Comorbidities
An exclusive preview of chapter 7 of the Gender Framework
Comorbidities
7.2.2 Cognitive dissonance in trans identities
Many transgender people are very focused on “passing” as either male or female. Arguably, internalized transphobia is the root of this desire to pass, as the individual does not want to accept that they are transgender and prefers to pretend to themselves and the world that they are actually a person who has been born as the opposite sex. While the person who has medically transitioned may not want to be perceived as transgender, we operate within a social context, and some people may wish to know about the biological sex, rather than the gender identity, of the people in their vicinity; some for safety reasons, others for more complex reasons. Until very recently, medical technology was not able to sufficiently transition a person so that they could pass in public. Now that technology has caught up, some people who have medically transitioned can pass easily. This means that for the first time in history, a person’s biological sex is no longer automatically and publicly visible. These developments have generated significant implications for both individuals and society. In this context, contested questions of policy and safeguarding have arisen in schools, sporting activities, bathroom facilities, changing rooms, and other shared environments, and these tensions are analyzed further in chapter ten.
Stealth transition can be a source of significant cognitive dissonance for trans-identified people. Cognitive dissonance may arise when a person holds conflicting beliefs, attitudes, or values. In the context of a stealth transition, cognitive dissonance can arise due to a sense of shame or discomfort about their transgender identity, while at the same time, seeking to promote the rights of people who identify as trans to live with dignity and pride. “Going stealth” can inadvertently bring about cognitive dissonance within the trans-identified person as non-disclosure of their transgender status, especially to close friends, may generate feelings of dishonesty. Intimate friendships and relationships require honesty, and a growing sense of inner conflict can develop as the individual begins to experience and evaluate the long-term advantages and disadvantages of passing. The person who is living “in stealth” (i.e., not disclosing their transgender identity) can become distressed and conflicted by a fear of discovery. This can lead to photographs from the past being hidden and past experiences being fabricated. Their sense of privacy can become rigid, and this can create difficulty with intimacy. The incongruence between the person’s inner sense of identity and their biological sex may remain unaddressed as the person instead focuses on their outer presentation. They may grapple with feelings of shame, guilt, or self-judgment, which can conflict with their self-acceptance and even their self-worth. Debates around privacy and autonomy can become heated in the context of stealth transition, as it is argued that it is up to the individual to decide when, how, and to whom they disclose their transgender status. Notwithstanding this, honesty and transparency are already recognized as necessary elements of healthy relationships, so we suggest that individuals embrace their transgender status rather than “go stealth.”
These challenges are increasingly evident in schools, youth clubs, and extracurricular activities, where policies on accommodation, safeguarding, and participation can place staff in difficult positions when balancing competing rights and responsibilities. Moreover, schools and other institutions should recognize that there can be legal implications with respect to purporting to offer sex-segregated spaces, especially within residential accommodation. “Going stealth” in schools is discussed further in chapter twelve. These tensions and dilemmas around disclosure and privacy are not limited to personal relationships: prisons, domestic abuse shelters, and other sex-segregated institutions have had to reconsider safeguarding frameworks in light of policies that prioritize gender identity over biological sex. Thus, supporting a stealth identity can generate further issues as the individual may need to decide when, how, and to whom they should disclose their transgender status.
As honesty, transparency, and authenticity are valuable traits and contribute to a better society, we suggest that being truthful about being transgender is more helpful for the person who identifies as transgender and for society. Internalized transphobia is perhaps better approached with open communication, honesty, and authenticity. This can be a highly contentious area, and opinions may vary widely. It is crucial to approach these issues with sensitivity and respect for diverse perspectives and experiences, keeping in mind the importance of supporting the well-being and rights of all.
7.2.3 Relational, sexual and romantic challenges
Relationships are intrinsic to good mental health. Although advocates of affirmation and medicalization tend to focus only on the short-term impact of transition on the gender-distressed individual, gender transition routinely disrupts wider relationships with parents, siblings, peers, and society at large. Some of these challenges are discussed further below. By adulthood, the friendships of transgender individuals tend to be confined to other transgender individuals (often virtual friends known only online) and a limited set of others who are comfortable interacting with transgender individuals (Levine, 2017). Clinicians working with gender-distressed patients should take time to explore relationships, paying particular attention to whether the individual is disproportionately engaged in virtual, as opposed to “real life,” associations. It can be helpful to support gender-distressed patients in expanding their real-life connections, thereby building social confidence through interactions with a more diverse range of peers.
After adolescence, some transgender individuals find that the pool of partners willing to pursue romantic and intimate relationships with them is significantly diminished. Clinicians report that when a person who has medically transitioned and passes well reveals his or her natal sex, many potential mates lose interest. When a transitioned individual does not pass well, options are further diminished. Regardless of a person’s appearance, clinicians working with this cohort report that medically transitioned adults often discover that many of their dates are looking for exotic sexual experiences rather than genuinely loving relationships. Hormonal treatments and sex reassignment surgery can radically alter, and sometimes destroy, the ability to experience sexual pleasure. Cross-sex hormone use has even been associated with changes in sexual orientation (Auer et al., 2014). These changes are challenging for the transitioned individual, but they can be equally devastating to those who detransition and regret the permanent changes made to their bodies. Responsible clinicians working with gender-distressed patients, especially those considering medical transition, must make space for discussion of these intimate and sometimes uncomfortable topics.
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Dr. Stephen Levine is a Clinical Professor of Psychiatry at Case Western Reserve University School of Medicine in Cleveland, Ohio
Dr. Joseph Burgo is a Psychotherapist and Beststelling Author
Christina Buttons is an Investigative Reporter at the Manhattan Institute
Detransition Awareness Day 2026: Life Beyond Transition
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