Fact vs. Fiction: Debunking "Why 'Gender Dysphoria' is a lie"

The Inconvenient Truths about Dr. P/Pamela Williams' article

Today we are going to talk about an article that's been making the rounds lately, off and on since 20240704. The piece is called "Why 'Gender Dysphoria' is a lie" written under the nom de plume of Dr. P, also known as @Psychgirl211 on Twitter¹, or Pamela Williams (@psychdoc211) on Substack. Now, before we even get into the content of the article, it's worth noting that we don't have any verifiable information about the author's credentials or expertise. They claim to be a clinical psychologist, but provide no evidence to support that. As we'll see, the lack of citations and the contradictions with established scientific literature raise serious questions about the author's qualifications and understanding of this complex topic.

But let's give them the benefit of the doubt for a moment and look at what they're actually arguing. The author makes some pretty bold claims about Gender Dysphoria and the affirming care provided to transgender folks. As someone who believes in following the facts and evidence, I think it's important we take a critical look at what's being said here.

So let's break it down, point by point.

Lack of Evidence and Rigor

First off, the author claims that Gender Dysphoria was added to the DSM-5, the big diagnostic manual for psychological disorders, without proper scientific evidence or rigor. But here's the thing - that's just not true. The inclusion of Gender Dysphoria in the DSM-5 followed a systematic, scientific process, including thorough literature reviews, field trials, and consultations with leading experts in transgender health². It wasn't just haphazardly thrown in there.

It was included as a result of a careful, systematic process led by the Workgroup for Sexual and Gender Identity Disorders, chaired by Dr. Kenneth J. Zucker, a leading expert in the field, if controversial for his opinions on approaches³. This wasn't some fringe group or activist committee - it was a team of specialized clinicians and researchers following the scientific standards of the American Psychiatric Association.

Their work involved thorough literature reviews of the latest research at the time, clinical field trials, and consultations with other experts in transgender health⁴⁵. The shift from the old diagnosis of Gender Identity Disorder to Gender Dysphoria was made to better capture the distress many trans people feel when their gender identity is incongruent with their assigned sex, not to pathologize being transgender itself⁶⁷.

In fact, the DSM-5 makes a clear distinction between simply having a transgender identity, which is not considered a mental disorder, and experiencing clinically significant dysphoria, which can merit a diagnosis⁸. That nuance shows the careful thought and scientific rigor that went into crafting this diagnosis - it's not just equating being trans with having a disorder, as the article implies.

Even the specific wording of the diagnostic criteria was carefully chosen based on the latest understanding and terminology. The DSM-5 uses "experienced gender" instead of "desired gender" and "assigned gender" rather than "natal gender" to more accurately reflect the realities of transgender identities⁹¹⁰. These aren't just semantic quibbles - they reflect a real effort to ground the diagnosis in the best available scientific evidence and understanding.

So when the author claims Gender Dysphoria was just haphazardly thrown into the DSM-5 without proper scientific backing, they're simply not engaging with the facts. The reality is that this diagnosis was the product of a rigorous, scientific process led by experts in the field, based on the latest research and clinical best practices. To suggest otherwise is to ignore the substantial evidence and expertise behind the DSM-5's development.

On Stereotypes and Circular Reasoning

Second, Dr. P argues that the diagnostic criteria for Gender Dysphoria are based on stereotypes and circular logic, not empirical evidence. But again, that claim doesn't hold up to scrutiny. The DSM-5 criteria were developed based on years of clinical research and observations of the experiences of transgender individuals¹¹. They're not pulled out of thin air or based on stereotypes as the author suggests. In fact, the DSM-5 gives a pretty clear definition and diagnostic criteria:

"Gender dysphoria refers to the distress that may accompany the incongruence between one's experienced or expressed gender and one's assigned gender. Although not all individuals will experience distress as a result of such incongruence, many are distressed if the desired physical interventions by means of hormones and/or surgery are not available.

It then lists the following diagnostic criteria for Gender Dysphoria in adolescents and adults:

1. A marked incongruence between one's experienced/expressed gender and assigned gender, of at least 6 months' duration, as manifested by at least two of the following:

   1. A marked incongruence between one's experienced/expressed gender and primary and/or secondary sex characteristics.

   2. A strong desire to be rid of one's primary and/or secondary sex characteristics because of a marked incongruence with one's experienced/expressed gender.

   3. A strong desire for the primary and/or secondary sex characteristics of the other gender.

   4. A strong desire to be of the other gender (or some alternative gender different from one's assigned gender).

   5. A strong desire to be treated as the other gender (or some alternative gender different from one's assigned gender).

   6. A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one's assigned gender).

2. The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.¹²

Now, the anonymous author claims these criteria are based on nothing more than stereotypes and circular reasoning. But is that really the case?

Looking closely at the definition and criteria, I don't see the kind of crude stereotyping the article alleges. The focus is on the individual's deep-seated feeling of incongruence between their gender identity and assigned sex, and the clinically significant distress that incongruence causes. It's not about whether someone conforms to societal stereotypes of masculinity or femininity.

Sure, you could argue that terms like "other gender" and "typical feelings and reactions" could potentially be interpreted in an overly narrow or stereotypical way. But in context, it's clear the emphasis is on the individual's persistent, strongly held inner sense of their own gender, not external gender roles or norms. And the requirement for significant distress or impairment underscores that this is a serious clinical condition, not just a matter of social nonconformity.

So once again, the article's claims just don't hold up when we look at the actual source material. The DSM-5 definition and criteria for Gender Dysphoria are focused on the individual's inner experience of incongruence and the distress it causes. They're not the crude stereotypes or circular logic the author makes them out to be.

Now, to be fair, the language of the DSM-5 isn't perfect, and there's always room for thoughtful critiques and revisions as our scientific understanding evolves. But the anonymous author of this article isn't engaging in that kind of nuanced, evidence-based analysis. They're just making sweeping, unsubstantiated claims that don't align with what the manual actually says.

And that's a recurring problem throughout this piece. The author makes a lot of bold assertions, but doesn't back them up with careful, rigorous arguments or evidence. They oversimplify complex issues and misrepresent the sources they're critiquing.

That's not responsible scholarship or scientific discourse. It's rhetoric designed to push an agenda, not to grapple with the facts in all their messy complexity. And it should make us very skeptical of the author’s credibility and authority on this sensitive, nuanced topic and that of the article they have written.

On Unethical and Dangerous Care

Third, the author paints gender-affirming medical care as unethical and dangerous, claiming that:

“Gender Dysphoria is the ONLY clinical symptom in the DSM-5 whose treatment involves, (or even requires) surgical intervention!”

They portray this as evidence that gender-affirming care is dangerous and unethical. But this claim is misleading on several fronts. First of all, the World Professional Association for Transgender Health (WPATH) guidelines, which are based on the best available scientific evidence, make it clear that not every transgender person needs or wants surgery¹³. Medical interventions are undertaken after careful assessment and informed consent, aiming to alleviate distress and improve quality of life. It's not a one-size-fits-all approach.¹⁴

Secondly, the claim that Gender Dysphoria is the only DSM-5 condition that may involve surgical treatment is simply false. For example, Obstructive Sleep Apnea, another DSM-5 diagnosis, is often treated with surgeries like tonsillectomy or maxillomandibular advancement in severe cases¹⁵. Similarly, Binge-Eating Disorder, also in the DSM-5, may be treated with bariatric surgery when other interventions have been ineffective¹⁶.

The author's attempt to portray gender-affirming surgeries as uniquely dangerous or unethical among DSM-5 conditions is a gross misrepresentation of both the science and the standards of care. It ignores the rigorous guidelines and safeguards that govern these treatments, as well as the extensive evidence of their benefits for many individuals with Gender Dysphoria¹⁷¹⁸.

In reality, gender-affirming surgical care is not some reckless experiment, but a well-established and extensively studied treatment option that has been shown to greatly improve the mental health and quality of life of transgender individuals who need it¹⁹. To suggest otherwise, as this article does, is to prioritize fearmongering over facts and to deny the lived experiences of countless trans people who have benefited from these treatments.

Of Misattributions and Misdiagnosis

The author's anecdotal claim that they have only encountered one child with gender issues in their 30-year career is used to suggest that Gender Dysphoria is extremely rare and likely misdiagnosed. They imply that the current rates of Gender Dysphoria are inflated and that the condition is being misattributed to other issues. However, this argument is problematic for several reasons.

First, anecdotal evidence from a single clinician's experience is not representative of the overall prevalence of Gender Dysphoria. Individual practitioners may see more or fewer cases depending on their specialization, location, and referral patterns. The author's experience cannot be generalized to the entire field of mental health.

Moreover, the author's experience of rarely encountering gender issues in their UK practice may reflect historical underdiagnosis and lack of awareness, rather than a true absence of Gender Dysphoria. Stigma, lack of access to affirming care, and limited provider knowledge can lead to significant underdiagnosis of Gender Dysphoria²⁰. The author's anecdote may say more about past barriers to care than about the actual prevalence of the condition.

In fact, epidemiological studies suggest that Gender Dysphoria is more common than the author's experience would suggest. Estimates of the prevalence of transgender identity range from 0.1% to 2% of the population, with higher rates among younger generations²¹²². While still a minority, these figures indicate that Gender Dysphoria is not as exceedingly rare as the author implies.

The author's central claim that Gender Dysphoria is routinely misdiagnosed and misattributed to other conditions is also not supported by evidence. The diagnostic criteria for Gender Dysphoria in the DSM-5 and ICD-11 are specific and require persistent, clinically significant distress related to gender incongruence²³. Differential diagnosis is a key part of the comprehensive assessment process outlined in the WPATH Standards of Care Version 8²⁴.

The SOC-8 acknowledge that rates of referral for Gender Dysphoria have increased in recent years, particularly among youth. However, they attribute this to increased social acceptance, access to information, and availability of affirming care, not to widespread misdiagnosis²⁵. Greater awareness and reduced stigma have allowed more transgender individuals to seek help, not created a wave of false diagnoses.

Ultimately, the author's anecdotal claim is not a reliable basis for questioning the validity of Gender Dysphoria as a diagnosis. Rather than relying on one clinician's limited experience, it's important to look at the broader scientific evidence and expert consensus. The SOC-8 and other guidelines emphasize the importance of comprehensive, multidisciplinary assessment to accurately diagnose Gender Dysphoria and differentiate it from other conditions²⁶.

Suggesting that Gender Dysphoria is routinely misdiagnosed or misattributed, as the author does, is not supported by the standards of care or the scientific literature. It's a claim based on anecdote and speculation, not on facts and evidence. As such, it should be treated with great skepticism, not accepted as a credible argument against the validity of Gender Dysphoria as a diagnosis.

Body Anxiety Disorder is just BAD

I won’t delve too deeply into this one as we have already written extensively on other aspects of the misattributions and misdiagnosis claims. The author suggests that the distress of Gender Dysphoria is really just a misattribution of other mental health issues or social factors (as described above), and should be rebranded as "Body Anxiety Disorder" and treated with talk therapy. But that argument ignores the growing body of neurobiological research indicating that transgender identities have a biological basis²⁷²⁸. Brain imaging studies have found that the brains of transgender individuals more closely resemble their identified gender than their sex assigned at birth²⁹.

The scientific evidence, as well as the lived experiences of countless transgender individuals, strongly suggests that gender identity is innate and immutable. Tragically, history has shown us that even when children are raised from a very young age as a gender that does not align with their identity, and despite extensive efforts to socialize them as that gender, their innate sense of self persists. This underscores the reality that being transgender is not a choice or a product of socialization, but a fundamental aspect of identity that cannot be changed through talk therapy or other external interventions.

Suggesting that being transgender is just an "anxiety disorder" to be talked out of existence is not only inaccurate but also deeply invalidating to trans folks' experiences.

The Diagnostic Process: Ideal vs. Reality?

A central theme in the article is the supposed discrepancy between how Gender Dysphoria should be diagnosed (in the author's view) and how they claim it is actually being diagnosed in practice. The author paints a picture of a rigorous, comprehensive diagnostic process that they contrast with a hasty, uncritical "affirmation" of self-declared gender identities.

According to the author, a proper diagnosis of Gender Dysphoria should involve extensive psychological testing, detailed clinical interviews, gathering information from multiple sources (self-report, parents, teachers), and ruling out other potential causes of the reported distress. They emphasize the need for a systematic evaluation that looks at the whole person in context.

In contrast, the author suggests that in current practice, Gender Dysphoria is being diagnosed based solely on a patient's self-report, without proper psychological assessment or consideration of differential diagnoses. They imply that clinicians are simply affirming a patient's gender identity without due diligence.

However, this characterization of how Gender Dysphoria is actually being diagnosed is a strawman that does not reflect the established standards of care or the practices of reputable gender clinics. The WPATH Standards of Care, widely recognized as the gold standard in the field, call for a comprehensive diagnostic assessment that aligns closely with the author's idealized process.

According to the SOC³⁰, this assessment should include a detailed clinical interview, psychological testing (as indicated), gathering of collateral information (with consent), and a thorough consideration of differential diagnoses and co-occurring mental health concerns. The goal is to understand the patient's gender identity, their experiences of dysphoria, and their overall psychosocial situation.

Importantly, the SOC state that incongruence between a person's gender identity and their assigned sex is not sufficient on its own to merit a diagnosis of Gender Dysphoria. The incongruence must be accompanied by clinically significant distress or impairment. This distress must also not be better explained by other conditions.

In other words, the standards of care already call for the kind of comprehensive, contextual assessment that the author advocates. While individual clinicians may not always adhere to these best practices, that is not an indictment of the field as a whole.

Moreover, even after a diagnosis is made, the SOC recommend a staged approach to treatment that starts with reversible interventions and only progresses to irreversible ones after further assessment. This belies the notion of automatic "affirmation" leading to hasty medical transition.³¹

In setting up a contrast between an idealized diagnostic process and a caricatured reality, the author creates a false dichotomy. The established standards of care and best practices in the field are much closer to the author's ideal than to the strawman they construct.

While there is always room for improvement and a need for ongoing research, it's important to base our critiques on the actual standards and practices of the field, not on assumptions or anecdotes. The author's portrayal of the diagnostic process for Gender Dysphoria appears to be more of a rhetorical device than a factual representation.

The New Fad That’s Incredibly Dangerous!

The author's claim that Gender Dysphoria is a "new, false and incredibly dangerous explanation" for distress arising from various other conditions is a serious assertion that requires careful scrutiny. However, upon closer examination, this argument is deeply flawed and not supported by scientific evidence.

First, the author suggests that Gender Dysphoria is a "new" phenomenon that is being used to explain distress that was previously attributed to other conditions. This ignores the fact that experiences of gender incongruence have been documented throughout history and across cultures³². What is relatively new is the formal diagnosis of Gender Dysphoria and the development of affirming care protocols, not the existence of transgender identities themselves.

The author provides a list of conditions that supposedly explain the distress misattributed to Gender Dysphoria, including autism, learning disabilities, bullying, same-sex attraction, family dysfunction, and trauma. However, this list is presented without any evidence of a causal link. While these issues can certainly cause significant distress, there is no scientific basis for the claim that they are the real reason behind the experience of Gender Dysphoria.

In fact, the WPATH Standards of Care Version 8 (SOC-8) explicitly state that Gender Dysphoria is distinct from distress related to other mental health concerns, negative life experiences, or nonconformity to gender norms. The SOC-8 emphasize the importance of comprehensive assessment to differentiate Gender Dysphoria from other conditions and ensure appropriate treatment³³. The author's attempt to lump these various issues together as explanations for Gender Dysphoria is not supported by the standards of care or the scientific literature.

The author's claim that childhood sexual abuse is a "huge driver" of later transgender identification, especially in girls, is a particularly inflammatory assertion that is not backed by evidence. While some studies have found higher rates of trauma exposure among transgender individuals, this does not prove causation³⁴. Correlation does not equal causation, and the SOC-8 caution against assuming that trauma or mental health concerns cause Gender Dysphoria³⁵.

Moreover, the suggestion that mental health professionals have "successfully treated" the conditions listed by the author "forever" is a dubious claim at best. Conditions like autism, personality disorders, and the complex effects of trauma are often lifelong challenges that require ongoing support, not issues that are easily "cured" by some established treatment. This calls into question the author's broader credibility and understanding of mental health topics.

Finally, characterizing gender-affirming care as "incredibly dangerous" is not supported by the scientific evidence. As discussed previously, the SOC-8 and numerous studies have found that gender-affirming medical and psychological treatments, when provided in accordance with established guidelines, can significantly improve mental health outcomes and quality of life for individuals with Gender Dysphoria ³⁶³⁷. The author's fearmongering claim is contradicted by the very standards of care they dismiss.

In summary, the author's argument that Gender Dysphoria is a false, catch-all explanation for distress caused by other conditions is not supported by scientific evidence or expert consensus. It relies on unsupported assertions, inflammatory claims, and a dismissive attitude towards the complexity of mental health conditions.

The WPATH Standards of Care Version 8 and the broader scientific literature make it clear that Gender Dysphoria is a distinct clinical phenomenon that requires comprehensive, individualized assessment and affirming care³⁸. Attempts to dismiss or misattribute the experiences of transgender individuals, as this author does, are not only factually inaccurate but also perpetuate harmful stigma and barriers to care. Such claims should be rejected in favor of evidence-based, compassionate approaches that prioritize the health and well-being of transgender individuals.

Unethical, Experimental, Mutilation, and Other Claims

The author makes a number of sensationalized and unsubstantiated claims about the supposed dangers of gender-affirming care. They assert that a diagnosis of Gender Dysphoria inevitably leads to "highly unethical and entirely experimental use of synthetic cross-sex hormones and the surgical mutilation of physically healthy bodies." They further claim that such care is "actively anti-medical" and will lead to cognitive impairment, disability, dementia, and premature death. But these alarming assertions are not backed up by any credible scientific evidence.

First, the characterization of gender-affirming hormonal and surgical treatments as "experimental" and "unethical" is a gross misrepresentation of the well-established standards of care in this field. The WPATH Standards of Care, which are based on the best available scientific research and expert consensus, provide detailed guidelines for the safe and appropriate use of these interventions³⁹. These are not reckless experiments, but evidence-based treatments that have been extensively studied and refined over decades of clinical practice⁴⁰⁴¹.

The author's use of inflammatory terms like "surgical mutilation" and "supposed gender identity" betrays a clear bias and lack of respect for the experiences of transgender individuals. This kind of loaded language has no place in a serious discussion of medical science and ethics. It serves only to stigmatize and demean transgender people seeking necessary care.

Moreover, the claim that gender-affirming care aims to "remove healthy tissue and organs" is a fundamental misrepresentation of the purpose of these treatments. The goal is not to cause harm, but to alleviate the clinically significant distress and impairment associated with Gender Dysphoria⁴². This is done through carefully considered and extensively researched medical interventions, not reckless destruction of healthy bodies.

The author's litany of supposed long-term harms, from cognitive decline to early death, is perhaps the most egregious example of fearmongering without evidence. There is simply no credible scientific basis for the claim that gender-affirming care leads to "damaged" IQ and cognitive function, "progressive disability," "intractable infections," dementia, or premature death.

In fact, numerous studies have found that access to gender-affirming care significantly improves mental health outcomes and overall quality of life for transgender individuals⁴³⁴⁴. Research has shown no evidence of cognitive impairment or neurological damage from gender-affirming hormone therapy or surgery⁴⁵. On the contrary, these treatments can improve cognitive functioning by alleviating the distress of untreated Gender Dysphoria⁴⁶.

The baseless assertion that gender-affirming care shortens lifespan is directly contradicted by research showing that access to these treatments substantially reduces rates of suicidality among transgender people⁴⁷. Spreading such misinformation is not only scientifically inaccurate, but actively dangerous, as it may discourage transgender individuals from seeking potentially life-saving care.

In making these sensationalized claims, the author is engaging in irresponsible fearmongering that prioritizes shock value over truth. Their arguments are not grounded in scientific fact, but in inflammatory rhetoric and unfounded speculation. This kind of biased and misleading reporting has real potential to cause harm by perpetuating stigma and misinformation about medically necessary care.

As responsible consumers of information, we must reject such baseless assertions and look to the actual scientific evidence. And that evidence clearly shows that gender-affirming care, when provided in accordance with established standards and guidelines, is safe, effective, and often life-saving for transgender individuals who need it⁴⁸. To suggest otherwise, as this author does, is a reckless disregard for the facts and for the well-being of the transgender community.

Ideology, Activism, and Corporate Greed

Finally, the author claims that gender-affirming care is driven by ideology, activism, and corporate interests rather than science, and that it causes long-term harm. But the evidence just doesn't support those assertions. Numerous studies have found that access to affirming care significantly improves mental health outcomes and quality of life for transgender individuals time and time again⁴⁹⁵⁰. And major medical organizations across the globe, from the American Medical Association to the NHS, recognize the necessity and efficacy of gender-affirming care⁵¹⁵². To suggest some sort of ideological or financial conspiracy is, frankly, ridiculous.

Moreover, the UK's Cass Review, while expressing some caution, ultimately aligns with the WPATH Standards of Care Version 8 in acknowledging the benefits of gender-affirming care and the consensus of major medical organizations. As Dr. Hilary Cass stated:

'There are young people who absolutely benefit from a medical pathway, and we need to make sure that those young people have access — under a research protocol, because we need to improve the research — but not assume that that's the right pathway for everyone.'⁵³

This nuanced perspective aligns with the positions of major medical organizations worldwide, such as the World Professional Association for Transgender Health (WPATH) and the Endocrine Society, which have developed clinical guidelines for the treatment of gender dysphoria in adolescents that recognize the potential benefits of gender-affirming care for some individuals⁵⁴.

The author's suggestion that this consensus is driven by ideology or financial interests, rather than science and concern for patient wellbeing, is baseless. By that logic, one could just as easily accuse oncologists of inventing cancer diagnoses for the sake of the $223 billion global oncology market in 2023, projected to reach $409 billion by 2028⁵⁵, or suggest that the $2.1 billion eating disorders treatment industry is exaggerating the prevalence of anorexia for the sake of the 6.2% CAGR projected through 2028⁵⁶.

The reality is that gender-affirming care, like cancer treatment or anorexia care, is a legitimate and necessary medical intervention for a serious condition. To single it out as uniquely corrupt or profit-driven, while not applying the same cynicism to other fields of medicine, says more about the author's biases than any real conspiracy. The consistent evidence for the benefits of gender-affirming care, recognized by major medical organizations worldwide, speaks for itself.

Finally…

Look, I get it. Gender Dysphoria and transgender identities can be complex and challenging topics for a lot of people to understand. But that's all the more reason to stick to the facts and evidence, not spread misinformation that can worsen stigma and barriers to care. As the famous saying goes, everyone is entitled to their own opinions, but not their own facts. And the facts here are clear - Gender Dysphoria is a real, scientifically-recognized condition, and gender-affirming care is a safe, ethical, and effective treatment approach. Period.

In the end, the article 'Why 'Gender Dysphoria' is a lie' is a case study in how not to approach complex issues of science and health. From start to finish, it substitutes ideology and sensationalism for scientific facts and evidence.

The author's claimed expertise as a near 30-year clinician is called into serious question by their lack of familiarity with basic diagnostic criteria and recommended processes, their misrepresentation of established standards of care, and their reliance on anecdote over epidemiology. One has to wonder how a supposed expert could be so out of step with the scientific consensus of their field. To verify their bona fides would go a long way to better understanding their areas of study, expertise, practice, and perspective that they apply to this article. Without that, well, I am afraid Hitchen’s razor applies.

But expertise, real or imagined, does not give one license to spread misinformation. The claims made in this article - that Gender Dysphoria is a false diagnosis, that affirming care is dangerous and unethical, that it's all a matter of ideology and profit - are not just scientifically baseless. They are harmful, contributing to a climate of stigma and discrimination that puts transgender lives at risk.

The truth, as affirmed by major medical organizations worldwide and backed by a growing body of research, is that Gender Dysphoria is real, transition-related care is effective and often lifesaving, and transgender identities are valid. No amount of fearmongering or pseudoscience can change these facts.

So let this be a call to do better. To ground our discussions in science and compassion, not prejudice and conspiracy theories. To listen to the voices of transgender people and the consensus of experts, not self-appointed authorities peddling debunked myths. To build a world where every person can access the care they need to live authentically and thrive, without fear.

Anything less is a disservice to truth and a danger to public health. We can, and must, demand better. Articles like 'Why 'Gender Dysphoria' is a lie' take us further away from that goal. It is set to divide us. It's up to all of us to demand better, and to stand stronger together.

1. X.com. (n.d.). X (Formerly Twitter). https://x.com/Psychgirl211/status/1808825717204922755

2. Zucker, K. J. (2015). The DSM-5 diagnostic criteria for gender dysphoria. In C. Trombetta, G. Liguori, & M. Bertolotto (Eds.), Management of gender dysphoria: A multidisciplinary approach (pp. 33-37). Springer.

3. Ibid.

4. Ibid.

5. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).

6. Ibid.

7. Davy, Z., Sørlie, A., & Schwend, A. S. (2018). Democratising diagnoses? The role of the depathologisation perspective in constructing corporeal trans citizenship. Critical Social Policy, 38(1), 13-34. https://doi.org/10.1177/0261018317731716

8. Zucker, K. J. (2016). The DSM-5 Diagnostic Criteria for Gender Dysphoria. In W. P. Bouman & J. Arcelus (Eds.), The Transgender Handbook: A Guide for Transgender People, Their Families and Professionals (pp. 23-37). Nova Science Publishers.

9. See 1

10. See 6

11. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).

12. See 1

13. Coleman, E., Radix, A. E., Bouman, W. P., Brown, G. R., de Vries, A. L. C., Deutsch, M. B., Ettner, R., Fraser, L., Goodman, M., Green, J., Hancock, A. B., Johnson, T. W., Karasic, D. H., Knudson, G. A., Leibowitz, S. F., Meyer-Bahlburg, H. F. L., Monstrey, S. J., Motmans, J., Nahata, L., ... Arcelus, J. (2022). Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. International Journal of Transgender Health, 23(sup1), S1-S259. https://doi.org/10.1080/26895269.2022.2100644

14. Turban, J. L., King, D., Carswell, J. M., & Keuroghlian, A. S. (2020). Pubertal Suppression for Transgender Youth and Risk of Suicidal Ideation. Pediatrics, 145(2). https://doi.org/10.1542/peds.2019-1725

15. Epstein, L. J., Kristo, D., Strollo, P. J., Friedman, N., Malhotra, A., Patil, S. P., Ramar, K., Rogers, R., Schwab, R. J., Weaver, E. M., & Weinstein, M. D. (2009). Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. Journal of Clinical Sleep Medicine, 5(3), 263-276.

16. Brownley, K. A., Berkman, N. D., Peat, C. M., Lohr, K. N., Cullen, K. E., Bann, C. M., & Bulik, C. M. (2016). Binge-Eating Disorder in Adults: A Systematic Review and Meta-analysis. Annals of Internal Medicine, 165(6), 409-420. https://doi.org/10.7326/M15-2455

17. Murad, M. H., Elamin, M. B., Garcia, M. Z., Mullan, R. J., Murad, A., Erwin, P. J., & Montori, V. M. (2010). Hormonal therapy and sex reassignment: A systematic review and meta-analysis of quality of life and psychosocial outcomes. Clinical Endocrinology, 72(2), 214-231.

18. Bränström, R., & Pachankis, J. E. (2020). Reduction in mental health treatment utilization among transgender individuals after gender-affirming surgeries: a total population study. American Journal of Psychiatry, 177(8), 727-734.

19. See 16 & 17

20. Safer, J. D., Coleman, E., Feldman, J., Garofalo, R., Hembree, W., Radix, A., & Sevelius, J. (2016). Barriers to healthcare for transgender individuals. Current Opinion in Endocrinology, Diabetes and Obesity, 23(2), 168-171. https://doi.org/10.1097/MED.0000000000000227

21. Flores, A. R., Herman, J. L., Gates, G. J., & Brown, T. N. T. (2016). How Many Adults Identify as Transgender in the United States? The Williams Institute.

22. Zhang, Q., Goodman, M., Adams, N., Corneil, T., Hashemi, L., Kreukels, B., Motmans, J., Snyder, R., & Coleman, E. (2020). Epidemiological considerations in transgender health: A systematic review with focus on higher quality data. International Journal of Transgender Health, 21(2), 125-137. https://doi.org/10.1080/26895269.2020.1753136

23. See 10

24. See 12

25. See 12

26. See 12

27. Guillamon, A., Junque, C., & Gómez-Gil, E. (2016). A Review of the Status of Brain Structure Research in Transsexualism. Archives of Sexual Behavior, 45(7), 1615-1648.

28. Saraswat, A., Weinand, J. D., & Safer, J. D. (2015). Evidence supporting the biologic nature of gender identity. Endocrine Practice, 21(2), 199-204.

29. See 10

30. See 12

31. Ibid.

32. Stryker, S. (2017). Transgender history: The roots of today's revolution (2nd ed.). Seal Press.

33. See 12

34. Schneeberger, A. R., Dietl, M. F., Muenzenmaier, K. H., Huber, C. G., & Lang, U. E. (2014). Stressful childhood experiences and health outcomes in sexual minority populations: a systematic review. Social Psychiatry and Psychiatric Epidemiology, 49(9), 1427-1445. https://doi.org/10.1007/s00127-014-0854-8

35. See 12

36. Ibid.

37. Bränström, R., & Pachankis, J. E. (2020). Reduction in mental health treatment utilization among transgender individuals after gender-affirming surgeries: a total population study. American Journal of Psychiatry, 177(8), 727-734.

38. See 12

39. Ibid.

40. Ibid.

41. Murad, M. H., Elamin, M. B., Garcia, M. Z., Mullan, R. J., Murad, A., Erwin, P. J., & Montori, V. M. (2010). Hormonal therapy and sex reassignment: A systematic review and meta-analysis of quality of life and psychosocial outcomes. Clinical Endocrinology, 72(2), 214-231.

42. See 22

43. See 24

44. See 34

45. Nguyen, H. B., Loughead, J., Lipner, E., Hantsoo, L., Kornfield, S. L., & Epperson, C. N. (2019). What has sex got to do with it? The role of hormones in the transgender brain. Neuropsychopharmacology, 44(1), 22-37.

46. Owen-Smith, A. A., Gerth, J., Sineath, R. C., Barzilay, J., Becerra-Culqui, T. A., Getahun, D., Giammattei, S., Hunkeler, E., Lash, T. L., Millman, A., Nash, R., Quinn, V. P., Robinson, B., Roblin, D., Sanchez, T., Silverberg, M. J., Tangpricha, V., Valentine, C., Winter, S., ... Goodman, M. (2018). Association between gender confirmation treatments and perceived gender congruence, body image satisfaction, and mental health in a cohort of transgender individuals. The Journal of Sexual Medicine, 15(4), 591-600.

47. See 27

48. See 22, 24, and 27

49. Dhejne, C., Van Vlerken, R., Heylens, G., & Arcelus, J. (2016). Mental health and gender dysphoria: A review of the literature. International Review of Psychiatry, 28(1), 44-57.

50. Murad, M. H., Elamin, M. B., Garcia, M. Z., Mullan, R. J., Murad, A., Erwin, P. J., & Montori, V. M. (2010). Hormonal therapy and sex reassignment: A systematic review and meta-analysis of quality of life and psychosocial outcomes. Clinical Endocrinology, 72(2), 214-231.

51. American Medical Association. (2019). Health insurance coverage for gender-affirming care of transgender patients. https://www.ama-assn.org/system/files/2019-03/transgender-coverage-issue-brief.pdf

52. NHS England. (2020). Gender Identity Development Service for Children and Adolescents. https://www.england.nhs.uk/commissioning/spec-services/npc-crg/gender-dysphoria-clinical-programme/gender-dysphoria/children-and-adolescents/

53. Cass, H. (2023). Independent review of gender identity services for children and young people: Final report. The Cass Review. https://cass.independent-review.uk/final-report/

54. World Professional Association for Transgender Health. (2022). Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. https://www.tandfonline.com/doi/full/10.1080/26895269.2022.2100644

55. IQVIA. (2024). Global Oncology Trends 2024: Outlook to 2028. https://www.iqvia.com/insights/the-iqvia-institute/reports-and-publications/reports/global-oncology-trends-2024

56. Research and Markets. (2023). Global Eating Disorder Treatment Market Size, Share & Industry Trends Analysis Report By Disorder Type, By Treatment Type, By End User, By Regional Outlook and Forecast, 2022 - 2028. https://www.researchandmarkets.com/reports/5240304/global-eating-disorder-treatment-market-size