This text was first published in The psychology journal
Psychologists proudly claim a reputation as society's champions of good mental health. We dedicate our lives to the wellbeing of others, and shout at the top of our voices when figures are presented showing that young people's mental health has deteriorated. In the so-called "gender debate", many of the loudest voices seem to be more concerned with whether transgender people actually have insight into their own gender identity than with the state of transgender people's health. I choose to believe that the vast majority of psychologists tacitly wish trans people well. This article is intended for you. I can't understand how we can care about mental health and at the same time remain silent about such a vulnerable group.
1 in 3 transgender people have attempted suicide, and more than half of all transgender people report symptoms of anxiety and depression (Andersen et al., 2021). At the same time, 1 in 4 have experienced violence in the past five years. Around half are subjected to bullying and harassment at school and in the workplace (Andersen et al., 2021). These are hair-raising figures. There are hardly any groups that report similar mental health problems and discrimination.
In 1978, Foucault argued that homophobia is pervasive in Western culture. He points out that homophobia did not disappear, but only changed character over the course of the 20th century: from sin, to criminal, to sick. "I think the same applies to transphobia. As the figures above show, today's society is still characterised by transphobia. Today's transphobia often takes the form of a perception that trans people threaten traditional values.
Many people may think they can sit still and wait for society to improve. But that's not the case. Some people are driving this development forward. And some are standing in the way, pulling in the opposite direction. On 28 January 2025, an order was issued by the White House in the USA to stop gender affirmation treatment and to punish those who promote or perform such treatment (the treatment is referred to as "chemical and surgical genital mutilation" in the order). Major technology companies, such as Meta (Facebook and Instagram), now no longer consider hate speech against queer people to be a violation of their policies. Global chains, such as McDonald's, have withdrawn Pride-related products and changed their employee policies around queerness. All of this facilitates more hate, incitement and discrimination, and expands the boundaries of what society tolerates in terms of harassment of minority groups. We see similar conservative currents all over the world, including in Norway, most recently exemplified by KrF and FrP wanting to take teaching about gender diversity out of Norwegian schools (Engesbak, 2024).
I get a stomach ache just thinking about where this could go.
In 2018, transgender people were finally defined out of our sacred 99 commandments - the F diagnoses in ICD-10. Gender incongruence and gender dysphoria are now referred to as a condition under "sexual health", on a par with pregnancy. In other words, it is a condition that entitles you to health care, without it meaning that you are ill. The new diagnoses are also intended to describe the experience that is relevant to health care: that there is a discrepancy between one's personal/social gender and the gender assigned at birth, and that this causes severe discomfort. The dysphoria - the discomfort - will generally be reduced or disappear as you live out your gender identity and possibly undergo medical gender-affirming treatment.
This means that the healthcare system will no longer decide whether a person is trans or not. What will be assessed is whether gender-affirming treatment would be appropriate to reduce gender dysphoria. In other words, people do not undergo gender-affirming treatment primarily to improve their mental health or quality of life - this is a side effect. In comparison, an abortion is successful if it terminates the pregnancy and it feels right, not if the person scores better on anxiety and depression scales. Most people would agree that informed consent is the best way to decide whether someone should have an abortion. Similarly, psychologists can help transgender people explore their thoughts and feelings about gender-affirming treatment. But we don't, and shouldn't, decide whether someone should undergo such treatment.
By the way, I would just like to mention that those who regret having undergone medical gender-affirming treatment often say that they regret it because of increased discrimination. And yet we are talking about less than 5 % (Bustos, 2021; Narayan et al., 2021). One study showed that 12 % regret prostate cancer treatment (Morris, 2015), and 10 % regret knee arthroplasty (DeFrance & Scuderi, 2023), but I see few advocating to stop any of it.
Psychological work with transgender people can also be exciting from a professional perspective, if you manage to put aside your own insecurities. As psychologists, we can help the patient to see gender reassignment as a form of invalidation, and explain the consequences of regular invalidation over time. The patient can be helped to explore the connection between emotion regulation difficulties and past or present aversion to their own body. By strengthening self-assertion and creating control over one's own narrative, we can build resilience in an unsafe world. The psychological mechanisms behind mental illness can be elegantly intertwined with society's discrimination mechanisms, and both psychologist and patient can experience the treatment as rewarding.
Mental health care should not be confused with so-called "Gender Exploratory Therapy". This form of treatment has been promoted as an alternative to medical gender-affirming treatment, and it is difficult to read it in any other way than that medical treatment is considered unnecessary as long as one's own gender identity is sufficiently explored (Ashley, 2022). If you engage in a practice that has the consequence of preventing the patient from receiving gender-affirming treatment, you are at the same time contributing to the patient having to live as a gender other than their own. Such an approach seems to me to be closer to conversion therapy than anything else, which is both harmful and illegal. Of course we should explore the client's gender identity together, but it must be on the basis of the patient's wishes and be based on the fact that it is just as good to be transgender as cisgender. This position must be clear and explicit before any kind of exploration can begin. You must show that you are a safe person to talk to.
Spring is on its way, and we're getting closer to Pride. I'm looking forward to it, and it's going to be fun. But I'm also dreading it. The hatred towards queer people is being made visible, and it hurts. Shit is being written about us online, there's ugly jeering in the streets. I have to prepare myself for the possibility that I, or someone I know, may be struck down. Now is the time for you, the silent majority, to raise your voice. Talk about it at work, share on social media, raise your voice with friends. Everything helps. Anything but silence.
Andersen, N., Eggebø, H., Stubberud, E. & Holmelid, Ø. (2021). Sexual orientation, gender diversity and living conditions. University of Bergen. https://hdl.handle.net/11250/2760732
Ashley, F. (2022). Interrogating Gender-Exploratory Therapy. Perspectives on Psychological Science 2023, 18(2), 472-481. https://doi.org/10.1177/17456916221102325
Bustos, V. P., Bustos, S. S., Mascaro, A., Del Corral, G., Forte, A. J., Ciudad, P., Kim, E. A., Langstein, H. N. & Manrique, O. J. (2021). Regret after Gender-affirming Surgery: A Systematic Review and Meta-analysis of Prevalence. Plastic and Reconstructive Surgery - Global Open, 9(3). https://doi.org/10.1097/GOX.0000000000003477
DeFrance, M. J. & Scuderi, G. R. (2023). Are 20% of Patients Actually Dissatisfied Following Total Knee Arthroplasty? A Systematic Review of the Literature. The Journal of arthroplasty, 38(3), 594-599. https://doi.org/10.1016/j.arth.2022.10.011
Engesbak, R. (2024, 30 April). KrF and FrP want pink expertise out of schools. Blikk. https://www.blikk.no/fri-frp-krf/krf-og-frp-vil-ha-rosa-kompetanse-ut-av-skolene/247433
Foucault, M. (1978). The History of Sexuality. Volume 1: An Introduction. Random House.
Morris, B. B., Farnan, L., Song, L., Addington, E. L., Chen, R. C., Nielsen, M. E., Mishel, M., Mohler, J. L. & Bensen, J. T. (2015). Treatment Decisional Regret Among Men With Prostate Cancer: Racial Differences and Influential Factors in the North Carolina Health Access and Prostate Cancer Treatment Project (HCaP-NC). American Cancer Society. https://doi.org/10.1002/cncr.29309
Narayan, S. K., Hontscharuk, R., Danker, S., Guerriero, J., Carter, A., Blasdel, G., Bluebond-Langner, R., Ettner, R., Radix, A., Schechter, L. & Berli, J. U. (2021). Guiding the conversation - types of regret after gender-affirming surgery and their associated etiologies. Annals for Translational Medicine, 9(7). https://doi.org/10.21037/atm-20-6204
