Peter O’Connor aka anemoneprojectors, CC BY-SA 2.0, via Wikimedia Commons
The medical establishment now draws a distinction between gender identity disorder, which it classifies as a mental disorder, and being transgender, which it insists is not. Official diagnostic manuals such as the DSM-5 and ICD-11 separate the issue into two categories:
Gender dysphoria – distress caused by the incongruence between one’s experienced gender and assigned sex.
Gender incongruence – a mismatch between identity and sex that may not cause distress.
The reasoning is that distress often comes not from the incongruence itself but from social rejection, discrimination, or lack of access to transition-related care. Advocates argue that once people transition and receive support, they may no longer feel distress.
This distinction, however, raises serious questions about consistency in medical diagnosis. In nearly every other psychiatric condition, the diagnosis is based on symptoms within the patient, not society’s response.
PTSD, for example, is defined by intrusive thoughts and hypervigilance, not by whether trauma survivors are stigmatized. Depression is diagnosed by changes in mood, sleep, or appetite.
Autism is based on communication and behavior, schizophrenia on delusions and hallucinations. In all these cases, the diagnosis is rooted in the individual, not in external acceptance or rejection.
Research shows that most people who seek gender-related medical care report distress and therefore meet the criteria for dysphoria.
The supposed separation between dysphoria and incongruence often creates confusion, barriers to care, and inconsistent diagnoses across different contexts.
By shifting the focus from internal symptoms to external social variables, psychiatry has departed from the standard medical model.
If someone experiences distress about their biological sex, that distress exists regardless of the surrounding environment.
The current classification blurs the line between science and ideology, leaving open the question of whether the changes reflect genuine medical progress or political influence.
Gender dysphoria is the diagnosis typically used to justify hormone therapy, puberty blockers, and surgery. Insurance coverage and treatment protocols are tied to this diagnosis, with the aim of alleviating clinically significant distress.
Gender incongruence without dysphoria, however, presents no pathology. This creates a treatment gap: if there is no distress, the medical rationale for invasive procedures becomes unclear.
It raises questions about medical necessity, insurance coverage, and whether such procedures belong in a model of medicine that is supposed to treat disease or dysfunction.
This produces a clinical paradox. The system has divided the condition into “pathological” (treatable) and “non-pathological” (questionable), yet in both cases patients may seek the same interventions.
In most areas of medicine, major surgeries and powerful drugs are not prescribed without a diagnosable condition.
The current classification introduces an inconsistency, permitting invasive medical treatment even when no disorder is present.
Data reinforce this contradiction. In the 2015 U.S. Transgender Survey of 27,715 respondents, 78 percent said they wanted hormone therapy at some point, but only 49 percent had ever received it.
A follow-up sample found that 14 percent received no medical intervention, 18 percent received hormones only, and 68 percent received both hormones and surgery.
Surgical rates vary. The 2015 national survey reported that 25 percent of respondents had undergone at least one gender-affirming procedure.
Among transgender men, fewer than 5 percent had phalloplasty or metoidioplasty, 14 percent had a hysterectomy, and another 57 percent wanted one.
A Boston Medical Center study found that 35 percent of endocrinology patients had undergone surgery, with higher rates among trans men (54 percent) than trans women (28 percent).
Barriers to access remain significant. Many respondents cited insurance denials and cost, and up to a quarter of those seeking coverage for hormone therapy reported being turned down. This explains part of the gap between the desire for treatment and actual receipt.
These facts highlight the core inconsistency. Officially, treatment is medically indicated for dysphoria, while incongruence without distress does not qualify. In practice, both groups often receive the same interventions.
Either the diagnostic categories lack real clinical meaning, or medical practice has already moved away from the policy framework that is supposed to guide it.
The rise of “informed consent” models has further blurred the line. Many clinics no longer require psychological evaluation or a confirmed dysphoria diagnosis.
Instead, patients can access treatment simply by signing consent forms, bypassing traditional safeguards.
In practice, the distinction between gender dysphoria and gender incongruence is more theoretical than real.
Most people seeking medical transition report some level of distress, yet the classification does not align with how care is delivered.
This leaves two possibilities: either the diagnostic categories are meaningless, or medical practice has quietly diverged from official standards.
There is also a fundamental logical issue with the treatment approach. If a man is distressed about being male and wants to be female, hormone therapy and surgery do not cure his feelings about being male.
These interventions do not change biological sex, resolve the distress about birth sex, or make the patient feel better about their original gender.
Instead, they work by creating the appearance and some secondary characteristics of the opposite sex, allowing the patient to live socially as the opposite sex, and reducing distress through this approximation.
This creates several problems. The treatment does not directly address the source of distress; it alters appearance rather than the reality of sex. Its effectiveness depends heavily on external validation, since the outcome relies on others perceiving and treating the person as the opposite sex.
The resolution is incomplete because biological sex remains unchanged at the chromosomal and developmental level.
Finally, these interventions require lifelong medical maintenance and social cooperation, unlike treatments that cure a disorder.
Clearly, the approach does not truly treat gender identity disorder in the traditional medical sense. It manages distress by constructing and sustaining a social and physical simulation of the opposite sex.
This raises the question of whether such interventions should be considered medical treatment for a disorder or elective modifications to support an illusion.
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