On Dysphoria

I no longer find the concept of “dysphoria” to be useful in reference to myself, and no longer refer to myself as dysphoric. Dysphoria is a big, somewhat amorphous word that obfuscates nuance. I sometimes find that putting that label onto my feelings prevents me from exploring them further; it is a “just-because” answer.

I have been reading some detransition blogs, and this has been one of my key takeaways. One criticism detransitioners have of how transition currently functions is that the moment a person has “dysphoria”, transition is often the only solution offered by medical professionals, and the nature of the dysphoria is not discussed.

I am speaking personally, of course. Lots of people find dysphoria a useful framework within which to understand their experience of the world, which is fine. However, I also find that medically, the concept is mainly used to 1. Gatekeep transition related procedures, and 2. Medicalise transness by making it a diagnosable condition.

I have several issues with the medicalisation of transness. I am deeply uncomfortable with the idea of discussing my gender with doctors. Anxiety, cancer, the flu, are medical issues. My gender is not. My gender is a personal thing I have no desire to have examined or treated or even talked about under fluorescent clinical lights. Gross!! My gender does NOT need treatment. I resent having to broadcast my gender in order to access physical transition.

I disagree that “do you or do you not have dysphoria?” is the right question to ask before “allowing” somebody access to medically gatekept transition related procedures. A better question would be, “would you or would you not benefit from this procedure?”. The former values cis bodies above trans bodies. It implies that without diagnosable, “clinically significant” dysphoria, no assumed-cis person would transition or be trans.

I think that the psychological treatment of gender dysphoria should be separated from physical transition. For some people, physical transition is all that is needed to deal with dysphoria. That is fine. I am instead concerned with folks who may also benefit from therapy (i.e. most people, including cis people). Treating physical transition as the ONE answer to dysphoria does a disservice to people for whom physical transition may only be part of the answer, for any amount of reasons.

Clearly, if a person is in “clinically significant” gender-related distress, which is how dysphoria is defined, they should get professional help. But mental health professionals are simultaneously supposed to help people cope with gender dysphoria while gatekeeping access to transition. This is a conflict of interest, and for many trans people, therapy requirements become hoops to jump through rather than any opportunity for actual meaningful therapeutic relationship. I think that these functions need to be separated by demedicalising and providing free and easy access to physical transition.

The idea that cis bodies and lives are valued above trans ones is elaborated on here in Julia Serano’s piece on detransition and desistance. An example she provides is that if an assigned female at birth cisgender girl started producing testosterone (possibly due to an intersex variation), she would find it much easier to access hormonal treatment than a transgender girl, despite comparable safety of the treatment, and age/maturity of the girls. A transgender girl is much more likely to be told to live with her “natural” body until she is “old enough” to decide, while we are much more likely to accept that of course the cisgender girl is correct in her assessment that she does not want the excess testosterone. Thinking that everyone should obviously try as hard as they can to be as cisgender as possible is the same condescending position as “queer people deserve rights because queerness is not a choice… because who would choose THAT?”.

Transness as a choice, rather than an objective discoverable Truth, is elaborated on in Ozymandias’ blog here. They write that an identify-based framework in which you try to figure out if you are REALLY trans, and whether what you feel is REALLY dysphoria is often recursive and unhelpful. If transition would improve your life, you can just do that.

These are of course unorthodox views not in line with WPATH standards. The medical establishment, after all, is always between two and five steps behind trans people. This does throw quite a wrench into my hopes to qualify for transition…

On Dysphoria

Transition: where I’m at

I’ve been tracking my menstrual cycle for a few of the seven years I’ve had one, but rather ineffectively with a messy excel spreadsheet. A few months ago I finally got the app Clue, which I mainly use to track sleep and mood, but also occasionally other related stuff like pain and caffeine intake. It’s a pretty good, reasonably customisable, gender neutral app.

Recently I noticed that I tend to get tired and sad right around the end my period and just after the middle of my cycle, with varying degrees of incapacitation. These periods correspond to the increases in estrogen, as seen in the chart below. Some months are a lot worse than others, but it does seem to happen predictably. I don’t know if it happened before I started to notice it or if it is a new thing. I have also known for a while that I tend to be anxious and unable to sleep just before my period, though that has gotten better this year. That is pretty common, and probably due to the decreasing progesterone. I usually feel great during the first three days of my period, when everything is low. I used to get bursts of anger but not recently.

Fig 1.1: random unsourced chart from The Internet. Day 0 is the first day of menstruation.

Definitely hormones aren’t the entire story and my mental health is a complex culmination of things, and obviously hormones themselves are much more complex than the chart implies. This is also based on observation and fitting of my menstrual cycle and not blood tests, so I don’t actually know my levels for sure. But increasing estrogen does seem to be an unpleasant thing for me, which is unusual but not unheard of in cis women. Everyone reacts to hormones differently, but in general the decreasing levels right before menstruation is the unpleasant part, which is why premenstrual syndrome is a thing.

There isn’t necessarily a solution to this, nor is it an extremely debilitating problem, though being able to identify what is happening does help when I occasionally suddenly can’t function for no apparent reason. People put up with a shocking amount of terrible shit in relation with their menstrual cycles and that is considered “normal”. Or, if they do try to do something about it, they are usually told, maybe after a bunch of scans etc that don’t find anything, that there is nothing medical science can do for them and they just have to put up with it. Which, first of all, is not true. There are hormonal methods of regulating or stopping periods that are generally considered safe, and should be tried or at least considered if your menstrual cycle is causing debilitating pain or otherwise significantly impacting your quality of life. Some doctors just aren’t up to speed on that front and you should maybe try another one. (I asked the uni health service doctor about this once and he hadn’t heard of it and laughed at me.) But that also isn’t a perfect solution because messing with your hormone levels is always iffy and lots of people have weird side effects on birth control pills.

Which brings me to testosterone. If I want to even out my estrogen levels I could take birth control pills, which are rather expensive, and might fuck me up even more, or I could take T. And that’s a whole other thing.

There is some evidence that trans people with physical dysphoria may simply have brains that aren’t suited for the bodies they are born with. Trans people who start Hormone Replacement Therapy often talk about how more than the physical changes, the most positive change is that their emotions start to make more sense to them. It’s like they’ve been living on the wrong hormone all their life, and their brain and body weren’t supposed to be bathed in the amounts of hormones they naturally produce. This is the part of transition that is impossible to predict or know until you try. It is impossible to know if you will be more functional on different levels of hormones than the only levels you have known. (We also cannot know if there are cis people who might be happier on different hormones, but most of them aren’t asking themselves that, which in my opinion is their loss.)

I don’t know how I would emotionally respond to testosterone until I try it. That’s not helpful for decision making. So I think about how I feel about the other changes. I don’t want to be read as a man all the time. I like many of the things about me that are soft. I like having soft skin. I don’t want to look like a man. But I want to move a little in that direction. I don’t know, ideally I would have a mix of gender signifiers. I want a more masculine face and body shape but not a lower voice. But I also wouldn’t mind having a slightly lower voice as long as I didn’t read as completely male. You know?? But the voice drop on T is weird and you have to stretch and do vocal exercises for optimal results, and I am lazy af. I could also voice train without T but I am super awkward about that. I am neutral about having more body and facial hair, but I’m chinese so I wouldn’t get a lot of that even on a full dose of T. I think that I don’t have specific dysphoria about particular traits, I just want a more even mix than I currently have. I think that I would like to look “soft boy”, and not just soft. (I love the term soft boy and hate that it now means something bad.)

What is dysphoria and what is just, vanity? Do I even have dysphoria or is it just an aesthetic that I want? I want more muscle tone, and I know not all of that comes naturally with T. I will have to work out, but I am lazy and most likely will not. I would LIKE to have a flat chest, but I don’t have debilitating dysphoria about it. Is that enough to justify surgery? Surgery is a big deal. Would I rather have my current chest or a flat but uneven/scarred chest if surgery goes badly? Whenever I see someone with beautiful pecs, my wish for top surgery increases. Wanting that is different from just wanting a flat chest. Do I have unrealistic expectations? Do I just want to transition because I keep looking at beautiful men thinking that’s how I want to look? Would I still want to transition if I end up average, which is realistically what will happen? I feel like I should only get surgery if I think it will make me happier no matter how it turns out.

When I imagine myself years later post-physical transition, I think of myself, but cooler.. more powerful. Do I just want to transition for aesthetics? Do I just like the idea of change and transformation? Do I think that looking different will change the things I don’t like about myself?

Currently I’m just sitting on these things. It doesn’t really bother me that I don’t have answers right now. I have loose plans to start low dose T and get top surgery in the next few years if I decide I do want them. Maybe at some point I will just have to take the leap, but I also have the rest of my life to decide. I am fortunate that none of my dysphoria is crippling, so none of this is urgent. But I also think that I deserve to take the steps that will make me happy, without having to be suffering where I am now.

I do know that I definitely don’t want a hysterectomy though. Apparently removing your uterus might suppress ovarian hormonal production, while oopherectomy would stop that completely. That commits you to permanently supplementing either estrogen and progesterone or testosterone, because not having one of these in healthy amounts is pretty bad and causes osteoporosis. I don’t want to do this. I am extremely okay with having a uterus. I don’t mind it much, and it’s good to have a backup source of hormones that I don’t have to buy. In Singapore you have to do this in order to change your gender marker, but fortunately I don’t want to do that either. Mainly for safety reasons I would rather have an F than M, even if it disqualifies me from subsidized public housing. No, I would not remove my uterus or give up my F for subsidized housing, though I joke about it frequently.

Transition: where I’m at

Doctors: Allies/Gatekeepers

So it turns out that parts of the trans healthcare landscape in Singapore, and in particular my therapist, are much more excellent than I had thought.

I am hypothetically maybe possibly perhaps thinking about going on T, but not soon: a post for another time. Meanwhile though, I have been researching my options and thinking about things. One thing I have been wondering about is: do I, a nonbinary person, have to lie about being a binary trans man in order to get prescribed T? Continue reading “Doctors: Allies/Gatekeepers”

Doctors: Allies/Gatekeepers