Do Some Men Who Desire Sex Reassignment Have A Mental Disorder? Response to Lawrence (2011)

Abstract

It is always an intellectual pleasure to be challenged by Anne Lawrence, because of her thorough scrutiny of logic and data in the course of scientific arguments. Yet, the title of Lawrence’s (2011) comment here, ‘‘Do Some Men Who Desire Sex Reassignment Have A Mental Disorder?’’, is misleading. Posed that way, the question yields trivial answers, because humans of almost any category include individuals with ‘‘a mental disorder,’’ provided the sample is large enough. As her comment shows,however, thequestionLawrencereallyaddresses isadifferent one, namely:‘‘Is the desire for sex reassignment in some men to be understood as a mental disorder in terms of a particular classification system of psychiatric conditions?’’ From a nosological perspective,‘‘sex reassignment’’is a treatment or management procedure, whereas psychiatric diagnosis classifies mental conditions; for the latter purpose, a procedural term is not appropriate nor is the term of a desire for such a procedure. Analogously, in somatic medicine, a malignant tumor is diagnosed as pathology whether or not the patient desires its surgical removal. Moreover, the nonhomosexual men who come to clinicians like myself with a stated desire for sex reassignment are very variable in their gender history and current psychological condition, especially in adolescence. By contrast, persons with gender identity variants (GIVs) of a degree that they meet DSM-IV criteriaforGender IdentityDisorder (GID)usually impressmeby the uniformity of their presentation relative to other conditions described in the DSM, and interclinican agreement tends to be high. (My use of the DSM-IV criteria here is merely for purposes of description and should not be taken as an indication that I have come to a definitive conclusion whether or not GIVs should be categorized as a mental disorder in DSM-5.) Thus, unlike Lawrence, I do not see the contemporary gender-identity construct as particularly‘‘abstract’’or‘‘impreciselydefined,’’and,basedonmy experience in developing a variety of psychological assessment instruments, I do not find its operationalization to be unusually difficult. For the main focus of this discussion, I will, therefore, assume that the section of the transgender spectrum, on which Lawrence focuses, comprises adult 46,XY persons with male-typical primary andsecondary somatic sex characteristicswho meetDSMIV criteria A, B, and C for GID, are sexually attracted to females, and desire hormonal and surgical sex reassignment from male to female (MtF). Note that this delineation is narrower than Lawrence’s,but ifweconsider includingamongthesementhosewho do not meet DSM-IV criteria for GID, Lawrences’s rationale becomes even more problematic. Now to Lawrence’s answer to the mental disorder question. The developmental sequence and related conclusions regarding psychopathology, as described by her for nonhomosexual MtF transsexuals, can be summarized as follows.