Gender Identity and Mental Health
When it comes to debates about identity, culture, and mental health, one topic has increasingly come under the spotlight: gender identity and the medicalization of gender dysphoria. As a clinician, I find it crucial to examine this issue through the lens of mental health and psychology, rather than through the cultural and political war zones where it often resides.
At its core, gender dysphoria is classified as a mental health condition in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). It is characterized by significant distress or impairment due to a mismatch between one’s experienced gender and biological sex. This distress is a psychological phenomenon, yet the prevailing approach today is medical affirmation through hormone therapy and surgical interventions. This raises an important question: Why are we affirming psychological distress with medical intervention rather than addressing it through therapeutic means?
The Psychological Model of Treatment
We do not affirm schizophrenia. We do not tell someone with delusions that their altered perception of reality is valid and should be encouraged. We do not affirm generalized anxiety disorder by reinforcing fears. Instead, we offer therapy, medication, and support aimed at alleviating distress and helping individuals function within reality. So why do we take a different approach when it comes to gender dysphoria?
The argument for medical transition is that it alleviates distress, leading to improved mental health outcomes. However, the long-term data on satisfaction and regret remains complex and nuanced. According to a 2021 study published in JAMA Psychiatry, transgender individuals who underwent gender-affirming treatment reported a reduction in psychological distress. However, other research, including a 2019 study in The American Journal of Psychiatry, later corrected its initial conclusions and found that gender-affirming surgery did not significantly reduce mental health treatment utilization.
Further, a systematic review published in Current Psychiatry Reports in 2022 noted that while some individuals benefit from gender-affirming treatments, there remains a subset of individuals who experience continued or worsened mental health struggles post-transition. This suggests that while medical intervention may help some, it is not a universal remedy and should not be the sole or primary approach.
The Risks of a Medical-First Approach
There is also the emerging concern of rapid-onset gender dysphoria (ROGD), particularly among adolescents, where social factors and underlying psychological conditions may be contributing to the rise in transgender identification. A study published in PLOS One in 2018 by Dr. Lisa Littman identified social contagion as a potential factor influencing adolescents’ sudden identification as transgender. While this research has been met with both support and criticism, it highlights the need for careful psychological evaluation before proceeding with irreversible medical treatments.
In countries such as Sweden and Finland, medical guidelines are shifting away from an immediate affirmation model. Sweden’s National Board of Health and Welfare now recommends psychotherapy as the first line of treatment for gender dysphoria in minors, citing concerns about the long-term effects of medical transition. Similarly, the UK’s National Health Service (NHS) has closed its primary youth gender clinic, Tavistock, due to concerns over inadequate mental health assessment before transitioning treatments were prescribed.
The Role of Psychotherapy
This is not to say that people should not have the right to express their identities or live as they see fit. On the contrary, it is crucial to acknowledge and respect each individual’s personal journey. But respect does not mean abandoning psychological principles. We must ask whether our field is prioritizing affirmation over careful assessment and whether we are neglecting the mental health treatment component in favor of a purely medicalized response.
Therapy should always be the first step in addressing psychological distress, including gender dysphoria. A comprehensive mental health approach that includes psychotherapy, exploration of underlying issues, and consideration of multiple treatment paths is essential. Cognitive-behavioral therapy (CBT), psychodynamic therapy, and dialectical behavior therapy (DBT) have all been used effectively to help individuals struggling with gender dysphoria. These therapies can address underlying factors such as trauma, depression, and anxiety, which often coexist with gender dysphoria.
Moving Toward a Balanced Approach
Mental health treatment is about understanding distress, not affirming it. The increasing politicization of gender identity has, in some cases, overshadowed the importance of individualized psychological care. We must reaffirm our commitment to therapeutic principles, ensuring that those experiencing gender dysphoria receive the psychological care they need, rather than a one-size-fits-all medicalized solution.
The well-being of individuals struggling with gender identity deserves a thoughtful, evidence-based approach—not one dictated solely by sociopolitical trends. Mental health professionals have a duty to provide nuanced, research-backed care that prioritizes long-term well-being over ideological conformity. It is time for the mental health community to lead with science and compassion, ensuring that all individuals receive the appropriate psychological support before irreversible decisions are made.
Max E. Guttman is the owner of Mindful Living LCSW, PLLC, a private mental health practice in Yonkers, New York.
