By Heather Cassandra Blessing, LMFT September 28, 2018 As a therapist that specializes in working with people who are transgender or gender expansive, I often hear statements or questions based on myths about transgender youth. Here are the top 10…
June 22, 2018
Just a couple of days ago the World Health Organization (WHO) announced that they are including video game addiction in their update to the international classification of diseases (ICD). You can read our article about that here. Just a couple of days after this, the WHO announced that they will no longer be considering transgender people and what they term “gender incongruence” to be a mental disorder. This is a great step for equality and destigmatization for trans and gender non conforming (GNC) people. However, there are lots of considerations we should talk about and I am not hearing anyone mention any of them…so far.
The WHO announced that it is removing “gender incongruence” from the ICD category of “mental disorders”. This is something a lot of the headlines are missing. “gender incongruence” is still going to be in the ICD 11, but they moved it to the category of “sexual health conditions”. So it’s still there, just in a different place. The argument for this is that reclassifying it in such a way is basically saying “we recognize that this is an issue that needs to be addressed, but we know now that it is not something that means a person is “mentally ill””. Saying someone has a mental disorder suggests that they deviate from healthy functioning and something is wrong with them. Nothing is wrong with Trans and GNC folx, they are who they are, but there are problems associated with being trans, and that’s what we’re going to talk about in the cons section.
Gender Identity Disorder vs. Gender Dysphoria
We’ll start this one out with a very abridged history lesson. Until the DSM V came out a couple of years ago, in the US, transgender people were diagnosed as having “gender identity disorder“. The DSM V removed this and replaced it with Gender Dysphoria. The argument for this was similar to what the WHO is saying now: the term “gender identity disorder” communicates that there is something fundamentally wrong with transgender people and that their identities are a disorder. Gender dysphoria on the other hand aims to specifically address the negative symptoms experienced by trans people. So essentially the DSM attempted to go from diagnosing the identity to diagnosing the negative symptoms. In practice though, the name is the only thing that significantly changed and someone can be diagnosed as having gender dysphoria without being dysphoric in any way.
What is Gender Dysphoria?
For those who aren’t in the know, gender dysphoria in a nutshell means that the incongruence between your gender identity and your body makes you really unhappy…..or at least that’s the idea. In practice a diagnosis of gender dysphoria can be applied to anyone who meets at least 2 of 6 diagnostic indicators. This means someone can be diagnosed with gender dysphoria if they have “a strong desire to be of the other gender” and “a strong desire to be treated as the other gender”. These two taken on their own say nothing about dysphoria and more closely define “transgender” than gender dysphoria.
The DSM says that gender dysphoria is
“In adolescents and adults gender dysphoria diagnosis involves a difference between one’s experienced/expressed gender and assigned gender, and significant distress or problems functioning. It lasts at least six months and is shown by at least two of the following:”
But none of the 6 diagnostic indicators say anything that resembles dysphoria. There’s a lot in here about having “a strong desire” to be congruent with one’s gender identity, but nothing about unhappiness/dissatisfaction/dysphoria. In this way, the diagnosis of gender dysphoria fails to truly remove gender identity as a disorder. Where it should be addressing the symptoms, it extends itself to apply to either the symptoms or the identity, or both.
What is Gender Incongruence?
So in theory gender dysphoria is supposed to be a diagnosis that focuses more on the symptoms and less on pathologizing gender identity, but clearly that’s not always the case. Its more like gender dysphoria, as written in the DSM, is a catch all for being transgender. Gender incongruence on the other hand, as written in the ICD11, actually sounds like a better description of gender dysphoria to me:
“Gender incongruence of adolescence and adulthood is characterized by a marked and persistent incongruence between an individual´s experienced gender and the assigned sex, as manifested by at least two of the following: 1) a strong dislike or discomfort with the one’s primary or secondary sex characteristics (in adolescents, anticipated secondary sex characteristics) due to their incongruity with the experienced gender; 2) a strong desire to be rid of some or all of one’s primary and/or secondary sex characteristics (in adolescents, anticipated secondary sex characteristics) due to their incongruity with the experienced gender; 3) a strong desire to have the primary and/or secondary sex characteristics of the experienced gender. The individual experiences a strong desire to be treated (to live and be accepted) as a person of the experienced gender. The experienced gender incongruence must have been continuously present for at least several months. The diagnosis cannot be assigned prior the onset of puberty. Gender variant behaviour and preferences alone are not a basis for assigning the diagnosis.” -ICD 11-
The real issue at hand when comparing these two is semantics. The phrase “gender dysphoria” purely linguistically describes being unhappy with your gender, but the actual DSM diagnosis means a lot more. Gender incongruence on the other hand linguistically sounds more like its describing the state of being transgender, but the actual diagnosis is much more like dysphoria.
Before we get into the negative stuff, there are lots of pros to this news! It really is a step in the right direction and should help us get to a better place with gender in society. We really need to destigmatize gender issues. I really think of gender as being just another part of your personality, and just like personality, there are far more than just 2 types of gender. At birth we assign people “boy” or “girl” based on what’s between their legs. It’s true that there are biological differences between men and women, but we assume and assert that boys should be masculine and girls should be feminine. This is wrong, and a terrible assumption.
It’s also a fact that some people are in a sense, born into the wrong bodies. A recent study showed that a set of trans people studied tended to have brain characteristics resembling the sex they identified with rather than the one they were born into. This really supports the fact that trans people are what they are and y’all should stop bullying them for it!
Declassifying transgender people as having a mental health disorder is important because it says to the world that (at least the medical community) is accepting that being trans is a natural thing that happens sometimes. It also communicates that being trans does not make someone broken, flawed, or deficient in some way. It also removes the stigma associated with having been classified as a mental disorder. Generally people see mental illnesses as things that need to be fixed or healed. Transgender people don’t need to be fixed, they need to be loved, accepted, and supported in their pursuits to alleviate gender dysphoria. That’s the important distinction. Gender dysphoria needs to be treated, not gender identity.
The Cons / Complications
Ok, so this is where we get into the hard stuff that might be controversial. I’ll start this section out with saying that I have worked with a lot of trans people in my therapy practice. In my time working with trans and GNC clients there has been a theme/question that has come up a few times. Should being transgender be demedicalized? The first time someone brought this up in session was after they saw a poster somewhere that said something to the effect of “demedicalize gender”. I’ve had many good conversations with people about this and some have brought up interesting points that I might not have thought of on my own. These are some concerns that come up around the idea of demedicalizing being transgender.
Does Demedicalizing Diminish?
The main argument I have heard against demedicalizing trans issues is that it could diminish recognition of the hardships faced by trans people. The question here is whether gender dysphoria being classified as a sexual health issue could make it seem less serious to some people. This might be similar to the way a lot of cis men don’t appreciate the misery of having a monthly period. I think people tend to hear the words “sexual health” and think either “this thing has to do with sex” or “this thing is optional and treating it would only help the person’s sex life…which isn’t necessary for survival”. I think it’s good that they’re no longer labeling as a mental health disorder, but a sexual health issue? So we still think you’ve got something wrong with you…it’s just sexual, not mental….I guess?
Another concern that comes up around this is the issue of insurance. Every time something changes in the world of mental health diagnoses, there are inevitable follow up questions about insurance coverage. If gender issues are demedicalized, it is very possible that some insurance companies will try to argue that the associated medical procedures are elective or even cosmetic. Could they also argue that “sexual health issues” shouldn’t be covered for minors?
On a similar note, could this provide ammunition to parents who reject their childrens’ gender identities? I’m picturing -“No Timmy, you can’t be a girl, thats a sexual health issue and you’re too young to be thinking about sex.” This is of course, totally wrong because we’re talking about gender, not sex. But I could see this happen. This brings us to the next issue at play here:
Gender is Not a Sexual Health Issue
Labeling “gender incongruence” as a sexual health issue is bad because it suggests that everyone who is trans or GNC has something wrong with them sexually. I think you could argue that being transgender is a sexual issue insofar as it involves a person’s sexual organs, but what do we actually mean by “sexual health”…and what will the public perceive its meaning to be?
It is often said that sex is whats in your pants and gender is what’s in your head…..so have we really changed things that much? They’re arguably going from saying the problem is your gender identity and its in your head to the problem is your gender identity and its in your pants. We need to be more clear about medicalizing the symptoms of gender dysphoria and not gender identity.
This is where we should have a quick talk about the differences between sex, sexuality, and gender:
- Sex is the bits you are born with that make you a man, woman, or intersexed
- Sexuality refers to the types of people you’re attracted to. ie: gay, bi, pansexual, etc.
- Gender is a collection of social/cultural norms that traditionally define someone as “boy” or “girl”. These are things like names, behaviors, clothing choice, whether you’re into glitter or football, etc.
By calling “gender incongruence” a sexual health issue, we’re saying that the way trans people identify is somehow sexually unhealthy…or inherently has a negative impact on their sex, sexuality, or relationship to sex. Think of it this way. If you are a cisgendered man, is your masculinity a sexual health issue? If you’re a cisgendered woman, is your femininity a sexual health issue? Certainly for the cis guy, prostate issues are related to sexual health, and for the cis woman, her period is related to her sexual health, but not their gender. In this way, reclassifying “gender incongruence” as a sexual health issue isn’t really all that much better because it is still labeling trans and GNC experiences and identities as less than or deviant. Which brings me to my overall point:
Gender Dysphoria is a Mental Disorder. Gender Identity is Not
Really when you stop and think about it, is gender dysphoria a mental health issue? I think so. The word “dysphoria” according to the Merriam-Webster dictionary is “a state of feeling very unhappy, uneasy, or dissatisfied”. The way the DSM defines it however, can be used to describe a person who is transgender and/or who is dysphoric. I think most trans people would agree that dysphoria is a disorder and a mental health issue. Nobody likes dysphoria, and a primary goal of therapy for trans issues centers around alleviating gender dysphoria. I think what’s at the heart of all of this is that we shouldn’t look at transgender and GNC people as having something medically wrong with them. Gender identity is not a mental health issue. But dysphoria is.
After spending a lot of time reading and writing about this, I think it comes down to the fact that we really need to clearly cut ties with the notion that gender identity is a disorder or mental illness when it is incongruent with one’s gender assigned at birth. Gender dysphoria is a mental illness, because it’s emotional and people who experience it suffer. We need to have a better diagnosis that clearly names and describes the symptoms of gender dysphoria and doesn’t pathologize gender identity.
Is This a lot of Media Hubub?
By changing the diagnosis from a mental health disorder to a sexual health issue, are we diminishing its significance? Are we taking away from recognition of the very real mental suffering that those with dysphoria experience? I don’t know, but I’ve seen a lot of articles about this issue over the last day and they are all pitching it as “transgender people are no longer considered to have a mental illness”….which makes it sound like they’re demedicalizing trans people. But in reality they’re just re-categorizing the symptoms that many trans people experience. I really like that the word “disorder” is not longer associated with it, but this change is far from completely demedicalizing transgender issues.
All in all I think this is a good step, but there are some things we should watch out for. Changes like this can bring up new problems. They can also bring new opportunities and positive changes in the world. The takeaway I want people to get from reading this is that no gender is a health issue of any sort. There are some symptoms that can arise due to a person’s gender identity, but aside from gender dysphoria, those issues are typically a response to rejection, criticism, and bullying by others. It is arguably fair to consider gender dysphoria a sexual health issue, but gender itself is not. We need to be clearer about describing the symptoms of gender dysphoria so that we are pathologizing the hurt and suffering and not the gender identity.
If you or someone you love is trans, GNC, or working on issues related to gender identity, check out our page of gender therapists. Gender therapists can help with all kinds of issues related to gender, including family relations, how to talk with people about it, coping skills, hormone therapy, sex reassignment surgery, etc. At the very least, seeing a gender therapist can help through providing you a safe place to talk with someone who is knowledgeable about the subject and isn’t going to judge you.
About the Author
Joe Borders is a marriage and family therapist located in Roseville and Sacramento. He is primarily a sex positive gender therapist, but also specializes in working with couples, teens, addiction, and the LGBTQ community. Joe is also the owner and founder of SacWellness. You can find out more about him by visiting his sacwellness listing or by visiting his website: therapy and counseling in Roseville and Sacramento