Swindling the Diagnosis: Patient Strategies in Navigating Gender-Affirming Care

• In Event: Medical Sociology Section Roundtables
  In Refereed Roundtable (90 minute): Table 20. Gender Minority Health

Abstract

This paper examines how diagnostic authority and discretionary power structure access to gender‑affirming care (GAC) in the United States. Drawing on 72 oral histories with trans and nonbinary adults, I analyze how participants navigate a fragmented and uneven clinical terrain in which access to treatment is frequently routed through the contested diagnosis of Gender Dysphoria (GD). While diagnostic criteria and standards of care ostensibly guide clinical practice, participant accounts reveal that GD functions less as a neutral classification and more as a site where institutional variability, clinician discretion, and political pressures converge. I conceptualize this environment as diagnostic chaos, coined to describe the inconsistent, shifting, and sometimes contradictory evaluative practices that patients encounter when seeking GAC.

Amid this uncertainty, participants describe extensive preparatory labor: researching treatment pathways, interpreting diagnostic expectations, and relying heavily on community‑generated knowledge shared through peer networks. These forms of experiential expertise operate as essential infrastructure for navigating the diagnostic process, particularly in settings where providers lack training or adhere to restrictive interpretations of GD. When preparation alone is insufficient, many participants engage in what I term here as diagnostic swindling, a strategic calibration of disclosure to align with physicians’ perceived expectations. Far from deception, these tactics constitute pragmatic forms of self‑preservation in response to unequal conditions of evaluation. By filtering or reframing personal narratives to secure diagnosis, patients actively negotiate the discretionary authority that shapes their access to care.

This study contributes to the sociology of diagnosis via trans studies by demonstrating how discretion converts institutional variability into diagnostic labor borne primarily by patients and their communities. By centering patient perspectives, it reframes lay expertise as integral to clinical practice and offers a broader framework for understanding how contested diagnoses operate across marginalized health contexts.

Author

• Alexander Everett Coulter Hill, Michigan State University