Running head: SOCIAL CONTEXT FOR GENDER DYSPHROIA

"Every time I get gendered male, I feel a pain in my chest ":

Understanding the social context for gender dysphoria

M. Paz Galupo, Lex Pulice-Farrow, & Louis Lindley

Towson University

Accepted Author Copy for Stigma and Health

Corresponding Author:
M. Paz Galupo, Ph.D.
Professor of Psychology
Towson University
8000 York Road
Towson, MD 21252-0001
pgalupo@towson.edu
SOCIAL CONTEXT FOR GENDER DYSPHORIA 2

Abstract

The present study aimed to expand current understandings of gender dysphoria by explicating

the social context in which it is experienced and by centering the analysis on the lived experience

of trans individuals. Data were collected online from a non-clinical sample comprised of 610

transgender participants. Participants answered two open-ended prompts to describe their gender

dysphoria as experienced in a social context. Thematic analysis was used to code the data and

determine main themes. Four socially-salient themes emerged regarding gender dysphoria: 1)

External Triggers; 2) Internal Processing; 3) Interruption of Social Functioning; and 4)

Moderated by Transition. When describing their experiences, participants identified external

triggers for dysphoria that were social in nature as well as internal processes that occurred in

response to those triggers. Often this led to an interruption of social functioning. For some of our

participants, gender dysphoria was moderated by transition. Results of the present study suggest

that trans individuals’ experience of gender dysphoria is greatly impacted by social context.

Discussion focuses on the way the present findings may be best understood in relation to the

literature on minority stress. Consideration of gender dysphoria as a proximal stressor may help

to conceptually disaggregate gender dysphoria from psychological stress in the way we frame

mental health considerations for trans individuals.

Keywords: Gender dysphoria; Social dysphoria; Misgendering; Minority Stress; Non-binary

SOCIAL CONTEXT FOR GENDER DYSPHORIA 3

"Every time I get gendered male, I feel a pain in my chest ":

Understanding the social context for gender dysphoria

The present study investigates the way trans1 individuals describe the social context in

which they experience gender dysphoria. Gender dysphoria refers to the distress that may occur

when gender identity does not coincide with assigned gender/sex (American Psychiatric

Association, 2013). Although trans experiences have been primarily interrogated through the

lens of gender dysphoria in the clinical literature, it is important to avoid conflating the two as

not all trans individuals experience gender dysphoria (Byne et al., 2018; Chen et al., 2016).

Among those who do, gender dysphoria is not static; it is not uncommon to experience general

fluctuations in gender dysphoria, as well as to experiences changes associated with

developmental and transition-related milestones (Pulice-Farrow, Cusack, & Galupo, In Press).

There has been much debate about the need for a gender dysphoria diagnoses (Lev, 2013; Vance

et al., 2010, Zucker & Duschinsky, 2015; Zucker, 2016) and/or whether a diagnosis should be

conceptualized as a medical or mental disorder (Drescher, Cohen-Ketternis, & Winters, 2012).

Also debated is the nature of distress, and whether it originates with gender incongruence or

whether it stems from stigma associated with cisnormativity (Bouman, Bauer, Richards &

Coleman, 2010; Riggs, Ansara, & Treharne, 2015). Despite these debates, the current reality is

that a Gender Dysphoria diagnosis allows access for some trans individuals to obtain medically

necessary treatments (Olson, Schrager, Belzer, Simons, & Clark, 2015; White Hughto, Rose,

Pachankis, & Reisner, 2017). Thus, the way gender dysphoria is conceptualized in the literature,

and how those conceptualizations resonate with trans individuals’ lived experience of dysphoria

warrants further consideration.

1
The word trans has been chosen as more inclusive term to encompass the range of identities of people who do not
identify with the gender/sex they were assigned at birth.
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Gender Dysphoria and the Body

Historically, gender dysphoria has been framed from a clinical lens which emphasizes

body incongruence and dissatisfaction (Pulice-Farrow et al., In Press). Because the majority of

early research has focused on trans women2, models of dysphoria have reinforced the “woman

trapped in a man’s body” narrative (Serano, 2010), are reminiscent of outdated typologies for

trans women (i.e. Benjamin, 1966; Blanchard, 1989ab), and have conceptualized gender

dysphoria in ways that reify binary understandings of gender/sex (Galupo & Pulice-Farrow, In

Press). Diagnostic criteria for Gender Dysphoria in the DSM-5 include a focus on the body (e.g.

“strong desire for the primary and/or secondary sex characteristics of the other gender.”) as do

clinical gender dysphoria scales (e.g. “I hate having breasts” from Utrecht Gender Dysphoria

Scale [UGDS]; Cohen-Kettenis & van Goozen, 1997). Other, more recent scales, have been used

as a measure of gender dysphoria and include a focus on body congruence (e.g. “I have felt that

my chest does not match my gender identity” from the Gender Congruence and Life Satisfaction

Scale (GCLS) Jones, Bouman, Haycraft, & Arcelus, 2018; and “I feel that my mind and body are

consistent with one another” from the Transgender Congruence Scale (TCS), Kozee, Tylka, &

Bauerband, 2012).

Recent research complicates the clinical literature and emphasizes that trans individuals’

accounts do not always support clinical classifications and research (Galupo & Pulice-Farrow, In

Press; Veale, Clark, & Lomax, 2012). In a qualitative study utilizing a non-clinical sample, trans

individuals described body dysphoria by disaggregating the concept. That is, when discussing

body dysphoria their descriptions that centered on the body were often separate from their

2
Early clinical literature refers to trans individuals on the basis of their “biological” or “natal” sex. Consistent with
more contemporary understandings of trans experiences, we refer to transgender individuals by centering on their
gender identity. Thus, while early typologies focused on “natal males” we describe these models as focused on the
experiences of trans women.
SOCIAL CONTEXT FOR GENDER DYSPHORIA 5

descriptions of distress. This was exemplified in the thematic structure where separate themes

focused on disconnection from body and manifestations of distress. Participants also specifically

described changes in dysphoria that fluctuate across time and social context. In particular, body

dysphoria was often described as being triggered by situational and gendered expectations, and

became salient when having to socially negotiate identity (Pulice-Farrow, Cusack, & Galupo, In

Press). This research supports the need to broaden our understanding of the way gender

dysphoria is experienced in a social context.

Gender Dysphoria and Social Context

Clinical definitions have incorporated social role into the way gender dysphoria is

conceptualized. This is present in the DSM-5 criteria for gender dysphoria for both the child (e.g.

“a strong preference for cross-gender roles in make-believe play or fantasy play”) and adult

versions (e.g. “a strong desire to be treated as the other gender [or some alternative gender

different from one’s assigned gender]” American Psychiatric Association, 2013). Likewise, the

UGDS, includes the item, “I prefer to behave as a boy/man” (Cohen-Kettenis & van Goozen,

1997). Recent gender congruence scales, instead of focusing on social role, address gendered

social interactions with others. For example, the TCS includes an item worded “I am generally

comfortable with how others perceive my gender identity when they look at me” (Kozee et al.,

2012). And the GCLS includes items that include how other people interact with them (e.g. “I

have felt satisfied with the pronouns that others use when talking about me,” Jones, et al., 2018).

Current debates regarding gender dysphoria have also suggested that the “distress”

requirement for the diagnosis can be understood in a social context. Specifically, it has been

suggested that not all of the distress originates from gender incongruence per se, but may instead

originate from stigma stress associated with a cisnormative societal expectations (Bouman,
SOCIAL CONTEXT FOR GENDER DYSPHORIA 6

Bauer, Richards & Coleman, 2010; Riggs, Ansara, & Treharne, 2015). Indeed, research using the

minority stress model has identified both discrimination/prejudice (distal stressors) and internal

processes (proximal stressors) that contribute to health disparities for transgender individuals

(Hendricks & Testa, 2012; Timmins, Rimes, & Rahman, 2017). It is likely, then, that additional

qualitative research focused directly on trans experiences could provide a fuller understanding of

the social context in which gender dysphoria is experienced.

Statement of the Problem

Definitions of gender dysphoria have primarily centered on body incongruence and

dissatisfaction. The social context in which dysphoria is experienced has been implicitly

acknowledged in clinical conceptualizations of gender dysphoria as well as research focused on

transgender experiences. The present study represents a sample of non-clinical trans individuals

and focuses directly on their descriptions of gender dysphoria in relation to social experiences.

We take a qualitative approach and focus on addressing the following research question: How do

trans individuals describe the social context in which they experience gender dysphoria?

Method

Participants

Participants included 610 transgender adults who identified as transfeminine (n = 208),

transmasculine (n = 206), non-binary (n = 146), and agender (n = 50). Participants ranged in age

from 18 to 74 (M = 26.79, SD = 8.71) and represented 45 states, Washington D.C., and 34

countries, with the majority of the sample representing the U.S. (83%). The sample had limited

racial/ethnic diversity, with 81.1% of the sample identifying as White and 18.9% identifying as a

racial or ethnic minority. To participate in the present study, participants had to be 18 or older

and identify as transgender, transsexual, non-binary, or as having a transgender history. Table 1

SOCIAL CONTEXT FOR GENDER DYSPHORIA 7

displays further demographic information regarding the sample, including gender identity,

race/ethnicity, education, and sexual orientation.

Recruitment announcements were posted to social media sites, online message boards,

and emailed via LGBTQ and transgender-specific listservs. Some of these resources were geared

to certain aspects of the transgender community (e.g., FtM, AMAB, non-binary) while others

served the transgender community more broadly. Participants most frequently accessed the

survey via Reddit (57.7%) and Facebook (27.4%). The remainder were referred to the survey by

a friend (2.8%), found it through Tumblr (4.3%), or through another venue (7.8%).

Survey

The current study focuses on transgender individuals’ experiences of gender dysphoria

centered around sex roles/expectations. Participants completed an online survey wherein they

answered questions about their gender identity, demographics, and experiences of gender

dysphoria. Participants reported their gender identity as a write – in response and were then

asked to select the gender identity with which they most identified (i.e., transfeminine,

transmasculine, non-binary, agender). Participants were also asked to describe their experiences

gender dysphoria in relation to 1) sex roles/expectations; and 2) other people’s thoughts about

their gender and appearance.

Procedure

This study was approved by the Institutional Review Board at Towson University. This

study employed an online survey and recruitment of participants took place via postings on

social media (e.g., Facebook, Reddit) that included a link to the survey. No incentive was

provided for participation. Participants completed the online survey seeking to explore

transgender individuals’ experiences of gender dysphoria. Once the survey was completed,
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participants were given a prompt thanking them for their participation and were provided an

opportunity to leave suggestions to improve future studies.

Data Analysis

Thematic analysis (Braun & Clark, 2006; 2013) was utilized to capture participants’

qualitative descriptions of their experiences with gender dysphoria centered around sex

roles/expectations. Thematic analysis is particularly useful for large datasets (Nowell, Norris, &

White, 2017). In order to ensure trustworthiness of the findings, we divided the dataset into two

halves using random assignment. We developed the thematic structure on the first half of the

data and then confirmed the codes on the second half. This allowed us to verify that the dataset

was saturated, and to establish confirmability in our coding (Nowell et al., 2017).

The research team started by independently reviewing the data while considering

potential themes of dysphoria. Next, the research team met to discuss and develop an initial

thematic structure. The second and third author then independently coded the data set. The

first/senior researcher served as external auditor in order to ensure dependability in the coding

(Nowell et al., 2017). After several rounds of coding and revision a final thematic structure was

agreed upon. A final round of coding was conducted, resulting in an inter-rater reliability of

86%. All discrepancies were resolved via consensus. To validate the coding structure, the team

then coded the second half of the dataset resulting in an inter-rater reliability of 92%. Final

quotes were selected to represent both the themes and the diversity of the participants.

Beyond describing each theme, comparison was permitted via Chi Square analyses which

highlighted patterns of experiences across gender identity (Sandelowski, 2001). Four major

themes were identified and were coded using a binary (1 = present; 0 = not present) system. Chi-

square tests for independence were conducted to examine frequencies of themes across
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participant self-identification (transmasculine, transfeminine, nonbinary, agender). For those

themes where a significant main effect was found, post-hoc paired comparisons were conducted

in order to further differentiate patterns of responses across groups.

Several steps were taken by the research team to increase the validity of our results. First,

participants were given the chance to provide feedback regarding our questions and thus provide

additional context for understanding their answers. Second, the themes were thoroughly

discussed and clearly defined and operationalized by the entire research team. Because the

authors have varied experiences with dysphoria, this diversity was a strength in our approach.

Third, researchers coded data the data without knowing the identities of the participants. Finally,

all responses were independently coded two times to ensure accuracy of coding before the final

outcomes were agreed upon.

Positionality

The research team included a Professor of Psychology who identifies as a

bisexual/pansexual cisgender woman, a first year Ph.D. student in Counseling Psychology who

identifies as a transmasculine non-binary queer person, and a first year M.A. student in Clinical

Psychology who identifies as a queer trans man. All members of the research team had training

in both qualitative research and transgender research. Because of the range of our collective

experiences across gender (identity, expression, dysphoria), we came to these discussions with

different perspectives. At each coding meeting we actively reflected on our reactions to the data,

processed personal biases, and engaged in bracketing in order to increase the rigor of our process

(Tufford & Newman, 2012).

Results
SOCIAL CONTEXT FOR GENDER DYSPHORIA 10

Analysis focused on participants' responses to two open-ended prompts. Specifically,

they were asked to describe their gender dysphoria related to sex roles/expectations and other

people’s thoughts about their gender and appearance. Thematic analysis revealed four main

themes conceptualizing gender dysphoria in a social context: 1) External Triggers; 2) Internal

Processing; and 3) Interruption of Social Functioning; and 4) Moderated by Transition. Table 2

illustrates the thematic structure, accompanied by the percentage of the sample expressing each

theme. Themes are not mutually exclusive as individual responses could be coded as

exemplifying more than one theme. The results are described using direct quotes from the

participants, and are contextualized with the participants’ self-identified race, gender identity

label, and age.

External Triggers

The first theme that emerged regarding the social context for gender dysphoria centered

on external triggers that were derived from social interactions. The theme was seen most

frequently in this dataset and was reported by 66.2% of our participants, where expression of

theme differed across gender identity, C2(3) = 10.11, p <.01. Transmasculine (68.5%), non-

binary (72.0%), and agender (74.0%) individuals described this theme more frequently than did

transfeminine individuals (58.5%).

Participants’ descriptions of individual instances of dysphoria often detailed a specific

action or response from others that triggered the gender dysphoria. Often this came in the form

of misgendering. One participant described that misgendering was “like a gut punch, visceral

feeling of alienation and being misunderstood.” (White trans woman, 20). Another participant

described it in the following way:

SOCIAL CONTEXT FOR GENDER DYSPHORIA 11

“If someone misgenders me I feel like I've been forced to be naked and that people are

making comments about my genitalia. I know this seems like a stretch from the outside.

But I know that this is what they are referring to me by - the assumptions they make about

parts of me only I should get to talk about or address, or decide who gets to talk about. It

feels like nails on a chalkboard, but like they are peeling back skin inside my spine. It's

like a visceral, violating, physical manifestation of psychological pain for me.” (White

genderqueer/non-binary person, 23)

Participants often described feeling triggered by misgendering when they were referred to

with an inappropriate name or pronoun.

“He. Him. Sir. Son. Deadname. . . each of those is a knife, and because I'm not passing,

they are free and open for everyone to use.” (White woman, 28)

“Mostly someone calling me "she" and me being reminded that other people see me as a

girl. If it's someone in public then it's a brief knife in the back that I can get over pretty

quick. If it's my parents, or someone I interact with regularly, then it wears me down a

lot. Either way, whenever it happens, it's kinda jarring.”

(White man, 19)

It is important to note that gender dysphoria triggered by social interactions did not have

to occur in-person in order to cause distress. As exemplified in the following quote, it can also be

triggered via online interactions.

“I especially hate it when people refer to me by birth name online. It makes me panic and

want to hit them because why would you use my birth name when I keep telling you to use

my preferred name, the fuck?” (Biracial/multiracial transman, 23)

SOCIAL CONTEXT FOR GENDER DYSPHORIA 12

Misgendering was also signaled through the use of gendered language beyond names and

pronouns. For example, participants’ gender dysphoria was triggered when people used gendered

terms for them.

“My parents or other people call me dude, bro, son, brother, guy, etc. It’s like a nails on

chalkboard type feeling.” (White woman, 20)

“When a parent at work refers to me as ‘the lady’ to their child and my hands

involuntarily ball into fists for a second to move the stress away from my head and chest

and into my hands.” (White non-binary person, 25)

“I find it quite distressing when wait-staff at a restaurant or bar address me as "sir." I

get a knot in my stomach, and I will usually be distracted from my meal or conversation

by the distress.” (White woman, 55)

Participants often noted the way gender is encoded in different languages, making it

impossible to communicate with others without being misgendered.

“Poland is a hell for social dysphoria. Every single verb is altered by your gender, and

people will address you with those verbs in almost any conversation, no matter how

small. It makes it obvious that I don't pass. That I don't look male enough.” (White man,

18)

Beyond linguistic triggers, participants described that other people’s gendered

assumptions regarding how they should behave and interact with others elicited feelings of

gender dysphoria.
SOCIAL CONTEXT FOR GENDER DYSPHORIA 13

“The one thing that really *really* ignites my dysphoria is when people assume I have

produced (or will one day produce) offspring. . . This can be extremely, soul-crushingly

painful. If someone asks me whether I have made children, or when I'm going to make

children, or even if I am filling in forms at the doctor's office and am asked when the date

of my last period was and whether I might be pregnant and what I'm using for birth

control - this stuff still sets off my dysphoria in a big way. . . It's a huge source of

dysphoria for me.” (White genderqueer person, 28)

“Boys/men flirting with me was the absolute worst and most "dysphoria"-inducing. I was

not a woman but that was all that anyone saw.” (White man, 23)

Many participants described that their gender dysphoria was triggered by explicit

interactions with other people based on gendered language and questioning. However, some

participants described more subtle ways that their dysphoria was elicited, by disapproving looks,

extended glances, or being given an extra level scrutiny.

“I get distress over people potentially noticing my chest despite my overall masculine

appearance” (Black transmasculine person, 22)

“The crushing anxiety of being constantly stared at unkindly by strangers; knowing there

are some places you will never be welcome, and that many of those places can't be

avoided. Transgender people are killed every year just for being who they are. Every time

I leave the house, I'm effectively risking my life.” (White non-binary person, 33)
SOCIAL CONTEXT FOR GENDER DYSPHORIA 14

A common experience for our participants was the way their gender dysphoria was more

readily elicited by others when in decidedly gendered spaces such as restrooms. For example,

one participant noted their dysphoria was triggered when “going to bathroom and not passing”

(Asian non-binary person, 23). Another participant also described gendered spaces as being

particularly problematic:

“I experience intense anxiety if I am in largely masculine spaces in which I'm being read

as male and treated like "one of the boys." (White non-binary person, 18)

In general, participants described the ways gender dysphoria was sensitive to social

context where interactions with others served as external triggers. Most commonly, dysphoria

was triggered by misgendering, gendered language, gender role expectations, as well as

encounters in gendered spaces.

Internal Processing

The second theme that emerged centered on the way gender dysphoria manifested as

internal processing regarding social interactions (including anticipated interactions). Internal

Processing was reported by 53.7% of our participants, with no significant difference in frequency

across gender identity. Gender dysphoria often presented as intrusive thoughts, perseveration,

and preoccupation with how other people were reading or thinking about their gender. For

example, one participant stated, “I get intrusive thoughts about how people perceive my gender,

and my anxiety goes up.” (White agender person, 19). Another participant noted:

“My voice is too deep, and every time I speak to someone, I worry about it. I over think

the majority of social interactions with others. I figure my posture, my mannerisms, my

choice of words, my inflection are all very "male." I think about how I shouldn't have to

think about that, because men, women, and all nb (non-binary) people in between should
SOCIAL CONTEXT FOR GENDER DYSPHORIA 15

not have to conform to gendered expression, and feel guilty over my worry.” (White

trans femme, 21)

“Constant wondering if what I’m wearing will draw attention to the fact that I am not

cisgender, fear of being invalidated by my peers and family, and fear of being physically

harmed by individuals due to my gender orientation.” (Biracial/multiracial male, 18)

Many participants described their internal processes as a type of preoccupation with

other’s peoples’ thoughts about their gender. For example, one participant described being

“uncomfortable that other people are perceiving parts of my body that I'm uncomfortable with,

as I don't want other people to be aware of those parts of my body.” (White agender person, 23)

Participants described constant worry about how other people identify them, resulting in

a self-scrutiny of their own body and a fear that it will betray their authentic selves. For example,

one participant described their inner monologue in this way:

“Do they think I act like a girl? Do I act like other guys? Like other queer guys? If

someone finds me attractive, is it because I’m ‘pretty’? Am I obviously shorter than

other men? Do they notice my hands? My tiny feet? At the rock wall, I worry that my

harness emphasizes my hips, and that people notice. Do I touch my hair in a way that

says ‘I USED TO BE A GIRL.’” (Latino transmasculine person, 23)

Similarly, the following participant described her worry about other peoples’ perception

of her gender as she anticipated the way that their treatment of her might shift based on how they

read her gender:

SOCIAL CONTEXT FOR GENDER DYSPHORIA 16

“I often worry that I will be "clocked" as trans, and the dynamic will shift, regarding how

others perceive me. I am fortunate in a way that I benefit from a certain amount of

‘passing privilege’, but occasionally when someone figures it out, they can go from being

incredibly nice, to very stand-offish or outright rude.” (White female, 40)

Gender dysphoria was characterized by participants as internal processing (e.g. gender

identity rumination, worry, preoccupation) that centered on the way other people perceived their

gender. This processing focused both on the interpretation of past social interactions and the

anticipation of future interactions.

Interruption of Social Functioning

The third theme that emerged focused on the way gender dysphoria served to interrupt

social functioning. Interruption of social functioning was reported by 22.6% of our participants,

and the frequency of expression did not significantly differ across gender identity. Participants

described limiting their social interactions in order to avoid triggering their dysphoria. One

participant noted, “I get anxiety and try to hide away from social situations and it causes me

depression as well.” (American Indian/Alaska native woman, 24)

Sometimes participants described limiting their social interactions for fear that their trans

identity would be discovered. For some, dysphoria centered around their speaking voice as

illustrated in the following two participant quotes.

“I feel awkward interacting with other women because I don't feel like I look and sound

enough like them to be acceptable. A typical instance would be me being quiet in a group

of other women trying to avoid talking because I don't want them to hear my voice or

look at me too long.” (White woman, 34)

SOCIAL CONTEXT FOR GENDER DYSPHORIA 17

“For instance, voice dysphoria causing you to limit or shorten social interactions to a

minimum, because you worry that your voice causes people to perceive you as the wrong

gender.” (White woman, 30)

Participants also described the way their social functioning was interrupted at times when

gender becomes a topic of conversation or salient to the social situation.

“I usually mumble about my thoughts about my gender identity when I'm on my own. But

when other people question it, I try to deflect it or run away depending on the location.”

(Asian/Asian American man, 21)

“I find myself ignoring people when they mention anything gender-related concerning my

body. I find that I hate leaving my house because my body is not yet what it’s supposed to

be. Hanging out or meeting new people is so stressful.” (Black agender person, 23)

“I see a cis man (assumed cis) or a very masculine person interacting with others and I

feel insecure and unconfident, sometimes even panicked, anxious or dissociative.” (South

Asian transgender man, 19)

Participants often described avoiding interacting with strangers. For example, one

participant indicated that they “I just avoid talking to, looking at, or being around strangers.”

(White nonbinary person, 24). Another participant noted:

“Flat out terrified of running into a bad scenario where people will want to hurt me

physically or kill me. . . The larger the place and the greater the crowds leads to panicky
SOCIAL CONTEXT FOR GENDER DYSPHORIA 18

attacks, fear of being in one place too long. Never going into stores that I want to for fear

of treatment. A near paralyzing fear of new people and dating.” (White woman, 37)

Other participants noted the way that dating and relationships were difficult to navigate

as it brought out a new level of dysphoria.

“I have a hard time being flirted with when I'm out, because I can't trust that this person

is genuinely invested in me, or likes me for my body/the idea that I'm female. If engaging

in relationship type stuff, I have to do so incredibly intentionally, which isn't a bad thing,

but it's a lot of work.” (White non-binary person, 25)

Participants described avoiding gendered spaces such as restrooms, and seeking out

(presumably) safer spaces, such as “queer friendly spaces and bars.” Participants also described

avoiding certain social interactions. Often they avoided being in new situations where they were

not sure how their gender would be read, or simply avoided being in public generally.

“I avoid new social interactions when out of a professional setting. I fidget with myself, I

can’t keep eye contact, lose my train of thought.” (White man, 43)

“I am terrified to go out in public, with or without my husband and friends.” (White FTM

agender person, 25)

At its extreme, interruption of social functioning occurred where individuals were cut off

completely from the social world. For example, one participant stated, “I am a shut-in, for lack of

a better word. It doesn't feel right to be out among other people.” (White man, 25)

Moderated by Transition

The fourth theme that emerged focused on the way the social context for gender

dysphoria shifted with transition. This theme was expressed by 11.1% of our participants.
SOCIAL CONTEXT FOR GENDER DYSPHORIA 19

However, it was differentially expressed across gender identity, C2(3) = 6.55, p <.05 where

transfeminine (12.94%) and transmasculine (13.61%) individuals were significantly more likely

to express this theme than either nonbinary (.06%) and agender (.08%) particpants. Sometimes

this was noted by participants when other people used medical transition as a requirement for

recognizing their gender.

“When people doubt or completely disregard the validity of my gender identity due to the

fact I have not begun my medical transition (as medical interventions are not yet

available to me), leading me to believe that I am not and never will be masculine enough

to be acknowledged as male, which is very distressing for me.” (White transgender man,

18)

Often, participants mentioned the social context of dysphoria by referencing one or more

of the above themes (external triggers, internal processes, interruption of social dysphoria) and

then describing the way that these were experienced differently at various phases of transition.

For example, the following participant described an interruption of social functioning that they

believed would be mitigated with transition steps, “I don't plan on going swimming again until I

get top surgery.” (Canadian Metis trans man, 26).

Another participant, stated that prior to medical transition their gender dysphoria

impacted their sexual relationships: “I never got naked for sex. Never. I kept my binder and

underwear/prosthetic on at all times, only shedding them as I underwent each relevant

operation” (White man, 22).

Some participants noted the way their appearance shifted with transition:

“Early on (hormone replacement therapy) when my appearance was more ambiguous,

getting gawked at in public was unpleasant." (Asian trans woman, 38)

SOCIAL CONTEXT FOR GENDER DYSPHORIA 20

And others noted that gender dysphoria was reduced (e.g. “Much better post transition”)

with transition. Finally, a number of participants spoke to the way their gender dysphoria is no

longer present.

“I've finished transitioning and don't experience dysphoria anymore.”(White woman,22)

“As someone who is mostly post-transition and socially "stealth," this is no longer

something I experience.” (White man, 39)

“I do not experience social dysphoria because I am read as and treated like a man 100%

of the time. After surgery and hormones, I pass 100%.” (White man, 25)

As is clear in these quotes, participants attributed the reduction of this type of gender

dysphoria to no longer being “read” as their assigned sex, and therefore the social triggers were

no longer present.

Discussion

The present study utilizes a non-clinical sample of trans individuals in order to directly

characterize how they experience gender dysphoria in a social context. When describing their

experiences, participants identified external triggers for dysphoria that were social in nature as

well as internal processing that occurred in response to those triggers. Often this led to an

interruption of social functioning. For some of our participants, this social-related gender

dysphoria was moderated by transition. Collectively, these themes can be understood from

within the framework of minority stress which posits that individuals with minority identities

experience additional chronic daily stressors that are uniquely associated with their minority

status (Meyer, 2003; 1995). Distal stressors are defined as external events or conditions (e.g.,
SOCIAL CONTEXT FOR GENDER DYSPHORIA 21

harassment and victimization) while proximal stressors are subjective internalizations of negative

events and attitudes (e.g., self-stigma, anticipated stress, and vigilance). It is noteworthy that the

first two themes described by participants map onto these definitions of distal and proximal

stressors. Implications of our findings, then, may be best understood in relation to the literature

on minority stress.

External Triggers as Distal Stressors

Clinical research has predominantly emphasized the body in descriptions of gender

dysphoria (Pulice-Farrow et al., 2019) with an explicit focus on primary and secondary sex

characteristics (Fisher et al., 2014). However, our participants described ways that their feelings

of incongruence were triggered by external factors. That is, for many, it was social interaction

that elicited feelings of gender dysphoria. Participants described linguistic triggers including

being misgendered or having their identity questioned by others. In this way these triggers

ultimately served as distal stressors. These same types of experiences have been described in the

transgender microaggression literature as distressing (Galupo, Henise, & Davis, 2014; Nadal,

Skolnik, & Wong, 2012; Pulice-Farrow, Brown, & Galupo, 2017). In particular, Nadal,

Davidoff, Davis, & Wong (2014) describe trans individuals’ distress following microaggressions

as including anxiety and trauma. McLemore (2018) framed misgendering as a unique minority

stressor for transgender people, demonstrating its association with psychological distress (i.e.

anxiety, depression, stress, and felt stigma). Other researchers have similarly framed identity

invalidations as distal stressors for transgender individuals (Johnson, LeBlanc, Deardorff, &

Bockting, 2019).

Within the context of the present findings gender-based microaggressions and identity

invalidations take on a new level of meaning. Consistent with the literature (Galupo et al., 2014;
SOCIAL CONTEXT FOR GENDER DYSPHORIA 22

McLemore, 2018; Pulice-Farrow et al., 2017; Timmins et al., 2017), microaggressions served as

external triggers for participants’ feelings of distress. However, the present findings underscore

the way that these distal stressors elicited specific feelings of gender dysphoria (characterized by

participants as gender focused internal processing).

It makes sense that when discussing the social context for gender dysphoria that external

triggers would manifest from within interpersonal exchanges, such as microaggressions and

misgendering. It is important to note, however, that participants also described external stressors

that were more systemic and institutional. For example, misgendering was not limited to usage of

names and pronouns; rather, participants described being misgendered through the larger

language / grammar system. This is consistent with the way Ansara & Hegarty (2013)

characterize that our language conventions are embedded with sexist and cisgenderist

assumptions that ultimately result in misgendering. Participants also described that the binary

organization of social and institutional spaces served as external triggers for feelings of gender

dysphoria. These types of systemic manifestations of cisgenderism, then, should also be

understood as distal stressors that heightened our participants’ experiences of gender dysphoria.

Internal Processing as Proximal Stressors

Minority stress theory frames proximal stressors as internalized processes that happen in

response to, or in anticipation of, distal stress (Meyer 1995; 2003). Proximal stressors such as

internalized stigma, identity concealment, and vigilance for others’ suspicions have been linked

to psychological stress for trans individuals (Hendricks & Testa, 2012; Timmins et al, 2017). Our

participants described ways that their gender dysphoria presented as preoccupation with others’

thoughts or intrusive thoughts related to how other people were reading or thinking about their

gender in a way that resonates with recent conceptualizations of gender-identity rumination

SOCIAL CONTEXT FOR GENDER DYSPHORIA 23

(Bauerband & Galupo, 2014). Gender-identity rumination is distinct from general rumination in

which repetitive thoughts are centered on negative and depressive thoughts. Gender-identity

rumination has been characterized in the literature as persistent thoughts regarding gender-

identity, inclusive of perseveration, rumination, and preoccupation with other people’s thoughts

(Bauerband & Galupo, 2014).

The present findings suggest that for some individuals gender dysphoria may be

functioning as a type of proximal stressor and that social context is central to experiences of

gender dysphoria even when it manifests as an internal process. Specifically, conceptualization

of gender dysphoria as a proximal factor is supported by the fact that: a) proximal stressors are

understood as occurring in response to distal stressors (Meyer, 1995; 2003); and b) our

participants described gender dysphoria as being triggered by external social interactions and

navigation of social/gendered environments. Conceptualizing some experiences of gender

dysphoria as a proximal factor for mental health outcomes (e.g. depression, anxiety)

differentiates gender dysphoria from other types of distress. The present findings have important

implications for establishing how minority stress theory may be uniquely applied to transgender

individuals. It also has implications for clarifying definitions and criteria for distress in the

research and clinical literature surrounding the diagnosis of gender dysphoria. The present

findings support the contention that not all of the distress originates from gender incongruence

per se, but may instead originate from stigma stress associated with negotiating social

interactions in a cisnormative context (Bouman, Bauer, Richards & Coleman, 2010; Riggs,

Ansara, & Treharne, 2015). Additional research is needed to further explore the

conceptualization of gender dysphoria as it is experienced in a social context and the specific

way gender dysphoria may act as proximal stressor.

SOCIAL CONTEXT FOR GENDER DYSPHORIA 24

Social Withdrawl and Transition as Strategies for Mitigating Gender Dysphoria

One way that participants described the social context for their gender dysphoria was by

articulating how their dysphoria served to interrupt important aspects of their social functioning.

This was seen when participants avoided speaking to or interacting with other people, sometimes

altogether. This theme goes hand and hand with the way the literature has described dysphoria

minimizing behaviors as strategies and behaviors enacted to mitigate distress (Pulice-Farrow et

al., In Press). Our participants similarly described ways that they limited their social interactions

in order to minimize their felt dysphoria.

Likewise, when describing the social context for their gender dysphoria, participants

often referenced the way their dysphoria was moderated by transition. In particular, they credited

social and/or medical transition as allowing them to “pass” or present as their experienced

gender, thus eliminating the social context for their dysphoria and ultimately eliminating their

dysphoria itself. It is noteworthy that the vast majority of participants articulating that their

gender dysphoria was modified by transition were those with more binary (transfeminine and

transmasculine) identities. Non-binary and agender individuals very rarely expressed that

dysphoria was reduced with transition. Non-binary trans individuals often conceptualize their

gender in ways that are outside of traditional definitions of gender identity (i.e. male, female,

both or neither; Tate, 2014; Tate, Youssef, & Bettergarcia, 2014) endorsing multiple labels,

trans-specific labels, and describing their gender in fluid and flexible ways (Galupo, Pulice-

Farrow, & Ramirez, 2017). Therefore a static gender presentation may not be one that best

reflects their felt gender and may shift on a daily basis. The social context in which they

experience gender dysphoria, then, may also shift with their gender presentation. Our findings

suggest that although our non-binary participants were more likely to report external social
SOCIAL CONTEXT FOR GENDER DYSPHORIA 25

triggers for gender dysphoria than some binary trans individuals, they were also less likely to

report that their dysphoria is abated with transition. Therefore it is critical that future research is

devoted to understanding the unique ways that non-binary individuals experience gender

dysphoria. Likewise, it is important that we reconsider our current models for gender dysphoria

(inclusive of diagnostic criteria, research and clinical measures, and guidelines for clinicians

when working with transgender clients) and whether they are sufficiently inclusive of non-binary

experiences of gender dysphoria.

Limitations and Strengths

The present study extends current understandings of gender dysphoria by focusing on the

way it is experienced in a social context. However, it is not without limitations. Our participants

represent an online convenience sample. Online studies tend to oversample White, educated, and

middle class participants (Christian, Dillman, & Smyth, 2008) and our sample was not an

exception. Our results, then, should be interpreted in light of these sample demographics. Despite

their limitations, online surveys are useful for reaching potential participants who are

marginalized, may not be connected to community, and who may have privacy and identity

disclosure concerns. For these reasons, online data collection may particularly be effective when

recruiting and surveying trans individuals (Riggle, Rostosky, & Reedy, 2005). In addition,

hosting our study online allowed us to collect a large sample that is geographically diverse.

Using two-open ended prompts we were able to capture rich data regarding the social

context in which our participants experience gender dysphoria. A potential limitation to this

method is that it was not possible to allow participants to provide feedback to our thematic

structure as often happens with face-to-face interviews. In order to address this limitation and to

increase the validity of our results, every participant response was read several times by the
SOCIAL CONTEXT FOR GENDER DYSPHORIA 26

entire coding team. Our team included three coders who collectively represented varying

experiences of gender and gender presentation. In addition, final coding was conducted by the

second and third authors while the first author served as an auditor in order to increase

trustworthiness of our coding (Nowell et al., 2017).

Another limitation may be the way we used a mixed-method approach to analyze the data

given the large and heterogeneous sample. We used thematic analysis to explore themes of social

dysphoria and Chi-square analysis to explore patterns of experiences across gender identity

(Sandelowski, 2001). However, we may have missed opportunities to deeply explore specific

intersections of trans identity (e.g. trans people of color, non-binary trans individuals). Because

we know discrimination and other distal stressors are experienced uniquely across race and

gender identity (Lefevor, Janis, Franklin, & Stone, 2019; Pulice-Farrow, Clements, & Galupo,

2017) it makes sense that the way gender dysphoria manifests in a social context would also be

unique at different intersections of identity. This represents an important direction for future

research.

The present research, by focusing on the social context for gender dysphoria, expands our

understanding of gender dysphoria in important ways. When attending to social context,

participants’ descriptions of gender dysphoria were consistent with the framework of minority

stress. First, social interactions in the form of misgendering, microaggressions, and negotiation

of gendered environments all served as external triggers (distal stressors) for gender dysphoria.

Second, when describing their gender dysphoria participants detailed internal processes such as

gender identity rumination and preoccupation with other people’s thoughts. These findings

suggest that gender dysphoria may be functioning as a type of proximal stressor and indicates

that even when gender dysphoria manifests as an internal process, social context is central to
SOCIAL CONTEXT FOR GENDER DYSPHORIA 27

those experiences. Third, participants described ways that gender dysphoria interrupted their

social functioning, where limiting social interactions was performed in attempt to minimize

dysphoria. Fourth, some participants referred to reduction or elimination of dysphoria through

transition efforts. Importantly, consideration of gender dysphoria as a unique proximal stressor

within minority stress theory may help to conceptually disaggregate gender dysphoria from

psychological stress in the way we frame mental health considerations for trans individuals. It

may also help clarify the way distress associated with gender dysphoria is dually experienced

based upon gender incongruence and upon stigma and stress.

SOCIAL CONTEXT FOR GENDER DYSPHORIA 28

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Table 1. Participant Demographics

Total (N = 634)
Age Mean (SD) 26.76 (8.89)
Gender Identity (%)
Agender 7.8
Non-binary 23.5
Transfeminine 35.2
Transmasculine 33.4
Ethnicity (%)
American Indian/Alaskan Native 0.8
Asian/Asian American 2.4
Biracial/Multiracial 5.2
Black/African American 1.3
Hispanic/Latinx 3.8
White 82.3
No Answer 0.8
Other 3.6
Education Level (%)
High School Degree/GED 43.0
College Degree 40.8
Graduate Degree 12.2
Doctorate/Terminal Degree 3.9
Sexual Identity (%)
Asexual 11.5
Bisexual 19.3
Fluid 1.1
Gay 8.5
Heterosexual 5.5
Lesbian 11.9
Pansexual 19.8
Queer 16.6
Other 5.8
SOCIAL CONTEXT FOR GENDER DYSPHORIA 36

Table 2. Thematic Structure.

Theme %
External Triggers 66.2

Internal Processing 53.7

Interruption of Social Functioning 22.6

Moderated by Transition 11.1