The mere fact of inclusion in the The Diagnostic and Statistical Manual of Mental Disorders (DSM) automatically induces psychological stigmatization encouraging cultural disapproval.
Gender transition is impossible to hide, since gender is a pervasive facet of all aspects of one’s life.
The psychiatric diagnosis of gender dysphoria and its more recent medical treatment is contested and eroding.
Although "medicalisation" has helped transgender people to acquire therapy and social acceptance, transgenderism is part of a larger social struggle between defenders of the "natural" and "God-given" and the right of individuals to control their own bodies and define their own lives.
American psychiatric perceptions of etiology, distress, and treatment goals for transgendered people are remarkably parallel to those for gay and lesbian people before the declassification of homosexuality as a mental disorder in 1973.
The American Psychological Association has published four benchmark editions of the DSM. It has also published two “Revised” editions. DSM I was published in 1952. DSM II was published in 1968. DSM III was published in 1980 and revised in 1987. The latest benchmark edition of the DSM, DSM IV was published in 1994 and revised in 2000. It is referred to as DSM IV -TR. (1, 2, 3, 4, 5, 6)
Although both the DSM I and DSM II mention “Transvestism,” neither manual addresses the issue of gender identity per se. Gender Identity as a separate issue does not appear until the third edition. In DSM III a new category of disorders entitled Psychosexual Disorders appears. It has four subsections: the Gender Identity Disorders, the Paraphilias, the Psychosexual Dysfunctions and Other Psychosexual Disorders, which includes the now-defunct, Ego-dystonic Homosexuality and Psychosexual Disorders Not Elsewhere Classified.
The Gender Identity Disorders are further subdivided into three specific areas: Transsexualism, Gender Identity Disorder of Childhood, and Atypical Gender Identity Disorder.
If we start with the premises that only the individual can know their gender, we must acknowledge that a gender variant individual, adult or child, is right and justified in experiencing difficulty trying to cope in an unvaried binary gendered system.
Gender identity appears to have no other function in the human psyche than to impose masculine or feminine expression. To be forced to adopt a cross-sex gender expression as a way of being in the world in order to be accepted by friends, family and society at large has been shown to be unsustainable.
What else can explain the large number of people who in mid-life have risked all that they know and love to resolve their sex/gender discontinuity by transitioning to the opposite gender role? Further more, how else to account for the overwhelming number of successful outcomes if in these cases these individuals were not “right” about their gendered sense of self?
At the 2003 American Psychological Association (APA) conference in San Francisco, participants discussed whether Gender Identity Disorder should be removed from the DSM altogether.
Citing the current APA thinking that homosexuality is not a mental disorder, participants suggested that lacking proof otherwise, the gender variant condition may also be a regularly occurring condition in humans.
Karasic and Kohler reported,” There are a lot of problems with the way psychiatry has viewed transgender folks. In labelling an identity as a mental disorder, as opposed to identifying symptoms in the same way we do for, say, major depression, anxiety disorder or other disorders in the DSM, the consequence of this is pathologizing and really hurting our clients.”
All transgendered people who want medical assistance currently must undergo a lengthy and expensive period of psychological assessment and must have their gender choice formally ratified by a committee of medical experts as appropriate for them. This is a fearful adjudication.
Part of the criteria commonly used is that they will make a reasonably attractive member of the "other" gender. If they are not able to do this, they are advised to grin and bear their lives in the wrong gender.
Further, many people who this article would define as transgender reject the term altogether, along with other related terms (transsexual, cross gender, etc.). This is most commonly seen with people who have changed sex but who do not define themselves as transsexual.
A common statement is that a transsexual is someone who is undergoing a change from one sex to another; someone who has already done so is simply a "man" or a "woman".
A person’s gender identity cannot be changed. In the past, some therapists tried to “cure” people with gender dysphoria through aversion therapies, electro-shock treatments, medication and other therapeutic techniques.
These efforts were not successful and often caused severe psychological damage.
Based on contemporary medical knowledge and practice, attempts to change a person’s core gender identity are considered to be futile and unethical.
It seems remarkably inconsistent to classify cross-gender identity as pathological because it is rarer than homosexuality and not apply the same argument to homosexuality versus heterosexuality, or left-handedness versus right-handedness. Moreover, defining deviance as disease has two fundamental problems (Ullmann, 1975). First, some unusual conditions are very desirable, such as very high intelligence. Second, a statistical definition equates mental health with conformity, discounting the historical contributions of nonconformists and the social dangers of over conformity.
The definition of "mental disorder" included in the DSM-III through DSM-IV is stated as follows:
In the DSM-IV, each of the mental disorders is conceptualized as a clinically significant behavioural or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom. (APA, 1994)
This definition does not include statistical deviance as a justification for psychiatric classification. Just as statistical prevalence does not necessitate the pathologization of gay and lesbian people, it does not justify the psychiatric classification of all transgendered people.
Psychotherapy or counselling may indeed be helpful to transgendered people dealing with issues of shame, secrecy, depression, and prejudice.
The central issue of medical necessity is one of treatment focus. Is the distress of genitalia and assigned roles that are incongruent with inner gender identity the focus of treatment, or is gender identity itself the disorder when incongruent with genitalia and assigned role?
An over inclusive psychiatric classification of an entire class of people is problematic, especially when the distress associated with the condition results from social stigma that is exacerbated by the classification itself.
The diagnostic categories of Gender Identity Disorder and Transvestic Fetishism, like Homosexuality in past decades, may or may not meet current definitions of psychiatric disorder depending on subjective assumptions regarding "normal" sex and gender role and the distress of societal prejudice.
Recent revisions of the Diagnostic and Statistical Manual of Mental Disorders have made these categories increasingly ambiguous and reflect a lack of consensus within the medical professions.
The result is that a widening segment of gender non-conforming youth and adults are subject to diagnosis of psychosexual disorder, severe stigma, and loss of civil liberty.
Revising these diagnostic categories will not eliminate transgender stigma but may reduce its legitimacy, just as DSM reform did for homophobia in the 1970s. It is possible to define a diagnosis that specifically addresses the needs of those requiring medical treatment with criteria that are clearly and appropriately inclusive.
Until this is accomplished, the disparate treatment of sexual orientation and gender expression represents medical policy harmful to those it is intended to help.