Trans* People And Mental Illness

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?

Ask me a question.

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3 comments

  1. pikaperdu

    Hi. As the spouse of a transgender person, I found your post very interesting. My husband is in the beginning stages of transition; which is to say he is more openly cross-dressing now, and has begun to share this side of himself with family and friends, although he has not yet begun hormone therapy. We are both learning a lot as we go along about medical details and the ‘red tape’ details of where and how access to treatment. We’ve also spent a fair amount of time online, reading personal accounts of individual transgender people as they approach the hurdle of transition.

    One of the more frustrating things I have come up against thus far in my readings is the general assumption that a transgender person must be really unhappy with his or her life pre-transition in order to achieve validity. Perhaps this is an exaggeration, and I also do not want to diminish the struggle for acceptance that many transgender people experience (whether the struggle is for self-acceptance or for acceptance by peers and family). But… Not everybody is like that. To hear my husband talk, he has led a pretty happy life. That isn’t to say his interest in cross-dressing or becoming female is a new one. It’s not. Not at all, and he knows that the decision to go through hormone therapy and perhaps, eventually, surgery, is not something to be made lightly. He says that he could continue to live a happy life without transition, but that he would be happier with it. And that, I think, is a very valid viewpoint, from a valid trans-person.

    As I’ve said already, my husband and I are in the beginning stages of this journey. I’m just learning the difference between informed-consent clinics and clinics that have gatekeeper programs, and we are just starting to find out what options are available in our geographic vicinity. If my husband has to go through the gatekeeper process (seeing a counselor and getting a diagnosis before being able to proceed with hormone therapy), I do worry that he will be rejected for being too happy or well-balanced or otherwise far from the ‘norm’ of what is expected from a person with Gender Dysphoria.

    Also, and this is me speaking here, although I 100% support him in his decision to transition, I hate the idea of him having to be labeled with a word like ‘dysphoria’ at all. If he truly was depressed, the word dysphoria (“a state of unease or generalized dissatisfaction with life”) would seem more appropriate. And yes, he is dissatisfied with being male enough to want to become a female. In that sense, he fits the diagnosis. It may seem like a petty thing to many people, but I just wish that the gatekeeper process was less about identifying how unhappy a person is, and was more about identifying how serious a person is about beginning a serious medical process. To me, there is a world of difference between these two approaches, and in my mind, the latter approach affords a bit more dignity while at the same time doing the gatekeeping job of making sure people aren’t making the decision to transition for the wrong reasons.

    • rimonim

      Hi, pikaperdu! Thanks for your thoughtful comment. Congratulations to you and your husband on beginning this journey!

      You’re right–there is a pervasive narrative that all trans people are in total anguish pre-transition. There are a number of reasons for this. For many people, transition is a life-or-death issue. I think it’s also an attempt to legitimize transition in a hostile, ignorant society.

      This narrative is definitely not true for everyone, though. I have known at least one person who transitioned, to great success and happiness, who said he could have continued in his assigned gender and been okay. I completely agree that this is a valid experience and a valid way to be trans. I can see why “dysphoria” would be a bad fit to describe someone like this.

      The gatekeeper system is hugely problematic. I disagree with it on so many levels, I don’t know where to start! Mental health professionals should not be in the position of deciding who is really trans or what course of action is right for people. Instead, they should be helping each individual to make his or her own genuine, informed decision. And they should be helping people learn adaptive behaviors to cope with whatever comes up in life, during transition and in all the years after.

      If you ever need to ask a question about those red-tape details from someone who’s been through it, please don’t hesitate to contact me. Since I’m a trans man, and depending on your location, my experience may only go so far. But I would be happy to share any info that might help–about the red tape or anything else.

      I hope you are able to find a competent, compassionate provider who will support your husband’s process.

      • pikaperdu

        Thanks Rimonim. I don’t have any questions right now, but I’ll pass your info on to my husband in case he does.

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