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rangi-siebert-0lbNd1xPA_U-unsplash.jpgThe field of mental health has made significant advances in supporting transgender and gender expansive individuals (TGE) by identifying ways the sociocultural environment oppresses TGE individuals and contributes to health disparities (Hendricks & Testa, 2012). The focus of research and clinical services for TGE individuals has overwhelmingly been on understanding and reducing the harms associated with trauma, discrimination and gender dysphoria (Beek et al., 2016). Gender dysphoria, or the distress associated with a misalignment between one's gender identity and their assigned sex at birth (and associated societal expectations), has been the concept most central to conceptualizing TGE identity for decades (American Psychiatric Association, 2022). Although reduction of distress and impairment among TGE individuals is vital, this focus has been criticized for prioritizing negative aspects of TGE identity at the expense of experiences that embody affirmation, strength, pride and joy (Beischel et al., 2022).
Gender euphoria is a term that may be unfamiliar to many, as it is rarely found in research literature and academic settings (Beischel et al., 2022). “Gender euphoria” originated in TGE communities and refers to the profound sense of alignment and comfort in one's body, as well as a felt sense of physical congruence with one's gender identity (Beischel et al., 2022). This is experienced by TGE individuals when their gender identity aligns with their gender presentation, resulting in feelings of joy, pride and a sense of being "right" in gender expression and recognition from others (Beischel et al., 2022). The scant research that has asked about euphoria reveals that many TGE people experience not only a distressing push away from the sex and expectations assigned to them (i.e., dysphoria), but also an exciting, invigorating pull toward gender identities and expressions that feel more authentic and enjoyable (Beischel et al., 2022). Further, TGE participants readily report joyful experiences, including joy in being members of minoritized groups, and preferences to be TGE. Embracing one’s TGE identity and/or being in environments that foster authenticity, is associated with increased self-confidence, peace, positive feelings about one’s body, deeper interpersonal relationships and joyful community membership (Shuster & Westbrook, 2022).
Overall, gender euphoria is a fundamental experience for many TGE people, yet psychological assessment, clinical care and research remain focused on dysphoria. This can perpetuate harmful stereotypes (e.g., “the trope of the transgender person in misery;” Shuster & Westbrook, 2022, p. 2), and result in limited opportunities for self-acceptance and access to medical care (Jacobsen & Devor, 2022). Meeting criteria for gender dysphoria is still often a prerequisite for access to gender-affirming services (including surgery, hormone therapy, etc.), which creates unnecessary barriers for those who may not meet strict diagnostic criteria (Kumar et al., 2022). This “damage-centered” perspective (Levitt et al., 2022): 1) places practitioners in a powerful, gate-keeping role over the health and well-being of TGE people and 2) can lead to TGE individuals feeling as though they must present a specific narrative of pain, distress and trauma to qualify for care (Levitt et al., 2022). In addition, the “classic” dysphoria narrative (e.g., “born in the wrong body”) does not map clearly onto many TGE identities. In therapy, lack of clinician awareness surrounding TGE joy and gender euphoria may result in missed opportunities to incorporate these constructs into clinical care, resulting in over-pathologizing TGE experiences while underestimating their strength, resilience and progress. On the macro level, the types of questions that underlie psychological scholarship filter out to the public (through outlets such as the news and systems of education), and inform public opinion, understanding of TGE issues, and legislation that directly impacts TGE people (Shuster & Westbrook, 2022). When the narratives surrounding TGE people (and other minoritized groups) continue to center on suffering, members of those groups may be more likely to attend to despair rather than joy in their own lives. Imagine the difference between a young TGE child learning about TGE role models and seeing TGE people living full happy lives, as opposed to simply being exposed to stories of TGE-related violence and pain. In the face of disproportionate rates of trauma, a healthy self-concept, one that includes euphoria and joy, may be especially powerful in healing from individual and communal trauma.

Clinical recommendations

To counter these barriers, mental health professionals should create environments that acknowledge the diversity of TGE individuals without requiring them to fit into predetermined narratives (Halloway, 2023). Assessment and treatment should emphasize joy, strengths and resilience, and promote personal growth and well-being (Halloway, 2023). When working with individuals who do experience gender dysphoria, clinicians should not only help manage it (e.g., “what makes you feel uncomfortable in your body?”), but also work to find and foster gender euphoria (e.g., “what makes you feel really good in your body?”). TGE joy can be incorporated into many different theoretical orientations and treatment protocols. For example, positive psychology shifts the focus from symptom management to fostering resilience, self-acceptance and overall well-being (Domínguez et al., 2015). This may include cultivating positive emotions, practicing gratitude and building social support networks to bolster psychological resilience and enhance gender euphoria. Gender exploration and/or gender affirming activities can be built into Cognitive Behavioral Therapy frameworks, for example, as behavioral activation or items on exposure hierarchies. Gender euphoria and authenticity can guide values-consistent living in Acceptance and Commitment Therapy (Stitt, 2020). Regarding trauma-informed care, trauma can impact individuals’ beliefs about themselves, including seeing themselves as damaged or weak (Ehlers & Clark, 2000), and these beliefs may interact with experiences of TGE discrimination and dysphoria (Dworkin et al., 2018). A strengths-based approach that highlights resilience while fostering joy and euphoria in one’s gender is imperative for client-centered treatment for TGE individuals. Finally, anyone can experience gender euphoria, and conversely, anyone can experience oppression due to gender roles and strict societal gender binaries. Through principles of liberation psychology, Singh (2016) encourages all psychologists to: 1) examine their own gender journey, 2) recognize areas of relative privilege and oppression and 3) engage in social change in a way that promotes the shared liberation of all people.
Positionality statement: Georgina identifies as white, queer, trans and non-binary. Kelly identifies as white, queer, pansexual and non-binary. Cara identifies as white, queer and non-binary. Mauricio identifies as Latino, queer and cisgender. Finally, the authors wish to acknowledge their focus in this article on TGE identity within the context of the United States, as this reflects their lived experiences. Within this context, it is important to recognize that the gender binary was historically introduced and enforced by white Eurocentric colonizers, establishing an enduring and inseparable connection between the gender binary and white supremacy. 

About the authors

Georgina M. Gross, PhD (they/them), is at the VA Connecticut Healthcare System and Yale University School of Medicine, Department of Psychiatry.
Kelly Harper, PhD (she/they), is at the National Center for PTSD, Behavioral Science Division, VA Boston Healthcare System and the Psychiatry Department, Chobanian & Avedisian School of Medicine, Boston University.
Cara S. Herbitter, PhD (they/she), is at the Psychiatry Department, Chobanian & Avedisian School of Medicine, Boston University and the VA Boston Healthcare System.
Mauricio Montes, PhD (he/him), is in the Department of Counseling, Developmental and Educational Psychology at Boston College. 


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