Dysphoria and disorder: a tale of two disturbances
If a friend is debilitated by significant anxiety, stress, low self-esteem, and depression, we naturally want to help alleviate this dangerous dysphoria (profound state of unease, anxiety or dissatisfaction). But first we need to find out why our friend is unhappy. Dysphoria is usually a symptom of an underlying problem: tension at home, traumatic experience, sense of meaninglessness, chemical imbalance, pathogen, or other factor(s). It could also result from a combination of factors, which may be more or less severe and more or less persistent. We might say that dysphoria results from disorder: problematic symptoms arise from something that is out of its properly ordered state.
None of this suggests that our friend is at fault for causing the underlying disorder. It is likely that he or she has been victimized in some way, perhaps even by happenstance. There is nearly always some contributing cause outside a person’s own will or desires. So “disorder” is not a term that ascribes culpability to the person, but an objective identification of a problem. If we want to help our friend we need to know the underlying disorder.
When diagnosing mental health issues, psychologists and psychiatrists in the U.S. refer to a volume created and updated by the American Psychiatric Association (APA) called the Diagnostic and Statistical Manual of Mental Health Disorders, now in its fifth edition (DSM- 5). The World Health Organization maintains a comprehensive International Classification of Diseases (ICD). Health care providers and insurance companies in the United States currently make use of its tenth revision (ICD- 10) for diagnostic coding, and the DSM-5 classifications identify which ICD-10 codes to use for billing.
So let’s consider gender dysphoria, which is a lasting discrepancy between experienced gender and assigned gender. It is not mere gender nonconformity. The diagnostic term “gender dysphoria” was formally introduced in the DSM-5 only in 2013. In the previous edition of the DSM, the term was “gender identity disorder.” Why the change?
According to the APA, the rationale for the change was twofold. First, it aimed to remove any implication that the patient is “disordered.” Nonetheless, other mental health diagnoses with the term “disorder” remained unchanged, and the DSM-5 still uses the term “mental disorders” in its title. Second, it aimed to retain a diagnostic term without compromising the first aim. In fact, following the rationale of eliminating “disordered” connotations, the complete removal of gender identity disorder had been proposed; but a psychiatric diagnosis was still needed to enable access to and insurance coverage for “gender transitioning” counseling, hormonal interventions, and surgeries.
So the term “gender dysphoria” purposefully mutes the disorder and emphasizes the distress that results. The psychiatric problem is no longer lack of identification with one’s bodily sex, but rather the unhappiness associated with it. “Treatment” can therefore mean eliminating the dysphoria—not the underlying identification issue—by reinforcing the perceived gender through “gender-affirming” counseling, hormones, surgery, or all of these. Affirm the conviction and change the body to make the person feel better.
Masking the problem of an identity disorder by focusing on the consequence of dysphoria gravely undermines the possibility of authentic healing for vulnerable persons experiencing gender confusion. It reflects a fundamental misunderstanding of what it means to be a human person, who is a unity of body and soul. Maleness or femaleness is found in the unified, embodied person. There is no “inner self” that can be a distinct source of personal identity over and against bodily sex; rather, the convictions or desires of the mind might be at odds with the person’s embodied sexual identity. In fact, the DSM- 5 lists six criteria that can be invoked for a gender dysphoria diagnosis, five of which reference a “desire” or “conviction.”
Focusing on the dysphoria while attempting to deny the disorder demands reinforcing the disorder and mutilating the body to meet an imagined version of the “self” at odds with the person’s body-soul reality. This cannot bring authentic joy and fulfillment. The pastoral constitution Gaudium et spes of the Second Vatican Council reminds us that “man is not allowed to despise his bodily life, rather he is obliged to regard his body as good and honorable since God has created it and will raise it up on the last day.” Let us bear in mind the need to love and understand people experiencing gender identity confusion, while also helping them to understand and love their male or female bodies as beautiful manifestations of their authentic selves.
JOHN A. DI CAMILLO, PH.D., BE.L., is a staff ethicist at The National Catholic Bioethics Center in Philadelphia. He earned his bioethics doctorate and licentiate degrees at the Pontifical Athenaeum Regina Apostolorum in Rome.