Recently there’s been a fair bit of discussion about the changes being made to Gender Identity Disorder (now, as it it seems it will become, Gender Dysphoria) in the DSM-V, the Diagnostic and Statistical Manual used by American psychologists (as well as some from other countries). This renewed discussion has brought up an issue that has come up many times over the years, that of removing diagnoses related to transsexualism from the DSM. I’m going to address one of these arguments, and why I don’t think it really holds up.

Essentially, this argument can be summed up as that transsexualism is a physical disorder rather than a mental one, and should be removed from the DSM on that basis. This statement is generally backed up by one of a couple reasons. The first of these reasons is that studies (most commonly Zhou et al., a study that looked post-mortem at transsexual and cissexual brains) show that transsexualism has a physical cause, and thus it is a physical disorder. The second is that the brain is the arbiter of gender, and so a body that differs from it is disordered, meaning the problem with transsexualism lies with the body rather than the brain.

Though these are both important points, they fail to hold up in this case. First of all, though there are many issues with Zhou et al., which I will address at a later date, let us assume that it shows that there is a usually a clear physical correlate for transsexualism, and further let us make the logical leap that this physical correlate is in fact some sort of cause for transsexualism. Even assuming this, it’s still unreasonable to conclude that transsexualism is therefore a “physical disorder”. Every disorder in the DSM has a physical correlate in the brain, and we can assume this even if we haven’t actually found it since everything that has any mental consequences whatsoever (from schizophrenia to deciding to eat ice cream one day) has a physical correlate in the brain. In many cases, such as depression or ADHD, the specific neurobiological correlates are better characterized than in transsexualism, with larger sample sizes and effects that can be measured adequately in the living. So, a neurobiological correlate isn’t sufficient to consider something to not be “mental”.

Second, there is the argument, which I believe to be more compelling, that the body is disordered rather than the brain, and so therefore the disorder is physical. This is sometimes phrased as saying that since the treatment is physical, transsexualism is a physical disorder. This still fails to hold up for me as a reason for removal from the DSM, because even if it is the body that is disordered, the only way that this could actually be discovered is through communicating with the patient – that is, through a mental diagnostic process. Now, at this point, you might be objecting – “but if there’s a physical cause to transsexualism, can’t that be measured instead?” The issue with this is that even though there might be a physical cause in nearly all the cases, wherever they do disagree, it would be cruel or unusual to deny or administer the person treatment based merely on a brain scan. Therefore, the person’s self identification, and therefore, ultimately, their mental state, has to always be the gold standard for diagnosis. Since the DSM is a diagnostic manual (rather than a treatment guide), the -diagnostic- character of the condition has to take precedence, and since transsexualism can only ever be diagnosed mentally, it will remain a mental disorder for the purposes of the DSM (even if it retains a physical treatment, along with depression, schizophrenia, and other established mental disorders).

Finally, some people argue that transsexualism should not be considered a mental disorder because that might stigmatize trans people by lumping them in with other people who have mental illness. This is an excellent argument for having a blank DSM, since -everything- in the DSM could potentially be stigmatized for being in a book of mental illnesses. In logical terms, this is the fallacy of special pleading. The proper response to this is to fight the stigma surrounding mental illness, not to argue on completely arbitrary terms that specific disorders should be deleted from the book by virtue of the fact that being in the book causes stigma. This, I think, is both the weakest argument and the true motivation of many people who want transsexualism out of the DSM.

I just thought I’d share my thoughts on this, and I know I’ve left a lot of things untouched, but I’d be eager to hear thoughts on this and address the remaining issues in another post. In particular, I haven’t addressed why I think transsexualism is a “disorder”, but that topic is big enough to justify its own post.