Saren Craig





Right now, most routes to gender-affirming care in the U.S. healthcare system run through a DSM diagnosis of Gender Dysphoria (F64.0). That diagnosis is designed to describe distress—how someone feels in their body and how they are impacted socially when their gender isn’t recognized or when their body doesn’t align with their lived sense of self. But being transgender is not a disorder. It is an identity—an aspect of who someone is—distinct from any cluster of symptoms. The diagnosis exists to document the harm and distress created by incongruence and by social conditions, not to define trans people. Transgender identity is as real and as significant as any other identity, and access to respectful, medically necessary care should not require treating a person’s identity as pathology.

At the same time, we live in the system that exists. If using this diagnostic pathway is what it takes to access medically necessary care—and that care alleviates dysphoria and improves quality of life—then we will use it. This is why I write letters of support for gender-affirming surgical care and include the Gender Dysphoria (F64.0) diagnosis when it is required for insurance authorization of surgery or required by a hospital system or surgical clinic. I also want to name a reality of U.S. healthcare: mental health diagnoses are often stigmatized, and that stigma can be used to discredit people or narrow what they’re allowed to want. A disability justice lens helps us hold the complexity here—recognizing that diagnosis categories are socially loaded and imperfect, while also recognizing that they are one of the few ways people can access care, accommodations, and material resources in a gatekept system. In that context, using diagnostic language strategically to access medically necessary care is not “pathologizing identity”—it is warranted advocacy, a practical way to claim power and protection within the system that currently controls access.


In counseling, our conversations are private, but there are certain situations where I am legally required to break confidentiality. These include if I believe you may harm yourself or someone else and have a specific plan, if there is any disclosure of abuse or neglect involving a child, elderly, or dependent adult, if I’m issued a court subpoena, or if I need to defend myself against a complaint made by you to the licensing board. Please feel free to ask any questions about this.


 I am outraged by the immense harm being inflicted on minoritized communities in this moment in history—particularly immigrant communities and the transgender community, which I am part of. I refuse to treat this as normal, acceptable, or debatable when people’s safety, dignity, and basic rights are being deliberately targeted. During this time, I will do everything in my power to protect my clients, safeguard their confidentiality, and uphold my moral duty to help prevent harm—to themself or to others.

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Image artist: Daniel Quasar, Portland Oregon


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