Don't let your schooling interfere with your education.
~ Pete Seeger

Sunday, June 14, 2009

Commentary on the DSM-IV, or When Should a Trans Person Transition?

The DSM-IV, published by the APA (American Psychiatric Association) to describe and diagnose mental disorders, describes a mental disorder thus: "In DSM-IV, each of the mental disorders is conceptualized as a clinically significant behavioral 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. In addition, this syndrome or pattern must not be merely an expectable and culturally sanctioned response to a particular event, for example, the death of a loved one. Whatever its original cause, it must currently be considered a manifestation of a behavioral, psychological, or biological dysfunction in the individual. Neither deviant behavior (e.g., political, religious, or sexual) nor conflicts that are primarily between the individual and society are mental disorders unless the deviance or conflict is a symptom of a dysfunction in the individual, as described above."

The DSM-IV lists Gender Identity Disorder as one of these disorders, though the information they provide is clearly inaccurate.

However, by the APA's own definition of mental disorder, I am not insane when I am a woman; I'm insane when I try to live as a man. Note that last sentence. Every function of my life improved following transition. The same is true of every trans person of whom I have knowledge. The mental anguish experienced by trans people is primarily between the individual and society, and the dysfunction many trans people experience is a direct result of the discomfort of living "in the closet" – hiding their true selves, choosing the safety of invisibility and isolation over the risk of social ridicule, approbation, and violence. Again by the APA's definition, that indicates that the condition of gender dissonance itself is not a mental disorder, but hiding in the closet is. A better term for it would probably be "Gender Identity Denial Disorder," and it's easily cured by transition.

Besides which, I find it extremely odd that the same organization that diagnoses this as a mental disorder prescribes surgery and non-psycho-active drugs to treat it. "Oh, you're schitzophrenic? Here, have some aspirin for the pain, and I'll prescribe surgery to split you into the appropriate number of persons."

So, when should trans people transition?

I believe that that depends on what is meant by transition. There are several different aspects of it, including gender presentation, hormone replacement therapy, and surgery. Each of these is, ultimately, the choice of the individual. Almost all trans people choose to live in the gender that feels right to them; their gender presentation, the way they live their lives, is dependant on their internal sense of gender, their subconscious sex. So, I live my life as a woman, a trans man lives his life as a man. Most choose hormone treatment, as it really helps both gender presentation and an internal sense of calm. Less, but still many, choose surgery.

I think children should be allowed to present as who they are. A kid has a better sense of who she is than anyone else, and if she chooses to dress as a girl, and play with girls, even though she has a penis, she should be allowed to do that. Not encouraged – but not discouraged, either. So gender presentation transition should happen as soon as there is an awareness of it. Many parents are starting to do this, and I applaud them. Again and again, I see that trusting kids about their own lives is the best way to go.

Hormone therapy shouldn't start until secondary sex characteristics begin following puberty, and the best way to do that is probably to avoid taking actual hormones at first, and just take hormone blockers. I don't know if there are blockers for female hormones, but there are effective androgen blockers, which can delay the development of secondary sex characteristics until the child is fully confident that this is the direction she wishes to go. In the case of female-to-male transition, this can prevent the need for breast removal surgery; and male-to-female people can prevent the need for painful and expensive electrolysis.

As for surgery, I think that should wait until a child reaches majority, and can make that decision with full awareness of risks and consequences, fully as their own responsibility. No other person should bear that burden.

I believe that this is the best way to support the mental health of trans people, the best way to integrate them into the lives they will lead, and the best way to honor their individuality. I recognize that others, including trans people may disagree, and I welcome comment and discussion on the subject.

And the DSM-IV is still full of crap.


David Carrel said...

I recently watched a video in which Psychiatrists admitted that they never had success stories in their practice. I thought that was pretty interesting whether completely true or not.

Seda said...

Doesn't surprise me. Psychiatrists typically treat mental issues with drugs, and that can be okay to relieve acute distress; but I think most mental disorders are caused by trauma or isolation, and the only way to really get through them is to face them and live through it. A friend who understands empathy will do more for you than a psychiatrist any day - and they're typically cheaper, or free.

In my case I had some childhood trauma issues, which I relived and grieved deeply and let go through therapy, and very intense isolation issues caused by living in the closet for 40 years, which were cured simply by leaving the closet - by transition.

Ironically, many Christians would have me go right back into the closet. My "behavior" - transition, presumably - was recently called "an abomination." The depth of their hubris and arrogance staggers me. They wouldn't hesitate to send me right back to that hell.

Not gonna happen.

anne said...

Hey girl,

And some issues are only physical, like my own depression which was severe enough to want to suicide (caused by dairy) and epilepsy (thought I was insane). But EVERY trans and gay person I know KNEW that this was a problem in their early teens. And that's hundreds of queers, folks, closet or flaming.

A trans person should be able to transition as soon as they want to. End of story. To put this decision in the hands of anyone else is not honoring the selfness of the individual. I hold that most sacred, that it's one dance for one person. Anyone else is just involved in the drama, not in the core problem.

How's the house, girl? I should call...


David Carrel said...

I am listening to a Pastoral Counseling class now that is pretty interesting. He talked about drugs in the last class and made some interesting points about them. One being that those who diagnose them generally spend little time with the patient and it is almost like giving them drugs just makes them feel good that they have a problem they can get attention for and shows proof that they have an excuse for the way that they act. (To put it bluntly like a good yankee. haha

Security is mostly a superstition. It does not exist in nature, nor do the children of men as a whole experience it. Avoiding danger is no safer in the long run than outright exposure. Life is either a daring adventure, or nothing. To keep our faces toward change and behave like free spirits in the presence of fate is strength undefeatable.
~Helen Keller

Reading List for Information about Transpeople

  • Becoming a Visible Man, by Jamison Green
  • Conundrum, by Jan Morris
  • Gender Outlaw, by Kate Bornstein
  • My Husband Betty, by Helen Boyd
  • Right Side Out, by Annah Moore
  • She's Not There, by Jennifer Boylan
  • The Riddle of Gender, by Deborah Rudacille
  • Trans Liberation, by Leslie Feinberg
  • Transgender Emergence, by Arlene Istar Lev
  • Transgender Warriors, by Leslie Feinberg
  • Transition and Beyond, by Reid Vanderburgh
  • True Selves, by Mildred Brown
  • What Becomes You, by Aaron Link Raz and Hilda Raz
  • Whipping Girl, by Julia Serano
I have come into this world to see this:
the sword drop from men's hands even at the height
of their arc of anger
because we have finally realized there is just one flesh to wound
and it is His - the Christ's, our