Why Must We Keep Diagnosing Trans People as Ill?

As the right to health care for transgender and gender-diverse people is wielded as a political cudgel, the field of psychiatry has a duty to uncouple gender diversity from the stigma of diagnostic classifications suggesting illness.

Clinicians like myself find that an affirming approach to care for transgender and gender-diverse people, in which diverse gender identities are validated without an assumption of pathology, reduces stigma. What is the value in assigning a diagnosis to a patient with no immediate medical needs, when a description of a specific service code such as "gender-affirming counseling" would suffice? And what is the rationale for requiring that a prepubescent child who is exploring their gender identity and expression receive a clinical diagnosis before mental health care can be delivered? The same is not required of children and adolescents questioning their sexual orientation.

As we grapple with these questions, it is instructive to look at how "homosexuality" came to be removed as a psychiatric diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (DSM). Street activism was one hero. Activists inspired by the Gay Liberation Front, which was formed in the wake of the 1969 Stonewall riots, disrupted the American Psychiatric Association's 1970 annual meeting, with shouts from the floor demanding that doctors stop treating homosexuality as an illness. These protests continued at APA meetings for three more years, until the APA Board of Trustees voted to stop defining homosexuality as a psychiatric disorder in 1973. In addition, scientific data and research, including Evelyn Hooker's groundbreaking experiments in the 1950s comparing the psychological health of gay and straight men, were key to the APA Board of Trustees' initial decision to stop classifying homosexuality as an illness. Despite this great progress, healthy sexual diversity remained in the DSM in one form or another until 2013. From 1952, when homosexuality was considered a sociopathic disorder, to 2000, when the DSM retained the descriptor of "sexual disorder," psychiatry's stance toward sexual minority communities was fraught, divisive, and polarizing.

Today, the centrality of clinical diagnoses before health insurers will cover care for transgender and gender-diverse people has fueled misconceptions that perpetuate stigma. For instance, the World Professional Association for Transgender Health Standards of Care 7 (WPATH SoC 7) requirement for psychiatric evaluation prior to gender-affirming surgical care is widely misunderstood as a threshold test to determine whether a patient is sufficiently dysphoric to warrant surgical intervention. In truth, the WPATH SoC 7 rationale for psychiatric evaluation before gender-affirming surgical care is now to ensure that patients are connected to wellness services as needed, during a potentially stressful period of personal change. This distinction is nuanced, but deeply meaningful. Importantly, the requirement for any psychiatric evaluation prior to gender-affirming surgery is controversial and will likely continue to be reduced in the coming years, as a way to miminize harmful gatekeeping of gender-affirming care.

There are complications to the removal of clinical diagnoses related to gender diversity that political advocates for the removal of homosexuality from the DSM did not have to contend with. Clinical diagnoses related to gender identity have served as part of an effective legal framework used over the last decade to advocate for civil rights and protections for transgender and gender-diverse people. For example, the diagnosis of "gender dysphoria" has been cited in lawsuits advocating for health insurance coverage of medical care for transgender and gender-diverse people, including those who are incarcerated.

It is important to recognize that considerable progress has been made in the movement towards greater acceptance and visibility for transgender and gender-diverse people in the field of psychiatry. Momentum is evidenced in the condemnation by major professional organizations of the myriad forms of discrimination that transgender and gender-diverse people face. Even so, some within our field continue to resist guidance to affirm gender diversity as a natural and healthy aspect of human experience. Some continue to impose deeply harmful practices, such as gender identity conversion efforts.

One bridge to a future in which psychiatry supports the autonomy and dignity of transgender and gender-diverse people is an alternative care framework that affirms gender diversity without pathologizing based on gender identity. Within such a framework, transgender and gender-diverse people with major depressive disorder or substance use disorders would receive care responsive to their experiences dealing with societal stigma. Treatment and coverage would not hinge on a diagnosis of gender dysphoria, and the ultimate value of psychiatry in supporting the mental health of transgender and gender-diverse people would be in the culturally tailored, trauma-informed care we provide.

Alex Keuroghlian, MD, MPH is Director of Education and Training Programs at The Fenway Institute and senior author of the British Journal of Psychiatry editorial "Envisioning a future for transgender and gender-diverse people beyond the DSM."