Is Gender Identity Disorder A Disorder?


In 1973, homosexuality was largely removed from the DSM, or Diagnostic and Statistical Manual, the guide to diagnosis and classification of mental illnesses and personality and mood disorders for use by the psychological and psychiatric community. Initially, a vestigial diagnosis, “Ego-Dystonic Homosexuality”, was included in its wake but this too was ultimately shed in 1986.

This stood as a very significant step forward in the normalization and acceptance of homosexuality as a naturally occurring variance in human sexuality rather than a pathological disorder that required diagnosis and subsequent ethically, scientifically and medically dubious “treatment”. It was perhaps the first major success of the gay rights movement, and signified that progress was being made, that the fight was worth fighting.

Similar debates are now occurring within the transgender community regarding the inclusion of Gender Identity Disorder (or, alternately, Gender Dysphoria), in the current edition of the DSM. So much of the thinking goes, if declassification of homosexuality was such a significant achievement for gay rights, such a significant step in the direction of its normalization and acceptance, and was so deserved by the gay community, why does the trans community deserve any different? Are we, comparably, “sick” relative to the “healthy” nature of gay, lesbian and bisexual people?

But I’m not sure these two issues are comparable. I’m not sure it’s wise to assert that Gender Dysphoria is not a disorder. And I’m not sure that any theoretical, abstract benefits of removing it from the DSM would not be outweighed by massive and widespread harm, particularly to the least privileged members of our community, who are most dependent on asserting to the public, the medical community and those in power, that our access to things like hormones and surgery is a medical need, not a “cosmetic” dalliance or “lifestyle choice”.

There are five main points I’d like to address to make my argument on behalf of Gender Dysphoria.

1) Homosexuality’s inclusion is not a comparable issue

A considerable amount of the debate regarding GID’s classification as a mental health issue leans, as said, on comparison to the significance of homosexuality’s extant removal from the DSM in 1973, and full elimination in 1986. But there are very significant differences between homosexuality and transgenderism, and very significant differences in the reasoning behind their inclusion or exclusion from the DSM.

Homosexuality’s removal from the DSM and declassification as a mental illness was significantly hinged on the basic argument that, in and of itself, homosexuality is in no way harmful or distressing for those who engage in it, nor can it necessarily be pathologized as an inherent condition of an individual rather than just a general pattern of desires, behaviours and intimacies. In so far as homosexuality, particularly in prior generations of our particular cultural context, “produced” any distress or meaningfully negative impact on quality of life, it was by proxy through the social stigmas and cultural hostility levied against it. Gay, lesbian and bisexual people of the 60s and early 70s didn’t “suffer” from homosexuality, they suffered from homophobia and heterosexism.

It’s not difficult to imagine a semi-utopian society in which homosexuality experiences complete acceptance and inclusion (and even is no longer pathologized or rendered a category of person at all) and in which, consequently, no one experiences any suffering or distress whatsoever in relation to their sexual orientation. It’s slightly more of a stretch, but no less feasible, to imagine a semi-dystopian society in which heterosexuality is the hated, pathologized, marked iteration of sexuality, and in which the negative, harmful “symptoms” previously associated with gay, lesbian and bisexual individuals would be observed amongst the straight population instead.

In contrast to this, a society that wholly and completely embraces transgenderism and genderqueerness, and has done away with enforced binary gender roles, would not eliminate the distress and negative impact on quality of life produced by gender dysphoria, and would not eliminate the need for medical treatment of it (transition). While social stigma, transphobia, cissexism, institutionalized and systemic discrimination, pathologization, threat of violence and consistent and open ridicule and hatred certainly greatly worsen the suffering of trans people, and contribute to the harm to quality of life produced by gender dysphoria, they are not the sole cause of it.

On this basis, homosexuality had absolutely no right to be in the DSM, since the inclusion itself was part of what was producing the “symptoms” they sought to treat. It was bad science and a self-fulfilling prophecy. Treat homosexuality as a medical disorder and you will produce the suffering required to justify treating it as a disorder. But if your aim as a doctor is to actually improve the lives of gay, lesbian and bisexual people, you stop treating them as sick.

But if your aim as a doctor is to improve the lives of trans people, you offer them easy, accessible, affordable (or better yet, free), non-conditional access to the medications and treatments they need.

Or put more simply: homosexuality does not require diagnosis or treatment. Transsexuality does.

2) What constitutes a disorder?

Regardless of the potential political gains of eliminating Gender Dysphoria from the DSM (gains which are by no means certain, and even less certainly outweigh the potential harms, a point I’ll address below), we don’t have much of a case if we can’t actually produce a justified argument for why it should not be considered a disorder.

I mentioned above the fact that gender dysphoria, regardless of whether cultural stigmas are present or absent, will always produce distress and a negative impact on quality of life relative to those who don’t experience it. This is very key, particularly the suggestion of what little role is played by context.

As alluded to in yesterday’s repost, concepts of disorder or disability are relative to a partly subjective and partly objective model of optimum human health and ability. This model of optimum health and ability is pruned of cultural bias by comparison to how the alleged disorder, disability or illness would operate in other cultural contexts, real or hypothetical. The more actual, or more reasonably conceivable, is a context in which the alleged condition ceases to be a disadvantage relative to others, the less it warrants being classified as a disorder, illness or disability.

The hypothetical society in which homosexuality is accepted and normalized is a very, very easy thing to conceive. Such societies have indeed already existed, and we are yet achieving them again, a scant 28 years after the full removal of homosexuality from the DSM. By way of contrast, a cultural context in which blindness ceases to be a relative disability (such as a society where everyone is blind, or where sightedness somehow results in such distress and harm that it itself takes on the role of relative disability) is certainly conceivable (see previous parenthetical: I totally just conceived it!), but it’s nonetheless wildly improbable, and isn’t particularly desirable. So outside of extreme improbability, all other variables being equal, a sighted human being will always be at an advantage relative to a blind human being. Therefore it’s not unreasonable to subjectively categorize blindness as a “disability”.

The hypothetical contexts in which Gender Dysphoria does not produce suffering and loss of quality of life relative to those who experience gender congruence are arguably even less conceivable than the contexts in which blindness ceases to be a relative disability. I suppose maybe some kind of situation where everyone experiences gender dysphoria? But would it even be conceptualized as gender dysphoria in such a context, and not just the “normal” process through which one arrives at their gender? Regardless, it would look and function so differently under such extremely improbable conditions that it would be almost a categorically different phenomenon.

So yeah, outside of extreme improbability, all other variables being equal, a human being experiencing gender congruence will always have a better quality of life relative to a human being experiencing gender dysphoria. Therefore it’s not unreasonable to subjectively categorize Gender Dysphoria as a “disorder”.

And consequently, it doesn’t make much sense to insist it is unreasonable. No matter how politically convenient you might imagine that to be.

3) The dysphoria is what is classified as “disorder”, not the simple fact of being transgender.

A considerable degree of the objection to the classification of Gender Dysphoria as a disorder, and its inclusion in the DSM, is very personal in nature. As trans, we’re consistently subjected to a culture that pathologizes us, describes us as sick, unnatural, sinful, mutilated, wrong. To see this idea that we’re sick, that being trans is a disordered state, made official in the medical community’s primary touchstone for what is and is not a mental health “problem”, is extremely painful and angering.

Except that’s not actually what Gender Dysphoria’s inclusion in the DSM does.

It’s inclusion in the manual for diagnosis does NOT categorize being transgender as in any way an illness. It categorizes the dysphoria that typically precedes and motivates transition as a disorder. Being trans is not the illness. I, as a transition(ed/ing) woman, am no longer suffering from gender dysphoria. Or, at the very least, am no longer suffering it nearly as acutely. The disorder has been treated, and is being held in check, through transition and exogenous endocrine treatment. Being a trans member of your identified sex is the ordered condition that responds to, and arguably “cures”, the disorder.

As a trans woman, right now I’m not sick. I’m not suffering. I’m okay. I’m happy. And like gay, lesbian and bisexual people during the years that predated homosexuality’s removal from the DSM, the only significant ways in which my quality of life is compromised by being trans are only a result of living in a cultural context hostile to that. But in comparison? My pre-transition self was definitely suffering. “He” was definitely not okay and was not happy and the ways in which “his” quality of life was compromised had fuck all to do with cultural stigma because nobody even knew. Externally, I appeared to be a white, cisgender, able-bodied man, and had access to most of all the related privileges. But I was still absolutely miserable, and that suffering was resultant from the dysphoria. My condition was rather inarguably disordered. I was not, by any stretch of the imagination, well.

It’s extremely important to bear in mind that when we classify Gender Dysphoria as a disorder and include it in the DSM what we’re talking about is not our post-transition lives wherein we find ourselves happy, confident, secure, healthy, but rather we’re actually talking about those awful lives we lived in the years leading up to that decision, with all the attendant shame, self-hatred, pain, alienation, and discomfort in our own skins, often with co-morbid suicidality or addiction. Don’t question how you feel about your present self being classified as disordered. Question how you feel about your prior self being classified as such.

4) Who stands to benefit? How? Who stands to be harmed?

Remember how I made sure to clarify that the political benefits of removing Gender Dysphoria from the DSM are by no means certain? Well… yeah. That’s a pretty huge deal. Because honestly, I think were “we” to succeed in this agenda, we would bring considerably more harm than any theoretical, semantic benefit. This, more than any of the other reasons I’ve delved into here, is why I feel extremely strongly about this issue. It feels to me like we’re preparing to throw a ton of human beings under the bus in the name of some academic, abstracted theory. That prioritization of the abstract and theoretical over the actual concrete needs and lived experiences of human beings, with genuine suffering that can be alleviated (or can be made much, much worse by our mistakes), is something I consider to be on the absolute principle problems in the queer community. There are people who are living and dying by these word games. We need to take the consequences of how we petition organizations, governments, and scientific and medical communities very, very seriously.

We live in a world where not everyone who requires transition related medical care is able to access it. In many circumstances, it is access to insurance and healthcare coverage that determines whether or not someone will be able to access the medical care they need. We can’t all pay for our transitions out of pocket. Removing the capacity to define transition as the medical need it is, for treatment of a medical condition, will have enormous consequences for this. Insurance companies and socialized healthcare plans simply will not finance something if we’re simultaneously insisting it’s not really a medical problem. In all honesty, it’s outright absurd to make the claim “it’s necessary for us to have access to medical treatment, but we totally don’t have a medical condition!”. And those in power, who already have a very poor track record of giving a fuck about us, are going to laugh in our faces, and resolve the contradiction in the way that costs them the least: agreeing it’s not a medical condition OR need, and throwing us to the wolves.

Those with the most privilege, who can afford to fly to Thailand and pay Dr. Suporn out of pocket, won’t have a problem of course. But the rest of us…

A couple nights ago a friend of mine argued that removal of Gender Dysphoria from the DSM would “maybe inconvenience a few of the most privileged, but otherwise wouldn’t have any effect”. When I pressed him for an explanation for a statement that seemed, to me, the exact opposite of the reality, he responded by saying it’s only the most privileged who have trans-inclusive health insurance anyway. The blatant USAcentrism aside, this seems like the absolute worst kind of social justice: fight to have everyone equally fucked over (except it wouldn’t be equal, in that it only fucks over trans people, but I digress…). Furthermore, Gender Dysphoria’s inclusion in the DSM is a global issue, with global consequences. Making the decision purely through the lens of a particular nation’s social and economic dynamics is immensely selfish and myopic. In Canada, for instance, the people this would harm would NOT be the “most privileged”. They can afford to pick and choose whatever surgeon they want, and bypass Canadian healthcare’s additional gatekeeping hoops, and don’t really have to worry about whether anyone thinks their decision is necessary because they can afford to make those decisions purely for themselves. The rest of us, who are dependent on others and on the social safety net that is only collectively supported, need to play along in the hopes of getting on Dr. Brassard’s waitlist. Canadian taxes are NOT going to finance treatment for something that isn’t even classified as a medical condition. Why would they? They wouldn’t even finance hormones.

I’ve also heard it argued that the potential benefits of eliminating Gender Dysphoria’s classification as a disorder would somehow destabilize the authority through which the gatekeeping model is maintained. Again, I think this is an incredibly foolish strategy, and as said, prioritizes abstracted, political queer theory above the immediate consequences to trans people’s lives. The fact that the medical establishment has often abused the authority we can’t help but lend them doesn’t change the fact that we are dependent and surgeons.

Imagine a village that is starving due to a corrupt lord’s unequal distribution of food. Only the very lucky are adequately fed. One of these lucky, well-fed ones says “this corruption is unacceptable! Let’s destabilize his power by saying we’re not hungry!”. They listen to him, and take his advice. The lord laughs, and says “fine, I guess I don’t need to feed any of you!”. Things get worse.

Imagine instead that one of the villagers says “this corruption is unacceptable! We need to mobilize, march on his keep, and shout ‘we are starving, and all of us deserve to be fed!'”

We have a medical condition. And all of us deserve treatment.

5) Who makes the diagnosis?

The final piece of the puzzle, and one I didn’t put in place until quite recently, over tea with a good friend, was the realization of why the diagnostic criteria belong in the DSM rather than elsewhere.

For awhile I grappled with the fact that although I thought it was immensely dangerous to petition for the removal of Gender Dysphoria from the DSM, I believed that it would be appropriate to do so if and when a replacement diagnostic criteria had been established elsewhere. The motivation behind this belief was that although I considered it reasonable to classify it as a disorder, I didn’t consider it reasonable to define Gender Dysphoria as a psychological or psychiatric disorder, and instead, due to the likely etiology of the condition, the available scientific evidence in regard to that etiology, and the form that treatment takes (by way of adaptation to an immutable aspect of mind/self), saw it as a neurological condition, or even more accurately: a disordered relationship between mind and body.

But as my friend sagely pointed out, the DSM is NOT primarily a taxonomic document, designed to say what ontological category a given condition falls under. It’s a guideline for the purposes of diagnosis. And honestly, due to the fact that things like gender dysphoria, gender identity and transgenderism can ONLY be asserted or “proven” subjectively, and therefore ONLY be diagnosed through interpreting a patient’s subjective experience and descriptions thereof, ONLY psychologists and psychiatrists are in any way qualified to make that diagnosis. Whether or not it’s really a psychological/psychiatric disorder is totally irrelevant to that fact.

The trans community is awash with stories of people who were in the grips of dysphoria and had brought themselves to accept the need to transition, but due to factors like their geographical location were unable to access a qualified psych for the diagnosis and ended up obliged to see a GP or other physician untrained in recognizing and dealing with gender identity issues, only to be confronted with absurdly incompetent responses like “mid-life crisis”, “just a phase”, “let’s up your testosterone”, etc. Or worse “I’m afraid I have to drop you as a patient”.

Gender identity and dysphoria is an immensely nuanced issue. Patients are capable not only of lying to their doctors, but also to themselves. To receive the best care, someone who has expressed something indicating gender dysphoria needs to be seen promptly by a psychologist or psychiatrist who is specifically educated, and preferably well experienced, in dealing with trans patients. Ideally someone who is capable of knowing with certainty that someone is trans even before they’re willing to admit it to themselves. And definitely someone who know what they’re fucking doing. Psychologists and psychiatrists are the ONLY professionals with the proper training to deal with the preliminary stages of identifying and diagnosing Gender Dysphoria, and recommending treatment, even if they ultimately aren’t qualified to dispense and monitor and treatment. Since the nature of Gender Dysphoria demands that psychiatrists and psychologists make the diagnoses, it makes abundant sense that the diagnostic criteria be included in their diagnostic manual.

Right now, the system by which trans people access the medical care they need is very deeply broken, and requires considerable improvement. But that improvement is happening. We’ve made considerable strides over the last twenty years. In 1992, concepts like “non-op” didn’t even exist yet and it was still largely impossible for anyone to successfully transition without lying to their doctors at least a few times. As recently as 1999 it was still taboo to admit sexual attraction to members of your “target sex”. But we’re getting there. We’re inching forward, and we WILL ultimately get there. We WILL arrive at a position where every trans person’s medical needs can be reasonably expected to be met, but NOT by claiming those medical needs don’t exist. Destroying this system, when we have nothing to fall back, is making a ridiculous gamble with other people’s lives.

Please stop poking this hornet’s nest with a stick.

Comments

  1. Rilian says

    Natalie, where is that post you wrote about how transwomen are in a position to inform others about male privilege? I tried searching for it but no success.

  2. Anders says

    If gender dysphoria is the main symptom, then I definitely agree that it should be a psychiatric disorder. Gender dysphoria is a mental state – that falls under the purvey of psychiatrists.

    I had a long paragraph about how a clinic specializing in transsexuals would look, but I think it may be more fruitful to ask the community – what medical services are absolutely necessary, what services are important and what services would be nice to have? And you can’t have more than one unicorn.

  3. Catherine says

    Couldn’t agree more with this, I don’t understand the obsession of removing it, often it comes from well meaning “allies” who think they know what’s best without actually asking us… I was very dysphoric prior to transition now due to my treatment path I am getting less so, thus my dysphoria is an illness to be treated, the fact I am trans however is not though the dysphoria comes from being trans, if that makes any sense?

    • Anders says

      I’ve been toying with calling it estrogen or testosterone deficiency. It’s not entirely correct, or SRS wouldn’t be needed sometimes, but it conveys an important truth. You need your hormones to feel good. We are not doing anything more esoteric than replace what your body can’t produce. Like insulin to a diabetic.

      • Catherine says

        Except post puberty the hormones are not the only source of the problem anymore but the things they created… so isn’t quite that simple. Sure estrogen/T-blockers make me feel better but its not the whole solution.

        • Anders says

          Absolutely, hence the need for SRS. But a hormone deficiency is an important part of it, right?

          Are there people who only want SRS and not hormone treatment?

          • Catherine says

            It isn’t just a deficiency is also generally a surplus of the wrong hormones which are what do the “damage”. Some neutrois people (those who feel they have no gender) may have surgery without hormones other than a small amount to prevent osteoporosis.

          • Crip Dyke, Right Reverend Feminist FuckToy of Death & Her Handmaiden says

            Yes, but not necessarily a lot of people. For those people with which I am familiar, there are some who would like hormones but choose not to because of the cost of ongoing expense.

            That’s an economically constrained choice, but still a choice. I don’t think it’s the case you’re looking for, but I think it’s important to recognize that it’s there.

            But also there are people who have family history of, for instance, breast cancer. I know 2 people in this situation. Taking hormones increases risk of breast cancer and they don’t wanna die, so one chose to take hormones for a limited period of time then stop completely. For one person it was scary enough that she chose not to take any hormones at all, though she did have surgery and electrolysis.

            I don’t know any persons who made the choice to not take or to stop hormones without an economic or health constraint. BUT I don’t want to quibble about why they made those choices. They made them. They constitute examples of the rare group in which you were showing interest. So I thought I’d mention them.

            If, however, you want to disallow reasons like lack of money/insurance and health concerns, I don’t know anyone who had surgery who didn’t wish that they could take hormones – there are simply some cases in which they felt that they shouldn’t.

          • Anders says

            I yield, I yield before the weight of your arguments. (And it was such a beautiful formulation too :()

            Interesting about the neutrois. Notice how they don’t really fit in with the body map theory. There’s something more going on. I’m still interested in the hypothalamic network – I have some new musings that will lead to a new theory that will unite all we’ve leard about Natalie.

            It’s probably wrong, though. But I’m bored and dreaming up theories entertains me.

          • Rilian says

            Weeell, I don’t really want to take hormones. I’m fine with my body as is except for a few specific body parts. If were to take hormones, it would be for social reasons. But I don’t think I’m gonna do it.

    • jerrywood says

      I am a transgenderist my self. I have never felt like I have a Dissorder. Being transgendered has merly been called a Disorder as a way for the Dr’s to say there is some thing wrong with us that is all there is to it. Just because Society sees it as wrong does not make it so just as just because the DR’s say there is something worng with us does not make it so. If Being transgender is a dissorder ghan we should be able to draw a check baced on it. In several states an employer can fire a person for no reason thus giving them an out for fiering a trans for being trans. they just have to not list a reason.

  4. Crip Dyke, Right Reverend Feminist FuckToy of Death & Her Handmaiden says

    This post is good and lays out a lot of the basic transfeminist thinking on this issue. I like how you write with detail and well – and I like how you do it without so much emotion as to turn opponents of GID so defensive that they can’t hear your points.

    However, I do have some criticisms.

    1. You conclude
    section one saying, homosexuality does not require diagnosis or treatment. Transsexuality does.

    But this is the first time you’ve spoken about transsexuality in the whole piece. Ultimately when you later say it’s about the dysphoria, not the gender, you are trying to get people to understand that

    …if you do not experience distress, by yourself, which would exist regardless of most foreseeable cultural contexts, then the diagnosis is not applicable to you and not “for” you…

    This is a great point and something that advocates of removal utterly fail to get most times. I want people to get this point.

    However… you confuse everything above that and below that. Consistently you’re using “transgender” when you don’t mean that drag kings are or should be concerned with and/or assigned this diagnosis. You really mean that people who have a dysphoric relationship with their sexed bodies should be concerned with and/or assigned this diagnosis.

    If you want to include some number of people that you don’t consider transsexual in with that last category, that’s fine. But it certainly isn’t all transgender people.

    I know arguing about transsexual/transgender and other categories is seen as impractical.

    However it has the practical effect of undermining your argument when you use “transgenderism” “transgender” and even “genderqueer” without making the time to distinguish one term from another. If someone can read your argument and think that GID is to be applied to transgender people, then they don’t get your argument.

    And if you never intended it that way, then the failure to get your argument isn’t their fault, it’s a problem with the writing.


    2. Your point
    about comparing things to other cultural contexts is mostly very helpful. But to the extent that you are using transgender folk as the standard unit of analysis, people who have a different experience than yours can simply say, “But no: all of my distress was a result of my society, even when no one knew what was going on!”

    The point isn’t that “transgender people” will experience distress regardless of foreseeable social context. The point is that transsexual people and possibly, depending on your definitions, some limited subset of transgender people will experience such distress. Then if someone says, “But all of my distress was social,” the response is, “then you obviously do not belong to the subset under discussion.”

    When you write with transgender the way you do it seems to either
    a) invalidate the experience of those folk whose distress was entirely due to social conditions
    or
    b) allow those folk to believe that your argument makes no sense…and thus your argument fails to reach people who really need to hear it.

    …more later…

  5. Crip Dyke, Right Reverend Feminist FuckToy of Death & Her Handmaiden says

    and this is the more…


    3. While providing
    a clear articulation of the transfeminist case for inclusion of GID, you do not actually do anything to dismantle the arguments for removal.

    The fact that some pain would exist regardless of social context is not an argument that we shouldn’t remove the remainder of pain through destigmatization.

    This is how the advocates of removal hear about the pain of folk (typically unlike them) who would experience severe distress (not to say “dysphoria”) in the intrapersonal relationship context and yet argue for removal to “improve” the interpersonal context.

    We who participate in this argument often find it become intensely heated. It’s important to understand why. There are at least two common positive reactions to being told one has GID. (which can happen with diagnosis or with a “helpful” friend saying, “Look, I heard all about this GID thing in my psych 101 class and it’s totally you!”) These do not compose a duality, but it’s very common to experience one or the other, and much less common to experience both or neither.

    1. I have a disease? So when the family told me I killed Uncle Ben b/c his heart attack came just six weeks after my mom found that copy of My Gender Workbook under my bed, that wasn’t my fault?

    None of this is my fault? You mean I’m not a horrible, horrible person who has been voluntarily inflicting pain on those I love? You mean none of this is my fault and some god or other might still love me cause I was made this way and not just making horrible sinful choices?

    w00t!

    2. I have a disease? Are you kidding me? FFS, I’ve been trying to – against all of societies efforts – look in the mirror and see someone who is *not* broken. People have been telling me I’m sick and wrong all my life and it’s cause me so much pain. After all those years of messed up insistence by others that I’m broken and wrong when I just know that it’s right for me to live as I now do, you’re going to use all of the might of your institutional power to land on me and say, “Yes. You are most certainly broken.” Don’t you realize that jumping down on me with all that power might be exactly what is breaking my back? If I’m broken, it’s your fault not mine.

    BUt you are saying it’s all my fault. You’re saying you are some neutral arbiter of truth and the truth is that I am screwed up and thus am doing screwed up things. I will not believe that the choices I am finally making are screwed up. Only when making these choices have I finally been able to become happy, and now that I have a tentative foothold in happy land, you want to take it from me. Well I won’t let you!!!

    …So, if you’re in category 1, diagnosis is a relief. Not to mention it also means that hormones and/or surgery and/or other treatment has a chance at coverage – another w00t. If you’re in category 2 it’s an effort to throw a person back in pre-coming out hell.

    Now these are simplified examples of the thought process, but they are very common patterns nonetheless. The problem, however, becomes very clear when we realize how common suicidal ideation is in trans communities.

    It’s very easy to see diagnosis as saving one’s life (either through relief of the emotional burden of “fault” or through access to treatment that can also make a major difference in suicidal ideation…and follow through) for folk in category 1. It’s also very easy to see diagnosis as threatening the life of folk in category 2.

    If the diagnosis is threatening your very life, it’s easy to see how someone would be an activist for removal. If that removal threatens your very life, it’s easy to see how a heated push back becomes necessary, or at least inevitable.

    However, if we followed my section one and two in the earlier post (not just category 1 & 2 here), we can see that it’s very hard to be in category 2 and be covered by the diagnosis. If you are actually diagnosed by a professional, that professional may have misunderstood and certainly has misused the diagnosis. If you merely feel your life is implicated by the diagnosis, you have to consider the possibility that you are being misled, mainly by non-professionals.

    Persons in category 1 can be misdiagnosed or properly diagnosed (just because you respond with relief to the diagnosis doesn’t mean it was automatically properly given), but it matters much less since the reaction is positive.

    Thus we end up with a removal argument from folk who are, mostly, not implicated in the diagnosis…but who are willing to argue and commit to action as if their lives were literally at risk, because they believe that their lives literally are.

    It’s important that everyone in the argument understand this, because the existence of this situation means that the current context is intolerable. Given the current context, people might be tempted to say that given that destigmatization helps everyone and depathologization only hurts a minority…and given that depathologization aids in destigmatization, the resulting net benefit tells us that we should remove GID.

    This. Is. Wrong.

    And it’s wrong because of the last piece of the transfeminist argument, which is really important because it’s what truly reveals the problems with the strategy of removal itself, rather than merely making a claim about likely consequences that are empirical questions which might lead people to try it, at least in some countries, to see whether the claim is true or false.

    Last piece coming up separately.

    • MaNonny says

      “BUt you are saying it’s all my fault. You’re saying you are some neutral arbiter of truth and the truth is that I am screwed up and thus am doing screwed up things. I will not believe that the choices I am finally making are screwed up. Only when making these choices have I finally been able to become happy, and now that I have a tentative foothold in happy land, you want to take it from me. Well I won’t let you!!!”

      I think that Natalie’s subtler point about how the dysphoria is the disorder, not the trans status, touches on this. Also, I think there is intersectionality here about not wanting to be one of *those* people with mental disorders. If mental disorders weren’t so stigmatized, then having one wouldn’t mean you are “broken,” and the new life the person is living that gives them “foothold in happy land” would be the treatment (not the disorder). Trans is not sickness, dysphoria is. I guess I mean that this argument for why the diagnosis should be discarded doesn’t hold water beyond “eww, I don’t want to be like those icky sick people.” I don’t think you are arguing for this, however, based on your comments below; I am just pointing out that it doesn’t seem like much of an argument to me. Reducing stigma of mental disorders might answer this argument, but taking the diagnosis away from people with GID won’t.

      Does that make sense?

      • Crip Dyke, Right Reverend Feminist FuckToy of Death & Her Handmaiden says

        Oh I agree that the dysphoria is the disorder. I think you misunderstand part of this post, though, MaNonny – the point is that however correct are persons’ perceptions, those perceptions exist. And because we *perceive* that are lives are threatened (because of guilt or stigma or because someone is proposing removing a lifeline that is perceived to reduce/eliminate guilt/culpability or stigma) we fight each other – hard.

        Understanding dysphoria can give us arguments not to remove GID. But we need to understand that part of why this fight is so hard is because of the (predictable) psychology of the larger trans community. While we can say something is right or wrong, or just fight for something hoping it is, we still have to listed to the side with which we disagree and have consideration for how our actions affect them. In this case, I think removal is very, very wrong. But I don’t wanna tell the people advocating removal that they are very very wrong. The strategy is based on messed up ideas that it’s okay to stigmatize mental (and other kinds of) illness. We should work against that. But understanding why others are arguing so forcefully can allow us both to reach them with our arguments better *and* to craft our strategies and messages in such a manner as to do the least harm to them along the way.

      • Crip Dyke, Right Reverend Feminist FuckToy of Death & Her Handmaiden says

        Okay, after making that earlier response to you, I just realized that you mis-read that paragraph you quoted as if it were *my* voice. I was using the first *2* paragraphs as the representative words of people whose emotional reactions lead them to support removal. That quoted para is paired with the one above and separated from the one below by the ellipsis. It’s only after the ellipsis that I’m speaking in my own voice again.

        Sorry for any confusion. I should have used italics or something.

        • MaNonny says

          @ Crip, I was arguing against the hypothetical person’s argument you were presenting. Despite confusion, I think we are agreeing – reducing stigma for mental disorders will help people and taking away diagnosis (DSM or other system) of gender dysphoria won’t necessarily help people in the long run. And, this is a discussion to continually have within the trans and medical communities in order to figure out how to best help the people affected.

  6. Emily Aoife Somers says

    Please allow me to repost some of my thoughts on this (enriched, as always, through very productive conversations with Natalie). From my FB anti-blog, which is to say it’s erratic thought mongering in which the personal ever precedes the theoretical:

    Part of the disapprobation in the trans* community about ‘disorder’ as part of the overarching discourse that theorizes and reifies our lived experiences — as I discuss below — is the inscriptive power that ‘disorder’ frames the subject within. No one wants to be disordered. We like order. We like normal. We prefer that which fits our expectations and holds congruence with our prior experience. We like knowledge that confirms our suppositions of what knowledge has to offer.

    If ‘disorder’ is meant to imply that some entity called the ‘trans brain’, as a medicalized artefact of perturbation, then I can understand the disquiet with going along with such a term. I have no doubt that, in the formative period of gender therapy which was by all accounts a dark age, then this is true. ‘Tomboyish’ girls forced into feminization programmes with lipstick rewards and electroshock disciplinary measures. Reparative treatments meant to eliminate cross-sex identification. The history of psychiatry, shamefully, includes such practices. And in those cases ‘disorder’ meant just that: trans thoughts or feelings were the result of a disordered psychiatric makeup that needed enforced correction. The mental events of the trans person could, and should, be eliminated — through invasive measures that were physically and spiritually labotomizing.

    Other than the thugs at NARTH, I don’t know of any gender therapist who holds this view now. ‘Disorder’ now implies not a disordered person, but the rhetoric that identifies a disordered relationship — between a neurological foundation and a physiological cohabitation. Being trans is not a disorder. The brain of the trans person is not disorder. But the correlative make-up of the mind-body interaction is. Thus I would not think of genderqueer people as being GID, per se. If you enjoy genderfucking, and you experience no outright need to adjust anything about yourself to perform that genderfucking — all the power to you. But transsexualism, as a specific category, describes ‘dysphoria’ as a persistent (and debilitating) psychological feature that impairs pretty much all that is beautiful in life. That is what is disordered: the capacity to be fully present in one’s self and one’s body.

    I subscribe to the view that if an understanding of what ’causes’ — or, more preferably how transsexualism etiologically arises — the neurological element will be a primary reason. Biology is not destiny. Perhaps even neurobiology isn’t destiny: but it does exert a considerably determinative influence.

    Hence, my carry letter identifies me as living with a neuroendocronological condition — a cooperative give and take dynamic between my brain and my hormones, that constitute the morphology of my body.

    If the taxonomy of transsexualism is to be understood in such a way, one might argue that it should be removed from the DSM, since the DSM is a diagnostic tool for psychological conditions. I would disagree with such a removal.

    The reason is that while the ontological cause may be neurology, and the resultant effect may be a perception of the corporeal — in between lies an epiphenomenal zone that is mental, cognitive, emotional — psychological.

    Let me draw on personal experience. People say, how did I know I was trans? It wasn’t from an MRI scan. It wasn’t from a persistent physical pain in a particular region of my musculature. It had no visible symptoms or empirical aspects that could be weighed or measured. As my family insists, I didn’t “look” trans.

    What I had was a personal mythology of dreams, reflections, needs, desires, sufferings, yearnings, wishes, fantasies, aspirations, feelings, inward gazings . . . a huge pantheon of mental events that kept INSISTING (not suggesting) that the imperceivable was the factual. Despite not ‘looking’ like a girl . . . I was in fact a girl.

    Reaching this conclusion, in my case, was no easy task. As I wrote below, it involved a convoluted jigsaw puzzle built out of the husks and shells of my repressed feelings and frightened desires, tesselated bits of private names, personal longings, and secret identities. None of my mental processes were indistinguishable from that one prevalent *feeling* that all of my thoughts eventually orbited. That I was really female.

    In short, I knew I was trans because my psyche told me so. Incessantly. Desperately. Crying out in the void that lay between me and my self.

    I hold that gender dysphoria needs the expert care and attention of a trained medical professional who is a skilled clinical psychologist in recognising a trans person and working with his or her situation. I say this because of the luck that I had in my own diagnosis.

    After my suicide attempt, a friend forced me to seek emergency help at the university hospital. Even after having come three loose bolts away from depth, I still clung to my tenacious portfolio of denial that the ‘feelings’ would go away. I had given up meat, after growing up in a culture in which fried pork multiple times a day was considered nutrition. I abandoned a chronic pot smoking habit that, while perhaps not an addiction, was certainly unhealthy in its habituality. Many, many habits of thought I had eliminated. I thought being trans was the same.

    It’s not. As it is a neurological component, neurological, you can’t ‘fix’ it as such. I don’t think any gender therapist wants to find a magic cis potion to make the trans person disappear. But since the domain of trans self-awareness, and trans self-presentation, occurs through the mental faculties — the images and language we use to know ourselves and communicate that knowing — then proper psychological guidance is needed.

    When I went to UBC hospital, I met a very nice frontline emergency worker who listened to me with skill. After several hours of saying I was depressed because of money, because of a job, etc — I finally conceded: I’m a woman. I don’t look it. I don’t sound it. But please believe me. It’s me.

    He could have dismissed me. He might have told me I needed a wee think about it. He very well could have laughed. But instead he did the best possible gesture of care: he recommended me to a skilled gender therapist.

    This is the best thing that ever happened to me. And it’s why her name is amongst the very first in my dedications section to my second book.

    A skilled gender therapist is trained in recognising the symptoms of GID — which are, as I’m arguing, of a mental nature. He or she has the clinical experience, and the research background, necessary to guide the trans person to appropriate forms of treatment: often, this involves (but does not necessitate) hormones, coinciding with the recalibration of one’s gender identity through social presentation. He or she understands that the trans experience is *an event within the subjectivity of self-awareness*, an embodied awareness that correlates to the most fundamental workings of the conscious mind. Trans realities are neurobiological, but trans identities assert themselves in the epiphenomenal. Only through mitigating the relationship through brain and body, along the continuum of mental events, can gender dysphoria be improved. This is why so many trans people report *affective* results from HRT long before anything physical happens. The rewiring of the neurobiology produces mental events that are, quite literally, life-saving in the preciosity of newly awakened feelings.

    I required someone with the experiential background in gender dysphoria to accurately diagnosis me, realistically assess my options, but most importantly guide me through the miasma of my own self-denial in order to help me uncover the real subject, the real moment, the real person. Emily. Even coming so close to hanging myself, I was in obstinate refusal to admit trans had anything to do with it. Even 5 minute of coming to, having knocked myself out through cutting off blood to my brain, my first thought was — shite! I ripped the rod out of the wall! That’s gonna come out of my damage deposit? Have I any glue to fix that?” Only 10 mins ago I tied a ligature around my neck with the volcanic thought “I’d rather be dead than be a lie”, and only after coming away from that I’m screwing the fixture back into the wall, the very fixture I had been dangling from, driven to utter abyssal despair because I could not have the life I knew to be me — that there was this irresolvable gap between my day to day experience and the phantom of my true self betrayed.
    This is why the average GP is quite unequipped to deal with people presenting for help with gender dysphoria. In fact, they can often do more harm than good, as they are generally incapable of addressing the intense psycho-dynamic of the trans person’s struggle prior to transition.
    And this is exactly why a clinically trained gender therapist can provide salvific guidance to trans people who, often in the debilitating throes of gender dysphoria, need help and guidance in order to unpack the heavy morass of fear, doubt, self-hatred, and confusion.

    My gender therapist did me the best service possible by confronting me dead on about my unwillingness to transition, my rhetoric against my transness, and my inability to accept my feelings and thoughts as real and legitimate (rather than illusions or sporadic inklings to be banished or destroyed.) She said to me, “Emily, I won’t make any decisions for you. But you must know. The clinical research shows that people in your situation, who don’t transition, will make a second attempt on their lives. The history is there. I don’t want to frighten you. I want you to fully consider the opportunity that transition will give you real happiness”

    Such a statement addresses mental health: consider . . . happiness. This is the language of psychology, even if the underlying factor is neurobiological. My endo handles my blood levels; my gender therapist provided me the most important service . . . recognising what my blood and flesh were trying to *tell* me, in the secretive language of personal emotions.

    And so I will be dedicating my second book to her.

    Being trans is not a disorder. Having trans feelings is not a disorder. Having trans feelings and denying them, beating them down, and tying a BJJ rope around your neck because the feelings are too achingly sorrowful . . . that’s a disorder. Transitioning and being myself. That’s being trans. And it’s brought me that psychological gift called inner peace.

    • says

      in which the personal ever precedes the theoretical

      As well it should. As ever, the theoretical is pretty much useless if it can’t speak to lived experiences. And in this subject especially, prioritizing theory, semantics and politics over lived experiences (and lived consequences) is especially dangerous.

      Anyway, thanks for your comment. Lots and lots of valuable insight. Makes me feel like you just trumped my own post. ;)

    • says

      This is a really wonderful thing to read Emily, and I understand why you feel that diagnosis is good or necessary thing, since in your situation it was quite literally life saving, and it was instrumental in breaking down your denial. However, my experience is somewhat different, in the diagnosis represented not something to allow me to break through my denial and move forward, but rather something I feared as a barrier to transition. I had, after 30 years (and maybe 23+ years of constant wishful thinking and denial) managed to clarify that my feelings were real, not just some weird habit, or some kind of perversion. It was clear to me. In fact, within a very short time, maybe a week or so, I knew what my path ahead was to be (broadly, the timing has not quite cooperated). I just needed someone to give me hormones. And someone to work through my decades of ground in self-loathing. I didn’t need someone to tell me that, yes, I had Gender Identity Disorder, or Gender Dysphoria, or whatever. I knew that already. I was terrified of seeing a therapist, because I had come to the epiphany, I knew what steps I needed to complete to feel comfortable in my body, and I was deathly afraid that she would tell me no, you are delusional, you do not have Gender Dysphoria. And this is not an entirely irrational fear. It happens. Even with “experienced” gender therapists. It didn’t help that my family were waiting on a formal diagnosis before getting on board with me. And so it was a great relief when one of the first things my therapist said to me was, “I can’t diagnose you. I’d be wrong”. Which exactly with how I felt. Since only I could say if I felt dysphoric or not. There were no outward signs. And I felt that any delay was something unacceptable to me. As it was, she wanted to see me for three months before giving me a letter for hormones. I got spironolactone online a month into this wait. I told her, and she reduced it to another month. I still couldn’t accept this, so I got estrogen patches. I got my letter (which incidentally did not used the word “diagnose” in any form) eventually. But really, the only thing I’ve gotten so far out of “diagnosis” is easy access to blood tests (since all my endo did was say “yes” to my request to change to injectible estrogen)… I don’t know… I can see how it’s useful, but the disorder/diagnosis model can cause unnecessary stress, and can sometimes result in denial of treatment.

      • MaNonny says

        I feel like this might speak more to how GID is treated than whether it should be treated. Since surgery and taking drugs are involved, then not having any sort of medical sanctioning could lead to only those with enough money to get them “cosmetically” having the ability to access them. Maybe for some people it isn’t something they need help figuring out in the psychological sense, but in the end a doctor signed off on prescriptions etc. for you to have access (and hopefully they will be safer since the sources would be better regulated than stuff people buy under the table). Maybe we need reform in how it’s treated (maybe treatment is stigmatized like with drug addiction and other issues people don’t understand well?) based on evidence for best course. If the treatment plan had been streamlined, would the diagnosis itself have been harmful to you? It makes me think about how blood-letting used to be state-of-the-art medical treatment, but we know that isn’t best now. So, patient advocating could help with this. If it’s no longer seen as a medical need, is there a better way for all those who want access to counseling, hormones, surgery etc. to get it without it being written off as just a life choice?

        • says

          Oh, by no means to I think it shouldn’t be treated. I’d probably be dead now if I had been denied and there were no alternative ways to access medication. I don’t know… it’s problematic because there are a number of ways people arrive at realising they require treatment, of whatever sort, and so a one size fits all psychiatric diagnosis model is clearly flawed. I would go as far as arguing any model which puts diagnosis in the hands of anyone other than the trans person (putting the professional more in the role of a facilitator) is flawed, and carries a risk of drastically failing to achieve the patient’s needed outcomes. Of course, putting final diagnosis in the hands of the patient is very unconfortable for the medical profession, but transsexualism (which I single out from the rest of the transgender umbrella due to it being the main instance in which medical intervention is required) is an extremely complex and multi-faceted condition that goes beyond simply psychology (it being the only “psychological” condition for which the only clinically proven effective treatment is medical alteration of the body, as far as I know).

          I understand what you mean about about money creating a barrier without prescription, but as far as my experience goes (and many others who are either without insurance that covers trans issues, or who live in a country where transition related medicine is not publicly funded), prescription makes next to zero difference to the costs involved for me. In fact (and this speaks to your comment about lack of regulation in non-prescription medication), my endocrinologist, despite giving me a prescription, has informed me that all but one item on my prescription has to be purchased online (as they aren’t available in Australia). From the exact same source as I had ordered my non-prescription medication, no less.

          As far as I’m concerned, it is a medical need, and is most definitely not a “life choice” (in a much as not treating any non-directly life threatening but quality of life destroying medical condition is not a choice, although the option not treat is open). I’m quite happy with my current situation regarding my doctors, without which a “diagnosis” (which still doesn’t formally exist) would have been difficult, though not impossible. I have an enormous degree of input into my regimen, as my doctor is very open to my opinions and suggestions. But I still maintain that the main benefit I’ve gained is access to blood test without lying. Even being monitored is not a major benefit, as no doctor can really be any more certain any particular side effect will appear in a given patient than the patient themself… But, in any event, my experience is mine, and I probably shouldn’t try to extrapolate general assumptions from it.

          • Anders says

            Self-diagnosis in the form of rating scales are common in the profession when it comes to depression and anxiety. So I don’t think the barriers are quite as high as you’d like to make them. That’s definitely the way I would go were I to head a diagnosis project.

          • says

            Fear enough. It was, as I said, my experience. Two GPs wanted a formal diagnosis before they would deal with me, because in their word “we need to be sure it’s not a psychosis”… to which I replied “how likely is a psychosis that has persisted from at the least the age of seven and has neither deteriorated nor left me unable to function reasonably well?” I could see in his face I had him, but he still didn’t want to back down, unless I saw a psychiatrist they knew (since he didn’t think my therapist was entirely legit… which is somewhat fair, since she’s also a naturopath :/ )

            Rating scales are a little hard though. How would that work? What would the result categories be. It would need to be done very carefully so no one who feels they need medical intervention would not be turned away (so, it would need to be very much not like the GOGIATI, for example…)…

          • Anders says

            A rating scale would look something like this: https://www.outcometracker.org/library/MADRS.pdf (ignore the “total score” at the bottom; we hates it)

            Generally 0 – no symptoms, 2 – symptoms but not severe enough to disrupt daily life, 4 – symptoms severe enough to limit the patient, 6 – crippling symptoms. Remember, there is no concept of distance on a scale like this – the ‘distance’ between the points vary from individual to individual. As long as everyone agrees that 2 is larger than 1 (and so on), it works.

            I made a rating scale for mental fatigability. We did something like this – we began with a guess of what categories would be involved based on clinical experience. Then we tested it on 8-10 patients. Then we interviewed these patients and asked if there were items that didn’t belong, or items that they missed.So we constructed a new scale based on this, and repeated the process. After the third iteration we decided that enough was enough and went on to large scale testing and agreement with social function, certain objective tests we had developed, and so on. I don’t think there are objective tests for transsexualism, but I’ve been wrong before.

            So such a scale would need to be developed in close contact with the trans community. That is an absolute necessity IMO, and I don’t understand how you can dispense with it.

          • Anders says

            In this case, a result of 4 or more means there’s something that should be treated. It allows the therapeut to select the treatment depending on the patients’ symptoms, and it allows us to study what treatments are most effective for what symptoms.

          • MaNonny says

            The conversation moved on a bit in my absence, but I just wanted to thank you for your response, Miri. I think your experience does bring to light some things that should be considered when deciding about patient care. I wasn’t advocating that the relationship with the doctor should be one sided (“I hereby declare you transsexual, and you must take this treatment plan I decide for you”), but I like how you phrased it that the doctor should be more of a facilitator.

            Anders addressed how this does work in some psychiatric conditions, so it’s not an impossibility for gender dysphoria.

            I wonder if diagnosis became more well-accepted in the medical community (instead of treating patients as if they are in acute psychosis as someone mentioned), then advocating for insurance coverage would be easier. You know, if it’s considered “standard of care” instead of whatever category it is in now for most insurance plans (also, I know this may vary from country to country). Access/affordability may increase.

            My thoughts feel disjointed this morning. I have a feeling that what I’m getting at is “HELP ALL THE PEOPLE! STUPID MEDICAL COMMUNITY SHOULD HELP NOT HURT! STUPID INSURANCE HASSLES THAT KEEP PEOPLE FROM MEDICAL CARE! ARG!” which isn’t as articulate as I would like and is hardly conducive to changing the system in and of itself. :/

          • Anders says

            A word of warning though. How the researchers treat patients has a lot to do with which scientist you happen to get. We were a very informal, non-hierarchical group. There were no problems, for example, for me as a grad student to call the professor’s idea stupid. And with such a structure (or lack of structure), listening to the patients come very naturally. I can imagine that a more hierarchically structured group may find it more difficult to listen to the patients, because they are seen as laymen who rank lowest in the hierarchy.

            Btw, if you are invited to take part in a study be sure to read the paper you sign carefully. It should say “I may quit whenever I want. I do not have to give any reason. If I decide to quit this will in no way affect the standard care that I’m given.”

            All research must also conform to the Helsinki declaration (2008) or similar document, which says

            Medical research involving a disadvantaged or vulnerable population or community is only justified if the research is responsive to the health needs and priorities of this population or community and if there is a reasonable likelihood that this population or community stands to benefit from the results of the research.

            You have the right to ask how this research will benefit yourself or the transgender community (there’s no doubt that trans people are “disadvantaged and vulnerable”). I have scrapped research ideas because I couldn’t think of a way they would benefit the patients. Yes, I probably could have gotten them past the review board but I don’t want to be like that.

  7. Rasmus says

    I don’t think I have any business philosophizing about this sort of stuff, but I’ve been bad…

    Here’s my question. It’s probably not a very original one and it’s maybe a little bit of a devil’s advocate style question, so please bear with me. What if psychiatrists and politicians agreed to rename the DSM to something like “Insurance Claims Manual” and began to treat it as exactly that? In other words, can a person leverage their DSM diagnosis for something else, apart from getting insurance and access to treatment and support-networks?

    Whether or not something should “objectively” be classified as a disorder or a disease or a developmental defect, or just as a natural variation seems like a question of academic interest to me. But I don’t have a diagnosis, so there could be some benefit that I’m not aware of.

    • Anders says

      When I did research on patients with chronic mental fatigue, it was a great relief for them to get a diagnosis. Finally someone took them seriously. Finally they learned that they were not alone. Finally someone recognized what they were talking about.

      Of course, it helped that we didn’t try to lobotomize them.

    • amhovgaard says

      I don’t usually agree with Freud, but his view that as long as you can love and work you are healthy/”normal” enough, seems reasonable to me. You don’t have a disorder just because you are a bit unusual, but if it affects your ability to function, that’s a disorder. Obsessive/compulsive tendencies is perhaps the easiest example: you don’t have OCD just because you check the door twice when you leave in the morning, but if you have to call in sick because you can’t stop checking… that warrants a diagnosis. Or sexual fetishes – unusual sexual interests that don’t harm you or anyone else should not be seen as disorders, but if what you do/want sexually is harmful (I don’t mean causing bruises, but stuff that is neither safe nor sane – or things like pedophilia), that’s different.

      • Anders says

        I think all diagnoses in DSM has “causes clinically significant distress” as an obligatory criterion. Otherwise everyone would be mentally ill. And it’s implied that the distress should not be from social pressure to conform.

        • amhovgaard says

          Sure. But there’s a huge problem right there WRT GID in children, since “social pressure” means different things for children and adults. Adults can say to themselves “this is me, They don’t have a right to tell me I can’t be like this” even if they get beaten up, fired from their job, arrested… But children are completely dependent on their parents/other adults, not only for physical survival, but emotionally. And knowing how intensely, violently negative some parents’ reactions to a child’s failure to conform to the expected gender stereotype can be… I don’t understand how anyone can expect to be able to reliably tell the difference between a young trans girl and a feminine gay boy who has been convinced by the people around him that only girls do the things he likes to do and want the things he wants.

          • amhovgaard says

            In case it’s not clear: I think the trans girl needs a diagnosis, since her problems are not entirely due to other people’s reactions (even if that may well be the biggest problem, at least while she’s very young), but as the “gender-atypical” boy would be perfectly happy if people would just let him play with his dolls and kiss the pretty boys, a diagnosis is not just unnecessary but in my (professional, I’m a psychologist) opinion unethical.

          • Anders says

            Lets make sure that we can walk before we try to run, ok? We need a somewhat firm grasp on the diagnosis in adults before we go over to children.

  8. Anders says

    How come people never talk about ICD-10? Sure, the criteria are fairly similar (it would be embarrassing if they weren’t!), but at least ICD-10 gives you the option to classify GID as something other than psychiatry? Is there no love for ICD-10?

    • Crip Dyke, Right Reverend Feminist FuckToy of Death & Her Handmaiden says

      I don’t have time right now, though I really wish I did, to finish the earlier series of posts. I intend to conclude by discussing the misguided view that

      depathologization = destigmatization

      and even your formulation which is often seen as a compromise where

      de-psychiatricization = destigmatization

      even when (physical) medicalization still exists because

      psychiatricization = stigma
      but
      medicalization stigma

      This view is empirically wrong. Medical conditions are stigmatized all the time. People are committing the genetic fallacy – something is good or not depending on its etiology, therefore if we have a “good” etiology for transsexuality, we will not stigmatize transsexual people.

      But more than this, and I’ll go into this later when I have time:

      the equations
      depathologization = destigmatization
      and
      de-psychiatricization = destigmatization

      are ableist, dislabled-hating equations.

      When one is saying,

      “our experiences are represented in the DSM and stigma attaches and harm is done to us as people by being there, so we should remove ourselves from the DSM and escape the stigma,”

      One is also necessarily saying,

      “Anyone whose experience is in the DSM is stigmatized and harmed. We wish to leave that system in place but exempt ourselves from the negative consequences of that system by removing ourselves from the DSM but not abolishing the DSM or severing society’s connection of stigma and entitlement to harm with inclusion in the DSM.”

      This is why the ICD-10 gets short shrift. If you strategy is “Don’t hit me, hit those really sick and twisted folk that are actually psychologically broken over there,” I don’t care whether you implement that strategy by shifting a category to a theoretical ontology that appears to be less stigmatized or whether you want a clean break with all ontologies that appear to stigmatize to any degree.

      One is, at that point, arguing that one should be a special case. No stigma for me, stigma for those other people is fine.

      If the problem is stigma – and that is the problem identified that people are trying to address through DSM removal – then the answer is not playing around with etiologies and ontologies to find the one that least stigmatizes us while leaving systems of oppression in place.

      The answer is to destigmatize pathology itself. Why should being sick carry stigma? Do you support the stigmatization of people with HIV? If not, then why so eager to “depathologize” GID? Would the world be better off if HIV was entirely non-medicalized and HIV treatment was just a preference on which those people with sufficient resources could choose to spend money?

      Why-oh-why if we can destigmatize without depathologizing HIV can’t we do the same for GID?

      And why would we want to leave in place the entire system by which people are stigmatized in relation to ability and health (psychological and physical)?

      These are the questions that need to be posed to persons who propose the idea that

      depathologization = destigmatization

      and

      de-psychiatricization = destigmatization.

      I support a movement of completely destigmatizing pathology because I support the humanity of people with disabilities AND because I believe its the only real way out of the trap (otherwise we might not get the GID label, but without it therapists will label us depressed or dissociative or something else…and we will still be stigmatized).

      Crap I guess I did have time for the long version, or at least the long enough version…though now I’m late for something else. Sigh. Time management was never my strongest suit.

      • says

        Yeah! I wanted to say that, but I’m sure I would have messed it up somehow.

        I know you were talking about GID, but if you apply the same thoughts to homosexuality, you might get some weird conclusions. Was it wrong for homosexuals to exempt themselves from the stigmatization of disorders, rather than fighting for the destigmatization of all disorders?

        I think when people campaigned to remove homosexuality and ego-dystonic homosexuality from the DSM, they were probably doing it to reduce stigmatization. If we are being honest with ourselves, this didn’t do any favors to people who were stigmatized for other disorders.

        But at the same time, I still think homosexuality should be out of the DSM. From what I’ve read, to classify something as a disorder is to claim that the best way to address that thing is through the structure of medical/psychological care, and possibly public accomodations (such as wheelchair access to buses). I do not think that is the best way to address homosexuality, so I think it should not be in the DSM, stigmatization or no. With gender dysphoria, on the other hand, the classification of disorder makes more practical sense.

        • Crip Dyke, Right Reverend Feminist FuckToy of Death & Her Handmaiden says

          Assume for a moment that liking Brussel sprouts is in the DSM. One could argue that liking Brussel sprouts is not a disorder – not least because there is no treatment and the active eating of Brussel sprouts is not associated with co-morbidity or found to cause other conditions… and thus shouldn’t be in the DSM because, duh!

          However, if one says that liking Brussel sprouts is a disorder (because, duh! it leads to the icky taste of Brussel sprouts in one’s mouth) but that Brussel sprout likers are stigmatized and it’s unfair that Brussel sprout likers are treated to the same stigma and job loss as people who -in their disordered way- eat meat. And if that is your argument for removing BS likers from the DSM where liking/eating meat is categorized, THEN we can say your argument is messed up because liking/eating meat should not be stigmatized either (though liking/eating meat is clearly a disorder and we will leave it in the DSM).

          These are different and non-analogous situations.

          For trans folk even the people advocating removal admit that medical treatment is needed for some people. In fact, the need to not be seen as sick/broken is so strong that they use the fact that some people need some treatment as a reason for removal (“We don’t wanna be mistaken for the people who actually need medical intervention!”)

          So, yeah… it would produce weird results on “homosexuality” because homosexuality was being removed from a list of disorders not because of the stigma of being on the list (though that certainly motivated many of the activists to *care* about the list), but because it was recognized that “homosexuality” itself is not disordered.

          In this sense, one can critique the motivations and some of the rhetoric of the sexual orientation-removal movement, but they were still right on the fundamental issue of removal itself.

          Likewise, if Natalie and I and others are wrong and there is no disordered relationship between self and body in even a single trans person, if all distress was caused ever and only by the actions of society, then the advocates of removal would be correct that there is no disorder and that GID would be removed –but they would still be wrong that the *reason* to remove it is to remove stigma.

          A disability hating clock is still right twice a day. Likewise a person can mistake an asterisk for a plus and *add* 2 and 2 to get four…instead of multiplying 2 and 2 to get the same number. In this way – if and only if there are no trans persons with disordered relationships between self and body – the removal crowd could be right about the course of action while insisting on it for disability-hating reasons that can be separately critiqued.

          however, i don’t believe that there is no such thing as a trans person with a disordered relationship between self and body, therefore I’m convinced that the removal crowd is wrong on the substance *and* disability hating in the reasoning.

          Therefore Natalie’s post is vital to address the first part: they are wrong on removal *and* posts like mine are necessary to address the ableism in trans communities.

          I hope that this makes more sense of where removal of sexual orientation-as-disorder and removal of GID differ and where they are the same.

    • Anders says

      Yeah. The cynic in me also thinks it might have something to do with DSM being used in the english-speaking world and ICD-10 in the rest of the west (it’s standard in Sweden).

      And how can you not love a system that has a code for “Unspecified spacecraft accident injuring occupant, initial encounter” (V95.40XA)?

    • amhovgaard says

      The DSM and ICD systems are different in that DSM is (supposed to be) purely descriptive and symptom-based, while ICD is more of a mix of that + conditions with known or assumed causes. Psychologists mostly use DSM, while ICD is mostly for psychiatrists and other medical people. You (well, I ;) ) will often find similar-but-not-identical diagnoses from both systems in a patient’s journal. At least here in Norway ;)

  9. Brittany says

    Natalie,

    I have to admit that I was one of those people who bristled at the term “disorder” because I was really afraid that other people would just use that term as proof we WERE “insane” and only use it to demonize us.

    However, after reading your post I have to say that now I look at the term “disorder” differently than I did before. The way you (and Emily) describe ‘disorder’ as how we feel before we transition hits the nail right on the head.

    I have also fully agree that ONLY psychiatrists and psychologists who have experience and fully understand GID can diagnose and help people who have GID — and because of this GID should remain in the DSM.

    Thank you for helping me see all this in a completely different light!

  10. Sinead says

    I wish I wasn’t at work, there’s so much in this and the comments to read and re-read.

    One thing I hate is cis people who think we should have some sort of documentation to be trans just to justify the minority protections, like just going to the bathroom.

    • Anders says

      Well, what is included in minority protection?

      Is it something so valuable and sought-after that hordes of cis people would seek to take advantage of it? And is this worth the hazzle and humiliation that it causes trans people?

      I find it difficult to believe, but I’ve been wrong before. Many times, many of them on this blog.

      • Rilian says

        This reminds me of how some people say you can’t allow same-sex marriage because if you did then a bunch of straight people would take part in it. Too which I’m like, if that’s true, then so … what? If straight people want to get in same-sex marriages, fine let them. And if cisgender people want to live as if they are transgendered in any way at any time, fine let them. It doesn’t hurt me, it doesn’t hurt anyone else.

      • Sinead says

        There’s too many times where before I had my ID changed from an M to an F, that I was hassled in a number of situations. I have had to “out” myself at work because of the Social Security office and my W-2/W-4 didn’t match up.

        And then there is the bathroom issue, where a lot of cis people think we should have to document ourselves to prove that we’re in the right restroom.

      • Anders says

        I still don’t understand why cis people would try to pass as trans people. What are the fantastic perks that come with the territory?

  11. says

    Is there a website(s) that essentially acts as a white pages toward finding trans friendly psychiatrists/psychologists in various countries?

    It might serve to help foster proper diagnosis of gender dysphoria.

    • says

      I wish. There are resources and networks and message boards and stuff, but presently no basic, compiled directory (that I know of). I’ve tried setting up something of that nature both here and at Queereka, but interest and submissions from readers were vanishingly small. To accomplish it, I’d need people to help out and contribute information, via crowdsourcing, because I just don’t have the time to take on that kind of research project on my own. But thus far I just haven’t been able to build the necessary momentum.

      One thing I worry about, though, is that having such a directory being open and easily available could actually compromise the safety and efficacy of those organizations (threats from religious right and rad-fems, infiltration by chasers, etc.)

      • says

        I see. That is a problem. I can imagine what the WBC or horrible rad fem organizations might do if they had a list of places to picket. Making the access to the information require registration will only harm people that need it because many won’t want to register when it is so stigmatized.

        I am in “how can I help make this better” mode. I want tangible proactive things I can help do but I don’t want to end up accidentally causing harm. I get this way when the world seems so shitty.

        Perhaps a network that just links to various local networks for trans friendly therapists. Requires less contributions and more the power of Google and time to build.

        • northstargirl says

          I’m showing my age by writing this, but in the mid ’90s AEGIS kept a database of mental and physical health professionals in the US who were willing to help trans clients. You’d send them a request by postal mail with a self-addressed stamped envelope and they’d send back the information you needed. That’s how I located the endocrinologist who gave me my first hormone prescription. (My therapist was a Yellow Pages roll of the dice.)

          I’d love to see a similar system for people who need it, but with some way built in to keep the chances of harassment to a minimum. I’ve heard anecdotal evidence of trans people in my part of the world seeking hormones, but not getting cooperation from their doctors and even getting discouraged. I wish they could have a resource like the one AEGIS had back when I started out. If I hadn’t been able to get help from them, I probably never would have worked up the courage to ask any physician for help. Finding someone I knew was trans-friendly made an unbelievable difference.

          • says

            Spaces are traditionally disallowed in domain names, even though they are more than technically feasible. (Even spaces in the path and query elements of a URL are typically encoded as %20, meaning the character identified by hexadecimal value 20, decimal 32, which is the space in ASCII.)

            This all goes back to a lot of cultural and linguistic hegemony issues which mostly derive from fuzzy-headed Americans thinking they were building a system for Americans, rather than for the world. Even today it’s somewhat of a hassle to get an international domain name (with your native script), let alone to get the whole world to use it (instead of the romanization). It took nearly twenty years just to build acceptance that there should be international domain names, even. Behind the scenes, the non-ASCII scripts are actually still translated to ASCII using a peculiar encoding called “Punycode”. No one wanted to re-engineer the DNS system to work based on an Unicode encoding (which would handle basically all languages and more).

            You could use underscores, or hyphenate it, as Miri suggests. However, there’s no getting anyway from the fact that “therapist” is composed of the same letters in the same order as “the rapist”. It seems too late to change Internet culture to use proper punctuation in domain names, as well.

  12. Jeroen Metselaar says

    This is an important question. I myself am some kind of autistic and in that world the same thing is often asked. My answer is the same…

    In psychology there is not a clear line between normal and pathological…). The question is often not if a patient has a disorder, the real question is if the patient suffers and needs or wants help.

    Don’t make the fault to be insulted by being labelled with a disorder. If you do that you make the same mistake the whole society makes when judging people with psychological disorders. There is nothing to be ashamed about, it is just how you were born. Stupid people may judge you, but don’t do that to yourself.

    A diagnosis is NOT a judgement.

    Diagnosis is just a label. A handle useful in communication but still just a narrow pigeonhole. The spectrum of human psychology is so complicated that if we wanted a very precise labeling we would end up with about 7 billion labels.

    Actually we have labels like that, it is just your own name, it is YOU. We are all born different and nobody needs to apologize for what they are. Be you, it is all you need to be, all you can be. The quickest way to unhappiness is denying your own nature and trying to go against that.

    Don’t hate the diagnosis or the diagnostician. Hate the people that judge you for being different.

    If your being different causes suffering get the help you can. There is no shame in that either.

    (BTW I am one of those socialist Europeans so I think society has indeed the duty to help people with affordable medical care for anyone.)

  13. A. Person says

    Natalie, something that struck me is how you mention the term GID in the title, and then use the term gender dysphoria for almost the entirety of the piece. And I feel that the discussion of terms is the critical piece missing from your essay, because the term Gender Identity Disorder implies that the disorder lies in the person’s gender identity, not in the anxiety/stress/wrongness that comes from an incongruity between gender identity and body. Like your example of the old diagnosis of homosexuality, GID suggests that it is necessary to “correct” the gender identity, which results in “treatments” that just excerbate gender dysphoria. (This is why it is significant that the DSM-V is replacing the term GID with gender dysphoria.)

    Unfortunately, your point three simply isn’t true. For a long time, being transgender was considered the disorder and most people, including many in the medical community still believe that. The fact that WPATH has adjusted their understanding, doesn’t get rid of the cultural baggage. Again, the name change in DSM-V is a step in the right direction.

    I do agree with the rest of your argument that gender dysphoria is a disorder that needs treatment, and that the diagnosis is important for people to get treatment.

    • says

      My reasoning for that usage is that GID is the more recognizable term, and the one that would most clearly convey in the title what this post is about (and allowed me to do my Gertrude Stein repetition thing again). I switched to Gender Dysphoria in the body of the text because it’s my understanding that that is the present term used in the DSM.

  14. says

    Very good post. I got banned without warning for making a less eloquent version of this same argument on a prominent gay rights group on Facebook. This really irked me. Some gay activist to whom trans people were basically theoretical and expected to follow the gay model silenced me for expressing my girlfriend’s concerns about what would happen to her insurance coverage. This part doesn’t sound right, though:

    Furthermore, Gender Dysphoria’s inclusion in the DSM is a global issue, with global consequences.

    My understanding is the DSM is mostly an American thing, so an America-centric view of it is justified. Most of the world uses ICD.

    • Anders says

      The Anglo-Saxon world uses DSM. But since the Anglo-Saxon world is so dominant in today’s world, it has global consequences. Researchers have to at a minimum motivate why they’re not using DSM, for instance.

      • Dagda says

        In Germany, while the ICD-10-gm is used for coding purposes, the DSM IV is used as a diagnostical guideline as well.

  15. Ally says

    Hi Natalie,

    I really enjoy your thoughtful posts. By way of my personal background, I’m a Child & Adolescent Psychiatrist (which means I trained in adult psychiatry and then an additional two years in child psychiatry). I also transitioned. I’m not sure how many, if any, of us have.

    At any rate I personally find the diagnosis troubling for a few reasons but mainly because it’s overly broad and children and adults who simply don’t conform to traditional gender roles are given the diagnosis and pathologized and subjected to reparative therapy. So while the APA forbids it for homosexuality, it doesn’t for those with GID diagnosis, astonishingly. And reparation therapy is openly advocated where I work and trained by some, but certainly not all, psychiatrists. Also there is no “escape clause” as it is currently defined (DSM V notwithstanding). So once a transsexual always a transsexual. And lastly, are the people who are on the DSM committee – reading some of their seminal papers one might get the impression that they are incredibly biased and much of it reads as if non-conformity in of itself is a disorder and that being transsexual is akin to have a psychotic delusion.

    My thinking on this issue continues to change. ;) At this point in time, I think transsexualism might be a mental disorder. Or maybe a neurological disorder. The distinction is not really clear between the two which is one reason we have the same accrediting board. But I definitely think that GID is not a mental disorder as currently defined and should absolutely be removed from the DSM. Which it seems it may likely be in an ICD revision (removed from mental disorders section).

    There is actually a residual diagnosis relating to homosexuality – Identity Problem 313.82. If it’s really a problem, and by that I mean the idea of enjoying “cross gender play”, for example (whatever that is), is ego dystonic, not simply secondary to social ostracism then I see no reason why it couldn’t have a specifier – e.g. sexuality or gender type.

    • Sarah says

      Interesting comments, Ally. One thing you said confuses me, and I wonder if you could explain in a little more detail:

      “My thinking on this issue continues to change. ;) At this point in time, I think transsexualism might be a mental disorder. Or maybe a neurological disorder.”

      My own sense has been that the general consensus of both professionals and the trans community is converging on an idea that transsexualism is simply a neutral, naturally occurring variation among people, and any association with “disorder” arises only in connection with discomfort that people may feel due to social exclusion or discomfort that can occur in the absence of help with acceptance, coming out and obtaining hormones, surgery or other treatments that help to relieve feelings of discomfort with body image and help people function better cognitively and socially.

      So in this framework, setting aside the political considerations, and looking at it only as a question of whether someone is healthy and functioning well, then a happily transitioned transsexual would not be said to have any disorder. Are you saying that a well adapted and happy transsexual person has a disorder? If that is your contention here, does it mean you think there is something different or wrong with people who are transsexual, or are you simply concurring that a diagnosis of transsexualism as a disorder is appropriate to ensure continued access to treatment like hormones, etc., or something else? Maybe you are speculating about an altogether different model of transsexualism (i.e. something other than “natural occurring variation”)? Or have I totally misread you?

      Please understand, I am not looking to provoke or challenge, but simply to inquire, because it seems possible you might be alluding to a larger idea here, and I’m wondering what it might be…

      • Ally says

        Hi Sarah,

        Thanks for your questions. I haven’t had coffee yet this morning so I may not be thinking or articulating my ideas too clearly. ;)

        I do think that the “gender binary” is “un-natural” and that what we think of as cross-gender play/interests/etc are perfectly “natural” – meaning occurs widely in nature – and not inherently pathological. But I wonder whether it might be a disorder when someone says that they feel compelled to modify their body or they will suffer extreme distress. I’m not really sure. Which is why I’m still thinking about it. :)

        As an aside there are plenty of things that occur across the human spectrum that are natural in a sense but we would still consider “disordered” in the DSM – Asperger’s, Mental Retardation, etc. And there is this idea implicit in the DSM that a certain amount of a thing is “ok” but too much is not – e.g. a little anxiety is OK but too much = Generalized Anxiety Disorder. Or a little amount of sadness is OK but too much = Depressive Disorder NOS/Dysthymic Disorder/MDD. Or some increase in energy and productivity is OK but too much = (hypo)mania. So bringing it back – a certain amount of cross-gender identification is OK = GID (so should not be there) but a lot is not = transsexualism.

        One last thing I forgot to mention – another major problem with GID diagnosis as currently defined is that it isn’t really valid – 50-75% of children or so given the diagnosis grow up to be gay not trans* identified. So, imho, it really is a back-door way of putting homosexuality back in the DSM and pathologizing it. I think it would help if the DSM committee had some trans* people on it. We don’t rely an straight people to understand or define what it is to be gay, for men to define what it is to be women, and shouldn’t rely on non-trans people to define what it means to be trans. But that’s maybe a political argument. :)

        And btw there are a non-trivial amount of psychiatrists who think the DSM is complete nonsense in its entirety. ;).

        • Anders says

          A certain amount of these things are allowed. They become pathological only when they cause the patient or interferes with his life. A psychotic patient may feel rather good while slowly dying from an infected wound, for example. We need a continuous dialogue within society to decide where these limits go.

        • Sarah says

          Thank you for your reply, Ally. What you are saying is much clearer to me now. You raise several points that could easily expand into new topics on their own, and some of them will probably come around the topic wheel again soon enough, so I am quite content to leave any open questions at “still thinking about it”. Thank you for contributing to the conversation here – your background positions you to offer a unique perspective and speaking reader to reader, I hope to hear more from you here in the future.

    • northstargirl says

      Though I echo some of Sarah’s concerns, you’re absolutely right about the lack of an escape clause. That’s my biggest complaint about the current diagnosis. As far as I’m concerned my problem was resolved about a decade ago, yet to this day if I have to give a personal/medical history I run the risk of the diagnosis following me around and having to explain that, no, I’m not mentally ill. (It’s happened before, and while it didn’t derail things, it at least made them interesting. I don’t think I’ve had to supply so much documentation for anything in my life.)

      I understand the need for a diagnosis…but I fixed the issue, and very successfully. I’m happy and well-adjusted and secure in who I am. I no longer fit the diagnosis, and I’d sure appreciate a way for that to be officially acknowledged.

      • Anders says

        You’re in the same boat I’ll be if I ever find a way out of this depression. I’ll be on medication for the rest of my life. And you’ll still require hormones, am I right?

        In that case the doctor would say that you are asymptomatic but you still need treatment.

        • northstargirl says

          I’ll keep taking hormones, yes, but for the same reasons as would a woman who’s post-menopausal, had a hysterectomy or for whatever reason is on hormone replacement therapy. I haven’t noticed any real emotional or mental issues on those occasions when I’ve had to go without estrogen. So far as it stands now, for me it’s now a physical health issue (handled during routine check-ups by my OB/GYN) and not a mental health issue, and if I had some way to officially have that acknowledged it would have made life easier for me.

          • Anders says

            As I understand it, that’s not the typical experience. Stop the hormones and the dysphoria comes back. It’s interesting to hear other stories – they set the theorizing parts of my brain spinning.

  16. William Burns says

    With all the bad stuff that’s been happening to Natalie lately, I’m getting a little worried here with no Saturday post. I hope she’s OK wherever she is.

    • says

      I’m fine.

      Just thought that with such a light week, doing a recap post just wasn’t worth sacrificing the chance to have a nice, relaxing night off and de-trigger. Will include this past week in next Saturday’s recap.

          • Utakata says

            Oh no…I was sorta eluding to your “Day of Silence” post from before. Which I thought was an interesting take on not wanting post anything for that day. :)

            …sorry that didn’t come out right though.

            And please don’t feel bad. You post when you feel you want to post…so don’t worry about us. This is your blog afterall.

      • Anders says

        Good to see I’m not the only mother hen around here. Curl up with a good book or something. And sweet dreams of rainbows and puppies and unicorns.

  17. geocatherder says

    Didn’t have time to check out all the comments; I apologize deeply if this has been said before. But:

    Homosexuality equals attraction to the same sex. Not a disorder, just a relatively uncommon attraction. Might’ve had some evolutionary advantage in passing on the genes of one’s family via sisters. Doesn’t matter. Isn’t broken. Don’t try to fix it. May cause a great deal of personal angst, but that’s because of societal hangups, NOT internal problems.

    Transgender = brain gender not equal to body gender. Symptoms: lots of cognitive difficulty with what brain is saying vs. what body is saying. Lots of INTERNAL difficulty. Totally different from sexual attraction. Very difficult for person experiencing it, but for internal reasons as much or more than external reasons. Broken. Fix with transition, a non-trivial, fraught with distress fix (but better than to leave broken). Societal hangups may cause a great deal of internal angst IN ADDITION TO internal difficulty.

    So, is my analysis way off, or have I cut to the heart of the problem???? Because, while I see both these “conditions” (for lack of a better term) as normal human expressions of sex and gender, I also know that my “problem” of depression is a normal, though hopefully uncommon, state on the range of human experience. I might be able to embrace homosexuality, with the right role models, if my brain was wired that way. There’s no way I can embrace the problem of being completely depressively nonfunctional or even partially functional; I need meds and therapy. I expect the same is true of my transgender sisters and brothers; nonfunctional is not an acceptable operating state for them, partially functional is not an acceptable state for them, they need to be fully functional human beings. We suffer different ailments but search for the same kind of cure: restoration to completely functional humanity.

    • Crip Dyke, Right Reverend Feminist FuckToy of Death & Her Handmaiden says

      Except for conflating “transgender” with “gender dysphoria”/”transsexuality” you have hit on it.

      Transgender doesn’t mean what you think it means, however. Even to the extent that the word can sometimes be used as if inclusive of transsexuality, one certainly can’t describe what you did as the transgender experience or expect that people who ID as transgender have that experience. Crossdressers, drag players, and many others don’t experience what you describe but are certainly transgender.

      Also, “transgender siblings” might be better than “sisters and brothers”. Just sayin.

      But yes, you’ve gotten the essence of Natalie’s post correct.

  18. crayzz says

    Do psychiatrists and psychotherapists specialize like doctors do? ‘Cause as far as I know, they don’t. If I need to go to the hospital, I don’t want the cardiologist operating on my liver.

    By the way, I’m starting to think you might be psychic. Whenever I have some sort of criticism, your next paragraph almost always either refutes my criticism, or it shows that my point is irrelevant.

    • Anders says

      In Sweden psychiatrists can specialize. I don’t know about psychologists but it would surprise me if they couldn’t. That’s the people I want in my ‘perfect clinic’.

      • says

        Psychiatrists and psychologists in North America DEFINITELY specialize. At the VERY least in terms of what kinds of patients they see and issues they have experience with. There in fact IS a gender-specialized psych here in Vancouver named Melady Preece who does an absolutely fantastic job. Her practice is specifically geared towards seeing trans or questioning patients. There are also psychs who specialize in addiction, marriage, gay/lesbian issues, phobias, aging, careers, hoarding, death and grieving…all kinds of things! Where on Earth anyone would get the idea that they don’t/can’t specialize is beyond me, and HUGELY inaccurate to the reality.

      • crayzz says

        In hindsight, I dunno where I got the idea either. I mean, I had all the information I needed to realize that yeah, they do.

        • Crip Dyke, Right Reverend Feminist FuckToy of Death & Her Handmaiden says

          The difference is that they don’t specialize in the way that medical doctors do, because – at least with psychiatry – it is a specialization already.

          There is no board certification in sub-branches of psychiatry the way that there is board certification in cardiology, surgery, etc.

          In fact, a good comparison is between psychiatry and surgery. They are both specializations in which one can be board certified as a specialist, but surgeons can get board-certified in subspecialties, like neurosurgery or thoracic surgery. Psychiatrists cannot get board certification in a subspecialty.

          But of course they choose to work more with people from one population or in one type of life situation or with one set of diagnoses/problems more than others.

          That’s specialization in a sense. But it’s not at all the formal process of specialization that an MD goes through post medical school.

  19. Jean-Yves says

    I agree with most of what Nathalie said.

    My own argument for not letting people decide to transition by themselves, is that many who come for consults initially are at the same time certain that they want to transition at this very instant and very confused otherwise

    Yet, from my very long experience in contact with this group (22 years) most decide not to transition after a pretty short time in therapy. They had disphoria, but that disphoria didn’t require anything like transition to be relieved.

    Many others don’t transition immediately because disphoria masked other very significant issues that need to be resolved first or the transition will simply fail.

    Finally, most TS that end up transitioning are in significant distress initially and the disphoria has caused significant damage to the psyche that need to be sorted out as they move forward. Some exceptional individuals do come in having done all the heavy lifting before meeting a therapist, but they are the exception rather than the rule (for these people, therapy may indeed be seen as intrusive and annoying).

    Are those I’ve seen representative? In the absolute, probably not. Gathering a true snapshot of the pre-transition TS community is impossible. But, I it’s as fair as I can make it.

    So, allowing all of those suffering disphoria to simply get hormones on demand would be a potentially very damaging to the patient considering the present outcome of therapy. That’s why I think a significant amount of therapy needs to be involved to sort through the pain. Then, if required, the appropriate remedy to this pain can be given (hormones, surgery, etc.)

    • Anders says

      You could put them on GnRH analogues and hormone blockers while you do that therapy. A few months on them won’t cause any permanent harm.

      Also, I’d like to see some figures here. Has there been a study to see the dropout rate in a convenience sample just the people who came in and said “I want to transition.”?

      • Sarah says

        “You could put them on GnRH analogues and hormone blockers while you do that therapy. A few months on them won’t cause any permanent harm.”

        For that matter, why not let anyone who wants hormones go ahead and start them? If they decide after a few sessions of counselling not to transition, then no harm done, but on the other hand, the experience of actually taking the hormones can provide valuable information to someone while they are exploring their options. After all, it’s one of those things where there’s really no way to know what it feels like until you try it.

        But I’m crazy like that: I actually think it would be a great idea if everyone got at least a brief taste of the hormonal regimen of the opposite sex. It could do a lot improve understanding between the sexes, and it might also help people to gain some insights into how their own endogenous hormones influence normal cognition and body function.

        • Anders says

          With easy access to hormones over the Internet, we practically have that already. You’d want some limits though, otherwise all the psychotherapeuts who are specialized in transsexualism will be busy seeing the trans-curious.

          • earth & stars says

            Minor point: this is the case for the women, yes. Testosterone, on the other hand, is a controlled substance, so the guys have to depend on prescriptions if they’re not in a position to buy T illegally.

      • Sarah says

        And on a completely different tangent:

        “Also, I’d like to see some figures here. Has there been a study to see the dropout rate in a convenience sample just the people who came in and said “I want to transition.”?”

        This would be a very interesting figure. And it might be even more interesting to break it down by therapist. There might be significant differences in such a break down. Maybe one therapist discourages 9 clients out of 10 from transition, but four go on to transition later anyway, Or maybe a there are therapists who encourage 9 clients out of ten to pursue transition but four later de-transition.

        Generally, rates of de-transition and re-transition would seem to give a useful measure of diagnostic accuracy. So useful, in fact, that it seems likely that they must have already been tracked somewhere. Maybe some of the big HMOs have this kind of data? And if they do, how have they used it? Hmmmm…. Metrics like these could be used to determine whether therapy in general “works”, and to identify sub-sets of therapists who are either highly effective, or very ineffective, and use those results to search for commonalities in approach to treatment.

        • Sarah says

          Or then again, maybe 99% never go on to transition ever, and there’s no signal in this data… Probably time for me to stop speculating on things I know nothing about and go to sleep! (=

        • Anders says

          That’s why I’d like to follow different symptoms. To see patterns like that. So we can say “Ok, you have what seems to be Gender Dysphoria type II so you should get this kind of treatment.” Of course, sometimes we’d be wrong but I still think it would be better than a shotgun approach or a “one-size-fits-all” approach.

          I spoke about psychotherapy in an earlier post on this theme, but you could also vary the hormone treatment. Some people might need more than others, or in a different pattern (e.g. pulses vs. continuous infusion). We’ll never know until we look.

        • says

          Transition is rare within the general population. Lasting detransition (as opposed to temporary purges) is rare within the trans population. Finding reliable data is extremely difficult given how small the population in question are.

          • Anders says

            Ideally, you’d want to have a large group of trans people and follow them for ten years or so, but the numbers makes that impractical. You’d need to collaborate between several centers and running that for ten years…

    • Kizzy says

      By the time I was able to actually find someone to help me, I was thoroughly frustrated. I’m MTF transsexual, live in the U.S and began my transition 7 years ago. I’d literally spent years seeking out help. As a child, I asked for help from my GP but never received it (possibly due to parental consent issues). As an adult, I was referred to people who wanted to discuss my feelings or dispense psychiatric drugs, but my issues were left unaddressed. So hearing “let’s talk about this first” wasn’t exactly something I felt I could wait around for. I resorted to Internet support and self-medicating to make any progress. I suppose I also felt the need to tip the hand of my health care providers: Help me with this or I’ll continue on my own.

      Natalie, this is my first time posting here (and I know I’m really late to this discussion and you may not actually see this), but I want to thank you for writing. I’m in my second phase of trans information knowledge acquisition (post primary transition drive) and your blog has played a huge role in it.

  20. Helen says

    I like to say that being trans is not a state of mind, but a biological condition, especially if you read the abstracts Zoe Brain has collected and published here

    http://aebrain.blogspot.com/p/reference-works-on-transsexual-and.html

    There is a lot of research going on which points to our brains have developed differently either due to the way our DNA formed from our parents DNA or due to something happening during fetal development, or both, but that shouldn’t cause our biological condition to be considered a disorder, only a biological difference.

    Is my being left handed a disorder, or a natural state of the way my brain developed??? There is a lot of medical evidence that shows we lefties use the right hemisphere of our brain more than the left hemisphere of our brain, while all of you righties do the opposite.

    As to seeing a professional therapist, not all are trained or competent to help with GID. My first therapist was a true gatekeeper, with ivory tower trans knowledge, who followed the requirements set down for the university gender clinics we had all over the US back in the 70’s and 80’s. She said I shouldn’t transition because I have man hands and feet, and back then I wanted to try and save my marriage, instead of just destroying it, like she wanted. I am so lucky with my 2nd therapist who is also trans, they know and understand what I am going through and have helped me with my depression issues.

    To the commenter who mentioned NARTH, You need to look at Kenneth Zucker.

    • says

      Left-handedness does not cause clinically significant distress or negative impact on quality of life. Gender dysphoria does.

      Not to be snarky, but with some of these comments it feels like people didn’t even read the post…

    • Dagda says

      There is a lot of research going on which points to our brains have developed differently either due to the way our DNA formed from our parents DNA or due to something happening during fetal development, or both, but that shouldn’t cause our biological condition to be considered a disorder, only a biological difference.

      What about schizophrenia? All that can be said about schizophrenia as well. Or most medical conditions which are clearly disorders or diseases.

    • says

      If by “increased appreciation” you mean “increased desire to destroy my TV, my DVD, and all examples of the genre I can find in a misanthropic rage”, then yes, I have an increased appreciation for chick flicks.

      :D

      • Anders says

        I believe that is technically termed “chick flick dysphoria.” :)

        There was a study a few years ago that came to the conclusion that men and women dislike chick flicks with roughly equal intensity. But when you’re a guy on a date you take the gal to a chick flick, because that’s what chicks like, right? And if you’re the gal you come with him, because that’s what chicks like and you don’t want him to think you’re weird.

  21. says

    OK, so I didn’t read this post. And I’m really only commenting to subscribe to new posts by email, since this is the simplest way to do so.
    But…
    NO IT’S NOT A DISORDER. Society is the one that’s fucked up, not me. I’m just me, and I don’t have a single problem with who I am whatsoever.
    Thank you for tolerating my comment.

    • says

      No, you’re right, you’re not fucked up. Being trans is not a disorder at all. But the dysphoria, which in a transitioned person isn’t really much of a problem, IS. Read the post.

  22. says

    Hi Natalie, and anyone else reading,

    I got an email about a petition to remove “gender dysphoria” from the DSM. I replied, briefly, to point readers to this blog (and Emily’s comment!). Then the original writer ericajfriedman, a gmail address, replied in a long email: she particularly encouraged others to enter the dialogue.

    She says

    trans activists who oppose this position are precisely some of the people whom I would like to involve in this discussion so that they may consider the ideas and experiences of others who live elsewhere in the world, have different experiences from their own, and who agree on achieving biomedical pathways for gender affirmation.

    Assuming this is sincere, it makes sense that others here might want to contact her.

    Erica J. Friedman, M.A.
    College Assistant, Office of the Provost, Hunter College (CUNY)
    Doctoral Student, Social-Personality Psychology, The Graduate Center (CUNY)

    I don’t know if it makes sense for me to reproduce the entire pair of emails online, and I don’t have a place in the discussion itself. But I would be happy to forward the emails, which contain a lot of links, to anyone who asks (contact me also at gmail, elizabethsqg).

  23. Chevy says

    Hmm… my four penn’orth is that I can sometimes (italics) glimpse the ‘advantage’ of retaining ‘gender identity disorder,’ and it’s pejorative derivatives, on the DSM. In a country like Britain that, notionally at least, has a free at the point of use National Health Service, but much prefers to spend its resources on Banksters and waR, it is a route to some free NHS treatment.

    I do question the idea (wonderful, if true,) that everyone is ‘happy,’ ‘confident,’ socially succesful et cetera post op. In my experience a lot of the time it’s Joe Public who has ‘gender identity perception disorder’ and of course that isn’t helped by those transwomen who have convinced themselves of their deep stealth and other delusions.

    So, please occasionally spare a thought for those of us continuing to push water uphill with our noses to get the treatment we need from an unelected government and the overwhelmingly hostile and Transphobic public that certainly does abuse, sack and, in extremis, kill us.

    • transmom says

      Chevy – I can absolutely 100% feel the gravity of your situation. But the transphobic public you speak of exists only because of the lack of medical knowledge about the condition. Our child has been turned away from many psychiatrists because they believe that it’s a psychiatric-neurological condition, and that goes against the “PC” perspective that it’s biological – so rather than get hate mail and have their reputations smeared, they just won’t treat that condition at all. Let’s embrace all possibilities, and hope for relief, in whatever manner suits someone, for all people who are struggling with the unusual conditions. Peace. :)

  24. transmom says

    It’s a tragedy to me that “trans” cannot be inclusive of a variety of causes, and then treated from that point forward.

    If a child was not “born” with the urge or desire to be trans, but instead endured grossly horrific trauma (sexual abuse, neglect, etc) in infancy/early childhood that caused a myriad of disorders as a result, which later progressed into body dysmorphia, then gender dysmorphia — why should that fall under a general trans label?

    Why would anyone encourage just such a person to cut off their body parts in order to feel “cured”? Would you not treat the CAUSE? Wouldn’t it be more morally and ethically correct to avoid permanent physical surgery, and instead treat the mind and the scars from the trauma?

    This is why it angers me to see the LGBT – “T” being the key component there – dragging trans individuals into their fold… it’s not out of “likeness” (trans is not the same as being gay)… its for shear numbers and political strength… and I say this after much contemplation (no, I am not homophobic).

    When we look at trans people as human beings with a serious medical need (afterall, isn’t the brain an organ like any other that deserves prompt medical attention, just as our liver, heart, kidneys, etc) – then the compassion and empathy from the public will naturally follow.

    Take it out of “LGB” — and give it the sole-focuse it deserves and requires to be addressed uniquely tailored to each individual.

    If, in the end, surgery is that person’s only source of relief – by all means, let’s support it. But please stop telling trans kids that their only hope is to cut off their body parts.

    And let’s ask the LGB-“T” to please stop throwing stones at those trans people who come forward later in life to say that they spontaneously stopped feeling “trans”, or that therapy helped them in some way, or that they resolved their situation through time and healing. While rare, it does happen – and sadly, sometimes after the body has already been transformed.

    Compassion & Empathy is a two way street.

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