There has been a lot of talk about the depathologisation of transsexualism recently, including mentions of a petition to the ‘World Health Organisation’ to have it removed from the ICD11. Interestingly, the trans community appears to be divided on the subject with many being behind the move as they feel that they are not mentally ill and so should not be treated as such, whilst others are against the move fearing the affect this might have on their access to treatment – especially those in countries with socialised healthcare systems (such as the NHS).
As both a healthcare professional and as a member of the transgender community, I am firmly against the depathologisation of transsexualism for precisely this reason. I feel that in a world where it is necessary to fight for treatment – as I did – despite the fact that it is included within publications such as the ICD and DSM, depathologisation would make it nigh on impossible for someone to access the care they need. However, I also do not feel that transsexualism (as it is currently called clinically) should be perceived as a mental illness.
There is an important yet subtle distinction between depathologisation and reclassification of the condition from psychiatric to another more suitable heading. Depsychopathologisation – as this process is known – has actually been called for by the ‘World Professional Association for Transgender Health‘, whilst outright depathologisation has not. Similarly, it is worth noting that several western governments have also already stated that they will no longer consider transsexualism to be a mental illness; most notably the British government in 2002, the French government in 2009, and the European Parliament in 2011.
It seems fair to say that progression is forthcoming and has been for some time. As such, as a community we no longer need to be asking whether we are getting anywhere, but rather whether we are heading in the right direction. Whilst it might be tempting to follow in the footsteps of our friends and allies within the Lesbian and Gay Communities by setting our sights on outright depathologisation, I fear this would be incredibly foolish. After all, although our communities face many of the same trials and tribulations there is a key distinction; we are seeking medical intervention as a consequence of our identity.
A number of people have taken to attempting to construct parallels between pregnancy and transsexualism, in an attempt to highlight the fact that medical intervention can be routinely given for something that is not recognised as a medical condition. Whilst I do not deny that pregnant women receive medical attention, it is important to note that this would be best described as ‘watchful waiting’ rather than ‘active intervention’. This is to say that the care given during pregnancy is preventative in nature, designed to bring down what has traditionally been a very high mortality rate. Meanwhile, the treatment given in transsexualism aims to correct a diagnosed underlying condition.
Pregnant people are provided with dietary advise, medical imaging and easy access to specialist practitioners so that any problems which might arise are caught early and dealt with. Additional treatments are reactive in nature and there is no definitive pathway in terms of intervention. In fact, I would go so far as to state that the treatment provided is not for the pregnancy itself, but rather for the numerous health conditions which are associated both with foetal development and with the additional strain which pregnancy puts on the body. This is completely different to the treatment of transsexuality in which – following the standard series of assessments – there is an almost standardised linear treatment pathway of hormonal and then surgical intervention.
So, why is transsexualism even classified as a psychiatric condition to begin with? The simple answer is that it’s not so much due to the condition itself, but rather the differential diagnoses which it needs to be distinguished from. In short, these can be classified into the two categories; intersex conditions and delusions. The former should be excluded by karyotyping* (i.e. chromosomal analysis) whilst the latter can only be excluded through psychiatric assessment. Since, from a clinical perspective at least, the intervention of a psychiatrist is required it would be sensible to classify the condition as being psychiatric in nature, in spite of a lack of evidence that this is the case.
I’m certain that a number of people reading this article will question why the intervention of a psychiatrist is needed at all. If I know – and am certain – that I am a gender other than that which I was assigned at birth, then why does this need to be confirmed by a member of the medical community? After all, a small number of hour-long interviews can never give a true representation – or even a representative cross-section – of the underlying cognitive processes of something as complicated as a human being. Especially with regard to something as subtle as gender dysphoria, or anything based on a complex amalgamation of nature, the products of socialisation and of the perception of both the self and of gender roles within society, right?
I feel that the role of the psychiatrist is largely misinterpreted within the transgender community. Yes, this might be down to individual experiences of psychiatrists who take a more domineering or controlling role than maybe they should, or even a general distrust of psychiatrists or doctors in general. However, the fact of the matter is that in the case of transsexualism the role of the psychiatrist is akin to a safety net. The issue with surgical intervention and, to a lesser extent, hormonal intervention is that the effects are [largely] irreversible and – as such – have the potential to do a great deal of harm if left without proper regulation. As such, it would a failure in the duty of care of the medical profession at large if this ‘safety-net’ was not in place. Although some might argue – and have experienced – otherwise, the role of the psychiatrist in the treatment of transsexualism should not be one of a gatekeeper, but rather that of a concerned ally assessing your certainty so as to ensure you do not do irreparable damage to your life. This might not be the case in all practice; but should be the case in best practice.
This places transsexualism in the unique position where it is a non-psychiatric condition which requires psychiatric intervention so as to ensure that the medical profession can still fulfil their ‘duty of care’ prior to involving the endocrinologist or urogenital surgeon. The obvious question which arises therefore is under which heading – if not psychiatric – should this condition be classified? Neurobiological? Endocrine? Surgical? Other? Moreover, which of these headings actually have distinct sections within the ICD?
Personally, I would suggest it be reclassified as a form of intersex condition. Yes, there may be no evidence to suggest that it should be treated as such but there is little to no evidence which would suggest it should fall neatly into any other category either; psychiatric included.
*In reality this is not usually undertaken due to the costs associated with karyotyping. Moreover, it could be argued that actually performing a karyotype would be a waste of resources since it would not affect the underlying dysphoria or alter the treatment pathway.
Edited 21/10/12 to include references. Apologies for the delay – I was having issues with my internet connection.