Reality Check

Gender affirming mental health care has come a long way;  it's no longer the norm to  assume that transgender people are deviant at worst, deluded at best. Although it remains appropriately controversial that we even need a diagnosis to ensure access to care, the DSM V’s renaming of Gender Identity Disorder in 2013 was a step forward. Now Gender Dysphoria, the diagnosis at least recognizes that a gender independent person (the term is used by Jake Pyne) does not have an identity disorder, but experiences unbearable dissonance with the gender they were assigned at birth. A lot of potential for thinking more sensibly about what it means to be trans or non-binary is made possible by this conceptual shift.

But we still have an awfully long way to go. This is obvious if we look at the current noxious political climate and the backlashes against our gains it is enabling. It’s also obvious in the physical and emotional violence that continues to be perpetuated against trans communities, and by the targeted victimization of trans women of color especially. In fact, as I was getting ready to post this today, the Huffington Post published an article which details how hate crimes against LGBTQ people are the highest they have ever been, due to Trump’s election and the rhetoric he continues to use. Again, people of color bear the brunt, with over 70% of deaths last year suffered in those communities, according to the report.

It can be easy, in the Bay Area especially, amongst our wonderful, gender affirming colleagues, to also forget the ways in which the members of the mental health establishment are still often reactive, ignorant, or unreconstructed. I recently came across an infuriating example of an article that takes the gains that have been so painstakingly made, and tries to recast them as the tainting of apparently objective scientific thought by a wrong-headed concern with human rights.

Last year, the Journal of Sex & Marital Therapy published an essay by Stephen B. Levine entitled, “Ethical Concerns About Emerging Treatment Paradigms for Gender Dysphoria.” Levine is a psychiatrist who has been involved in formulating rules for best practices and diagnosing gender-related issues. He’s well-known as an expert on human sexuality and gender. In this recent paper, Levine developed an argument he made in the same journal almost 10 years earlier (the citations are provided at the end of this post, for those who are interested). Both papers argue that there is a difference between a discourse of civil rights, designed to advance claims of personhood in a culture, and clinical pathology that needs to be named as such, and not subverted to a political cause. 

In the earlier paper, “Meanings and political implications of ‘psychopathology’ in a gender identity clinic: A report of 10 cases,” published in the Journal of Sex & Marital Therapy in 2008, Levine and his co-writer begin by asserting that an, “Emphasis on civil rights is not a substitute for the recognition and treatment of associated psychopathology” (2008, p. 40). They write about how patients “unknowingly disrespect the professional” when they “announce, ‘I am a transsexual,’ urgently want hormones, and impatiently threaten the doctor to go elsewhere” (Levine and Solomon, 2008, p. 51). They say that this political pressure is one reason professionals facilitate transitions instead of more properly treating the desire to transition as part of a profile of mental health co-morbidities.

Another reason is “the” transgender community’s (as though there were only one) rejection of psychiatry’s need to categorize. In a reductive representation of a complex debate, Levine and Solomon defend the necessity of the concept of a diagnostic category, and object to the “outrage” of advocates and community members about the necessity of a diagnosis for (what was then called) gender identity disorders: “Not only does this complicate productive dialogue between lay and professional audiences, it skews what is publicly said about these problems” (2008, p. 41). The very presence of transgender voices in a discussion about how they are understood by the profession is understood as confusing and problematic. If transgender people are allowed the right to articulate their own identities, this is wrong-headed political correctness at work. There are transgender rights, and then there is good clinical practice, and by definition, according to Levine and Solomon, they are opposed to each other.

Levine and Solomon’s “gender professional” is a bemused cisgender doctor, helplessly caught between the ethical desire to do no harm and the tantrums of confused, co-morbidly ill patients and the politicized imperatives of a crazy discourse of human rights. They appear not to consider the growing number of professionals who are also transgender or gender non-binary, and whose experiences are arguably the best place to begin looking for answers to the issues that bother Levine about gender affirmative care: that political imperatives skew clinical judgement in this arena. “When organizations mix audiences of the transgendered [sic] and professionals, professionals are not free to have an in-depth discussion of the issue. Social forces then conspire to create a gender identity problem that is not a pathology” (2008, p. 45), he and Solomon write. Implicit in this presentation of the problem is the belief that “professionals” should – indeed, to properly do their job need – to be left alone in peace to talk about the people they claim to listen deeply to. Explicit is the assertion that gender identities that are not cis are pathological.

And Levine’s thinking clearly hasn’t changed in the decade between this paper, and the one I read last year. Ten more years he has been working with transgender people vulnerable to his professional power. A decade of disrespecting the things they say about their own experiences:

"Gender incongruence or gender dysphoria could be viewed as something closer to mental illness than mental health. From a life course perspective, there is a vast array of cisgender adaptive possibilities that become increasingly apparent over time to males or females. Transgender narratives about their true identity are based on stereotypes. Equally important, if not more so, is that perceptions of the retreated-from gender are also based on stereotypes… To cis adults, these stereotypes are often offensively oversimplified notions that signify aberration if not mental illness" (2017, p. 7).

Where is the evidence that there is a generalizable pattern to “transgender narratives”? Where are the studies that show that “cis adults” (what, all of us?) are offended by said monolithic constructions? Stating something as though it were true does not make it true. Making claims in a scientific journal with no evidence is to pretend that assertions and assumptions should be underwritten by the profession just because someone who says he is a gender expert decides to make them. In fact, over the past ten years, actual research suggests the exact opposite: that if we believe the things gender independent people say, and we support them, they live happy and healthy lives (see, for just a few examples, De Vries 2014; Ehrensaft 2016; The Family Acceptance Project; Hembree 2013; Hidalgo 2013).

Levine’s evidence, if such it is, for the idea that the need to transition is pathological, lies in the list of difficulties someone is likely to face as a transgender person. He provides an appropriately scientific-looking table of “potential negative consequences” of transitioning (2017, p. 5). These include:

"Emotional distancing and isolation from family with eventual persona non grata status with married siblings with children; Exchange of friends for friends from the trans community; Greatly diminished pool of individuals who are willing to sustain an intimate physical and loving relationship with you; Become of sexual interest to a special group of men who are interested in your trans status; Eventually being neither male nor female… being in the category of trans rather than simply a man or a woman;… Higher death rates; The larger world will always regard you with suspicion."

The obvious rebuttal is that the cause of pathology here is transphobia. Levine knows this. “Stigma may not be the sole explanation for the repeated observations of adaptive disadvantages, adverse outcomes, and shortened life spans of trans individuals” (2017, p. 9), he writes. Maybe not. But insinuation is not scientific evidence; and the scientific evidence that does exist suggests that stigma (and prejudice, oppression, exclusion, and violence) is a significant part of the explanation of why many transgender individuals struggle with some mental health issues. In addition, many transgender people live loving, happy, and fulfilled lives. “Declaring trans identity as a healthy choice does not make it so” (2017, p. 9), Levine insists. But declaring it by definition an illness does not make it so either, and declaring it a choice is ignorant and disrespectful.

The number of people, including youth, identifying as transgender, non-binary, or other terms indicative of a gender expansive identity is on the rise. This is not because a discourse of human or civil rights has overtaken clinical common sense, as Levine suggests. It also does not correlate with an increase in mental illness in this population, as his argument would lead us to believe. Instead, some cultural space is finally being made for the truth of gender identity as fluid and not necessarily binary.

Transgender and non-binary children, youth, and adults who are unable conform to the binary gendered rules of Western society are not mentally ill. However, they are particularly vulnerable to punitive policing of their bodies, minds, and senses of self, especially now. Given these vulnerabilities, it is not surprising that the incidence of poor mental health outcomes is high within these groups. The antidote to this scale of mental, emotional, and socio-economic suffering is a gender affirmative understanding of the lives of transgender people – not irresponsible stigmatizing statements and counter-transferential acting out on the part of cisgender providers. And in this current political climate, such prejudice is complicit in the increase in violence being perpetrated against transgender people, as well as other folks who subvert heteronormative gender and its assumptions about sexuality by being LGB or Q.


Works Cited

De Vries, A. L. et. al. (2014). Young adult psychological outcome after puberty suppression and gender reassignment. Pediatrics. 134(4):696-704

Ehrensaft, D. (2016). The gender creative child: Pathways for nurturing and supporting children who live outside gender boxes. New York: The Experiment. 

Family Acceptance Project.

Hembree, W.C. (2013). Management of juvenile gender dysphoria. Current Opinion in Endocrinology, Diabetes and Obesity 20(6): 559-64.

Hidalgo, M.A. et al. (2013). The Gender Affirmative Model: What We Know and What We Aim to Learn. Human Development. 56. 285-290.

Levine, S.B. (2017). Ethical concerns about emerging treatment paradigms for gender dysphoria, Journal of Sex & Marital Therapy, 0(0), 1-16. 

Levine, S.B. & Solomon A. (2008). Meanings and political implications of ‘psychopathology’ in a gender identity clinic: A report of 10 cases, Journal of Sex & Marital Therapy 35(1), 40-57.

Pyne, J. (2014). Gender independent kids: A paradigm shift in approaches to gender non-conforming children. Canadian Journal of Human Sexuality 23(1) pp. 1–8.