A critical discussion of The frequency of personality disorders in patients with gender identity disorder (2014) (open access text available here), and the related issues of deviancy and pathologising the experiences of transgender people
TW for transphobia and intersexism and mentions of colonialism/racism
Disclaimer: I'm cisgender. I write this, what is sure to be controversial as all writing supporting transgender people is, not speak over any transgender people. If you are a transgender person who has something to say about this piece then I welcome your opinion. I am only writing here what I have learned from the amazing transgender people who share their lived experience and philosophy. There are some things for which my sources are very personal, from the experiences of my transgender friends and discussions within various unpublished LGBTQ chats on programs like discord so I cannot cite them but I have tried to provide various sources for all that I can. Many sources are American-centric because that is where the vast amount of accessible English literature is from, unfortunately.
Abstract
Background: Co-morbid psychiatric disorders affect prognosis, psychosocial adjustment and post-surgery satisfaction in patients with gender identity disorder. In this paper, we assessed the frequency of personality disorders in Iranian GID patients.
Methods: Seventy- three patients requesting sex reassignment surgery (SRS) were recruited for this crossectional study. Of the participants, 57.5% were biologically male and 42.5% were biologically female. They were assessed through the Millon Clinical Multiaxial Inventory II (MCMI- II).
Results: The frequency of personality disorders was 81.4%. The most frequent personality disorder was narcissistic personality disorder (57.1%) and the least was borderline personality disorder. The average number of diagnoses was 3.00 per patient.
Conclusion: The findings of this study revealed that the prevalence of personality disorders was higher among the participants, and the most frequent personality disorder was narcissistic personality disorder (57.1%), and borderline personality disorder was less common among the studied patients.
Mazaheri Meybodi A, Hajebi A, Ghanbari Jolfaei A. The frequency of personality disorders in patients with gender identity disorder. Med J Islam Repub Iran 2014 (10 September). Vol. 28:90.
First and most importantly, the World Health Organisation has recently affirmed that being transgender is not in itself a mental disorder. When the ICD-11 comes into practice, being transgender will no longer be defined under "gender identity disorder" under mental health and is now reframed as "gender incongruence" alongside sexual health problems. Nice.
Language and Biology
"In a cross-sectional study, the prevalence of MTF and FTM GID was calculated as 1:145,000 and 1:136,000, respectively, and the total prevalence as 1:141,000. The sex ratio of MTF to FTM GID was 0.96:1."
Despite frequently being used in research papers, the terms "FtM" and "MtF" are rather dated and inaccurate for describing transgender people. The research being from Iran this may be explained by language and cultural differences. The researchers are also discussing people who are trying to access gender confirmation surgery, but they are not specifically addressing the surgery itself, only covering demographics. Honestly, I am hesitant to give cisgender researchers diagnosing trans people with NPD who then go on to say things like "biological males" that much credit.
"The prevalence of GID is estimated 1:10,000 to 1:20,000 in men and 1:30,000 to 1:50,000 in women and the sexual ratio (biological males to biological females) is between 3 and 5 to 1. However, this ratio seems to be close to 1 to 1 in our country."
Labeling a person "biologically male" or "biologically female" assumes that our biology is inherently gendered. Transgender people, intersex people, and various feminist theorists have been at the forefront of combating such biological essentialism. People will point to various traits that make "essential males" and "essential females" but none of these things are guaranteed to be present when a baby's sex is decided. When a baby is born doctors look at their genitalia and assign the baby a sex accordingly. No genetic test, or looking into the future for puberty effects or adult hormone levels or ability to carry a child, or thorough scans to ensure no internal organs dispute this. Sex is decided upon the ornamentation between people's legs which can be quite easily changed by a qualified surgeon.
However, even genitalia doesn't fall so neatly into the sex binary. One literature review found 0.1%-0.2% of babies have been subjected to unnecessary unethical "corrective" surgery, but the percentage of babies born with genitalia that doesn't conform to the idealised notions of "male" and "female" may be as high as 2%. Another literature review considering all the various influences on sex characteristics estimates that the percentage of people with "disorders of sex developments" (DSDs) may be as high as 1%.
It is worth mentioning too that notions of "male" and "female" both in the sense of sex and gender binary are highly racialised and tied to colonialism. Victorian sexologists marked the various sex characteristics of racialised people as "abnormal" in studying the biology of sex. Spurious links were drawn between the "primitive" genitalia of racialised women and sex workers, linking diversity in sex characteristics to deviancy and criminality, and these stereotypes continue to influence modern ideals to this day. The imposition of the gender binary was and is a tool of colonialism too. Various people across the world historically had different terms and concepts of gender and sexuality which contradict the culture imposed on them by Western European colonialism, and trying to understand these ideas through western ideas of queerness and being transgender is just modern cultural imperialism.
Both the concepts of strict binary sex and strict binary gender are simply false, entirely pseuoscientific and nothing more than a method of classifying people to establish entirely arbitrary power structures. In reality, the sexual diversity and variation of gendered behaviour is vast across all the animal kingdom. This is not to say that sex and gender aren't real, they are and they have real world impacts, but they are imperfect human constructs much in the way that race is. Sociological and not biological. As such, they are subject to change and evolve as society changes, tied inherently to culture rather than biology, clear from the various pre-colonial variations in gender and gender roles around the world that colonial powers tried so hard to suppress and eradicate. This is a very important point to make because the denial of gender's existence at all leads quickly to violent transphobic rhetoric, as demonstrated by modern "trans exclusionary radical feminists". We live in a gendered society, we have gender, it is currently a huge part of culture and identity and impacts how we live our lives and understand each other. Gender is not, however, biologically essential, and neither is sex.
Catch-22
"Another important aspect of studying co-morbid psychiatric disorders in GID is helping the clinicians to make definite and accurate diagnosis. GID patients usually look for hormone-based treatment or sex reassignment surgery (SRS), but in many cases the patients asking for SRS have psychiatric disorders other than GID such as personality disorders which should be considered before surgery."
Gender confirmation surgery is a medical necessity for those that need it. Not all transgender people experience dysphoria, and those that do don't experience it to the same extent and to the same specifics, but dysphoria in itself can be agonising. Denying people medical care because they have psychiatric issues is horrifically unethical, but unfortunately a problem that is not all that unusual.
In transgender people, so much of the comorbid psychiatric issues are because of horrific violence (1, 2, 3, 4, 5, 6, 7), incredible discrimination, and the overwhelming stress of marginalisation. Studies into suicide attempts draw direct relationships between discrimination and internalised transphobia and suicidal ideation. A study into the minority stress model as applied to transgender people found that not only is it predictive of psychiatric issues, but that peer support is effective at combating this distress. Not only that, but studies into the mental health of children and young people find that those that are supported by their parents and enabled to socially transition as children are protected from the horrible distress and psychiatric issues associated with being transgender. If children were encouraged to explore who they are and who they want to be, including their gender identity, then transgender and gender non-conforming people would not be in so much agony. This supports the theory that high levels of psychiatric issues within transgender people is related to mistreatment, as similar protective factors against trauma can be found for those that experienced other kinds of abuse as children.
When the research and evidence is very clear that the psychiatric issues associated with being transgender come from violence and discrimination, it is backwards to then use this as justification to deny medically necessary healthcare to transgender people. Access to medical care, including gender confirmation surgery, has long been acknowledged as alleviating gender dysphoria, relieving some of the incredible stress that transgender people are burdened with and improving their mental health. Validating, accepting, and embracing the identity and experiences of transgender people protects them and helps heal them from the harm the world inflicts on them. Denying the medical means to realise their transition is the opposite of that. Access to hormonal treatment for adolescents has demonstrated to be far better for the wellbeing of young transgender people than denying intervention until later, and research has also indicated that access to surgery earlier in life is associated with better outcomes. Delaying treatment because of psychiatric issues denies the reality of the cause of these issues and prolongs the distress for transgender people.
The transgender looking glass
"It can be concluded that personality disorders are more widespread among surgery candidates than the general GID samples. Furthermore, the higher rates of narcissistic personality disorder in these patients (surgery candidates) may be due to the fact that they are more preoccupied with their own appearance and beauty and need more praise by others."
I guess this whole article has been a waste of time because the researchers just dunk themselves. Might it be that the agony of gender dysphoria, being constantly bombarded with images and narratives of the Ideal Woman and Ideal Man, being attacked and discriminated against because their body doesn't conform to these notions, might make an individual "preoccupied with their own appearance". Might it be that, as research has demonstrated, support and validation both significantly protects and heals transgender people therefore they might "need more praise by others".
When considering the perceived vanity of transgender people, it is negligent to not mention the fact that "passing", or appearing to conform to gender expectations, is also a vital matter of safety. Being visibly transgender or gender non-conforming makes a person vulnerable to bigoted attack and hate motivated crimes. Research has shown that non-conformity to gendered expectations is even directly related to levels of homelessness and all the related issues around it. Being "preoccupied" with their appearance can be a matter of life and death. Plus, as awareness around transgender people has risen in the past few years, so has the level of conformity required in order to safely pass.
There is also this transphobic notion that transgender people just reinforce gender stereotypes, but having to "pass" goes beyond just attracting the attention of strangers and harassment in public places. Conforming to gender norms is also tied directly to ability to access medical interventions or legal recognition.
“I was ‘overweight and would look weird after surgery if my stomach was bigger than my chest.’ Doctor’s words.” Johnny, a thoughtful trans man who was kind enough to answer my questions, continues, “it seems like a very thinly veiled ‘you won’t be attractive enough for us to proudly call you our patient.’” -Kivan Bay
"Somehow the people who believe that gender is just a set of harmful stereotypes that hurt women want the legal process for changing gender to include living according to sexist stereotypes for a set period of time first. This is all it always is. Gender testing. Trans people never have the chance to live authentically because we are forced to contort ourselves into others’ gender prescriptions in order to achieve equality under the law." -Katelyn Burns @transscribe
For non-binary people, who might have some aspects of dysphoria and want hormones or even certain surgeries but do not identify as male or female? They are stuck in an impossible position. Gender neutral legal markers don't even exist in many places.
Trans people are held to impossibly high standards to prove themselves and protect themselves from violence and pathologising them or blaming them for this is morally reprehensible.
Deviant personality
It's convenient that those outside of the gender norms might be so easily pathologised by the construct of personality disorders. Rather than acknowledge that children who deviate from the norm, as LGBT children often do, are particularly vulnerable to abuse from both their peers and the adults in their life, researchers suggest that abuse might make children queer. Despite brief acknowledgments that navigating the world as a marginalised person requires you to think and act in certain ways to survive, clinicians still operate on the understanding that it's the behaviour of these marginalised people that is the problem.
I don't have a copy of the Millon Clinical Multiaxial Inventory II so I can't speculate as to why transgender people might have scored so high on "narcissistic traits" in this particular study when others find high rates of "borderline traits" instead. However, I think it's worth looking at the descriptions and criteria for all cluster B personality disorders within the DSM-III-R and the DSM-V. With all the evidence of the impact of ongoing discrimination and the perpetual threat of violence, it should be easy to pick apart just how profoundly wrong this "trait" interpretation of the experiences of transgender people might be.
The idea that those who are gender non-conforming or transgender have an unstable identity is so prevalent that this paper cites a theory that "transsexualism" is a subtype of borderline personality disorder. This is, I hope, evidently egregious. For young people pushing the boundaries of who they are and how that relates to their gender, there can be much uncertainty as they are butting against the narrative of their assigned sex that they have been told their entire lives. If they have doubts and are unsure this is not a pathological trait, it is simply the reality of living in a world where the existence of transgender people is denied and vilified. Transgender people give others so much anxiety, so directly challenging the norms, requiring such an upheaval of worldview for many. I have no citation for this but I imagine that for many it is so much easier to pathologise the transgender person's identity than face the questions that they raise for others. Even if a trans person knows deeply and with absolute certainty who they are, they are still liable to be slandered with ideas of "unstable self" because of the clincian's transphobic inability to reconcile the dissonance between a person's assigned sex and their gender identity. Science has a long history as a tool of reinforcing the status quo, and psychology especially has a very long history of pathologising that which is other to reassure those that consider themselves "normal".
The prejudice of clinicians goes further. Through the straight cis gaze the culture of LGBTQ people is provocative and eccentric and flamboyant, full of risky behaviours like drugs and frequent hookups. Queer people have long since been considered shallow and vain and dysfunctional. Considered overemotional, overreacting to "harmless" jokes at our expense that is salt on the wound of violence and discrimination. Considered loud and shoving our identity in people's faces. Considered to have some kind of agenda. Considered to think of themselves as special and needing special treatment, despite asking only for dignity and respect and basic human rights. A cis straight clinician measuring a queer person by cis straight cultural norms is guaranteed to find that person deviant, but this misunderstands the history of our culture. The long history of being criminalised and attacked pushed queer people's expression underground, and created the culture of quick hookups and shady bars and an association with illicit activity. In the USA, the famous Stonewall Inn was literally run by the mafia. To this day we still struggle to be free to express ourselves without violence. In the face of being shamed LGBTQ people are proud, but it is resistance and not personality defect, and this is especially so for transgender people.
Beyond just clinicians, the level of social prejudice towards transgender people means that relationships can be very difficult. Relationships with family are often unstable and abusive, and making friends can be hard if a large portion of the population finds your existence distasteful, some willing to commit violence against you. On top of this, transgender people are incredibly vulnerable to domestic violence and sexual assault. Transgender people, like other marginalised people, are specifically targeted by abusers because enacting violence against those that society doesn't care about has no consequences. Discrimination makes people further vulnerable through homelessness, unemployment, and social isolation--all of which trap people within abusive relationships.
The affective instability, the risky behaviour, substance abuse, the self harm and suicidal ideation, these are not symptoms of a trait disorder but of persistent incredible distress and have long been related to the enduring effects of trauma. Minority stress and the exceptional levels of violence, the prevalence of abuse, and lack of support faced by transgender people is acknowledged as the primary cause of all these mental health issues. Besides the direct impact of such abuse and discrimination, discrimination pushes people towards doing risky things to survive.
When breaking the law is recognised as a symptom of a disorder, this inherently pathologises those who are criminalised and targeted by the law, as transgender people often are. The pathologising of criminality and sexual promiscuity stands out to me because for transgender people, particularly trans women of colour, discrimination means that many turn to sex work, even at a young age. Transgender teenagers are particularly susceptible, even among the LGBTQ community, to sexual exploitation because of homelessness and discrimination. Between this, accusations of being deceptive, a potential history of truancy because of peer abuse, risky behaviour associated with sex work, the perception of trans women in particular as aggressive and violent and predatory, and high levels of substance abuse, it would be so easy to paint transgender people with the broad brush of personality disorder.
But aetiology matters. Medicalisation makes it easy to distance the symptoms of distress from the cause but the reason a person is in pain matters, it dictates what serves as the best solution to this pain. As obsessed as researchers and psychiatrists are with the biomedical model and increasingly with trait theory, doing anything they seemingly can to avoid addressing the socio-political causes of mental health issues, socio-political issues remain the primary cause of mental health issues by far. The UN special rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health just recently published a scathing report that urges states to address inequality and discrimination as the primary way to protect people's right to mental health. The framework of disorders is abhorrent when it leads to the pathologisation of transgender people instead of addressing the discrimination that leads to high rates of poverty, the incredible abuse, and the constant threat of violence. The disorder that hurts transgender people is one of society and not their personality.
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