This 2009 analysis of “gender identity” by psychiatrist Dr. Colin Ross argues that it is unethical for doctors to go along with the demands of delusional or dissociated patients who say they are the opposite sex. The author correctly points out that there is good money to be made in the “gender identity” business and this is why mainstream psychiatry is so keen to protect its “gender” racket. Other elite shrinks were starting to conjure up the DSM-5 at the time he wrote this.
Bizarrely, by 2016 most medical and psychological aspects of transgenderism, as well as “social services” aspects, are now covered by Obamacare and national health insurance in many other countries. The “transgender child” industry is particularly big business. The mainstreaming of transgenderism has also been a gold mine for all kinds of pseudo-scientific academic researchers who push this agenda.
The medical profession in general, and psychiatry in particular, take the position that gender identity disorder is a genuine medical condition. The primary purpose of this stance, it appears, is to justify treatment being paid for by insurance companies.
Why then, do we not have a DSM-IV disorder called psychogenic micromastia? Breast augmentation in biologically normal women could then be justified as a treatment for the mental disorder of psychogenic micromastia. Breast augmentation for biologically normal women is currently classified as a cosmetic procedure in order that insurance companies can justify not paying for it. What we have is a financial tug-of-war between doctor and third-party payers over whether the procedure is cosmetic or medical—in order for it to be considered medical it must be treatment for a medical disorder. When there is no identifiable biological abnormality, the backup position is to define the condition as a mental disorder, and place it in the DSM system.
This brings us to the core problem with the DSM-IV-TR diagnosis of gender identity disorder: it is the only diagnosis in the system in which treatment is designed to reinforce and agree with the so-called disturbance that is the basis of the disorder.
WHY IS GENDER IDENTITY DISORDER A MENTAL DISORDER?
Setting politics, money, and power aside for a moment, it is illogical and self-contradictory to classify gender identity disorder as a mental disorder, and then proceed with gender reassignment. Consider the following range of other DSM-IV-TR disorders.
I once interviewed a normal-looking woman who told me that she was so grossly ugly and deformed that people crossed the street rather than having to pass by her on the same sidewalk. After excluding other diagnoses like schizophrenia, I made a diagnosis of dysmorphophobia, which was included under atypical somatoform disorder in DSM-III . In DSM-IV this condition is categorized as 297.1 delusional disorder, somatic type.
The treatment for this woman was antipsychotic medication. I did not advise her to get plastic surgery. A similar case involved a woman who believed she smelled so badly that coworkers stayed home rather than being exposed to her horrible body odor. She smelled the odor in my office but it was entirely delusional. I did not recommend skin disinfectants or caustic solutions to her.
Another woman I assessed washed her hands over 100 times per day to get rid of germs and contaminants. Here I diagnosed obsessive compulsive disorder. I did not instruct her on how to wash her hands more effectively.
In another case, an adult woman advised me that she was a 10-year-old girl with a different name. She described herself as having different hair color, height, and eye color from her friend who shared her apartment, who was actually the adult host personality. I made a diagnosis of dissociative identity disorder. I did not call child protective services to tell them that a 10-year-old girl was living with an unrelated adult friend rather than with her parents, where she belonged.
On another occasion, a woman told me that she had been blind for the last three days. After a thorough workup, I made a diagnosis of conversion disorder. I did not refer her to the National Institute for the Blind.
A general problem with the DSM system is the fact that all these false beliefs about body and identity are scattered around in a variety of different diagnostic sections in an arbitrary fashion. If a person washes her hands 100 times a day she has an anxiety disorder (obsessive compulsive disorder), but if she plucks her hair out 100 times a day she has an impulse control disorder (trichotillomania). If she can’t move her hand at all, she has a somatoform disorder (conversion disorder). If she thinks her hand is grossly fat and starves herself to lose weight, she has an eating disorder (anorexia nervosa). If she was a child and used her hand to make rude hand gestures at her parents, teacher, and psychiatrist, she would have oppositional defiant disorder. However, if she used her hand to masturbate excessively, she would have a psychosexual disorder.
In all these cases, the abnormal behavior or belief is defined as a symptom of a mental disorder. Whether the abnormal belief, behavior, or identity is classified as a delusion, body image distortion, compulsion, conversion, dissociation, or impulse dyscontrol is immaterial: in all cases, the goal of treatment is to remove the symptom. The body is not fat, ugly, dirty, 10 years old, or under the control of a demon or ancestor spirit (trance possession disorder). The psychiatrist does not suggest to the possessed woman that she actually is a demon, or tell her that she has ego-dystonic identity disorder due to social demonophobia.
The psychiatrist does not send the possessed woman to a program that will help her come out of the closet as a demon to her friends, family, and employer. Only one delusion elicits that response from the psychiatrist: the belief that one is a man trapped in a woman’s body.
The psychiatrist tells the woman with gender identity disorder that she is biologically female. The woman agrees, which confirms that she is not delusional concerning her biological gender. She is only delusional about her psychological gender. However, the psychiatrist doesn’t then offer antipsychotic medication or behavioral therapy to rid the woman of her delusion. Instead, he refers her to a gender reassignment clinic.
In gender identity disorder, and in that diagnostic category alone, the psychiatrist agrees with the patient’s delusion. He tells her that she is correct, that she really is a man trapped in a woman’s body. He refers her to a clinic that will fix her mistaken body so that it agrees with her correct psychological gender identity.
The problem is not with the gender reassignment surgery: it is with the logic of the diagnosis.
If gender identity disorder is a mental disorder, then its core symptom is a symptom of mental disorder : the claim to be a man must be disordered, incorrect, mistaken, delusional, disturbed, or false. The psychiatrist cannot use the term delusional because that term will block the gender reassignment procedure. DSM-IV-TR gets around this problem by saying that, “Insistence by a person with a Gender Identity Disorder that he or she is of the other sex is not considered a delusion, because what is invariably meant is that the person feels like a member of the other sex rather than truly believes that he or she is a member of the other sex” (AMA, p. 581).
However, DSM-IV-TR contradicts itself five lines later on the same page in the diagnostic criteria by stating that “the disturbance is manifested by four (or more) of the following: (1) repeatedly stated desire to be, or insistence that he or she is, the other sex.”
If a woman told a psychiatrist that she was a gorilla, this would be classified as a “bizarre delusion” according to the text for schizophrenia. If she said she was the last Neanderthal left on earth, this also would be a bizarre delusion. But if she tells him she is a man trapped in a female body, the psychiatrist agrees to have her body fixed. DSM has to exclude the term delusion from the description of gender identity disorder in order to prevent its being reclassified as a psychosis, which would in turn block gender reassignment. That is fine, but the problem remains: the gender belief is still the basis for diagnosis of a mental disorder .
In order to proceed with gender reassignment, however, the psychiatrist must agree with the person’s mind. If the mind is correct and the body mistakenly doesn’t match the psychological gender, then it is the right of the person to request the appropriate plastic surgery. Gender reassignment is then no different, conceptually, from cosmetic breast augmentation surgery.
If this is true, however, then there is no mental disorder. Gender identity disorder should be removed from DSM-V just like homosexuality was removed from DSM-II. The only reason to retain gender identity disorder as a diagnosis is to maintain the control, power, and income derived from participation in gender reassignment by psychiatrists. Alternatively, if gender identity disorder is dropped from DSM-V (or shifted to egodystonic gender identity disorder in DSM-V, and then psychosexual disorder not otherwise specified in DSM-VI), and if psychiatrists are retained on the gender reassignment team, then they should also be added to the breast augmentation and liposuction teams.
Their role there would be to rule out other conditions such as delusional disorders and eating disorders.
All of these arrangements either happen or do not happen solely for political, power, and financial reasons. They have nothing to do with the rational classification of mental disorders. Treatment outcome data are irrelevant to the scientific validity of gender identity disorder as a DSM diagnosis: even though the overall treatment outcome for so-called surgical correction of psychogenic micromastia is excellent, that does not prove the surgery is medical rather than cosmetic.
Biologically normal women pay cash for cosmetic breast augmentation because they have high odds of good outcomes and of being satisfied with the procedure. Yet there is no lobby group arguing that such women suffer from a mental disorder. It would make no sense to tell biologically normal women seeking breast augmentation that they are mentally ill and suffer from psychogenic micromastia, and then go ahead and perform the procedure. This is exactly what happens when the diagnosis is gender identity disorder, however.
GENDER IDENTITY DISORDER AND DISSOCIATIVE IDENTITY DISORDER
Two DSM-IV-TR diagnoses have three words in their name, with only one out of the three words being different: gender identity disorder (GID) and dissociative identity disorder (DID). However, there is no discussion of DID anywhere in the text or diagnostic criteria for GID. This makes no sense. In DID, by definition, there are different identities, who often have different genders. The outcomes of successful treatment, for a woman with DID, can include heterosexual or homosexual orientation, and, in principle, male or female gender identity. In practice, however, I have never heard of a person with DID treated to integration who did not have a psychological gender congruent with his or her biological gender. The opposite outcome is not impossible in principle, but it is exceedingly rare if it ever occurs. A homosexual orientation postintegration is quite common, however.
Why is thinking you are a male trapped in a female body a dissociative symptom treated with psychotherapy if there is a group of identities, but a gender identity disorder treated with surgical reassignment if there is only one identity? This is inconsistent. It is also a problem with great practical implications.
I have interviewed a small series of biological men with undiagnosed DID who have undergone surgical reassignment for GID. I have spoken directly with male alter personalities who are very upset about their genitals being removed and breasts being grown with hormones. In these cases, female alter personalities temporarily gained control of the internal system, presented to gender reassignment clinics, and won the internal war for control and gender identity. The male identities were further suppressed once hormone therapy was started, and disappeared altogether for years postsurgery, until some life stress destabilized the system, overt switching began again, and the diagnosis of DID was made.
The DSM text for gender identity disorder does not discuss dissociation for several reasons. If it did, the core dissociation between biological and psychological gender might be called a dissociative symptom. If this happened, the disorder could be reclassified as a dissociative disorder. This would threaten the turf control of specialists in gender identity disorder. It would necessitate careful evaluation of all GID cases for DID, and it would expose gender reassignment clinics to considerable legal liability for undiagnosed DID cases that have already been reassigned.
To protect the GID turf, then, DID must be discredited, not mentioned, or said to be extremely rare. This is what happens in gender reassignment clinics. However, 11 studies in seven countries show that previously undiagnosed DID affects, on average, 3.7% of general adult psychiatric inpatients (Ross, Duffy, & Ellason, 2002). There is abundant evidence that DID versus GID is a real differential diagnostic problem. It certainly has real consequences when there is a false positive diagnosis of GID and a false negative diagnosis of DID.
This is fundamentally an ethical problem. Either the diagnosis of gender identity disorder should be removed from DSM-V, or gender reassignment should be stopped. Having it both ways protects the financial interests of specialists in GID, but not society or the individuals who request gender reassignment. This violates the fundamental principle of “first do no harm.” Maintaining a logically self-contradictory diagnostic category in the DSM system in order to force third-party payers to pay for a cosmetic procedure is unethical. If gender reassignment is a reasonable and ethical procedure, then believing you are of the opposite gender from your biological gender cannot be a mental disorder. It is unethical to have it both ways at once.
Excerpt from: Ross CA. Ethics of Gender Identity Disorder. Ethical Human Psychology and Psychiatry 2009 11:3 (165-170)
SEE ALSO: World Health Organization proposed ICD-11 billing codes designed by trans activists to facilitate medical billing and insurance payments for transgenderism while still somehow pretending that transgenderism is healthy and fine.