A reader asks,
As an aspiring mental health professional and a trans* person, what are your thoughts on the recent changes to the DSM-5?
Thanks for this interesting and important question. Short answer: I have a lot of thoughts! This is a complex issue. As a first-year grad student in counseling, I am just beginning to learn about mental health and the healthcare system. There is a lot to address with this topic.
First, a bit of background. Here’s a good overview of the changes to diagnoses affecting trans* people in DSM-V.
One of the biggest revisions is the move from “Gender Identity Disorder” to “Gender Dysphoria.” This change reflects that trans* gender identities and expressions are not mental disorders, while dysphoria–clinically significant distress that often goes along with being trans*–is a mental illness. This diagnosis is intended to be more respectful and less stigmatizing, while still helping to facilitate treatment for dysphoria in the form of counseling, hormone therapy, etc. Check out this fact sheet from the APA (pdf) for more on Gender Dysphoria. There are still problems here, but overall, I consider this a major improvement.
On a more negative note, DSM-V includes a diagnosis called “Transvestic Disorder” (formerly “Transvestic Fetishism”). Frankly, this is a bullshit diagnosis applied to people who are sexually aroused by cross-dressing. Here is a thorough treatment of the problems with Transvestic Disorder.
On to my thoughts on trans* folks and DSM-V–or rather, trans* folks, mental illness and diagnosis. I’m of several minds here.
First, I should say I am no fan of the DSM, period. The DSM is a culturally, historically specific document, which reflects social norms as much as anything. Psychology has frequently been used as a tool of the system to forcibly normalize and stigmatize people. I think mental health workers should focus on helping people live better lives, not on categorizing, diagnosing or describing them. I am suspicious of the validity of pretty much all diagnoses, not just those related to sexuality and gender. (This is largely why I chose to pursue the program I did, counseling, instead of another, such as clinical psychology.)
On the other hand, I sometimes feel uncomfortable when people criticize the inclusion of trans* experiences in the DSM. Sometimes, I think the cries that being trans in not a mental illness smack of ablism. I think we need to be very careful not to perpetuate bias against people who do experience mental illness. “Mentally ill” people are very stigmatized in US society. I use quotes because there is no fixed group of mentally ill people, separate from the general population. A huge fraction of people experience a mental illness, and people move in and out of this category during the course of their lives.
Of course there is nothing wrong with trans people–except insofar as dysphoria, discrimination, etc. interfere with a person’s life. In other words, there is nothing wrong with being gender variant, but people who are suffering may need some help.
At the same time, there is nothing wrong with so-called mentally ill people–except insofar as depression, anxiety, etc. interfere with a person’s life. There is nothing wrong with having gone through trauma, having atypical brain chemistry, or whatever, but people who are suffering may need some help. In many cases, people who have any form of disability suffer mainly because the majority has organized society in ways that don’t meet their needs. Sound familiar?
Personally, I think my dysphoria absolutely was and is a mental illness. For me, symptoms of dysphoria included: years of depression, panic attacks, trying to numb myself with alcohol, trouble forming relationships, trouble enjoying life, wanting to die. If that’s not mental illness, what is?
My gender identity, meanwhile, is absolutely not a disorder of any kind. Trans* people are part of the beautiful, natural variation of the human species. I don’t think being trans has to go along with experiencing mental illness–it’s just that it often does, in some societies. If I had been recognized and affirmed for my gender from an early age, if I were not considered inferior because of my trans status, etc., I doubt I would have experienced much distress at all. I think I would still have wanted to transition and change my body. I just wouldn’t have nearly died in the process.
So my mental illness was caused by the interaction of myself and my society. I think that goes for a lot of mental illness and other disabilities.
In conclusion: DSM-V is an improvement from DSM-IV, but major problems remain. I think the DSM itself is a flawed, historically specific text, and I don’t think it’s the best way for us to approach mental health. As long as it’s here, I think it’s reasonable to say that dysphoria is a mental illness, while trans* identity is not. I think folks who are quick to say that trans* people have no place in the DSM might want to take a second look at their opinion of “mentally ill” people.
Basically, it’s difficult for me to take a stance here, because I disagree with some basic premises that often frame the conversation. These include assumptions that the DSM is a good authority, that mental illness can be easily separated from social norms, and that being described as mentally ill is always bad.
I hope that answers the question. Anyone else have a take on this?