Dissociative Experiences Among Transgender Women: A Phenomenological Study

ABSTRACT

There is little published research on dissociative experiences among transgender people, and none from an in-depth qualitative perspective. In-depth, open-ended interviews (N = 7, 6 trans women, 1 trans man) were conducted to explore how dissociation is experienced (particularly among trans women) and its possible relation to negative emotions. There were several similarities across the dissociative experiences described by participants: six felt themselves disconnected from their body as a whole (in contrast to feeling disconnected to a specific body part), and from the world around them and/or themselves. Four acted out different personalities, and five felt emotionally numb when they were dissociating. Six participants described that their dissociation lessened after they started hormone therapy. Respondents tended to distinguish between dysphoric and dissociative experiences: dysphoric phenomena were more clearly distressful while dissociative ones were more emotionally numb.

KEYWORDS:

• Dissociation
• transgender people
• gender dysphoria
• qualitative research

Introduction

A transperson is someone whose gender identity and/or expression does not align with the gender they were assigned at birth according to Swedish law (RFSL, 2020, March 17). The diagnoses used to describe the suffering of transpeople have changed over time; the one most in use currently is “gender dysphoria” (a factor related to being transgender but not defining of it; American Psychiatric Association, 2013, p. 495). The largest survey of U. S. transpeople conducted (N = 92,000) found that 94% felt a little or a lot more satisfied after transitioning gender, with almost all respondents reporting greater satisfaction after hormone treatment or gender-affirming surgery (James et al., 2024).

Many transpeople are in the process of being assessed for possibly receiving a diagnosis and the wait times are long even in Sweden, even though healthcare is publicly financed (Statens offentliga utredningar, 2017). In countries where healthcare is not publicly financed, economical means might prevent them from getting a gender dysphoria diagnosis (Johnson, 2015; Vipond, 2015), which means that many people who identify as transgender do not have access to treatment even if they experience distress. Furthermore, transpeople who do not conform to gender norms may be disbelieved and face greater resistance from medical personnel, including being refused diagnosis or treatment (Alonso, 2023; Vipond, 2015) even though such care can improve psychological well-being. Transpeople who are homosexual, non-binary, did not develop their trans-identity until later in life, and/or are not interested in surgical interventions, are particularly at risk of being questioned and refused diagnosis. For minors who suffer from gender dysphoria, it is difficult to receive a diagnosis even after getting past the long wait times. A study indicated that only 27% of clinicians provided a diagnosis when assessing a vignette of a child who fulfilled DSM-IV criteria (Ehrbar et al., 2008). Even after treatment, transpeople suffer from increased levels of psychiatric comorbidity, suicide risk and social isolation as compared with the general population, which indicates a need of substantial support before and after treatment (Bränström et al., 2021; Dhejne et al., 2011)

Transpeople suffer from higher levels of depression, anxiety, and general psychological symptoms than the population at large: in a study, 42% fulfilled the criteria for depression, 50% for anxiety, and 24% for general psychological symptoms (M. Colizzi et al., 2013). They also suffer from higher dissociation. Walling et al. (1998) administered the Dissociative Experience Scale (DES; Bernstein & Putnam, 1986) to 64 transexuals and 10% had scores of 30 or more, suggestive of a dissociative disorder, higher than the 4% prevalence of pathological dissociation in a national sample (Simeon & Putnam, 2022). M. Colizzi et al. (2015) reported a 30% prevalence of probably dissociative disorders among transpeople after sex reassignment, but this was based on the Dissociative Disorders Interview Schedule (DDIS; Ross et al., 1989) and the mean scores in the DES for the whole sample was 13.54 (SD = 10.78), considerably lower than the score of 30 suggestive of pathology.

Shiah et al. (2004) evaluated the level of psychiatric distress and dissociative symptoms among Taiwanese trans women diagnosed with gender identity disorder with the Symptom Checklist Revised (SCL-90;-R Derogatis & Cleary, 1977) and the DES. Compared to a control group of cis (those whose gender identity and/or expression aligns with the gender they were assigned at birth) men, trans women had significantly higher scores on both measures. In contrast, a study that measured the level of depersonalization among postoperative German trans women compared to cis people found no significant differences between the groups (Wolfradt & Neumann, 2001). The pattern across these various studies seems to be that before surgery transpeople suffer from greater dissociative and other symptomatology, which may reduce or disappear postsurgery.

The risk factors for transpeople to develop dissociative symptoms have been barely studied, but risk factors to develop depression, which is related to dissociation, have received more attention (Brauer et al., 1970; Fung et al., 2020). They include, among others, discrimination, sociodemographics, socioeconomic status and substance abuse, while access to healthcare and social services and surgical interventions have a protective effect (Rotondi, 2012). A study on LGBTQ+ individuals found that among transpeople experiencing distress, discrimination related to PTSD and dissociative symptoms (Keating & Muller, 2020).

Although a majority of the studies reviewed suggest that transpeople report higher dissociation than the population at large, at least before surgery, the studies do not show if there are aspects of dissociation that relate to being transgender besides the dissatisfaction with birth assigned gender, nor how transgender people interpret and relate to their dissociative experiences. This study, which might be the first to use a qualitative approach to study dissociation among transpeople, investigated how they experience dissociation, interpret these experiences, and how they affect them.

Better knowledge of similarities and differences and potential links between dissociation and gender dysphoria is important to understand how ill health can arise and be alleviated. Providing health professionals with more information on how dissociative experiences tend to be expressed can help them differentiate between gender dysphoria and dissociative pathology. This issue also relates to a previous study that discussed the limitations of its approach in that the questionnaires used did not differentiate between dissociation and gender dysphoria (M. Colizzi et al., 2015). For instance, an answer of yes to “your body doesn’t feel like your own” could be interpreted as expressing either dissociation or gender dysphoria.

Materials and methods

This is a qualitative study based on in-depth interviews analyzed through a realist-informed thematic analysis (Braun & Clarke, 2006). We recruited people who self-identified as a transperson, and who were early in the transition process. We also specifically recruited those who considered themselves to have had previous dissociative experiences. To help potential participants identify whether their experience is what we were interested in investigating, we provided an easy to understand description of dissociation (“an experience where you feel in some way disconnected from your surroundings or yourself. Perhaps that your body, your emotions, or the world around you feel unreal in some way”). This definition follows closely one of the two main descriptive concepts of dissociation offered by Cardeña (1994, p. 22; see also Brown, 2006). We deemed that the other main concept of dissociation, referring to mental parts or compartmentalization, would have been difficult to explain succinctly.

Interviewees were recruited via internet forums aimed at transgender people, where a message was posted with general information about the study and its purpose. Interested parties were asked to get in touch if they were interested and wanted more information. Two forums and their moderators were contacted and gave their approval for these posts. On those forums transwomen are a majority of users, therefore a forum aimed specifically at transmen was contacted to compensate for this but its moderators did not respond.

The criteria for participation sought to decrease the risk of potential dysphoric responses to volunteersWe limited participation to those 18 years or older, fluent in English or Sweden (most interviews were conducted in Swedish), and who recognized the definition of dissociation as something they had experienced. Those who were in therapy were asked to talk with their therapist as to whether they could participate in the study safely and those who scored 25 or more on the Kessler Psychological Distress Scale (see below), a score suggestive of moderate psychological distress, were excluded to minimize the risk of negative effects during the interview. Those excluded for this reason were told that unfortunately we could not include them for safety reasons but they were welcome to talk with EC, an expert in dissociation, for an explanation if they so desired (none did). The Swedish Ethical Review Authority reviewed and approved this protocol (# 2021–04310).

Questionnaire

The Kessler Psychological Distress Scale (K10) is a 10-item self-report global measure of distress (anxiety and depression) during the most recent 4 weeks, with high internal reliability good test-retest reliability, and discriminant validity (Kessler et al., 2002; Merson et al., 2021)

Procedure

If a person met the inclusion criteria, they were contacted and an appointment was made for a video call interview via Zoom. The interview was conducted in either Swedish or English as the participants were not necessarily from Sweden. The interview was open-ended and the interviewer (ES a trans person) asked questions based on what the interviewee said. She had previously been trained in this type of interview by EC. The interview began by confirming the interviewee’s consent to participate, reminding them that the conversation would be recorded and everything they said was confidential and they could discontinue participation at any time without having to explain why. Participants were asked if they wanted to ask any questions before the interview started. The interview then began by the interviewer repeating the definition of dissociation given in the information sheet and asking participants if they could tell us about a dissociative experience they had had. Follow-up questions sought to get a clearer picture of the experience(s), the meaning attributed to them, the degree of functional impairment, and so on. Questions that often reoccurred between interviews were “Have you received any gender-affirming care?,” “When di you started having these dissociative experiences?,” “Were there situations where your dissociation became more prominent or more difficult to deal with?,” “How was your everyday function affected?,” “Are there any body parts you feel more disconnected to than others?” and “Are there any particular bodily sensations when you dissociate?.”

Any identifying information provided during the interview was erased after the interview. During the recording, the software VoiceMeeter was used to disguise the interviewee’s voice and after the interview Audacity software was used to further disguise the voice to de-identify the participant. At the conclusion of the project the recordings were deleted.

Analysis

The interviews were transcribed and then processed using thematic analysis informed by Giorgi’s and Giorgi (2003) phenomenological approach to interviewing, integrated into thematic analysis in accordance with Braun and Clarke (2006). The themes were developed inductively without any theoretically based themes in advance to capture the participants’ experiences. The process of analysis consisted of various phases, the first involved reading the text to get a sense of the whole. During the second, the text was read through again, highlighting any change in meaning regarding the phenomenon under investigation. The third phase consisted of rewriting the units found in the text into descriptions to highlight the psychological meaningfulness of the interviewee’s experience. The fourth consisted of using these descriptions to develop an overall description of the structure of the interviewee’s experience and highlight its essence. The last phase consisted of extracting generalizable elements from the experience, which were then used to compare the different texts with each other. These elements became the themes the study examined.

Results

Participants

Sixteen people registered their interest, of which eight met the inclusion criteria and provided an e-mail address. One of those people stopped responding to e-mails before an interview could be arranged, leaving seven participants in the study. Six of them identified as female and the seventh as male. To make identification more difficult, age was inquired in a span of ages; 3 participants were between 18–22 yoa (one of whom was the male participant), 1 between 28–32, 2 between 33–37, and 1 between 48–52 Five of the participants, including the trans man, resided in Sweden, the other two in the United States. All participants but one had come out to their relatives, and one had not come out to anyone in their social circle. Four of the females and the male participant had started hormone therapy. No participant had undergone gender confirmation surgery.

The following sections outline what emerged in terms of the experiences participants described around dissociation, how functioning was affected by their dissociative experiences, and whether it was a hindrance or a help. Finally, it describes the circumstances that alleviated or exacerbated their dissociation. The following results center on the six female participants, with supplementary comments relating to the male.

Dissociation and dysphoria: linked but different

Five participants (and the trans man) described experiences in which they felt disconnected from their body as a whole, and the same number had experienced disconnection from themselves as a whole person or the outside world. The experiences of depersonalization and derealization often merged and connected to each other. Participant 7 described experiences of feeling like a spectator in her own life and that someone else was acting out her behaviors:

It feels surreal. Like I know this is, I know, I know as far as I understand I’m still in my own reality, like nothing’s happened. But it would feel like … I’m watching like a movie of my own life. Happening in real time is, I think, the best way to describe it. Cause it’s such a strange feeling. Or, hm, like you’re watching yourself from like a third … outside perspective. When you’re, you know, you’re obviously still really in your own body.

Participant 3 described how she had difficulty connecting her experiences to the outside world:

There is a distance between… Like my internal experiences and what I have around me…. well, I always know where I am, who I am and what’s going on, I’m not confused in that way. But I still feel that there is more, that I am not really present. Yes, everything that happens around me. Sometimes it can also manifest itself in that I kind of… I can look at something and hear it, but not really connect… that what I see and what I touch are connected in the same way. Kind of more divided experiences.

When participants differentiated between their dysphoric and dissociative experiences, the dissociative ones had mostly neutral or unclear valence, while the dysphoric had an overt negative valence. This is how participant 3 described how dissociation was for her:

Mostly like, no! A bit like this… Looked odd, like it didn’t fit together, like it was like this, like a- a puzzle piece was in the wrong place. But kind of stuck, but it was not supposed to? But just kind of… weird. So it’s a very, very weird, difficult thing to explain.

In the context of dysphoria, they often felt overtly negative emotions such as disgust or sadness and had thoughts about how their body should be or how they would like it to be. Participant 1 described it so:

Then when it’s like, it’s like dysphoria … it’s like negative butterflies in your stomach, they- it can be like this bodily also like feeling, that you want to be like this… I don’t know what it’s called in Swedish, but like have completely, curled up … You know, crying away about this, this, this bad feeling that you have in you. Like, like, so overwhelmed by the fact that, that, your name, you feel that you’re a failure, that, that who you are as a person, that you’re not who you really are. That-that feeling that you’re really a woman, but you’re kind of a man in everyone’s eyes… And it makes me kind of, like, curl up and hug myself and cry.

Dissociation, on the other hand, entailed a sense of disconnection from the body/body part and that it existed separately from the person, while not giving rise to the same sense of “wrongness.” It was common for both phenomena to occur in the same situation, as the feelings that emerged from dysphoria then led to dissociation. Participant 3 described how she had an internal image of her appearance that did not match the real one or that they ignored their real appearance to focus on mental aspects of their identity:

And in the past, I’ve also clearly had experiences where I have a picture in my head of what I look like, that I’m very shocked by when I see myself in the mirror and look that way. So it’s still a form of dissociation I would describe, that I can think, that my self-image of what I look like or I should look like in my head is so disconnected from what I actually look like that I’ve been able to genuinely, like, walk past a shop window and just wow, that doesn’t look like me.

A recurring trigger for dysphoric feelings and dissociation were occasions when participants were reminded of their body, such as seeing themselves in the mirror. Participant 5 described her experience of detachment:

Before, it was really kind of like you saw yourself in the mirror and then it was like, oh. Like, you kind of know like this, I knew it was me in the mirror, but it didn’t really feel like that, so to speak.

No participant doubted that the mirror image actually belonged to them, but had a “wrong” feeling or that the mirror image did not feel like their own. This feeling was often not perceived as particularly unpleasant in itself, although it did provoke reflection.

Dissociation may have a negative effect

Two participants (and the trans man) described how dissociation could negatively affect their everyday functioning. They had to make more effort in their work and personal life to maintain concentration and do things that were not normally a problem for them. Participant 3 described how dissociation hindered her social life and made her have to make an effort to appear to be present in conversations:

During the periods when my dissociation is worse, I can also feel disconnected from other people. That I can be with someone and not, and sort of take in what’s happening but still sometimes feel that I haven’t really listened. Almost like when you have read two pages in a book and realize that you haven’t really read anything, you just continued. I can sometimes have that feeling in conversations with people when I have a worse dissociation.

Participant 6 talked about how dissociation prevented her from concentrating on her work:

Sometimes I’d get through all day and be so detached from what I was doing I would have a couple of hours of my shift and go, yeah, nothing done today. Because you know, I’ve been kinda floating off in space.

However, all participants learned to cope with dissociation to the extent that it did not significantly affect work or social relationships. Participant 3 described that she had learned to act in a way that her friends do not notice anything and are surprised when she tells them that she dissociated afterward:

I have learned not to be afraid of it and I have learned to be able to still do things, without it being noticed outwardly at least. Um, there are also people who are very close to me, like my partner who may be with me very often, who sometimes say when I’ve kind of told them that oh, I’m dissociating a lot today, they may say this: Oh! Really? It was not noticeable.

Nevertheless, dissociation still represents a barrier that makes socializing more strenuous for her and makes it more difficult to feel present. Therefore, her coping method alleviates the problems caused by dissociation, but does not eliminate them.

Pretending to be someone else

Three of the participants (and the trans man) described acting out a personality different from their own in various ways in social settings. For some it was deliberate behavior to fit in better, which then made them feel cut off from others and themselves. Participant 6 described how she experienced dissociation after she had to return to presenting as a man:

Everyone in my home knew what I was going through, got to dress how I want and be myself. Then I had to go back to work where I was not out yet. Uhm, that first week was a bit hard. I think the first day-ish I was, I felt really dissociative, but … That took adjustment going from I get to be myself to I have to go pretend this person I’m pretending to be.

For participant 5, however, it was an unconscious behavior that developed on its own, and when asked when the behavior started, she could not place it herself, but said: “It’s hard to say. But it feels like it usually grows depending on what, I do in the moment, sort of. What is needed in the moment a bit too.” She described that she felt that she had several different personalities within herself that changed according to need or situation, which led to different emotional reactions, views on herself and behaviors. She described that she could completely forget something sad she had been informed about in the morning at her job, only to remember it again when she switched away from that personality:

There was one morning that I… woke up to a friend sending me something incredibly horrible. Something incredibly bad, I was very sad that morning. Then I thought like shit, I have to go to work anyway. Then I thought that uh, when I had come out and kind of clocked in, it was almost as if it hadn’t happened. Until like afterwards when you had come home again and like you realized oh shit, that has happened.

In other participants where the behavior seemed to be practically motivated there were elements that indicated that there was a dissociative character to the experience.

Participant 7 described how she learned over the years to play a male role to fit in socially:

I spend a lot of time learning how to pretend to be male. And you do anything for [43–48] years you’ll get good at it. And I did. It took me about thirty years to get good at it. And you know, and then for [13–18] years I felt like, hey, alright, I’m doing okay! Good for me! And then I realized no, wait a minute. This is all wrong. Uhm … So, I’m very aware now that it is an act. That I am playing a role that is not me. It’s a, … It’s just a role I play because it’s what is keeping me safe in the world. This is how I get through my life.

She also explained how it prevents her from feeling genuine in any social contact and makes her feel disconnected from others.

The male participant described how he adapted to the female gender role and what his boyfriend wanted, but could not decide what he wanted, “I don’t really know what will make me happy anyway. I haven’t found a form of woman [to be] that would make me happy. So, I might as well try to be what you want.”

Numbing, both protection and separation

Emotional numbness was described by four participants (and the trans man). The emotions they could express were very limited and when they could be expressed they were negatively charged such as anger and sadness. Participant 6 tells how before her transition she had a limited experience of her emotions:

it felt like I didn’t have emotions. Uhm, in, for a lot, most of that period like, I felt that the only emotion I could feel was anger. Uhm, it took a lot to like make me feel sad and like cry and actually like express it. Usually, the only time I could think, over that time period was when my grandmother died. It was the only time I was able to express sadness.

This was something that clearly improved after participants had started the social and/or medical transition and it was something that was experienced as very good, although it could also mean difficulties in suddenly starting to experience emotions more strongly. Participant 5 described that she found it more difficult to distance herself from her emotions after she started her transition, “It’s harder… I can’t do it anymore in the same way […] it hasn’t been in the same way like it’s just pushed away and becomes irrelevant like that.” However, she answered that she preferred how it is now that she cannot put her feelings away as before:

I probably prefer to feel things more thoroughly. Well, they-it feels more genuine to the person I am to… well, feel things. To be… Yes, that it’s relevant like. It’s… What can I say… Almost now, kind of scary that it was possible to do that once upon a time!

Participants repeatedly reported that the emotional numbness decreased as they got further into their transition. Participant 5 described how she started to care more about herself when she could feel more connected to the world and her body:

I didn’t feel good before in a way like I didn’t really feel emotions around things… ah but I wasn’t really sad about how I looked, or sad about who I was really or like this. Because it wasn’t that way, it didn’t really exist. But, so in a way it’s not like that, it’s not good to feel like that, but when you started to feel, or when I started to feel a bit more like myself, then around that time. So it was also that you broke the barrier you had built up for yourself then. When there was a connection, there was suddenly a reason to be sad about your weight, or how you look, or the difference between how you want to look compared to how you look today. … with the initial connection, there were more reasons to care and sort of… to be connected to, like, your body. Or to your reality

She also described how she was able to feel more pleasure in different activities and social contacts, whereas before she mainly found pleasure in escapist interests such as books and computer games. Feeling more connected to her emotions helped her reach out more to other people, pursue more interests, and take better care of her health:

I don’t read books much anymore. Um, I find it hard to get lost in it in the same way … I have continued to play computer games, but it has become more of a… a thing I do with people than a thing that I do alone like. It became much more of a social activity, and at the same time I’ve picked up more social activities like… Well, music is one of them.

Three participants (and the trans man) interpreted their dissociation as functioning to protect them from or avoid unpleasant feelings related to being transgender. Situations associated with gender dysphoria, such as looking at themselves in the mirror or agonizing over not being born as a cisgender person of their gender, tended to be the situations where they experienced more tangible dissociation. Participant 6 noted that dissociation emerged in situations where she focuses on a part of her body that evokes strong feelings of disgust. Therefore, she speculated that dissociation served to protect her from those feelings that she could not handle during that period of her life:

‘cause I would look in the mirror and I’d like note, in times I wasn’t having a dissociative episode, like I’d notice me but I’m disgusted by what I see. …] And sometimes I think, when I would kinda become aware about how I felt about myself, then I would kinda just unplug.

Participant 7 said that dissociation becomes stronger when she imagines how her body will age and become more masculine, and that dissociation protects her from the discomfort of these thoughts:

But there would be a lot of times where I would kinda realize that I’m … like I’m transforming into an older man. … I would try to do whatever I could to not think about that. And sometimes it would result in dissociation. Though I couldn’t really connect the two at the time.

Participant 5 described how dissociation allowed her to ignore unpleasant feelings and stop herself from ruminating in order to cope with everyday life. She thought that if she had had more access to her emotions, the dysphoria would have caused more problems in everyday life:

It, it was almost a way for you to function. Kind of like not caring about my body to … get through everyday life and do things that I want to do without constantly being sad about who I wasn’t.

Participants described that disconnecting from their emotions helped them cope with everyday life earlier on when dissociation was worse and that they thus had some positive associations with their dissociation. However, they were also happy when that disconnection decreased and they began to experience a wider range of emotions.

Dissociation intensifies when things get tough

Five participants noted that their dissociation was exacerbated when their general wellbeing was worse, for example if they had slept or eaten poorly recently. Participant 2 explained the link by saying that when she was more stressed, it became more difficult to deal with her gender dysphoria and added dissociation to distance herself from those feelings. She described that “When it feels tough, it’s often harder to deal with the fact that my body doesn’t feel the way I think it should. And then it becomes easier to disconnect the thought completely.”

Four participants (and the trans man) remembered that their first dissociative experience took place when they were at the age of puberty (10–15 years) and reflected on whether this may have been the triggering factor (or one of several). The dissociative experiences at that age could in several cases be linked to either biological changes or the fact that they started to adapt more to the gender norm, which may indicate that the biological and social factors during this period could lead to the onset of dissociation.

In other cases, they developed depression without a clear cause and they have only subsequently been able to link it to gender dysphoria. The fact that many participants described that they first noticed dissociative experiences at this age indicates that this may be a period of life worthy of special attention when investigating gender dysphoria.

Three of the participants said that they were better able to deal with their dissociative experiences when they realized what they were and/or what it referred to. Knowing that it was because of being transgender reduced anxiety and de-dramatized the experiences. Some experiences lost their negative charge and became something that felt funny rather than unpleasant. For participant 7, it could even feel affirming to her, as the experiences proved to her that she was transgender during a period of her life when she could not express it to others:

But those have been since understanding that I’m trans and since understanding that dissociative feelings are a part of dysphoria. And, you know, so I can understand, and I can contextualize them now … And they don’t bother me I don’t … They don’t make me feel bad or uncomfortable or anything. It’s just a reminder, you know, yes this is a part of my life and until I get to a place where I can transition this will probably continue to be a part of my life. But it is, you know, it is a reminder of my identity, in a certain strange way.

However, for the trans man and one of the trans women, the realization that they are transgender led to a deterioration in their well-being and dissociation took different forms or intensified rather than diminished. Participant 4 described that during the period after he realized that he was trans, his everyday function deteriorated more than before:

Then you just felt worse and worse and became quite withdrawn and quite kind of deeply depressed, but… And then my parents started to realize that this isn’t working and they took me home… Because I was out studying at the time

Dissociation began to take the form of thinking of himself as something fundamentally bad that he just wanted to get away from:

I remember how I used to think of my, myself, and like both body and mind as a city. And like a, bad city that I don’t want to live in. But I’m kind of stuck there. That it’s like, this is a shitty city, I’m one person in this city, I can’t change a whole fucking city, just move away. But… you couldn’t. [laughs] So I used to think that this is like… I’m just waiting for something else to come.

This suggests that realization does not always make dissociation easier, but can also cause discomfort and problems.

The importance of care and treatment

Five participants (and the trans man) said that when they received gender-affirming care or started having their gender identities affirmed, their dissociative experiences decreased. The dissociation did not disappear completely, but it was alleviated and became easier to deal with. This could happen quickly, with one participant reporting that she had experienced a clear effect just two months after starting treatment, despite the fact that the bodily changes that hormone therapy brings generally take longer (RFSL, 2021). Participant 5 notes that the two major occasions where her dissociation decreased were when she came out and when she started hormone therapy:

There was a pretty clear breaking point after I had started… Ah but especially after I had come out in public, and started presenting myself femininely. Ahm, and then there’s a pretty clear breaking point after I had started taking hormone therapy.

Participant 3 exemplifies how dissociation was alleviated by how she stopped feeling divorced from her appearance after starting treatment:

Even when I have worse dysphoria nowadays, I don’t get that kind of real… feeling that I’m not myself I see in the mirror sometimes. I don’t get, like, I don’t get shocked anymore when I kind of… happen to see my reflection. And that was since I started hormone therapy.

Participant 5 described how her personality differences in different situations decreased after treatment and that she began to feel less disconnected from herself. The tendency to switch personalities decreased and the personalities became less extreme and different from each other:

It’s kind of almost like the more you, I get kind of connected to myself and kind of to reality, these differences in my, how I experienced myself, more embarrassment, because it became more obvious how I saw myself at different times.

A similar description was given by participants that dissociation decreased after they started social transition, they came out to relatives and started expressing their gender identity more in their lives. In some cases, these events occurred in conjunction with each other, making it difficult to determine the relative impact of hormone therapy and social transition.

Discussion

All but one participant gave clear examples of feeling disconnected from their body and/or the outside world. Sometimes participants differentiated between their dysphoric (overtly negative, such as disgust or sadness) and dissociative (neutral or unclear) experiences. Nonetheless, they were linked because dysphoria could give rise to dissociative reactions and dissociation intensified when dealing with challenging situations. Dissociative reactions were seen as affecting negative everyday functioning, disturbing concentration and connection with others. Nonetheless, the effect of emotional numbness was more complex because at the same time that it encouraged separation it gave some protection from difficult emotions. Despite the emphasis on experiential detachment in the definition provided to the participants, the majority described something akin to the sense of parts or compartmentalization, acting out deliberately or automatically a personality different to their own. Finally, almost every participant mentioned that after receiving gender-affirming care, the dissociation decreased and became easier to control. The trans man’s reports were similar to those of the majority of trans women, with the exception of increased psychological deterioration and dissociation after the insight of being transgender.

The descriptions of the participants’ experiences were consistent with the definition and characteristics of dissociation. They include phenomena that Radovic and Radovic (2002) describe as common in dissociation, the “as if” similes and feelings of unreality. Although the participants understood that it was their own body and they themselves who were acting, they felt that they were not acting but being observers in their life and/or had a sense of unfamiliarity and unreality, in agreement with various concepts of depersonalization/derealization (e.g., Ackner, 1954; Cardeña, 1994; Cardeña & Carlson, 2011; Colombetti & Ratcliffe’s, 2012). The emotional numbness described by the participants is consistent with Ackner’s (1954) description of symptoms of depersonalization/derealization. The spontaneous mention of parts/compartmentalization supports the notion that these phenomena are commonly linked (e.g., Cardeña, 2011; Cardeña et al., 2021) rather than being very discreet (cf. Van der Hart, 2021).

Several of the participants described that their dissociation intensified when dealing with challenges and functioned as a way to deal with the discomfort and anxiety associated with their gender dysphoria. The exact emotions involved were not always known by the participant, but disgust and anger were among them. Dissociation allowed them to manage their daily lives better by shutting out unpleasant emotions they could not handle at the moment. This may indicate that dissociation is not necessarily problematic in and of itself for the people who experience it, but may be recognized as a sign of other sources of distress. Nonetheless, for some participants, dissociation, at least for a period of their life, was a clear obstacle in their life, so it is relevant for practitioners to explore whether their patients need support for dissociation, as otherwise there is a risk that patients may not recognize their experiences as dissociation and not seek support for them. The majority of participants remembered having their first dissociative experience at the age of puberty (10–15 years), which contrasts to how often early childhood is focused when considering transgender people and gender dysphoria. It may be, as some participants speculated, that the stressors of puberty served as triggers and is also consistent with depersonalization’s mean age of onset being around 16 years of age (Simeon et al., 2003).

Regarding the difference between gender dysphoria and dissociation, participants characterized as dysphoric negative emotions such as sadness, while experiences characterized by emotional numbness and distance from themselves were described as dissociation. Often, dissociative experiences themselves had a neutral valence, in contrast to the distress that Ackner (1954) describes as being caused by dissociation. However, there was a hint that dissociation caused some distress as participants described how they could be happy when it decreased after treatment or other life changes. In the cases where dissociation caused distress, it was because the person had difficulty being present in everyday life or became anxious about what the experiences might mean, while the dysphoric feelings were experienced as unpleasant in and of themselves.

Reduction of dissociation after coming out to relatives, but especially after starting hormone therapy, was common. Most participants experienced no or less dissociation than in earlier periods of their lives, and described coming out and starting hormone therapy as the breakpoints when dissociation decreased. Several also described how their dissociation became easier to deal with and was not as unpleasant after it was put in the context of being transgender, or that they began to understand what dissociation is and that it is harmless.

Research on how hormone therapy affects the quality of life for transgender people is unfortunately limited, but M. Colizzi et al.’s (2013) study indicates that hormone therapy leads to improved psychological well-being, consistent with a major survey (James et al., 2024). The fact that several participants describe how they experienced a clear improvement in their dissociation in connection with that treatment supports this and indicates how hormone treatment can be an important measure against dissociation. However, because many participants came out to their relatives and started hormone treatment around the same time it is difficult to determine the impact of each event on dissociation. M. Colizzi et al. (2013) suggest that the effect of hormone treatment may be psychological and that the treatment provides relief that alleviates dissociation. Healthcare professionals could help trans people’s well-being by helping them link their dissociative experiences to their gender dysphoria after explaining what dissociation is and how it works, but a participant told us that she had had trouble finding professionals who are aware of dissociation. As none of the participants had undergone surgical treatment for their gender dysphoria, this study could not evaluate whether it reduces dissociation.

Participants’ dissociative experiences were in many cases clearly linked to their gender dysphoria in terms of when the dissociation appeared and how they perceived and interpreted their experiences, and in that gender-affirming care and treatment from the environment resulted in a significant improvement in their dissociation and general well-being. However, other participants described their dissociative experiences as something mostly separate from their gender dysphoria, suggesting that in those cases the dissociation was a comorbidity rather than part of the gender dysphoria. For some, however, gender-affirming treatment and coming out to their social circle reduced dissociation. So it may be that when gender dysphoria is alleviated dissociation decreases, without necessarily being part of the gender dysphoria.

Whether dissociation was caused by factors other than gender dysphoria itself is difficult to determine, with minority stress in particular being a factor to keep in mind (Testa et al., 2015). The fact that dissociation decreases in the context of gender-affirming care supports the link to gender dysphoria, but it may also be caused by reduced minority stress as the person is not perceived by others as transgender as often anymore. Furthermore, the start of gender-affirming care may relate to the person having progressed further in their transition and thus having better social network with other transgender people and pride in their identity.

That dissociation linked to the body as a whole occurred to such a high extent among the participants suggests that it may be linked to gender dysphoria. Remarkably, only two of the females and the one male described dissociative experiences linked to specific body parts and it was not as prevalent among participants’ as disconnection to the body as a whole. This is in contrast to the fact that the gender dysphoria diagnosis in DSM-5 (American Psychiatric Association, 2013) asks how the patient relates to specific gender characteristics and not the body as a whole. Furthermore, the second DSM-5 criterion is formulated so that the patient needs to have a strong desire to rid themselves of their gender characteristic, which risks missing trans people who feel disconnected from their body but do not experience a strong repulsion for their body parts. For example, some of the participants described that they did not have strong feelings about their body and appearance before they were further along in their transition, as they were previously emotionally numb and/or avoided thinking about it by distracting their thoughts with other things.

Research can investigate how common dissociation is among transgender people and what forms it takes, to see if it is something that is linked to gender dysphoria and can be used in the diagnosis of gender dysphoria. Interview studies that focus on differentiating gender dysphoria and dissociation could provide further insights into similarities and differences between these experiences.

Strengths and limitations

The first author is a trans person herself, which probably benefited the study by making the participants more comfortable talking about their experiences during the interviews. They might not have shared certain experiences if they were interviewed by a cis person and had previous experiences of being distrusted if they do not fit the typical transgender narrative (Vipond, 2015). This also means that the researcher was more familiar with the terms used by the interviewees and the different experiences that trans people often have.

The study has the general goal of describing dissociative experiences in transgender people, but the possibility of generalizing from the results is circumscribed by the limited N, which on the other hand is not uncommon for an in-depth qualitative study, and the sample being formed almost exclusively by trans women. This was partly caused by attrition between initial contact and when the interview was to take place, and the small sample of transpersons reachable through forums, willing to participate, and not likely to be adversely affected by the interview. Nonetheless, the sample is close to a review finding that interviews with more conventional samples can reach saturation with an N = 9 and is consistent with the Code Meaning criterion for saturation after arriving to an understanding of the codes for the first 3–4 interviews (all but one of the codes were identified by the first 4 interviews) (Hennink & Kaiser, 2022).

The importance of anonymity for participants and the sensitivity of the topic makes it difficult to present detailed information about them (Elliott et al., 1999), which impairs the ability to interpret the results in context. Differences in responses within a theme are presented so as not to give the impression that they are uniform.

Credibility controls where the researcher’s analysis is checked is desirable for qualitative research, but was weak in this study (cf. Elliott et al., 1999), although the research was supervised by the senior person who is fluent in Swedish, so there were exchange of ideas and questions throughout the research process.

Among the participants, there was only one transman and no non-binary people represented, which means that mainly transwomen’s experiences were secured and the study is generalizable only to transwomen. Nonetheless, we have annotated ways in which the single transman agreed or differed from transwomen, which may be useful in generating hypotheses for additional research. All of the participants were recruited through the internet site Reddit, which may mean that how they processed their experiences and put them into words differs from transpeople who have not been in contact with that forum. The participants were probably more accustomed to reproducing and describing their dissociative experiences than the average transperson is, given the participation in the forum, but their descriptions may have been influenced by discussions with others.

Most participants had come out to their social circle, started hormone therapy and other gender-affirming treatments and all of them described that dissociation had decreased because of that, which means that many of the participants described experiences that had happened earlier in life and not ongoing experiences. It is possible that different descriptions would have been obtained if the experiences were closer in time, as memories can change over time (Belli et al., 1994)

Nonetheless, this study evaluated dissociative experiences from a qualitative perspective not previously used and can serve to provide a better basis for future research in the field, as well as pointing out issues that healthcare professionals should consider to support transpeople.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

Due to the nature of the research, due to ethical reasons (confidentiality) supporting data is not available.

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.