After attending a workshop led by Amy Sousa (@KnownHeretic), a women’s rights activist and educator with an MA in psychology, I felt compelled to expand on Amy’s excellent critical examination of the DSM-V’s criteria and the current diagnosis of Gender Dysphoria. As a Licensed Marriage and Family Therapist (LMFT) with over 20 years of experience, I approach this subject with a feminist perspective and decades of understanding derived from my psychotherapy practice. What we see today, particularly in how Gender Dysphoria is diagnosed and treated, raises significant ethical and social concerns that must be addressed.
My journey in studying mental health therapy practices began in 2002 when I entered and subsequently completed a Master’s program in Feminist Clinical Psychology in San Francisco, CA. During my program, I was introduced to transgender care, which consisted of a single 2-hour presentation in my human sexuality class. I recall a trans-identified man from the trans community speaking to our class, telling us that, as psychotherapists, we should never question or explore the experiences of trans clients seeking “treatment.” We were told it was detrimental to clients with Gender Identity Disorder (GID) to act as gatekeepers—our role was to offer support, not to ask more questions, as we would with any other client coming in for treatment, as that could unintentionally "harm" the client. At the time, a letter from a mental health therapist was required in California for anyone to access gender-affirming medical interventions like puberty blockers, cross-sex hormones, or surgeries such as mastectomies.
After that class, I remember discussing the topic with professors and classmates; many of us were surprised and expressed discomfort with this approach, particularly because it would be our license on the line if we gave the green light for these life-altering medications and surgeries, and the individual later felt they had been improperly treated in our care. We compared the transgender client’s request for non-medically indicated surgical interventions to those classified as having Body Integrity Identity Disorder (BIID). BIID is the phenomenon where individuals desire the amputation of one or more healthy limbs or desire paralysis. Some of these individuals mutilate themselves; others ask surgeons for an amputation or for the transection of their spinal cord. People suffering from BIID report that a particular limb does not belong to them and that they feel "over-complete" and want the alien limb amputated.
Instinctively, it seemed absurd to me not to explore the Gender Dysphoric client’s distress further, especially given the gravity of the decisions at hand. The standard of care for all other body dysmorphia never includes cosmetic surgery. Ethically, surgeons won’t amputate a healthy limb without medical need, as it violates the "do no harm" principle. No insurance company will cover the cost of such surgery, stating, “The risks and consequences of such a procedure can be lifelong, dangerous, or even deadly. Amputation may not resolve the underlying psychological issues, and there’s no guarantee it will bring the outcome you expect. Additionally, amputations are permanent and cannot be undone if you're unhappy with the result” (Cleveland Clinic, OH).
However, the prevailing attitude regarding Gender Identity Disorder (GID) then and now is that affirming care is the right and only way to practice, all the while dismissing the therapist’s training and ignoring the internal world of a client presenting with distress and gender dysphoria.
It wasn’t until years later, after I had my first daughter in 2013, that I fully realized the gravity of the shift in how we treat gender-stereotype-related distress, particularly in children. Today, the prevailing model of immediate affirmation leaves little room for exploring the emotional, psychological, and social factors contributing to distress. This approach is not only concerning but dangerous, and it has spread outside of the therapy room and into the educational system, encouraging and prompting students as young as preschool age to question if they might be “a boy, a girl, or neither.”
One of the most alarming developments in the last 10 years is the rapid increase in gender-affirming surgeries among minors. A Manhattan Institute report revealed that between 2017 and 2023, 5,000 to 6,000 girls under 18 underwent gender-affirming double mastectomies, with at least 50 patients younger than 12.5 years old. This staggering number far surpasses previous estimates and underscores the urgency of reconsidering how we approach gender dysphoria in young people.
Another equally troubling aspect of this conversation is its direct impact on vulnerable women and girls. The widespread use of the Gender Dysphoria diagnosis has opened the door to legal policies that allow men—who identify as women—to enter women’s prisons, bathrooms, sports, and even lesbian-only spaces. This raises not only ethical but also safety concerns, as women are now being forced to share private spaces with men who claim to be women based solely on self-identification.
This issue now extends far beyond matters of identity and personal choice in clothing style, peers, or activity choices. Many of these trans-identified men would likely meet the criteria for Transvestic Disorder, a condition often co-diagnosed with autogynephilia—a male’s sexual arousal at the fantasy of himself as a woman. Transvestic Disorder is frequently linked to other paraphilias, including fetishism and masochism, and, in some cases, dangerous behaviors like autoerotic asphyxia. It’s important to understand that Transvestic Disorder is almost exclusively diagnosed in males, many of whom identify as heterosexual and still seek sexual relationships with women. Despite this, therapists trained under the affirmation model unilaterally fail to ask the necessary questions to determine whether a diagnosis of Gender Dysphoria truly applies or if the individual’s distress is more accurately aligned with a paraphilic disorder.
This becomes even more concerning when we consider that these men with transvestic tendencies are increasingly infiltrating lesbian-only dating spaces, masquerading as "lesbian women." This dynamic puts women, particularly lesbians, at risk of exploitation by men driven by paraphilic desires but treated under the broader, inaccurate umbrella of "gender dysphoria."
A study from Sweden highlights the problematic correlation between transvestic fetishism and other concerning behaviors. The study found that 2.8% of men reported instances of transvestic fetishism, which was strongly correlated with pornography use, frequent masturbation, exposing genitals, voyeurism, and masochism. Despite the prevalence of these behaviors, many individuals with this exact presentation are freely walking around, demanding access to women-only spaces and insisting on being acknowledged as women.
The conflation of Gender Dysphoria with Transvestic Disorder under the DSM-V not only muddies the diagnostic waters but also puts vulnerable women and girls in harm’s way. By allowing men who experience sexual arousal from cross-dressing or embodying female characteristics to claim a female identity, we are opening the door to potential exploitation in women-only spaces like bathrooms, prisons, and sports. This isn’t merely a matter of ideological debate; it is a real and present danger to the safety and well-being of women and girls.
This raises a critical question: Are mental health clinicians failing to diagnose these cases accurately, thus encouraging men with paraphilias to enter women’s spaces under the guise of "gender identity" and diversity, equity, and inclusion policies? To what end?
As mental health professionals, we have a responsibility to explore the broader emotional, psychological, and social factors contributing to a person’s experience of distress.
The current state of affairs not only medicalizes and minimizes gender nonconformity but also perpetuates dangerous and sexist stereotypes. Gender identity is being treated as a standalone issue, divorced from the many complexities that often underlie it. In reality, much of what is being diagnosed as Gender Dysphoria, experienced as distress, for men may more accurately fall under paraphilic disorders, which demand a different treatment approach and different social response. Yet these men are given free rein to occupy spaces that were once safe havens for women.
To protect women and girls, and to practice ethical, evidence-based psychotherapy, we must advocate for a return to careful, thorough assessments that do not immediately leap to medicalization or affirmation.
In conclusion, the rising tide of gender-affirming care demands greater scrutiny. It was a breath of fresh air to see the Cass Review emerge from the UK, voicing similar concerns that are surprisingly being ignored by the majority of influential psychological and medical institutions in the USA.
From the staggering number of minors undergoing irreversible surgeries to the vulnerable women and girls put at risk by men entering their spaces under the demand for inclusion of "gender identity" in law, it is clear that the current diagnosis and care model is deeply flawed. It is time for mental health professionals, parents, activists, and educators to stand up and advocate for ethical, thoughtful care that truly considers the long-term well-being of all individuals, especially our most vulnerable populations.
Thank you. This is very clearly written and very succinct.
Do you believe that there is actually such a thing as "Gender Dysphoria"?
It seems just as likely that it was invented as a marketing tool, in a similar way to Listerine inventing Halitosis as a means to sell floor cleaner as a mouth wash.
Thank you. This is very clearly written and very succinct.
Do you believe that there is actually such a thing as "Gender Dysphoria"?
It seems just as likely that it was invented as a marketing tool, in a similar way to Listerine inventing Halitosis as a means to sell floor cleaner as a mouth wash.