kid is real gender dysphoria, and they need help with it. But the solution isn’t necessarily affirmation and transition.

If you’ve read TikTok Tics and Mass Sociogenic Illness you might remember that some people in the Middle Ages with “dancing mania” would dance themselves literally to death. More recently, kids who learn anorexia or bulimia from other kids have a real problem that could kill them.

So, “socially contagious” does not mean your kid is latching onto a trend and can stop any time they want. They’re not just pretending. It’s not as simple as going along with the crowd or following fashions. They’ve developed a real mental health problem, probably on top of some other mental health problems, and they need real treatment.

So let’s talk about that.

Gender Dysphoria Is a Specific and Increasingly Common Mental Health Diagnosis, and Anyone Can Truly Have It

Here are the criteria for gender dysphoria, according to the American Psychiatric Association:

Criteria: Gender Dysphoria in Adolescents and Adults

A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least six months’ duration, as manifested by at least two or more of the following:

*A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or in young adolescents, the anticipated secondary sex characteristics)

*A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics)

*A strong desire for the primary and/or secondary sex characteristics of the other gender

*A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender)

*A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender)

*A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender)

The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.

That’s it. For six months, a person has to fit “two or more” of these seven criteria, and they must experience significant distress as a result.

So, for example, a middle-school girl who has a strong desire to be a boy (criterion 5) and a strong desire to be treated as a boy by the people in her life (criterion 6), and who is really acutely unhappy because she’s not a boy, can be diagnosed—legitimately, officially—with gender dysphoria.

That’s all gender dysphoria is: You wish your body were different, you wish you were treated differently, and you’re very unhappy about it to the extent that it affects your life negatively.

Let me repeat:

That’s all gender dysphoria is.

Go look at those criteria again if you don’t believe it.

Gender dysphoria is not — as some people seem to believe — some subtle, tricky, real-world medical condition diagnosed by specialists, where as Jazz Jennings once described it, a person has “a girl brain but a boy body.”**

No.

The sooner everyone understands this, the better.

Not only has no one — anywhere, ever — been diagnosed with having a brain in an opposite-sex body, but it’s also the case that there is no evidence that anyone can, even hypothetically, have a male brain in a female body, or vice versa.

If you think about it, it’s not too surprising. There is likewise no evidence, even hypothetically, that anyone can be born with a female kidney in a male body, or a male liver in a female body.

It’s just not a thing. There’s no hypothetical mechanism for it ever to be a thing.

That’s just not what gender dysphoria means.

Anyone Can Truly Have Gender Dysphoria, Including Your Child, but There Are an Enormous Number of Causes of Gender Dysphoria, None of Which is “Being Trans” in the Wrong-Body Sense

As long as we are clearing up misconceptions, here’s another one:

Having gender dysphoria does not mean a person “is trans.”

If gender dysphoria means that a person is acutely distressed about their sexed body, there can be — and have always been — a number of causes for that distress. Plenty of middle-aged lesbians and gay men (and some middle-aged straight people) will tell you they went through a phase in life where they strongly, genuinely wished they were the opposite sex.

However, since there wasn’t an entire culture telling them, way back then, that they might “be trans” and could transition, people eventually accepted their own bodies, usually by the end of adolescence when they came to terms with their sexuality and began to enjoy their own bodies.

Note: The failure to offer to transition these people didn’t negatively affect their lives. They came out of this phase in life naturally, not as a result of conversion therapy, or people telling them their desires were wrong, or anything else. The fact that the overwhelming majority of people, if left alone, in earlier times passed through this phase and became content with their bodies was the basis for “watchful waiting” — the treatment approach that preceded “affirmation and transition.” The conventional wisdom was: let kids express themselves how they wish, and let this play out naturally.

There are very, very few people who went through that phase in life who wish transition had been an option for them as adolescents. I haven’t met one. More often than not, people will tell you they’re relieved they grew up when they did, because they believe they would have been sold on transition, and it would have been a mistake for them.

Gender dysphoria involves strongly wishing you were the opposite sex and being extremely upset that you’re not — but common sense will tell you that it might not be a permanent wish. It’s also common sense that such a general wish might have a lot of different causes.

Who Transitioned in the 20th Century?

In the mid- to late 20th century — the old days — there were primarily two groups of people who experienced gender dysphoria and went on to transition, and these were described by Ray Blanchard: “homosexual transsexuals who are attracted exclusively to men and are feminine in both behavior and appearance; and autogynephilic transsexuals [typically heterosexual men] who are sexually aroused at the idea of having a female body.”

Blanchard described only transwomen because back then, if transwomen were incredibly rare, transmen were even rarer.

We can ask ourselves all day, from a mental health perspective, why these two groups of men sought transition — but make no mistake: this was considered a mental health problem at the time, not a physical “wrong body” problem. Even if the patient occasionally believed himself to be in the “wrong body,” this was considered as reasonable as a belief that he was Napoleon or being followed by the CIA. No reputable clinician would have considered “affirming” any of those things.

Why feminine gay men?

One hypothesis as to why some feminine gay men sought transition is that in the 20th century there was still a lot of stigma attached to being gay. It’s not too big a leap to imagine the source of at least some of these men’s gender dysphoria was that they wished they were women so their sexual desire for men and/or their love of feminine things — colorful clothes, makeup, long hair — would be socially acceptable.

The fact that we seem to see very few feminine gay men today choosing transition might reflect that we now live in a time when it’s more socially acceptable to be a feminine gay man.

Why men with autogynephilia?

One hypothesis as to why some men with autogynephilia wish to transition is that for some, their fetish becomes more like an addiction — what starts as a harmless sexual thrill gradually takes over their lives and gets out of control (much like any other addiction or obsession can get out of control). Why do some people have problems with alcoholism, and others remain social drinkers their whole lives? No one knows, really.

Some men who are sexually attracted to the thought of themselves as women limit it to fantasy, cross-dressing, or role-play with their partners. Some people can remain at this casual level forever. But like any addiction, for a few people the desire to really be a woman can get more and more intense, and require more and more extreme actions to play the part, until as Renee Richards (former pro tennis player who transitioned in the 1970s) said, “I didn’t have a choice.”

This New York Times article describes Richards’ experience this way:

“Dr. Richards never writes that she regrets having had her surgery, yet she lists so many regrets relating to her sex change that it is like someone who returns again and again to the edge of a great pit, but refuses to leap in. Those feelings were also evident in past interviews.

“In 1999, you told People—” the reporter begins.

Dr. Richards interrupts.

“—I told People what I was feeling, which I still feel: Better to be an intact man functioning with 100 percent capacity for everything than to be a transsexual woman who is an imperfect woman.”

In the same interview, Dr. Richards talked about wishing for something that could have prevented the surgery.

“What I said was if there were a drug, some voodoo, any kind of mind-altering magic remedy to keep the man intact, that would have been preferable, but there wasn’t,” Dr. Richards says. “The pressure to change into a woman was so strong that if I had not been able to do it, I might have been a suicide.”

Note what Renee Richards doesn’t claim: Richards doesn’t claim to “really” have been a woman, as our culture currently understands “being trans” in the 21st century. Richards describes pressure to “change into a woman” that overrode everything else in her life.

So Who Transitions Today, in the 21st Century?

We see some of these old-school trans people today in the 21st century. For example, Blaire White is an example of someone who was born male, and doesn’t mind saying so, who was attracted to men and chose to transition. Rather than being obsessed with her gender, her transition, and so on, she seems to have moved beyond her gender dysphoria to live a full and happy life.

And we see some autogynephilic men choosing transition in the 21st century too. Week before last, the podcast “Gender: A Wider Lens” featured Shannon Thrace, a woman who was married to a man who became gradually more and more obsessed with gender. Her husband began by cross-dressing and doing some role-play in bed, and she supported that. He believed he was a straight guy who enjoyed femininity, but as time went on, he came to believe he was a guy who liked to “present as a woman” (part-time, then full-time), and as he increased his involvement with online communities and trans porn, he became distressed when people in his real life didn’t mistake him for a woman. Gradually he came to believe he was a woman and became uninterested in all other aspects of his life. Ultimately the couple divorced, and he had surgery—but he still struggles with his mental health.

If you’re hoping to understand autogynephilia sympathetically, this is a particularly good podcast episode to listen to, because Shannon expresses compassion and love for her ex-husband and sadness for what happened to his mental health and their relationship.

These two groups of people — the gay guys who enjoy feminity so much that they want to be women, and the straight guys with an increasingly obsessive sexual fetish — are still around. The fact that two very different groups of people traditionally were both lumped together as “being trans” illustrates that gender dysphoria can have wildly different causes.

Side note: Some doctors in the 20th century tried to weed out autogynephilic men from being considered for transition, because they believed they had less successful mental health outcomes than gay men. Indeed, as a general rule that seems to be true, but even back then, autogynephilic men who were intent on living out their sexual fetish learned what to say to make it sound as if they had always felt feminine “on the inside” since childhood. They developed a set of talking points (playing with dolls, etc.), much as teens are sometimes accused of doing today, which frustrated the doctors. So even back then, transition was not considered by everyone to be the universal treatment for distress about one’s gender.

What a lot of people can’t help but notice today is that the demographics of people with gender dysphoria have expanded and changed. If feminine gay men and men with autogynephilia have different causes of their gender dysphoria, it’s not a leap to suppose that new groups of people with gender dysphoria might suffer with it from their own unique causes, which may even require unique treatments.

Why Might Teens and Young Adults Have Gender Dysphoria?

Any parent — or anyone who used to be a teen or young adult — can tell you: young people’s relationships with their bodies and gender roles are fraught. It’s really not hard to come up with a list of reasons that a young person might really wish to be the opposite sex. A few of them might be:

• Shame at being same-sex attracted.

• Distress at the way their changing body has led to being treated in sexualized ways (being groped, verbally harassed, catcalled).

• Distress at a history of sexual abuse or assault that led to thoughts of “If I were a boy, this wouldn’t have happened.”

• Distress at gender nonconformity — being a girl or boy who doesn’t conform to Barbie and Ken gender role stereotypes. Not everyone is a cheerleader or football player — in fact, most people aren’t.

• Distress at feeling socially awkward or socially out of sync — whether these are kids on the autism spectrum, kids with chaotic home lives, kids who change schools a lot, kids who have a history of being bullied — the reasons for feeling socially out of sync, uncomfortable in their own skin, are many for young people.

• Even distress, as Wesley Yang explained so well last week, about being a boring straight kid. As he describes it, “being a boring straight kid (especially a boring straight girl!) puts you at the absolute bottom of the hierarchy, a totally acceptable target for barely concealed contempt and passive bullying.” Once you’re feeling bad about yourself for being a “boring straight girl,” it’s easy in today’s climate to interpret those bad feelings to mean you’re not a straight girl at all.

In earlier generations, kids had many of these problems and more, but “Maybe you feel like this because you’re trans!” was not on anyone’s mind as a possible explanation (not in the medical or mental health community, not in the media, not in schools).

But now, in the 21st century, “Maybe you feel like this because you’re trans!” is a commonly offered hypothesis to young people with any kind of gender nonconformity, awkwardness, mental health struggles, or social failure. And once these teens self-diagnose as “being trans,” affirmation and transition are posed by our culture as the concrete and definite solution.

Imagine being a young, inexperienced person in distress — or even just a person going through the awkwardness and changes of adolescence. Who at that age doesn’t feel ill at ease in their own body sometimes?

But if everywhere in the culture today, the idea is floating around “maybe you feel like this because you’re trans!” it’s no surprise that this becomes a widespread cultural belief — an “idiom of distress.”

Every culture, every time and place, has its idioms of distress. In you lived in medieval Europe and your life wasn’t going as you wished, you might have believed the local witch had put a hex on you and the Devil was therefore directly intervening in your affairs. As silly as it sounds to us now, that was a common idiom of distress then.

If you live in the 21st century West, a common belief for adolescents and young adults is “my distress is caused by being trans.” It’s a common idiom of distress now, but no one would have attributed their distress to “being trans” in 16th century Europe. People 500 years from now will laugh at the idea that anyone thought “transition” was the solution to anyone’s problems, just as we laugh at people who thought they were hexed by witches 500 years ago.

No One “Is” Trans — at Least Not in the Way That Everyone Seems to Think

Just as the local witch wasn’t a witch at all — and didn’t put a hex on you — having bad feelings about your body doesn’t mean you “are trans” in the sense that the average person on the street seems to think it means.

There is no evidence that anyone could be “in the wrong body.” Gender dysphoria is not a medical problem, so there’s no reason to suppose the best, most evidence-based treatment is medical, either.

Transition is a set of cosmetic procedures, which might or might not enhance your life. Blaire White is the rare person for whom transition seems to have enhanced life, but Blaire White also still believes she’s male and is happy with that — she transitioned and no longer has gender dysphoria. If, for example, someone misgenders her, she might think that person is rude, but her mental health won’t suffer.

Our New Rules and Practices for Treating Trans People as if They’re Fragile Demonstrate That We’re on the Wrong Track

So think about this for a minute: In the 21st century, we have this cohort of people who are supposedly very fragile. But if “being trans” is their “problem” and transition is the evidence-based treatment for that, then transition should make them happy and fulfilled, right? If transition is right for them, wouldn’t they be like Blaire White, and laugh off things like being misgendered or deadnamed? Once transitioned, wouldn’t formerly awkward quirky teens be happy and move on with their lives, spending their time on fulfilling interests, friends, and hobbies?

Wouldn’t their mental health problems be successfully addressed by the treatment that intends to resolve their mental health diagnosis of gender dysphoria? And if not, what is the treatment doing, other than sterilizing them; placing them at increased risk of various cardiovascular problems, osteoporosis, and cancers; destroying their sexual response; and limiting their future dating and partner pools?***

The fact that we seem to have created a cohort of transitioned people who are still so fragile and dysphoric that they can’t tolerate being misgendered or deadnamed is a huge red flag that transition hasn’t helped address the underlying causes of their gender dysphoria. We’re on the wrong track.

They had — still have — a real mental health diagnosis of gender dysphoria, and yet transition (which we’re supposed to believe is the progressive and evidence-based treatment for everyone with gender dysphoria), didn’t make their gender dysphoria go away.

Is it possible, say, that a quirky and socially awkward girl might develop a sincere belief that her awkward feelings are due to being in the wrong body, because that’s the idiom of distress that our culture offers to her in our time and place? (There’s a reason she’ll be much more likely to attribute her social problems to gender and not to a witch’s hex.) Might this girl therefore develop a true case of gender dysphoria? Yes.

But then when affirmation and transition are offered as the treatment, it’s quite likely this girl discovers she’s still quirky and socially awkward—just as her counterpart in the Middle Ages found that her crops still failed after the witch was burned at the stake. Somehow, she doesn’t feel as great as she expected to feel.

If you visit the subreddit /r detrans you’ll find many people, post-transition, sharing their stories and saying that their problems didn’t disappear. The treatment didn’t work. Often if they choose to detransition, they are blamed for their own problems — they must have made a mistake; they weren’t “really trans,” they’re told.

I might agree that they weren’t “really trans” (since no one is, in the way that our 21st century gender ideology conceives of it) but they “really had gender dysphoria,” and who’s at fault here? The patient or the doctors? Detransitioners have every right to be angry at being led down this path. It’s a problem that’s only going to get worse before it gets better.

How does this happen? These folks had (and sometimes still have) real gender dysphoria — their diagnosis was 100% correct — but the treatment of transition, based on the misunderstanding that gender dysphoria is caused by “being trans,” is the problem.

After a couple decades of these experimental treatments being carried out on an increasing number of adolescents and young adults, the lack of “Blaire Whites” in the world demonstrates that. The sheer numbers of fragile, unhappy, emotionally distressed people who remain fragile, unhappy, and emotionally distressed after transition tell us that we need different treatments for gender dysphoria.

This is a problem of treatment, not a problem of diagnosis. If a doctor tells you your child has gender dysphoria and you believe that, you don’t necessarily have to agree that the solution is transition. It’s not.

*But feel free to share this newsletter so these ideas — particularly of “trans as a cultural creation” can have more influence. I plan to keep content free to all, although I deeply appreciate the few subscribers (thank you!) who choose to pay to support this project.

**Jazz Jennings was a healthy three-year-old boy who wanted a sparkly girls’ swimsuit, and he was transitioned on that basis, not because of “his brain” — but that’s a discussion for another day.

***Other than that, Mrs. Lincoln, how did you enjoy the play?

"I cannot go on" by delboy/hammer is licensed under CC BY-ND 2.0.