Transgendered and Mentally Ill?

This post is part of a series of guest posts on GPS by the graduate students in my Psychopathology course. As part of their work for the course, each student had to demonstrate mastery of the skill of “Educating the Public about Mental Health.” To that end, each student has to prepare two 1,000ish word posts on a particular class of mental disorders.

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Transgendered and Mentally Ill? by Elaine Cooper

Much discussion surrounding the transgender community has lately focused on the inclusion of “Gender Dysphoria” in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Previously labeled “Gender Idenitity Disorder”, the recently published (May 2013) DSM-5 made changes to move away from labeling the transgender experience as a disorder. The question that remains is: does the mere inclusion of gender dysphoria in the DSM label the transgender community as mentally ill?

Gender dysphoria is defined as a marked incongruence between one’s experienced and expressed gender and their assigned gender. Simply put, they experience an overwhelming feeling of desire to be of the other gender. One cannot help but draw comparisons to the classification of homosexuality as a mental disorder up until 1973. Following its official removal, a different diagnosis emerged: Ego-Dystonic Homosexuality. “Dystonic” specifically qualifies individuals who are unhappy with their same-sex feelings and desires. By removing the initial diagnosis of homosexuality, the DSM-III only considered individuals who viewed those same-sex feelings as unwanted to be “disordered”. While this diagnosis seems like a stretch, it remained in the DSM-III for 7 years until it was completely removed in 1980. One particular article reviewed extensive studies conducted to determine the cause of homosexuality, blaming over-involved mothers and distant fathers. There was a need in society to explain this so-called disorder. Further, it was found that these -what now seem absurd- findings were resurrected in the late twentieth century to explain transsexualism

The inclusion of homosexuality in the DSM mirrored societal opinions surrounding it at the time. Here we are 30 years later with a very similar situation. One cannot help but draw parallels between homosexuality and gender dysphoria as mental disorders. The DSM-5 still includes a diagnostic category that stigmatizes a minority group, transsexuals, as it once did with homosexuals. Our society is already full of stereotypes surrounding transgender groups, but does the label of mental disorder reinforce and validate these existing stereotypes?

American transgender activists and mental health professionals have argued for the removal gender diagnoses all together or to at least reform diagnostic criteria. While gender dysphoria is still included in the DSM-5, gradual steps have been made in a positive direction. Firstly, and most obviously, the name is now gender dysphoria, removing the label of “disorder”. Dysphoria highlights the confusion about one’s experienced gender in contrast to the gender they were assigned to at birth. It is this marked incongruence and the distress surrounding it that makes this experience unique. Further, the language of the diagnostic criteria emphasizes distress and dysphoria rather than gender nonconformity. Nonconformity labels individuals who do not fit into societal expectations or an established norm, and should not be used as a label of mental disorder. The individual must experience distress in order to be diagnosed with gender dysphoria. Is this to say that a transgender individual who does not experience distress should not be diagnosed with gender dysphoria? Technically, yes. Generally, individuals do experience forms of depression or anxiety due to the stigmatization of transgender people by society.

The changes made in the DSM-5 reflect a shift of perspective by the American Psychological Association; a perspective more closely aligning to that of individuals in the LGBTQ community.

While many are still unhappy with the inclusion of gender dysphoria in the DSM-5, there are many arguments for why it should still be included. One of the major arguments for the inclusion of gender dysphoria is for insurance coverage. In order for insurance companies to pay for treatment and therapy, there must be a recognized and universal diagnosis. Right now in the United States, insurance companies are increasingly paying for therapy of transgender people, but refuse to pay for hormone therapy and sexual reassignment surgery. It is argued that, , insurance companies will eventually begin to increasingly pay for these other aspects of transition, but in order to do so gender dysphoria needs to remain a diagnosed mental disorder. In the mean time, the classification of gender dysphoria as a mental disorder will only provide an individual coverage for psychotherapy, but no further treatment (surgery and hormones) that has been proven to improve the quality of life in transgender people.

Further, legislators have excluded transgender people from identity-based protective legislation available to gay, lesbian, and bisexual people. Transgender people are not legally protected from discrimination at a national level in the way that other minority groups are, due to the “mental disorder” label assigned to this group. While many states have created local laws to fight against discrimination, the lack of national laws and protection reflect the stigma assigned to transgender people by society as a whole. A state by state legal approach has left many transgender resdients living in states where it is legal for them to be discriminated against. In states without such laws, it is legal for a company to refuse hiring a transgender simply because of their “mental disorder”. As long as gender dysphoria is included in the DSM and is considered a mental disorder, this stigma will remain. As one article says “transgender Americans are too sick to be protected, but not sick enough to be provided help.” This is far from ideal.

The most obvious issue that the transgender community faces is the stigmatization they experience on a daily basis. Insurance companies, the government and society as a whole are all guilty of this. So the pressing question is, how can this stigma be removed? It is not to say that taking it out of the DSM will remove the stigma, but is keeping it in there reinforcing the perception of transgender people as mentally disordered?