Despite the central role of gender dysphoria in the lives of many transgender people, discussions of gender dysphoria remain scant in conversations about affirmative practice. As such, scholars have called for qualitative studies to explore gender dysphoria through the voices and perspectives of transgender people. The primary aim of this study is to use grounded theory methodology to gain a more in depth and comprehensive understanding of gender dysphoria from the perspectives of transgender adults. Data for this study is associated with the online, written responses of 362 transgender adults (nonbinary ϭ 118, trans woman ϭ 49, trans man ϭ 133, genderqueer/genderfluid ϭ 49, and 2-spirit ϭ 8). Data deepen understanding through the following 7 themes: (a) being impossible to explain, (b) never being seen as me, (c) living in an imposter's body, (d) shapeshifting nature of gender dysphoria, (e) being tortured by one's own body, (f) emotional suffering, and (g) disrupting impact. Findings shed light on the multifaceted impact of gender dysphoria as well as the depth and severity of suffering associated with these experiences. Participants' first-person descriptions of their own experiences with gender dysphoria offer concrete as well as metaphorical examples that elucidate the nature, severity, and impact of distress on multiple dimensions of functioning. Findings underscore the importance of transgender affirmative medical and mental health care rooted in comprehensive knowledge of the scope and impact of gender dysphoria and the interventions (e.g., transition related care) that help to alleviate gender dysphoria. Public Significance StatementThis study provides rich description of experiences of gender dysphoria among transgender individuals. Study findings dispel the myth of the singular transgender experience while advancing understanding about the range, severity, and impact of gender dysphoria. Findings offer important insights to inform the development of affirmative practices and policies to advance access and availability of comprehensive transition related care.

Background The COVID-19 pandemic has been impacting the need, utilization, and delivery of mental health services with greater challenges being faced by clients and providers. With many clients facing reduced access to services and social isolation, a focus on suicide risk assessment and prevention is critical. Concern is particularly increased for clients with schizophrenia spectrum disorders given data show suicide rates are disproportionately high for those with psychosis in comparison to the general population. Provider perspectives of challenges in service delivery are needed to inform efforts to improve access, feasibility, and quality of mental health care throughout the evolving pandemic. This study explored mental health provider perspectives of client challenges in service utilization and provider challenges in service delivery, including remote engagement, suicide risk assessment, and treatment of psychosis. Methods Data were collected from social work mental health providers (n = 12) in United States community mental health setting. Providers consented to participate and responded to questions about service delivery experiences in late 2020 and in relation to COVID-19. Demographic and practice-related provider data were explored descriptively using SPSS and qualitative data using open coding and grounded theory methods in Dedoose. Results Among the 9 providers who engaged in remote service delivery, 7 (77.8%) experienced challenges in remote engagement with clients and 8 (88.9%) experienced challenges in treatment of psychosis. Among the 7 providers who engaged in remote suicide assessment, 4(57%) experienced challenges. Qualitative themes emerged including logistic (e.g., technology access and use), engagement (e.g., virtual rapport-building and limited remote services), and clinical (e.g., difficulty assessing suicide risk, internal stimuli, abnormal involuntary movement, and affect) challenges in service delivery. Conclusions Provider perspectives are essential to inform efforts to build resources and problem-solve challenges and barriers that both providers and clients face throughout various shifts in mental health service delivery. Findings emphasize the need to troubleshoot client access to technology, bolster support for providers to prevent burnout, and greater provider training to improve skills in remote engagement, assessment, and treatment, particularly in relation to psychosis and suicide prevention. Study implications are not only critical for the evolving COVID-19 pandemic, but also in preparation for ongoing shifts in service delivery as technology evolves.

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