Thursday, April 22, 2010

The DSM Diagnosis and The Workplace

Answers About Transgender Issues - City Room Blog -

My question was in the New York Times today, answered by Dr. Laura Erickson-Schroth, who is working on “Trans Bodies, Trans Selves,” a resource guide for transgender and other gender-variant people:

Q: As a professor of law, specializing in workplace law and policy, I often consult with business organizations where employees are undergoing gender transition. One question that frequently comes up is whether transgender employees are mentally ill, given that the American Psychiatric Association still includes “gender identity disorder” (but not homosexuality). Some express concern that transgender co-workers will pose a sexual danger in the workplace. While I explain that there is no need to fear such a result based on my research with many hundreds of companies, I have difficulty explaining away the diagnosis. Can you provide a better explanation for the presence of “gender identity disorder” in the Diagnostic and Statistical Manual of the American Psychiatric Association?

— Posted by Dr. Jillian T. Weiss


As you describe, Dr. Weiss, individuals who identify as transgender are classified as having gender identity disorder (GID) in the A.P.A.’s Diagnostic and Statistical Manual of Mental Disorders (D.S.M.), which mental health providers use to diagnose mental illness. The fifth edition of the D.S.M. is expected to be released in May 2013, and there has been a lot of controversy over the G.I.D. diagnosis. The A.P.A.’s Web site allows you to see the current G.I.D. criteria, as well as some of the proposed changes for the new edition. The group most active in opposition to the categorization of transgenderism as a mental illness is GID Reform Advocates.

One of the reasons for retaining the G.I.D. diagnosis in some form in the D.S.M. is that many people use the diagnosis to receive psychological services and medical care, such as hormones and surgery. In the medical field, diagnostic codes are very important for billing. In order to be reimbursed for assessment or treatment, health care providers must write down the suspected diagnosis along with its code.

While it’s obvious that our billing system is flawed, my guess is that it will not change anytime soon. There are health providers and researchers who argue that transgenderism should change from a psychiatric diagnosis to a neurological or endocrinological diagnosis. However, diagnoses outside of the D.S.M. are mostly derived from International Classification of Disease codes set by the World Health Organization and thus not up to American physicians alone, as the D.S.M. diagnoses are. (Interestingly and unfortunately, we set the worldwide agenda for psychiatric diagnosis).

I see the switch from a psychological to a neurological or endocrinological diagnosis as a reasonable alternative because it avoids the stigma of mental illness, but retains the access to care. Of course, many insurance policies explicitly deny coverage for medical treatment for gender-transitioning purposes anyway – regardless of diagnosis.

In my opinion, gender-variance is not a mental illness, but is instead a normal variation. We sometimes forget that just because something is less common, that does not mean that is it abnormal or unhealthy. Our ideas about gender norms and roles make it very easy for us to jump to the conclusion that those who don’t fit our stereotypes are mentally ill, but that is only because it is easier than challenging our own assumptions about gender. Long before we are born, the world is preparing for our entrance in blue or pink. When it takes inhuman strength to reject the innumerable labels and expectations placed on us based on our sex, is there something wrong with us or with society?

Intersex is the modern term for people we once called hermaphrodites – those whose bodies do not conform to the sexual binary. Examining the way we treat intersex people demonstrates how difficult it is for us to allow anyone to exist outside the two categories we have created. Even with evidence of many sexes, we continue to insist on just two. Until recently, many physicians attempted to erase intersex people by performing surgeries on them in early childhood and insisting that they choose a gender in order to fit in.

The D.S.M. is a measure not just of our scientific knowledge, but of social and cultural understandings at this particular point in history. That is to say, the D.S.M. is written by people, and therefore is influenced heavily by culture. Because our culture is so dependent on male and female gender roles, we have a very hard time understanding those who do not conform to these. Homosexuality and bisexuality challenge our cultural assumptions in much the same way, because they confront the expectations we have for the gender roles of men and women in sexual relationships. Homosexuality was categorized as a mental illness in the D.S.M. until 1973, when cultural changes convinced people that we had placed social norms before science.

I became a health care provider, and specifically a mental health provider, so that I could help people live healthy, productive and happy lives. Studies of transgender people so often seem to be about building theories around causes of transgenderism. More of our research should investigate how we can make life better for people who happen to fit in this category.