Last week, after President Trump announced his intention to ban transgender people from serving in the military in a series of tweets, the White House followed up this abrupt ill-considered decision by including an essay supporting the ban and pushing the view that transgender people are mentally ill in a daily emailed White House reading list. Although the Diagnostic and Statistical Manual of Mental Disorders and mainstream mental health professionals have shifted away from labelling transgender people as mentally ill, the belief that they are lingers in the public at large. Pre-existing biases towards people who fails to conform to societal gender norms combine with widespread ignorance about mental illness to form a particularly toxic combination, one that hurts trans people first and foremost, but also reinforces the widespread stigma towards those who are genuinely suffering from mental illness.
“Distress is the key to disentangling identity versus mental illness,” explained Dominic Sisti, an assistant professor in medical ethics and psychiatry at the University of Pennsylvania who runs the Scattergood Program for Applied Ethics in Behavioral Health Care. “With trans people there’s a confusion that feelings of gender mismatch are somehow unnatural or diseased, when in fact they’re not.” Sisti explained that distress is a “key necessary condition” for a condition to be considered a mental illness, and that being transgender by itself does not cause people to be distressed.
Gender dysphoria is the distress a person experiences when their physical, birth-assigned sex doesn’t match their inner sense of what their own gender is or should be. It replaced gender identity disorder in the DSM-V in an effort to shift the focus away from the incongruence between a person’s gender identity and their birth-assigned sex and onto the distress that this incongruence might cause. Not all transgender people experience gender dysphoria because not everyone feels pressured or conflicted over expressing their gender identity, and transitioning medically and/or socially usually relieves or significantly reduces gender dysphoria for those who do.
Eric Yarbrough, the director of psychiatry at the community health center Callen-Lorde, which serves the LGBTQ community in New York City, agrees that transgender people are not necessarily mentally ill: “I think there’s a lot of misinformation out there, people hearing opinions that are not based on research. If you look at the research you’ll see that once trans people are in a supportive environment, they tend to be pretty happy and not experiencing a lot of symptoms like anxiety or depression.” (For information about what current research on transgender health shows, a recent Reddit AMA makes a good starting point.)
“As part of my job as director of psychiatry, we have to do letters regarding gender confirmation surgery,” Yarbrough continued. “Those are always the easiest appointments because the majority of trans people don’t have a mental illness. I think mental health professionals who primarily work with very sick populations, they associate the two because any trans people they see are also going to be mentally ill. They don’t get to see a lot of the mentally healthy trans people who are out there living their lives.”
Both Sisti and Yarbrough emphasized that the psychiatric view is that transgender people can be as mentally healthy as anyone else—and that the increased risk of psychological distress among trans people is caused by prejudice against them and the stress and hardship that prejudice can cause. According to the 2015 U.S. Transgender Survey, 39 percent of trans respondents reported serious psychological distress in the month before completing the survey, compared to only 5 percent in the US population at large.
“I think a main problem is that there’s so much stigma against mentally ill people in general, people keep it a secret or resist getting care. Being trans does not mean you’re mentally ill, but you may still suffer like anyone else, and being LGBTQ in a place that’s not accepting can exacerbate symptoms like depression and anxiety as well,” Yarbrough explained.
For trans people who have also experienced mental illness, it’s common to see their symptoms as having been worse pre-transition and then improving as the trans person began to live as their true self.
“In hindsight, it’s very clear that a significant amount of my mental distress was caused by undiagnosed and unrecognized dysphoria,” said Billie, a 24-year-old trans woman who has suffered in the past from major depression, generalized anxiety disorder, and type 2 bipolar disorder. “A lot of my identity issues absolutely screamed gender dysphoria. I was begging to be heard and I didn’t know why, or what I wanted people to hear, but I feel that if the counselors and therapists I had seen had been better trained to recognize and diagnose dysphoria they would have helped me much, much earlier.”
Many cis people see the desire to transition as a sign of disorder and imagine that, in order to be mentally healthy, a trans person would need to learn to live comfortably as the sex they were assigned at birth. But trans people tend to believe the exact opposite—that living as the wrong gender made them anxious and depressed, and through transitioning to the right gender they were able to experience mental health. Research showing that mental health outcomes improve after transition supports this latter view up, while there is no evidence that any psychiatric treatment can turn a transgender person into a mentally healthy cisgender one.
For Billie, prejudice about mental illness combined with prejudice against trans people makes for a scary mix.
“I fear that a history of possibly unrelated mental illness will wrongly validate some people's opinions that I'm just making this up for attention, or … whatever the strange Machiavellian endgame of trans people is in the minds of bigots,” Billie told me. “I try not to concern myself with what they think, but it can be difficult when close-minded, hateful people seem to be on every corner. I think that both mental illness and the trans community are overdue for destigmatizing in the American consciousness.”