Understanding Transgender Ideation

A new way to describe a familiar psychological phenomenon

Over the past number of years I’ve spent thousands of hours working with detransitioners, regretters, parents of trans-identified children and young people who identify as transgender. Again and again, I found myself reaching for terms such as gender dysphoria, rapid-onset gender dysphoria, autogynephilia, autism, ADHD, trauma, and obsessive thinking. All are clinically important and yet none of these terms provide a name for the common cognitive symptom that could emerge through these otherwise very different psychological pathways.

One of psychology’s central tasks is to distinguish and describe recurring patterns of cognition. We recognise concepts such as suicidal ideation, obsessions, intrusive thoughts and ruminative thinking and they are valuable because they describe what is happening psychologically to the individual. Suicidal ideation, for example, may arise in various conditions such as depression, psychosis, trauma or personality disorder. No psychiatrist would assume that every patient experiencing suicidal ideation was suicidal for the same reason. The symptom comes first; formulation follows.

We have no equivalent descriptive term for the persistent cognitive preoccupation that happens when a person becomes transfixed by the idea of identifying as another sex or gender identity. Instead, we tend to move straight to explanation. One clinician sees autism; another sees a paraphilia. A trauma-informed clinician might be convinced its a manifestation of trauma while a gender-affirmative clinician will view it as gender dysphoria. Many will point to social contagion. The problem is that the debate begins before we have agreed on what it is we are trying to explain.

I propose the term transgender ideation to describe a psychological symptom characterised by a persistent or recurrent cognitive preoccupation with being, becoming, or identifying as another sex or gender identity.

This cognitive preoccupation may also find behavioural expression in repeated information seeking, changes in presentation, pronoun changes, binding, packing, tucking, hair removal, voice training and body modification. Many people with transgender ideation will seek social or medical transition. Like suicidal ideation, transgender ideation may emerge through multiple psychological pathways.

I have chosen the term deliberately. “Ideation” is already familiar within psychology and psychiatry. It refers to a recurring pattern of thought without implying a diagnosis or a particular cause. By using the term transgender ideation, I am proposing an analogous descriptive construct that identifies a recurring cognitive symptom while remaining agnostic about its origins, meaning and appropriate treatment.

The distinction is more than semantic. Once we have a descriptive symptom, meaningful scientific and clinical questions become possible. We can begin to measure its prevalence, identify risk factors, compare different psychological pathways, examine which interventions are associated with improvement or persistence, and investigate whether particular patterns predict medical transition, detransition or long-term psychological outcomes. At present, many of these questions remain difficult to answer because we have not first agreed on what it is we are trying to describe. I believe transgender ideation provides a missing piece of the conceptual framework needed for that work to begin.

Lisa Littman’s work on rapid-onset gender dysphoria was an important attempt to describe a recognisable clinical presentation that many parents and clinicians were observing. Rapid-onset gender dysphoria, however, refers to a particular pattern characterised by an apparently sudden onset of gender dysphoria during adolescence or young adulthood, typically as a maladaptive coping mechanism and influenced by social contagion. Transgender ideation is broader. Some people with transgender ideation may have gender dysphoria; others may not. Some may experience a rapid onset, while others may develop the symptom gradually over many years. Rapid-onset gender dysphoria therefore describes one possible clinical presentation. Transgender ideation describes the cognitive symptom itself, irrespective of age of onset, developmental pathway or diagnosis.

The term transgender ideation is not mine. Keith Jordan and the organisation Our Duty have used it for several years and developed a lifecycle model describing how an individual may come to contemplate or believe themselves to be transgender, how these thoughts may become persistent through rumination, and how they may eventually lead to social and medical transition. Their work was important in recognising that the cognitive process itself deserved a name, rather than treating transgender identification as a simple statement of identity.

My proposal builds on that insight but uses the term somewhat differently. I am using transgender ideation as a descriptive psychological symptom while remaining agnostic about its cause. It may arise through social influence, as Our Duty emphasises, but it may also emerge through obsessive thinking, autism, trauma, gender dysphoria, autogynephilia or other psychological pathways. In that sense, I hope to extend Keith Jordan and Our Duty’s original insight into a construct that can be investigated clinically and empirically.

This concept also sits comfortably alongside Mia Hughes’ work on the Overvalued Belief (OVB) model. Transgender ideation is a descriptive psychological symptom. It identifies a recurring cognitive preoccupation without attempting to explain its origins. The OVB model is a psychological formulation that seeks to explain how an individual’s thoughts may become increasingly rigid, emotionally invested and resistant to challenge. In simple terms, transgender ideation describes the what; the OVB model helps explain how the idea can become increasingly entrenched.

Clinicians need language that distinguishes what a person is experiencing from assumptions about why they are experiencing it or how they should be treated. A descriptive symptom allows clinicians to ask more precise questions about what is actually occurring psychologically before drawing conclusions about diagnosis, prognosis or treatment. Gender dysphoria describes distress associated with one’s sex or gender; transgender ideation describes a pattern of cognition. The two may overlap, but neither necessarily implies the other.

This distinction reflects a longstanding principle within psychology. Clinicians routinely distinguish between cognition, affect and behaviour because each provides different information about a person’s psychological functioning. Cognition concerns what a person thinks, believes or repeatedly imagines; affect concerns what they feel; behaviour concerns what they do. These domains are closely related but are not interchangeable. A person may experience persistent suicidal ideation without acting upon it. Likewise, an individual may experience intense gender dysphoria without transgender ideation, while another may have transgender ideation without being gender dysphoric.

By locating transgender ideation within the cognitive domain, I am identifying one component of psychological functioning that deserves description in its own right.

Consider the hypothetical child described by Hilary Cass in the House of Lords. Cass’s account suggests that he had been socially transitioned by his parents from the age of two onwards. This meant that between the ages of two and eleven, the child had been told that he was transgender and needed to transition. His life was organised around living as a girl. Whether that represents gender dysphoria, transgender ideation or both would require careful assessment. Nevertheless, the account suggests a recognisable cognitive preoccupation that itself deserves description before we debate its cause.

Now consider a 15-year-old teenage girl with no childhood history of gender distress who develops an intense preoccupation with transition following months of social isolation, deteriorating mental health and immersion in online transgender communities. Whether her presentation is understood as rapid-onset gender dysphoria, obsessive thinking, autism, trauma or social influence, the recurring cognitive symptom is equally recognisable. She has become preoccupied with the idea that transition is the solution to her distress.

These two young people may arrive at to similar conclusions through very different developmental pathways. The common psychological feature is not necessarily the cause of their distress, but the recurring cognitive preoccupation with becoming another sex or gender identity. This, I believe, is the phenomenon we need to describe consistently.

Recognising transgender ideation does not commit us to any particular explanation. It may arise alongside obsessive thinking, autism, childhood gender dysphoria, trauma, body dysmorphic disorder, eating disorders, anxiety, depression, loneliness, autogynephilia or some combination of these factors.

Whether transgender ideation ultimately proves to be a useful construct is not something any individual can determine. Like every psychological concept, it should stand or fall on its ability to improve clinical understanding, inform research and improve clinical practice. My proposal is simply that psychology currently lacks a descriptive term for the phenomenon that many different professions are already trying to understand through their own conceptual frameworks. The language we currently use remains necessary, but it is not sufficient. If transgender ideation helps provide that missing descriptive framework and enables us to ask better questions before reaching conclusions, it will already have served a valuable purpose.