The emphasis on distress in the diagnosis of gender dysphoria is problematic in two ways:

1. This may reduce access to treatment and legal recognition for transpeople who do not experience chronic or intermittent gender dysphoria.
2. This may represent the lives of transpeople.

The true transsexual model referred to a person who required physical changes to their body to fully express their gender identity. However, many transpeople are not able to get these changes due to social, cultural or political reasons. Besides that, this model is focussed on the gender binary and neglects the true experience of transpeople.

It is difficult to call transpeople gender atypical as there is no clear cause for gender behaviour and there is no clear masculine or feminine behaviour. The DSM-5 criteria for gender dysphoria are derived from stereotypes applied in gender identity clinics serving transpeople.

Blanchard’s model states that there are two types of transsexuals:

1. Autogynephiles
   These are transsexuals who are aroused by the idea of having a female body.
2. Homosexuals
   These are homosexual males who transition to make it easier to make themselves sexually attractive to heterosexual men.

This model strongly links gender dysphoria to homosexuality and cross-dressing and is heavily contested. For example, autogynephilic fantasies (i.e. imagining having sex as a female) are not specific to transwomen. This model is used in the DSM-5 as these subtypes are used for gender dysphoria. This needlessly sexualizes the diagnosis, which may exacerbate social discrimination and intensify the stigma.

Clinical encounters may not fully account for the multiple ways in which transpeople have lived their lives prior to accessing psychiatric assessment in a gender clinic. This may be because transpeople may be reluctant to relay anything to the gender clinic psychiatrists that may be viewed as different from the perceived ‘correct’ trans narrative. Transpeople tend to tailor their clinical narratives because they realize that psychiatrists have the power to stop their transitioning process. This leads transpeople to need to show distress to convince a psychiatrist.

Psychiatrists use a highly stereotyped notion of gender to provide a framework for assessing and treating transsexuals even though this stereotype may not be accurate. Psychiatrists fail to acknowledge the multiple ways for expressing and identifying with a particular gender (i.e. not necessarily only gender-conforming behaviour).

The heterosexual matrix refers to heterosexual gender roles being seen as natural rather than socially constructed. Intersex refers to the range of conditions affecting the chromosomal make-up (1), the reproductive system (2) and/or the sexual anatomy of a person (3).

The biological advocates of transsexuals state that gender identities are the product of biological dispositions. They claim that these dispositions are caused by hormonal influences in the foetus which produce feminized or masculinized neurological brain structure, which leads to a post-natal desire to transition. This, thus, claims that transsexualism is an innate, biological variation.

There are several things wrong with the biogenetic explanation:

• This explanation continues to stigmatize transsexuals.
• This explanation makes use of the gender binary.
• This explanation does not distinguish between gender role and gender identity.
• This explanation suggests that gender dysphoria unavoidably develops from an intersex condition which assumes that intersex people are either male or female.
• This explanation neglects environmental factors.

Many trans advocates argued in favour of gender dysphoria disorder for healthcare reasons (e.g. insurance pay). The standards of care stress that it is important for healthcare professionals to recognize that transpeople’s interventions need to be based on patient decision. The stigma surrounding transsexuality can only be reduced by depathologizing transsexuality. However, this may complicate the health care costs of transitioning.