“Being transgender is a mental illness”: What does the DSM really say?

“Transgender people are mentally ill.” “Being trans is a mental disorder.” How many times have you heard some variation of these claims? It’s hardly a rare opinion: according to a 2017 poll, 21% of Americans believe that being trans is a mental illness. From the slush pile of online comments sections to the organized transphobia of Paul McHugh, Walt Heyer, Michelle Cretella, the American College of Pediatricians, the Family Research Council, and the Witherspoon Institute, this accusatory labeling of transgender identity as a “mental disorder” is one of the most well-worn arguments against recognizing and affirming our genders. Typically, the extended form of this claim is argued as follows:

“Being transgender is a mental disorder – after all, it’s listed in the DSM (Diagnostic and Statistical Manual of Mental Disorders).

“Therefore, a person whose gender identity is at odds with their assigned sex should receive psychological therapy focusing on aligning their self-perceived gender with their body, rather than medical treatment to adjust their body to their gender.”

It’s a simple and superficially appealing line of reasoning. It’s also completely wrong.

Those making this argument seek to apply the expertise of psychology and psychiatry – yet they wholly disregard the expert consensus of those fields on the treatment of gender dysphoria. The American Psychiatric Association, publisher of the DSM, stated in a 2012 report that “Overall, the evidence suggests that sex reassignment is associated with an improved sense of well-being in the majority of cases”, and “Gender transition can foster social adjustment, improve self-esteem, and relieve the anxiety and mood symptoms that can accompany gender dysphoria” (Byne et al., 2012). In a position statement, the APA concluded that transition is beneficial and medically necessary (Drescher, Haller, & APA Caucus of Lesbian, Gay and Bisexual Psychiatrists, 2012):

Significant and long-standing medical and psychiatric literature exists that demonstrates clear benefits of medical and surgical interventions to assist gender variant individuals seeking transition. However, private and public insurers often do not offer, or may specifically exclude, coverage for medically necessary treatments for gender transition. Access to medical care (both medical and surgical) positively impacts the mental health of transgender and gender variant individuals. …

Therefore, the American Psychiatric Association:

1. Recognizes that appropriately evaluated transgender and gender variant individuals can benefit greatly from medical and surgical gender transition treatments.

2. Advocates for removal of barriers to care and supports both public and private health insurance coverage for gender transition treatment.

3. Opposes categorical exclusions of coverage for such medically necessary treatment when prescribed by a physician.

This support for medical transition as an effective and necessary treatment is shared by other professional mental health organizations, including the American Psychological Association (2015) and the American Academy of Child and Adolescent Psychiatry (Adelson & AACAP CQI, 2012). Notably, the American Psychiatric Association acknowledged in its position statement that “the presence of the GID diagnosis in the DSM has not served its intended purpose of creating greater access to care”. Listing gender dysphoria in the DSM was explicitly not meant to rule out transitioning as a treatment. To the contrary, this was intended by its authors to facilitate access to gender-affirming treatment and medical transition.

This is an instance of a broader misunderstanding: while the DSM has “mental disorders” in its title, this does not therefore mean that the conditions it lists are “all in the mind” or that these illnesses are best treated with counseling or psychotherapy. Rather, the DSM-5 includes a number of conditions with a clearly physical component, including (American Psychiatric Association, 2013):

• Alcohol withdrawal, which can be fatal without medical treatment (p. 499)
• Narcolepsy, diagnosed using polysomnography or cerebrospinal fluid levels of hypocretin (p. 372)
• Obstructive sleep apnea (p. 378)
• Cognitive deficits associated with Alzheimer’s disease, Lewy body disease, vascular disease, Parkinson’s disease, Huntington’s disease, or traumatic brain injury (p. 602)
• Bedwetting, which can be partially heritable (p. 355)
• Premature ejaculation (p. 443)
• Restless legs syndrome (p. 410)

Alcohol withdrawal is in the DSM, so does that mean someone with delirium tremens and seizures just needs to try a session of talk therapy? Of course not – but that’s exactly what this senselessly reductive argument implies. The DSM-5 itself states that its diagnoses can be applied to disorders with physiological processes and correlates (p. 19):

The symptoms contained in the respective diagnostic criteria sets do not constitute comprehensive definitions of underlying disorders, which encompass cognitive, emotional, behavioral, and physiological processes that are far more complex than can be described in these brief summaries. Rather, they are intended to summarize characteristic syndromes of signs and symptoms that point to an underlying disorder with a characteristic developmental history, biological and environmental risk factors, neuropsychological and physiological correlates, and typical clinical course.

The naïve assumption that there are mental conditions that should be addressed with mental treatments, and physical conditions that should be addressed with physical treatments, proposes a neat and tidy dichotomy that does not actually exist. The mind is not separate from the body – it is a part of the body, and the DSM-5 recognizes that it needs to be understood in the context of that larger system, not apart from it. Such an assertion makes no more sense than claiming that there are kidney conditions that should receive kidney treatments and physical conditions that should receive physical treatments, and never the twain shall meet.

Transitioning cannot be slotted into the false “physical vs. mental” dichotomy. The “physical” treatments that constitute medical transition, such as hormone therapy and gender-affirming surgeries, are not strictly physical – these are also mental health treatments. Even if we were to grant that gender dysphoria can be termed a “mental illness”, transitioning reduces gender dysphoria, and is associated with an improvement in psychological symptoms (Murad et al., 2010).

These arguments have mistaken the map for the territory: the choice of whether or not to label gender dysphoria a “mental disorder” does not alter the underlying reality of which treatments are known to be most effective. The DSM-5 acknowledges this, describing itself as a “cognitive schema imposed on clinical and scientific information to increase its comprehensibility and utility” (p. 10). Currently, the World Health Organization is considering whether to move gender dysphoria from the mental disorders category to “conditions related to sexual health” in the 11^th edition of the International Classification of Diseases. Are gender specialists therefore waiting until the publication of ICD-11 to begin providing trans people with gender-affirming care? No. The purpose of healthcare is not to uphold some chosen arrangement of words or concepts – the purpose of healthcare is to treat patients. Shoring up a particular abstraction, no matter how cherished that abstraction may be, is not more important than a person’s well-being.

These arguments are clearly not based on a useful or accurate understanding of mental health conditions and their treatment. When mental illness is instead used to dismiss and invalidate the real experiences and needs of trans people, this is nothing more than a straightforward use of mental health stigma against us. Not only does this fail to address our health in a helpful way – anti-trans stigma actually makes our lives worse. The American Psychiatric Association has noted that “some authors have concluded that such stigmatization largely accounts for mental illness among individuals with GID” (Byne et al., 2012), and a recent study found that experiences of rejection and victimization largely accounted for trans people’s distress and impairment, rather than this being a result of their gender identity itself (Robles et al., 2016). Genuine concern for our mental health means recognizing the established treatments that actually improve our lives, not contributing to the issues we already face. ■

References

• Adelson, S. L., & American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Quality Issues (CQI). (2012). Practice parameter on gay, lesbian, or bisexual sexual orientation, gender nonconformity, and gender discordance in children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 51(9), 957–974.
• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
• American Psychological Association. (2015). Guidelines for Psychological Practice With Transgender and Gender Nonconforming People. American Psychologist, 70(9), 832–864.
• Byne, W., Bradley, S., Coleman, E., Eyler, A. E., Green, R., Menvielle, E. J., . . . Tompkins, D. A. (2012). Report of the APA Task Force on Treatment of Gender Identity Disorder. American Journal of Psychiatry, 169(8), 1–35.
• Drescher, J., Haller, E., & American Psychiatric Caucus of Lesbian, Gay and Bisexual Psychiatrists. (2012). Position statement on access to care for transgender and gender variant individuals. Washington, DC: American Psychiatric Association (APA Official Actions).
• Murad, M. H., Elamon, M. B., Garcia, M. Z., Mullan, R. J., Murad, A., Erwin, P. J., & Montori, V. M. (2010). Hormonal therapy and sex reassignment: a systematic review and meta-analysis of quality of life and psychosocial outcomes. Clinical Endocrinology, 72(2), 214–231.
• Robles, R., Fresán, A., Vega-Ramírez, H., Cruz-Islas, J., Rodríguez-Pérez, V., Domínguez-Martínez, T., & Reed, G. M. (2016). Removing transgender identity from the classification of mental disorders: a Mexican field study for ICD-11. The Lancet Psychiatry, 3(9), 850–859.