24/02/2022 | Writer: Seven Kaptan

Dr. Seven Kaptan shares their notes with clinicians and clients on gender dysphoria assessments.

Notes for clinicians and consultants on gender dysphoria assessments Kaos GL - News Portal for LGBTI+

From clients who come with gender dysphoria and from our colleagues who evaluate these applications, we sometimes witness that the process is carried out like an approval and testing process, almost like a driver's license exam.

The rigid judgments, norms and expectations of the binary gender system lead people into this trap.

The significance of the story: compass or checklist?

When we look at it from the clinician's point of view, we unfortunately see that the system's perception of 'woman like a woman' and 'man like a man' obscures the view of trans/non-binary clients. The clinician, who looks for traces of non-conformity with gender norms in childhood stories (games played, playmates chosen, clothes preferred), seems to lose their way when they cannot find these memories. As if there could not be such a trans person according to the gender norms we are taught and internalized without questioning… For example, as if the person could not have turned their mind away from their body during their childhood, remained indifferent to themselves and their gender, suspended questioning their identity, but questioned that something in their adult life felt missing and wrong…

One of the most important reasons for researching the past is to understand the client's story and to get to know them better. It is not possible to prepare a realistic plan for the difficulties they will experience in the process of gender affirmation and to strengthen the client about these difficulties; without knowing the possible bullying they have experienced in the past or even if they have not experienced it themselves their testimonies, their intensely suppressed anxieties that prevent them from coming to the level of consciousness, the difficulties in understanding themselves and naming their identity. It is no different than throwing a person who can't swim without knowing how much weight they have on them.

From the client's point of view, we can see that sometimes the person exaggerates the dysphoria they experience and tells a fictional childhood story in order to convince the doctor that they are transgender enough and to start the gender affirmation process. The fact that their sexual orientation is not heterosexual, their lifetime dysphoria is different from the majority, and the identities they define themselves and their gender expressions are not binary, are questioned by experts, the criteria for gender affirmation in the trans/non-binary community result in word-of-mouth disinformation. Unfortunately, we, the physicians, have a great role in spreading this disinformation practice.

The clinician's role and duty… the client's role and duty ...

Not every client may have the symptoms based on knowledge from books. Without giving direction on the questions we asked and researched about their stories, we should emphasize that the answers to these questions are not criteria and convey our desire to understand how long they have felt different and perhaps had difficulties in terms of not complying with gender norms. This can open the door to reaching the real story of the client without disinformation.

While our job is to "heal mental distress", our compass should also be this distress: what is happening now, what is the relationship of these troubles with the past, is there a realistic treatment expectation with future plans for these troubles, etc.

The responsibility of the client, on the other hand, can start with conveying their unique story in all its reality in an ideal order. Developing the ability to express oneself when faced with the prejudiced attitudes of the doctor, knowing their rights, and cooperating with associations and institutions from which they can receive appropriate support can facilitate them for taking steps in this regard.

Out of expectation? When is the real-life experience? in what way? Can it be tested? Who passed the test? Do those who fail to pass, fail the class?

In the follow-up of the gender affirmation process, the client's opening up to their environment, the identity they feel and their representation in appearance is called 'real-life experience' (1). This process may vary according to the economic, social and family conditions of the person. Rather than questioning why the person who has difficulties in expressing themselves at work or in the neighborhood they live in does not wear the clothes and does not have the hair length expected(?) from their gender, it would be a more appropriate approach to raise the issues related to coming out and support them to produce realistic solutions.

On the other hand, helping the client to gain insight into their unrealistic avoidance driven by internalized transphobia, is one of the most important steps in psychotherapy. The knowledge that a person is valuable as an individual as they create safe spaces and represent their identity in these spaces, not by hiding, causes an improvement in their self-confidence and mental health, which has been damaged because they do not conform to social norms. This, in turn, will have an absolute positive effect on them by making their gender identity one of the valid essentials of their identity, that is, by normalizing it, from a feature that they have to hide at all costs.

As a result, real life experience is unique to the person, even if it is experienced sometimes in a house, sometimes in a neighborhood or at work, and the speed of this experience cannot be assessed independently of its conditions. Passing the 'real life experience' test is not about how much the person looks like a woman or a man, instead it happens as; in cases where they can express themselves without any trouble under the conditions they want or are necessary, in possible discriminatory attitudes where they realize that this situation is a social situation, not about themselves as a subject, and eventually when they emerge from these situations with pride and strength, not vulnerability. Not complying with gender norms and not being a binary transgender does not prevent anyone from getting the hormone therapy they need and completing the gender affirmation process, it should not. Even though this test is implicitly imposed on all of us throughout life (test of being a woman like a woman, a man like a man), it cannot be a test that trans/non-binary identities have to give over social gender norms, just like cisgender people who have not passed this test while obtaining their identities! Therefore, the task of mental health professionals should not be to increase the pressure of these binary gender norms which troubles our souls as one of the social authority figures, but to contribute to our healing from social distress by questioning these norms.  

Breaking the mold: Evaluation of non-binary clients

In recent years, as the binary gender system has been discussed, many people have declared that they position themselves outside of this system and sought support from mental health experts in order to overcome the dysphoria of varying intensity they experience. The number of non-binary clients has increased, especially in adolescent admissions.

Some of the clients with non-binary identity, who are coded to think about dualities, have never questioned this (either you are a woman or a man), which is more difficult to understand for parents and older family members, can make binary discourses and demands in order to get the support they need. This can cause disinformation that I mentioned above in terms of their real needs. Sometimes we can also see that non-binary identity takes place as a step-in factor in self-discovery. First of all, going beyond the expectations and perceptions imposed by the assigned gender may function to create a neutral (uncharged) space for the construction of the gender one actually feels.

While all the rules are shaped within the binary system (toilets etc.), studies have shown that non-binary identities carry a higher risk of mental illness such as anxiety disorder and depression than trans binary identities. (2,3)

We can observe that finding oneself (in the gender spectrum) and expressing it as one feels is an existential problem. Although the possibility of this search is primarily dependent on the person, it is not independent of the society in which they live in. In particular, its sustainability depends on the dual gender structure of that society and the flexibility of these norms. In societies where this flexibility does not exist, can the desire of the social structure to pull people into one of their binary gender poles be ceased? Many of my non-binary clients stated that their gender-related social dysphoria was more intense than their gender dysphoria. For example, ‘I want to be perceived as a male gender, but I don't want to be masculine. In a society where I am perceived as a man, I might not need hormone therapy, I have no desire to have a beard.' Or as, 'I feel comfortable if I'm perceived as an androgynous woman, I don't have a surgical plan. But in that situation, I don't know what kind of difficulty I will experience, whether I need more...’

Social perception may expect more than the gender roles that are actually intended to be represented. But how far? Could it be that for social acceptance (for a visible representation/gender perception) the person feels like they have to take hormone or surgical treatments that they do not actually need? While you can easily represent yourself in a society where this expectation (binary) is less, how can you live in peace by trying to persuade whom, how and how much in a Turkish society, which is not homogeneous in itself? Of course, the answer to this question should not be forced migration.

Where should we, mental health professionals, stand in the equation when gender-related social dysphoria is more intense than gender dysphoria?

It is clear that it is not only up to mental health professionals to find answers from the burden of questions, it is the responsibility of everyone who bothers about gender binary, and that these questions can be answered with solidarity. It is possible to organize 'another life'. Just like in our history… We set off; we continue!

Translation: Aras Örgen


  1. Coleman E., Bockting W, Standards of care Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. Int J Transgerism. 2012; 13: 165-232
  2. Chew D., A Tollit M., Youths with a non-binary gender identity: a review of their sociodemographic and clinical profile. Lancet Child Adolesc Health, 2020 Apr;4(4):322-330.
  3. Thorne N, Witcomb G.L. , A comparison of mental health symptomatology and levels of social support in young treatment seeking transgender individuals who identify as binary and non-binary. Int. J Transgend. 2019; 20(2-3): 241-250. 

*This article was produced with the financial support of the European Union. Its contents are the sole responsibility of Kaos GL Association and do not necessarily reflect the views of the European Union.


Tags: human rights, health