Transgender Identities: Do we Need Diagnostic Criteria?

By Jay A. Irwin

In a recent NYT piece, a discussion was presented regarding the potential for the World Health Organization (W.H.O.), to declassify transgender identities as mental disorders in the ICD (International Classification of Diseases). This topic has been hotly debated within the transgender community for years, particularly during the update from the DSM IV-TR to the DSM-V. The DSM, or the Diagnostic Statistical Manual is the American Psychiatric Association’s version of the ICD, but the U.S. version only focuses on mental disorders, while the ICD classifies all diseases and conditions. Similar to the debate during the update to the DSM V, the conversation around changes to the ICD focuses on weighing the pros and cons of dropping classifications related to “transsexualism” or “GID” (gender identity disorder), the common codes related to trans people in the current ICD 10.

In my own research regarding transgender people living in Nebraska, transgender individuals are at a heightened risk of mental health conditions such as depression and suicidal ideation. Countless other studies have found similar negative health outcomes for transgender individuals. A major predictor of these health disparities lie in societal acceptance, as a number of studies show that trans individuals who have better social support (particularly family support for trans youth and young adults), higher social capital, and experience less discrimination have better mental health outcomes than trans individuals who lack these social resources.

Another major theory, both within the trans community and among some in the clinical psychological/counseling world, is that these health disparities can be due to the fact that one’s identity is stigmatized by the mere fact of being included in a medical classification system like the DSM or ICD. The social label of the “crazy” transgender person can be seen in public media and online discussions of transgender people even today. This kind of stigmatization and stereotyping of a whole group has led to a larger social misunderstanding of transgender people. The removal of trans identities from the ICD and the DSM could help to reduce the stereotypes society has of trans folx (an inclusive version of folks that has been recently adopted by the transgender community), similar to what we saw when homosexuality was removed from the DSM in 1973.

Furthermore, removing trans identities from these medical codebooks removes a barrier to care for trans people, particularly trans people with lower socio-economic statuses. Most medical providers require some form of “proof” from a therapist that their patient is “actually’” transgender before providing other care such as hormone therapy or surgical interventions. This process, for the trans person, is both costly and can be seen as patronizing; often regarded as having to have your identity gain a stamp of approval from someone else. While therapy may be very beneficial to trans individuals as they move through their transition process, having it be required does push some trans individuals into less than legal transition processes, such as street hormones and medical procedures done by unlicensed providers in less than ideal, and sometimes down right unsanitary conditions. Therapy should be undertaken when desired by the trans person, not as a required “hoop” to jump through.

Now, it’s at this point in the conversation that people start to typically bring up the potential negative ramifications of removal of trans identities in medical classification systems. The point that is often made is that our medical system is built on the referral system, and that without a diagnosis from a psychological expert, how will insurance companies and doctors know how/if to treat patients? This is a bit of a false argument, as many clinics, specifically clinics for the LGBTQ community, already operate on an informed consent model. In an informed consent model clinic, the medical provider sits down with the trans person and discusses what the trans person want in terms of transition (as there is no one/right way to transition), the pros and cons of each type of medical intervention, all done without the need of a formal referral letter from a mental health expert proving a person’s sanity and gender identity.  The informed consent model is not new as it relates to transgender individuals, as it dates back to around 1993 in San Francisco. This is just one example of a potential reworking of the medical system in which we currently exist, should such diagnoses be removed from these medical handbooks.

The notion that a psychological evaluation of a transgender person is necessary for further care is rooted in deep seated stereotypes of trans people as mentally unable to assess their own gender identities and are thus potentially confused, requiring an outside “expert” to certify one’s gender identity. I don’t use the hyperbolic air-quote around expert lightly, but due the fact that little to no training is currently provided to counselors, psychologists, or psychiatrists about trans people during their formal education. Furthermore, the bulk of providers, both mental and physical health providers, are cisgender (i.e. non-trans) people, which can act as a barrier to fully understanding the needs of trans clients. Based on what we know from social science research, the feedback from many clinicians (trans and cis alike), and the lived experience of trans people, the potential pros far outweigh the potential cons to removing trans related diagnoses in all diagnostic manuals.

 

Jay A. Irwin is an Associate Professor of Sociology at the University of Nebraska at Omaha. HiJay Irwins research areas include transgender health and identities, LGBT health, and sexualities. He is also highly active in the local trans and LGB communities, and identifies as a queer trans man.

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