Depersonalization in gender dysphoria: widespread and widely unrecognized

I’m going to list some descriptions of certain feelings, and I’d like for any trans or gender-questioning readers to think about whether they’ve felt anything similar to this over the course of their lives.

• A sense of detachment or estrangement from your own thoughts, feelings, or body: “I know I have feelings but I don’t feel them”
• Feeling split into two parts, with one going through the motions of participating in the world and one observing quietly: “There is this body that walks around and somebody else just watches”
• Feeling as if you have an “unreal” or absent self: “I have no self”
• Experiencing the world as distant, dreamlike, foggy, lifeless, colorless, artificial, like a picture with no depth, or less than real
• Being absorbed in yourself and experiencing a compulsive self-scrutiny or extreme rumination
• Having an ongoing and coherent dialogue with yourself
• Feeling like a veil or glass wall separates you from the world
• Emotional or physical numbness, such as a feeling of having a head filled with cotton
• Lacking a sense of agency – feeling flat, robotic, dead, or like a “zombie”
• Inability to imagine things
• Being able to think clearly, but feeling as if some essential quality is lacking from your thoughts or experience of the world
• A sense of disconnectedness from life, impeding you from creative and open involvement with the world

These are taken directly from clinical descriptions of depersonalization and derealization, symptoms which are generally characterized as “feelings of unreality” (American Psychiatric Association, 2013; Sierra, 2009; Steinberg, Cicchetti, Buchanan, Hall, & Rounsaville, 1993; Medford, 2012). This is not a matter of “delusion” – while these are considered dissociative symptoms, individuals who experience them without other dissociative conditions typically have an intact grasp of reality. They’re able to recognize and understand the real world in a normal way, but their experience of life and of their own existence takes on an “unreal” sensation.

Despite the reduced emotionality of those with depersonalization, they often find these feelings to be deeply unpleasant and distressing, and can suffer “extreme emotional pain” as a result (Medford, 2012; American Psychiatric Association, 2013). An additional challenge is that the subjective experience of depersonalization can be “particularly difficult for patients to describe, and can sometimes go unnoticed or can be experienced by patients habituated to it as ‘normal’” (Steinberg et al., 1993).

Depersonalization symptoms can also occur in the context of untreated gender dysphoria, yet this is not widely recognized among the public or in most literature on transness and transitioning. Descriptions of depersonalization-like experiences feature prominently in many trans people’s recountings of their lives prior to transition, and these symptoms can heavily impact their general quality of life. But with very little attention given to depersonalization as a discrete symptom experienced by many with gender dysphoria, some trans people may struggle to recognize that this could be an indicator of dysphoria, and may not be aware that they could find relief via transitioning.

Narratives of depersonalization in gender dysphoria

The most-read article I’ve ever written, “‘That was dysphoria?’ 8 signs and symptoms of indirect gender dysphoria”, was my initial attempt to describe a sense of pervasive discomfort and unease that didn’t seem to be directly connected to any matters of gender, but which subsided entirely once I started transitioning. Since I published this post in September 2013, numerous trans people across the web have noted that my descriptions resonate strongly with their own experiences, sometimes with an almost uncanny similarity.

While some of the feelings I listed align more closely with depression and anxiety – both of which I’ve been treated for since transitioning – many now stand out as clear examples of depersonalization symptoms. I wasn’t aware of the phenomenon of depersonalization at the time, yet much of this post reads like a textbook definition of it: a feeling of unreality, distance from emotions, splitting into a “participator” and “observer”, sensations of numbness, feeling like a robot, lack of agency, separation from the world by a “veil”, ongoing critical self-dialogue, and the misconception that this was simply normal for me.

A sense of misalignment, disconnect, or estrangement from your own emotions. I could almost never cry at all, even when I wanted to. I would feel like crying, I would know on some level that I should be crying, but I just couldn’t make it happen. When I rarely did manage to cry, that was even worse. … And I dreaded crying, because afterward and for the next day or so, I would be smothered in this horrible feeling of emotional deadness. It felt like my head was full of concrete, like my consciousness was trying to wade through molasses, and it was a feeling that seemed to be genuinely physical in nature.

A feeling of just going through the motions in everyday life, as if you’re always reading from a script. Everything always seemed like it was somehow less real than it ought to be. I didn’t feel like I was my own person – I had no sense of myself as someone who could make my own choices and decisions as I wished. I often lacked that internal initiative that wants things and seeks things for no reason other than the fact that you simply want them and that’s that.

Since I didn’t want to do anything, I just did whatever was expected of me and said whatever was expected of me. That was all I ever did. I felt like an actor, being handed my lines by someone else, and I didn’t know how to be anything other than that.

It felt like my mind was constantly talking to itself without any interruption, and it was overanalyzing everything around me. Some second, parallel existence seemed to be running alongside my direct experience of consciousness: an inner monologue of sorts, but a very toxic one. I couldn’t stop thinking about everything – it was as though this loud voice in my head kept me from simply existing in the moment.

There always seemed to be some invisible skin separating me from the rest of reality – I could move around in the real world, interact with it, but never actually touch it or feel it.

For a few years, my emotions weren’t just blunted or dysfunctional – they went missing almost entirely. I felt nothing, day in and day out. And each day was the same, a robotic routine of just waiting for the time to pass.

When you don’t know what this is, or that it’s even an actual condition, it’s easy to mistake it for who you naturally are. … Because I viewed my lifelong unease in this way, I initially believed that I didn’t even experience dysphoria, and that I was already okay. I didn’t know there was anything wrong with me.

For me, these symptoms were something I could only discern as being separable from myself once they vanished upon starting HRT:

I could cry and feel good afterward, as if it replenished me rather than draining me of emotion. It was possible to feel things in all their detail and depth and texture, rather than being limited to either numbness or emotional overload. The skin of separation was gone, and life was a breeze: I was just happy, all day, without constantly intrusive thoughts distracting me and separating me from the world. I can truly care about everything I choose to work towards, because it matters now. I’m the normal person I always wanted to be, and I can get on with simply living. Finally, I was a whole human being. Nothing was wrong and nothing was missing anymore. I found what I was looking for, and it gave me back the life that dysphoria had taken from me.

My girlfriend Penny, a trans woman, described similar experiences before and after beginning HRT:

When it’s something you grow up with, it can be very difficult to realize that you’re not “supposed” to be feeling that way, that your normal is not the norm. Even recognizing what’s going on, finding the language to describe your feelings and experiences, is insufficient.

Seemingly intrinsic feelings of dread, hopelessness, and rootless melancholy melted away, lifting the lifelong haze that had clouded my vision of not just the world but even my own self.

A number of trans and questioning people on message boards and elsewhere mention many of these same themes, such as persistent emotional numbness, a sense that one’s feelings are somehow unreal, feeling robotic, seeing the world as distant or flat, separation into an observer of oneself, having an absent self, and feeling like less than a “real” person:

Complete lack of motivation, very discouraged and bleak. Can’t care about anything. … Can’t summon the willpower to ‘be a person’ to people, feeling sort of like a wall that provides yes or no answers. Nothing seems important. A feeling of disconnect from myself, as if my mind and body are two separate entities. My day-to-day goals hold no weight in my decision making. … Nearly all the time I feel generally apathetic to things, my external reactions are more of a formality than what I actually feel about something. A faint feeling that I’m acting like a person as if it’s a social requirement? – Reddit user haventa, 7 May 2016

Over time (when I hit the age of 13 or 14) it evolved into the numb feeling, where I would go through my days casually like some unconcerned outsider and on those days it felt more like a sequence of scenes in a movie than something that was an experience of my own. When I looked at my body and at bodies of other people, I saw just the meat, the blood running through their veins, etc. I often had a feeling that all the things and people around me are there just for show. My friends, my family, strangers on the subway, all of them just soulless husks. – Reddit user witchhunt32, 25 Jun 2017

My emotions feel completely artificial at times. Even when provoked, My actions are always calculated, and it feels like a performance when I get mad or act on emotion. In fact, I always get mad in a rational way, and I only express my anger after deciding “I should get angry right now to assert myself.” I have a great ability to step back and observe my feelings from an objective standpoint. At times there’s a hypercritical monologue that runs alongside my life. It’s like that I haven’t grasped this is my life, and that the things surrounding me are real. – Reddit user Terracorner, 25 Jun 2017

I don’t think I’ve cried, like really cried, in a long time without having some piece of media- a film or a song, mainly- that’s extremely relatable to something I feel I should be crying about, and even then, I feel like I’m fighting my brain to continue as it tries to pull me away and shut it down. On top of all of that, I found out recently that when people finish crying they feel energised and refreshed or something, I just go back to feeling empty, and turned off… – Reddit user shoelaze, 2 May 2016

So, when I was younger (especially noticed this in high school), I absolutely had the experience of “this body moves around, somebody else watches” and of feeling things but also not feeling them at the same time. I remember once just bawling after a fight with my dad when I was in high school, and I walked into the bathroom so I could see myself cry, and thought “Ah yes. That is definitely me crying. Interesting how my face has gotten red.” And this was true pretty much constantly; there was a Me dispassionately observing my every waking moment, watching and considering my emotions or actions instead of participating in them. – Reddit user arco_darco, 25 Jun 2017

In that state, I was a dispassionate observer of my own life. The person who went through the motions wasn’t the observer-me. Whenever the acting-me felt any emotions, the observer-me recognized the emotions but didn’t feel them herself. Furthermore, the observer-me had complete control over the acting-me in the sense that the observer-me could deliberately detach any part of the mind so that neither of the selves could access it. … All these symptoms disappeared very rapidly after the start of HRT. About one month in I started to sense that I was more present in the present than before, and the reality appeared more substantial and vividly colored. It was like actually standing at some spot instead of watching a black-and-white TV broadcast of the situation. My compartmentalized mind merged during one unforgettable moment about five weeks into HRT, and I gained full access to all my emotions… – Reddit user calisthymia, 26 Jun 2017

At age 14 I experience hard derealization/depersonalisation, feeling that even my dreams were more real that life, that I looked at myself through a movie. Now it’s different, more like a numbness of all senses and feelings, my outer self playing this theater play for me to the out world. – Reddit user Korf74, 26 Jun 2017

What also alerted me to the fact that something was off was when I started training for Roller Derby and I realized I had no real sense of who I was. Pick a derby name related to something about you! I realized I knew nothing about myself and couldn’t describe who I was. At all. – Reddit user LeighDavidMaxwell, 26 Jun 2017

I have found myself asking: Is this only a dream? It is everything around me even real? I felt deja vu and sense of acting just every day. Also, internal dialogues are such a big part of me. – Reddit user intheabyss90, 26 Jun 2017

I was never really present in my life. Everything was grey, foggy, and not really there. Nothing really got through to me. Eventually I ended up talking to myself a lot in my head and eventually felt like I was two seperate people. I have been described as not being there at all. Post HRT it’s better; colour’s come back and I’m one person for sure now. Still working on the being fully there part; I drift off a lot. – Reddit user lapisblaze, 26 Jun 2017

All of my memories from when I was 7 through 24, are all in third person. Day to day, I felt like a zombie, just going through the motions. I was completely detached from my emotions and either was angry or felt nothing. – Reddit user addyftw1, 26 Jun 2017

i’d spend all day in school with my arms crossed in silence or just like going through the motions. feelings started to go eventually, i couldn’t find myself through the mask i was wearing, it was like i was suffocating. – Reddit user dysphoricdude, 3 May 2016

I find myself very detached from my emotions. It’s felt like that for me for a long time, probably since puberty. As a result, I’ve always thought that my brain chemistry was wrong, because there are many times where I want to really feel that emotion but somehow can’t. – Reddit user cheerbear02, 2 May 2016

Well for my dysphoria just felt like i was always smothered in some sort of heavy blanket or fog. Simple things seemed too tedious to do, always mentally exhausted from little things, and just an overall sense of being different…plus my emotions were totally whack. When i started taking steps towards transitioning, it kinda felt like that “fog” of mind was going away with every doctor and therapist visit – Reddit user einnaeJ, 3 Oct 2013

It’s like this is how I’ve lived my entire life, I don’t know any different. I often tell my wife that I think of it like Pleasantville, and I’m still monochrome, but I’ve seen that it’s possible to live in color! – Reddit user Chloe_Stark, 25 Jun 2017

The cliché is that you’re a woman trapped in a man’s body, but it’s not that simple. It’s a feeling of detachment from your body and from yourself. And it’s shitty, man. It’s really fucking shitty. – Laura Jane Grace, 2012

It’s almost impossible to explain. But it’s so destructive. It’s the worst. It stops us dead: it’s the dysphoria that comes along and fucks everything, undoes the hard work, undermines our confidence, undermines our identities. It pulls the rug out from under our personal realities. It’s actual hell. – tg101.blogspot.com

Many of these individuals have spent years living what feels like an incomplete life, struggling to make sense of painful feelings of internal emptiness and a sense of dislocation from the external world. I can attest that it’s a very short step from there to seeking out unsafe ways of feeling even briefly alive, or concluding that life may not be worth living at all. The distress we experience as a result of this is very real – and being unaware of the potential benefits of transitioning in treating depersonalization can mean spending many more unnecessary years having to cope with this feeling of being a void, living in a void.

Effects of transitioning on depersonalization symptoms

Depressive and anxious symptoms are highly prevalent among trans people, and these are significantly reduced following treatment with HRT (Costa & Colizzi, 2016). A handful of studies have also examined depersonalization and broadly dissociative symptoms in trans people, though usually not in much detail. These studies consistently find that rates of dissociative symptoms, including depersonalization, are elevated in trans people, and that this declines following medical transition (hormone therapy and/or surgery).

• Walling, Goodwin, & Cole (1998) found that scores on the Dissociative Experiences Scale (DES) were significantly lower in trans people who had reassignment surgery compared to trans people who had not, most significantly on the subscale of depersonalization.
• Wolfradt & Neumann (2001) studied trans women who had completed reassignment surgery, finding that their levels of depersonalization symptoms were comparable to cisgender male and female controls.
• Kersting et al. (2003) compared the scores of trans people (only 17.1% of whom had surgery) to those of cis controls on an expanded version of the DES. Trans people had a mean score of 18.33 on the depersonalization subscale, whereas the cis control group had a mean score of 2.80. Those trans people who had surgery showed a mean depersonalization score of 10.95, compared to 19.85 for those who did not have surgery. However, the authors note that the overall trans group’s elevated depersonalization score was primarily due to their answers to one DES item having to do with body sensations (“Some people have the experience of feeling that their body – or parts of their body – does not seem to belong to them”). When this item was excluded, the mean depersonalization score for the trans group overall fell to 8.37.
• Bandini et al. (2013) found that trans people who had not undergone genital surgery showed elevated scores on the depersonalization subscale of the Body Uneasiness Test (BUT) compared to cis male and female controls, while trans people who had undergone surgery scored similarly to cis controls.
• Fisher et al. (2014) studied trans men and trans women who had not undergone surgery, finding that trans women on hormones showed a significant drop in BUT depersonalization scores compared to trans women who weren’t on hormones, but trans men did not exhibit a significant difference.
• Colizzi, Costa, & Todarello (2015) noted that trans people show a lifetime prevalence of any dissociative disorder of 29.6%, compared to 12.2% of the general population. In their longitudinal study, trans people’s mean DES depersonalization subscale score decreased following HRT (19.05 at baseline vs. 9.31 at followup), but showed no further drop following surgery (9.31 vs. 9.66). However, when the “feeling that their body does not belong to them” item was excluded from the depersonalization subscale, their baseline score fell from 19.05 to 12.72.

While existing studies are sparse, the literature offers evidence that, much like depression and anxiety, depersonalization is a distinct symptom experienced by many trans people that can be effectively treated by transitioning. A large part of the reported elevation in these symptoms appears to be due to elements of bodily estrangement that may be inherent to feelings of gender dysphoria, but depersonalization remains high even when this is omitted.

Hypotheses and future research directions

Several possible mechanisms have been proposed to explain the effect of transitioning on depersonalization symptoms.

1. Bodily congruence with gender due to physical changes. Researchers have contended that reductions in dissociative symptoms following transition may be due to the changes induced by medical transition, bringing the body’s physical form into alignment with gender identity: “dissociative symptoms may be considered as a reaction to the non-satisfaction connected to their incongruent image. Instead, hormone therapy induces desired changes in GD patients’ body features and shape and this could translate into a better quality of life for the patient himself” (Colizzi et al., 2015).

However, this was contradicted by the finding that patients whose bodies already largely aligned with their genders still exhibited similar levels of these symptoms: “the few patients who passed in their desired gender role without hormonal treatment did not show a lower prevalence of dissociative symptoms than all the other patients, both at baseline and follow-up” (Colizzi et al., 2015).

2. Psychological significance of making progress in transition. Relief of psychiatric symptoms upon beginning transition has also been attributed to a kind of “placebo effect”, in terms of excitement or enthusiasm about taking major steps toward actualizing one’s gender: “the initiation of the hormonal treatment could have a psychological meaning which per se could be fundamental in reducing distress” (Colizzi et al., 2015).

3. Short-term direct action of hormones on dissociative symptoms. This possibility is the least strongly supported by published studies, but is supported by the anecdotally reported experiences of some trans people on HRT. While changes in physical development typically only begin after 1–3 months of HRT and can take years to reach their full extent (Hembree et al., 2009), trans people have sometimes noted positive changes in mood beginning within a few weeks of starting hormones, including feelings of happiness, calmness, a stronger experience of emotions, a sense of normality, feeling that the world is “clearer” or “brighter”, feeling “alive”, or dramatically “feeling better than ever” (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28).

Speaking personally, I noticed the lifting of depersonalization symptoms within one to two weeks after beginning HRT, and this was something that I had simply never felt before – neither during previous transition milestones such as coming out and presenting as a woman full-time, nor at any other point. Nothing has ever come close before or since. The difference felt almost undeniably chemical; merely being excited about major events in my life had never caused such a noticeable and unexpected change. Estrogen can act on NMDA receptors, which are implicated in dissociative symptoms broadly, although the potential role of such a mechanism in gender dysphoria is highly speculative.

While Colizzi et al. (2015) had a followup time of about 12 months after starting HRT, tracking depersonalization symptoms over a shorter period of 1–2 months could help establish whether these changes can indeed occur even more rapidly. The possibility of vivid short-term changes in depersonalization symptoms also suggests that a brief trial of HRT could be of diagnostic value for some gender-questioning individuals, allowing for the opportunity to see whether hormones have beneficial psychological and emotional effects before any lasting physical changes take place.

The significance of recognizing gender dysphoric depersonalization

In terms of the public’s general understanding of the experience of gender dysphoria, the element of depersonalization tends to be almost totally absent. While themes of feeling “trapped in the wrong body”, becoming “comfortable in one’s skin”, or “making the outside match the inside” are typically prominent, far less attention is given to the pervasive and severe emotional pain of dissociative symptoms that often accompany dysphoria – the sheer suffocating emptiness of life; the total starvation of any genuine experience of emotion; the desperate wish to find some way of simply feeling like a part of the real world.

Failing to comprehend the significance of these symptoms, and the relief we can find in transitioning, can easily lead cis people to underestimate the importance of living as our selves and receiving the care we need. For many of us, this is absolutely irreplaceable, something that cannot be subject to negotiation and something that we would never, ever give up. This is so much more than a matter of being “comfortable” – it’s a question of being consigned to a lifetime of lifelessness, or finally escaping from that all-consuming veil and touching reality for the first time. Transitioning is about more than just being a man or a woman. It’s about being a person. ■

References

• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. [Excerpt]
• Bandini, E., Fisher, A. D., Castellini, G., Lo Sauro, C., Lelli, L., Meriggiola, M. C., . . . & Ricca, V. (2013). Gender identity disorder and eating disorders: similarities and differences in terms of body uneasiness. Journal of Sexual Medicine, 10(4), 1012–1023. [Abstract]
• Colizzi, M., Costa, R., & Todarello, O. (2015). Dissociative symptoms in individuals with gender dysphoria: is the elevated prevalence real? Psychiatry Research, 226(1), 173–180. [Abstract]
• Costa, R., & Colizzi, M. (2016). The effect of cross-sex hormonal treatment on gender dysphoria individuals’ mental health: a systematic review. Neuropsychiatric Disease and Treatment, 12, 1953–1966. [Abstract] [Full text]
• Fisher, A. D., Castellini, G., Bandini, E., Casale, H., Fanni, E., Benni, L., . . . & Rellini, A. H. (2014). Cross-sex hormonal treatment and body uneasiness in individuals with gender dysphoria. Journal of Sexual Medicine, 11(3), 709–719. [Abstract]
• Hembree, W. C., Cohen-Kettenis, P., Delemarre-van de Waal, H. A., Gooren, L. J., Meyer, W. J. III, Spack, N. P., . . . & Montori, V. M. (2009). Endocrine treatment of transsexual persons: an Endocrine Society clinical practice guideline. Journal of Clinical Endocrinology & Metabolism, 94(9), 3132–3154. [Full text]
• Kersting, A., Reutemann, M., Gast, U., Ohrmann, P., Suslow, T., Michael, N., & Arolt, V. (2003). Dissociative disorders and traumatic childhood experiences in transsexuals. Journal of Nervous and Mental Disease, 191(3), 182–189. [Abstract]
• Medford, N. (2012). Emotion and the unreal self: depersonalization disorder and de-affectualization. Emotion Review, 4(2), 139–144. [Abstract]
• Sierra, M. (2009). Depersonalization: A new look at a neglected syndrome. New York, NY: Cambridge University Press. [Google Books]
• Steinberg, M., Cicchetti, D., Buchanan, J., Hall, P., & Rounsaville, B. (1993). Clinical assessment of dissociative symptoms and disorders: the Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D). Dissociation, 6(1), 3–15. [Abstract] [Full text]
• Walling, D. P., Goodwin, J. M., & Cole, C. M. (1998). Dissociation in a transsexual population. Journal of Sex Education and Therapy, 23(2), 121–123. [Abstract]
• Wolfradt, U., & Neumann, K. (2001). Depersonalization, self-esteem, and body image in male-to-female transsexuals compared to male and female controls. Archives of Sexual Behavior, 30(3), 301–310. [Abstract]

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