The Dysphoria Paradox

For some trans people, treating gender dysphoria can temporarily worsen its severity. But that doesn’t mean transition is dangerous.

A person looks at their face in a compact mirror.
Treating gender dysphoria often involves changing one’s body or public presentation in ways that can be affirming and unsettling at the same time. Getty Images Plus

This post is part of Outward, Slate’s home for coverage of LGBTQ life, thought, and culture. Read more here.

Every time I take a step forward in my gender transition, I go into it expecting immediate relief. I will be so comfortable in my own skin after I do this, I imagine, so free. And yet, after completing a given transitional step (getting a new haircut, changing my name or gender marker, coming out to friends and loved ones, starting hormones, or changing my pronouns), I am instead met with a sudden rush of anxiety and self-consciousness. Instead of feeling authentic and unburdened, I start worrying I’m a ludicrous fraud.

After a time, these anxious, tightly wound feelings recede, and I end up loving myself and the changes I’ve made. Cutting my hair, changing my name and gender marker, going on testosterone, and coming out to loved ones were all good ideas, ones that helped me drop a social veil that long kept me alienated from other people. But that doesn’t mean those veils weren’t intensely terrifying to drop.

Being assigned the wrong gender at birth is complexly traumatic, and recovery from complex trauma is rarely linear. Yet much of public writing and thought about trans issues posits that transition should be unilaterally positive in order to be worthwhile. That expectation feeds into a lot of dangerous misconceptions—including the popular trans-critical myth of “rapid-onset gender dysphoria.”

Trans-critical writers and researchers coined the term rapid-onset gender dysphoria to refer to the phenomenon by which a trans person, upon realizing that they are transgender, suddenly becomes much more visibly distressed by the disconnect between their gender identity and their gender assignment at birth. After years of not exhibiting obvious “tells” of a trans identity (such as expressing a desire to change their genitals), a newly out trans child or teen may begin to exhibit symptoms of dysphoria more obviously, which can look a lot like brand-new symptoms manifesting out of nowhere.

Unsupportive parents of trans kids find the concept of rapid-onset dysphoria especially alluring: From the outside, it can easily appear that their once-cis kid became familiar with the language of trans-ness, then suddenly became obsessed with symptoms they never reported before. When you throw the increasing rate of trans identification into the mix, you have even more dubious “proof” that being trans is a shared social delusion that’s growing in popularity.

An additional key piece of “rapid-onset dysphoria” rhetoric involves pointing to a 2011 Swedish study that purportedly shows that transitioning doesn’t improve the mental health of trans people and, in fact, makes it worse. The oft-cited, oft-misreported study does demonstrate that transitioned people have an elevated suicide rate—but only compared with cisgender people, who never endured the significant physical and psychosocial traumas associated with being raised in the wrong gender all their lives. Though the study is so poorly sample-matched as to be virtually useless, critics of “trans ideology” claim it proves that trans-ness is an unhealthy obsession that ought not to be entertained, as the more you focus on it, the worse it tends to get.*

Sadly, that’s the one thing they are correct about. Treating dysphoria sometimes does make it worse, at least for a time. But that doesn’t prove that ROGD is real; it just shows that the trans person is taking difficult steps to examine and treat something they’ve long ignored.

In mental health circles, it’s often noted that seeking help for a symptom is often correlated with increased symptom severity. There are a lot of reasons this happens. First, a person is most likely to seek help when their suffering is at its worst. If my post-traumatic stress disorder flashbacks are suddenly occurring more frequently, I’m way more likely to start therapy, which can create an aggregate trend that links severity with help seeking.

Second, working on a symptom necessarily involves focusing more on it and being mindful of how it fluctuates day by day. Several months ago, I started practicing mindfulness in order to treat anxiety; I’m now constantly paying attention to my anxiety levels, and it’s unpleasant! Coming out as trans can also result in a trans person being subjected to far more transphobia, which can trigger or worsen symptoms of anxiety, depression, and even PTSD.

Additionally, treating gender dysphoria often involves changing one’s body or public presentation in ways that can be affirming and unsettling at the same time. When my voice began to drop in pitch as a result of testosterone, I was ecstatic. I was starting to sound the way I’d always imagined myself sounding! But I was also starting to spend a lot more time looking in the mirror, tracking my face for minute changes in hair growth, fat distribution, and puffiness. The closer my face got to my personal, androgynous ideal, the more aware of its remaining shortcomings I became.

Ultimately, what external, cisgender observers often see as ROGD is actually a trans person openly processing for the first time something that they have privately harbored their whole lives. When a trans person is open for the first time about a long-concealed pain, it can be disruptive to the status quo. It forces the trans person’s friends, family, and peers to confront a long-standing trauma and injustice they might rather hand-wave away. It’s less tragic to believe that a wound is newly invented than to accept someone you care about has been struggling with it for their entire life.

At times, I have worried that pursuing authenticity via gender transition was just another form of fakery, like pretending to be a cisgender woman was for most of my life. In other moments, pursuing my ideal body and gender presentation has made me acutely aware of how far from my goals I am. I often have felt social pressure to turn back, to stop making myself a spectacle in my pursuit of honesty, to grow my hair out, wear makeup, and let the shes and hers fly in my direction freely. It sometimes seems like it would be easier to ignore my identity and stop fighting for its recognition. I could carry on unseen for decades, repressing my dysphoria at every turn.

But ultimately I can’t deny the ways in which transition has made my life better. Telling a person my pronouns is anxiety-inducing, but it allows me to connect with them in a genuine way. Changing my body with a binder and hormones was scary, but once I adjusted to their newness, I found I was more comfortable, with better posture and more physical ease. The improvements to my body image, confidence, and self-esteem were all worth the temporary pain of transition.

Psychological research is consistent with my experience: Transition improves long-term mental health and wellbeing for the vast majority of people who go through it. But supporting trans people and their transitions requires that we dispense with the expectation of immediate joy. Trans people deserve the freedom to have messy, gradual, honest recoveries from the symptoms they were once forced to suffer with in silence. No trans person recovers from a lifetime of dysphoria in a day.

*Correction, Feb. 3, 2019: This post originally mischaracterized a July 2018 Atlantic piece by Jesse Singal. The piece did not cite a 2011 Swedish study on transitioning and suicidality, and it does not claim that transness is an unhealthy obsession. The link to the piece has been removed.