The Complicated Question Of Diagnosing Transgender Identities

A number of ThinkProgress readers have expressed concern over Monday’s widely-shared post, “APA Revises Manual: Being Transgender Is No Longer A Mental Disorder,” about the American Psychiatric Association’s decision to revise the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) to reclassify “Gender Identity Disorder” (GID) as “Gender Dysphoria.” A prominent LGBT scholar called the headline “erroneous,” noting that as long as a designation exists in the DSM, trans identities are still treated as a disorder. One trans advocate pointed out that “Gender Dysphoria” still stigmatizes trans people because there’s no exit clause to the diagnosis. Another activist shared a letter (Ansara, et al) that she and others submitted to the APA criticizing much of its framing around trans identities and providing possible alternatives. One other trans health activist called the article “a bit of a pinkwash” — essentially an attempt to give the APA more credit than it deserves.

As a cisgender (not trans) gay male who edits ThinkProgress’s LGBT vertical, I assume a heightened responsibility to report on trans issues effectively and thoroughly. For all members of the LGBT community, there are many issues that impact us in very personal and unique ways, resulting in many seemingly-conflicting points of view that all have validity. Many of the points submitted by readers have such merit, and the continued discussion seems an apt opportunity to further explore the complexity of anti-trans stigma and the potential impact of the APA’s decision.

For what it’s worth, ThinkProgress was not alone in its framing. Slate similarly reported “Being Transgender Is No Longer a Disorder.” The AP also compared this change to the 1973 removal of homosexuality as a disorder. Other LGBT outlets, like GLAAD, reported that “Gender Identity Disorder” had been removed from the DSM and that the idea trans people are disordered is now antiquated. Indeed, this was the intention behind yesterday’s post: to emphasize the value of the rhetorical change while acknowledging that complications remain.

It is true that trans identities are still contained within a manual of mental disorders, which alone can be stigmatizing regardless of how the classification is labeled. Still, for many trans patients, the availability of this diagnosis remains important in a way that it was not for homosexuality decades ago. For those who seek a physical transition to achieve a sense of personal congruity, some insurance providers will only cover the expenses if they are deemed “medically necessary” by a physician. The United States does not have the same luxury of government-guaranteed healthcare without discrimination as is available in other countries (like France, as the Ansara letter references).


It’s also worth noting that not all people who experience some form of gender variation will qualify under “Gender Dysphoria.” The diagnosis for GID only applies if the individual demonstrated “significant distress or impairment in social, occupational, or other important areas of functioning.” The “Gender Dysphoria” change expanded this criterion to include “or with a significantly increased risk of suffering, such as distress or disability.” Critics point out that the use of the term “distress” implies a struggle to achieve comfort and not a pathology; thus, the diagnosis does not belong in a manual alongside other disorders. Still, it remains unclear if therapists could do more to guarantee medical coverage if they classify the identity in any other way.

One separate aspect of the DSM-5 that has not been reported as widely is the expansion of the DSM-IV’s “Transvestic Fetishism” to “Transvestic Disorder.” This new radical diagnosis rests on the unscientific assumption that anybody who enjoys any violation of the gender binary — from someone who occasionally cross-dresses to someone who completes a gender transition — is motivated by a sexual obsession to see themselves as the opposite sex. Rather than facilitate medical care, the diagnosis continues to be used to justify shame-based ex-trans therapy and stigmatize all forms of gender variation among all sexes and all sexual orientations. Though therapists can easily disregard this bizarre interpretation of gender identity, it makes it easier for some to justify anti-trans stigma.

Moving away from any connection between trans identities and “disorder” is important, and the APA’s change is a step in that direction, even if it is more rhetorically symbolic than it is diagnostically significant. A vast umbrella of diverse trans and genderqueer identities will likely never constitute Gender Dysphoria, but the diagnosis exists for those who do require medical care. It may not yet be perfect, but it hopefully represents progress away from stigma and pathology toward affirmation and support.