In his infamous work The Myth of Mental Illness, the late Dr. Thomas Szasz argued that psychiatry was not a branch of medicine concerned with treating real illness, but rather an institution of social control. He believed that psychiatry fulfilled this function by bringing under the umbrella of “disorder” those behaviors and beliefs that society at large found undesirable or difficult to deal with. In Szasz’s opinion, the mind or, speaking more precisely, one’s internal experience could not be subject to disease, only to factual error. He argued against the idea of psychosis as a manifestation of illness and considered delusions to be errors of judgment instead of symptoms of an underlying mental disorder.
While nonpsychiatric medicine concerns itself with lesions of the physical body, psychiatry’s object of inquiry has always been the internal experience of a person. Contrary to Dr. Szasz’s insistence that there is no such thing as mental illness, mainstream psychiatry has continued to adhere to the notion that the internal experience of a person could be subject to a variety of conditions that represented mental pathology. Just how one defines psychiatric disorder has been a subject of much debate. The difficulty in arriving at the definition is related to the difficulty in adequately defining what constitutes mental health. After all, when considering whether the mental state of a person is normal, does one consider statistical, cultural, biological, functional, or other parameters of normality? The fourth edition of the Diagnostic and Statistical Manual, the American Psychiatric Association’s compendium of psychiatric disorders, noted that “no definition adequately specifies precise boundaries for the concept of mental disorder.” To be sure, noting the difficulty in arriving at a precise definition is not the same thing as endorsing Szasz’s position that such disorders do not exist. Although hard-pressed to define it, a practicing psychiatrist’s attitude toward mental disorder is often akin to Justice Potter Stewart’s definition of pornography: “I know it when I see it.”
The term “internal experience” refers to the sum total of a person’s thoughts, feelings, and perceptions. Although the number of psychiatric diagnoses has increased greatly over the years, there are roughly four areas in which an internal experience may be viewed as disturbed: emotion, arousal, reality testing, and intellect. These correspond to diagnostic entities in the often-overlapping categories of mood disorders, anxiety disorders, psychoses, and cognitive dysfunction. For the clinical psychiatrist an essential consideration bearing on whether a psychiatric disorder is present is the extent to which the internal experience of the person varies from that body of collectively shared observations and experiences we refer to as reality. For example, intense fear in the midst of an aerial bombardment is considered psychiatrically normal. A condition in which intense fear occurs in the absence of any external threat is a symptom of mental pathology called panic disorder. Feeling bored when sitting in a quiet environment is within the limits of normal human experience, but hearing voices when no one around is speaking is not.
Psychiatry has traditionally considered as pathological those beliefs a person may hold about himself that are at odds with objective reality. Such false beliefs or wrong judgments held with conviction despite incontrovertible evidence to the contrary are what a medical dictionary defines as a delusion. People who falsely believe that they are undercover FBI agents, underweight people who believe themselves to be obese, people who wrongly believe that their body emits an unpleasant odor, and those who believe that they possess more than one psychological identity all exhibit delusional beliefs. Using this line of thinking one would have to conclude that a person claiming to be of a different race or age group than he actually was would also have to be suffering from a delusion.
What about people with the normal anatomy of one sex who believe that they have an identity of someone of the opposite sex, or who claim to be neither male nor female?
In the last few years an idea has spread within society at large that having the body of one sex and believing oneself to be of another or even of no sex at all should be considered a part of normal human experience. It is an idea to which official psychiatric organizations such as the American Psychiatric Association have lent credence. The current position of the APA as expressed on its website is that “many transgender people do not experience their gender as distressing or disabling, which implies that identifying as transgender does not constitute a mental disorder.” This position remains unquestioned in mainstream psychiatric publications, which often publish articles stating that transgender individuals experience mental distress as a result of discrimination but never discuss the possibility that having transgender beliefs is in itself evidence of mental abnormality. Whether a condition causes subjective distress and disability is an important treatment consideration, but this is not the defining diagnostic characteristic of medical pathology, which has usually been understood as some malfunction of the organism. It is common knowledge in general medicine that many conditions which are pathological by virtue of being examples of bodily malfunction nevertheless do not cause obvious distress or disability. In the field of mental health, every psychiatrist who has been in practice for some time has encountered patients who exhibit delusions and even hallucinations that are not subjectively disturbing to them and whose disability consists largely of how other people respond to them. The relatively unperturbed state of such individuals does not and should not cause us to pronounce them as psychiatrically healthy.
Although the psychiatric diagnosis of “gender dysphoria” is used for those who experience distress associated with the mismatch between the “gender” with which they identify and their anatomic sex, the implication of the APA position seems to be that, such distress aside, the condition is psychiatrically normal. This implication is not consistent with clinical logic because it ignores an essential feature by which normal internal experience has traditionally been distinguished from an abnormal one: whether such experience is consistent with external reality. Not all mental suffering and disability are the result of mental illness, and not all mental illness necessarily leads to suffering and disability. There must, therefore, be a philosophically sound criterion other than subjective discomfort by which abnormal psychiatric experiences are distinguished from normal ones. Traditional psychiatric wisdom has held that the further a person’s internal experience is from reality, the greater the degree of psychiatric impairment. A question no one seems to be asking in mainstream psychiatric press is whether a person’s internal experience can be so far removed from reality as to justify a “sex reassignment” surgery and still be considered psychiatrically normal.
An MSNBC article quoted APA member Jack Drescher as saying that “All psychiatric diagnoses occur within a cultural context. . . . [T]he therapist’s job isn’t to pathologize.” It is certainly true that cultural context is one determinant for what psychiatry considers normal and that such considerations may even apply to apparently psychotic phenomena, such as hallucinations of deceased loved ones. However, it is important to realize that psychiatry and medicine at large not only reflect the cultural context in their notions of normalcy versus pathology but also help to create that very cultural context. It was largely as a result of vocal advocacy on the part of the medical community that smoking has become culturally unacceptable in many parts of our society. In fact, heavy smoking is now a psychiatric diagnosis called “nicotine use disorder,” yet no one seems to worry that this diagnosis may “pathologize” behaviors or attitudes. As an opposite example, one of how psychiatry helped to give cultural sanction to a condition previously considered clinically pathological, we must remember the removal of homosexuality from the DSM in 1973. The official opinion of the APA, an organization that describes itself as the voice and conscience of American psychiatry, that identifying as transgender does not imply having a mental disorder is not a reflection of the cultural context. It is an example of how cultural context is created.
Any phenomenon suspected of being a medical illness needs to be evaluated in the light of philosophical principles on which our notions of disease and health rest. Lacking precise laboratory and imaging diagnostic testing modalities of non-psychiatric medicine, psychiatry currently has no other choice but to rely almost exclusively on a system of value judgments as the building blocks of its knowledge base. Without such value judgments and without assumptions regarding what is real and what exists only in the mind of the patient there is no such thing as psychiatry. One may argue, as did the late Dr. Szasz, that a discipline based exclusively on such value judgments and assumptions has no place calling itself part of medicine. Not surprisingly, such an argument has not gathered many followers among practitioners of psychiatry. However, when it declares the transgender experience psychiatrically normal while considering numerous other experiences that have little basis in objective reality to be examples of mental pathology, official psychiatry tarnishes its own image as a legitimate medical specialty.
Although issues pertaining to the negative public perception of transgender patients are certainly not trivial, they must not be confused with the real lesion of transgender disorder. To argue otherwise is akin to suggesting that the suffering and disability of schizophrenic patients is primarily a result of stigma against them. Although such statements have been made, they reflect an antipsychiatric stance typical of Dr. Szasz and his followers. Opinions often expressed in the psychiatric press to the effect that the suffering and disability of transgender people are primarily related to their negative reception by the public are ultimately grounded in sentiment instead of clinical judgment. Beyond their sentimentality such opinions are essentially antipsychiatric. It was the antipsychiatry psychiatrist Dr. Szasz who argued that only the body and not the internal experience of a person could be diseased. The notion prevalent in current psychiatry that there is nothing wrong with the internal experience of transgender patients and that it is their bodies that ought to be recipients of surgical and hormonal treatment is perfectly consistent with Szasz’s arguments. Extending such an argument further, if one accepts that there is no mental pathology in having a “gender identity” that is different from one’s physical anatomy, there is no reason to see mental pathology in any other experience of one’s identity that is at odds with physical reality. Oddly, this is how psychiatry dissolves itself into a nonentity. After all, if mental illness is, indeed, a myth, psychiatrists have no business being in the medical business.
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