Often, transphobes use the continued psychopathologization of transgender people as evidence that we are mentally ill. This is, of course, manifestly absurd.
What the authorities actually say
There are various mental health authorities that push back against the notion that trans people are “mentally ill” purely by virtue of being trans.
The American Psychiatric Association
The American Psychiatric Association, around the time they published the fifth edition of the Diagnostic and Statistical Manual (DSM), wrote a paper about the diagnosis of gender dysphoria.1
DSM-5 aims to avoid stigma and ensure clinical care for individuals who see and feel themselves to be a different gender than their assigned gender. It replaces the diagnostic name “gender identity disorder” with “gender dysphoria,” as well as makes other important clarifications in the criteria. It is important to note that gender nonconformity is not in itself a mental disorder. The critical element of gender dysphoria is the presence of clinically significant distress associated with the condition. […] Part of removing stigma is about choosing the right words. Replacing “disorder” with “dysphoria” in the diagnostic label is not only more appropriate and consistent with familiar clinical sexology terminology, it also removes the connotation that the patient is “disordered.”
This is the thing. The American Psychiatric Association, a professional organization of psychiatrists that publishes the DSM, states clearly: gender nonconformity is not a mental disorder. The objective of changing the diagnosis to gender dysphoria is to remove the connotation that the patient is “disordered”. That’s literally their stated intention. It also states that the rationale for continuing to have a diagnosis in the DSM is to ensure continued coverage of care. The American Psychiatric Association also made the following statement.2
Being transgender or gender variant implies no impairment in judgment, stability, reliability, or general social or vocational capabilities; however, these individuals often experience discrimination due to a lack of civil rights protections for their gender identity or expression.… [Such] discrimination and lack of equal civil rights is damaging to the mental health of transgender and gender variant individuals.
The American Psychological Association
From the article on the American Psychological Association’s website, they answer the question “Is being transgender a mental disorder?” thus:
A psychological state is considered a mental disorder only if it causes significant distress or disability. Many transgender people do not experience their gender as distressing or disabling, which implies that identifying as transgender does not constitute a mental disorder. For these individuals, the significant problem is finding affordable resources, such as counseling, hormone therapy, medical procedures and the social support necessary to freely express their gender identity and minimize discrimination. Many other obstacles may lead to distress, including a lack of acceptance within society, direct or indirect experiences with discrimination, or assault. These experiences may lead many transgender people to suffer with anxiety, depression or related disorders at higher rates than [cisgender] persons.
According to the Diagnostic and Statistical Manual of Mental Disordersopens in new window (DSM-5), people who experience intense, persistent gender incongruence can be given the diagnosis of “gender dysphoria.” Some contend that the diagnosis inappropriately pathologizes gender noncongruence and should be eliminated. Others argue that it is essential to retain the diagnosis to ensure access to care. The International Classification of Diseases (ICD) is under revision and there may be changes to its current classification of intense persistent gender incongruence as “gender identity disorder.”
Which, of course, leads us to our next citation.
The World Health Organization
Since that article was written, the World Health Organization has published the ICD-11. In fact, they have created two diagnoses of gender incongruence: one for adults and one for children. In fact, the WHO describes their rationale for creating these diagnoses as such when answering the question “What does the ICD revision aim to do for transgender health?”:
ICD-11 has redefined gender identity-related health, replacing outdated diagnostic categories like ICD-10’s “transsexualism” and “gender identity disorder of children” with “gender incongruence of adolescence and adulthood” and “gender incongruence of childhood” respectively. Gender incongruence has been moved out of the “Mental and behavioural disorders” chapter and into the new “Conditions related to sexual health” chapter. This reflects current knowledge that trans-related and gender diverse identities are not conditions of mental ill-health, and that classifying them as such can cause enormous stigma.
Inclusion of gender incongruence in the ICD-11 should ensure transgender people’s access to gender-affirming health care, as well as adequate health insurance coverage for such services. Recognition in the ICD also acknowledges the links between gender identity, sexual behaviour, exposure to violence and sexually transmitted infections.
Okay, so why should we take their word for it?
Put simply, there is no basis for the claim that being transgender is a mental illness. The simplistic thinking that being transgender is a mental illness is based on the presumption that transgender people are actually the sex we were assigned at birth rather than the sex we actually are. This presumption is, of course, not supported by reality.
On political pressure
During the discussion of the proposed changes to the ICD-11, it was claimed that the World Health Organization changed the diagnosis, not because of merit, but rather because of political pressure. This allegation is, of course, entirely unfounded. There is no evidence to substantiate the claim that there was political pressure to support such a change.
Political pressure to delegitimize gender affirming care
However, there is evidence of political pressure to try to change diagnostic criteria and medical consensus to the contrary. The Trump Administration has demanded responses from six major American medical associations, including two of the authorities cited above. The US Department of Health and Human Services has misrepresented gender affirming care as “sex-rejecting procedures” that have “documented substantial evidence of harm”. However, this report has failed to stand up to scrutiny. Criticisms of said report include:
- how quickly it was produced
- its authors’ well-documented opposition to pediatric gender-affirming care, and
- the fact that it did not undergo peer review before publication
While the American Society of Plastic Surgeons has updated its policy to be less supportive of gender affirming care, it has done so without peer-review. In fact, the ASPS admits that it relied on the HHS report and the equally debunked Cass Review instead of evidence and peer-review.
The Federal Trade Commission has also filed a meritless lawsuit against WPATH alleging it “has provided the means for medical providers to make false and unsubstantiated claims to parents in order to sell pediatric medical transition services”. The FTC knows this lawsuit is meritless. I cite WPATH’s own press release in response to the suit to explain why:
In previously ruling against the FTC, a federal district court has already found WPATH is in a strong position to prove that the FTC is acting out of pure retaliation as part of the federal government’s relentless and targeted campaign to undermine gender-affirming care by attacking the First Amendment rights and the independence of professional medical organizations. We expect the same result when we oppose this latest attack on WPATH and its mission to promote evidence-informed care and guidance for doctors and their patients.
The Cass Report
The Cass Report is a poorly written, poorly research diatribe against gender affirming care. It is an embarrassment that it has been cited in legal fights against access to gender affirming care. Yale Law has written a thorough debunk of the Cass Review. Here is a summary of the debunk:
- The Cass Review does not follow established standards for evaluating evidence and evidence quality. Hillary Cass did this to shrink the overwhelming body of evidence that supports gender affirming care.
- The Cass Review fails to contextualize the evidence for gender-affirming care with other areas of pediatric medicine.
- The Cass Review misinterprets and misrepresents its own data.
- The Cass Review levies unsupported assertions about gender identity, gender dysphoria, standard practices, and the safety of gender-affirming medical treatments. It also repeats claims that have been debunked by sound evidence.
- The systematic reviews relied upon by the Cass Review have serious methodological flaws, including the omission of key findings in the extant body of literature.
- The Review’s relationship with and use of the York systematic reviews violates standard processes that lead to clinical recommendations in evidence-based medicine.
None of these facts have stopped hostile governments from using the Cass Report to push laws to deny gender affirming care.
In short, it is not only deceptive to claim that there was ever political pressure to create diagnostic criteria that were more favourable to providers gender affirming care and their patients, it is wildly hypocritical given the actual direction of the political pressure relating to this subject. The only evidence of pressure to change a professional opinion is to diverge from science and oppose gender affirming care.
- You can find the fact sheet in a list here. However, given the APA’s website is particularly susceptible to link rot, you can find a copy here. [↩]
- Drescher J, Haller E; American Psychiatric Association Caucus of Lesbian, Gay and Bisexual Psychiatrists. Position Statement on Discrimination Against Transgender and Gender Variant Individuals. Washington, DC: American Psychiatric Association; 2012 [↩]