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Mental Illness and Transgender People

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Many transgender people, me included, bristle at the notion that we are mentally ill. This was especially the case when Andrea Lafferty of the Traditional Values Coalition spoke out in April against allowing teachers who transition genders to retain their jobs:

Why are we giving our schoolchildren over to people with a serious mental disorder?" ... "We have no problem with people with a serious mental disorder receiving help, but to give them an elevated status within civil rights, within law is very different.

The "elevated status" we seek is merely to not be fired from a job because of being transgender, a protection currently available in only 40 percent of the country.

The "serious mental disorder" she refers to is the diagnosis of Gender Identity Disorder in the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association, the catalog of mental disorders.

I decided to look in the DSM to see who else is in there besides me. I don't know why I've never done that. Did you know that people diagnosed with depression, anxiety, ADHD, or phobias are considered to have mental disorders, too?

I wondered, then, how many people might be mentally ill. According to the National Institute of Mental Health, "about one in four adults suffer from a diagnosable mental disorder in a given year." That's a lot. And it means that Lafferty likely has someone in her immediate family who has a mental disorder. Does she look down on her relative, too?

I thought back to the April Associated Press story that mildly or moderately depressed airline pilots are now allowed to take anti-depressants. That means some pilots are mentally ill, too. Pardon the pun, but given the fact that we regularly entrust them with our lives, I think they constitute a group that already has "elevated status."

It turns out that the prior concern about depressed pilots was not depression itself, but rather that the older anti-depressant medications could cause drowsiness, never a good thing when one is at the wheel. Depressed pilots taking new medications that don't cause drowsiness can now fly.

In fact, many people with mental disorders are able to control their illness and adequately perform their job duties. Their ability to retain their job is based upon their job performance. Transgender people should have the same chance.

Why are transgender people unfairly singled out for job discrimination? In part it is because the current DSM has its own bias against transgender people. As opposed to the other diagnoses, individuals who successfully resolve their gender incongruence, through a gender transition or otherwise, are still considered mentally ill. This bias is removed in the draft of the next version of the DSM due in 2012.

But transgender people argue that gender variations are normal occurrences in nature, not a mental disorder. A recently published paper in the International Journal of Transgenderism stated that, of the international organizations surveyed whose concern is the welfare of transgender people, 56 percent felt that the diagnosis should be excluded from the next version of the DSM.

So why not remove it? In the survey, the primary reason cited was that, without the diagnosis, transgender health care would not be covered by insurance reimbursement in most countries. Most except the United States, of course, where transgender care is generally not covered by health insurance, diagnosis or not.

Scott Leibowitz, MD, of Children's Hospital Boston has found another group opposed to removal of the diagnosis: parents who accept their children as transgender, and who want to show that acceptance is based on professional diagnosis when they are accused of parental whim.

Sadly, the next version of the DSM does not consider whether or not the transgender person is experiencing distress. Some of us are well-adjusted in spite of our gender incongruence. For others, the problem is usually not their gender identity but rather society's reaction to it.

Dr. Leibowitz, who is coordinating a pilot gender and sexuality psychosocial program at Children's, believes that measuring the degree of invalidation a person feels can provide the metric to assess the level of intervention needed. Invalidating factors include external forces ranging from rejection to abuse and internal factors such as the person's own internalized transphobia. Perhaps Leibowitz's pioneering work will be able to inform subsequent versions of the DSM.

But the next version of the DSM is already far along, going into "field trials" soon. The World Professional Association for Transgender Health has pronounced the new DSM name for the diagnosis - Gender Incongruence - "a commendable attempt to depathologize," while at the same time noting several new concerns.

This is clearly a puzzle that's not going to be solved anytime soon.