Gender Identity Debate: When Reality Causes Distress

The American Psychiatric Association (APA) has published the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Among the changes is the creation of a new diagnostic class — "Gender Dysphoria" — which replaces "Gender Identity Disorder." "Gender Dysphoria" is defined as:

"A marked incongruence between one’s experienced and expressed gender and assigned gender … a strong desire to be of the other gender or an insistence that one is the other gender (or some alternative gender different from one’s assigned gender)."

Although the explanation for the changes at the end of the volume doesn’t specifically mention it, in the introduction, the authors explain that "patients, families, lawyers, consumer organizations and advocacy groups have provided feedback, and one of the goals of their participation was to ‘reduce stigma.’"

A blog by "transgender" activist Kelley Winters organized supporters of changes in the DSM, arguing that the diagnosis of Gender Identity Disorder imposed the "harmful stigma of mental illness and sexual disorder on gender-variant and nonconforming children" and described transition from one’s birth sex to the other sex as "symptomatic of pathology" (April 2010).

Many of the changes proposed by the transgender activists found their way into the DSM-5.

This is not the first time that the APA has negotiated with clients. In 1973, the APA removed homosexuality from its manual of mental disorders. In his book Homosexuality and American Psychiatry: The Politics of Diagnosis, Ronald Bayer, who supported the decision, wrote:

"The result was not a conclusion based on an approximation of scientific truth as dictated by reason, but was instead an action demanded by the ideological temper of the times."

According to Bayer, it was "undeniable" that "the American Psychiatric Association responded to the concerted pressure of an angry, militant movement that had made full use of coercive and intimidating tactics."

Those familiar with the tactics and thinking of activists can see their influence in this new definition. The so-called transgender community views the identification of a baby’s sex by observation and the community’s reinforcement of the child’s sexual identity as an arbitrary and oppressive "assignment," not as the recognition of the reality of sex difference.

The inclusion of "some alternative gender different from one’s assigned gender" gives recognition to the "GenderQueer" movement, which is growing in influence. The GenderQueer reject the binary division of persons into two sexes. They want the freedom to be either, both or neither, depending on their mood.

According to Riki Wilchins, writing in GenderQueer: Voices From Beyond the Sexual Binary: "Gender is the new frontier: the place to rebel, to create new individuality and uniqueness, to defy old, tired, outdated social norms, and, yes, to occasionally drive their parents and sundry other authority figures crazy."

Another major change is the replacement of sex with gender. According to the explanation of changes in DSM-5: "Gender instead of sex is used systematically because the concept ‘sex’ is inadequate when referring to individuals with a disorder of sex development (those born with genetic or congenital abnormalities)."

Many use the words "sex" and "gender" as though they were synonyms. In the past, "sex" referred to the totality of what it means to be male or female; "gender" was a grammatical term. Certain words can have gender — male, female or neuter.

However, in the 1950s, a new definition for "gender" was introduced.

"Gender" was redefined to refer to the sex a person identifies with — either male or female — and "sex" is restricted to the biological reality. Thus, according to this theory, a person whose biological sex is male could have a female gender identity and vice versa. And since gender was detached from the reality of biological sex, a person could change his or her gender or adopt an alternative gender.

The APA has also altered its definition of "mental disorder." One might assume that a person who ignored the obvious biological evidence and insisted that he or she should be or actually was or could become the other sex was suffering from a mental disorder — a failure to live in reality. However, according to the definition of "mental disorder" in the DSM-5, in order for a person to be diagnosed with a mental disorder and be a candidate for therapy, the person must suffer from distress and impairment.

"Distress" is defined as anxiety, obsessions, guilt or shame. If believing that one is the other sex does not cause distress, then, according to this definition, the person does not have a mental disorder.

Although the DSM-5 does not prescribe the kind of therapy appropriate for each diagnosis, this insistence that distress be present in order to classify a mental state as a disorder presents a problem in the area of gender dysphoria, as well as in several other areas.

Should the goal of therapy be the removal of distress by helping clients to accept the biological reality of their sexual identity or should the distress be eliminated by pretending that gender-dysphoric persons are the other sex?

According to the DSM-5, distress may not be manifest in social environments supportive of the child’s desire to live in the role of the other gender and may emerge only if the desire is interfered with.

The implication is that, since interfering with the desires of gender-dysphoric people will cause distress, society should be supportive of their desire to live as the other sex.

Not everyone agrees with this. Dr. Paul McHugh of Johns Hopkins University, after commissioning a study of the outcomes of so-called sex-change operations, ordered the procedure halted. He wrote:

"I concluded that Hopkins was fundamentally cooperating with a mental illness. We psychiatrists, I thought, would do better to concentrate on trying to fix their minds and not their genitalia.

"As for the adults who came to us claiming to have discovered their ‘true’ sexual identity and to have heard about sex-change operations, we psychiatrists have been distracted from studying the causes and natures of their mental misdirections by preparing them for surgery and for a life in the other sex. We have wasted scientific and technical resources and damaged our professional credibility by collaborating with madness rather than trying to study, cure and ultimately prevent it."

When alleviation of distress by supporting a person’s cross-sex desires is the chosen therapeutic model, such alleviation of distress comes at a high cost, both to the individual and to society. So-called transgender activists are already demanding that gender identity and expression be added to anti-discrimination laws. They accuse anyone who refuses to affirm a person presenting as the other sex of discrimination, transphobia, bigotry and/or a hate crime.

Speaking the truth, such as calling a man a man in spite of cosmetic or surgical alteration, could be criminalized. Schools are being forced to allow boys to come to school as girls and use the girls’ bathroom and play on girls’ teams.

Forcing other students and staff to pretend that a student is other than his or her birth sex is a violation of those students’ and staffs’ freedom of thought and religion.

The Catholic Church does not accept that people can change their sex. Baptismal records cannot be altered. People claiming to be the other sex cannot marry. Women claiming to be men cannot be ordained.

Activists have also been part of the movement to criminalize therapy designed to alleviate gender dysphoria by helping children accept their true sexual identity. Such laws have already passed in California and New Jersey.

While those who are gender dysphoric insist that the only solution to their distress is a society that supports their cross-sex desires and permits hormonal and surgical interventions, total acceptance may not solve their problems. Those who try to live as the other sex often sacrifice reproductive capability and sexual sensitivity.

According to Walt Heyer’s 2013 book Sex Change — It’s Suicide, they will have to live a lie, not telling sexual partners they were born the other sex, or risk rejection if they reveal their biological sex. Surgical interventions are painful and carry risks. Regret is not unknown.

Starting hormone treatments in adolescence can cause permanent changes in the body, even though only in a small percentage of children with gender dysphoria does the condition persist.

The male-to-female transgendered are more likely to be HIV positive than any other group. According to the DSM-5, persons with gender dysphoria are at high risk of suicide attempts and suicide. The "Injustice at Every Turn" study by Jaime Grant et al found that 41% of transgendered persons have attempted suicide, many succeed, and, according to the DSM-5, even after gender reassignment, "suicide risk may persist."

This may be because, after transitioning, they realize that, after all they have sacrificed, they are still only imitations of the other sex.

Dale O’Leary is a freelance writer and lecturer and the author of

One Man, One Woman: A Catholic’s Guide to Defending Marriage.

She currently lives in Florida.