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

Zinnia Jones“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 11th 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. 

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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.

About Zinnia Jones

My work focuses on insights to be found across transgender sociology, public health, psychiatry, history of medicine, cognitive science, the social processes of science, transgender feminism, and human rights, taking an analytic approach that intersects these many perspectives and is guided by the lived experiences of transgender people. I live in Orlando with my family, and work mainly in technical writing.
This entry was posted in Gender dysphoria, Psychology and psychiatry, Transgender medicine, Transphobia and prejudice and tagged , , . Bookmark the permalink.

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

  1. A very interesting and informative read. I have always found the claim that trans women are “biologically male” because penis/muh chromosomes to be notably stupid considering that being trans IS a biological phenomenon. Exactly what do these people think the human brain is? Do they think that our brains are just magical pixie dust that doesn’t need to be explained? I mean, gee, what would be more appropriate to determine one’s gender, the core of their thought, conscious, and their entire being, or whether or not they have a phallic appendage hanging between their legs?

    And yeah yeah, I know “muh fertility” is likely the response from them, but the problem is, has been repeatedly mentioned, intersex people exist. The sheer fact that it is possible for someone to have a penis or XY chromosomes and still be listed as a woman at birth or vice versa shows how flawed of a system this is. Yes, intersex people are atypical examples, but the problem is that using strictly genitals or chromosomes as what determines biological sex is the equivalent of if we decided that human beings were determined based on bipedality. While yes, humans are a bipedal species, someone being born with only one leg or no legs does not mean that they are not a homosapian.

    As such, this leads me to believe that from a strictly biological point, trans people fall into the intersex category as well; having the physical traits of both men and woman. Just because someone can’t see the physical actions that take place to cause gender dysphoria does not mean they don’t happen. The sheer fact that we have a treatment for it disproves that. And considering that Intersex people are usually just put under the label of whatever they choose to identify as, I see no reason why that shouldn’t be the case with trans people.

  2. Dee says:

    Zinnia,

    For me, this article could not have been more timely. I’ve been fighting myself for a while and am in (talk) therapy. The very recent diagnoses were GD and bipolar affective disorder type I. I present with 3-4 (depending on the day) of the 6 markers for GD. So, pretty sure of that one. The therapist concluded the BAD I was triggered by stress associated with my reaction to the GD. She’s treating the BAD first with drugs. Once that is under control we’ll have to play the GD by ear.

    But it’s good to remember that GD is itself not a disorder. The stress associated with it and society’s reaction to it can indeed trigger all sorts of mood disorders. But those are not GD!

  3. Sve Bojilova says:

    While I agree with this article it would have been good if you’d talked about the stigma around mental “illness” a bit more – like the fact any type of neurodivergence is considered an illness based on the medical model of disability and under that model queer people can indeed still be classified as mentally “ill” but most of us have been granted the privilege of our sexuality being taken out of the DSM solely due to societal pressures but other people who struggle with atypical thoughts and behaviours are still considered mentally “ill”. The point I’m making is that under the social model of disability queers are not considered mentally “ill” and we should advocate for it and include disabled people in our social justice activism. This person explains it much better than me (ignore the clickbait-y title): http://thediscourseblogs.tumblr.com/post/163504587070/all-queers-are-mentally-ill

    Basically, queers used to be a part of the disabled community but now we’ve turned our backs on them and have left out our intersectional members in the cold while still fighting a lot of the same fights (marriage equality, bathrooms laws). I think it would have been beneficial if you’d mentioned the fact that mental illness is a social construct and the biggest problem with the statement “trans people are mentally ill” is its underlying ableism.

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  5. mike says:

    Has there even been a study of dysphoria approached as mental illness through psych drugs or talk therapy and the success rate of those methods in comparison to transition? I tried to look for it but couldn’t find anything so perhaps not but that might help drive home the point of the efficacy of transitioning and the physical nature of dysphoria

  6. Rachel says:

    I would like to point out, in the most polite fashion, that this article is just a red herring in its’ entirety. I cannot claim that I have extensive knowledge in this particular subject; however, I can certainly point out a logical fallacy when I see one. The title of the article suggests that it will refute the claim that gender dysphoria is a mental illness, and yet the entire piece avoids the entire point that it set out to prove; rather, it presents reasons defending the efficacy of a physical transition instead. When the author makes the claim that mental and physical disorders should not always be grouped/treated independently of one another (when considering a hypothetical “granting” by the presumed gender analysts that GD is a mental disorder), I agree. It is hard not to call to call to mind, however, the cases of Body integrity identity Disorder. I understand it to be an illness of the mind that is, in fact, also physically associated (by means of wanting to either paralyze/amputed parts of one’s own body). Both disorders pose very real risks to a person: emotionally, mentally, and, if a disordered individual takes it upon themselves to correct their physical appearance, even physically. I am aware that there are many factors, both similar and different, that are at play in the causation of either GD or BiiD, but it is difficult for me to distinguish where the figurative “line is drawn” to separate conditions such as BiiD, a mental illness, from GD.

    Thank you for your time to consider this topic from a new point of view. If anyone would like to clarify any misinterpretations I may have, I welcome you to do so.

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