The Transgender Illness
The American Psychiatric Association (APA) is currently putting out their new Diagnostic Statistical Manual on psychiatric disorders where “Gender Identity Disorder” remains in the books as a mental disorder. The APA task force is chaired by Dr. Kenneth Zucker with a practice that supports “reparative therapy” for transgender people. You can find the the APA Task Force Report on Gender Identity and Gender Variance here.
Lynn Conway, a professor of Electrical Engineering from the University of Michigan recently released a report that strongly criticizes the APA task force report (Via Paradox) (Via Queers United.) You can find Conway’s study here.
Summary and Findings
The APA Task Force Report on Gender Identity and Gender Variance
The underreporting of GID prevalence derives from a deliberate misuse of clinical definitions and a failure to mention known calculation errors in sources. The unreasonably low prevalence numbers are given to three significant figures in the Report, as if they were precisely accurate – while failing to mention well-known sources of estimation error.
The Task Force then dismisses recent work by Olyslager and Conway that had exposed large errors in earlier studies by calling that work a “minority position” – as if a scientific analysis must be certified by a majority vote, rather than judged on its merits.
The Task Force further dismisses the work of Olyslager and Conway by insinuating that citation by “transgender activists” somehow reduces its validity – while failing to cite it themselves. Finally, the Task Force fails to mention recent scientific studies that report far higher-levels of GID prevalence than does their Report.
Is it too much to ask that the APA assure an un-biased and balanced committee in their taskforce for such a critical issue? Is it too much to demand for a fair and accurate assessment of the available literature and research? It is neither fair or balanced when the committee chair has built his entire career on understanding transgender behavior as a disease.
It has been over 35 years since the APA discredited homosexuality as a mental disorder. But GID still has not been objectively and critically evaluated as a mental illness. The damage that this does is twofold. It validates misinformation and provides no useful guidelines on treating trans-related mental health problems for health care providers. And it further stigmatizes an already marginalized and poorly-understood community.
In 1991, Silence of the Lambs showcased one of our first trans characters –a psychopathic killer who got off on killing women and dressing like a woman. Our understanding of the transgender community has not evolved too much beyond this.
Trans-gender people have often been the most visible members of the queer community, and have taken the brunt of the hate, violence, intolerance and ignorance. Despite the passage of Prop 8, the gay movement has made enormous strides over the past decade in integrating and normalizing LGB issues into our everyday. Disappointingly, the same cannot be said about the transgender community.
It’s a community where people continue to struggle to live their lives as they choose free of violence and hate. The near total silence from gay activists on this issue and an absence of a truly fair and balanced APA committee ensure that the transgender community will continue in their struggle.
Update: My own bias on why I think GID should be removed from the books is simple. I don’t believe that a strong desire to be the opposite gender is a mental illness. And understanding transgender people through this medical prism too often narrows our understanding of the same. And too often it has been used to stigmatize and violate human rights of the trans. community.
Having said that… here’s a useful comment reply from Helen G. that sounds better informed of what is actually happening with this issue.
The concerns of many trans and other gender variant people is that Drs Zucker, Blanchard and their colleagues in the APA’s Sexual & Gender Identity Disorders Work Group may well remove GID as a possible diagnosis, at which point it is likely that more people will be incorrectly diagnosed. The treatment of GID would become ‘cosmetic’ and, at its most extreme, it could also mean that things like HRT could be considered ‘harmful behaviours’.
But the argument for removing GID from medical classification is complex: when (in 1974) homosexuality was removed from the DSM, gay and lesbian rights began to gain prominence. It has been a suggested that if GID was removed, then trans people’s rights could also benefit. My concern about this is that it ignores the fact that many trans people have medical needs which did not, and do not, necessarily apply to GLB people, and provision needs to be made for this.
On the other hand, it is a concern that transsexual people are classified under the DSM as having a ‘mental disorder’ – an umbrella phrase which covers a wide range of conditions and which needlessly stigmatises many. From this there can follow the concept of being ‘mentally unfit’ which can, and does, lead to things like workplace discrimination or the loss of custody/visitation rights of children.
In the UK, at least, the removal of GID from medical classification may pave the way for a corresponding removal of the already limited and restrictive state (NHS) funding of medical treatment for the condition of gender dysphoria. In my opinion, the condition needs to be destigmatised without removing the funding.
Cellar Door 
Hello and thank you for linking…
The concerns of many trans and other gender variant people is that Drs Zucker, Blanchard and their colleagues in the APA’s Sexual & Gender Identity Disorders Work Group may well remove GID as a possible diagnosis, at which point it is likely that more people will be incorrectly diagnosed. The treatment of GID would become ‘cosmetic’ and, at its most extreme, it could also mean that things like HRT could be considered ‘harmful behaviours’.
But the argument for removing GID from medical classification is complex: when (in 1974) homosexuality was removed from the DSM, gay and lesbian rights began to gain prominence. It has been a suggested that if GID was removed, then trans people’s rights could also benefit. My concern about this is that it ignores the fact that many trans people have medical needs which did not, and do not, necessarily apply to GLB people, and provision needs to be made for this.
On the other hand, it is a concern that transsexual people are classified under the DSM as having a ‘mental disorder’ – an umbrella phrase which covers a wide range of conditions and which needlessly stigmatises many. From this there can follow the concept of being ‘mentally unfit’ which can, and does, lead to things like workplace discrimination or the loss of custody/visitation rights of children.
In the UK, at least, the removal of GID from medical classification may pave the way for a corresponding removal of the already limited and restrictive state (NHS) funding of medical treatment for the condition of gender dysphoria. In my opinion, the condition needs to be destigmatised without removing the funding.
Helen G:
thank you for your thoughtful and useful reply. I had one comment, though. When you say,
“My concern about this is that it ignores the fact that many trans people have medical needs which did not, and do not, necessarily apply to GLB people, and provision needs to be made for this.”
I agree. I have googled the defination of GID and what I see in the diagnostic handbook is pathetic. It includes behaviours and activities that (in my opinion) should never be considered a mental illness. Of course, trans people have many medical needs, especially physical health issues that are truly unique. But when understanding trans. mental health, it seems hugely regressive to simply categorize the entire condition (or any part of the condition) as a disorder. Which is not to say that trans-people do not suffer from mental illnesses. They do. Which is why we need better tools to diagnose them. GID doesn’t cut it.
The evidence is that Transsexuality is caused by a neurological anomaly in an otherwise normal body. Though you may as well say that it’s caused by a normal brain with immense anomalies in the body.
Anyway, the mismatch causes, in many cases, severe distress. Just as say, having a cleft palate or other obvious congenital anomaly causes severe distress. We classify a cleft palate as a medical condition requiring surgical intervention, but don’t classify it as a psychiatric illness despite the immense distress and sometimes suicidal ideation that can result. When surgically corrected, the psychological symptoms go away, though there may be co-morbidities caused by decades of being treated as a “freak” in less enlightened societies.
The parallel with transsexuality is obvious. Medical intervention to align brain and body is a necessity in severe cases, yet the condition itself isn’t a “purely psychiatric condition”, or even a psychiatric condition of any kind. It no more belongs in the DSM than cleft palates do – yet neither is the treatment “cosmetic”, it’s reconstructive to give close to normal functionality.
I think this confuses the issue. I am sure there is a ton of research out there on the transgender community that makes some point about some receptor or another. But I think it is misleading (in this instance) to confuse physical/biological “anomalies” with mental health issues.
What remains true is none of this research is at a point where it can inform policy. To put it a little differently, I am sure if you did a whole bunch of research on homosexuals (or heterosexuals with say… red hair) you would find any number of interesting “anomalies”. None of this, however, has any policy impacts. (And it shouldn’t.) This is not true with transsexuality as long as it is treated as a mental disorder. This is problematic for all the obvious reasons.
All I am saying is that an objective evaluation is long overdue. Is feeling like you should be born a woman when you are biologically a man the same as feeling you are a dinosaur. People who believe they are dinosaurs are typically psychotic and violent and have a depressed quality of life. Surely, we understand that transsexuality doesn’t have the same significance and impact on mental health. It is misleading and more importantly, dangerous for transgender patients who try to access mental health care from providers.
Better policy and practice is not automatically contingent on more research. It is, however, contingent on listening and responding to the community. This is not happening as it stands right now.
“Is feeling like you should be born a woman when you are biologically a man the same as feeling you are a dinosaur.”
It definitely isn’t – such delusional thinking excludes a diagnosis of GID under the DSM is all its versions. It’s a “differential diagnosis” to use the technical term. GID is quite specific, and shows none of the signs commonly associated with such disorders. It doesn’t have similar symptoms, neither does it respond to anti-psychotic medication.
In order to qualify for treatment, those with GID have to have multiple peer-reviewed assessments at different stages which are aimed at ensuring that they’re *not* bonkers, to put it bluntly.
Those patients with rare endocrine disorders that cause natural “sex-changes” usually show similar symptoms, either before or after their change. These conditions, while rare, are not so rare that they haven’t been studied extensively.
Zoe:
Hmm, that’s interesting, and also very good news. But also confusing. So basically if someone has GID, the health care provider has to show that they do not also have another mental illness? That’s weird. An added layer in mental health diagnosis that is surely cosmetic. I don’t know. It certainly sounds like a whole lot of circutious diagnostic pathways for the cost of misleading information and stigmatizing communities.
No-one who is delusional or psychotic can give informed consent for surgery. GID patients have to be certifiably sane for the treating team to be legally protected, not to mention the ethical issues.
It’s this contradiction that makes the placement of GID as a “mental illness” in the DSM so problematic. In order to have treatment the patient must have GID, and thus be “mentally ill”. But in order to consent to treatment, they must be sane, *not* “Mentally ill”.
The whole situation is a messive contradiction, and if not for the 98% success rate with treatment, and 0% success rate without, would have been abandoned long ago as a logical and actual absurdity.