Open Letter to Dr Hilary Cass

Ok, so now define “gender identity” in a solid enough way to be part of a research trial protocol.

Gender dysphoria isn’t BDD because the core issue isn’t misperception. People with BDD believe a body part is defective when it isn’t. People with gender dysphoria accurately perceive their bodies. The distress comes from a mismatch between their physical sex traits and their gender identity, not from thinking the body is “wrong” or “abnormal.”

When you talk about someone wanting to remove a limb you’re talking about Body Integrity Identity Disorder (BIID). Again something different to gender dysphoria. BIID is about a desire to have a limb amputated and become disabled. They both involve distress, but the causes and treatments are different.

And if the perception of the body is correct - a male child correctly perceives they have a male body - why does the body need to change? What can’t the identity become comfortable with what you say is the correct body?
I didn’t say the body is correct, only
that the person could correctly perceive their sex characteristics. People have tried to force trans people to change their identity and it doesn’t work.

People with gender dysphoria do not perform rituals in that way.

Isn’t dressing as the opposite sex in ritualised ways, and other things like fixating on stereotypes, enforcing pronouns, discussion amongst similar individuals online and so on, all forms of ritual and compulsive behaviour?

Many trans people describe experiences like “gender euphoria” and rituals associated with dressing up and transforming into a different persona in exactly the same kinds of ways that others describe compulsive behaviours - some of the very first narratives of “trans” people and groups involve compulsive dressing up and ritualised behaviours behind closed doors, obsessive thoughts, and fixations on specific kinds of clothing, makeup or body parts.

And to bring it back to the thread:

The DSM 5 criteria for GD doesn’t focus on any of your points. It’s about stereotypes. And if you, as an adult, can’t logically explain what it is that’s wrong without raising more questions, how is this any sort of basis to enact irreversible lifelong sterilising treatments on children?

How can a study happen on something that can’t be defined?

Psychiatrists and psychologists. By definition it is an obsessive worry about a perceived flaw that involves compulsive behaviours.

But I didn’t ask about the compulsive behaviour part. I asked why it’s only body dysmorphia when one sees a body part as female when it isn’t? Why is it not similar to BDD when you perceive something that shouldn’t be there? What’s the difference between wanting a limb gone or wanting your penis or breasts gone?

Ok, let’s say they’re not the same disorders, but there are similarities, aren’t there?

The perception of a flaw with one’s body that isn’t correct. There is nothing wrong with a child’s body is there?

but then you say:

In gender dysphoria, the body is perceived accurately but feels incongruent with identity.

So what part of a child’s identity is incongruent with the body?

And if the perception of the body is correct - a male child correctly perceives they have a male body - why does the body need to change? What can’t the identity become comfortable with what you say is the correct body?

This sounds an awful lot like what people with gender dysphoria describe to me. Constantly wishing they were the opposite sex. So people with GD don’t do this, according to you?
A wish is not the same as compulsive behaviour to reduce anxiety and distress. People with gender dysphoria do not perform rituals in that way.

Why is it only dysmorphia if you’re male and perceive it to be female? Why is it not dysmorphia if you’re male and perceive your genitals as wrong as you want them to be female?
Male person who perceives a characteristic is female when it objectively is not and has obsessive worries and compulsions: distorted perception
Male person who believes they should have female genitals: no distortion because they know they accurate perceive their body to have male genitals.

Who says dysmorphia only works one way like you say?
Psychiatrists and psychologists. By definition it is an obsessive worry about a perceived flaw that involves compulsive behaviours.

In body dysmorphia, the body is perceived inaccurately.
In gender dysphoria, the body is perceived accurately but feels incongruent with identity.
One is a misperception; the other is a mismatch. That’s why clinicians don’t treat them as the same disorder

Dysmorphia involves obsessive worries and compulsive checking behaviours. Someone with dysmorphia could believe a specific facial feature makes them ugly and then compulsive compare their appearance with other people and spend a lot of time looking in a mirror.

This sounds an awful lot like what people with gender dysphoria describe to me. Constantly wishing they were the opposite sex. So people with GD don’t do this, according to you?

Because they are accurately perceiving that their body is male or female. They believe it should be different

But why do they believe it should be different? Why do they think it’s wrong as it is?

If a man perceived a body feature to be female when it wasn’t and obsessed about it, that would be dysmorphia

Why is it only dysmorphia if you’re male and perceive it to be female? Why is it not dysmorphia if you’re male and perceive your genitals as wrong as you want them to be female? Who says dysmorphia only works one way like you say?

BDD: perceive a limb to be there but wishes it wasn’t. Seeks amputation.

GD: perceives the penis/breasts to be there, but wishes it wasn’t. Seeks removal.

So how are these different?

Dysmorphia involves obsessive worries and compulsive checking behaviours. Someone with dysmorphia could believe a specific facial feature makes them ugly and then compulsive compare their appearance with other people and spend a lot of time looking in a mirror.

Gender dysphoria does not involve compulsive behaviours.

“And how are people with dysphoria accurately perceiving their bodies if they are falsely perceiving the sex of their bodies as somehow wrong?”
Because they are accurately perceiving that their body is male or female. They believe it should be different, but they are able to objectively view their body. If a man perceived a body feature to be female when it wasn’t and obsessed about it, that would be dysmorphia

The research on outcomes is mixed at best. Plenty of studies show worsening mental health after transition.

How is gender dysphoria not an obsessive focus on a perceived flaw. Aren’t people who claim a trans identity who seek medical transition focused on the perceived flaw of the sex of their body, obsessively so? If it wasn’t obsessively so, why would there be a driving need to alter the body through medical or surgical means? Surely if it was a casual focus, medical transition would be neither here nor there.

And how are people with dysphoria accurately perceiving their bodies if they are falsely perceiving the sex of their bodies as somehow wrong?

There is also plenty of published research that shows dysphoria does get better with transition.

Dysmorphia is an obsessive focus about a perceived flaw with the body, and gender dysphoria is not. People with dysphoria are able to accurately perceive their body and that’s what makes it different.

There is plenty of published research to show it doesn’t get better.

But before that, how is it different? You say it’s about the sex of your body. What makes that part define it as a dysphoria, as opposed to someone have a different issue with their body that makes it a dysmorphia?

I think neutral talking therapy to help someone explore their feelings is a good thing. But if the goal of that therapy is to convince someone they’re not trans, that would be conversion therapy.

Gender dysphoria and body dysmorphia are separate issues. Dysmorphia is distress about a perceived flaw, and dysphoria is distress about the sexed body and internal sense of self. People will dysphoria are able to accurately perceive their body.

Dysmorphia doesn’t get better when the person changes their body, but gender dysphoria goes get better with transition.

And you acknowledge that many in the so called trans community claim that gender dysphoria is not a requirement

Do you think that talking therapies equals conversion therapy? Or do you believe that total affirmation is not helpful for young (and older) people?

So how is this different to a body dysmorphia, and why is the treatment for this body dysmorphia to alter the body, in opposite to the treatment for other body dysmorphias?

And why does a male child need to alter his body in order to have good friendships with women and girls?

I know it’s not a fashionable view in the trans community, but yes I do believe it’s a requirement

So do you have to have gender dysphoria to be transgender?

It's about giving children and young people the space and freedom to become the adult human female or adult human male they want to be, without feeling that they are in some way 'wrong' and need to transition into something else.

But all the while denying them the space & freedom to live as they want to be should it be otherwise without feeling that they are in some way 'wrong' & need to repress their inclinations into who they are not. Puberty isn't a neutral act but a zero sum gain.

The misunderstanding here is the assumption that the default setting is the correct one that's only a matter of psychological 'acceptance'…..the logic that underpins conversion therapy & its indisputable ineffectual damaging consequences.

If by "transgender" people mean someone who is internally the opposite sex to their biological sex then I absolutely do not believe that is possible. I do think people can have issues with their identity, sexuality and feel deeply unhappy in themselves and that some of them imagine they are the opposite sex and wish to look like and live as the opposite sex. However they are not born in the wrong body nor do they have a female brain or soul in a male body.

Children should not be given these drugs for this reason, it is not medically necessary or appropriate and the trial is highly problematic. If an adult wishes to alter their body then that is up to them, it still doesn't make them the opposite sex and they should by that point be aware that legally they will always be their biological sex.

For me, it was distress in knowing that I’d eventually start to develop harsher features, facial hair and that my voice would deepen instead of female secondary characteristic. There was also a social element about not being able to develop deeper friendships with women

So the DSM 5 criteria for gender dysphoria for children is defined by stereotypes. So how are you defining gender dysphoria?

What was that to you?

Gender dysphoria. The strong feeling I should’ve been born female and distress from my male body.

tried for a long time to ignore it

What is “it”? What were you trying to ignore?

I’m glad you didn’t have to go down that route. It’s not easy and I wouldn’t wish it on anybody. I tried for a long time to ignore it and I reached a point where it felt like the only option. I know it doesn’t work for everyone, but my experience has been incredibly position. I’ve managed to build a life and friendships that wouldn’t have been possible if I didn’t transition.