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.