Not mad. Not bad. Just normal.

There isn’t a single day when I don’t see somebody claiming that trans people are mentally ill and/or degenerates. Here’s some geniuses from this morning.

A huge problem is that public awareness of trans people – and of what the medical consensus is about trans people – is incredibly out of date.

For a long time, normal human variety and behaviour has been pathologised – that is, labelled as a medical problem when it isn’t.

A good example of that is in the pathologisation of women. In the Victorian era, women who rebelled against domesticity could be labelled insane and thrown into asylums. Doctors considered women to suffer from an invented condition called “hysteria”, a condition that should be cured by finding a husband. In the 1950s, women were routinely sedated to deal with their unhappiness. In the 1960s and 1970s, feminism was considered by many to be a medical problem.

And that’s before we get to the queer folk. In the US, homosexuality was classified as a medical condition until 1973. It isn’t, of course, but the supposed science was based on gender beliefs about the supposedly essential qualities of men and women. To put it simply, if you weren’t a manly straight man or a girly straight girl there was clearly some sort of medical problem.

The treatment was harsh. Some people were given electro-shock therapy, a practice that continues in China to this day, or aversion therapy, or other supposed cures that caused great damage.

The Bible of psychiatric conditions for US doctors is the Diagnostic And Statistical Manual, or DSM for short. It’s a reference manual produced by the American Psychiatric Association (APA) and its first two editions included homosexuality. The APA was very resistant to improved scientific knowledge because it contradicted its members’ beliefs that gay people had a “degenerative” condition.

American psychiatry mostly ignored this growing body of sex research and, in the case of Kinsey, expressed extreme hostility to findings that contradicted their own theories.

Some gay activists were complicit in this.

…some mid-20th century homophile (gay) activist groups accepted psychiatry’s illness model as an alternative to societal condemnation of homosexuality’s “immorality” and were willing to work with professionals who sought to “treat” and “cure” homosexuality.

It’s easy to condemn now, but “be nice to them, they’re mental” was a step forward from “throw rocks at them, they’re perverts”.

Eventually, though, science won: fact beat faith, and homosexuality was no longer a medical condition in the DSM III onwards – although it remained a “sexual orientation disturbance” until 1987. Nevertheless, “APA’s 1973 diagnostic revision was the beginning of the end of organized medicine’s official participation in the social stigmatization of homosexuality. Similar shifts gradually took place in the international mental health community as well.”

There was a wider context to this: the World Health Organisation’s International Statistical Classification of Diseases and Related Health Problems, ICD for short. In 1948, the WHO published version six of the ICD, ICD-6, which classified homosexuality as a “sexual deviation”.

The ICD listed homosexuality as a mental disorder until 1992.

Most people understand that gay people are perfectly normal, but until very recently the official medical literature said otherwise. And that legitimised hatred.

As a result [of removing homosexuality from the DSM and ICD], cultural attitudes about homosexuality changed in the US and other countries as those who accepted scientific authority on such matters gradually came to accept the normalizing view. For if homosexuality was no longer considered an illness, and if one did not literally accept biblical prohibitions against it, and if gay people are able and prepared to function as productive citizens, then what is wrong with being gay? Additionally, if there is nothing wrong with being gay, what moral and legal principles should the larger society endorse in helping gay people openly live their lives?

The result, in many countries, eventually led, among other things, to (1) the repeal of sodomy laws that criminalized homosexuality; (2) the enactment of laws protecting the human rights of lesbian, gay, bisexual and transgender (LGBT) people in society and the workplace; (3) the ability of LGBT personnel to serve openly in the military; (4) marriage equality and civil unions in an ever growing number of countries; (5) the facilitation of gay parents’ adoption rights; (6) the easing of gay spouses’ rights of inheritance; and (7) an ever increasing number of religious denominations that would allow openly gay people to serve as clergy.

Most importantly, in medicine, psychiatry, and other mental health professions, removing the diagnosis from the DSM led to an important shift from asking questions about “what causes homosexuality?” and “how can we treat it?” to focusing instead on the health and mental health needs of LGBT patient populations.

Guess what? The DSM and ICD also pathologised trans people. The DSM detailed “gender identity disorder” until 2013, when DSM-5 reclassified it as “gender dysphoria” – not perfect, but better.

The widely circulated belief in a made-up condition called Autogynephilia (short version: trans women are either narcissists or confused gay men; as ever, trans men aren’t given much thought) has been thoroughly debunked; being trans is not considered a mental illness in the DSM any more: the problem isn’t being trans, but the distress that comes from trying not to be.

The same thing is happening with the ICD. As the WHO announced last year, “transsexualism” is being removed from ICD-11 – so the diagnosis I have, of “transsexualism male to female ICD10 F64”, will be consigned to the history books. The change was ratified this month by the Assembly of States of the WHO.

As with the DSM, some concerns remain (not least whether US insurers will continue to pay for trans people’s transition-related healthcare).

Here’s the Council of Europe Commissioner for Human Rights.

While the removal of gender identity from the list of mental illnesses is a positive step, several concerns remain with the ICD11, and I call on WHO member states to continue improving the text to promote respect of human rights.

Such concerns include the term “gender incongruence” retained in the ICD11 which may lead to interpretations suggesting abnormality, as well as the continued listing of gender incongruence in childhood in the ICD.

I particularly regret that no progress was achieved in the ICD11 toward depathologisation of intersex people, and that terms such as “sex development disorders” continue to appear in the text. Language in the ICD Foundation suggesting sex “normalising” surgeries remains, which is of major concern.

As with the DSM, it’s not perfect, but it’s better. As the Commissioner says:

The pathologisation of trans people has served to justify serious violations of their human rights over the years, including attempts to “cure” them through conversion or reparative therapies; psychiatric evaluations, and sterilisation. In many countries, legal gender recognition is only possible upon medical diagnosis.

Science, knowledge and understanding isn’t a fixed point. We now know that feminist women are not hysterical or insane. We know that you can’t pray the gay away or make people straight by electrocuting them. And we know that being trans isn’t an illness.



, ,