When we talk about "trans people" as a monolithic cohort, we are lumping together groups of people who really don't have much in common and shouldn't be grouped together.

Because we are dealing with people with many varying needs and (usually) only one symptom in common, viewing them as a monolith impedes our ability to treat every patient's needs individually. Not every patient will benefit from actual transition. Some will, but many won't.

It also makes it hard to have competent societal/legal conversations when we talk about one group ("trans people") where there are actually many groups under that umbrella who may need different considerations.

I'd like to talk about a taxonomy, or cluster analysis, of different people grouped under the umbrella of "trans" from what I've observed in medical and social settings. I'd like to hear your thoughts on this, too.

1. Dysphoric adults. These folks are what activists dismissively call "truscum," or, adults with gender dysphoria who have idiopathic negative feelings about their birth sex and want to transition to live as the other sex.

We don't really know what causes dysphoria despite many theories, but the classic treatment pathway (supportive therapy, social transition, surgery and hormones) was developed for these folks and seems to be a good choice and have the best outcomes for them.

2. Adolescents and adults with trauma, depression, or other psychiatric comorbidities: especially in females, this patient cohort may display classic signs of PTSD, including depersonalization and an obsession with changing/controlling the body, and

be seeking transition as an outlet for abandoning their female bodies. They are often survivors of sexual assault and often do not seek or are not offered psychiatric care for trauma beyond transitioning. Both young men and young women in this cohort often have depression,

anxiety, or social issues that can't be explained away just by dysphoria and often aren't resolved by transitioning, although clinicians often ignore psychiatric comorbidities when the "easy" diagnosis of dysphoria is made.

This is a major reason why it should be accepted clinical practice to attempt to resolve/ stabilize comorbid psych issues prior to transition. Calling this "conversion therapy" prevents people from getting the care they need for problems that transition will likely not resolve.

3. Lifestylists/fetishists: People who want to live as the other sex for fetish purposes, including autogynophiles. Med pros should be having a conversation about whether transitioning is an appropriate treatment for a paraphilia.

Medically and socially we should acknowledge that because some people have AGP, it doesn't invalidate genuinely dysphoric adults or other peoples' reasons for transitioning. Denying that it's happening doesn't help anyone, including the patients.

4. Munchausen-by-Proxy: if your kid is a toddler or very small child, they are not trans. Period. Child development scholarship shows us with certainty that it is NORMAL for young children to undergo a developmental stage where they don't yet understand that their sex is fixed.

They almost all go on to develop that knowledge unproblematically on their own. Clinicians who indulge this parental delusion should be put in a pillory. Even for the very few who would grow up to be trans adults, early medicalization inhibits genital tissue & fucks people over.

5. Trenders: Social contagion is a real thing. Again, trenders' existence doesn't invalidate dysphoric people or transitioning in general, & just because transition is encouraged by social factors doesn't mean it isn't "real." It's absolutely real & the patients need dealt with!

Harmful and confusing activist messaging (e.g. "if you question your gender you're trans," "egg culture," etc) contributes to this. This cohort is normally young (pre-college age) and some will never seek medical care, just engage in pronoun changes, etc.

However for the many that do seek some measure of medical transition, this is why a careful approach, therapy, and waiting to make permanent physical changes are all important.

6. Gay people with homophobic families encouraging transition: this unfortunately happens, especially given the overwhelmingly strong research showing that a huge majority of dysphoric adolescents who are given puberty blockers would have gone on to become homosexual adults.

7. Non-dysphoric transhumanists: The only cohort that doesn't share the dysphoria symptom marker, some of these folks want to engage in hormonal or surgical changes just because they want to and feel they have personal freedom to manipulate their bodies. Fine, whatever.

But two problems here: one, this cohort is highly responsible for spreading medical misinformation, particularly the fantasy that you can swap out or remove body parts with limited or no systemic effects. This ideology contaminates other peoples' treatment expectations.

And secondly, a conversation should be had about whether a medical setting is the proper place for catering to this cohort: they aren't dysphoric, so we aren't actually "treating" them for anything, and we may be causing problems instead of solving them.

Medically, we can think about this as somewhat analogous to cancer. There are over 100 different cancers, & many different treatments depending on the type you have. Stem cells, radiation, chemo, hormones. It isn't one size fits all. Your treatment depends on YOUR circumstances.

Dysphoria is like this. Not every dysphoric patient has an identical etiology or presents with similar symptoms. An adult man with AGP has very little in common with a teenage girl who has dysphoria as a byproduct of trauma.

Both of them have little in common with a toddler who doesn't yet have a cognitive comprehension of fixed sex. And so forth. All of these patients need to be approached in ways that suit their varying circumstances, both medically and socially.

Activism to provide easy, as-fast-as-possible, as-early-as-possible transition to every single patient with dysphoria is not helpful to these patients. It doesn't take their circumstances and varying etiologies into account.

It doesn't admit that some people WON'T benefit from transitioning, or that kids can't consent to making cosmetic changes with lifelong non-cosmetic ramifications. It is important that we continue investigating how to help ALL people with gender-related discomfort.

Sorting out people who will benefit from a treatment from people who will be harmed by it isn't "conversion therapy," it is just *medicine.* Just because transition isn't right for one patient doesn't mean that it isn't right for someone else.

That's all I got.