Transgender: a mental diagnosis, a physical condition, or normal variation?

| Dec 8, 2008
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Doctor Maureen OsborneHi friends! It’s been a mixed bag weekend for me so far — I got some of my Christmas decorations out, which is always enjoyable, especially with some nice seasonal music for inspiration. On the other hand, I had a plumbing disaster which involved a substance looking like espresso pouring out of all my sinks and… well, enough said. After many emergency calls to the ironically named “Aqua Pure” company and several hours of service calls, I finally have water again. Oh, the things we take for granted.

Gender comfort is one of those things most people take for granted, like water pouring out when you turn on the faucet. Not so for my transgender friends, including many who wake up every morning with a feeling far more pressing and uncomfortable than brown water pouring out of a faucet. What are we to make of gender discomfort? That is the topic for my column today, and, like the Standards of Care, it has created a lot of controversy.

At the present time, transgender issues can be found described in two diagnoses of the Diagnostic and Statistical Manual of Mental Disorders. The DSM is the dominant classification system for psychiatric disorders, and is currently in its fourth revision (DSM-IV) since 1952. Although the DSM is the Bible of the mental health field, it is a curious document which reflects social norms, scientific research, the politics of the day, and the requirements of health insurance companies.

Cover of the DSM-IVAlthough I am intimately familiar with the DSM-IV, I have almost never found any diagnosis to describe precisely the particular nuances of any client’s life struggle. Like the Standards of Care, the DSM specifies a series of parameters that aims to characterize an individual’s life dilemma. I don’t find it particularly useful, and I rarely think of people in terms of psychiatric diagnosis, but in order for my client to receive insurance reimbursement for therapy, I am required to supply a diagnosis. That said, I almost never use the diagnoses specified for gender variant conditions in the DSM-IV.

My position on psychiatric diagnosis for trans clients is very similar to that described by Dr. Anne Vitale in a 2005 paper titled “Rethinking the Gender Identity Disorder Terminology in the DSM-IV”. In that paper, she summarizes the evidence that gender identity is largely determined by biology, and argues that any psychological intervention would be more aptly characterized as treatment for the anxiety accompanying trans issues, which she calls Gender Expression Deprivation Anxiety Disorder (GEDAD). This diagnosis would be less stigmatizing than the current ones — Gender Identity Disorder, and Transvestic Fetishism — which are included within the category of sexual disorders. Since Dr. Vitale’s diagnosis is not part of the DSM-IV, my choice is usually to diagnose the client with “Adjustment Disorder with depressed and anxious features.” This is a pretty accurate description of what I am attempting to treat through psychotherapy with a transgender individual. When I treat the anxiety and depression an individual experiences as a result of the internal and external consequences of gender variant feelings and behavior, I can draw on a wide range of modalities including couple, and family therapy, group therapy, psychoeductional methods, and possibly adjunct medication.

Arlene Lev, in the chapter on Diagnosis and Transgenderism in her groundbreaking book, Transgender Emergence, offers a thorough discussion of the problems with applying mental diagnoses to non-normative social behaviors. Homosexuality was considered a psychiatric diagnosis until it was removed in 1973 (well, almost – there is still a category for “persistent and marked distress about sexual orientation”). Lev points out that there is a circular logic involved where a person is distressed about having feelings society defines as deviant, and the distress itself becomes the justification for a psychiatric diagnosis. Sound familiar? One of the questions I often ask a client is “what would you do about your gender if there were no negative consequences from society or family?” It often becomes clear that social stigma is a huge part of the transgender dilemma.

I tend to side with those who think that gender issues intense enough to create serious distress and impairment would be better classified with a medical diagnosis. Recent research seems to point toward a neurological basis for gender identity disorder, and the success of contrahormone therapies and gender confirming surgery would appear to support this position. In fact, the American Medical Association published a statement in June of 2008 stating that it “… firmly rejects the IRS’s position that gender identity disorder is without a medical basis or that there is any question about the effectiveness of the established treatments for it.

I tend to view transgender phenomena on a continuum, so to my thinking, there is no justification for a separate diagnosis of transvestic fetishism to apply to cross-dressers who have no interest in transitioning. There might be aspects of a cross-dresser’s functioning that would create mental distress or social impairment (e.g., marital/family conflict, obsessive thoughts or compulsive behaviors), but those can be diagnosed according to the major symptoms such as generalized anxiety, obsessive compulsive disorder, adjustment disorder, etc. Diagnosing cross-dressing as a sexual disorder says more about what is acceptable in current society than about intrapsychic distress. And of course, the fact that female cross-dressing seems not to exist in psychiatric terminology is another illustration of the way in which social mores influence diagnosis. If a male wears women’s clothes, he must be disturbed, whereas a woman cross-dressing either goes unnoticed or is seen as making a fashion statement!

Some will argue that gender variance is a rare but normal and natural outcome of human development, and should not be viewed as any type of pathology, medical or psychological. In some respects, I agree with this position, and if our society were much further along in its knowledge and acceptance of diversity, I think it would be the most beneficial approach. Being transgender might be like having curly hair or a photographic memory. Gender might be seen as more fluid, and gender roles and expression less rigidly enforced. However, the current social structure tends to view transgender phenomena with greater tolerance when seen as outside a person’s control. My concern is that taking this condition out of the realm of the medical/psychological makes it seem like a lifestyle choice, which it is not, and might give credence to the idea that children can be “trained” out of transgender feelings or that surgeries are misguided “mutilations” of healthy organs.

Well, that’s all for this month’s check-in. I wish everybody a wonderful holiday with a minimum of stress and the warmth of family and friends all around you. May your cup runneth over with pure, clear water (not the sludgy brown variety), and may the new year bring you that much closer to your heart’s desire.

Question or comment by email to Dr. Osborne or use the Comment box below.

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Category: Transgender Body & Soul


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