The American Psychiatric Association Issues Historic Position Statements on Trans Issues

Now don’t be sad
‘Cause two out of three ain’t bad
–Meat Loaf, 1977

On May 18, 2009, about 150 trans community members and allies gathered outside the Annual Meeting of the American Psychiatric Association in San Francisco to protest diagnostic policies that psychopathologize gender diversity. Bull horn in hand, I and others called upon the APA leadership to issue three public position statements in support of the dignity and health of trans and gender variant people:

1. That gender identity and expression which differ from assigned birth sex do not, in themselves, constitute mental disorder or impairment in judgment or competence.
2. That hormonal and/or surgical transition treatment, for those who need them, is medically necessary and should be covered by insurance and health care policies.
3. That the APA opposes discrimination on the basis of gender identity or expression and supports legal recognition of all people according to their gender identity and expression.

A month later, over 400 supporters endorsed a letter to APA President Alan Schatzberg and President-elect Carol Bernstein urging passage of these policy statements. The APA had, after all, issued numerous similar statements in support of other marginalized groups in past years but had never made a single position statement supporting civil justice and health care access for trans and gender variant people.

The response from APA officials was silence– three years of it.

Then last week, on August 16, the APA announced two of these position statements, authored by Drs. Jack Drescher and Ellen Haller and approved by votes of the Assembly and Board of Trustees. The first acknowledged the efficacy and medical necessity of hormonal and/or surgical transition treatment and the barriers to accessing this care faced by those who need it. Similar transition care policy statements were issued in 2008 by the American Medical Association, the American Psychological Association, and the World Professional Association for Transgender Health (WPATH).

Position Statement on Access to Care for Transgender and Gender Variant Individuals

Therefore, the American Psychiatric Association:

1. Recognizes that appropriately evaluated transgender and gender variant individuals can benefit greatly from medical and surgical gender transition treatments.
2. Advocates for removal of barriers to care and supports both public and private health insurance coverage for gender transition treatment.
3. Opposes categorical exclusions of coverage for such medically necessary treatment when prescribed by a physician.

The second position statement acknowledges harassment and discrimination that trans and gender variant people face in employment, education, parental rights and civil justice. It notes that trans people are frequently victimized in violent hate crimes and inappropriately assigned in gender-segregated facilities . Similar nondiscrimination statements were issued by the National Association of Social Workers in 1999, the American Psychological Association in 2008, and WPATH in 2010.

Position Statement on Discrimination Against Transgender and Gender Variant Individuals

Therefore, the American Psychiatric Association:

1. Supports laws that protect the civil rights of transgender and gender variant individuals
2. Urges the repeal of laws and policies that discriminate against transgender and gender variant individuals.
3. Opposes all public and private discrimination against transgender and gender variant individuals in such areas as health care, employment, housing, public accommodation, education, and licensing.
4. Declares that no burden of proof of such judgment, capacity, or reliability shall be placed upon these individuals greater than that imposed on any other persons.

Although the American Psychiatric Association lags years behind other leading medical and mental health associations in speaking out, these position statements represent an unprecedented shift in acceptance of human gender diversity by the APA leadership and membership. The background text to the discrimination statement notes:

In contrast to its strong affirmation of lesbian and gay civil rights since the 1973 decision to remove homosexuality from the DSM, APA has not issued position statements in support of transgender civil rights… Other organizations, including the American Medical Association and the American Psychological Association, have endorsed strong policy statements deploring the discrimination experienced by gender variant and transgender individuals and calling for laws to protect their civil rights .

The statement text reaffirms the role of advocacy in the APA mission: “ Speaking out firmly and professionally against discrimination and lack of equal civil rights is a critical advocacy role that the APA is uniquely positioned to take.”  Given the APA’s unique position in setting diagnostic policy that has been historically used to limit civil justice and transition care access for trans people, these position statements come far better late than never.

However, the APA statements fall short of debunking the false stereotype that gender difference is inherently pathological. The association’s ambivalence on the mental illness stereotype is reflected in the “Report of the American Psychiatric Association Task Force on Treatment of Gender Identity Disorder ,” published in June, 2012:

The Task Force could not reach a consensus regarding the question of whether or not persistent cross-gender identification sufficient to motivate an individual to seek sex reassignment, per se, is a form of psychopathology in the absence of clinically significant distress or impairment due to a self-perceived discrepancy between anatomical signifiers of sex and gender identity. 

In other words, this APA Treatment Task Force (a separate group from the DSM-5 Task Force) declined to refute the false stereotype of “disordered” gender identity. This is troublesome, because the proposed diagnostic criteria for the Gender Dysphoria category in the pending Fifth Edition of the APA’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5) continue to mischaracterize gender identities and expressions that do not conform to birth-assigned gender stereotypes as symptomatic of mental illness. By describing social and medical transition itself, or the desire for transition, as pathological, the new Gender Dysphoria diagnosis, like its controversial predecessor Gender Identity Disorder (GID), contradicts rather than supports the medical necessity of transition care that is affirmed in the new APA position statement. Even worse, the Transvestic Disorder category in the DSM-5 ascribes nonconforming gender expression and medical transition for many transsexual women and men to a defamatory false stereotype of sexual deviance and paraphilia. Ironically, the medical care statement acknowledges these contradictions in the DSM–

…the presence of the GID diagnosis in the DSM has not served its intended purpose of creating greater access to care–one of the major arguments for diagnostic retention .

Thankfully, there is evidence of change in attitudes toward gender diversity at the American Psychiatric Association. In 2010, the DSM-5 Task Force proposed to rename the widely despised Gender Identity Disorder title (intended to imply “disordered” gender identity) to Gender Incongruence and a further change in 2011 to Gender Dysphoria (from a Greek root for distress). These revisions were explained as a paradigm shift from diagnosing difference to a focus on incongruence or discrepancy that causes distress or impairment.

we have proposed a change in conceptualization of the defining features by emphasizing the phenomenon of ‘gender incongruence’ in contrast to cross-gender identification per se.

The APA Position Statement on Discrimination contains the APA’s strongest statement to date that gender difference is not disease:

Being transgender gender or variant implies no impairment in judgment, stability, reliability, or general social or vocational capabilities; 

The fourth bullet point of the APA Position repeats this key principle:

Declares that no burden of proof of such judgment, capacity, or reliability shall be placed upon these individuals greater than that imposed on any other persons. 

This particular wording is historically significant; it is paraphrased from a 1973 quote by Dr. Robert Spitzer, chief editor of the DSM-III and DSM-III-R, arguing to depathologize same sex orientation:

In the past, homosexuals have been denied civil rights in many areas of life on the ground that because they suffer from a ‘mental illness’ the burden of proof is on them to demonstrate their competence, reliability, or mental stability.

Throughout his career, Spitzer has refused to apply this same reasoning to the plight of gender variant and especially transsexual people, who continue to bear a very similar burden.

Though long overdue, these position statements on Discrimination and Access to Care for Transgender and Gender Variant Individuals represent a historic step forward in reducing barriers to civil justice and transition care access. But they do not go far enough in deconstructing false stereotypes that equate gender diversity with mental sickness and sexual deviance. In the context of the proposed gender diagnoses in the DSM-5 and the recent treatment task force report, they represent a mixed message. In contrast, the World Professional Association for Transgender Health issued an unambiguous De-Psychopathologisation Statement in 2010 that provides a model for professional organizations that serve trans and gender diverse people:

The WPATH Board of Directors strongly urges the de-psychopathologisation of gender variance worldwide. The expression of gender characteristics, including identities, that are not stereotypically associated with one’s assigned sex at birth is a common and culturally-diverse human phenomenon which should not be judged as inherently pathological or negative. The psychopathologlisation [sic] of gender characteristics and identities reinforces or can prompt stigma, making prejudice and discrimination more likely, rendering transgender and transsexual people more vulnerable to social and legal marginalisation and exclusion, and increasing risks to mental and physical well-being.

Please join me in thanking Drs. Drescher and Haller and the American Psychiatric Association leadership for these policy statements that acknowledge the worth and dignity of trans and transsexual individuals. In addition, I urge the APA to issue a position statement that gender identity and expression which differ from assigned birth sex do not, in themselves, constitute mental disorder; to correct diagnostic criteria in the proposed Gender Dysphoria category that malign gender nonconforming expression and transition itself as pathological; and to delete the punitive and scientifically capricious Transvestic Disorder diagnosis from the DSM-5.

Copyright © 2012 Kelley Winters, Ph.D., GID Reform Advocates