Understanding the Drive to Medically Transition as a Mental Illness
Since 2017, I’ve immersed myself in the complex and often painful realities of gender dysphoria—through research, dialogue with leading experts, and thousands of hours spent with families, detransitioners, transgender individuals, and those who feel “lost in transition.” I understand this condition not only as a psychotherapist, but also as someone who experienced profound gender-related distress as a child.
At Genspect, our team hears weekly from people aged 18 to 80 who regret undergoing irreversible medical procedures in pursuit of an identity that ultimately failed to bring them peace. Tragically, many now feel they’ve passed the point of no return.
After years of listening to those most directly affected, our conclusion has become unavoidable: the drive to transition is rooted in unresolved mental illness. Clinicians best serve trans-identifying patients not by affirming a medical pathway, but by addressing the underlying psychological distress with honesty, insight, and compassion.
Angels dancing on the head of a pin
Back in the Middle Ages, theologians were mocked for debating how many angels could dance on the head of a pin. The phrase became a metaphor for intellectual exercises so detached from reality that they bordered on the absurd. Today, many mental health professionals are engaged in a similarly futile pursuit—except the debate is not about angels, but about gender identity.
A person’s sense of gender identity cannot be tested, proven, or disproven. It is unfalsifiable, beyond the reach of evidence-based scrutiny. This elusive, 21st-century notion of self can only be declared by the individual. Yet such nebulous internal feelings have led to deep psychological anguish for many. Across the Western world, at high-level conferences, experts agonise over how best to respond to gender dysphoria: Should puberty blockers be offered to a carefully selected few? Should cross-sex hormones be withheld until a certain number of psychotherapy sessions have taken place? When should a person be given the green light for genital surgery?
The Genspect team takes the position that medical transition is a harmful intervention lacking a robust evidence base. As Carl Sagan famously put it, extraordinary claims require extraordinary evidence. Yet despite years of research and growing international scrutiny, we still lack the extraordinary evidence needed to justify recommending that any individual undertake the life-altering and often irreversible process of medicalising their sense of inner identity.
While we have many self-reports from individuals who express satisfaction with their decision to transition, this type of testimony, though interesting, is not equivalent to rigorous scientific evidence. Human beings are naturally inclined to affirm the choices they have made—particularly when those choices come with high personal, social, or physical cost.
However, we do not support banning medical transition outright. Prohibition is unlikely to serve anyone’s best interests and would inevitably drive vulnerable individuals toward unregulated and unsafe alternatives. The world needs fewer DIY hormone clinics operating without oversight, not more.
Instead, Genspect proposes a more responsible path: medical transition should not be publicly funded, nor should it be offered in hospitals under the banner of healthcare. Rather, it should be recognised for what it is—cosmetic intervention performed in response to psychological distress. In essence, it is extreme body modification, not medically necessary treatment.
Whether someone identifies as non-binary, demi-girl, genderfluid, agender, or any other label from an ever-expanding lexicon, many therapists now believe it is inappropriate to question a patient’s identity. Often, they are swayed by the patient’s fervent certainty. Even though certainty itself is a red flag—rigid conviction is frequently a symptom of mental illness. Few are more certain than the anorexic who insists she is fat and greedy. By contrast, psychologically healthy individuals tend to express doubt, nuance, and ambivalence.
What was once recognised as a "therapeutic process" has been reduced to mere "therapeutic support"—focused not on psychological inquiry or analytical depth, but on affirmation. Even when gender-critical clinicians suspect that such validation may lead to irreversible and harmful medical interventions, many still feel compelled to honour the patient’s declared identity rather than investigate the deeper distress driving it.
Yet the underlying truth is difficult to avoid: the desire to irreversibly alter a healthy body through hormones and surgery—driven by a subjective sense of self—is not a medical issue, but a manifestation of profound psychological distress. It should be recognised and treated as a mental illness. To pretend otherwise is to legitimise an elaborate and institutionalised form of self-harm.
The shift in the DSM
In a more grounded time, this was the prevailing view. Until 2013, the Diagnostic and Statistical Manual of Mental Disorders (DSM) classified the condition as Gender Identity Disorder (GID). This diagnosis recognised the mismatch between one’s biological sex and internal identity as a psychological disorder, rooted in internal conflict. Treatment typically involved psychotherapy, aimed at helping the individual understand their distress and, ideally, resolve it. Medical transition was considered a last-resort intervention, offered only after all therapeutic avenues had been thoroughly exhausted.
But then came the DSM-5. In 2013, the American Psychiatric Association replaced GID with Gender Dysphoria. At first glance, this appeared to be a minor rewording. In reality, it marked a radical shift: the identity itself was no longer considered disordered, only the distress it caused. The result? If someone believes they are the opposite sex and experiences no distress, they are considered mentally well. And if they are distressed, the recommended treatment is no longer to work with the mind, but to alter the body. Meanwhile, the World Health Organization (WHO) asserted “that trans-related and gender diverse identities are not conditions of mental ill-health, and that classifying them as such can cause enormous stigma.” Yet this position is itself stigmatising, as it implies that mental illness is inherently shameful and best avoided altogether.
Medical interventions have come to function less as cautious, last-resort measures and more as seductive solutions—akin to offering liposuction only to the anorexic who can convince her therapist that “skinny” is not a symptom of illness, but an identity she is entitled to embody.
Millions of people live with mental illness. Many are sensitive, thoughtful, brilliant, and compassionate. To attempt to dissociate from mental illness—as though it were inherently shameful—is profoundly offensive. Psychological distress does not diminish a person’s worth. Those who suffer deserve the same respect, care, and dignity as anyone else.
Since the DSM shift, the situation has only grown more surreal. Therapists increasingly surrender clinical judgment, allowing patients to define not only their identities but also their treatment plans. Some vulnerable individuals—often neurodiverse and struggling with internalised homophobia—now identify as therians (non-human animals such as wolves or cats) or otherkin (non-human beings such as elves, dragons, or other fantastical creatures). While it is considered unethical to dehumanise a client, reinforcing such identities arguably does just that—it affirms a distorted self-concept rather than helping the person reconcile with reality.
This erosion of rationality has occurred alongside the growing glorification of the term identity. In our post-religious age, identity has become sacred—a sense of self that must be honoured without question. Yet clinicians would better serve their patients by remembering that identity is neither divine nor immutable.
People often identify as Irish despite never having set foot in Ireland. Such identification is usually harmless; it does not require surgery or medical intervention. But when identity becomes the basis for irreversible treatments that can result in infertility or impaired sexual function, the stakes are immeasurably higher. Identity is a subjective, fluid construct. It should never be mistaken for a diagnosis.
While people are free to identify as they wish, clinicians are bound by ethical standards. Affirming a patient’s self-perception without scrutiny is not compassionate care. No ethical therapist would affirm a person with OCD who believes their hands are permanently contaminated. They don’t validate the patient’s perceptions. They treat the illness, not the obsession.
The DSM’s reclassification was not driven by clinical insight but by political activism. It facilitated access to medical transition while recasting it as personal liberation. The result is a new kind of stigma: it is now taboo to treat gender-related distress as a mental health issue. The mind is off-limits; only the body may be altered.
Should we change our minds or our bodies?
Why is irreversible surgery now considered more ethical than a careful psychological process?
The mental gymnastics surrounding "conversion therapy bans" have paralysed clinicians. They are no longer permitted to ask why a girl hates her body, or why a boy spends hours in the bathroom obsessively removing every hair from his body in a desperate attempt to feel female. Such questions are now labelled "conversion," while approving mastectomy or castration is celebrated as affirmation.
This is a catastrophic failure of mental healthcare.
For decades, therapists helped patients explore the roots of internal conflict. Many who felt alienated from their sex came to recognise deeper causes—trauma, shame, family dysfunction, or internalised homophobia. But today, that therapeutic path is blocked.
Instead, growing numbers of vulnerable individuals—especially adolescent girls—are being fast-tracked onto a medicalised pathway.
This shift reflects a profound misunderstanding of human suffering. The desire to escape one’s body is not a harmless variation of human experience—it is a cry for help. A symptom of deeper distress that demands understanding, not surgical endorsement.
It’s time for mental health professionals to stop counting angels on the head of a pin and confront reality. The drive to medically transition is, at its core, a mental health issue—one that demands not ideology, but compassionate and ethical care.
A compassionate way forward
Join Stella and the Genspect team this September at The Bigger Picture conference in New Mexico. After nearly a decade of well-intentioned but deeply damaging practices carried out in the name of kindness, Stella will address the stark realities of medical transition. With clarity and courage, we’ll explore how to navigate the path ahead with integrity—and why telling the truth, now more than ever, is essential to real progress.
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