Forty-five years ago, members of the American Psychiatric Association decided, by a slim 58 percent majority, to remove “homosexuality” from the list of mental disorders in its Diagnostic and Statistical Manual of Mental Disorders. In his old age, the great gay rights activist Frank Kameny recalled Dec. 15, 1973, as the day “when we were cured en masse by the psychiatrists.”
In a single stroke, the A.P.A. helped transform homosexuality from a medical condition to a social identity. It would take another 27 years for the World Health Organization to eliminate homosexuality from its own classification of mental disorders in the International Classification of Diseases, the comprehensive manual of some 55,000 diagnostic codes that doctors everywhere use for diagnosis and insurance reimbursement. But this summer, the W.H.O. beat the A.P.A. to the punch on another issue — transgender rights — by moving “gender incongruence” from its chapter on mental health to its chapter on sexual health. On its website, under the heading “Small Code, Big Impact,” the W.H.O. says that gender incongruence is a sexual health condition for which people may seek medical services, but that “the evidence is now clear that it is not a mental disorder.”
The A.P.A. should now do the same by eliminating its category of gender dysphoria, a technical term for people unhappy because of their gender incongruence. It would be an important step in advancing transgender rights and reducing the stigma and prejudice that people experience when, because of nothing they or anyone else did wrong, they cannot abide the sex they were assigned at birth.
[The Opinion section is now on Instagram. Follow us at @nytopinion.]
The 1973 decision on homosexuality taught us that we shouldn’t expect too much too quickly. Indeed, Frank Kameny overstated the A.P.A.’s power for sarcastic effect. Most of the 42 percent who objected clung to the psychoanalytic view articulated by Sigmund Freud in 1914 that homosexuality was a developmental problem. Nor did the A.P.A. immediately excise homosexuality from the D.S.M. As a compromise, the organization retained diagnoses in subsequent editions to denote people unhappy about being homosexual — ego dystonic homosexuality, for example — and eliminated homosexuality completely only in the 1987 revision.
History is now repeating itself. Echoing the compromise on homosexuality, the A.P.A. decided in 2013 not to remove gender incongruence entirely from the D.S.M. but to change “gender identity disorder” to “gender dysphoria,” just a slight tweak of the equivalent word “ego-dystonic” that had been paired with homosexuality in the 1980s. The worthy aim of coining this new diagnosis was to lessen the stigma of gender incongruence. But as was the case with the short-lived “ego-dystonic homosexuality,” the A.P.A. is just delaying the inevitable.
Jack Drescher, who was a member of the A.P.A.’s work group on sexual and gender identity disorders, cautions that there is one crucial difference. “Unlike homosexuality,” he told me, “we wanted to retain a gender category so that people could get access to services, and insurance coverage for hormone therapy and gender-affirming surgeries.” However, that goal could be achieved by following the W.H.O.’s pragmatic approach, which says that gender incongruence is not a mental illness. For the W.H.O. it is a physical health concern with a billable insurance code. For trans people who want mental health care, psychiatrists can still bill for whatever mental illness category is most appropriate. After all, being transgender does not immunize someone from anxiety, depression or any other mental illness. Why should the transgender person who is sad, tired and losing weight have “gender dysphoria” while a straight or gay person with the same symptoms has “depression?”
Being trans should be a personal or social identity, not a psychiatric one. Indeed, for many transgender rights advocates, a category of gender dysphoria makes no more sense than having a category of mobility dysphoria for someone distressed by a lifelong need for a wheelchair, or African-American dysphoria for people who experience emotional distress associated with discrimination against them as minorities.
“Gender dysphoria” also puts the responsibility on trans people for their suffering, and not on the social and moral environment that stigmatizes them. According to the National Center for Transgender Equality, about half of all people who identified as, or were perceived to be, transgender while still in school (K-12) report being verbally harassed, and nearly a quarter report being physically assaulted because they were transgender. More than a third of all transgender individuals have attempted suicide at least once. Civil rights protections for trans people will be at even greater risk if, as has been widely reported, the Trump administration seeks to define sex under Title IX as either male or female and as unchangeable.
The conservative reaction to gender nonconformity is that it is a violation of nature, but many biologists and anthropologists disagree. While reproduction occurs between males and females, there is nothing natural about limiting all sexual behavior to male-female pairs or all gender identities to male and female. Between 1 percent and 2 percent of all human births qualify as intersex and, in fact, many societies have multiple genders and do not presume they are psychiatric or physical disorders at all. The hijras in India are neither male nor female — though most were born with male genitalia — and are generally revered. In Indonesia, on the island of Sulawesi, there are three sexes and five genders. In Polynesia, the mahu are also neither male nor female, and traditionally they engage in sex with both men and women, without any sort of sexual stigma. In North America, the Navajo believed that intersex people were divinely blessed and essential to society. Without them, as a Navajo interviewee told the early anthropologist W.W. Hill in 1935, it “will be the end of the Navajo.” Our sexual lives and identities are determined not by our genes but by our cultures.
The D.S.M. is also a product of culture that reflects the values of its authors. If the American Psychiatric Association truly believes that gender nonconformity is not a mental illness, it should follow the W.H.O. Psychiatrists will still have all the billable insurance codes they need to provide care, and transgender people will be able to carry on with their lives, suffering if they must from the same things that everyone else suffers from, but at least with one fewer burden.
Roy Richard Grinker is a professor of anthropology at George Washington University. His book about stigma and mental illness is forthcoming.
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Home » Analysis & Comment » Opinion | Being Trans Is Not a Mental Disorder
Opinion | Being Trans Is Not a Mental Disorder
Forty-five years ago, members of the American Psychiatric Association decided, by a slim 58 percent majority, to remove “homosexuality” from the list of mental disorders in its Diagnostic and Statistical Manual of Mental Disorders. In his old age, the great gay rights activist Frank Kameny recalled Dec. 15, 1973, as the day “when we were cured en masse by the psychiatrists.”
In a single stroke, the A.P.A. helped transform homosexuality from a medical condition to a social identity. It would take another 27 years for the World Health Organization to eliminate homosexuality from its own classification of mental disorders in the International Classification of Diseases, the comprehensive manual of some 55,000 diagnostic codes that doctors everywhere use for diagnosis and insurance reimbursement. But this summer, the W.H.O. beat the A.P.A. to the punch on another issue — transgender rights — by moving “gender incongruence” from its chapter on mental health to its chapter on sexual health. On its website, under the heading “Small Code, Big Impact,” the W.H.O. says that gender incongruence is a sexual health condition for which people may seek medical services, but that “the evidence is now clear that it is not a mental disorder.”
The A.P.A. should now do the same by eliminating its category of gender dysphoria, a technical term for people unhappy because of their gender incongruence. It would be an important step in advancing transgender rights and reducing the stigma and prejudice that people experience when, because of nothing they or anyone else did wrong, they cannot abide the sex they were assigned at birth.
[The Opinion section is now on Instagram. Follow us at @nytopinion.]
The 1973 decision on homosexuality taught us that we shouldn’t expect too much too quickly. Indeed, Frank Kameny overstated the A.P.A.’s power for sarcastic effect. Most of the 42 percent who objected clung to the psychoanalytic view articulated by Sigmund Freud in 1914 that homosexuality was a developmental problem. Nor did the A.P.A. immediately excise homosexuality from the D.S.M. As a compromise, the organization retained diagnoses in subsequent editions to denote people unhappy about being homosexual — ego dystonic homosexuality, for example — and eliminated homosexuality completely only in the 1987 revision.
History is now repeating itself. Echoing the compromise on homosexuality, the A.P.A. decided in 2013 not to remove gender incongruence entirely from the D.S.M. but to change “gender identity disorder” to “gender dysphoria,” just a slight tweak of the equivalent word “ego-dystonic” that had been paired with homosexuality in the 1980s. The worthy aim of coining this new diagnosis was to lessen the stigma of gender incongruence. But as was the case with the short-lived “ego-dystonic homosexuality,” the A.P.A. is just delaying the inevitable.
Jack Drescher, who was a member of the A.P.A.’s work group on sexual and gender identity disorders, cautions that there is one crucial difference. “Unlike homosexuality,” he told me, “we wanted to retain a gender category so that people could get access to services, and insurance coverage for hormone therapy and gender-affirming surgeries.” However, that goal could be achieved by following the W.H.O.’s pragmatic approach, which says that gender incongruence is not a mental illness. For the W.H.O. it is a physical health concern with a billable insurance code. For trans people who want mental health care, psychiatrists can still bill for whatever mental illness category is most appropriate. After all, being transgender does not immunize someone from anxiety, depression or any other mental illness. Why should the transgender person who is sad, tired and losing weight have “gender dysphoria” while a straight or gay person with the same symptoms has “depression?”
Being trans should be a personal or social identity, not a psychiatric one. Indeed, for many transgender rights advocates, a category of gender dysphoria makes no more sense than having a category of mobility dysphoria for someone distressed by a lifelong need for a wheelchair, or African-American dysphoria for people who experience emotional distress associated with discrimination against them as minorities.
“Gender dysphoria” also puts the responsibility on trans people for their suffering, and not on the social and moral environment that stigmatizes them. According to the National Center for Transgender Equality, about half of all people who identified as, or were perceived to be, transgender while still in school (K-12) report being verbally harassed, and nearly a quarter report being physically assaulted because they were transgender. More than a third of all transgender individuals have attempted suicide at least once. Civil rights protections for trans people will be at even greater risk if, as has been widely reported, the Trump administration seeks to define sex under Title IX as either male or female and as unchangeable.
The conservative reaction to gender nonconformity is that it is a violation of nature, but many biologists and anthropologists disagree. While reproduction occurs between males and females, there is nothing natural about limiting all sexual behavior to male-female pairs or all gender identities to male and female. Between 1 percent and 2 percent of all human births qualify as intersex and, in fact, many societies have multiple genders and do not presume they are psychiatric or physical disorders at all. The hijras in India are neither male nor female — though most were born with male genitalia — and are generally revered. In Indonesia, on the island of Sulawesi, there are three sexes and five genders. In Polynesia, the mahu are also neither male nor female, and traditionally they engage in sex with both men and women, without any sort of sexual stigma. In North America, the Navajo believed that intersex people were divinely blessed and essential to society. Without them, as a Navajo interviewee told the early anthropologist W.W. Hill in 1935, it “will be the end of the Navajo.” Our sexual lives and identities are determined not by our genes but by our cultures.
The D.S.M. is also a product of culture that reflects the values of its authors. If the American Psychiatric Association truly believes that gender nonconformity is not a mental illness, it should follow the W.H.O. Psychiatrists will still have all the billable insurance codes they need to provide care, and transgender people will be able to carry on with their lives, suffering if they must from the same things that everyone else suffers from, but at least with one fewer burden.
Roy Richard Grinker is a professor of anthropology at George Washington University. His book about stigma and mental illness is forthcoming.
Source: Read Full Article