A Straight Dope Classic from Cecil's Storehouse of Human Knowledge

Are transsexuals mentally ill?

August 17, 2012

Dear Cecil:

In a recent Straight Dope Message Board thread about transsexuality, one commenter offered the following: “People who have gender identity disorders … are just dudes dressing up as chicks and/or dudes who have gotten a doctor to mutilate them to have imitation female genitalia (or [the other way around for women], I guess.) … GID patients have a mental illness and society should be looking into ways to eradicate that mental illness through some form of treatment that isn't the equivalent of giving a paranoid schizophrenic who thinks he's Napoleon a bicorn hat and a saber.” Care to comment?

Cecil replies:

I’m not inviting that guy to the next meeting of my LGBT support group. However, from a certain perspective, he’s got a point.

Standard medical opinion is that transsexuals are mentally ill. The revised fourth edition of the Diagnostic and Statistical Manual of Mental Disorders offers a long description of gender identity disorder that boils down to this: you think you’re the wrong sex, and you’re not happy about it. The International Statistical Classification of Diseases and Related Health Problems calls it transsexualism and defines it this way: “A desire to live and be accepted as a member of the opposite sex, usually accompanied by a sense of discomfort with, or inappropriateness of, one's anatomic sex, and a wish to make his or her body as congruent as possible with the preferred sex through surgery and hormone treatment.”

Fact is, most transsexuals agree there’s something wrong with them. The difference is they think it’s with their bodies, while unsympathetic outsiders say it’s with their heads.

The professional view of transsexuality is evolving. DSM-V, currently under development, proposes replacing gender identity disorder with “gender dysphoria.” From what I can see this is mostly an exercise in euphemism: you still think you’re the wrong sex, and you’re still not happy about it. But others think the whole notion of transsexuality as a disorder should be abandoned. For example, in 2009 the French health ministry declared it would no longer classify transsexualism as a psychiatric condition.

Not to get all peace-and-love about it, but the core issue really is unhappiness. DSM-III dropped the old classification of homosexuality as a disorder because of the dawning realization that whatever gays and lesbians might be unhappy about, it wasn’t about being gay or lesbian as such — the main issue was social disapproval. In contrast, even with all the social acceptance in the world, transsexuals are still going to think they’re the wrong sex.

Why they do so is unknown. Some researchers think a percentage of transsexuals have an underlying physiological condition, essentially a wrong-gendered brain. Regardless, few in the field believe transsexual impulses can be eradicated or cured. The choices are some combination of hormones and surgery, or else you just deal.

The surgery part is what makes some people recoil. They cite another condition proposed for the DSM, body integrity identity disorder, characterized by the wish to have a part of your body amputated, typically the left arm or leg. You don’t see anybody claiming BIIDers are paragons of mental health and doctors should merrily saw away. But another way to look at it is that sex reassignment surgery or hormone treatment is more like a full-body tattoo. Would I do it? No, but I don’t much care if other people do.

The question is whether reassignment makes transsexuals happy. Most studies say yes, but that conclusion was questioned by the UK newspaper the Guardian in 2004. Having interviewed several SRS patients who said they were no happier after surgery and felt they’d made a big mistake, the paper commissioned the Aggressive Research Investigative Facility (ARIF) at the University of Birmingham to review the medical reports. ARIF’s conclusion: most studies of SRS outcomes were fatally flawed, the major failing being that a huge percentage of SRS patients dropped out of sight.

For example, one study found that of 727 subjects who had undergone male-to-female SRS, 539 had a known address, 420 of those had a correct known address, 417 of those were still alive, 355 of those agreed to participate, and 232 of those returned their forms. Of the last group, 86 percent rated their “happiness with result” at 8 or higher on a 10-point scale, and only four percent said 5 or below.

You can spin this any way you want. The responders are a pretty satisfied group, but what’s up with the nonresponders?

Some are surely dead. A large-scale 2011 study from the Netherlands found treated transsexuals had much higher than normal death rates due to suicide, drug abuse, AIDS, and so on. Then again, other studies have concluded that while post-ops have high suicide rates, pre-ops’ are even higher.

The subject deserves more investigation. If I were desperate enough to consider sex reassignment surgery seriously, I’d still want to be damn sure it would help.

Related Posts with Thumbnails


Asscheman, Henk et al. “A long-term follow-up study of mortality in transsexuals receiving treatment with cross-sex hormones” European Journal of Endocrinology 164 (2011): 635–642.

Bazarra-Castro, Maria Angeles (2009). Etiological Aspects, Therapy Regimes, Side Effects and Treatment Satisfaction of Transsexual Patients. Dissertation. Aus dem Max Planck Institut für Psychiatrie, Klinisches Institut, München. Director: Prof. Dr. Dr. Florian Holsboer.

Clements-Nolle, Kristen et al. “HIV Prevalence, Risk Behaviors, Health Care Use, and Mental Health Status of Transgender Persons: Implications for Public Health Intervention” American Journal of Public Health 91.6 (June, 2001): 915-921.

“Comorbidities in Transsexual Patients under Hormonal Treatment Compared to Age- And Gender-Matched Primary Care Comparison Groups” Reproductive Sys Sexual Disord 1.1 (2012).

Cuypere, Griet De et al. “Sexual and Physical Health After Sex Reassignment Surgery” Archives of Sexual Behavior 34.6 (December, 2005): 679–690.

Gooren, Louis J. “Care of Transsexual Persons” New England Journal of Medicine 364.13 (2011): 1251-1257.

Gooren, Louis J. et al. “Long-Term Treatment of Transsexuals with Cross-Sex Hormones: Extensive Personal Experience” J Clin Endocrinol Metab 93.1 (January, 2008): 19–25.

Haas, Ann P. et al. “Suicide and Suicide Risk in Lesbian, Gay, Bisexual, and Transgender Populations: Review and Recommendations” Journal of Homosexuality 58 (2011): 10–51.

Kesteren, Paul J.M. van and Asscheman, Henk. “Mortality and Morbidity in Transsexual Subjects Treated with Cross-sex Hormones” Clinical Endocrinology 47 (1997): 337-342.

Kidd, Jeremy D. and Witten, Tarynn M. “Transgender and Transsexual Identities: The Next Strange Fruit—Hate Crimes, Violence and Genocide Against the Global Trans-Communities” Journal of Hate Studies 6 (2008): 31-63.

Landen, M. et al. “Factors predictive of regret in sex reassignment” Acta Psychiatr Scand 971 (1998): 284-289.

Lobato, Maria Ines Ines et al. “Follow-Up of Sex Reassignment Surgery in Transsexuals: A Brazilian Cohort” Arch Sex Behav 35 (2006): 711–715.

Michel, A. et al. “The transsexual: what about the future?” Eur. Psychiatry 17 (2002): 353-362.

Michel, A. et al. “A psycho-endocrinological overview of transsexualism” European Journal of Endocrinology 145 (2001): 365-376.

Mueller, Andreas and Gooren, Louis “Hormone-related tumors in transsexuals receiving treatment with cross-sex hormones” European Journal of Endocrinology 159 (2008): 197–202.

Murad, Mohammad Hassan et al. “Hormonal therapy and sex reassignment: a systematic review and meta-analysis of quality of life and psychosocial outcomes” Clinical Endocrinology 72 (2010): 214–231.

Newfield, Emily et al. “Female-to-Male Transgender Quality of Life” Quality of Life Research 15.9 (Nov., 2006): 1447-1457.

Smith, Yolanda L.S. et al. “Adolescents With Gender Identity Disorder Who Were Accepted or Rejected for Sex Reassignment Surgery: A Prospective Follow-up Study” J. Am. Acad. Child Adolesc. Psychiatry 40:4 (April, 2001): 472-481.

Snaith, P., Tarsh, M.J., and Reid, R. “Sex reassignment surgery. A study of 141 Dutch transsexuals” British Journal of Psychiatry 68 (1993): 681-685.

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