Like lesbians, gay men, and bisexuals, transgender people have long struggled under the burden of being labeled mentally disordered or diseased. The simple answer to the question of whether transgender people suffer from a mental disorder is, no, they do not. But the reality of living as a transgender person is not simple, and there are some transgender activists and allies who believe there is an ongoing utility to labeling transgender as a medical disorder of some kind.
There are different theories, but no scientific consensus, about what causes people to feel that their gender identity does not fit with the sex they were assigned at birth. Some scientists stress biological factors, arguing that hormonal fluctuations in utero may play a role. Other explanations have focused on “psychogenic” factors, such as how familial and psychological dynamics shape gender identity. Increasingly, physicians and psychiatrists understand transgenderism to be a normal variation in the way some people experience their bodies and their selves as gendered individuals. From this perspective, transgenderism is not a condition that needs to be cured. And it is certainly not—as terms such as “mental disorder” suggest—a pathology. Rather, it is an identity or just a sense of felt experience that requires acceptance and support.
Affirmation of transgender life and experience has been hard-won, and remains an ongoing struggle. The idea that transpeople are not “sick” is still not universally accepted in the medical and psychiatric communities. Nor is it necessarily accepted by American society.
The belief that transgenderism is a mental disorder makes it easier for some nontransgender people to understand transgender people’s accounts of feeling they are in the wrong body. But what does it mean to feel like you are in the wrong body, that the sex assigned to you at birth does not accord with the gender identity you feel inside? Transgender activists would turn this question around and ask nontransgender people, What does it feel like to be in the right body, and how do you know?
There is a long history to the question of who is authorized to speak about, or for, transgender people and what role medical knowledge plays in defining transgenderism. This history overlaps with some key medical debates over homosexuality. Well into the twentieth century, homosexuality continued to be classified as a mental disorder and was labeled as such in the Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM, first published in 1952, is the professional handbook for psychiatrists, psychotherapists, and—crucially—insurers. It identifies and classifies “disorders,” their causes, their standard treatments, and the likelihood of cure. It is painstakingly revised approximately every fifteen years to reflect changing understandings of mental disorders and available treatments. In the first two editions, homosexuality was listed as a mental disorder. In 1973, LGB activists and their allies in mental health communities succeeded in having it declassified as a pathology.
Nearly four decades later, transgender activists confronted a similar dilemma. They needed to undo the harmful stigmas resulting from being labeled, and treated, as a disordered identity. In 1980, the third edition of the DSM described transsexualism in adults and significant gender nonconformity in children as mental disturbances. Previously, transsexualism in adults was not listed as a separate disorder, and there was no diagnosis for gender-nonconforming children. DSM-III was also the first edition in which homosexuality per se did not appear as a mental disorder. Some LGBT activists have speculated that gender identity disorder in childhood—the diagnosis given to gender nonconforming children, and especially to nonconforming boys—was a deliberate attempt to get homosexuality back onto the list of mental disorders by pathologizing young sissies.1
The fourth edition of the DSM, in 1994, presented a unified diagnosis, gender identity disorder (GID), which could manifest in adults, adolescents, and children.2 (“Transgender” is not a medical term and nowhere appears in the DSM.) The recommended treatments for GID varied depending on the age of the person. GID’s indicators were “a strong persistent cross-gender identification (not merely a desire for any perceived cultural advantages of being the other sex)” and an individual’s “persistent discomfort with his or her sex or sense of inappropriateness in the gender role of that sex.” The DSM-IV’s diagnostic criteria also considered social impact and required evidence that “the disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.”
Transgender activists and allies protested gender identity disorder, claiming it stigmatized transgender identity. Many transgender people do suffer profound distress because of the incongruence between how they perceive themselves—their core gender identity— and their assigned sex. They do not feel at home in the bodies they were born into. This experience of self-estrangement can lead to suicidal depression and other serious emotional distress. However, these emotional problems are not caused by a transgender person’s core identity but by the embodied or felt tension between this core identity and the sex assigned at birth. This distress can start at a young age. Although trans children might not be immediately diagnosed with GID, they could easily be seen by family, friends, and physicians as “different” or “special.”
In other societies, “different” and “special” can be positive, even honored attributes. Many nonwestern cultures have historically created room for a third sex or third gender, individuals who are seen as falling in between the two biological sexes or who embody the gendered qualities of both.3 The hijras of South Asia are an example of a culturally and legally recognized third gender. The berdache of some Native American traditions are another. Such third-sex individuals are frequently assigned crucial ritualistic roles in their societies as priests or priestesses, shamans, or intermediaries between deities and humans. Transgender adults and children in the United States are not asking to be given a special role; they want to be allowed to live their lives and have access to the trans-specific medical care they need—all without being told they are a problem to be solved.
Transpeople need equal access to general health care as well as access to trans-specific care. The latter may take several forms. Some transpeople who feel “persistent discomfort” in their assigned sex may want medical interventions to change their bodies— this is called transitioning. This process could include removing the breasts (known as “top surgery”) or surgically changing the genitals (“bottom surgery”). Other transpeople may want hormone treatment, which will allow them to change secondary sexual characteristics and more easily pass as their inner, experienced gender (see myth 3, “All Transgender People Have Sex-Reassignment Surgery”).
Many transpeople rely on psychotherapy to deal with “clinically significant distress.” Their experience of “impairment in social, occupational, or other important areas of functioning” is a direct result of widespread prejudice and legal discrimination. In most US states, it is legal to fire people or refuse to rent them an apartment because of their gender identity (see myth 19, “Antidiscrimination Laws Protect LGBT People”). Transpeople are frequently targets of violent hate crimes because of their gender nonconformity. There are thus many reasons for transgender people to manifest “clinically significant distress.” It is very difficult to separate the distress resulting from the tension between gender identity and assigned sex and the distress experienced from external pressures such as prejudice. For some transpeople, the former could be the internalized version of the latter. That is, other people’s negative judgments about transgenderism can get transformed into a transperson’s internal experience of shame or “badness.”
In addition to contributing to social stigma and prejudice, the diagnosis gender identity disorder also creates legal disadvantages. Legal advocates point to many instances in which transpeople were at risk of losing custody of their children because they were labeled “mentally ill.” Such reasoning could affect employment, as well. Trans activists have worked to change how psychiatry and medicine look at transgender identity, focusing on the enormous influence of the DSM. When the American Psychiatric Association began work on the DSM-V, published in 2013, it formed a working group of psychiatrists to reconsider the current diagnosis, treatment recommendations, and nomenclature for gender identity disorder. Transgender advocates formed their own working groups, wrote policy papers, and made recommendations, too, so that their concerns would be taken into account.
The DSM-V represents a victory for transgender people and their allies. References to gender identity disorder have been dropped. Instead, DSM-V now lists gender dysphoria, which applies only if a transperson’s experience of gender incongruity causes significant distress to him or her. Not all transpeople experience this kind of distress, so the new diagnosis creates space for different experiences and desired embodiments among transgender people. Gender dysphoria also applies in cases where a transperson’s situation impairs basic life needs, such as holding a job or securing housing.
Many trans activists wanted all references to transgender experience deleted from the DSM. Transgenderism, they argued, was not a medical problem. Decisively separating trans from categorization as a medical problem or condition could certainly help pave the way toward recognizing it as simply a normal variation of human gender identity and experience. Unfortunately, American society cannot accept this yet. More important, transgender health-care advocates in the United States and internationally have made a compelling case for why transgenderism should be in the DSM in some form. Their argument is that some kind of medical diagnosis is often necessary for transpeople to access the many types of medical care they need for transitioning or taking hormones. Without a psychiatric diagnosis attesting to a transperson’s persistent sense of incongruence between gender identity and body, the few insurers that will cover medical transitions might no longer do so. Additionally, many medical professionals would be unwilling to offer transgender people transition-specific care, even if they were paying out of pocket, because there was no medically recognized condition to treat.
During the debate over DSM-V, legal advocates for transgender people expressed concerns about how declassification of gender identity disorder might affect transpeople in other areas, as well. Lambda Legal Defense argued that when transgender people in the United States want to change their legal name and sex on state documents, such as licenses and birth certificates, they often need to provide a doctor’s statement that they live full-time in their experienced gender identity. Frequently, this medical documentation requires a psychiatric diagnosis of some kind. Without it, Lambda points out, transpeople may find their legal and health-care options limited. This would be a very dangerous outcome for transpeople, whose options are already highly limited. In the name of freeing transpeople from the stigma of mental illness, other unintended harms may follow.
The new diagnosis of gender dysphoria thus represents a pragmatic and destigmatizing compromise. In an ideal world, the vast multitude of genders would be recognized and legitimated with equal social benefits, including access to comprehensive physical and mental health care. At the same time, the distress caused by the difficulty or unwillingness to uphold gender norms can be real, and serious, for any individual, not just transpeople. This is equally true of the struggle many people may have around their sexuality. The DSM also lists a sexuality dysphoria, although it is not categorized under that name. But we know that such an experience, whether applied to gender or sexuality, is common in less acute but no less insidious forms in the contemporary United States.
The reality is that we, as a society, lack a useful, comprehensive language for mental distresses of all kinds. We are afraid, or ashamed, to speak about them. We are often afraid to discuss our own fears and problems. All too often we use mental illness as an easy way to compartmentalize and discuss people to place their problems and lives into neat little boxes. This makes us feel “healthy” and “normal.” Given the cultural confusion about transgender identity and gender fluidity, is it any surprise that terms such as “gender identity disorder” and “gender dysphoria” can make nontransgender people feel comfortable about those “other” people?
Our languages—whether medical, legal, or everyday—for talking about and naming gender identity have not kept pace with the diversity of ways in which people are already experiencing and expressing their gender identity, whether they identify as trans or not. Maybe what we as a culture need to think about is not how to label others, but how all of our gender and sexual identities do not perfectly fit the prescribed norms. Doing this may make others’ lives—and our own—a little easier.