Treating Transsexuality: To Help or To Harm?
By: D. L. Shultz
Tags: Transgender, Psychology, Mental Health, History, Culture

A trans (or, transgender) person is anyone whose gender identity does not align with the gender expectations that are placed upon their assigned sex; a cis (or, cisgender) person, by contrast, is anyone whose gender identity aligns with these expectations. For example, if someone has a penis, and identifies with masculinity or as a man, then they are cisgender; if someone has a penis and identifies with or as a non-masculine gender, then they are trans. Transsexuality refers generally to trans identities and lived experiences, and cissexuality refers to cis identities and lived experiences. Gender itself is a behavioral achievement, while assigned sex is framed as a biological fact. “Be male!” is an unintelligible command, while “Be a man!” is used to motivate male-bodied individuals to “man up” by reaffirming their alignment with masculine gender expectations. Gender is thus performative, sex is assumptive, and there are consequences that occur when the assumption of sex is violated by non-normative gender presentations.

In this essay, I will describe arguments for and against the representation of transsexuality in the American Psychological Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM), and answer whether its inclusion as a diagnosis is overall more helpful or harmful to trans people. I will first outline how transsexuality has been represented in the DSM to represent the viewpoint of psychiatric professionals on the topic of transsexuality. I will then present the opposing viewpoint by outlining criticisms of transsexuality in the DSM that have been made by trans activists. There are parallels that can be drawn between how homosexuality and transsexuality have been represented in the DSM, and how activists have responded to this representation, so I will be begin by outlining a brief history of homosexuality’s presence in and removal from the DSM.

Homosexuality in the DSM

The APA considered homosexuality to be a mental illness from 1952 until 1973, which was when it was removed from DSM-II after gay rights activists lobbied for its removal (Drescher, 2015). Gay rights activists during this time “[believed] psychiatric theories to be a major contributor to antihomosexual social stigma” and so they “disrupted the 1970 and 1971 annual meetings of the APA” (Drescher, 2010, p. 434). A Nomenclature Committee was assembled and they determined that subjective distress and impaired social functioning were recurring elements behind the diagnosis of all mental illnesses, and concluded with the APA that “homosexuality in itself does not meet the criteria for being considered a psychiatric disorder” (as cited in Drescher, 2010, p. 435). This led to its removal, but there were two attempts to keep it in the DSM through inadvertent means: the first was Sexual Orientation Disturbance (SOD)*, which was added to DSM-II in 1973 after the removal of homosexuality (Drescher, 2015). SOD referred to distress caused by same-sex sexual desire along with a desire to change one’s sexuality, and provided the rationale for conversion therapy (Drescher, 2010). Ego Dystonic Homosexuality (EDH) replaced SOD in DSM-III (1980), but this diagnosis was removed in DSM-III-R (1987) because the APA realized that the diagnosis implicated that anyone who was distressed by an element of their identity (e.g., their race, weight, height, etc.) could qualify for this kind of diagnosis (Drescher, 2010). Homosexuality is no longer alluded to as a mental illness in the DSM, and gay rights activism has since resulted in the legalization of gay marriage and the integration of gay people into mainstream popular culture.

Transsexuality in the DSM

Transsexualism, gender identity of childhood (GIDC), and atypical gender identity disorder first appeared in DSM-III in 1980. All three diagnoses relied upon the persistent presence of perceived incongruence between assigned sex and gender identity, and varied depending on other criteria. Transsexualism emphasized “a persistent wish to be rid of one’s genitals and to live as a member of the opposite sex” (American Psychiatric Association, 1980, p. 261–262). GIDC diagnosed children who insisted that they were a boy or a girl despite having a genital assumed to indicate otherwise, and atypical gender identity disorder referred to any gender-sex-related concerns not accounted for by the other criteria (Beek, Cohen-Kettenis, & Kreukeis, 2016). Gender Identity Disorder of Adolescence or Adulthood, Nontranssexual Type (GIDAANT) was added to DSM-III-R in 1987, and referred to recurring distress about assigned sex without a desire to change sex characteristics (Drescher, 2010). In DSM-IV, GIDAANT was removed, and transsexualism and GIDC were collapsed into gender identity disorder (GID), which had different diagnostic criteria to differentiate symptomology between children, adolescents, and adults (Drescher, 2010).

DSM-5 was released in 2013, and in it GID was “renamed ‘gender dysphoria’ in order to imply a diagnostic entity in its own right, not necessarily associated with severe comorbid psychiatric findings, and better characterized the gender incongruence-related experience and discomfort” (Costa & Colizzi, 2016, p. 1954). According to Kenneth Zucker, Chair of the Sexual and Gender Identity Disorders Work Group for DSM-5, GD was chosen as the name of the diagnosis in DSM-5 because it gets at the “core phenomenology” of the condition, which makes the “diagnostic criteria more precise” (Zucker & Duschinsky, 2016, p. 31). Zucker admits that discrimination and social rejection contribute to the experience of subjective distress in trans populations, and “that the distress/impairment criterion has never been well studied when it comes to gender dysphoria or its predecessors” (Zucker & Duschinsky, 2016, p. 29). Symptoms of cross-gender identification and discomfort about assigned sex were also combined for GD, and gender identity was reframed from a dichotomous (male/female) identification to a multi-dimensional spectrum of identifications (Cohen-Kettenis & Pfåfflin, 2010). GD therefore acknowledges both binary (e.g., male-to-female [MtF], female-to-male [FtM]) and non-binary (e.g., genderqueer, transmasculine/feminine, etc.) trans identities, and thus allows for more access to medical treatment for trans populations.

This is how I feel about gender.

Treatment and Transsexuality

There is a 41% suicide attempt rate among trans and gender nonconforming populations, which stands in contrast to the 10–20% prevalence among cisgender lesbian, gay, and bisexual (LGB) adults, and the 4.6% national prevalence (Haas, Rodgers, & Herman, 2014). Trans children who have socially transitioned, or are supported in their trans gender identification by family and peers, show equal levels of depression and slightly higher levels of anxiety than national averages, which contrasts with children who have been diagnosed with gender dysphoria (GD), who show high levels of internalizing disorders (Olson, Durwood, DeMeules & McLaughlin, 2015). Social context and support therefore play an important role in modulating the severity of symptoms associated with GD. The role of social context is a non-constitutive element of the diagnosis of GD, however, which is part of what makes GD a controversial diagnosis.

Sex-reassignment surgery (SRS) and hormone-replacement therapy (HRT) are important medical treatments that help reduce the severity of symptoms associated with GD. SRS and HRT are the means by which a trans person can transition, or begin to align their sexed bodies with their gender identities. SRS refers to any procedure that modifies primary or secondary sex characteristics (e.g., breast removal, gynopalsty, phalloplasty, tracheal shaving, etc.), and HRT refers to modification of the distribution of testosterone and estrogen in the body, often to induce the development of secondary sex characteristics (e.g., breasts, facial and body hair, vocal changes, etc.). SRS and HRT are medical procedures that have been shown to significantly improve self-esteem and overall well-being, and significantly reduce levels of anxiety, dissociation, perceived stress, and social distress in TGNC populations (Costa & Colizzi, 2016; Dhejne, Van Vlerken, Heylens, & Arcelus, 2016). I will focus on having access to SRS and HRT as a primary point of concern in this review, as it is possible to get access to these treatments only through diagnosis of GD.

Criticisms of Transsexuality in the DSM

Trans activists have opposed transsexuality in the DSM in a number of different ways. Some critics argue that transsexualism and GIDC emerged in DSM-III in reaction to the elimination of homosexuality as a mental illness. Their reasoning is that gender atypical behavior is common among children who later come out to be gay or lesbian, and so therefore GIDC was specifically designed to prevent the development of homosexuality by pathologizing gender nonconformity in children (Drescher, 2010). Zucker and Spitzer (2005) argued against this by saying that GIDC was not a “backdoor maneuver”** to replace homosexuality because ego-dystonic homosexuality was included in DSM-III and was removed in DSM-III-R after it was shown that it was conceptually flawed and lacked empirical support, and because there were individuals on the subcommittee for psychosexual disorders who argued for both the removal of homosexuality in DSM-II and for the inclusion of GIDC in DSM-III. Activists challenged this counter-argument by highlighting how early clinical efforts to “treat” trans children who were diagnosed with GIDC “aimed at getting them to reject their felt gender identity and to accept their [assigned] sex” (Drescher, 2010, p. 428).

GID was scrutinized because it implied that a trans person’s gender identity itself was disordered, which implicates that trans gender identities are inherently pathological (Drescher, 2010). Reconceptualization stances toward GID took pragmatic positions by agreeing that GID needed to be renamed with less stigmatizing language, but that it should remain in the DSM so that trans people can have access to medical transition. Those in favor of reconceptualization argued that structural reform to the entire health care system was too lofty a goal, and that it was more pragmatic to lobby for a change to the diagnosis instead of a total elimination of it (Drescher, 2010). The fact that GID was renamed to GD in DSM-5 is a reflection of the success of these more moderate reconceptualization approaches to representations of transsexuality in the DSM.

Those fully opposed to representations of transsexuality in the DSM have used a few different strategies to argue for its removal. One strategy involves citing evidence from neurological research to show that transsexuality is a naturally-occurring phenomenon. Zhou, Hofman, Goore, and Swaab (1995), for example, found that the bed nucleus of the stria terminals (BSTc), a brain area related to sexual behavior, was of a similar size between transgender and cisgender women, which points toward a neurological basis for gender identity. This research was used to argue against the stigmatization of transsexuality by showing it has a biological basis, which is similar to how research on neurological differences between homo- and heterosexual people were used to argue against the stigmatization of homosexuality (LeVay, 1993).

Another strategy involved reevaluating prevalence rates of transsexuality in the United States to show that it is more common than American society has been led to believe. Conway (2002) found that an estimated 1 in 2,500 people in the United States received MtF SRS between the early 1960s and early 2000s, which implies the prevalence of transsexuality is much higher than the 1 in 30,000 psychiatric professionals reported as the prevalence rate. This strategy attempts to normalize transsexuality, as activists believe that part of its stigmatization involves its representation as something that is uncommon. This is similar to how gay rights activists referred to Alfred Kinsey’s research to show that homosexuality was more common than mental health professionals initially claimed.

The gatekeeping role that mental health professionals play in providing access to medical care through psychiatric diagnosis of GD is a primary point of contention for trans activists. They argue that a diagnosis of a mental illness should not be required in order to have access to SRS and HRT, and that this decision should be transferred out of the jurisdiction of mental health professionals and over to physicians who can provide direct access to these procedures (Drescher, 2010). Their arguments highlight how it is unethical that transgender individuals must choose between being diagnosed with a stigmatizing mental illness and receiving access to medical care, or avoiding stigmatization through diagnosis and not having access to medical care (Serano, 2007).

My Position

I take a critical-pragmatic approach to this issue by saying that GD does currently need to remain in the DSM, but this is only because removing it would prevent trans people from being able to transition through SRS and/or HRT. My approval is ambivalent, however, because I also believe that lobbying should continue so that GD is removed entirely from the next edition of the DSM, and that access to medical care is transferred out of the jurisdiction of mental health professionals. I resent the paternalistic gatekeeping role psychologists play in providing access to medical care for trans people, and think that requiring a diagnosis of GD still ultimately upholds cultural investments in the conflation of transsexuality with psychopathology. I believe this connotation leads to the legitimization of anti-trans stigma in the United States, and projects sociocultural problems with gender nonconformity onto trans bodies. As Zucker mentions, there needs to be more research on the factors that contribute to the maintenance of gender dysphoria in trans populations, especially with regard to role of social support and location. There also needs to be critical attention placed on the cultural ideologies that make it the case that gender nonconformity is subject to discrimination in the first place. It seems easier for the APA to assume that someone who does not follow gender norms must be mentally ill than to consider that the mental illness actually belongs to American culture.

While I agree with Zucker that GD better captures the phenomenology of distress behind the experience of transsexuality, it still fails to acknowledge how sociocultural investments in maintaining cissexuality as the norm are what make transsexuality appear pathological in the first place. Phenomenology is conceptually limited in its ability to account for the role of context in psychological disorder as it locates disorder within the confines of individual conscious experience, and ignores sociocultural factors that contribute to subjective distress. I, for example, am subjectively distressed whenever I wear lipstick in public because I notice how many people stare at me, and often fear for my safety. Reactions from the public thus play an irreducible role in my experience of subjective distress while wearing lipstick, but according to the DSM, this subjective distress is caused by GD, and the role others play in the distress is tangential. This is a fundamental problem with the diagnosis: it locates the diagnosis within the confines of the trans person who dares violate gender norms, and allows for potentially violent social regulation and enforcement of gender norms to continue unchecked. Gender normativity and cissexism are the real problems underlying GD, and these problems are based in American cultural ideology.

I believe that transitioning is something that one should be able to decide for themselves without requiring prior psychiatric evaluation and diagnosis of GD. If the APA’s treatment of transsexuality were ethical, then psychiatric evaluation and diagnosis should be consistently required for anyone who wants to undergo a medical procedure that drastically changes their physical appearance. This should include those who decide to get breast implants, and should have certainly included Erik “The Lizardman” Sprague who medically transitioned into resembling a lizard with green full-body tattoos and subdermal facial implants. It is not fair that trans people need to be psychiatrically evaluated and diagnosed with GD in order to transition while cis people can change their appearance as much as they want without formal psychiatric evaluation or diagnosis. This double-standard reflects how transsexuality is still assumed to be inherently pathological in American society, and how the APA’s treatment of transsexuality is overall more harmful than helpful for trans people in the United States.

Activism should aim toward the complete removal of transsexuality in the DSM, just as the work of gay rights activists advocated for the total removal of homosexuality from the DSM. Trans activists should disrupt APA meetings just like gay activists did in the 1970s. Trans psychologists should come out to increase trans visibility within psychiatric institutions, just like gay, lesbian, and bisexual psychologists came out during gay rights activism. Presentations of gender nonconformity should be practiced in psychological research communities so that gender nonconformity can start to be normalized from within the institution itself. The scope of lived trans experience should be expanded to include anyone who experiences discomfort about the expectations placed upon their genitals, including those who are commanded to “Be a man!” when their phallic integrity is questioned. Research should focus on showing how sexism underlies the stigmatization of both homosexuality and transsexuality; it is, after all, through cultural projections of gender non-conformity that gay men are assumed to be effeminate, and lesbian women are assumed to be threateningly masculine. Naming sexism as a sociocultural factor that affects public health on a widely-subversive scale should be the ultimate goal of gender-sexual activism, especially within psychological institutions. Just as anti-gay sentiment was named in relation to SOD and EDH, so too does cissexism need to be named in relation GD. GD continues to implicate that there is something inherently pathological about transsexuality, and that the symptoms that underlie GD are based solely within the phenomenological experience of trans people. Psychological conceptualizations of mental illness should shift away from phenomenology and toward sociology, as American values are implicated by every diagnosis in the DSM — especially when the diagnosed are also stigmatized.