On the current episode of the SGU, because it is pride month, we expressed our general support for the LGBTQ community. I also opined about how important it is to respect individual liberty, the freedom to simply live your authentic life as you choose, and how ironic it is that often the people screaming the loudest about liberty seem the most willing to take it away from others. That was it – we didn’t get into any specific issues. And yet this discussion provoked several responses, filled with strawman accusations about things we never said, and weighed down with a typical list of tropes and canards. It would take many articles to address them all, so I will focus on just one here. One e-mailer claimed: “It is obvious to me that the 98% of trans people have a mental illness that should be treated like any other mental illnesses.”

Being trans itself is not considered a mental illness, but this deserves some extensive discussion. It’s important to first establish some basic principles, starting with – what is mental illness? This is a deceptively tricky question. The American Psychiatric Association provides this definition:

Mental illnesses are health conditions involving changes in emotion, thinking or behavior (or a combination of these). Mental illnesses can be associated with distress and/or problems functioning in social, work or family activities.

But this is not a technical or operational definition (something that requires book-length exploration to be thorough), but rather a quick summary for lay readers. In fact, there is no one generally accepted technical definition. There is some heterogeneity throughout the scientific literature, and it may vary from one illness to another and one institution to another. But there are some generally accepted key elements.

First, as the WHO states, “Mental disorders involve significant disturbances in thinking, emotional regulation, or behaviour.” But then we have to define “disorder”, which is typically defined as a lack or alternation in a function possessed by most healthy individuals that causes demonstrable harm. “Significant” is also a word that’s doing a lot of heavy lifting there. This is typically determined disorder by disorder, but usually includes elements of persistent duration for greater than some threshold, and some pragmatic measure of severity. For example, does the disorder prevent someone from participating in meaningful activity, productive work, or activities of daily living? Does it provoke other demonstrable harms, such as severe depression or anxiety? Does it entail increased risk of negative health or life outcomes?

Further, symptoms and outcomes need to be put into cultural context. Specifically, it has been increasingly recognized that negative outcomes do not qualify as mental illness if they are entirely due to outside factors, such as social norms and acceptance. If you are a rugged individualist living in a collectivist society, your individualism is not a mental illness simply because it puts you in conflict with the dominant cultural norm. In other words, mental illness must be a product of inherent brain function (although this can be in response to extreme stress or environmental conditions, such as PTSD), and not simply culture.

As psychiatry evolved and matured, and wrestled with many complex issues, it also became clear that a diagnosis of mental illness should not be used simply to enforce cultural norms, or as a value judgement to be imposed on individuals. Along those same lines, it has become increasingly recognized within biology, medicine, and neuroscience specifically that living things, including people, exhibit a lot of variation within very broad parameters that can be considered healthy. Also, evolution typically involves lots of trade-offs, and different trade-offs are often just different, not better or worse. This is why we no longer used value-laden terms like “normal”,  “abnormal”, or “deviant”. Rather, it is more appropriate to use value-neutral terms such as typical and atypical. Not everyone who is atypical is abnormal or suffering from a disorder.

Grappling with these complex issues is extremely important, because they get right to the heart of the liberty question. Historically the designation of mental illness has been used as a tool of authoritarian governments to deprive citizens of liberty. Not cooperating with a collectivist ideology was considered a mental illness, and “treated” by confinement in reeducation camps. Anti-psychiatry organizations, like Scientologists, take this principle to an extreme, and deny the very existence of mental illness and portray all mental health treatment as political oppression. This is the other end of the spectrum, equally nonsense. An optimal approach is somewhere in the middle – recognizing the many abuses and pitfalls of giving someone a diagnosis of mental illness, the tremendous power this can give someone over someone else’s liberty, but retaining the ability to recognize genuine problems in order to give proper help to those who need it.

With this as background, let’s consider an historically relevant case – is homosexuality a mental illness? In the first DSM published in 1952, the manual of psychiatric diagnoses, it was considered a mental illness. This was based upon one competing theory of homosexuality that pathologized it. For example, psychiatrist and psychoanalyst Edmund Bergler wrote in a book for general audiences:

“I have no bias against homosexuals; for me they are sick people requiring medical help… Still, though I have no bias, I would say: Homosexuals are essentially disagreeable people, regardless of their pleasant or unpleasant outward manner… [their] shell is a mixture of superciliousness, fake aggression, and whimpering. Like all psychic masochists, they are subservient when confronted with a stronger person, merciless when in power, unscrupulous about trampling on a weaker person.”

This was closely tied to cultural normative value judgements, that anyone who did not conform to social norms around sexual behavior were “deviant”. In the second edition published in 1973, the competing theory that homosexuality was simply part of human variation prevailed, and homosexuality was removed as a mental illness. This was also based on an analysis following the principles I outlined above. Being homosexual does not seem to correlate with any pathology, mental deficiency, or inability to function – except to the degree that is being imposed from the outside by society. It is not a reaction to stress, bad parenting, or social contagion. People seem to be born gay, because that is how their brains developed, and it’s just part of variation that we see pretty much across the entire animal kingdom.

When it comes to individuals who identify as trans or non-binary, we see essentially the same story playing out. Accusations that being trans is a mental illness is being used to justify taking away their liberty, marginalizing them in society, and even depriving them of health care. But there is equally little reason to consider a trans identity a mental illness as being non-heterosexual. It is true that trans individual do have a higher risk of depression, anxiety, and suicidality. But again, this seems to result from acceptance in society, rather than an internal factor.

With respect to the DSM, the same evolution has occurred. The original designation was “gender identity disorder”, but after debate and review it was considered that this was just as much a bias as considering homosexuality deviant. The GID designation was removed, and replaced with “gender incongruence” as a descriptor under the sexual health section (The DSM also lists traits, personality types, and other things which are not considered disorders or illnesses). There is also a separate diagnosis of “gender dysphoria” which is a negative emotion that can (but does not always) arise from gender incongruence. For context it’s important to recognize that part of the purpose of the DSM is to give a label to anyone who might be seeking help, so that they can be treated and insurance can be billed. That’s why there are many conditions that are not considered a mental illness. For example, someone might seek mental health treatment because they are suffering from reactionary grief following the loss of a loved one. This is considered a healthy reaction to a life event, not a mental illness, but they still may benefit from intervention.

Critically, the consensus among mental health experts is that the trans identity itself is not a manifestation of some mental illness, but is simply part of the natural variation of a complex biological system. Some people are trans or non-binary. This may result in increased mental stress, but that is generally a societal issue, not an issue of brain health.

To be clear, and to head-off the likely strawmen arguments thrown my way, there is a meaningful discussion to be had about how to optimize health care for trans people, to balance concerns about outcome, risks vs benefits, maturity, and consent. But such a conversation should be had among experts, and free of misinformation, biases, bigotry, outdated notions of deviance, or the imposition of external cultural norms (no matter how well entrenched and firmly held they are).

Dismissing trans individuals as “98%” mentally ill is just misinformed bias, and a way to deprive a marginalized community of their humanity, dignity, rights, and liberty.