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The End of Transgender as a Mental Illness

Trans persons are no longer classified by the medical community as mentally ill, this decision coming 39 years after homosexuality was declassified as a mental illness. I have been involved in many civil rights campaigns, but as a physician, none has mattered more to me than this one.
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The march forward for trans civil rights proceeds apace, its momentum unflagging. It was one year ago this week that Judge William Pryor of Alabama, a man not known for his sympathies for the LGBT community, stated in the 11th Circuit Federal Court of Appeals in Atlanta that trans persons were a protected class under the 14th Amendment. Now the Board of Trustees of the American Psychiatric Association (APA) has ratified the DSM-5, the fifth edition of what is known colloquially as the "psychiatrists' bible," so as of Dec. 1, trans persons are no longer classified by the medical community as mentally ill, this decision coming 39 years after homosexuality was declassified as a mental illness by the same organization.

I have personally been involved in many civil rights campaigns, but as a physician, none has mattered more to me than this one. The fact that my medical colleagues now better understand basic human sexual biology is a source of both relief and pride. I can recall prowling the psychiatric literature in the stacks of the Uris and Olin libraries at Cornell and the medical library at Penn, finding only the most egregiously vile descriptions of who I was as a human being. I recall making surgical rounds at Pennsylvania Hospital in 1976 and listening to the disparaging remarks made by attending physicians and students alike about a trans woman who had just undergone genital reconstruction. I recall the hate speech of opponents to trans anti-discrimination bills in the halls of Congress, Annapolis and Rockville, Md., constantly harping on the supposed mental illness of the gender-nonconforming and the threat we posed by our very existence.

Don't underestimate the significance of this evolution. That we no longer have to take such talk seriously in the legislatures and courts and can roll our eyes as we do when fundamentalists chatter on about gay men showering with straight ones is a hugely positive change. That we now have the gender identity consultation staff at the Johns Hopkins School of Medicine speaking out forcefully for comprehensive civil rights protections when not long ago we lived with the reality that Hopkins, with the infamous Emeritus Professor Paul McHugh as its spokesperson, was in the vanguard of denying trans women their humanity is remarkable progress. This is part of the cultural change that influences courts and legislatures, which, in turn, dialectically influence the culture. As an example, it would not be a reach to believe that the leadership of the corporate community on LGBT equality in Atlanta had a salient impact on Judge Pryor. Nor would it be hard to imagine that the quiet, dignified work of physicians Greg Lehne, Bill Reiner, Chris Kraft and others at Hopkins influenced the antediluvian opinions of Paul McHugh and his colleagues.

When the closing bell is rung, we should remember those who toiled through the decades with little expectation of recognition or success. Just as President Obama's support of the trans and gay communities these past four years was only the final push of sufficiency needed to create so much change, this landmark achievement would not have been made possible without the yeomanly work of so many.

A few whom I feel are particularly noteworthy of mention are Jack Drescher, M.D., who has long been active on LGBT concerns within the APA; Edgardo Menvielle, M.D., who led the workgroup of the Washington Psychiatric Society, which rewrote the gender dysphoria text, and on which I was honored to serve; and Roger Peele, M.D., Chief Psychiatrist for Montgomery County, Md., a strong advocate for the trans community on the Board of Trustees of the APA. We all owe a great deal to Kelley Winters, Ph.D., who has been the conscience as well as the motivating force in the campaign to depathologize the state of being transgender.

I don't want to leave the impression that the job is complete. Just as the removal of homosexuality in 1973 was partial, the exclusion not completed until 1987, there is still work to be done for the broader trans community. The DSM still dehumanizes garden-variety cross-dressing under the category "transvestic fetishism," particularly insulting in its use of the term "fetish." And there are many activists who feel that the APA didn't go far enough and oppose the mention of any form of cross-gender behavior in the DSM, including the new category, "gender dysphoria."

Still, while for many people the devil will be in the details, in its larger sociopolitical impact this ranks with the major declassification of homosexuality in 1973. Our greatest accomplishment on the Working Group was reconceptualizing the state of "being trans" from a mental illness to a normal human variant. Now accepted by the American psychiatric community (and years ago by the psychological), this conceptualization defangs the most potent arguments of the opposition, which often portrays trans women as sexual predators. Back in 1990 trans persons were lumped together with pedophiles in the Americans With Disabilities Act (ADA), reflective of a common misperception that trans women were inherently deceptive and fraudulent, monstrous beings whose only purpose was sexual assault on the innocent. This new edition of what passes for the consensus of the medical community regarding issues of sexuality finally brings trans persons into the light with the rest of the community of humanity.

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