Transgender clients face unique challenges within health system

The DSM once contained homosexuality. It still contains Gender Identity Disorder. (Photo: Cummings)

By Jenny Westberg, Contributing Columnist
Published in Street Roots, Oct. 29, 2010

In December 1973, a psychiatric breakthrough wiped out all signs and symptoms of mental illness for millions of Americans.

It wasn’t a new drug. It was an ex cathedra pronouncement by the American Psychiatric Association, declaring that homosexuality was not, in fact, a mental disorder. The change meant that more than 100,000 Oregonians went to bed one night with a diagnosable psychiatric problem and woke up the next morning with none at all.

Thirty-seven years later, however, being transgender — nothing more — is still enough for a psychiatric diagnosis, with a seven-page listing in the official diagnostic manual, the DSM-IV. Clinically, it’s called Gender Identity Disorder (GID).

The label is bad enough. But with GID, it’s not just, “You’re sick.” It’s often, “You’re sick… or else.”

GID is a gateway requirement for surgical transition. That means some people have little choice; like it or not, they have to submit to a psychiatric diagnosis that identifies them as “disordered.”

There are all sorts of reasons to get rid of GID. It lacks clinical sufficiency. It supports the idea that transgender persons are “sick” or “weird.” It treats distress as a psychiatric symptom, even when it’s due to discrimination and harassment.

At the same time, there are people who really need surgery, and removing GID from the manual could add to their difficulties. Portland therapist Reid Vanderburgh, MA, says it can be hard to object. “Most people bite the bullet and accept a GID diagnosis,” he says. “The desire for surgery trumps any activist instinct they might have to fight back and NOT accept it.”

But Vanderburgh, who has transitioned himself, manages to avoid GID in clinical practice. “I don’t include GID in my referral letters, for either hormones or surgery,” he says. “I find that my letters are accepted.”

“This leads me to question the actual usefulness of the diagnosis,” says Vanderburgh. “Is GID really necessary at all?”

Mental health for transgender persons doesn’t begin and end with GID; some people have a contrived problem, plus a real one.

Julie Trana, MS, who practices therapy in Portland, often sees transgender clients with depression, “likely resulting from years of feeling rejected or ‘not normal.’ They can also struggle with low self-esteem and suicidal ideation associated with the depression.”

Anxiety is frequent, as is substance abuse. There may be high rates of PTSD, stemming from harassment, discrimination, verbal assaults, attacks, beatings and rapes, which frequently go unreported to police. In addition, transgender people are subject to the same mental health problems as nontransgender people, such as bipolar disorder or schizophrenia.

But trying to get help can be difficult and discouraging. Alix Kemp wrote about the experience in a zine called “Genderfailz.” As a 21-year-old college student, Kemp’s mood began to drop. He became more and more depressed. It took months to gather the nerve to go to the campus health center, and still more months to get an appointment. He was near suicide when he finally talked to a psychiatrist.

Kemp was born female, but carefully explained to the doctor, “I’m trans.”

“But – you’re so pretty!” the psychiatrist said. To Kemp it meant, “You’re not going to find help here.”

He tried again, this time choosing a clinic specializing in gender issues. A nurse introduced him to the psychiatrist.

“This is Alix,” said the nurse. “She’s female-to-male, she’s 21, she’s a student…” The “trans-friendly” clinic worker was using the wrong pronoun.

Misunderstandings such as these are the rule, not the exception, and stigma is everywhere, even where you would ordinarily look for support. In groups of mental health consumers, transgender people may need to hide their gender identity. In LGBT communities, they might have to hide their psychiatric problems.

Inpatient treatment facilities have “male” patient rooms and “female” patient rooms. Clinicians may tell patients to act more “masculine” or “feminine,” and chart conformity as progress.

Some mental health professionals think transgender people suffer from psychotic delusions, believing they’re male when they’re actually female or the other way around. Transgender persons may be misdiagnosed as having borderline personality disorder because of the upheaval, confusion and conflict that often accompany being transgender. Or they may be labeled “manic” because of overwhelming relief at transitioning.

In hospitals and residential programs, some of the worst treatment can come from other patients, including hostility, physical aggression and name-calling that becomes a group sport.

Outpatient treatment isn’t much better. One person told Alicia Lucksted, Ph.D., “(During my transition from male to female), my psychiatrist asked me to dress as a man to meet with him, then said I wasn’t really transgender because I hadn’t had any suicide attempts.”

If you’re looking for transgender-friendly mental health care, where do you start?

“It can help to interview more than one therapist in order to make sure you find a good fit,” says Trana. “Be sure to ask specific questions about their comfort with and knowledge of transgender folks. You can also join support groups with other transgender folks if you want to talk to other people about their experience.”

Vanderburgh agrees. “Find someone who understands the issues.” Do you need to find a therapist who is transgender? “It’s useful to have gone through the process, it’s a shortcut to understanding, but everyone’s experience of gender is different anyway, whether they’re trans or not; being a trans therapist doesn’t convey automatic understanding of another’s experience.”

Most important: Seek out someone who makes you feel safe and comfortable. The resources below aren’t endorsements, but they are a starting place.


Reid Vanderburgh, MA, LMFT, 503-341-7001  –

Julie Trana, MS, 503-330-5312 –

Sexual Minority Provider Alliance –

Oregon State University LGBTQ, “I might be transgender…” –

Jenny Westberg is a board member of The Mental Health Association of Portland, a nonprofit advisory organization that supports advocacy efforts on issues around mental health. Information about their work is available at www.oregonarchive. org