The following excerpt from “You’re in the Wrong Bathroom!” tackles the idea that “Trans People Are Mentally Ill and Therapy Can Change Them.”
Are trans people confused, delusional, deranged… or just plain crazy? Can we be made to be “un-trans”?
Trans people are frequently viewed as unstable. Some imagine that our desire to change genders is a symptom of a larger dysfunction or a form of mental illness. Others argue that we would be able to simply let go of our feelings if properly “motivated” — that providers could, and should, encourage trans people to live according to our genders assigned at birth.
Since health providers first began working with trans people, some have advocated for treatment aimed at changing our gender identities to align with our genders assigned at birth. Though those providers and researchers are now in the minority, they remain stubbornly vocal.
The facts, however, are against them. Numerous studies have demonstrated that trans people are, in general, happier and more well-adjusted after transition, and that there is no form of therapy that is successful in making trans people “un-trans.” Trans people do have increased rates of mental health issues, but studies clearly show this is a result of living in a transphobic society rather than being transgender.
Numerous studies have demonstrated that trans people are, in general, happier and more well-adjusted after transition.
Like women, people of color, and LGB people before us, transgender and gender-nonconforming people have a long history of being pathologized by the medical and mental health community. Trans identity, originally called “transsexualism,” was first introduced into the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Version III, in 1980. The initial DSM diagnosis, almost always used to describe trans women, included those with a persistent desire to rid themselves of their genitals and to live according to the social norms of the “other” gender. It also suggested that these longings were virtually always present since childhood. The text did separate transsexualism from schizophrenia and other psychotic disorders; still, many providers cited the desire to rid oneself of fully functioning body parts and the belief in oneself as not being the gender assigned at birth to be clear indications of severe mental illness.
The inclusion of trans identities in the DSM firmly established that the mental health community deemed “trans-ness” as a condition to be “fixed.” In version four of the DSM, published in 1994, the diagnosis was changed to “gender identity disorder.” This term still defined trans identity as something other than the norm — something different, problematic, and in need of corrective treatment.
Early versions of the World Professional Association for Transgender Health’s (WPATH) Standards of Care also considered transition to be a last resort that might help those few individuals otherwise unable to live within society the possibility of a “successful” life. Those who were trans-identified were only permitted access to care once they had proven to the satisfaction of a team of specialists that they were truly trans. It was up to the provider to determine if the person’s condition was severe enough to justify the radical step of transition.
More recently, trans people have taken it upon themselves to force change. Responding in part to pressure from trans and LGBQ activists, version five of the DSM, published in 2013, now contains the diagnosis “gender dysphoria.” Though the new diagnosis remains in a manual of disorders, the term is more palatable to some, and the diagnosis it represents is more inclusive of gender-nonconforming people who do not fit into the gender binary. Simultaneously, transgender activism has driven the Standards of Care to be more flexible and somewhat more supportive of the full diversity of trans communities.
There is no form of therapy that is successful in making trans people “un-trans.”
The presence of trans identities in the DSM continues to be controversial. There is a powerful movement to have gender-related diagnoses removed altogether, as some feel that any mental health diagnosis is stigmatizing and continues to pathologize trans identities. Others argue that the inclusion has benefits, most importantly insurance coverage. Still, many insurance companies continue to categorically exclude coverage for transition-related care, whether there is a diagnosis for it or not. The International Classification of Diseases, used in many countries around the world, is a separate listing of health conditions, and the eleventh edition of the ICD, expected in 2018, proposes the new diagnosis, “gender incongruence,” which would be a non–mental health diagnosis and potentially less pathologizing, but which would allow for reimbursement of care.
Trans people have been historically stigmatized not only by the mental health community through the DSM but also by individual mental health providers. In 1979, Jon K. Meyer, under the direction of Paul McHugh, chair of the Johns Hopkins University psychiatry department, published a paper in which he wrote that transgender women who had undergone surgery at Johns Hopkins demonstrated “no significant improvement” over those who had been rejected from services. McHugh was outspoken about his political mission to close the Hopkins gender clinic — arguably the most important in the country — and to cease services for transgender people out of a personal belief that transgender people were inherently mentally ill.
Meyer’s study resulted in the closure of transgender clinics across the country, and ultimately very few places remained where transgender people could get legitimate care. Countless people suffered; denied treatment, they felt rejected, lived lives of despair, and turned to illicit treatment via black market sources or continued to suffer the torment of dysphoria. Through McHugh, the erroneous belief spread that transgender people were resigned to be depressed, anxious, and unsuccessful members of society, and that high numbers committed suicide post transition.
Not surprisingly, it was later revealed that the Johns Hopkins study was severely flawed. Meyer argued that his results showed that trans people were no better off after transition, but the measures he used to assess success included value judgments such as whether they were in “gender-appropriate” relationships. This “research” has been widely disproven.
The presence of trans identities in the Diagnostic and Statistical Manual of Mental Disorders continues to be controversial.
Amazingly, despite the current vibrancy and strength of the transgender community, McHugh continues to argue that trans people should not be supported in transitioning. Unfortunately, respected news sources such as the Wall Street Journal continue to publish his opinions. In March 2016, McHugh coauthored a position statement for a group called the American College of Pediatricians, an organization of physicians much smaller than the well-known American Academy of Pediatrics that uses its official sounding name to spread misinformation about transgender people. The statement paints trans people as mentally ill:
A person’s belief that he or she is something they are not is, at best, a sign of confused thinking. When an otherwise healthy biological boy believes he is a girl, or an otherwise healthy biological girl believes she is a boy, an objective psychological problem exists that lies in the mind not the body, and it should be treated as such.
Even though McHugh’s work has been discredited — as the last gasps of someone with very little relevance — his notions persist. Many practitioners with the misguided belief that “trans-ness” can and ought to be “cured” advocate a philosophy of care known as “conversion” or “reparative” therapy. Using coercion, manipulation, aversion therapy, and peer pressure, this form of treatment is designed to compel people to live heteronormative cisgender lives. These efforts have never been effective and have been strongly rejected as unethical by the American Psychiatric and Psychological Associations, American Academy of Pediatrics, American Academy of Child and Adolescent Psychiatry, and many other major organizations. Still, the efforts persist.
Even though Paul McHugh’s work has been discredited, his notions persist.
For example, for many years, Ken Zucker, a psychologist formerly with the Centre for Addiction and Mental Health (CAMH) in Toronto, was accused of practicing reparative therapy on gender-nonconforming children. His gender program was harshly criticized by clients and community members for enforcing outdated protocols that pressured transgender people to live as their assigned genders, being unwilling to engage with transgender and gender-nonconforming communities, and allowing only those who had “failed” to successfully live as their assigned genders to transition.
It appears that CAMH’s board of directors rightly agreed: Zucker was removed from his position at CAMH and the gender program was shuttered in 2015 pending review. Zucker continues to speak at conferences on transgender issues often over the outcry of the community itself, but his influence may be waning: one of Zucker’s two lectures at the US Professional Association for Transgender Health conference in February 2017 was canceled due to protests.
The good news is that supportive mental health providers are increasing in number. In addition to major mental health associations rejecting reparative therapy, a number of US states and Canadian provinces are calling for or have passed legislation making these techniques illegal when working with minors.
Though being trans is not in itself a mental illness, transgender communities bear a disproportionate burden of mental illness. LGBTQ+ people are nearly three times more likely to experience mental illnesses such as major depression and generalized anxiety disorder than others, and those numbers are even higher in trans communities. It is well documented that fear of coming out and being discriminated against for one’s sexual orientation or gender identity can lead to depression, post-traumatic stress disorder, and substance abuse. Trans people have significantly higher rates of smoking, obesity, and diabetes, physical health disparities that likely result from mental health issues such as depression.
For some, the agony of living in a body and assuming a role they feel is not genuine can be too overwhelming to bear. Lifetime suicide attempt rates among transgender people are shockingly high — possibly up to almost 43 percent, compared to just 1.6 percent of the general population.
This data is all consistent with minority stress models, which argue that ongoing exposure to discrimination, stigma, and sociocultural hostility drives poorer mental health outcomes, and that transgender and gender-nonconforming people are especially vulnerable. Increasingly, studies clearly show that it is society’s lack of acceptance that leads to mental health issues, and not being trans itself.
Although we may understand the cause, this does not take away from the fact that trans people have elevated rates of depression, anxiety, substance abuse, self-harming behaviors like cutting, and suicidality, and that treatment is essential. Unfortunately, many trans people who seek help for mental health or substance abuse issues find that they face discrimination and harassment even within settings where the goal is to improve mental health. In a 2007 study of transgender people in substance abuse programs, 60 percent reported being required to use sleeping and shower facilities that did not match their gender, and many described verbal abuse from staff and other patients. Over a third of participants reported that they had stopped going to these programs because of transphobia.
In many instances, even if a mental health program is ostensibly supportive, the staff may have little training in transgender-specific issues. Fifty percent of respondents in the National Transgender Discrimination Survey reported having to teach their providers about transgender care. There are a number of mental health providers with experience working with trans populations. Some work within LGBTQ+ health centers, which often, but not always, provide sensitive and competent transgender care; others have private practices. Many psychiatrists with this background are members of the Association of LGBTQ Psychiatrists. Psychologists may be part of Division 44 of the American Psychological Association, and the National Association of Social Workers has a committee on LGBT issues. The World Professional Association for Transgender Health and GLMA: Health Professionals Advancing LGBT Equality are two organizations open to health professionals of any kind who are interested in transgender health. Many of these associations provide online tools to search for providers by geographic area.
Ken Zucker continues to speak at conferences on transgender issues often over the outcry of the community itself.
There are also targeted programs in some cities to assist LGBTQ+ people who are struggling with specific mental health issues. For example, Callen-Lorde Community Health Center in New York City runs dialectical behavior therapy (DBT) groups for LGBTQ+ people looking to develop improved coping skills, especially if they have a history of trauma. Rainbow Heights Club, in Brooklyn, New York, is a psychosocial club that hosts meals, activities, and groups for LGBTQ+ people with severe mental illnesses such as schizophrenia and bipolar disorder.
The good news is that supportive mental health providers are increasing in number.
In addition to formal mental health care, there are other strategies that have been shown to promote resilience in transgender people. Helping parents with gender-nonconforming children learn to be supportive can have a significant impact. In a 2010 study by the Family Acceptance Project, LGBTQ+ young adults with high levels of family acceptance showed greater levels of self-esteem and general health and lower levels of depression, substance abuse, and suicidal ideation and attempts. A 2016 study on the mental health of transgender children clearly demonstrated that “out” trans youth living in supportive environments with supportive families, schools, and friends have no greater rates of depression and anxiety than youth in similar environments who do not identify as trans. In addition to environmental changes that can be made to assist trans people in building resilience from a young age, trans people often engage in behaviors that build their capacity to thrive in difficult situations. Studies of transgender people’s strategies for coping and resilience show that they often use techniques like positive reframing and self-talk, and turn to hobbies, humor, and spirituality to deal with transphobia in society. They also find ways to act as mentors to younger people, boosting their own and their mentees’ sense of agency.
Transition-related health care also promotes resilience. The data are clear: when we have support, we thrive. Several recent studies have made it unambiguous that quality of life for transgender people is overwhelmingly improved after transition, and that transgender and gender-nonconforming people allowed to live in their self-identified genders do far better emotionally and physically. A 2010 meta-analysis of twenty-eight studies showed that 78 percent of transgender people reported significant improvement in psychological symptoms and 80 percent in quality of life with hormonal transition. A follow-up systematic review in 2016 confirmed that results from studies released since 2010 continued to show benefits. Numerous studies have demonstrated similar improvements with surgery, when it is desired. In a 2015 Italian study, transgender people who had undergone gender-affirming surgeries reported a similar quality of life to cisgender people, when matched by age, marital status, and educational level.
Starting hormonal therapy during the teen years, when appropriate, can also have positive effects. A 2014 study of trans teens in the Netherlands showed that those who were treated in puberty had similar psychological function to cisgender teens the same age.
According to the 2011 Transition Survey by Gender Advocacy Training and Education, 94 percent of trans people show an improvement in their quality of life and 96 percent in their sense of well-being with transition.
All this suggests that trans people are happier and more well-adjusted post transition, and that it is social stigma and lack of acceptance that lead to depression, anxiety, and suicidality, not being trans itself. If anything, our mental health improves with transition.
Copyright (2017), Laura Erickson-Schroth and Laura A. Jacobs. Not to be reprinted without permission from Beacon Press.