Now don't be sad
'Cause two out of three ain't bad
- Meat Loaf, 1977
On May 18, 2009, about 150 trans community members and allies gathered outside the Annual Meeting of the American Psychiatric Association in San Francisco to protest diagnostic policies that psychopathologize gender diversity. Bull horn in hand, I and others called upon the APA leadership to issue three public position statements in support of the dignity and health of trans and gender variant people.
The response from APA officials was silence - three years of it.
Then last week, on August 16, the APA announced two of these position statements, authored by Drs. Jack Drescher and Ellen Haller and approved by votes of the Assembly and Board of Trustees.
The first position statement [pdf] acknowledged the efficacy and medical necessity of hormonal and/or surgical transition treatment and the barriers to accessing this care faced by those who need it. Similar transition care policy statements were issued in 2008 by the American Medical Association, the American Psychological Association, and the World Professional Association for Transgender Health (WPATH).
Position Statement on Access to Care for Transgender and Gender Variant Individuals
Therefore, the American Psychiatric Association:
- Recognizes that appropriately evaluated transgender and gender variant individuals can benefit greatly from medical and surgical gender transition treatments.
- Advocates for removal of barriers to care and supports both public and private health insurance coverage for gender transition treatment.
- Opposes categorical exclusions of coverage for such medically necessary treatment when prescribed by a physician.
The second statement [pdf] acknowledges harassment and discrimination that trans and gender variant people face in employment, education, parental rights and civil justice. It notes that trans people are frequently victimized in violent hate crimes and inappropriately assigned in gender-segregated facilities . Similar nondiscrimination statements were issued by the National Association of Social Workers in 1999, the American Psychological Association in 2008, and WPATH in 2010.
Position Statement on Discrimination Against Transgender and Gender Variant Individuals
Therefore, the American Psychiatric Association:
- Supports laws that protect the civil rights of transgender and gender variant individuals
- Urges the repeal of laws and policies that discriminate against transgender and gender variant individuals.
- Opposes all public and private discrimination against transgender and gender variant individuals in such areas as health care, employment, housing, public accommodation, education, and licensing.
- Declares that no burden of proof of such judgment, capacity, or reliability shall be placed upon these individuals greater than that imposed on any other persons.
Although the APA lags years behind other leading medical and mental health associations in speaking out, these position statements represent an unprecedented shift in acceptance of human gender diversity by their leadership and membership. Given the APA's unique position in setting diagnostic policy that has been historically used to limit civil justice and transition care access for trans people, these statements come far better late than never.
However, the APA statements fall short of debunking the false stereotype that gender difference is inherently pathological. This is troublesome, because the proposed diagnostic criteria for the Gender Dysphoria category in the pending Fifth Edition of the APA's Diagnostic and Statistical Manual of Mental Disorders (DSM-5) continue to mischaracterize gender identities and expressions that do not conform to birth-assigned gender stereotypes as symptomatic of mental illness.
By describing social and medical transition itself, or the desire for transition, as pathological, the new Gender Dysphoria diagnosis, like its controversial predecessor Gender Identity Disorder (GID), contradicts rather than supports the medical necessity of transition care that is affirmed in the new APA position statement. Even worse, the Transvestic Disorder category in the DSM-5 ascribes nonconforming gender expression and medical transition for many transsexual women and men to a defamatory false stereotype of sexual deviance and paraphilia.
Ironically, the Medical Care statement acknowledges these contradictions in the DSM.
...the presence of the GID diagnosis in the DSM has not served its intended purpose of creating greater access to care-one of the major arguments for diagnostic retention.
Thankfully, there is evidence of change in attitudes toward gender diversity at the American Psychiatric Association. In 2010, the DSM-5 Task Force proposed to rename the widely despised Gender Identity Disorder title (intended to imply "disordered" gender identity) to Gender Incongruence and a further change in 2011 to Gender Dysphoria (from a Greek root for distress). The new Position Statement on Discrimination [pdf] contains the APA's strongest statement to date that gender difference is not disease:
Being transgender gender or variant implies no impairment in judgment, stability, reliability, or general social or vocational capabilities;
Though long overdue, these position statements on Discrimination and Access to Care for Transgender and Gender Variant Individuals represent a historic step forward in reducing barriers to civil justice and transition care access. But they do not go far enough in deconstructing false stereotypes that equate gender diversity with mental sickness and sexual deviance. In the context of the proposed gender diagnoses in the DSM-5 and the recent treatment task force report, they represent a mixed message.
Please join me in thanking Drs. Drescher and Haller and the American Psychiatric Association leadership for these policy statements that acknowledge the worth and dignity of trans and transsexual individuals. In addition, I urge the APA to issue a position statement that gender identity and expression which differ from assigned birth sex do not, in themselves, constitute mental disorder; to correct diagnostic criteria in the proposed Gender Dysphoria category that malign gender nonconforming expression and transition itself as pathological; and to delete the punitive and scientifically capricious Transvestic Disorder diagnosis from the DSM-5.
An expanded version of this article with linked citations is posted on the GID Reform Blog. One two three graphic via Bigstock.