In the Fight for LGBTQ Rights, A Surprise Ally in Pyschiatry


As DOMA dominates the national legislative discussion on LGBTQ rights, a seemingly minor change in the realm of mental health could mean significant changes for trans people in America. 

On Saturday, the American Psychiatric Association (APA) announced that the revised version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has been reviewed and cleared for publication in May 2013. The new version of the DSM, which has served as the manual of psychiatric diagnosis across the U.S. since 1844, has been in the works for nearly two decades. The APA consulted with "more than 1,500 experts in psychiatry, psychology, social work, psychiatric nursing, pediatrics, neurology, and other related fields from 39 countries" to complete the revisions. While the DSM does not advocate specific treatments for the mental illnesses it classifies, its most important contribution to broader American society is just that: classification of mental illness.

A handful of media outlets have covered changes to the diagnostic criteria of autism, among other controversial changes — and some are quite upset about the changes that have been authorized. But one of the most radical changes to the DSM, as far as those invested in LGBTQ rights are concerned, has to do with the replacement of gender identity disorder with gender dysphoria.

Gender identity disorder, or GID, is the traditional diagnosis for individuals who identify as transgender. GID is defined by "strong, persistent feelings of identification with the opposite gender and discomfort with one's own assigned sex." In contrast, gender dysphoria is used to characterize "emotional distress over a marked incongruence between one's experienced/expressed gender and assigned gender."

Essentially, the change in defintion means that people who identify as transgender used to be considered mentally 'disordered,' according to the DSM. Now, what will be inspected is the individual level of distress a trans person may or may not feel over concerning their gender identity. The decision has been lauded as a success by some; GLAAD notes that "the idea that trans people are automatically 'disordered' ... [is now an] antiquated idea among health care professionals."

This is not the first time that the APA has adjusted its definitions of mental illness to better fit contemporary notions of human gender identity and sexuality. Until 1974, homosexuality was considered a form of mental illness under the DSM. (It was replaced by ego-dystonic homosexuality, which was "indicated by (1) a persistent lack of heterosexual arousal, which the patient experienced as interfering with initiation or maintenance of wanted heterosexual relationships, and (2) persistent distress from a sustained pattern of unwanted homosexual arousal." That diagnosis was removed in 1986.)

This is not to say that gender identity and sexual orientation are analogous. Indeed, as queer theorist Julie Waters correctly observes, the interaction between gender and sexuality is complex and knotty. Rather, it is to note that DSM diagnoses are often based on commonly-held assumptions of 'normal' human identity and behavior, which often reflect systemic prejudice.

As APA President Dr. Dilip Jeste puts it, "At present, most psychiatric disorders lack validated diagnostic biomarkers, and although considerable advances are being made in the arena of neurobiology, psychiatric diagnoses are still mostly based on clinician assessment." In other words, given our still-developing understanding of the physical causes of mental illness, the experts consulted for the DSM literally define what does and what doesn't count based on their own observations and expertise.

The APA explained the basis of its decision in August. Directly addressing the concern of some trans advocates that removing GID from the DSM would prevent trans individuals from accessing medical and surgical gender transition treatments, the APA advocated for decreased barriers to care and inclusion of gender transition treatment in health insurance plans.

Nonetheless, the step forward may be smaller than it seems. As ThinkProgress notes today, "It is true that trans identities are still contained within a manual of mental disorders, which alone can be stigmatizing regardless of how the classification is labeled. Still, for many trans patients, the availability of this diagnosis remains important in a way that it was not for homosexuality decades ago. For those who seek a physical transition to achieve a sense of personal congruity, some insurance providers will only cover the expenses if they are deemed 'medically necessary' by a physician."

It remains to be seen how trans people will fare under the Affordable Care Act, but the DSM's decision, while far from conclusive, seems to be a step in the direction of acceptance for trans communities.