Co-authored by Ignacio Rivera
This weekend marks the seventh annual International Day of Action for Trans Depathologization, organized by trans activists and people around the globe who are working to confront gender injustice. The global trans movement has grown exponentially in the years since the campaign started, and the effort to move away from a pathology framework and toward one based on the affirmation of identity has been central to forging the path to liberation.
The difference between these two ways of thinking is simple but critical. In the pathology model, being trans (having an internal sense of gendered self that is fully or partially at odds with our sex assigned at birth) is seen as a birth defect, a mental illness, or another kind of medical condition. By contrast, the identity model suggests that being trans is a part of who some people are. It isn't something that needs a medical diagnosis, because there's nothing wrong with being trans. There are many parts of our identity that we don't talk about medically, like our personalities, our interests, and our sexual orientations.
Of course, it actually wasn't long ago that sexual orientation was caught in the same bind. The depathologization of homosexuality in 1973, when it was removed from the Diagnostic and Statistics Manual (DSM) of the American Psychiatric Association, and in 1990, when the same decision was made for the World Health Organization's International Classification of Diseases (ICD), is now almost universally regarded as a turning point in the movement to change hearts and minds about the basic humanity of lesbians and gay men in the U.S. Today, lesbians, bisexuals, and gay men are no longer positioned as sick and thus in need of, at best, pity or treatment. Rather, we are seen as a group that has been marginalized because of who we are, and one that is struggling against a discriminatory, often violent system.
But we also know that depathologization is fraught with obstacles. Within the U.S. context, where both basic rights and access to health care are often withheld based on gender identity, race, and income, the move toward depathologization threatens the most vulnerable trans and gender-nonconforming people in our communities. Securing basic health care and critical medications for all, but especially for incarcerated and impoverished trans people, is largely dependent on medical diagnoses that force the state into health care provision, irrespective of their views on trans identity.
So, ironically, the most progressive forces within the U.S. movement for trans liberation often find ourselves stuck in ambivalence, unable to join fully with the radical activists around the globe who call for an immediate end to pathologizing diagnoses in the approach to trans identity and trans-affirming care. Here in the U.S., as in many places, pushing the state to cover essential costs of trans health can be a complex dance that requires nuanced navigations of what we know about ourselves and our communities as well as what we must accept to get what we need.
This year's theme for the Day of Action is childhood diagnoses, and nowhere is this territory more contested than in the pathologization of transgender and gender-variant kids. Fervent advocates for children claim a need for retaining a "special" diagnosis for trans children. The "good guys" on the side of this debate are trans-affirming therapists and doctors who fear that the elimination of gender-incongruence diagnoses in children will leave trans kids to the vagaries of individual parents navigating a fraught, anti-trans culture. Unlike for adolescents and adults, for kids, getting a diagnosis does not grant access to otherwise often-out-of-reach trans-specific medical care. The "bad guys" are the usual suspects: anti-trans policy makers and medical personnel who are trying to block any affirmative path for trans children to grow into their genders.
The National Transgender Discrimination Survey (NTDS), the largest existing data set on anti-trans discrimination, found good reason to be concerned about the welfare of gender-variant children. Originally created by the National Center for Transgender Equality and the National Gay and Lesbian Task Force, the survey found that of 6,456 respondents, 29 percent said they had presented as gender-variant in school settings from kindergarten through 12th grade. Within that group, 78 percent said they had been harassed, 35 percent said they had been physically assaulted, 12 percent said they had been sexually assaulted, and 6 percent said they had been expelled from their schools because of their gender identity/expression.
Worse yet, many of these people experienced this abuse at the hands of their teachers. One of the most dramatic negative findings in the NTDS was the apparent correlation between teacher abuse in K-12 and the percentage of respondents who had attempted suicide. Of those who said they had been abused by their teachers for presenting as gender-variant in grade school, an astounding 76 percent reporting having tried to end their lives at some point.
This finding attests to the urgency of the battle for depathologization. An end to the pathology framework can have a significant impact on stigma and violence in a variety of institutional settings, from schools to sports teams, churches to the workplace. And most importantly, a key learning from the lesbian and gay movement is that depathologization can have a major impact on family acceptance; there has been nothing short of a revolution in consciousness, acceptance and the integration of gay and lesbian children in mainstream U.S. family life since the removal of homosexuality from the DSM and the ICD.
Participants in the National Transgender Discrimination Survey whose families accepted them reported better health outcomes and more affirming experiences in almost every setting, whether it be the doctor's office, the workplace, a taxi cab or an ambulance. Family acceptance appears to provide a powerful protective foundation against often-harsh exclusionary practices and conditions in the culture at large. Depathologization is often a first critical step for many non-trans people to reconsider and rethink their anti-trans assumptions about their children and their lives.
In conclusion, sick systems create sick families, and traumatized children often grow up only to face more trauma. Given all that we are already surviving, the promise of depathologization offers the possibility of health, vibrancy and a generation of gender-variant kids living their childhoods with families that love and affirm them. Even as we fight to keep coverage for trans prisoners and the most marginalized among us, we must keep in the foreground of our activist imaginations what our world could look like when we can move beyond illness.