In this short blog I want to draw our attention to the term ‘diagnostic overshadowing’ and its use by anti-trans actors to mask attempts at conversion practices.
Diagnostic overshadowing is a medical term used to describe the situation where one medical condition or diagnosis ‘overshadows’ another one, leading to mis-diagnosis.
Trans communities will recognise the concept in the well documented ‘trans broken arm syndrome’. Transphobic or inexperienced medical practitioners can go into panic when treating a trans person, and mistakenly attribute completely unrelated medical issues to a person being trans or taking gender affirming hormones.
Trans patient: Look, my arm is clearly broken in several places, I need a plaster cast.
Emergency care Dr: Oh, you are trans! Are you on HRT? I don’t know how to treat you, we’d better send you to the psychologist.
In trans communities this type of ‘diagnostic overshadowing’ is recognised as a problem that we want and need medical providers to acknowledge and avoid. Trans people should not receive poorer medical care from professionals who presume their transitude is at the root of unrelated health conditions.
In these cases, diagnostic overshadowing is a problem, and something to be avoided.
Transphobes like to use the term diagnostic overshadowing in a different way, one that we need to be aware of and protect against.
Transphobes do not recognise self-identification as trans. They focus on transness as a diagnosis or medical condition, with an emphasis on people suffering from the condition of ‘gender dysphoria’. Rather than considering a trans person ‘being trans’ with affirmative healthcare are a route to self-actualisation and gender euphoria, they focus on a person ‘suffering from gender dysphoria’ with affirmation one of many potential ‘treatments’ for that distress.
Transphobes then use the term diagnostic overshadowing in a manipulative way that masks their true intentions.
For a transphobe, a trans child or teen is likely to have ‘mis-diagnosed’ themself as suffering from gender dysphoria. They are likely to ‘misattribute’ their anxiety, depression or suicidal ideation as being wrapped up in their mis-diagnosis. They are likely to argue that gatekeepers should ‘protect’ trans youth from mis-diagnosing their depression or anxiety as being linked to dysphoria or to being trans in a transphobic world. Transphobes argue that the first step in any service is to look for other causes and other ‘treatments’ for anxiety or depression before enabling affirmation. They argue that an affirmative approach (where clinicians accept a child’s identity) is going to result in ‘diagnostic overshadowing’ of other past traumas or mental health issues. Transphobes do not accept that being trans is a healthy part of human diversity, and do not recognise the mental health burden of being trans in a transphobic world. Importantly, their transphobic approaches to ‘treating’ gender dysphoria by denial of affirmation are already proven to be harmful, unethical and ineffective.
Transphobes then wield the term ‘diagnostic overshadowing’ to criticise affirmative healthcare. They say that any healthcare professional who accepts a child or teenager’s ‘self-diagnosis’ of transitude or dysphoria or transphobia as at the root of their mental health problems, is practicing ‘diagnostic overshadowing’ – allowing a self-diagnosis of gender dysphoria to explain other mental health issues (that, transphobes claim, are instead driving their gender confusion). Transphobes argue that to avoid ‘diagnostic overshadowing’ health professionals and teachers and parents need to take a ‘critical’ approach to a youth’s self-understanding. Clinicians need to look for ‘causes’ and ‘treatments’ for all areas of trauma, neurodiversity, depression, anxiety etc BEFORE enabling affirmation.
Florence Ashley’s scholarship is relevant here see (here, here and here)
Diagnostic overshadowing is already recognised as a ‘bad practice’ in healthcare. Something that we all want to avoid.
So, when transphobes say ‘we want to avoid diagnostic overshadowing’ this can easily be interpreted as something benign, as something positive.
BUT they are manipulating the term, to enable conversive practices. To enable harm to trans youth.
I am therefore extremely concerned to see the term used multiple times by Cass, including in her recent response to the draft NHS service specification.
I am extremely concerned at a lack of community push back to Cass’ use of this term – I have spoken to folks who didn’t really understand the term and simply assumed it was something benign, which is why I wanted to publish this blog.
I do think ‘diagnostic overshadowing’ is a genuine problem in trans healthcare. But in a transphobic NHS it is primarily a problem leading to denial of trans healthcare. Youth who are neurodiverse, disabled or mentally ill routinely experience ‘diagnostic overshadowing’ with clinicians focusing on their co-existing differences as a potential driver of their gender distress, with neurodiverse, disabled or mentally ill trans youth denied affirmative healthcare.
Cass is not tackling this type of ‘diagnostic overshadowing’. Instead, she is presuming that the NHS at present is allowing self-identification as trans to ‘overshadow’ other mental health problems or allowing mis-diagnosis as trans to get in the way of more pressing need to ‘treat’ anxiety or depression (without gender affirmation).
This interpretation is baked into the proposed service specification.
A service that was trying to ensure neurodiverse, mentally ill, disabled or traumatised trans youth have equitable access to trans healthcare would be designed with steps to ensure those youth have equitable access without their diversity counting against them. The new service spec does the opposite.
The new service spec instead looks for ‘solutions’ and ‘treatments’ outside of affirmation and affirmative healthcare.
This way conversion therapy lies.
Cass is enabling this without clearly saying so, using the term ‘diagnostic overshadowing’ to justify a marked shift to a conversion therapy adjacent model.
Cass is dangerous because she is enabling conversion practices by saying ‘we need to avoid diagnostic overshadowing’. This unclear term leads most people to just nodding in agreement, assuming the NHS knows best, always underestimating the power of institutional transphobia and trans-pathologisation.
When folks caution about the rise of fascism they remind us that fascism doesn’t (always) come with Heil Hitler salutes and swasticas, it comes with calls to protect family, nation, tradition.
We need to similarly recognise that a return to conversion therapy doesn’t come with a banner saying ‘Conversion here’. It comes wrapped in ‘gender exploratory therapy’ and a call to avoid ‘diagnostic overshadowing’.
I’m deeply concerned for trans children and teens under the NHS
I’m sick of folks (and organisations) giving Cass the benefit of the doubt just because she avoids inflammatory rhetoric.
Trans kids deserve better – they have a right to evidence-based affirmative healthcare. They have a right to safety from harmful conversive practices.