Mercedes Allen

Trans and Mental Health: "But It Shouldn't Matter If I Was."

Filed By Mercedes Allen | October 18, 2010 1:00 PM | comments

Filed in: Living, Transgender & Intersex

A guest post by Static Nonsense at Questioning Transphobia entitled Intersections of Disability and Transgenderism raises brain.jpgsome important points that apply to the campaigns to remove GID from the DSM and ICD that govern mental health issues:

But it sometimes goes to extremes. All too often people are quick to point out that they're not crazy. People with mental illness are crazy, and people shouldn't conflate the two. Trans people aren't loony like those real loony people are. Which causes a whole mess of problems a la ableism, psychophobia and a combination of misunderstanding and misinformation.

For one, it isolates trans people with mental illness, even when they don't relate. Because suddenly, they are those real loony people. The ones being targeted, within a community they're seeking support from.

Something I've had to do in trans 101 discussions is to be mindful of how discussing trans can impact others. Part of explaining who we are and how that's different from things like, say, sexual orientation, sometimes involves clarifying what we're not -- otherwise, there can be a withdrawal or push-back reaction when we violate false expectations, such as if someone were to accept me under the assumption that I'm trans because I like men, and then I show up with my wife. So it becomes a case of: "We're not all gay, but it shouldn't matter if we were," etc.

Likewise, people assume we all (MTF, at least) live high-risk lifestyles -- we don't necessarily, and it's fair to say that, but (remembering economic and coping realities) it shouldn't matter if we do. That's been my problem with the HBS/classic transsexual philosophy too, how explaining the difference between transsexual and any other form of trans descends into being a vilification of any other form of trans. Finding acceptance should never mean denigrating someone else in order to do so.

A part of decolonial thinking involves being aware of how what we say can impact other communities and people who overlap communities, i.e. by intersecting bases of prejudice. Every human has a right to dignity and respect, and even choice is a slip-shod basis upon which to attempt to make blanket judgments or deny that.

Being trans of itself is not a mental illness, but it shouldn't matter if it was.

You would think that we would have more empathy for the way mental health issues are regarded. More likely, the subject is button-pushing enough that we simply don't want to.

But keeping in mind how prevalent such high-function conditions as anxiety disorder or depression, and stress-related issues are in society, it's something that our community will need to recognize just as much as any other. If you honestly sat down with the DSM and scrutinized every individual on earth, I'd bet you'd be hard-pressed to find anyone who could say they've never experienced anything that resembles something that is catalogued within during their lifetime (which is in fact one problem with the way the DSM has evolved).

National Institutes of Mental Health (NIMH) recently reported findings that at this moment in time, around half of American teens are currently experiencing a clinically-classified condition, with nearly one in four experiencing impairment from a mood, behavior or anxiety disorder. Bipolar, obsessive compulsive, autism spectrum, schizophrenic, dissociative identity, panic and developmental conditions are inevitably going to be things that some in our community will face.

Because of the way we have to hide who we are prior to transition, agoraphobia and social anxiety disorders may occur in our community more often than is typical. There are aspects of pre-and early transition that lend themselves to behaviour and attitudes that resemble Borderline Personality Disorder, causing that diagnosis to sometimes be made as an alternate to GID. And Post Traumatic Stress is also something that we need to recognize, because there are aspects of trans experience that can often cause the development of it.

Asperger's Syndrome is one condition that bears scrutiny, since a few early studies have found a higher-than-typical incidence of it in our community. Having lived for seven years with someone diagnosed with Asperger's, I've known an unusual number of people in the trans community with the diagnosis and have observed a percentage of undiagnosed people within local communities with many of the same behavioural patterns and predispositions. I do tend to think that either 1) there is something about trans experience that can replicate Asperger's-like behaviour in some personality types, or else 2) that as biological traits that might predispose one to trans identity become known, we will find that perhaps one of these traits is likely to also be linked to Asperger's. It is suspected that Asperger's has a biological origin (as may other autism spectrum conditions, Bipolar, Schizophrenia, some forms of depression, OCD, some eating disorders and more). There could also be a third explanation, I suppose -- I'm only equipped with enough information to speculate. And please note that I am only talking about a percentage of the trans population -- maybe 1:50 to 1:20, but that's still a notably higher incidence than in the general population, which is sometimes pegged at 1:5000.

While there is a strong push to have Gender Dysphoria removed from the DSM and ICD, another evolution of thought on the subject is to "define disorder on the basis of distress or impairment and not upon social nonconformity." This recognizes that transsexuality itself shouldn't be regarded as a mental illness, but the societal biases against trans people can generate forms of anxiety, minority stress, a kind of survivor stress and conditions resulting from coping, of which PTSS is one. I recognize that there is a need to destigmatize transsexuality, and also that as long as any diagnosis exists it will be used against us (and in fact, if GID were dropped tomorrow, anti-trans people would simply allege that we're all transvestic fetishists -- Kelley Winters has issued a statement on the proposed revision to TF/TD that is well worth reading), but maintain that many are dependent on the current model for medical access, recognition and sometimes health care coverage who need to be thought of until there is a reliable alternative developed. The GID Reform proposal remains a reasonable way of balancing destigmatization and access, at least until that can happen.

Yet Another Binary

Part of the issue is that we're looking at yet another manufactured binary, which assumes that one is either totally healthy or dangerously mentally ill. And yet we know that the most common mental health conditions don't work that way. Mental health is the most underfunded, underestimated and under-respected aspect of human health, and the ongoing squick about it that our society has which drives sufferers into the closet is not helping anyone further themselves in our society, or in our own community.

(Crossposted to DentedBlueMercedes)

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"neural atypicality" seems a dangerous concept. It implies neural typicality. How does one prove one is not insane? Is there truly a dichotomy composed of Classic/HBS'ers and non extreme trans people just like male/female? Is there a sex spectrum or is there just a gender spectrum. Does everything exist along a single axis if the analogy of an axis exists?

There is no winning this argument. Plenty of people got medical assistance before transsexualism was made a category in the DSM. People who need hormones and surgery need medical treatment. People who don't, don't. People who are distressed for what every reason may need counseling. My experience was that counseling is counterproductive to a great extent.

In politics the majority gets to form definitions. Arguing against your point of view puts one at risk of being defined as extreme. The fact remains that a sex/gender distinction exists in most peoples minds. It's futile to argue against the point you make constantly about the need for GID to be in the DSM. I suppose I will have to resolve myself to living my life as an abstraction and a disordered one at that.

"neural atypicality" seems a dangerous concept. It implies neural typicality. How does one prove one is not insane?

How is this dangerous? Is it as dangerous as naming "cisgender," or "heterosexual," or "white," or "male"?

Because if so, working as intended.

Neural atypicality is a dangerous concept because it implies that there is a typicality to conform to and an atypicality to be cured. I'm thinking Maria New and dexamethasone and also how Gunter Dorner wanted to apply his theories. I did a Facebook Autism spectrum test last week. It was one of those survey type tests. It was all based on questions whose answers could be attributed to a wide variety of reasons not just neurology but not not neurology.

I think there is recent research which indicates that neurological changes take place post-natally that have to do with memory. I believe what a person is results from complex interactions between nature and culture, not one or the other. Some people are using chaos theory to work things out. I say fine, as long as they don't go down the same dead end roads others have. I think humans are infinitely complex. I think people need to be understood not sorted out into simplistic categories.

I do believe exposure to testosterone at critical points in both natal development and post natal development are important in understanding the nature of transsexualism or just anyone's sense of self. How certain facts are read and by whom is what is dangerous. I think just about everyone is atypical, some are statistically more atypical than others. Some, very much so.

As far as what is wrong with male. What if someone were labeled male but the description was so inaccurate it had extremely adverse effects on their life? Do you really believe there is nothing in between male and female? As far as white is concerned, Duana Fullwiley says when she is in France she is Afro-American and when she is in Senegal she is black. I don't understand what heterosexual is. I have trouble understanding what homosexual is, too. Queer? Well, that's a relative concept. Who's sayin'?

Cisgender? Well, I feel what people use the word cissexism to describe quite often. I don't think you have to come from a transsexual place to feel that. I would just call it sexism - sexism rooted in binary sexist stereotypes. I remember the first time I read someone use the expression "multi-axial" to describe how privilege works. It took me a few days to grasp what she was saying. She is an intersex person. Intersex people do exist in spite of what some people may try to tell you. I think she is from a mixed race background, lived a life of low economic status and is a very bright person in academia right now. Some people have a unique perspective from which to view things.

Neural atypicality is a dangerous concept because it implies that there is a typicality to conform to and an atypicality to be cured. I'm thinking Maria New and dexamethasone and also how Gunter Dorner wanted to apply his theories. I did a Facebook Autism spectrum test last week. It was one of those survey type tests. It was all based on questions whose answers could be attributed to a wide variety of reasons not just neurology but not not neurology.

You should google "neurodiversity movement" because you are are reading a lot of things into this that are not present. I do not call myself "neuroatypical" because I believe neurodiversity is something to be "cured." Quite the opposite. Also, there is a neurotypicality that everyone is expected to conform to, but the NT/ND/NA labeling is not what creates that expectation.

Cisgender? Well, I feel what people use the word cissexism to describe quite often. I don't think you have to come from a transsexual place to feel that. I would just call it sexism - sexism rooted in binary sexist stereotypes.

No, it's not sexism. It is related to sexism, but it is its own thing. Cissexism privileges coercively assigned sex at birth over transitioning or even having a gender that does not match coercive assignment whether or not you transition. It is not sexism, and cis women as well as cis men are both capable of perpetrating this upon trans people of all kinds. By calling it sexism all you do is elide the very real differences that exist, and make it easier for cis women to act as if they are incapable of perpetrating it.

I don't know what you're trying to say wrt intersex or "what is wrong with male?" My response was pretty much about neuroatypical, being that the label is pretty important to me.

Of course neurodiversity makes a lot of sense to me. Neuroatypicality is saying something entirely different, though.

I have many friends on line who are intersex. Most of them have an XXY karyotype. A lot of people think the frequency of those with XXY karyotypes are underestimated in medical studies because most don't even know they have the extra X chromosomes with Barr bodies, etc. The reason is that many don't learn about their variation until they arrive at fertility clinics or found to have some kind of learning disability.

XXY is generally characterized as Klinefelter's Syndrome which is supposed to express itself with very specific symptoms which are not much more than stereotypes based on a small study that was conducted many years ago. If you don't not express either one of those symptoms and you would karyotype that way or as mosaic with the karyotype, you are likely to go undiagnosed. I think there are phenotypical differences between those who inherit the extra X chromosome from their mother or their father. Some are also raised female in defiance of stereotypes.

I have a friend who is very bright who somehow found out they were infertile at a very young age. For years because of certain feelings of dual femininity/masculinity, empathy, etc., this person thought they were probably intersex. The doctors assured this person they could not be XXY or "Klinefelter's" because they were too intelligent. I think they have a Master's Degree in English Lit. The person is a poet who reads in the Berkley/Oakland area regularly, a highly respected member of their community in another state and a craftsperson. They had to wait until they were sixty-five to finally have it confirmed that they weren't "crazy"(wrong, "barking up the wrong tree"). Crazy is a relative term.

If you notice I am using the plural when I speak about this person. I am doing that out of the respect I have for the genuineness of this person's dual nature and complex gender identity. I definitely don't feel this way. Everyone has both masculine and feminine traits in varying balances, Some are more balanced out than others. Some have balances that are paradoxical.

What about the doctors who insisted this person couldn't be the way this person intuitively knew they were, all because the person did not conform to their prejudices? It is the foolish consistency that can become a lot more than a hobgoblin for some people. Why not insist a characterization is false when you know in your heart to be so? There is a lot about sense of self and gender identity formation that is not understood very well. Why should a person who is different but who is able to lead a perfectly productive life unless they are confronted with discrimination have to accept a label that classifies them as disordered?

There are many different reasons a person might feel the way they do. You don't even need a cause to trust your intuitions to be correct. I could tell you why I think a therapist might have diagnosed me with ADHD based on what I know happened to another friend of mine who you would characterize as "cis". I think there might have been a grain of truth to that assessment but I am pretty sure it was much too simplistic in a harmful way. It's too long a story to get into here.

I don't know enough about Thomas Szasz and I should read some Foucault but I don't think I am being relativistic when I say the GID diagnosis should not be accepted, especially if the only reason is that someone is worried about giving the appearance of compulsively distancing themselves from having a mental illness.

The cisgender/cissexist concept has a de facto validity but it creates a separation from me and what I feel I should be a part of. This only happens in certain circumstances, which makes me understand how real the effects are. I think what is read as privilege is actually delusion, in many ways, among those who are said to possess it. There is so much diversity and overlap between and within the sexes that privilege really seems to be a blindness that has adverse effects among many of those who are said to possess it.

neuroatypical refers to one person, neurodiversity refers to everyone who is not NT.

Neurodiversity is all about naming neurotypicality, though. The two terms go together and neuroatypicality is a natural outgrowth. I do not understand what your objection is because it's about naming and critiquing the idea that there should be a neurotypicality that everyone should aspire to, and you claim it is the opposite.

I don't know why you're talking to me about intersex.

Cissexism makes my life make sense as a trans woman. Saying it's just sexism denies a lot of the realities I experience.

I also think "delusions" have a specific meaning. The privilege exists. People who have it are objectively and empirically treated better in general - lower unemployment rate, lower homelessness rate, lower seropositivity rates, better access to medical care, economically better off in general. They are mistaken that being cis is a superior state to being trans, but it is not a delusion that this privilege exists.

Also, is it possible to not use mental health labels to describe privilege and bigotry? The idea is to avoid further stigmatizing of mental health issues in general, not shift the stigma around.

Hi Lisa,

I really don't know much about your personal history. I know what an anxiety attack feels like. I don't know how you are affected. I don't take those things lightly. My son was on anti-anxiety medications and anti-depressants. I don't think he has felt any of the kind of stigma that is spoken of here, though. He was able to get into medical school. I am glad he is finally off the medications he was on.

I don't want to write another long reply(but I have). I struggle with a lot. I have for a long time. I don't travel in circles where I find what I could call stigma attached to who I am, though. It is authenticity that is the problem I deal with most often. Kindness can become patronizing treatment which can be paralyzing.

Intersex is covered in the DSM-IV as GID-NOS. I have heard conflicting stories about where it's headed with the new revisions. There is a long history of mischaracterizations of intersex people - things like language development, impulse control and many other things that may or may not show up in an individual who is diagnosed with an intersex variation. The intersex people I know all seem pretty intelligent. Some are highly intelligent. Some, I am pretty sure, have been subjected to batteries of tests under the false assumption they were mentally deficient. I can think of one very well read, highly intelligent individual who was treated this way in adolescence.

There is a long list of misconceptions that have created impediments for intersex people. The rigid adherence to study findings becomes delusional when a clinician refuses to consider exceptions to the rule when those exceptions stare them squarely in the face and when the exceptions have a high incidence. This becomes obvious when a group of people gets together and discovers just how bad and prevalent the mischaracterizations are.

I share some things in common with some of my intersex friends, I have noticed, in terms of temperament and other things I don't want to get into right now. I think many of the mischaracterizations made of intersex people are sometimes relevant to some people born with transsexualism and probably some gay and lesbian people, too. Hypothalamic studies were done on gay men before they were done on people with transsexualism. There is controversy that surrounds such research. The reservations can be concerns that are well founded because of the way research findings can be distorted by people who possess various prejudices.

I personally believe that common perceptions of rigid sex dimorphism is a form of delusion.

Thank you, I think I understand where you are coming from now.

I've had panic attacks that were sustained over a period of weeks. I have had to deal with doctors who treated my anxiety as the primary cause of every complaint ever, and not having these things taken very seriously at all. I have had anxiety attacks for years, well over a decade.

I agree that a strict binary is not true, and that society via medicine and other means violently polices people into that binary no matter how poorly they would fit.

I again think delusional is a bad way to put it, because again it is putting prejudiced, oppressive behavior into the realm of mental disability, when I think it is an all-too-rational attempt to sustain the assumed status quo.

I find it interesting how many ADHD and autistic trans people I know. It is anecdotal, though, and thus not statistical.

I'm never sure I know exactly what I am saying. I spend a lot of time trying to sort things out. I read your blog when I get the chance. My thoughts are a composite of what I pick up from a lot of places trying to understand my situation. I am particularly concerned with how sex and gender are related to one another. There is a great deal of sex variation people are unaware of. Sex is not confined to the genitalia. There is a lot of ignorance where that is concerned. Quite often I feel like a squirrel that is run over on the freeway and driver of the car is not even aware of the fact that it just happened. Then there is oppression that is very consciously carried out and systemic.

I'm never sure I know exactly what I am saying. I spend a lot of time trying to sort things out.

I have this problem, although not consistently. Part of the reason I do not blog as often as I want. :(

And I agree that sex and gender are much more complicated than most credit.

Neuro-atypicality is not dangerous. It isn't meant as an epithet but it does have privilege in society, just as other privileged groups do. Now it might be true that we have a mix of privilege and discrimination. It's possible to have almost no discrimination at all too.

People with disabilities, (qualified medical conditions, some of them neurological and can affect all kinds of abilities to include any of the senses or speech and expression and various aspects of thinking/feeling, pleasure, pain, sensitivity etc), are real and they have communities which support them through discrimination. What can you call people without disabilities? You could merely say "People without a disability that tend not to understand easily" or something more accurate and relative to the topic. So neuro-atypicality is just fine in some contexts. I don't think it's a word that one can fling around takes some understanding and knowledge of the entire context. It's easy to judge a word out of context. How much exposure do you have to say Deaf culture or Autistics, Gimp Pride and other groups?

I personally prefer to look at it as "I am OK, but I am sure not convinced most everyone else is." I have worked through my issues of self condemnation which I faced much of my life. However some upon realizing I was possibly not born female may react oddly toward me. Others do not seem to have the issue or I do not seem to register as not being female to them. If asked I do fess up because I am not ashamed of the path I had to walk to get where I am as a person now. However at times, some days it even seems too often, people do treat me like I am either less stable or lacking morally. However if they do take the time to get to know me, they will find I certainly do not fall into what many seem to think a Transsexual is.

Socially we fall outside the norm, more so than many in most peoples minds. People who accept those who are Gay or Lesbian at times have issues with someone who is Transsexual. I see it all the time. Even with people who should know better like health care providers and medical professionals. Recently a couple friends of mine who are also Transsexual ( one M2F, one F2M ) both had the doctor they were being treated by close her practice. It has been a month or more and even after repeated efforts to locate a doctor, neither has managed to find one who will take on their care. So I submit it is not most of us who are transsexual that are mentally ill, but often it is the phobia on the part of others that show more illness than we present. In most cases our reaction is an attempt to cope with a situation which few would be able to. Sadly too many seem to find it impossible to understand or "walk the mile in our shoes" even if they are pumps.

"So I submit it is not most of us who are transsexual that are mentally ill, but often it is the phobia on the part of others that show more illness than we present."

All the more reason to support the idea of an interim diagnosis that shifts the emphasis from identity as disordered to the distress caused by societal attitudes.

So I submit it is not most of us who are transsexual that are mentally ill, but often it is the phobia on the part of others that show more illness than we present.

Please don't equate bigotry with mental illness. As a trans woman with mental disabilities, I find it pretty offensive to pathologize behavior that people choose to engage in.

I also find it pretty offensive that so many trans people try to distance themselves from the idea of mental illness without ever once criticizing the stimga attached to mental illness, as if this could magically erase the stigma attached to being trans.

I find some of this very interesting. There is an interesting fallacy in the whole GLBT position of recent decades that reads this way. People combat the concept of condemnation by saying "I was born this way". That is the same as saying "anyone who chooses to be gay or lesbian or trans or whatever should be condemned but I'm not one of those". I like you point that it shouldn't matter. My position is to say the opposite. God gave me free will and I don't accept anyone's condemnation for using it even if you have a book that you read as saying I am condemned. That same book says don't judge others. Until people stand up and claim their own lives and the right to live them this crap will go on and on. Sure there should be a few rules such as not harming others but beyond that my approach is "I won't condemn you and I expect the same in return".

Now just for grins and giggles I want to trash psychiatry and psychology from the reincarnation perspective. Until both disciplines accept the fact that all of us live in flesh many incarnations none of their theories or diagnoses will be worth a flip. Same goes for Christians. Being born again means exactly that and not some hokey ceremony or acceptance of the Christ spirit. Sheesh they can't even understand what Jesus is quoted as saying in their own Scriptures. When someone asks me if I've been born again I simply reply yes and don't even bother to tell them I mean many times in many bodies throughout many centuries. I learned long ago they can't understand the full answer.

"... the point you make constantly about the need for GID to be in the DSM..."

Then you've missed that point of my previous position, which is in fact not to say that we belong in the mental health manuals, but that before pushing for wholesale removal and replacing it with nothing (or worse, leave TF/TD or BPD to become preferred alternatives), we need to have thought out the consequences for those who are dependent on the current model.

My previous position was also was not the point of this article, which was to question how this whole debate causes us to isolate some in our community who do have a real need.

Hi Mercedes,

Sorry if I jumped to some hasty conclusions right off the bat based on misconceptions of what I have read elsewhere before. I went back to what Static Nonsense wrote. It seems I reiterated a lot of the point that was trying to be made, also. This is all very difficult to follow but I am still not convinced of the need to have transsexualism, which I prefer to call it, in the DSM. I think informed consent after a waiting period should be sufficient to get hormones and surgery. It worked for many in the past. This subject has been beaten to death, I suppose. In the immortal words of the immortal Doris Day, que sera sera.

This has long been a point I've argued about in my own work, and while leadership of efforts has almost uniformly been responsive to these concerns, the rank and file often is subject to the pervasive bigotry against those with a mental illness, going so far as to condemn people using the most rare and most negative of possible symptoms in order to smear and entire group.

And this sort of thinking actually makes getting health care and medical treatment more difficult for trans folk, not less, as it merely reinforces the marginalization of others and aids in their oppression, leading them to not seek medical help when they need it, or avoid it.

Good post on a topic that gets too little attention. It is a complex topic in our community, especially in reference to access to health care and personal autonomy. It is easy to get caught up in the fight against one oppression and forget about the intersectional oppressions involved. (note a similar post of mine Speaking as someone in the field, Psychological Health as an institution needs to re-evaluate of what implications we are making through these diagnosis-es (borderline is a perfect example of a socio-culturally influenced diagnosis). Changes need to be made, not just for trans folk, but for everyone's sake.

Being trans of itself is not a mental illness, but it shouldn't matter if it was

GID is characterized as a mental disorder. As things now stand, it has monstrous implications for some. The idea that there is such a thing as an ordered gender identity is problematic for many people, not just trans people. It is a characterization based on traditions surrounding behavior that is congruent with ones reproductive capabilities, even people who don't have reproductive capabilities because of the bodies they are born with. One only has to read the work of David Lane - How Shyness Became a Sickness, or David Healy's - Let Them Eat Prozac, to understand how much of a problem there is with being characterized with a mental disorder if one does not actually have one.

Many researchers are aware of how "people are born" with various kinds of "atypicality", also, like hypogonadism. Martin Kafka happens to be one. He would like to treat with SSRI's. It's a thinly veiled aversion therapy.

You would think that we would have more empathy for the way mental health issues are regarded. More likely, the subject is button-pushing enough that we simply don't want to.

Shouldn't it be everyone's responsibility to be empathetic? Atypicality exists even in outliers like the trans population and atypicality exists within the general population, as well. There wouldn't be any creativity without atypicality. High intelligence is atypical. Why should the atypical all be lumped together as if they were all typical of one another when they are not, just because there is one aspect of their atypicality that is based on something they don't have in common with a larger segment of the population? If trans people are homogenous does that mean everyone else who isn't trans is homogenous, too? Would you expect someone who is suffering from depression or alcohol abuse to be more sympathetic to the needs of trans people?

Mental health is the most underfunded, underestimated and under-respected aspect of human health,

The pharmaceutical industry overfunds psychiatry. That is a large part of why treatment is so poor. The way modern society is structured underlies many of the problems people have with things like mood disorders. There is a lot of money to be made patholigizing sadness, or distress over one's financial situation, etc. with chemicals.

My brother was on six or eight medications, some of which have notorious reputations, when he violently took his life over the holidays. It was a shock to everyone. Few were aware of his distress, even though he was in a treatment program that seemed to exacerbate his problems, rather than help him with them. It is a long story. He wasn't gay or trans. Of course I had empathy for him. I had helped him many times in the past. I would have again if he had asked for it.

I agree there should be much more funding directed toward well put together mental health programs but there are many factors preventing that. I knew a person on SSI who was forced into treatment he didn't need or want and, also, forced to pay for it. It had to do with law enforcement prerogatives, not anyone's mental well being, far from it, another long story.

I have been trying to avoid being drawn into this kind of discussion. I have been diagnosed w/ GID, however. I know others who are post surgery who have found ways to get around it. It has very bad implications for people who are transsexual. I can't help but protest vehemently when the subject comes up, however.

I understand that there is an apparatus that is in place without which things might be worse. It has to be changed, however. It is very bad the way things are now. It is not helpful towards the understanding of anyone's needs, even the most marginalized. There are so many who so much invested with terminology, too. I don't think the current terminology used is doing much to communicate the implications of "atypicality", if it does draw people into advocating for common causes.

"Shouldn't it be everyone's responsibility to be empathetic?"

Yes, absolutely. And if the rest of society fails to do so, it's not a license for us to shirk it as well.

"Why should the atypical all be lumped together as if they were all typical of one another when they are not, just because there is one aspect of their atypicality that is based on something they don't have in common with a larger segment of the population?"

Lumped together, no. Shown that there is a struggle we have in common and can benefit from mutually promoting respect for difference in general, yes, ideally (which doesn't necessarily mean it will happen, but it's still worth moving in that direction).

"The pharmaceutical industry overfunds psychiatry."

I should have been clearer. Whenever pharmacology enters the equation, yes, it is overfunded. What are vastly underfunded are treatment facilities, staff, mental health services, social services, and just about anything outside that -- usually the things geared toward finding long-term solutions, rather than providing triage.

This has been an extremely emotionally draining discussion. I don't expect you to respond. You have dropped out of the discussion for good reason. What I was trying to say in the comment I replied to is that it is curious who gets drawn into discussions about the delisting of transsexualism. Why is it only people who have been targeted as having GID? What I saw as a red flag immediately was the coupling of DID with "transgenderism". Both deal specifically with the mind. The brain is part of the body but how it relates to the sexual parts of the body is what is at issue with people who are mischaracterized as having GID. The medical and psychiatric establishment are in denial that intersex exists. Granted, it is less controversial than the concept of transsexualism as related to a person's body before medical intervention. How can it be denied that changes do occur after intervention that are not merely cosmetic, though? Intersex exists, with certainty and still the medical establishment avoids the issue almost completely.

There has been a lot thrown out about diversity and equivalence. I do not think transsexualism is equivalent to OCD or BIID or many other traits a person might have and the effect those traits might have on their ability to function. I have had a very close relationship to someone with anorexia nervosa and bulimia. I know from experience that is a disorder that is seriously debilitating that can result in death. I have known a lot of drug addicts and alcoholics, too. Alcoholism and drug addiction can kill a person.

No, SRS is not like "giving liposuction to an anorexic." There is nothing analogous involved. As far as male and female genital tissue is concerned, however, there is a great deal that is homologous. What does that have to do with the mind? The endocrine system has a lot to do with the mind but it does not exist only in the mind. It has an impact on the whole body. This is why I think transsexualism is a broad based medical/biological issue and not a narrow psychiatric issue confined to the mind. That is why I think it belongs in the broad based biological/ medical domain and not in a narrow, abstract psychiatric domain.

In all these discussions there seems to be a lot of cannibalism between people who are relegated to a "trans" spectrum. If we are going to be fair to everyone why not have a "non male disorder" for people assigned and raised female and the opposite for those assigned and raised male?

The odd timing of this post coincides with me dropping out of a listserve that has been indirectly and directly the subject of controversy lately. It was formed to discuss gender identity pathologization. I dropped out because these discussions can leave a person totally sapped of their energy. The problem just doesn't seem to want to go away, though. It is constantly rearing its ugly head. I remember two years ago arguing with someone who was an occasional crossdresser who kept going on about Occam's Razor and insisting that the desire for genital surgery was rooted in nothing more than OCD. No, sorry, not for me and how would they know? They weren't even considering it.

I have read long papers by academics from island countries in the South Pacific making the case that transsexualism is rooted in child sexual abuse, PTSD and DID. Maybe for that person it was. What does that have to with surgery and hormone treatment? I think stigma should be attached to child abuse. I think people living with PTSD benefit from treatment. If someone has DID and it doesn't interfere with their life, I don't think a value judgement has to be made on it. I don't think everything is relative, though.

I don't think surgery and hormone treatment are the result of any psychological disorder. I can't conceive how both interventions, which work in a complementary way, could ever be confused with BIID if someone truly tried to understand what is involved. I am not neutral on the subject of the removal of healthy limbs. Transsexual genital surgery is very much more complex. Ironically, many of the very people who characterize SRS as BIID are defending the removal of healthy tissue from intersex children which usually has a very negative impact on their sexual functions for reasons that are purely cosmetic. There is a lot people are not told about erectile tissue and its homologous nature in the sexes.

One only has to read the work of Christopher Lane - How Shyness Became a Sickness, or David Healy's - Let Them Eat Prozac, to understand how much of a problem there is with being characterized with a mental disorder if one does not actually have one.

I am tired of the criticisms of anxiety as "pathologizing shyness." I think that shows a remarkable ignorance about the nature of anxiety and how disabling it can be. It strikes me almost as concern trolling.

O K, one more time. "Concern troll" is a new one on me. I had to go to the urban dictionary to look that one up. I am not pretending to be an ally. What I have written is heartfelt. No one is asking you to agree with me. Please, do not insist that I not have my own point of view.

I have felt anxiety all day long because of the fact I am not able to bite my tongue well enough when it comes to discussion of the GID diagnosis. It has an impact on me. Forgive me, if you will, for giving my opinion. Getting involved in these discussions means getting involved in a human bondage that is a very brutal one.

I have seen quite a few smeared over the internet this past year. I guess I should just sit back and let human nature take its course. I'll try to restrain myself. I won't make any promises, though.

I didn't say you were concern trolling. I meant that book you referred to. I've been seeing a lot of "pathologizing shyness" and it's kinda frustrating because I have anxiety disorder, and it's not benign as the term "shy" suggests.

Sorry, I meant Christopher Lane, who is the author of How Shyness Became a Sickness.

Being Gay of itself is not a mental illness, but it shouldn't matter if it was.

I suspect that statement would put the cat amongst the pigeons.

FWIW I agree with you, Mercedes. But the very different reaction that the statement above would generate here illustrates the scope of the problem of cis-privilege.

Now onto the topic at hand.

As we've seen with all those bullied gay kids suiciding, gay kids too sometimes acquire mental problems because of the crap they have to take from society. Just as they sometimes acquire physical problems such as broken ribs, fractured skulls etc.

The distinction between the two is artificial. And we should no more persecute those with mental illnesses than we should persecute those with cleft palates. Both happen though.

Thanks, Mercedes, for your very insightful thoughts on a complex issue. I would like to clarify one point. I and others have proposed harm reduction in the DSM-5 that would replace the "disordered identity" paradigm of GID with diagnostic coding limited to distress with current physical sex characteristics (anatomic dysphoria) or distress with a social gender role that is imposed by others. The sole purpose of this limited diagnostic category would be to facilitate access to medical transition care for those who need it. In contrast, the current GID and proposed DSM-5 Gender Incongruence criteria contradict transition, describing it and nonconformity to birth-assigned gender roles as symptomatic of mental pathology.

Distress caused by external prejudice, however, is different than distress of medically treatable gender dysphoria: the former is a societal ill and not a dysfunction of the victim. I strongly feel that transpeople victimized by prejudice should not be classified as mentally ill because they are victims, just as people of color are not pathologized when victimized by racism or as cis-G/L/B people are no longer pathologized when victimized by homophobia. Zucker and Blanchard (1995) justified pathologization of gender nonconformity by arguing that external intolerance represents impairment or dysfunction. The APA correctly rejected this reasoning for cis-G/L/B victims of prejudice, when it removed the Ego-Dystonic Homosexuality diagnosis in 1987. Victims of transphobia should be treated with equal consideration.

Depression and anxiety certainly exist among trans people, as in all populations, and may result from societal intolerance. In my view, Trans people with these conditions should not be coded or treated differently than other people with the same conditions.

Thanks also, Mercedes, for calling attention to the often overlooked second diagnosis of Transvestic Fetishism, now renamed Transvestic Disorder. It plays no role in access to medical transition care and only serves to stigmatize and punish nonconformity to birth-assigned sex stereotypes. I hope that readers will join me in calling for its removal from the DSM-5.

Sorry for confusing this point -- that's a major memory failure on my part.

I'll need to look to find who/where I picked this up from, now, because there was something I thought rather illuminating about (not trans-specific) minority stress and how it can provide context and direct solutions. Which is something I should probably have clearer in my mind before I go further.

But again, sorry for mis-attributing, and thank you for clarifying this.

Your piece is awesome, Mercedes, and I like the posting by Static Nonsense that you cite. You both raise very important points. Thank you for bringing them to light.

Minority stress is an urgently important issue, as we are painfully reminded by tragic teen suicides recently. When external hatred is internalized to the point of depression or clinical anxiety, we and especially our youth need far better access to care. But this is a very separate issue from coding nomenclature for internal anatomic or gender role dysphoria which persist regardless of external stress. Zucker and Blanchard's use of minority stress to justify the defamation of gender variant people as crazy and the abuse of gender reparative therapies exemplifies the need to code the two issues separately.

I really like your reasoning in this piece, Mercedes. As a mentally ill person, I really appreciate the sensitivity and empathy this post shows.

I'm also thinking about how LGB people do the same thing - kick out the people diagnosed with a mental illness to make us look better. It wasn't too long ago that we were seen as officially crazy and that has left a mark.

Kick out the mentally ill? How exactly? Stigma is prevalent everywhere. What do you mean that LBGT kick out the mentally ill?

Hello. I'm SN, the person that wrote the guest post you're responding to.

I'd like to ask that you stop misrepresenting me and the point behind my post. While I did comment on society's perception of trans identity as a mental disorder via the categorization of Gender Identity Disorder, you have stripped the core of the post to adjust it to your own point. Namely, the fact that I am calling out a community on problematic behavior and mentalities and how it isolates the very people within that community, harming them in the process. My noting of society's perception regarding Gender Identity Disorder was to help construct the rest of my point, shown later on in the post. It is part of the foundation, not the whole.

I do not appreciate my calling out of people for their behavior and my intimate struggles as a trans person with mental illness being co-opted for your own points. Please stop.

I apologize.

I'd actually wanted to honour the spirit of your original post, although it obviously did not go that way. I hadn't intended to misrepresent your message.

I apologize, and withdraw myself from further comment.

Thank you, I appreciate it. Cheers :)