One problem with conceptualizing mental disorders is that the disorder is thought to reside within the individual, but we all exist within the context of our culture. A dysfunctional culture, however, will try to marginalize those who are mentally healthy enough to go against the flow regardless of the social penalties.
For example, in 1851 Dr. Samual Cartwright claimed that runaway slaves suffered from drapetomania, a mental disorder characterized by a desire for freedom. Yet, autonomy is a basic desire of all people – it’s hardwired into our brains.
In 1973 the American Psychiatric Association removed homosexuality from the Diagnostic and Statistical Manual of Mental Disorders (DSM) because there’s no scientific evidence that being lesbian or gay is pathological. Rather, it’s society’s prejudice that creates emotional conflicts for those who are not heterosexual.
I took psychopathology as a college student in the mid-1990s and was assigned a fifteen page term paper. Everyone else in the class chose well known mental disorders such as schizophrenia, bipolar, depression, and anxiety. I wanted to write about something no one else did, so I combed through DSM-IV (the fourth revision of the manual, published in 1994) and found gender identity disorder.
It had never occurred to me that a person could feel trapped in a body of the wrong sex.
I was also surprised by the lack of research. Most of what I found were outdated Freudian theories about unresolved Oedipal and Electra Complexes. Basically, it’s all your mother’s fault. Except that stories of transgender individuals often contained a common element: around age three or four, when children learn the concept of gender, a biological female knew he was male in a rather matter-of-fact way and couldn’t understand why no one else could see that. But this is not what you’d expect if the child’s demented mother unconsciously were trying to re-socialize the toddler as male.
There were some scientists who speculated that self-perception of sex is hardwired in the brain, and this hardwiring occurs during pregnancy when various features each have their critical period of development. They wondered if non-average levels of sex hormones during a certain phase of gestation could result in a female fetus developing a male brain, or vice-versa. Even today the question has yet to be definitively answered.
I should point out that genetically, XX and XY are not the only possibilities – there’s XXYY, XXXX, XXXY, and so on. This doesn’t necessarily relate to transgender, though sometimes it pertains to intersex individuals. And it’s important to realize that intersex and transgender are distinct.
In my paper, I concluded that more neuro-biological research needs to be done, and if evidence for a biological basis mounts then gender identity disorder should be removed from the DSM.
This was a cautious conclusion. Homosexuality was removed from the DSM even without definitive evidence of a biological basis. It was enough to show that gays and lesbians do not suffer from mental illness at a rate greater than heterosexuals (after controlling for distress related to living in a homophobic culture).
After college I found a job and ended up working with a transgender individual. This person made the theoretical real. Having tried everything to become the gender that would match the genitalia, having succeeded only in causing more distress, then turning to hard drugs for self-medication with resulting medical and legal problems, and suicide attempts, this person finally decided to accept it and found peace.
At that same time I had a friend who had been out as a gay man since his freshman year of college. One day we were discussing scientific attempts to prove a biological basis for homosexuality. He said the question was a distraction in many ways. Even if it’s nurture rather than nature, it becomes indelible early on. The notion that being gay is only legitimate if it’s biologically based struck him as homophobic.
That’s when I decided the same is true for being transgender (which is distinct from sexual orientation). Why is an interesting question, but it’s not central. DSM-V was published in 2013, and gender identity disorder has been replaced with gender dysphoria. The American Psychiatric Association states, “gender nonconformity is not in itself a mental disorder. The critical element of gender dysphoria is the presence of clinically significant distress associated with the condition”.
This is a move in the right direction. And greater societal acceptance is key to reducing “clinically significant distress”.
Society didn’t used to question what it means to be a man, but with shifting gender roles this has become a big question. However, society has always demanded that you prove you’re a man. And this can lead to some clinically significant stress and problematic behaviour.
How does a transgender man prove he’s a man? He shouldn’t have to. No one should have to. You’re a man because you say you’re a man. And there are myriad ways of being a man.
Gay men and trans men are outside the man box. But so are a lot of cis-gender heterosexual men. The latter, however, lack societal permission to be outside the box. We can change that.
A final thought. There are some awesome parents out there who listen to their transgender children and support them. The Whittington family posted a Youtube video showing how they support their son. An obvious question is: What happens when the child hits puberty? Hormone therapy can be tailored specifically for children, as Norman Spack explains in a TED Talk.