Transphobia

A Price Worth Paying For Gender Identity Disorder?

Associate Professor, Sam Winter, of the Division of Learning, Development and Diversity, Faculty of Education, University of Hong Kong

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This paper is about transpeople and transphobia, and the role of Western psychiatry in relation to both. By transpeople here I mean people allocated to one gender category at birth (normally on the basis of what was between their legs) but who later identify and deeply desire to live in another gender role. By transphobia I mean feelings of fear, disgust and/or hatred towards transpeople, feelings that my research student Mark King describes as "transprejudice"; feelings that are often expressed as discriminatory behaviour towards transpeople. And, as we know, discrimination can lead to minority stress and impaired mental health (low self-esteem, anxiety, depression) and worse.

The possibility arises that a mental-disorder model of transgenderism may support and encourage key transphobic attitudes.

Interestingly, mainstream Western psychiatry tends to regard transpeople, as I have defined them here, as pretty much mentally disordered by the fact of their transgenderism. Transphobic people, however, are apparently well-adjusted.

My research on transgenderism and transphobia is primarily in Asia; part of the TransgenderASIA initiative to develop Asian research in these areas. So I want to point out that transphobia is widespread across Asia. Depending on the culture concerned, transpeople experience varied amounts of discrimination at the hands of transphobics. And with human rights culture and law less well developed in Asia than in North America, Australia or Europe, transphobic discrimination is given a pretty free rein in some places.

So there are Asian transpeople who are rejected by family, subjected to abuse and violence in their homes, or are thrown out onto the street; who are taunted, ostracised and abused by peers at school, are subjected to gender coercion by school authorities, and for any of these reasons do drop out of education early. There are those, especially those drifting into the city with little education or few family contacts, who do find it difficult to get a job. Driven to the fringes of society, living on the streets, living on their wits, some do drift into sex work, where they are at risk of all sorts of harassment, even violence.

Against all this, Asian governments, even those two-thirds that have ratified the International Convention on Civil and Political Rights, often provide little legal or practical protection. Indeed many perpetrate their own discriminatory practices, whether by allowing the outlawing of sex reassignment surgery (for example Malaysia), denying opportunities to change legal gender status or enter heterosexual marriages (for example, "progressive" Hong Kong), or even denying gender-appropriate identification cards (for example "tolerant" Thailand). Abuse by police can be a problem; sometimes systematic, sometimes violent, sometimes both (as in the recent cases of Nepal and of India's Karnataka state), and often on the basis of ill-defined vagrancy and public decency laws that effectively criminalise cross-dressing. And of course, laws against homosexuality put heterosexual transpeople at risk of prosecution.

In short transphobia is an Asian issue. Anything that contributes to transphobia is as much a matter of concern to Asian transpeople as it would be to their Western brothers and sisters.

I recently led a team of ten people who together took an unusually international look at transphobia. Our study involved a thirty–item questionnaire completed by 841 undergraduate students in seven countries, examining attitudes and beliefs about transwomen (natal males living female lives). Again, unusually for research into transpeople, most of our data came from Asian countries, where 60% of the world's population live (and presumably a similar proportion of the planet's transpeople).

The countries, and researchers involved, were as follows: China (myself and Loretta Ho), Malaysia (Teh Yik Koon), Singapore (Wong Ying Wuen), Thailand (Nongnuch Rojanalert and Kulthida Maneerat), the Philippines (Raymond Macapagal and Chuck Gomez), as well as the United Kingdom (Anne Beaumont) and the United States (Pornthip Chalungsooth).

Now I could demonstrate how undergraduate students in these seven countries compared in terms of the levels of transphobia they displayed. But I think the results of a factor analysis we conducted on the pooled data are more important, in an effort to identify core attitudes and beliefs underlying our international data.

We identified five factors, together explaining 52.1% of variance. They were, 1) the belief that transwomen suffer from a mental sickness; 2) the belief that transwomen are not women, should not be treated as such, and should not be afforded rights as women; 3) rejection of contact with transwomen in a variety of social situations, including among family members and teachers; 4) rejection of contact with transwomen within one's peer group, and 5) the belief that transwomen engage in sexually deviant behaviour.

These factors were correlated. Particularly strong, and fairly consistent across the seven countries involved, were the links between, on one hand, the belief that transwomen suffer from a mental sickness and, on the other hand, (1) the refusal to regard or treat them as women or to afford them rights as women, as well as (2) an unwillingness to accept the idea of any social contact with them at all, either within one's family group or outside. The possibility arises that a mental-disorder model of transgenderism may support and encourage key transphobic attitudes.

This possibility is a worrying one. We already know that transphobia prompts minority stress, and that minority stress can lead to impaired mental health (and worse). Now if the pathologisation of transpeople, on the basis of their transgenderism, serves to support or encourage transphobia, then the result is one that can only harm transpeople. Indeed, there is perhaps the makings of a self-fulfilling prophecy, in which transpeople, regarded as mentally disordered, do indeed encounter mental health problems, but largely, perhaps only, as a result of being so regarded.

I will be accused of overstating the case. I can only say that, after eight years of work in this area in Asia, I have observed countless times what many have observed before me elsewhere; that, where significant others inside and outside the family are even moderately tolerant towards transpeople, those transpeople manage to get on with their lives without experiencing any of the mental distress or disability associated with mental disorder, or, arguably, even an increased risk thereof.

That observation is reinforced by my work with Liselot Vink in Thailand and the Philippines, and Serge Doussantousse in Laos, though the work is currently in an early stage of analysis. It therefore seems to me, just as other research has been suggesting for years, that there may be no Gender Identity Disorder, except the inability or unwillingness of transphobics to accept transpeople.

I am aware that psychiatric diagnosis has offered transpeople in some developed countries the hope or expectation of subsidised gender health care. Now presumably all this could be preserved if, in line with recent research on biologically-based brain sex, the medical world chose to see transgenderism as a somatic condition (indeed a form of intersexualism) rather than a mental disorder.

But for the moment, it is seen as a mental disorder, and our research clearly suggests that, where this view is held, transphobia is particularly intense. In short, the psychiatric pathologisation of transgenderism may indeed be enhancing the access of transpeople in the developed world to subsidised medical care. But transpeople worldwide, with different needs, different priorities, are paying the price.

I do not claim that the average Asian man or woman has read D.S.M.-IV. They do not need to. These ideas percolate down into the street in all sorts of ways. Consider the case of Thailand, where there are thousands of transpeople who, whenever at any stage in their lives they apply for a job, and are asked for their military service discharge papers, are obliged to show a document stating they were relieved of service on the basis of mental sickness.

Nor do I claim that transphobia arises solely out of the "mental disorder" view of transgenderism, or that it would go away overnight if transgenderism were to be depathologised. Religion, for example, also plays a role in supporting transphobia, including in Asia. My point is simply that psychiatric pathologisation is one of the ideas that prompts and props up transphobia. It is an idea, in my view, that is psychiatrically bankrupt, and socially disastrous for the trans community. De-pathologisation may not overnight erase the idea that transgender is a mental disorder; we all know people who still think of homosexuals as mentally sick! But de-pathologisation is a start. And that's why I today, like others before me, call for the removal of Gender Identity Disorder, Transsexualism and related psychiatric terms from future editions of the Diagnostic and Statistical Manual (D.S.M) and the International Classification of Diseases (I.C.D.), just as was done with homosexuality so many years ago. It is time to proclaim, more loudly than ever, that transpeople represent human diversity rather than mental disorder, and that the world is richer for the fact of their existence.

Much of the research quoted was conducted with the help of funding from the University of Hong Kong. The paper was presented on 17 April 2007 at the First World Congress for Sexual Health (18th Congress of the World Association for Sexology) in Sydney, Australia. It is reprinted here by kind permission of the author, Associate Professor Sam Winter, of the Division of Learning, Development and Diversity, Faculty of Education, University of Hong Kong. Professor Winter is happy to be contacted by email

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