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Identity Crisis

Is transgender teens’ desire to switch their sex a mental disorder that needs treatment, or is it the rest of society that has a problem?

Elliott has two scars across his chest where his breasts used to be. He has full sideburns down his gaunt cheeks, a strong chin, and sharp jawline. His voice is not deep enough to be considered baritone. At 22, he looks like a rather boyish young man. You would not mistake him for a woman, although he was born a woman. There’s a chance you might mistake him for Morrissey, which is the look he’s going for. The asexual British rocker poet has long been the patron saint of gay and androgynous youth.

Elliott’s story is one we are hearing more and more these days. About the time he hit puberty, his body started developing in a way that was incongruent to how he perceived himself. Breasts, new thatches of hair, and an emerging feminine shape pushed Elliott toward an identity that felt alien. By 16, he felt as though his body no longer belonged to him. “It was something happening to me. Like it wasn’t even a part of me.”

To say that Elliott felt like a man trapped in a woman’s body or that he was repelled by his own private parts, as the typical definition of a transsexual would have you presume, would be inaccurate. Elliott didn’t want to escape one sex role to embrace another, but he did have a desire to feel “more manly.” Disoriented and nervous about what was happening to him, he told his parents that he thought he was, perhaps, maybe, “bisexual?” But as time went on Elliott found that his feelings had less to do with which sex he was attracted to and more to do with which sex he wanted to be. In fact, for his age, Elliott thought very little about sex. He had somewhat resigned himself to a life of solitude, as lonely teenagers are wont to do. As Morrissey sings, “You don’t have to tell me ... I know I’m unlovable.”

His junior year of high school, Elliott found out about hormonal replacement therapy. Once he turned 18 he would be eligible to receive testosterone injections without parental consent and eventually his body would take on more masculine characteristics, including facial hair, a broader brow, deeper voice, and decreased breast size. To get the treatment, however, Elliott would have to undergo 15 sessions with a psychologist to prove that his biological sex caused him enough distress that it merited reassignment. That psychologist would then give him a letter addressed to a physician certifying that Elliott suffered from gender- identity disorder.

Elliott never believed he had a “disorder,” so he feared he would give the wrong answers, or not display enough distress. “It was all so ridiculous,” he tells me. “I was contemptuous of the whole thing. I basically had to keep meeting with this psychology grad student who handed me a fifty-question checklist on our first session. You can look up symptoms online to make sure you get your diagnosis letter, so I made sure I did that.” One thing trans-themed forums and blogs recommend is journaling about a “real life experience” to show a therapist. According to the “standards of care” put out by the World Professional Association for Transgender Health for the medical and psychiatric community, it’s recommended that prior to hormone therapy, the patient has a “documented experience” dressed as the gender he or she desires to be. This ultimately means going in drag to work, school, or among family to confront possible anxieties that come with a new gender and face “external consequences.”

Though the process frustrated Elliott, he did not want to buy hormones on the black market (which you can also do online) and self-administer, so he stuck with it, hoping for a positive diagnosis. Which is to say, he was hoping to be declared mentally ill—at least according to the Diagnostic and Statistical Manual of Mental Disorders (DSM), the standardized criteria written by the American Psychiatric Association and used by clinicians, psychia- trists, and psychologists to diagnose their patients. The DSM lists gender-identity disorder (GID) as a certifiable mental illness. A patient, like Elliott, exhibits not only the desire to become another gender but also demonstrates “relationship difficulties” because of the distress he or she feels about being the wrong one.

However, all that could change.

Since it was initially published in 1952, the DSM has undergone only four major revisions, and with each new edition there comes, rightfully, a great deal of controversy and advocacy, in and around the mental-health field. After all, the DSM is the book that separates the sane from the pathological, the neurotics from the normals. The slightest shift in sentence structure can cause major reverberations across the fields of medicine, biology, and pharmacology. When DSM-IV broadened the definition of bipolar disorder in 1994, there was a huge rise in prescriptions for “mood stabilizing” drugs that, prior to the change, were usually only recommended for people who suffered from convulsions or psychosis.

In certain cases, like, say, homosexuality, revising the DSM can have a vast social impact. The first two editions of the DSM classified homosexuality as a sexual disorder right along pedophilia and rubbing against strangers in public. It wasn’t until 1980
that homosexuality was removed entirely from the DSM, a move to which many activists, scholars, and clinicians attribute the destigmatization of homosexuality in American culture.

So when it was announced last year that the newest version of the DSM, to be published in 2013, would make significant revisions to the GID diagnosis, swaths of activists inside and out of the psychiatric establishment saw an opportunity to have the diagnosis removed altogether. They argue that the diagnosis further isolates transgender individuals, who are already a highly vulnerable and ostracized group.

The DSM work group assigned to gender identity disorder, a panel of specialized field experts, has already bowed to some external pressures. It has made clear that it intends to change the name of the diagnosis from “disorder” to “dysphoria”—which describes a passing mood rather than a fixed state. The work group has also made public its plans to not only preserve the core GID diagnosis, but to retain an even more controversial entry: GID in children.

* * *

Those who are in favor of keeping gender identity disorder in the DSM have two main arguments. The first is a clinical utility argument: If a person, especially a child, is distressed, suicidal, or self-harming because he or she feels incongruent with his or her gender, GID offers a diagnosis and path for treatment.

Robert Spitzer, the architect of DSM-III (the edition that removed homosexuality), acknowledged the fundamental question the term “disorder” dredges up.

“The concept of disorder is man-made,” Spitzer wrote in 1981. “Over the course of time, all cultures have evolved concepts of illness or disease in order to identify certain conditions that, because of their negative consequences, implicitly have a call to action” to caretakers, to the person with the condition, and to society. Spitzer concluded, “The advantage of identifying such conditions is that it makes it easier for individuals with those conditions to receive care that may be helpful to them.”

The second argument in favor of keeping GID in the diagnostic manual is where things get ethically murky. The removal of the diagnosis may also remove insurance coverage for transsexual adults who are being treated with hormonal or surgical reassignment. As of now, a diagnosis of mental illness is the only mechanism that transsexuals have for medical insurance to cover mastectomies, testosterone injections, and genital reconstruction surgeries (though very few insurance companies cover any sort of gender reassignment, because it is most often considered “cosmetic”).

Megan Smith, a Nebraska-based psychotherapist and an advocate for the removal of GID from the DSM, claims that the insurance argument is the one she most often encounters. Smith believes keeping the diagnosis for the sake of insurance coverage is “unethical and unscientific.” Smith argues, “I don’t believe it’s our obligation as mental health professionals to change psychiatric evaluations in order to play ball with insurance companies.”

When it comes to the issue of distress in children, the proposed revisions put the burden of proof on the parents. In the current proposal the work group includes a questionnaire to be completed by parents about their young sons:

Over the past six months, how intense was your son’s avoidance of rough-and-tumble play?

Over the past six months, how intense was your son’s dislike of his sexual anatomy (e.g., that he dislikes or hates his penis or testes)?

Over the past six months, how intense was your son’s desire for the sexual anatomy of a girl (e.g., sits to urinate, pretends to have breasts, would like to have a vagina)?


Or their young daughters:

Over the past six months, how intense was your daughter’s preference for the toys, games, and activities typical of boys?

Over the past six months, how intense was your daughter’s preference for boy playmates?

Over the past six months, how intense was your daughter’s desire for the sexual anatomy of a boy (e.g., that she would like to have a penis or to grow one; stands to urinate)?


For the activists opposed to keeping the diagnosis in the DSM-V, like Smith, this brings up a fairly obvious question: Whose distress are you treating—the child’s or the parents’? When Smith worked for a non-profit that served the homeless in Omaha, she encountered several transgender teens who had been cast out by their families. “Childhood is a time for people to explore their genders,” she says. “Much of the distress I see in my young patients isn’t from wanting to be another gender, it’s the anxiety of having to become a total outsider.”

The DSM does not allow much, if any, gender ambiguity—the word “transgender” appears nowhere in the current DSM or in any of its proposed revisions. “A lot of people I’ve spoken with don’t identify as either male or female,” says Smith. “They see themselves as gender queer, or atypical gender, or just plain trans,” never completely going over to one sex or the other.

The most nefarious outcome of GID remaining in the DSM, activists believe, will be the introduction of “reparative treatment” given by psychiatrists to transgender children, adolescents, and adults. Though condemned by the American Psychiatric Association in 1998, reparative or conversion therapy aims to cure homosexuality (there usually exists a moral or religious component to this sort of faux treatment). The APA spoke out against reparative treat- ment because it operated on the assumption “that homosexuality is a mental illness.” As long as gender-identity disorder remains in the DSM, the LGBT community will worry that society will view transgender people as in need of “fixing.”

However, Jack Dresher, a New York–based psychiatrist and a member of the 13-person Sexual and Gender Identity Disorder Work Group for DSM-V, wrote in a recent paper that no one in the work group condones “fixing” trans teens or gay teens. Psychiatry has historically conflated sexual orientation with sexual identity, he writes, but the work group rightfully distinguishes these into separate categories.

While Dresher acknowledges the parallels between the efforts of the gay-rights movement and the trans community to normalize their presence in society at large, he believes that acceptance of queer-identified individuals is progressing rapidly and would not be offset by GID staying on the books. Though he admits there would undoubtedly be some stigma for those diagnosed—as there is for individuals diagnosed with bipolar disorder or major depression—he thinks keeping the diagnosis for people who have distress about their bodies and identities “would be a less harmful choice.”

Dresher ultimately recommends adoption of less “stigmatizing language towards gender variant individuals” and a narrower definition of GID children to include just those suffering distress about their anatomy.

* * *

When Emmie told her parents that she was transgender at age 14, there were all kinds of details to work out. Not only would Emmie, who now goes by Jesse, need to change her documented sex at her private school, she would also need to figure out where she was going to change for P.E. and which school bathrooms she was allowed to use. Now 16, Jesse is identified as a boy by his school and peers. To minimize confusion for the other students, Jesse uses the nongen- der faculty bathrooms, changes in a separate room, and was asked by the administration to not wear a skirt, which would be now
be considered “drag.”

“The skirt thing was kinda funny because if you ask me, I don’t believe in a gender binary,” Jesse tells me on the phone after I contact him via the Transgender Student Rights Facebook page he runs. “I think of gender as more of a spectrum,” he tells me in a high-pitched voice that absolutely betrays his biological sex.

Before Jesse came out as transgender, he was in therapy four days a week because of his tumultuous childhood. When Jesse was 9 years old his mother died from anorexia and his father agreed to have the couple’s best friends adopt Jesse. After Jesse came out to his adoptive parents, they told his biological father. Jesse and his dad went to lunch, where his father showed him pictures of himself dressed like a woman. He told Jesse that from time to time he enjoys dressing up in drag, so there was nothing for him to feel ashamed about.

“My dad told me he always thought I’d be a weirdo because I came from such an eccentric family,” Jesse giggles.

When I ask how he feels about the possibility that under the DSM proposals he technically could be classified as mentally ill, Jesse laughs it off. “I think everyone could benefit from therapy, so while I would like to see the diagnosis totally gone from the DSM, because, like I said, I don’t believe in a gender binary, I don’t think therapists are the enemy.”

Jesse hasn’t decided whether he wants to go on hormone treatments once he turns 18. “I might want to have a kid one day and I don’t want to mess with that possibility right now.” Though, he admits, it would be nice to take his voice down to a lower pitch. “I might get top surgery [double mastectomy],” Jesse muses, but still isn’t sure. “You know, there are some days I wish my boobs would go away; there are other days where I kinda like them.”

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