Menus Subscribe Search
gender-dysphoria

(ILLUSTRATION: ASHLEY VAN DYCK/SHUTTERSTOCK)

Why Gender Dysphoria Should No Longer Be Considered a Medical Disorder

• October 18, 2013 • 8:00 AM

(ILLUSTRATION: ASHLEY VAN DYCK/SHUTTERSTOCK)

It does more harm than good.

As a wizened gender rights advocate, I know better than to assume the activists making the most noise are actually representative of “the community” they insist they represent. So, while American transgender activists have lately been fairly unified and very vocal about the need to remove “Gender Identity Disorder” (GID) from the Diagnostic and Statistical Manual of Mental Disorders (DSM), I know that not all trans people agree.

Medicalization is, after all, a complex experience. Even while being labeled as “mentally disordered” can be a stigmatizing experience, it is also the case that the inclusion of GID in the DSM has functioned to provide financial and institutional support for medical, surgical, and psychological care for some transgender people.

This is not true in most of the United States, but is true in more progressive places around the world, like Canada and the Netherlands. Having GID in the DSM may also, to some extent, legitimize the transgender experience as a “real” one for people who think a transgender person should just “get over” the feeling that the gender label assigned to them was the wrong one.

At least in this country, categorizing transgender people as “mentally disordered” leaves them in a sort of Never Never Land legislatively.

This is why, when I talk to clinicians about taking GID out of the DSM, the first thing they say to me is that taking it out will harm a good number of transgender people. Some foreign clinicians add that it is the individualistic and selfish American transgender activists who are forcing their identity politics on transfolk all over the world. Having GID in the DSM has, they claim, helped many of their patients and clients, particularly transgender youth who benefit from medically supervised reassignments during their puberties.

Yet critics of the “GID” category respond that, in fact, the DSM inclusion of what amounts to their identities results in more harm than good. They liken the inclusion of “GID” to the DSM‘s former inclusion of homosexuality, saying that it medicalizes them and treats them as diseased rather than just different.

They point to evidence from history and other societies that, in cultures that accommodate people who don’t fit the usual categories of male or female, transgender people do fine without being labeled “mentally disordered.” Some of the most persuasive evidence for this comes from recent work in Samoa by my colleagues (and friends) Paul Vasey and Nancy Bartlett.

In fact, in an article I consider key to understanding the issue, Bartlett, Vasey, and William Bukowski noted a fundamental contradiction in the DSM specifically where GID in childhood is concerned. Partly because of the history of the de-medicalization of homosexuality, the DSM specifically defines mental disorder as constituting a dysfunction in the individual, not “deviant” behavior nor a conflict between an individual and his or her society.

Yet the current DSM allows children who are merely notably gender atypical in their family’s culture to be labeled as having a mental disorder, even though in another society (say, Samoa), they might be considered perfectly acceptable. That sure does look a lot like the history of the de-medicalization of homosexuality.

Importantly, the increasingly nasty discourse surrounding the GID-DSM question obscures points on which both sides do actually agree. Most critics and most proponents of the “GID” inclusion want high-quality, safe, individualized care for people who are transgender. Most also want to see systems where such care is financed through public or private insurance, particularly for those who cannot pay for it themselves. Perhaps most significantly, almost all want to see transgender people suffer less, not more, stigma and shame.

Thus the people arguing back and forth may disagree on the methods to achieve these goals, but not on the goals themselves. That’s good news.

So, what to do?

Keeping “GID” in the DSM is problematic for many reasons. At least in this country, categorizing transgender people as “mentally disordered” leaves them in a sort of Never Never Land legislatively. In spite of being labeled “mentally disordered,” trans people have been specifically exempted from the Americans With Disabilities Act as a protected group, and their medical care (including hormones and surgeries) are not covered by most insurance systems, despite the fact that studies have repeatedly shown well-screened transgender people are better off psychologically and socially after hormonal and surgical transition.

Meanwhile, a number of legislators have used the fact that transgender counts as a “mental disorder” to exclude transgender people from identity-based protective legislation available to gay, lesbian, and bisexual people, so that transgender people are not protected in many venues from housing and employment discrimination, and their murders are not recognized as hate crimes, in spite of much evidence that that’s exactly what they are.

So transgender Americans are seen as too sick to be protected, but not too sick to be provided help! Now that’s a sick system.

On top of that, keeping “GID” in the DSM marks all transgender people as mentally disordered, no matter how well they are functioning, no matter how sensible they are about dealing with the challenges of being transgender. As philosopher Jake Hale has pointed out, the way the World Professional Association for Transgender Health (WPATH) “standards of care” work, transgender people are treated as incompetent until proven otherwise—quite the opposite of pretty much all other humans.

One response to this is to say, well, if you have a male body and feel you’re more of a female, then obviously you’re sick. But as an historian, I can’t help but remember all the gay men who were told loving men made them sick, nor can I forget all my feminist foremothers who were told—when they demanded education, professions, and voting rights—that they were mentally ill.

Yet I cringe at the idea of taking GID out of the DSM if what it means is that gender atypical children, teenagers, and adults can’t get the care they deserve. I also worry that simply changing over from “GID” (a mental disorder) to “transgender identity” will oversimplify the reality of genders. Many people may legitimately seek professional health care for complicated (or at least atypical) gender identities without really fitting the oversimplified media vision of “transgender.”

So here is a proposed solution that I think should be seriously considered:

Remove “GID” from the DSM as a “mental disorder.” But add in the DSM transgender feelings as a known possible cause of depression, anxiety, sexual dysfunction, and so forth. (After all, sometimes being transgender—like being a gay youth or a grieving widower—can lead to depression, anxiety, and so forth.) And in those cases, where evidence supports it, allow the treatment for those particular forms of depression and anxiety to include hormone treatments and surgeries, if the patient so wishes to follow those paths. After all, we have lots of research that such treatments, almost without exception, result in positive outcomes.

This DSM revision would cease the marking of all transgender people as mentally disordered. It would simultaneously acknowledge that being gender atypical is sometimes difficult, even in a society that accepts it.

This approach would have the added benefit of stopping legislators from having the medical profession’s accidental support in the denial of legal protections to people with transgender identities. And it might actually increase available funding for psychological, medical, and surgical care for transgender people, because it would recognize that sometimes the best treatment for depression that arises out of being transgender is hormonal or surgical. Thus it would treat transgender people the way postpartum women are treated; if depression or anxiety or profound sexual dysfunction arises in conjunction with that identity, then it is treated, with evidence-based care.

Making this move might also finally bring the medical system up to speed with the fact that more and more people are opting for some transgender-ish interventions, but not all. It would upend the one-size-fits-all traditional treatment model of transgender, and implicitly recognize that sometimes people very purposely want “top” surgery without “bottom” surgery, and sometimes people very purposely want a hormonal “sex” change without any surgery. It might even force open recognition that what gets labeled a “transgender” experience varies enormously, far more than you’d imagine if you’re only hearing about transgender lives from the usual suspects in the mainstream media.

Speaking of which, a postscript: As I was composing this, Chaz (formerly Chastity) Bono announced his identity as a transman. When a spokesperson hailed Bono’s “courageous decision to honor his true identity,” I was struck by that too-typical language of the “true identity,” and reminded again of how—though they often appear at odds—the medical establishment and the transgender activist community have long cooperated in speaking of transgender as if it is simply a matter of establishing authenticity. The language of “true selves” can be empowering, bonding, liberating, healing. But it can also be alienating and isolating to those whose feelings are more complex.

And regardless, it ought not be up to medicine to adjudicate who has a true identity and who a false one. It seems to me much better, as I have suggested here, for medical professionals to ask not, “Are you real?” but instead, “Are you suffering? And if so, what evidence do we have that we are the people who can help?”


This post originally appeared on the author’s personal site on June 22, 2009. It is republished here with permission.

Alice Dreger
Alice Dreger is a professor of clinical medical humanities and bioethics at Northwestern University's Feinberg School of Medicine. She has written for The New York Times, The Wall Street Journal, and The Washington Post.

More From Alice Dreger

A weekly roundup of the best of Pacific Standard and PSmag.com, delivered straight to your inbox.

Recent Posts

July 28 • 12:00 PM

Does Internet Addiction Excuse the Death of an Infant?

In Love Child, documentary filmmaker Valerie Veatch explores how virtual worlds encourage us to erase the boundary between digital and real, no matter the consequences.


July 28 • 11:11 AM

NASA Could Build Entire Spacecrafts in Space Using 3-D Printers

This year NASA will experiment with 3-D printing small objects in space. That could mark the beginning of a gravity-free manufacturing revolution.


July 28 • 10:00 AM

Hell Isn’t for Real

You may have seen pictures of the massive crater in Siberia. It unfortunately—or fortunately—does not lead to the netherworld.


July 28 • 8:00 AM

Why Isn’t Obama More Popular?

It takes a while for people to notice that things are going well, particularly when they’ve been bad for so long.


July 28 • 7:45 AM

The Most Popular Ways to Share Good and Bad Personal News

Researchers rank the popularity of all of the different methods we have for telling people about our lives, from Facebook to face-to-face.


July 28 • 6:00 AM

Hams Without Ends and Cats Tied to Trees: How We Create Traditions With Dubious Origins

Does it really matter if the reason for why you give money to newlyweds is based on a skewed version of a story your parents once told you?


July 28 • 4:00 AM

A Belief in ‘Oneness’ Is Equated With Pro-Environment Behavior

New research finds a link between concern for the environment and belief in the concept of universal interconnectedness.


July 25 • 4:00 PM

Flying Blind: The View From 30,000 Feet Puts Everything in Perspective

Next time you find yourself in an airplane, consider keeping your phone turned off and the window open.


July 25 • 2:00 PM

Trophy Scarves: Race, Gender, and the Woman-as-Prop Trope

Social inequality unapologetically laid bare.


July 25 • 1:51 PM

Confusing Population Change With Migration

A lot of population change is baked into a region from migration that happened decades ago.


July 25 • 1:37 PM

Do Not Tell Your Kids That Eating Vegetables Will Make Them Stronger

Instead, hand them over in silence. Or, market them as the most delicious snack known to mankind.



July 25 • 11:07 AM

The West’s Groundwater Is Being Sucked Dry

Scientists were stunned to discover just how much groundwater has been lost from beneath the Colorado River over the past 10 years.


July 25 • 10:00 AM

Shelf Help: New Book Reviews in 100 Words or Less

What you need to know about Bad Feminist, XL Love, and The Birth of Korean Cool.



July 25 • 8:00 AM

The Consequences of Curing Childhood Cancer

The majority of American children with cancer will be cured, but it may leave them unable to have children of their own. Should preserving fertility in cancer survivors be a research priority?


July 25 • 6:00 AM

Men Find Caring, Understanding Responses Sexy. Women, Not So Much

For women looking to attract a man, there are advantages to being a caring conversationalist. But new research finds it doesn’t work the other way around.


July 25 • 4:00 AM

Arizona’s Double-Talk on Execution and Torture

The state is certain that Joseph Wood’s death was totally constitutional. But they’re looking into it.


July 24 • 4:00 PM

Overweight Americans Have the Lowest Risk of Premature Death

Why do we use the term “normal weight” when talking about BMI? What’s presented as normal certainly isn’t the norm, and it may not even be what’s most healthy.


July 24 • 2:00 PM

California’s Lax Policing of the Fracking Industry Has Put the Drought-Stricken State in a Terrible Situation

The state’s drought has forced farmers to rely on groundwater, even as aquifers have been intentionally polluted due to exemptions for the oil industry.


July 24 • 12:00 PM

What’s in a Name? The Problem With Washington’s Football Team

A senior advisor to the National Congress of American Indians once threw an embarrassing themed party that involved headdresses. He regrets that costume now, but knows his experience is one many others can relate to.


July 24 • 11:00 AM

How Wildlife Declines Are Leading to Slavery and Terrorism

As wildlife numbers dwindle, wildlife crimes are rising—and that’s fueling a raft of heinous crimes committed against humans.


July 24 • 10:58 AM

How the Supremes Pick Their Cases—and Why Obamacare Is Safe for Now

The opponents of Obamacare who went one for two in circuit court rulings earlier this week are unlikely to see their cases reach the Supreme Court.



July 24 • 9:48 AM

The People Who Are Scared of Dogs

While more people fear snakes or spiders, with dogs everywhere, cynophobia makes everyday public life a constant challenge.


Follow us


Subscribe Now

NASA Could Build Entire Spacecrafts in Space Using 3-D Printers

This year NASA will experiment with 3-D printing small objects in space. That could mark the beginning of a gravity-free manufacturing revolution.

The Most Popular Ways to Share Good and Bad Personal News

Researchers rank the popularity of all of the different methods we have for telling people about our lives, from Facebook to face-to-face.

Do Not Tell Your Kids That Eating Vegetables Will Make Them Stronger

Instead, hand them over in silence. Or, market them as the most delicious snack known to mankind.

The West’s Groundwater Is Being Sucked Dry

Scientists were stunned to discover just how much groundwater has been lost from beneath the Colorado River over the past 10 years.

How Wildlife Declines Are Leading to Slavery and Terrorism

As wildlife numbers dwindle, wildlife crimes are rising—and that's fueling a raft of heinous crimes committed against humans.

The Big One

One in two full-time American fast-food workers' families are enrolled in public assistance programs, at a cost of $7 billion per year. July/August 2014

Copyright © 2014 by Pacific Standard and The Miller-McCune Center for Research, Media, and Public Policy. All Rights Reserved.