How 'Science Vs' Made Two Gender-Dysphoria Errors

A cautionary tale in how to cover a really complicated subject

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A Critique of the ‘Science Vs’ Episode on Being Transgender, Part 1

(Here’s Part 2 if you’re looking for it.)

I’ve been worried, for a while, about the level of bias creeping into mainstream journalism about gender dysphoria, and the frequency with which major outlets make basic errors when covering this subject. I’ve touched on this from time to time: In one blog post responding to critiques of my own work I showed that two of the journalists who cover this subject regularly weren’t familiar with the well-documented phenomenon of trauma sometimes appearing to cause gender dysphoria — a phenomenon you will come across if you have conducted any in-depth interviews with gender clinicians, or read much of the literature on this subject. In another, I critiqued a Slate article that, in my view, took an irresponsible and unsupported stance on the complicated question of what it means when someone goes on hormones and finds their dysphoria has, at least temporarily, gotten worse.

I could mention countless other examples, and at some point I might write a more general essay about this bias, which is affecting not only journalism but, in some cases, professional organizations like the American Academy of Pediatrics. But for now, I want to highlight two errors made in an episode on transgender rights and youth transition that “Science Vs,” Gimlet’s successful science podcast, posted in December, and touch on what they reveal about how honest, talented journalists are sometimes being veered off-course in their coverage of gender dysphoria.

These posts are going to be long. I don’t want to just point out the errors but, especially in the case of the second, more important one, try to dissect certain false claims about the science of gender dysphoria that have caught on in a big way, and which are going to keep tripping up journalists and potentially harming people with a direct personal stake in this subject, unless they are debunked. I have little faith these posts, or anything else, will fully debunk them, but I’m trying to nudge things in the right direction, at least. (The deep dive I’m going to do here will also serve as the promised ‘sequel’ to this post that I never had a chance to write — most of the points about desistance I planned on making there, I’ll make here instead.)

Here are the two errors:

(1) Science Vs claims that in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (the DSM-IV), “being trans” was a mental disorder, but that in the current edition, the DSM-5, being trans is no longer listed as such. This is incorrect on multiple counts. Being trans was not considered a mental disorder in the DSM-IV, nor is it one in the DSM-5. Rather, both editions sought to diagnose people who suffer from gender dysphoria, or a deep sense of discomfort with one’s biological sex* or its associated gender. The shift from “gender identity disorder” (DSM-IV) to “gender dysphoria” (DSM-5) brought with it various diagnostic tweaks, but there’s just no way to look at the DSM-IV and conclude that it diagnosed people as being mentally ill simply for “being trans,” rather than for experiencing a very specific type of distress that afflicts some trans people, but not others.

(*I know that “sex assigned at birth” is the preferred language in some quarters, but I think “biological sex” is far more accurate in these contexts in light of the form dysphoria often takes — severe distress not just at being seen as male or female, but at having a male or female body. People don’t go on hormones or get double mastectomies or orchiectomies because they were assigned certain body parts. Rather, the body parts themselves, or the physical ramifications of having one set of hormones or another coursing through your blood, cause severe distress: There’s nothing assigned about this aspect of dysphoria. Maybe I’ll explain this editorial decision further at some point but I’ve given it plenty of thought and am comfortable with it.)

(2) With regard to the gender dysphoria desistance debate — we’ll get there — the episode claims that “The only study we’ve found that zoomed in on kids [who identified strongly as being trans fairly early in life]… found that out of 45 of them… 44 grew up to be transgender.” Here Science Vs accidentally fabricated and published a study result. There is no such study. The producers appear to have made an error in interpreting a 2013 study that did not include any situation in which 45 deeply dysphoric kids were evaluated and 44 turned out to identify as trans in the long run. The error was likely abetted by unclear phrasing that snared me as well, albeit in a different context. (I ran this interpretation of the error by the study’s lead author and he agreed.)

Things from here will be organized as follows:

Part 1, this post:

I. A Quick Word on Science Vs and Something it Does Quite Well

II. The First Error: Yes, the DSM-5 Views Gender Dysphoria as a Mental Disorder


Part 2, Friday morning:

III. Background Info on the Desistance Debate, and What Desistance-Deniers Often Get Wrong

IV. The Second Error: The Phantom Desistance Statistic

V. Wrapping Up: It’s Hard to Report on Gender Dysphoria

I. A Quick Word on Science Vs and Something it Does Quite Well

“Science Vs,” notes its About page on Gimlet’s website, “takes on fads, trends, and the opinionated mob to find out what’s fact, what’s not, and what’s somewhere in between.” It’s hosted by Wendy Zukerman and the episode I’m critiquing, “The Science of Being Transgender,” went online on December 13th, 2018. Part of the reason I was able to write this critique in a relatively reasonable amount of time is that Science Versus has adopted the genuinely wonderful norm of posting, for each episode, a show transcript with hyperlinked footnotes — you click on a footnote, and it brings you down to a citation or to other evidence which can help you track down a given claim.

This is an excellent model and I wish other outlets would follow it. There’s a parallel universe in which figuring out what went wrong here, and why, would have taken me hours of emails to the producers, and/or guesswork with regard to which study they were referencing where, since in an audio program it’s tricky to give a full citation for every claim. Science Vs should be commended for this practice, and I hope other research-oriented outlets adopt similar practices. More generally, I’m convinced the producers of Science Vs were trying to get things right there — I do think it’s a trustworthy show in general, and I don’t want to give the impression otherwise.

II. The First Error: Yes, the DSM-5 Views Gender Dysphoria as a Mental Disorder

The first major error occurs during a segment in in which Zukerman interviews Joshua Safer, Executive Director of the Mount Sinai Center for Transgender Medicine and Surgery, a leading authority on trans healthcare:

Safer: There is no question within those medical communities nobody raises their hand and says Oh do we believe that transgender people are legit. That just isn't a thing anymore and [in?] a conventional medical community. So the idea that that out there in the lay world that people think that there are doctors debating. That's not true.[47]

Still though, it took a long time for science to work this out. [48] [49] The book that psychiatrists use to treat their patients -- the DSM-  it only stopped listing transgender as a mental disorder five years ago.  

(Here and throughout, anything in a transcript excerpt that isn’t italicized was delivered by Zukerman. The transcript is rough and I’m not going to bother [sic]ing minor errors, stray characters and so forth.)

This is an unfortunately common false rumor that has been circling forever, and Science Vs is far from the first outlet to disseminate it. Back in 2013, when the DSM released its fifth edition, in which “gender dysphoria” supplanted “gender identity disorder” but was (and is) still listed as a mental disorder, seemingly everyone covered this story wrongly. These headlines were everywhere: “APA Revises Manual: Being Transgender Is No Longer A Mental Disorder” went the ThinkProgress headline. “Being transgender no longer a ‘mental disorder’: APA,” went MSNBC’s.

I think this meme caught on because it tells an inspiring story of science correcting the great wrong of treating “transgender as a mental disorder,” and because it bolsters the ostensible parallels between being trans and being gay — homosexuality having gone through the process of first being seen as a mental disorder and then eventually accepted by the psychological establishment as non-pathological. It makes sense to promote this parallel, politically, given the astounding recent success of the American gay rights movement. But this is a real misunderstanding of what the DSM does and does not diagnose.

Here’s how GLAAD defines ‘transgender’:

An umbrella term for people whose gender identity and/or gender expression differs from what is typically associated with the sex they were assigned at birth. People under the transgender umbrella may describe themselves using one or more of a wide variety of terms - including transgender. Some of those terms are defined below. Use the descriptive term preferred by the person. Many transgender people are prescribed hormones by their doctors to bring their bodies into alignment with their gender identity. Some undergo surgery as well. But not all transgender people can or will take those steps, and a transgender identity is not dependent upon physical appearance or medical procedures. [bolding mine]

In neither the DSM-IV nor the DSM-5 is “being trans,” by the baseline, bolded definition, a mental disorder on its own. Here are the DSM-IV criteria for what was then gender identity disorder:

“Being trans” wouldn’t cause you meet these criteria unless you also had a very specific sort of distress that impaired you in your day-to-day life — gender dysphoria. GID was meant to capture gender dysphoria, not “being trans.” The word ‘transsexual’ and its variants, the closest common 1990s analogs to ‘transgender,’ only appear four times in my copy of the DSM-IV, in a “glossary of technical terms” and for the sake of explaining that an old diagnostic category that contained the term was subsumed, in the DSM-IV, by GID. So the DSM-IV, far from calling ‘transsexuals’ mentally ill, doesn’t really have anything to say about them at all.

The DSM-5, for its part, treats “gender dysphoria” basically the same way the DSM-IV treated gender identity disorder, with some tweaks. In Friday’s post we’ll hone in on the child criteria, but here is the adolescent and adult entry:

Neither diagnosis, except in the case of quackery, would be affixed to someone simply for “being trans.” If you are biologically male but identify and/or present full-time as a woman, and you don’t experience gender dysphoria, neither the DSM-IV nor the DSM-5 has a diagnosis for you. Now, in certain ways the DSM-5 was ‘tightened’ to make it less likely certain gender nonconforming people, particularly kids, without dysphoria would be seen as having a mental illness, so there’s a tiny kernel of truth buried in this false meme. But it’s still a false meme: In neither the DSM-IV nor the DSM-5 is being trans a mental disorder on its own.

Science Vs should correct this. This rumor has spread far and wide and it’s harmful. For one thing, the fact remains that as of today, trans people who seek medical care like hormones or surgery will, if properly diagnosed, likely be tagged with a mental-health diagnosis. Maybe you think that’s fine, or maybe you think that isn’t fine, but it’s impossible to have that debate when there’s widespread confusion about what the DSM does (gender dysphoria) and doesn’t (being trans) consider to be a mental disorder. It does a disservice to trans people and their advocates to spread false information about the current situation.

It’s also worth pointing out that this segment of the show reinforces some pretty negative ideas about people with mental illness. Look at the contrast between those two paragraphs: First comes Safer suggesting that doctors now recognize trans people are ‘legit,’ and then Zukerman notes that the medical field has indicated they are indeed legit by stating they don’t have a mental disorder. Unless I’m seriously missing something, this implies a dichotomy in which ‘legit’ people don’t have a mental-health diagnosis, and ‘illegitimate’ (I suppose) people do.

Let’s imagine, just for a minute, that gender dysphoria (not being trans) is a mental disorder. This might make you uncomfortable, but it’s the present stance of the American Psychiatric Association. If this is true, and if, as voluminous evidence suggests, many people with severe gender dysphoria will suffer needlessly and severely unless and until they’re allowed access to hormones and surgery, does the idea of gender dysphoria being a form of mental illness tell us anything about 1) people with GD’s moral worth and deservedness of dignity and healthcare, or 2) whether their feelings are ‘real’? Of course not. Gender dysphoria is obviously, frightfully real. It can absolutely upend and in some cases end the lives of sufferers if they are are not provided with access to care. Whether it’s a mental or physical condition, or some other, harder-to-define thing, has zero bearing on the moral urgency of helping people with it feel better, especially in a prosperous society where there’s really no good reason to deny anyone the healthcare they need.

And if it is a mental illness, guess what? It’s often cured by transitioning. So even if one takes the stance that we shouldn’t call GD a mental illness because that provides an opening for bullies and bigots — and I’m wary of the idea that we should build language and concepts around worst-case scenarios about how bad people might wield those terms — the fact is that any bigot or bully who seeks to deride a trans person who has transitioned as “mentally ill” is likely making an error: Many, many trans people find that after they transition, their gender dysphoria abates. And if someone who transitioned didn’t have gender dysphoria in the first place, they don’t have a mental disorder, either.

In other areas, it seems obvious that we shouldn’t tie the presence or absence of a mental-illness diagnosis to someone’s worth or to the genuineness of their anguish. If someone has severe, clinically diagnosed depression and requires medication for it, no decent person would say that their suffering isn’t ‘real,’ or that they don’t deserve sympathy and treatment, because it’s tied up in a mental disorder.

Anyway, the heated debate over gender dysphoria’s place in future DSMs is a bit too sprawling for this post. For those who are convinced GD shouldn’t be in there the next go-round, I’d just ask you to consider the not-small subset of GD sufferers, transgender and cisgender and detransitioned alike, who do view it as a mental-health problem that they have to manage like they’d manage any other condition — who find this model useful. Take Carey Callahan, a detransitioner whose story I told in my article in The Atlantic about youth gender dysphoria. “Gender dysphoria as originally conceptualized and as currently described in the DSM-5 criteria captures a wide spectrum of differing desires, convictions, and accompanying distress and impacts on functioning,” she told me in a Twitter direct-message conversation. “Rather than only being experienced by trans people, many gender non-conforming people report experiencing gender dysphoria. Notably, gay, lesbian, and bi/queer-identified people report episodic or longer-lasting experiences of gender dysphoria.”

Callahan and other detransitioners have been calling on the medical and mental-health establishments to better understand GD in its own right, not just as a signal that someone is trans, and to scientifically study admittedly anecdotal accounts from detransitioners and non-transitioners with GD who claim to have managed or at least partially alleviated their distress in various ways, without transitioning. (There do appear to be scattered cases in which someone’s gender dysphoria dissipates after they successfully address their other mental-health problems — the teenager Delta from my Atlantic story is one possible example of that — but for what it’s worth the clinicians I’ve spoken with said they view this as a pretty rare occurrence. I think many detransitioners would disagree, though.)

But, she said, there seems to be little appetite among mainstream researchers, clinicians, activists, and journalists to understand GD as anything but a mismatch between one’s body and “gender identity” — a rather slippery and under-defined concept often presented, falsely, as a well-understood scientific fact, despite the fact that plenty of trans people themselves have credibly critiqued it. Instead, Callahan has been met with a great deal of hostility for expressing the view that GD is a mental-health condition rather than an ironclad marker of an innate underlying identity. At the 2017 Philadelphia Trans Wellness Conference, for example, she was supposed to appear on a panel about detransition and helped plan another, on alternate ways of coping with GD for those who can’t or don’t want to transition. But both panels were cancelled as a result of activist pressure, on the grounds that discussion of these subjects could detract from the conference’s goal of ensuring a “safe, accessible, and respectful” space for those in attendance.

The fact that mere discussion of gender dysphoria as anything but an identity marker is seen as somehow dangerous or offensive might explain why media accounts are dominated by more essentialist explanations for the phenomenon that focus on gender identity. Science Vs falls into this trap: If you search the transcript for the term ‘dysphoria’ you’ll only find it in the citations. It doesn’t come up once in a 40-minute program largely devoted to exploring the science of puberty blockers, hormones, and surgery — that is, the only medically recognized treatments for gender dysphoria.

Read to Part 2, which covers the second major error and offers some informed speculation about how this all occurred? It’s here.

Questions? Comments? Emails that simply read ‘aaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaa’ because you fell asleep on your keyboard as a result of this post’s length and the hour at which I sent it? I’m at, or on Twitter at @jessesingal.