Stop Pathologization of Transsexual People!

A Statement of Social Psychiatric Service Cantone Uri (SPD Uri) on the Presentation by Helena Nygren-Krug, Health and Human Rights Advisor, World Health Organisation (WHO) at the launch of the report "DISCRIMINATION ON GROUNDS OF SEXUALORIENTATION & GENDER IDENTITY IN EUROPE", Strasbourg, 23 June 2011

Author: Institution: Adress:

Dr. med. univ. Dr. phil. Horst-Jrg Haupt Sozialpsychiatrischer Dienst Kanton Uri Seedorferstrasse 6 CH-6460 Altdorf

Contents
1 Introduction 2 Arguments against the pahologization of transsexual people 2.1 The current psychiatric diagnostics of transsexuality is not evidence-based 2.2 Psychiatric history: the tradition of the failure of psychiatric concepts of "transsexuality" . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.3 Psychiatric treatment and/or psychotherapy can not diminish the characteristics of transsexuality or make them go away . . . . . . . . . . . . . 2.4 Neuroscience: Towards a new paradigm of transsexuality as a neurobiological variation of sexual dierentiation and development . . . . . . . . . 2.5 With transsexuality there are as opposed to psychological disorders no fundamental social function limitations . . . . . . . . . . . . . . . . . . 2.6 In contrast to mental disorders in transsexuality clinical neuropsychological disorders are not evident . . . . . . . . . . . . . . . . . . . . . . . . . 2.7 There were/are many cultures and societies in which transsexual and transgender people can/could develop stable lifestyles and cultures appropriate for them. These cultures were/are an expression of social normality and healthy everyday culture, not an expression of a pathological derangement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Recommendations and Possibilities 3 5 5 7 15 17 21 23

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1 Introduction
The Commissioner for Human Rights of the Coucil of Europe has been criticizing for several years that transsexual people are perceived in the ocial medical classications as mentally disordered. This criticism is also directed against the International Classication of Diseases (ICD), which is regularly revised and published by WHO. The Commissioner, Thomas Hammarberg wrote on this subject in his Issue Paper: "The rst aspect in discussing health care for transgender persons is the existence of international and national medical classications dening transsexuality as a mental disorder? Such classications may become an obstacle to the full enjoyment of human rights by transgender people, especially when they are applied in a way to restrict the legal capacity or choice for medical treatment ... Alternative classications should be explored in close consultation with transgender persons and their organisations. From a human rights and health care perspective no mental disorder needs to be diagnosed in order to give access to treatment ..."1 This discussion was taken up by the WHO. Mrs. Nygren-Krug announced in her presentation in Strasbourg on 23rd June 2011, that the WHO will move in the direction outlined by the commissioner of human rights. Specically she formulated: "A third function of WHO is to establish and revise, as necessary, international nomenclatures of diseases. The above-mentioned ICD is the vehicle for this. It supports health authorities in determining what type of services should be made available to the population. The 11th version of the ICD is scheduled to be presented to the World Health Assembly (WHOs Governing Body) in May 2015. Although homosexuality is no longer included, other issues that may concern us remain, such as transsexuality as a mental disorder. How can we ensure that we address the health care needs of transgender populations without further stigmatizing them? I hope that transgender people and the transgender movement can help us in addressing this challenge invoking the key human rights principle of participation - nothing for us without us. To conclude, an important ingredient of success in making positive change is leadership and nowhere is this more evident than in the eld of human rights. Let me end by applauding the Member States of the Council of Europe for putting the issue of discrimination on grounds of sexual orientation and gender identity on the agenda of the Council of Europe."2
1

Council of Europe, Commissioner for Human Rights, Thomas Hammarberg, in his Issue Paper Human Rights and Gender Identity" https://wcd.coe.int/ViewDoc.jsp?id=1476365 2 http://www.who.int/hhr/news/strasbourg_sexual_orientation.pdf

1 Introduction The aim of our paper is to support organizations, that are committed to the interests and rights of transsexual and transgender people, in their future cooperation with the WHO. On the following pages important medical arguments are gathered to support clearly dened positions against the pathologization of transsexuality: To guarantee an excellent medical care of transsexual people, it does not require any pathologization.

c 2012 SPD Uri, Altdorf (UR)

2 Arguments against the pahologization of transsexual people

2.1 The current psychiatric diagnostics of transsexuality is not evidence-based
Nowadays, it is important in medicine to prove, that an applied medical method, ie a diagnostic or therapeutic action, represents the best possible (State of the Art). This has to be documented by results of studies and research. In earlier times it would have been enough, if a doctor had justied his action with his gut feeling or personal experience. It is no longer sucient, if at a conference several experts meet to discuss a consensus paper and then publish it. In such a situation, the results could be distorted by groupthink. Physicians should always try to justify their actions by the results of good-quality studies. Only then the "State of the Art" predicate can be awarded. In the terminology of medicine: If a course of action is justied by good studies, we evaluate the approach as evidence-based. Since the late 1980s, the medical sciences have developed an own discipline that deals with the principles of evidence base and its practice. The name of this particular discipline is Evidence-based medicine (EBM). The Evidence-based medicine distinguishes between dierent classes of quality of evidence. It applies the following rule: the better the studies (in background), the better the medical procedure can be justied. The best justication of an action is when it can rely on a number of large, very good studies (class I evidence). The Evidence-based medicine denes three quality classes of studies and research results: Class I: Excellent Evidence (Class Ia: meta-analysis of randomized controlled studies,
Class Ib: At least one randomized controlled study

Class II: Good evidence (Class IIa: at least one well-designed controlled study without
randomization; Class IIb: at least one other type of well-designed quasi-experimental study)

Class III: Explicit evidence (well designed non-experimental, descriptive studies, such as comparative studies, correlation studies and case control studies). A further principle of the Evidence based medicine says that "standards" (for diagnostics and/or therapy) may be dened only if the relevant studies show the evidence class I or nearly very well class II. Specically:

2 Arguments against the pahologization of transsexual people Recommendation standards of practice Dened criteria Existing Class I studies with appropriate sample size or Existing studies involving nearly very good class II evidence In available class I studies with methodological shortcomings or good Class II evidence with appropriate sample size There are several Class II and III studies.

practice recommendations

practical possibilities

If no evidence is apparent, one can enumerate only practical options. The most common psychiatric diagnoses regarding transsexuality are scientically very poor. Cohen-Kettenis writes for example about the GID diagnosis (= Gender Identity Disorder): "Unfortunately, in the clinical research literature on adolescents and adults, such inter-rater reliability studies have not been done. Also, no structured interviews assessing DSM-IV-TR GID and GIDNOS diagnoses have been developed, and no comparisons have been made between clinical diagnoses and diagnoses based on structured interviews. This means that there is also a lack of formal validity studies in this area."3 An Evidence-based diagnosis of Gender Identity Disorder, Gender Dysphoria or transsexuality is not possible in the absence of such studies. There are no discussions in the scientic literature on an appropriate concept of Evidence-based medicine. For example, the exploration of transsexuality requires studies with small samples and small numbers of cases or individual case studies. Large prospective randomized studies can not easily be realized in this area. These deciencies of the evidence are contrary to the supposed fundamental importance of the assessment results for the following treatment steps. Cohen-Kettenis: "Important in the decision to maintain a distinct diagnosis is the question, whether or not the diagnosis can be made reliably, that is, whether dierent clinicians assessing the same persons will come to the same diagnoses. As noted earlier, this is especially important for the diagnosis of GID, because one of the most drastic medical treatments, sex reassignment surgery, may ensue from this diagnosis."4 Thus transsexual people are not diagnosed as mentally disturbed, because medical studies and research ndings suggest this. There are probably to suggest other, nonmedical reasons. Very enlightening is the following statement from the German sexologist Becker:

3 4

http://www.cpath.ca/wp-content/uploads/2009/08/COHEN-KETTENIS.DSM_.pdf http://www.cpath.ca/wpcontent/uploads/2009/08/COHEN-KETTENIS.DSM_.pdf

c 2012 SPD Uri, Altdorf (UR)

2 Arguments against the pahologization of transsexual people Die Medizin und (nachfolgend) Rechtsprechung und Gesetzgebung haben sich auf den Geltungsanspruch der Transsexuellen eingelassen und sind ihrem Verlangen nach Geschlechtswechsel bzw. Geschlechtsumwandlung (wenn auch mit Vorbehalten, Bedenken und entsprechenden Hrden) entgegengekommen. Medizin und Rechtsprechung haben durch ihr Entgegenkommen das transsexuelle Verlangen weitgehend unter ihre Kontrolle gebracht, nicht zuletzt im Interesse der Aufrechterhaltung der traditionellen Geschlechterordnung.5 ("The medicine and (in the following) administration of justice and legislation have got into the validity of claim of the transsexuals and have met their desire for gender change or sex change (even if with reservations, doubts and suitable barriers). Medicine and administration of justice have brought the transsexual desire extensively under their control by their obligingness, not least in the interest of the maintenance of the traditional gender order.")6 Reservations, concerns, barriers, control are important catchwords that characterize the dealings of society with transsexual people. The psychiatric discourse on transsexuality could be at the service of these functions. And concerning this matter one can look back on a longer tradition.

2.2 Psychiatric history: the tradition of the failure of psychiatric concepts of "transsexuality"
The 19th Century was characterized by broad societal changes. Industrial revolution and the beginning of domination of industrial capitalism brought about a profound culture shock. Churches/religious institutions complained a profound decline of morals and ethics. Medicine also participated in these discussions dominated by pessimism: "By 1890 there was a growing fear of degeneration sweeping across Europe creating disorders that led to poverty, crime, alcoholism, moral perversion and political violence. Degeneration raised the possibility that Europe may be creating a class of degenerate people who may attack the social norms, this led to support for a strong state which polices degenerates out of existence with the assistance of scientic identication."7 In particular, the French school of psychiatry especially Benedict Morel took the view, that mental illness by degeneration would increase generation to generation: rst generation: nervous temperament and debauchery second generation: stroke, epilepsy, hysteria, and alcoholism as well as in the
5

Becker, S.: Transsexualitt Geschlechtsidentittsstrung. In: Kockott, G.; E.-M. Fahrner (Hrsg.): Sexualstrungen. Thieme Verlag 2004 6 Very free translation by the author 7 http://en.wikipedia.org/wiki/Degeneration

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2 Arguments against the pahologization of transsexual people third generation: suicide, psychosis and mental retardation, and nally in the fourth generation: congenital malformations and mental deciency. German psychiatry was inuenced by the theories of Morel. In the early 1890s, Koch developed the term of psychopathy ("Psychopathische Minderwertigkeiten") as an generic term for "personality disorders". He postulated an innate psychopathic degeneration on the basis of an organ pathologically altered brain constitution. The interest in the psychiatric discourse of degeneration is not purely of academic nature or only of medical historical interest. The degeneration theory was the intellectual root of the crimes of Nazi psychiatry: the cruel consequences of the degeneration concept were the T4-action, so the euthanasia killings to "annihilate life unworthy of living". And Friedemann Pfin has recently pointed out that the sterilization directive that is included in the German Transsexual Act of 1980, should be regarded as a late extension of the degeneration theory: Neben der geschlechtsangleichenden Operation forderte das Transsexuellengesetz als Voraussetzung fr eine Personenstandsnderung die dauernde Fortpanzungsunfhigkeit des Antragstellers, ohne diese Forderung nher zu begrnden. Dabei stand einerseits wohl der nachvollziehbare Gedanke Pate, fr Kinder knnte es verwirrend sein, wenn sie als Eltern zwei Mtter oder zwei Vter htten. Doch spielte im Hintergrund vermutlich noch die alte Degenerationslehre der Psychiatrie eine entscheidende Rolle, die solche Menschen von der Fortpanzung ausschlieen wollte.8 ("Apart from the gender reassignment surgery, the transsexual law required as a precondition for a change of civil status of the applicant, the permanent infertility without justifying this claim in more detail. First, the idea was in the foreground that, it might be confusing for children if they had two mothers or two fathers as parents. But the background was resumably still the old degeneration theory of psychiatry, which would exclude such people from reproducing.")9 But back to the rst psychiatric concepts of transsexuality derived from the degeneration theory in the late 19th century. At that time the German psychiatrist von Krat-Ebing saw neuroses as a transition state to the degeneration, sexual "abnormalities" he regarded as a degeneration phenomena ("perversions", "sexual psychopathy"). Homosexuality and transsexuality were not distinguished yet by him. Both are to be expression of degeneration: "In this case, the cause is to be sought only in an anomaly of central conditions, in an abnormal psychosexual constitution. This constitution, as far as its anatomical and functional foundation is concerned, is as yet unknown.
8

F. Pfin: Pldoyer fr die Abschaung des Transsexuellengesetzes. In: Recht und Psychiatrie 2011, 29. Jahrgang, 2. Vierteljahr, 62 9 Very free translation by the author

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2 Arguments against the pahologization of transsexual people Since, in nearly all such cases, the individual tainted with inverted sexual instinct displays a neuropathic predisposition in several directions, and the latter may be brought into relation with hereditary degenerate conditions, this anomaly of psychosexual feeling may be called, clinically, a functional sign of degeneration. This inverted sexuality appears spontaneously, without external cause, with the development of sexual life, as an individual manifestation of an abnormal form of the vita sexualis. having the force of a congenital phenomenon; or it develops upon a sexuality the beginning of which was normal, as a result of very denite injurious inuences, and thus appears as an acquired anomaly. ... In so called antipathic sexual instinct there are degrees of the phenomenon which quite correspond with the degrees of predisposition of the individuals. Thus, in the milder cases, there is simple hermaphrodism; in more pronounced cases, only homosexual feeling and instinct but limited to the vita sexualis; in still more complete cases, the whole psychical personality, and even the bodily sensations are transformed so as to correspond with the sexual inversion; and, in the complete cases, the physical form is correspondingly altered."10 Krat-Ebing distinguished between several severe forms: "II. Degree: Eviration and Defemination. If, in cases of antipathic sexual instinct thus developed, no restoration occurs, then deep and lasting transformations of the psychical personality may occur. The process completing itself in this way may be briey designated viration (defemination in woman). The patient undergoes a deep change of character, particularly in his feelings and inclinations, which thus become those of a female. After this, he also feels himself to be a woman during the sexual act, has desire only for passive sexual indulgence, and, under certain circumstances, sinks to the level of a prostitute. In this condition of deep and more lasting psycho-sexual transformation, the individual is like unto the (congenital) urning of high grade. The possibility of a restoration of the previous mental and sexual personality seems in such a case, precluded."11 "III. Degree: Stage of Transition to Metamoiyhosis Sexualis Paranoica. A further degree of development is represented by those cases in which physical sensation is also transformed in the sense of a transmutatio sexus."12 "IV. Degree: Metamorphosis Sexualis Paranoica. A nal possible stage in this disease-process is the delusion of a transformation of sex. It arises on the basis of

10

Dr. R. v. KRAFFT-EBING: Psychopathia Sexualis WITH ESPECIAL REFERENCE TO ANTIPATHIC SEXUAL INSTINCT A MEDICO-FORENSIC STUDy THE ONLY AUTHORISED ENGLISH TRANSLATION OF THE TENTH GERMAN EDITION BY F. J. REBMAN NEW YORK LONDON 1899 271-272 11 Dr. R. v. KRAFFT-EBING: Psychopathia Sexualis ... 284 12 Dr. R. v. KRAFFT-EBING: Psychopathia Sexualis ... 292

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2 Arguments against the pahologization of transsexual people sexual neurasthenia that has developed into neurasthenia universalis, resulting in a mental disease, paranoia."13 Already at that time rst edition of the book in 1886 all important concepts are found with regard to transsexuality which were discussed during the next 100 years on the part of the psychiatry: perversion, abnormality, psychopathy (personality disorder) and delusion. In 1962 the German sexologist Giese summed up about transsexuality (he still called the phenomenon "transvestitism"): Beim Transvestitismus geht es prinzipiell um eine Angleichung des Verhaltens an das Geschlecht, das nicht zur Verfgung steht. Anders als der Narzit, der das vorhandene Inventar seiner Krpers mit Lustgewinn erlebt, bespiegelt sich der Transvestit erst bejahend nach vollzogener Umgestaltung und Geschlechtsumwandlung. Die Ausgangs- und kritische Prfsituation vor dem Spiegel ist die gleiche, wenn gleich mit sozusagen umgekehrten Vorzeichen, so dass man das Verhalten des Transvestiten mit Kronfeld als von exquisit narzitischer Art bezeichnen kann. Beide wollen sich in der Hauptsache darstellen. Die berwertige Idee, sich selbst krperlich und leiblich dem Idol anzugleichen, wird sehr oft bis in die letztmglichen Konsequenzen hinein durchgefochten, ebenso von Frauen wie von Mnnern: bernahme der andersgeschlechtlichen Kleidung, des Namens, der Ausweispapiere, des Genitalapparats (Kastration, Penisamputation, Scheidenplastik, Mammaamputation, Penisplastik), der sozialen Rolle ... Vom Spiegel geht der Bann aus, der den perversen Zirkel in Gang bringt und hlt: den leiblichen Verfall an die krperlich sinnliche Qualitt des Sehens ... die Progression und Schtigkeit, den weiteren Symptomausbau ... Oenbar handelt es sich [beim Transvestitismus] ... um eine psychogene Strung im Bereich der Wir-Bildung, die zumeist in die Kindheit zurckzuverfolgen ist.14 ("For transvestites it is crucial to approximate the behavior of the sex that is not available. Unlike the narcissist who experiences the available inventory of his body with desire prot the transvestite preens himself only armatively after carried out sex transformation. The initial and critical test situation before the mirror is the same albeit with so to speak contrary signs, so that one can describe the behavior of the transvestites with Kronfeld as of exquisitely narcissistic type. Both want to present themselves primarily. The obsession to adapt physically and bodily to the idol is very often fought till the last-possible consequences, as much by woman as by men: Takeover of the opposite-sex clothes, the name, the identication papers, the genital apparatus (castration, penis amputation, vaginal plastic, mammaamputation, penis plastic), the social role ... The mirror causes the fascination which gets going the perverted circle and maintains it: Dependence of the
13 14

Dr. R. v. KRAFFT-EBING: Psychopathia Sexualis ... 316 H. Giese: Psychopathologie der Sexualitt Stuttgart 1973, 43

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2 Arguments against the pahologization of transsexual people physically sensuous quality of the seeing ... the progression and addiction, the further expansion of symptoms ... Transvestitism apparently seems to be a psychogenic disorder in the eld of the identication-of-us which is to be traced back to the childhood in most cases.")15 Giese distinguished a spectrum of sexual disorders which ranged from mild cases (deviation) up to severe perversions. The severe perversions were characterized by progressive course sexual addiction decay of the sensuousness constant increase and dierentiation of the perverse imagination constant increase in renement of the perverse practices. Also Giese went back to the classical psychiatric view of transsexuality: It is classied as a perversion, there are deformations of the personality (comparison with the narcissist), he proceeds from a norm, moreover it is supposed to be a question of a psychic illness and there are aspects similar to delusion (obsession). Gieses meaning is to be regarded as controversial. Although he (like his mentor Hans Brger-Prinz) was a member of the NSDAP and was inuenced spiritually by the Nazis, he became an important mentor of the second (German) generation of sexologists. In particular, his follower, the psychiatrist and sexologist Volkmar Sigusch, tied in directly with Gieses theory of perversion. Sigusch in turn inuenced international discussions about transsexuality in the 1980s and 1990s signicantly. Sigusch wrote in 1980 (The text reads like an homage to the classic psychiatric theory of sexuality): Das, was Gebsattel (1931) und Giese (1962) phnomenologisch-psychiatrisch als schtig-perverse Entwicklung, als besondere Verlaufs- und Manifestationsform klassischer Perversionen mit Krankheitswert beschrieben haben, liegt nach unserem Dafrhalten grosso modo auch bei der entfalteten Transsexualitt vor. Man erinnere sich an die Leitsymptome ... an die Progredienz ohne Ende, das Suchtartige, das Drang- und Zwanghafte, das der typischen transsexuellen Entwicklung innewohnt, an die besessene Einengung, das Ausgeliefertsein und den unstillbaren Verfall an den Wunsch nach Geschlechtswechsel, und man hat die schtig-perverse Entwicklung der psychiatrischen Sexualforschung vor Augen. Brger-Prinz, Albrecht und Giese (1953/1966) sowie Burchard (1961) haben das keineswegs bersehen ... Wir neigen ... dazu, die echten Transsexuellen ... strukturell den Borderline-Pathologien zuzuordnen16
15 16

Very free translation by the author V. Sigusch: Die Untersuchung und Behandlung transsexueller Patienten. In: V. Sigusch (Ed.): Die Therapie sexueller Strungen. Stuttgart 1980, 304

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2 Arguments against the pahologization of transsexual people ("What Gebsattel (1932) and Giese (1962) phenomenolocally/psychiatrically described as an addicted-perverted development, as a special form of course and manifestation of classical perversions with illness value, is given according to our appraisal grosso modo also with the full-grown transsexuality. You remember the cardinal symptoms ... the progression without end, the addiction-like, the impulsive and the compulsive, inherent in the typical transsexual development, the obsessive restriction, the dependency, and the insatiable desire for sex change, which corresponds to the addictive perverse development as described by psychiatric research of sexuality. Brger-Prinz, Albrecht and Giese (1953/1966) as well as Burchard (1961) did not overlook that at all ... We tend ... to assign, the true transsexuals ... structurally to the borderline pathology")17 Still in the middle of the 1990s Sigusch described the typical transsexual person (one seen, everybody seen!): Im rztlichen Gesprch wirken Transsexuelle khl-distanziert und aektlos, starr, untangierbar und kompromisslos, egozentrisch, demonstrativ und ntigend, dranghaft besessen und eingeengt, merkwrdig uniform, normiert, durchtypisiert ... Introspektions- und bertragungsfhigkeit fehlen weitgehend ... Trotz oft unablssiger Schilderungen des Leidensweges drckt der Patient kaum Aekte aus. Bei oft gesten- und oskelreicher Redseligkeit wirkt der Patient stereotyp, monoton, fassadenhaft ... Die zwischenmenschlichen Beziehungen Transsexueller sind stark gestrt, weil ihnen Einfhlungsvermgen und Bindungsfhigkeit weitgehend fehlen ... Alle Transsexuellen weisen eine Tendenz zum psychotischen Zusammenbruch unter Stress, in Krisensituationen auf.18 ("In the medical interview ranssexuals seem distant and aectless cool, rigid, emotionally untouchable and uncompromising, egocentric, demonstrative and threatening, liable obsessed, xated, strangely uniform, standardized, stereotypical ... the ability for introspection and transference are largely missing. Although the patient constantly describes his painful life, he looks aectless. Inspite of often incessant descriptions of his painful life the patient hardly expresses aects. With a talkativeness often accompanied by a lot of gestures and phrases the patient seems stereotypical, monotonous like a mask . ... The interpersonal relationships of transsexuals are very disturbed, because they largely lack empathy and the ability to bind ... All transsexuals have a tendency to psychotic breakdown under stress, in crisis situations.")19
17 18

Very free translation by the author Sigusch, V.: Leitsymptome transsexueller Entwicklungen. Wandel und Revision. In: Deutsches rzteblatt (1994), Nr. 91, 145558 19 Very free translation by the author

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2 Arguments against the pahologization of transsexual people The same author published in the following year a paper in which he stated to the failure of previous attempts to pathologize transsexual people. He also raised moral concerns and pointing to historical examples he showed the disastrous role of psychiatry: Im Laufe der Jahrzehnte ist der Transsexualismus beinahe allen bereitstehenden nosologischen Entitten mehr oder weniger bndig zugeordnet worden: Psychosen, Neurosen, Borderline-Strukturen, Fetischismus, Masochismus, negative Perversion, Homosexualitt, homosexuelle Panikreaktion (sog. Kempfsche Krankheit) ... Fahren wir damit fort, den Transsexualismus in erster Hinsicht oder ganz und gar tiopathogenetisch zu betrachten, werden wir Expertengeneration um Expertengeneration die jeweils in Kurs gesetzten psycho- und somatologischen Theorien an ihn anlegen und immer wieder vergeblich versuchen, das Rtsel der Metamorphosis sexualis paranoica zu lsen, von der vor einhundertjahren v. Krat-Ebing (1894, S. 224) gesprochen hat ... Eine Frage wre beispielsweise, worin das Gemeinsame, nicht der Unterschied besteht, wenn Psychiater am Beginn des Jahrhunderts (und weit darber hinaus) ganz sicher sind, bei Revolutionren eine bestimmte Psychopathie und bei Frauen, die sich Verhaltensweisen von Mnnern herausnahmen, einen moralischen Schwachsinn diagnostizieren zu knnen; oder wenn Psychoanalytiker wie Socarides (...) die Homosexualitt schon in der Adoleszenz aufspren, bekmpfen und generell verhten wollen, weil es bei Menschen mit dieser Neigung keine wirkliche Wahrnehmung des Partners oder seiner Gefhle, vielmehr lediglich einen anatomischen Haut- und Schleimhautkontakt gebe; oder wenn wir selbst auf dem Boden der jetzt oder immer noch herrschenden Ideologien und Krankheitslehren am Ende des Jahrhunderts zu dem Schlu kommen, da bei Transsexuellen eine BorderlinePathologie vorliege.20 ("Over the decades transsexuality has been assigned to almost all available nosological entities: psychoses, neuroses, borderline structures, fetishism, masochism, negative perversion, homosexuality, homosexual panic reaction (so-called Kempf disease) ... If we proceed to consider the transsexuality primarily or entirely etiopathogenetic, then we will continue to apply the current psycho- and somatological theories (experts generation for experts generation) and we will keep trying in vain to solve the mystery of metamorphosis sexualis paranoica (about this Krat-Ebing wrote a hundred years ago) ... A question would be, for example in what the common exists (not the dierence) if psychiatrists can diagnose at the beginning of the century (and far beyond it) condently, with revolutionary people a certain psychopathy and with the women who arrogated behaviour patterns of men, a moral dementia; or if such psychoanalysts as for example Socarides (...) who wants to track down, ght and in general already prevent the homosexuality in the adolescence because people with this inclination would have no real
20

Sigusch, Volkmar: Transsexueller Wunsch und zissexuelle Abwehr. Psyche - Zeitschrift fr Psychoanalyse 1995, 49, 811-837

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2 Arguments against the pahologization of transsexual people perception of the partner or his feelings, rather there is on their side only an anatomical skin and mucous membrane contact; or if we ourselves come topically at the end of the century on the basis of ruling ideologies and illness apprenticeships to the logical end that with transsexuals a Borderline pathology is given.")21 This classic psychiatry of transsexuality has had its day. Not least because human rights movements, United Nations and other political institutions express criticism on the psychiatrization of transsexual people. After the failure of classical psychiatry on the subject of transsexuality in the Mid1990s, the APA attempted to create in the fourth revision of the DSM-IV with Gender Identity Disorder a psychiatric diagnosis that seemed to be more innocuous. It was a snap decision: In developing the GID diagnosis the APA committee deviated from the usual way: In a decades lasting continuous professional debate psychiatric diagnoses are usually well-founded and developed very slowly by many case studies and discussions in scientic journals and at conferences. Already with the following DSM check the GID diagnosis also seems to have retired (lack of evidence base, see above), the discussions about Gender Dysphoria are a sign for this. The WPATH has presented, in the meantime, the 7th version of the standards of Care. In this version it is still held on to the psychopathologization of the transsexuality, now they favour the Gender Dysphoria (instead of the old GID) as a diagnosis. It seems that the WPATH have reacted to the increasing criticism of organisations of human rights and want to calm the critics by a skilful wording, a "soft-psychopathologization" and the denition of a psychic "soft disturbance". It is calmed down: "WPATH released a statement in May 2010 urging the de-psychopathologization of gender nonconformity worldwide ... Thus, transsexual, transgender, and gender nonconforming individuals are not inherently disordered. Rather, the distress of gender dysphoria, when present, is the concern that might be diagnosable and for which various treatment options are available"22 In spite of owery deferentially appearing formulation: there remains the fact that a psychic disorder is diagnosed. The implied assertion, the medical treatment requires a psychiatric diagnosis, cannot be maintained as we will still see. The medicine can be demanded, even if topically no disorder or illness is given.

21 22

Very free translation by the author WPATH: Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. 2011. URL http://www.wpath.org/documents/

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2 Arguments against the pahologization of transsexual people

2.3 Psychiatric treatment and/or psychotherapy can not diminish the characteristics of transsexuality or make them go away
Any genuine mental disorder may be treated in a psychiatric and psychotherapeutic way more or less successfully. It is considered as a success when the intensity of mental disorder decreases or mental disorder disappears at all, at least some symptoms should diminish in intensity or frequency of occurrence. This is true even for a mental disorder such as dementia: psychiatry here is trying to slow down the mental decline. Already in the 1960s the ineectiveness of psychiatric therapies of the "transsexualism" was generally noted. Burchard stated in 1961 that the usual psychiatric therapy had failed in any form.23 What this meant more precisely Sigusch described 15 years later: "The times, in which transsexuals were placed in psychiatric hospitals, were shocked with insulin, maltreated with electric power, imprisoned for psychotherapy or even operated on the the brain are a thing of the past."24 Likewise unquestioned is the fact, that a "retuning" of grown up transsexual people by psychotherapy is an impossible task, be it by psychoanalytic psychotherapy or by behavior therapy. All eorts by psychoanalysis to develop a usable theory of disorders in order to identify the roots of "incorrigible belief" of transsexual people have failed. Raucheisch noted: Obwohl sich in der Fachliteratur verschiedene psychodynamische berlegungen dazu nden, auf welche Weise eine solche Strung der Geschlechtsidentitt entstanden sein knnte, sind diese bei einzelnen transsexuellen Menschen gesammelten Beobachtungen usserst hypothetisch und nden sich durchaus auch in Familien Nicht-Transsexueller. Als psychodynamische Ursachen sind unter anderem genannt worden: der (oft unbewusste, zum Teil aber direkt ausagierte) Wunsch der Eltern, ein Kind des anderen Geschlechts zu haben; das eher weibliche() Aussehen und Verhalten des spteren Mannzu-Frau-Transsexuellen und das eher mnnliche() Aussehen und Verhalten der spteren Frau-zu-Mann-Transsexuellen; die (unbewusste) Tendenz eines Elternteils, das Kind dem Gegengeschlecht zuzuweisen, um damit den anderen Elternteil zu verletzen; das Fehlen oder die stark negative Besetzung des gleichgeschlechtlichen Elternteils, wodurch das Kind zur Identikation mit dem gegengeschlechtlichen Elternteil gedrngt werde; der Transsexualismus stelle eine Form der verdrngten, als verpnt erlebten, nicht akzeptierten eigenen Homosexualitt dar.25 ("Although one can nd in literature dierent psychodynamic thoughts about how such a gender identity disorder may have come into being: the
23

J.M. Burchard: Struktur und Soziologie des Transvestitismus und Transsexualismus. Beitrge zur Sexualforschung, Heft 21. Stuttgart 1961, 60 24 V. Sigusch: Transsexueller Wunsch und zissexuelle Abwehr. Psyche - Zeitschrift fr Psychoanalyse 49, 811-837, 1995 25 Raucheisch, U.: Transsexualitt Transidentitt. 2006, 19f.

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2 Arguments against the pahologization of transsexual people collected observations of individual transsexual people appear extremely hypothetical and can also be found in families of non-transsexual people. As psychodynamic causes have been referred among others: the (often unconscious, partly acted out directly) wish of the parents having a child of the opposite sex; the more feminine appearance and behavior of the male-tofemale transsexual people and the more masculine look and feel of femaleto-male ones; the (unconscious) tendency of a parent, to assign the child to the opposite sex in order to oend the other parent; the absence or the very negative meaning of the same sex parent, thus the child was forced to identify with the opposite sex parent; transsexuality is constituted as a form of repressed, rejected and not accepted own homosexuality.")26 In spite of these clear failures to prove a psychogenesis of the transsexuality, attempts were started stubbornly in the past converting in particular transsexual children in the direction of the gender assigned in birth. This has been euphemistically referred to as "reparative therapy". In particular, the Canadian sexologist Kenneth Zucker gained notoriety with those attempts (at least for the human rights organizations of transsexual people).27 Apart from the aspect of violation of human rights a set of studies (starting in the 1960s) provide evidence that such interventions can be classied as consistently unsuccessful.28 Regarding the theoretical foundations and eectiveness of these "treatments" there is no evidence.29 This is not surprising at all, because from a neurobiological point of view could be demonstrated that 70% of the "cross-dresser-behavior" of children can be attributed to genetic factors (see below).30 Moreover, those "therapy" concepts are based on theories which postulate specic family dynamics as a psychogenic cause of childlike transsexuality. Its pretty speculative to assume these causes (see above). From the neuropsychological point of view those "training trials" have no therapeutic
26 27

Very free translation by the author For this, the remarks by Lynn Conway on a website that deals with the ethical side of this issue: http://ai.eecs.umich.edu/people/conway/TS/News/News.html 28 Examples: Greenson, R. R.: On homosexuality and gender identity. International Journal of Psycho-Analysis, 1964, 45, 217-219. Gelder, M. G.; Marks, I. M.: Aversion treatment in transvestism and transsexualism. In R. Green; J. Money (Eds.), Transsexualism and sex reassignment (pp. 383-413). Baltimore 1969. Pauly, I. B. (1965). Male psychosexual inversion: Transsexualism: A review of 100 cases. Archives of General Psychiatry, 13(2), 172-181. Cohen-Kettenis, P. T.; Kuiper, A. J.: Transseksualiteit en psychothrapie. Tjdschrift Voor Psychotherapie, 1984, 10, 153-166. 29 which is acknowledged even by the users of the "therapy" somewhat shameful: "Because larger prospective studies are missing, particularly on the originating conditions, it seems necessary to reduce the demands on the evidence of dierent aetiological concepts a little" In: A. Korte; D. Goecker; H. Krude; U. Lehmkuhl; A. Grters-Kieslich; K.M. Beier: Geschlechtsidentittsstrungen im Kindesund Jugendalter. Deutsches rzteblatt J.105, 2008, Heft 48, 834. 30 C. E. M. van Beijsterveldt; James J. Hudziak; Dorret I. Boomsma: Genetic and Environmental Inuences on Cross-Gender Behavior and Relation to Behavior Problems: A Study of Dutch Twins at Ages 7 and 10 Years. Arch Sex Behav (2006) 35: 647658

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2 Arguments against the pahologization of transsexual people qualities: Although they rarely use direct aversive stimuli and direct sanctions, however they "take away" and "prevent" (eg, toys, cross-dressing), undesirable behavior is ignored. Dopaminergic, rewarding, sustained self-learning and exploring in open, communicative and satisfying relationships, as it assesses the neuroscience as essential for successful learning, can not be realized in such reparative settings. So there are: serious shortcomings of theoretical foundation the lack of evidence-based case studies and case histories in trans*-variant children and insucient evidence of ecacy. Not only human rights organizations, but also the majority of the scientic community reject such training trials ("something disturbingly close to reparative therapy for homosexuals"31 ). WPATH even had to admit in their recent SoC7 that such reparative therapy in children would violate ethical principles32 . Nevertheless, outsiders as Zucker could nd adepts in various countries, in Germany, for example, a sexologist named Beier and his colleagues propagate zealously "repairs" for trans*-variant children and try to make this acceptable: "The primary therapeutic principle in dealing with genderidentity disordered children is to strengthen the sense of belonging to the birth sex"33 . After all, this was published in one of the most widely read German medical journal, the "Deutsches rzteblatt". The steadfast certainty is ultimately the signum of transsexual people, which was formerly denounced as a delusion and which must be simply accepted now. Conclusion: One can only treat those phenomena in the logic of psychiatry successfully, which also have psychiatric disorder character. Not every individual phenomenon, which is maybe associated with suering, is therefore an issue of psychiatry.

2.4 Neuroscience: Towards a new paradigm of transsexuality as a neurobiological variation of sexual dierentiation and development
Without Milton Diamonds lifework the preparation of new neurobiological paradigm of transsexuality would have been very dicult. His famous phrase "Nature loves variety. Unfortunately, society hates it" was the leitmotif in the development of the new

31

s. Pickstone-Taylor, Simon D. (2003). Children with gender nonconformity. Journal of the American Academy of Child and Adolescent Psychiatry, 42, 266. 32 "Treatment aimed at trying to change a persons gender identity and expression to become more congruent with sex assigned at birth has been attempted in the past without success ... particularly in the long term ... Such treatment is no longer considered ethical." (SoC7 S. 16) 33 In: A. Korte; D. Goecker; H. Krude; U. Lehmkuhl; A. Grters-Kieslich; K.M. Beier: Geschlechtsidentittsstrungen im Kindes- und Jugendalter. Deutsches rzteblatt J.105, 2008, Heft 48, 840

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2 Arguments against the pahologization of transsexual people paradigm. Since 1965, he has gradually been working out in his publications that transsexuality seems to be a form of brain intersex.34 An important milestone on the way to the new paradigm was the GIRES-Review in 2006, during its nalization Milton Diamond played a major role. The list of authors of this article reads like a "Whos Who?" of international research charcters who deal with transsexuality. In this review, they summarized the current state of knowledge (2006) about the role of the brain in the development of transsexuality as follows: "In sum, gender identity, whether consistent or inconsistent with other sex characteristics, may be understood to be "much less a matter of choice and much more a matter of biology" (Coolidge et al., 2000). The scientic evidence supports the paradigm that transsexualism is strongly associated with the neurodevelopment of the brain (Zhou et al., 1995; Kruijver et al., 2000). It is clear that the condition cannot necessarily be overcome by "consistent psychological socialisation as male or female from very early childhood" and it is not responsive to psychological or psychiatric treatments alone (Green, 1999). It is understood that during the fetal period the brain is potentially subject to the organising properties of sex hormones (Kruijver et al., 2000; 2001; 2002; 2003). In the case of transsexualism, these eects appear to be atypical, resulting in sex-reversal in the structure of the BSTc, and possibly other, as yet unidentied, loci (Kruijver, 2004). The etiological pathways leading to this inconsistent development almost certainly vary from individual to individual, so no single route is likely to be identied. Dierent genetic, hormonal and environmental factors, acting separately or in combination with each other, are likely to be involved in inuencing the
34

The following articles are important to mention here: 1965 A Critical Evaluation of the Ontogeny of Human Sexual Behavior; 1974 Transsexualism, 1977 Human Sexual Development: Biological Foundations for Social Development; 1993 Some Genetic Considerations in the Development of Sexual Orientation; 1995 Biological Aspects of Sexual Orientation and Identity; 1997 Self-Testing: A Check on Sexual Identity and Other Levels of Sexuality; 1997 Sexual identity and sexual orientation in children with traumatized or ambiguous genitalia; 1997 Sex Reassignment at Birth: A Long Term Review and Clinical Implications; 2000 Sex and Gender: Same or Dierent?; 2002 Sex and Gender are Dierent: Sexual Identity and Gender Identity are Dierent; 2002 A Conversation with Dr. Milton Diamond; 2003 Whats in a name? Some terms used in the Discussion of Sex and Gender; 2004 Sex, Gender, and Identity over the Years: A changing perspective; 2005 Transsexuality, Intersexuality and Ethics; 2006 The Right to be Wrong: Sex and Gender Decisions; 2006 Atypical Gender Development: a review, 2006 Biased-Interaction Theory of Psychosexual Development: "How Does One Know if One is Male or Female?"; 2006 Variations of Sex Development Instead of Disorders of Sex Development; 2010 Intersexuality; 2011 Developmental, Sexual and Reproductive Neuroendocrinology: Historical, Clinical and Ethical Considerations

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2 Arguments against the pahologization of transsexual people development of the psychological identication as male or female. Psychosocial factors and cultural mores are likely to impact on outcomes (Connolly, 2003)."35 An important core idea is the following: there have to be postulated very dierent, very individual cause-eect pathways, similar to the intersex variations transsexuality is also a complex and multifaceted phenomenon. The research results in recent years have conrmed this. In particular, the genetics made important discoveries. Lauren Hare and colleagues summarized the results of their genetics study as follows: "In conclusion, our ndings indicate a signicant association between maleto-female transsexualism and the long polymorphism for the AR repeat. This nding links the androgen receptor and further implicates genes in the steroidogenesis pathway as playing a role in male-to-female transsexualism. We speculate that reduced androgen and androgen signalling might contribute to the female gender identity of male-to-female transsexuals. Further studies including replication in other populations, larger patient collections, and analysis of other polymorphisms, both for the genes studied here and other sex steroidogenesis genes, should be undertaken."36 Another important study in recent years has been the work of van Beijsterveldt and colleagues. This twin study (7 and 10 year-old twins) showed a surprising result: "Genetic structural equation modeling showed that 70% of the variance in the liability of cross-gender behavior could be explained by genetic factors, at both ages and for both sexes."37 Given the growing importance of genetics, it is appropriate to include their conceptual models even more. The discussions on polymorphisms and concordance show that genetic variants play a big role in transsexuality. Genetics, molecular genetics, in particular, is concerned primarily with variations. Diseases and disorders, however, are not a genuine subject of genetics. Geneticists refer their variants to models of disease which might have been delivered by medicine, or in the language of genetics: they investigate which variations are coupled with medical illnesses. Because transsexuality can currently not be based on an evidence-based disease model, and is apparently associated with genetic variations, it is advisable to leave it at rst (in the absence of any useful disease models) in the understanding of transsexuality as a variation.
35

GIRES: Diamond, M. et al. Atypical Gender Development: a Review International Journal of Transgenderism 9(1): 29-44, 2006 36 Lauren Hare, Pascal Bernard, Francisco J. Snchez, Paul N. Baird, Eric Vilain, Trudy Kennedy and Vincent R. Harley: Androgen Receptor Repeat Length Polymorphism Associated with Male-toFemale Transsexualism. BIOL PSYCHIATRY 2009;65:9396 37 C.E.M. van Beijsterveldt; James J. Hudziak; Dorret I. Boomsma: Genetic and Environmental Inuences on Cross-Gender Behavior and Relation to Behavior Problems: A Study of Dutch Twins at Ages 7 and 10 Years. Arch Sex Behav (2006) 35:647658

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2 Arguments against the pahologization of transsexual people Milton Diamond has the discussion about the brain sex of transsexuality summarizing determined that transsexuality must be a form of "brain sex" intersexuality. At the same time he speaks of "Trans-Variations": "Many people make a clear and sometime very vocal distinction between intersexuality and transsexuality. Most opposition to linking these two concepts or categories come from those intersexed individuals who think their own situation in the public eye is somehow diminished by the association. This is regrettable. Both of these sexual minorities are stigmatized in society and I think they not only should rather be allies in their ght against discrimination, but also, actually think they have things in common. I maintain that transsexuality is a form of intersex. I conclude this derived from my own clinical experiences, my own experimental research, and knowledge of the research of others. I accept that my thoughts on this matter are a minority view among colleagues and fellow scientists. I believe that transsexuals are intersexed in their brains as others are or might be more obviously so in their gonads, genitals, hormonal character, receptor, enzymatic or chromosomal constitution. And it is this brain intersexuality that biases the person to assert his or her gender identity. As one can vary on a Kinsey scale from 0 to 6, and can uctuate during ones life so too can one vary from 0 to 6 on the Benjamin scale (Benjamin 1966) demonstrating dierent degrees of a trans identity. This can be manifested from occasional cross-dressing to a full-time transsexuality where a person desires to live full-time in a mode dierent from the way he or she was born and raised. And this gender identity can uctuate from mild to intense during dierent times in ones life and in reaction to a variety of life experiences. These reect dierences, not disorders, of identity. While some persons are seriously impaired by these conicts of identity and societies views of propriety and might need and desire help in resolution, others have managed to come to terms with their inherent biases and the negative social demands they encounter and see no need for counseling or therapy. While some may be seriously psychically disturbed and require or desire counseling or medical assistance, I dont see persons with trans variations as mentally ill based solely on their manifestation of a trans condition. And certainly there are examples enough where obviously intersexed persons reared in one gender have decided later in life to switch to the other."38 Given the current state of scientic knowledge it is useful to speak of transsexual and transgender variations of sexual dierentiation and development. Also regarding intersexuality Diamond rejects the construct of a Disorder of Sexual Development (DSD) and speaks of variation (= Variation of Sexual Development; VSD) here as well. Transsexuality should be discussed as a special "TVSD". Or as a Brain Sex Variation of Sexual Dierentiation and Development (BSVSD).
38

Diamond, M.: Intersexuality. 2010. http://www.hawaii.edu/PCSS/biblio/articles/2010to2014/ 2010-intersexuality.html

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2 Arguments against the pahologization of transsexual people Variation does not mean at all that this is per se "harmless" and excludes suering. Such sexual identity variations may be associated with serious and continiously worsening pain. They are always associated with very high health risks. Suering and risks are increased by transphobic social structures and practices. The view of a variation has important consequences. Since there is not the transsexual person, but highly individual variations of the course, a personal approach to care is necessary, which is based on personal needs. Because transsexuality may be associated with extraordinary suering, low-threshold care facilities are the only human rightscompliant solution. The current practice of forcing transsexual people in a stage scheme, could result in additional pain and suering. The stage model for decades promoted by the WPATH means that interventions, rapidly onset, and adequate to the suering may be denied to sexual transsexual people and sending them to painful waiting loops. Apart from the fact that the WPATH staging system is not at all evidence-based.39 Given the lack of evidence-based ndings WPATH would do better instead of proclaiming "standards" to stay modest and only enumerate the possibilities of care of transsexual people. The latter approach would be the only scientically-reputable. The barriers built by many national administrations, for example in the civil status change or the change of birth certicates have similar consequences. The medicine and the state governments have developed adequate tools and methods to mitigate to reduce and eventually stop the suering of transsexual people. There are plenty of measures to promote the health of transsexual people adequately. What is lacking is the will to break down barriers and to coordinate overall well all measures required by the clients; the clients participation here is the crucial point. Individually we have some good tools, but there is no coherent "concert" This means support from a holistic client-centered medical case management, but also requires that the individual transsexual person should no longer be confronted with administrative problems. It all comes down to the personal needs. Transsexuality is not a disease but a variation that has many health risks. Those risks require low-threshold medical care und administrative support, if it is desired.

2.5 With transsexuality there are as opposed to psychological disorders no fundamental social function limitations
In almost all mental disorders there are pathognomonic social function limitations, ie the profound social impairment is a core characteristic of the mental disorder. An example: Every person can feel fear. This is nothing special. But if a person can not go away from home because of the fear and the person is blocked in his or her everyday life activities, in this case one can speak of an anxiety disorder that is a mental disorder. Any type of mental disorder - anxiety, anankasm, dementia, depression, mania, schizophrenia, post
39

Monstrey, S.; Vercruysse, H.; De Cuypere, G.: Is Gender Reassignment Surgery Evidence Based? Recommendation for the Seventh Version of the WPATH Standards of Care. In: International Journal of Transgenderism (2009), Nr. 11, 20614

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2 Arguments against the pahologization of transsexual people traumatic stress disorder, autism spectrum disorder, ADHD, etc. - has a typical, specic social impairment. The following statements are not evidence-based, but the case histories available to us allow clear conclusions: The majority of transsexual people has no social function limitations. Based on the available studies40 two-thirds of transsexual people are to be classied as mentally trouble free. The nding of the absence of mental disorders among transsexual people is not new at all; Schorsch wrote in 1974(!): Von den extrem seltenen Fllen abgesehen, bei denen die Transsexualitt Symptom einer Geistes- oder Gehirnkrankheit ist, ndet sich eine Transsexualitt bei meist psychisch nicht gestrten, im Durchschnitt gut intelligenten Persnlichkeiten ... Wenn sich jedoch im Laufe der Entwicklung besonders bei mnnlichen Transsexuellen in zunehmendem Mae psychische Beeintrchtigungen nden, dann sind sie meist Folge des starken sozialen Drucks und der dadurch bedingten Konikte, denen eine Minoritt ausgesetzt ist.41 ("Apart from the extremely rare cases in which transsexuality is a symptom of a mental or brain disease, transsexuality is found with on average well intelligent personalities who are usually not mentally disordered ... If, however, in the course of development, particularly in male transsexuals occur psychological impairment to an increasing degree, it is usually the result of the strong social pressure and the resulting conicts that they experience as a minority.")42 Raucheisch points out, that in the face of dicult circumstances transsexual people should dispose of strength, mental health and high social resilience, that is a good social functioning, to pass the obstacle-rich way of transition: Immer wieder bin ich mit transsexuellen Frauen und Mnnern zusammengetroen, die ... keinerlei psychopathologische Zeichen erkennen liessen und im Gegenteil eine grosse psychische Stabilitt aufwiesen. Allfllig auftretende Depressionen, Angstentwicklungen und andere Strungen erwiesen sich hug als Folgen der schwierigen Lebensumstnde, in denen sich transsexuelle Menschen auch heute noch oft benden. Etliche von ihnen verfgen aber ber eine grosse Belastungsfhgikeit, die es ihnen ermglichte, ihre zum Teil schwierigen Lebensumstnde ... mit Bravour zu meistern, eine Leistung, der ich meine ungeteilte Hochachtung zolle.43 ("Again and again I met transsexual women and men, who showed ... no psychopathological signs and - on the contrary - had a great mental stability. Any occurring depressions, anxiety disorders and other developments often
40

Gives a good overview e.g. Peper, C.: Klientel der Sprechstunde fr transsexuelle Patienten an einer Universitts-Poliklinik fr Psychiatrie: Eine deskriptive Studie. 2003 65 41 E. Schorsch: Phnomenologie der Transsexualitt. Therapie: Geschlechtsumwandlung ohne Alternative. Sexualmed 1974, 3: 195 42 Very free translation by the author 43 U. Raucheisch: Transsexualitt Transidentitt, Gttingen 2006 7f.

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2 Arguments against the pahologization of transsexual people proved as consequences of the dicult circumstances in which transsexual people are often still found even today. But a lot of them have a great carrying capacity, which enabled them to cope with their dicult living conditions ... with ying colors, a feat I hold in high regard without limitation.")44 Conclusion: Where there is no mental disorder, there is also no social impairment. Insofar it is imperative as well: transsexuality is healthy.

2.6 In contrast to mental disorders in transsexuality clinical neuropsychological disorders are not evident
The neuro-psychiatric research has been able to prove in the last 15 years that most prolonged mental disorders are associated with clinical-neuropsychological disorders or that neuropsychological decits are directly part of the psychiatric symptoms. In particular, psychological tests showed: Such disorders such as dementia, Korsakos syndrome, chronic depressions, schizophrenia, posttraumatic stress disorder, borderline personality disorders, anankasm, Austismus spectrum disorders or ADHD are associated with disorders in attention, memory and executive functions, which are objectiable in psychological tests.45 . One can prove impaired neuropsychological functions also better and better with the methods of the Electrical Neuroimaging (High-Density EEG, EEG Brain Mapping). The cognitive performance spectrum of transsexual individuals has been studied accurately as well (especially by neuropsychological tests) in recent years. They focused especially on the sexual specicity of neuropsychological functions. They studied, for example, whether the cognitive functions of transsexual women are similar to those of non-transsexual women. The results of these studies showed inconsistent results. One important result, however, was consistent: none of these studies found evidence for impaired neuropsychological functions in transsexual people.

2.7 There were/are many cultures and societies in which transsexual and transgender people can/could develop stable lifestyles and cultures appropriate for them. These cultures were/are an expression of social normality and healthy everyday culture, not an expression of a pathological derangement
Anthropology and cultural studies provide many examples of traditional social structures that allow intersex, transsexual or transgender people
44 45

Very free translation by the author a good overview can be found in: S. Lautenbacher,; S. Gauggel: Neuropsychologie psychischer Strungen. Berlin Heidelberg 2004

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2 Arguments against the pahologization of transsexual people to develop particular adequate ways of living or to adapt socially and culturally preformed or ritualized ways of life relevant for them or to adjust to the culture in corresponding cultural communities. A well-known example are the hijras (estimates up to 5 million hijras in India) with superordinate social, local, regional and pan-Indian organization structures: "The matrilineal chains for hijras therefore represent a stable social network that ensures the old age and health security system"46 It is a matter of a millennia-old cultural tradition of socially anchored "third sex". There have been desribed other various forms of the third sex as Berdache and Kathoy (an estimated 300,000 Kathoy in Thailand). Remarkable is: inspite of the fact that the ways of living are traditionally embedded in society, Hijras as well as Kathoys have to deal with oppression and human rights violations.47 48 From a psychiatric point of view it is implausible that such broad-based cultural traditions and ways of living should be an expression of mental derangement. Rather it has to be assumed that there are realized alternative ways of life on the basis of variations of sexual identity, for which in these societies there are specic cultural elds and facilities.

46

E. Fels: Das Geschlecht jenseits der Dualitt. Eine komprimierte Darstellung der dritten Geschlechtsposition Indiens. Erschienen in: Traude Pillai-Vetschera (Hrsg.); Zwischen gestern und bermorgen Sdasiatische Frauen im Spannungsfeld zwischen Gesellschaft, Politik und Spiritualitt. Frankfurt am Main, 2002, 236-256 47 Another and more in-depth material on the wide range of life options for TG/TS in Asian countries can be found on the pages of transgender Asia, which is maintained by Prof. Sam Winter, who teaches at the University of Hong Kong: http://web.hku.hk/~sjwinter/TransgenderASIA/ 48 on the situation of hijras see also http://ai.eecs.umich.edu/people/conway/TS/DE/TSDE-II.html# anchor172830

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3 Recommendations and Possibilities

There are still signicant deciencies on the subject of transsexuality regarding evidence base. This concerns the "diagnosis" and "therapy". Psychiatry is on this issue only relevant if transsexual people secondaryly and reactively get psychological problems, such as induced by discrimination, or they get mentally ill (totally independent of their transsexuality), just as any person whether or not a transsexual can get mentally ill. The clues gain intensity that transsexuality is to be regarded as a neurobiological condition. But also in this respect, further work is needed to detect the complexity of neurophysiological, neurochemical and neurogenetic mechanisms and neuroanatomical structuredness even better. Milton Diamond, for example, sees in this context, the most signicant opportunities of ndings for the future: "As we started this discussion, I said that people like to nd anatomical dierences between male and female brains theyre easier to see and understand than thinking dierences. The biggest dierences may not be in big structures, like an interstitial nucleus, or a BSTc. It may be in the dendrites, or the connections the nerves make. It may be in brain biochemistry. Im reminded of a joke. A guy sees his friend looking under a lamppost and the conversation goes something like this: What are you doing? Im looking for the watch I lost. Whered you lose it? I lost it down the street. Well, why are you looking here? Theres better light here. Thats what happens when we look for big things where the light is better. But the crucial answers we are looking for may require techniques not yet available or understand. We may have to look at some dierent hormones combinations, we may have to look at some biochemical reactions, some genetic thing that we dont know yet. Were just beginning to peel back the layers of the onion, as it were. And each time we come to a mole on the onion we say Hey, look at this mole. Well, it may just be a mole; we still have to get down to the core of the onion and understand the contribution of all its layers. I do believe there are dierences yet to be discovered in

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3 Recommendations and Possibilities the hypothalamus and in the stria terminalis, and in basal ganglia, in the amygdala in the forebrain and the cortex. Unfortunately we dont yet know how to measure them. When we rst came up with xrays or hologrames, people began to use those as images and analogies for how the brain works; now people make analogies between the brain and the computer. We might even have to nd new ways to conceptualize these complicated workings of the brain. Were still learning. . . we know a lot about the brain, but were also ignorant of many things about it."49 That was in 2002. Meanwhile, science has progressed in motion on the subject of transsexuality, but important work projects are still pending. Our knowledge and practice are on the move. Therefore, it would make sense to proceed in a very modest way. Let us rst assume that transsexuality is just a neurobiological condition, or in other words, a transsexual, transgender variation of sexual dierentiation and development, as a brain-sex form of intersexuality. For a psychiatric classication, there is no evidence. Therefore, transsexuality should be removed from the ICD chapter F. There are several ways to reassign: eg chapter Q or as a special case in chapter U. The relevant texts to describe the phenomenon should be dened as wide as possible, "hard denitions" should be avoided for a start. Thereby it is clear that transsexuality is a condition with extremely high health risks. Therefore, medical care and support is necessary, which is oriented towards the personal needs of transsexual people and should act according to the principle of medical case management. As with other high-risk groups as well (premature babies, pregnant women, etc.), medical care is "a priori" necessary to prevent health problems. This is not therapy. The direction of future work projects, Diamond aptly outlined.50 He demands the implementation of long-term composed collections of cases (case registers, as they have been established already with many conditions which were previously treated as a taboo (eg intersexuality)). These are subject to strict data protection and are administered with the involvement of Human Rights Movements and data protection authorities. The purpose is that gradually societal knowledge about the needs, experiences and distress of transsexual people is accumulated. For, as Milton Diamond notes rightly: the care of transsexual people is still based on life stories experienced by individual practitioners. In connection therewith, the scientic discussion of transsexuality should nally gain access to the tradition of Evidence-based medicine. That means forcing a concept of Evidence-based medicine, which meets the characteristics of transsexuality accordingly designed reviews
49

A Conversation with Dr. Milton Diamond; Interviewer/Author: Dean KotulaPublished: The Phallus Palace: Female to Male Transsexuals, Dean Kotula. http://www.hawaii.edu/PCSS/biblio/ articles/2000to2004/2002-conversation.html 50 Author: Milton Diamond Ph.D.: Developmental, Sexual and Reproductive Neuroendocrinology: Historical, Clinical and Ethical Considerations; Published in: Frontiers in Neuroendocrinology, Volume 32, Issue 2, April 2011, pages 255-263,. http://www.hawaii.edu/PCSS/biblio/articles/ 2010to2014/2011-ethical-considerations.html

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3 Recommendations and Possibilities Studies with small samples and small sample sizes or excellent individual case studies. Large prospective randomized studies in this area will remain the exception. Regarding the eld of care it should be noted rst of all: for all forms of "standards" it is still much too early. The level of evidence of actual knowledge is sucient at best to describe options of care, monitoring and treatment. The stage model of WPATH is not evidence-based and not human rights compliant. Flexible methods of care and support are required. These must meet the individuality of the course (ie, case management, see above). The requirement is a exible and low-threshold support, because the condition may be associated with tremendous suering. In this context we refer to the Guidelines on transsexuality ("Altdorf Recommendations") published by us (Uri SPD), that conceive especially for Swiss circumstances a hurdle-free support, care and treatment of transsexual people based on medical case management51 . It was strictly ensured that the Altdorf Recommendations are compliant with human rights. Activists of the Swiss-German human rights organization, ATME e.V., campaigning for rights of transsexual people, reviewed the document before publication for conformity with human rights and suggested improvements, that were implemented. The central principle of the Altdorf Recommendations regarding medical care is strict, exible orientation rst and foremost to the personal needs of transsexual clients. They negate the traditional levels schemes ( la WPATH) and are based on the principle of a primary non-pathological (transsexuality as a "neuro-biological variation") and healthy transsexuality. It is required that the non-medical measures, eg administrative ones, occur likewise low-threshold. It would be welcomed if the WHO supported approaches and practices that would advance the medical transsexual discourse towards Establishment of a genuine health paradigm of transsexuality (see Declaration of Alma Ata and the Ottawa Charter), that is to focus on Primary Health Care and Health Promotion Recognition of social causes of disease and disability, with transsexuality pathogenic conditions such as transphobia and discrimination Human rights compliance of dealing with transsexual people and modern preventive medicine and medical risk factors.

51

SPD Uri, H.-J. Haupt: Transsexualitt Grundlegende neurowissenschaftlich-medizinische, menschenrechtskonforme Positionsbestimmungen und daraus abzuleitende Empfehlungen fr die Begleitung,Betreuung und Therapie transsexueller Menschen (Altdorfer Empfehlungen, Finale Version 1.0. 2011) http://www.spduri.ch/fileadmin/dateien/downloads/Transsexualitaet_Altdorfer_ Empfehlungen_Finale_Version_1-0_18102011.pdf; http://www.spduri.ch/SPD-Publishing.53.0.html

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3 Recommendations and Possibilities WHO could join and become together with stakeholders-movements and progressive scientists/carers an important advocate to inuence governments and health authorities in this sense.

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