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.