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A most stigmatized population

December 9, 2013
by Michael Shelton
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Michael Shelton

Addiction professionals are well aware of the controversy surrounding diagnostic changes for addictive disorders in the DSM-5. Some are not aware, however, of an equally vociferous controversy regarding the diagnosis of gender identity disorder (GID), which was changed to gender dysphoria in the DSM’s most recent edition.

This change harkens back to the 1973 removal of homosexuality from the field’s diagnostic manual. According to Robin Rosenberg, a clinical psychologist and co-author of the psychology textbook Abnormal Psychology, “The concept underlying eliminating homosexuality from the DSM was recognizing that you can be homosexual and psychologically healthy or be homosexual and psychologically screwed up. Being homosexual didn’t have to be the issue.”1

In the same way, the new DSM recognizes that there are many transgender individuals who are living healthy and productive lives. For those who aren’t, it is not necessarily because of their transgender identity but possibly a result of living in a culture that stigmatizes those who do not conform to traditional norms.

Currently, gay, lesbian and bisexual adults are roughly twice as likely as the general population to lack health insurance, but rates of being uninsured are even higher for transgender individuals.2 Since the Affordable Care Act (ACA) mandates substance use and mental health services among the essential benefits that all qualified insurance plans must offer, behavioral healthcare systems soon might be dealing with an influx of more LGBT individuals and their families than at any other point in their history.

All sexual minorities have faced discrimination and hurdles in accessing supportive, safe and knowledgeable behavioral health treatment, but the transgender population has indeed fared the worst.


Defining transgender

The 2011 Institute of Medicine report The Health of Lesbian, Gay, Bisexual and Transgender People: Building a Foundation for Better Understanding defined transgender as “an umbrella term that encompasses a diverse group of individuals who depart from traditional gender norms.” The American Psychological Association (APA), in comparison, offered a more detailed definition: Transgender refers to “a variety of people who are gender variant in relation to cultural norms in significant ways. While the descriptor transgender typically brings to mind someone who wants to transition to the other sex/gender both socially and physically through surgical procedures, it can also refer to people who express gender atypicality along a continuum, including, for example, cross-dressers, those who present as gender ambiguous, or those who live in the role of the other gender without surgical or hormonal intervention.”3

A 2013 literature review published in Contemporary Sexuality determined that 2 to 27% of adults who received a GID di­agnosis as children continue to meet criteria for GID in adulthood, but the review acknowledged that research on the gender identity of adults iden­tified as gender nonconforming in childhood is scarce. The 2011 Institute of Medicine report summarized that the current generation of gender nonconforming individuals typically comes out in childhood or shortly after the onset of puberty. In contrast, transgender persons who are not visibly gender role nonconforming in childhood typically do not come out until much later in life, during midlife or beyond.

Earlier theories postulated parenting styles or trauma as the cause of gender nonconformity, but current research—built upon a conflux of biology, sociology, psychology, gender studies and queer theory—has dispelled these theories. For example, the Children’s National Medical Center in Washington, D.C., which runs an outreach pro­gram for children with gender variant behaviors and their families, counsels against the notion that there is a “cause” of gender nonconformity and instead presents “the concept of gen­der identity as something that begins with a ge­netic propensity, hard-wired in the brain before or soon after birth, and is then influenced by the gender roles that are learned and specific to each time and place,” as stated in the Contemporary Sexuality article.


Clinical concerns

“A 24-year-old African-American pre-op transsexual presents for intake at your residential drug treatment program. She is dressed in female attire and tells you she has been living full time as a female for more than five years. She has had a legal name change and has identification that states she is female. She tells you she is revealing that she is transsexual because she ‘doesn’t want there to be any trouble.’ She also tells you she has been in treatment before and says she had a very bad experience, including the fact that the staff refused to address her as female and other clients sexually and verbally harassed her. She says she has a long history of abusing heroin and alcohol and that she is ready to change her life and wants to enter your residential treatment program.”4

The above case example is from the 2001 Substance Abuse and Mental Health Services Administration (SAMHSA) release A Provider’s Introduction to Substance Abuse Treatment for Lesbian, Gay, Bisexual and Transgender Individuals. I have used this example to initiate conversations with behavioral health treatment providers in trainings across the country regarding working with the transgender population. In contrast to the responses elicited when using gay, lesbian, and bisexual case examples, professionals report that their treatment programs are least prepared to work with the transgender population, even though these individuals present with higher rates of HIV infection, smoking, drug and alcohol use, and suicide attempts.