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Stigma in psychiatry seen through the lens of sexuality and gender

  • Michael King (a1)

Abstract

The history of psychiatry and homosexuality illuminates how stigma develops in the professions, how it is linked to cultural values and religious attitudes and how it affects patients. Homosexuality was medicalised as a disorder in the late 19th century and this led to treatments to change it. Same-gender contacts between men were decriminalised in many countries in the 1960s and 1970s, but – as recently as the 1980s – 30% of doctors in the USA did not think that gay students should be admitted to medical school and 40% would not allow gay doctors to specialise in paediatrics or psychiatry. Lesbians and gay men were effectively debarred from training in the main psychoanalytical schools in the USA and the UK. Although mainstream psychological treatments to make gay and bisexual people heterosexual fell into disrepute in the 1980s, so-called conversion or reparative treatments took their place and are still practised today. Transgender people have been the target of similar disapproval and attitudes towards them have been even slower to change than those towards lesbians and gay men. This stigma had consequences on the health, well-being and social inclusion of those who were lesbian, gay, bisexual and transgender (LGBT). This history suggests we need to examine where psychiatry and psychology are making similar mistakes today.

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Copyright

This is an Open Access article, distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives licence (http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is unaltered and is properly cited. The written permission of Cambridge University Press must be obtained for commercial re-use or in order to create a derivative work.

Footnotes

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Conflicts of interest None.

Footnotes

References

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Stigma in psychiatry seen through the lens of sexuality and gender

  • Michael King (a1)
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eLetters

Professor Michael King

Michael King, Professor of Psychiatry, UCL
24 July 2019

Debate about sexual orientation and gender is important and so I concur with Clifford that a range of opinion needs to be heard. However, the point of my editorial was to show that professionals must be sensitive to how much their views may increase societal prejudice.

The view that transgender people should no longer be regarded as psychiatrically disordered is a decision taken by DSM and ICD. It is not a question of whether I approve of it or not. I am not sure what Curtis means by “therapies which aim to help them feel comfortable as they are”. That surely is what therapists and doctors working with trans people are trying to do – namely increase their comfort and stability in their perceived gender. Thus, I can only conclude that by, “as they are”, he means in terms of their sex registered at birth. In doing so, he illustrates what many trans people fear from professionals, namely that they must conform to the experts’ views. Well-intentioned therapists in the mid 20th century began trying make gay and lesbian people heterosexual as that was considered less harmful than imprisonment (in the case of men) and likely to lead to greater happiness if they could fit in with a heterosexual world. Unfortunately, it led to failure and considerable distress.

When I described “appropriate treatments to enable transition” I was not thinking in narrow medical terms. Nor was I recommending (as Griffin and Clyde suggest) that trans patients should embark on “a complex, painful medical intervention as an attempt to pass as the opposite sex”. Anyone familiar with NHS gender identity services would know that the approach varies from very careful exploration of the issues with young people and their guardians, through advice and psychological support, to social transition, to more extensive medical and social treatment (1). There is no rush to medicalise or adopt a one recipe fits all approach. Nevertheless, I am baffled why Curtis objects to people who do not have a disorder undergoing medical or surgical treatments – NHS plastic surgery services do this on a daily basis.

I had no space in this editorial about stigma to comment on the changes in referral patterns of children with concerns about gender. However, I concur with Griffin, Clyde and Clifford that the origins of this change, as well as how perceived gender evolves as the child matures towards adolescence, needs more research. We have good evidence on outcomes for older people referred to gender identity services (2). However, clinicians who manage young people with concerns about their gender identity, have to do so on the limited evidence available. They do that cautiously and with concern that they do no harm (1).

1. Butler G, Wren B, Carmichael P. Puberty blocking in gender dysphoria: suitable for all? Arch Dis Child 2019;104:509–510. doi:10.1136/archdischild-2018-315984

2. Wiepjes CM, Nota NM, de Blok CJM, et al. The Amsterdam Cohort of Gender Dysphoria Study (1972e2015): Trends in Prevalence, Treatment, and Regrets. J Sex Med 2018;15:582e590.

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Conflict of interest: None declared

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Dr

Damian Clifford, Consultant Psychiatrist , MRCPsych
19 July 2019

Professor King lays out a clear history of the stigma experienced by the LGBT community. Experienced stigma is a feature that the trans community has in common with the LGB community. However, as has been outlined in other reply's - gay people do not require any treatment, medical or surgical, this is not the case for trans people. All treatments need evidence to be delivered ethically. It is welcome that Professor King notes ; 'More evidence about gender identity and transgender youth is needed, particularly how gender dysphoria continues from childhood into adolescence and the impact of interventions for very young people who are transgender.' The implication being that current treatment for this cohort is not based on sound evidence, yet they are administered in increasing numbers across the West. Where is the concern regarding that ? Is it not reasonable to assume that the 'stigma' he alludes to from the medical profession, is in part professionally informed concern that we are not meeting our first duty as doctors to; ' first do no harm' ? The statement also begs the question, how young is very young ? If there is a high risk of overtreatment in children, why is this not a concern in young adults ?

Also, there is a risk that concentrating discussion on 'stigma', silences professionals from having mature discussion about the nature of 'trans' as an entity, and its treatments. This could lead to fewer professionals attending to this issue. With less scrutiny the potential for escalating harm grows. This needs to be avoided, alongside addressing prejudice and stigma.

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Conflict of interest: None declared

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Challenging stigma in sexuality and gender

Lucy Griffin, Consultant Psychiatrist, RCPsych
Katherine Clyde, Consultant Psychiatrist, RCPsych
18 July 2019



We read Mike King’s article with interest and welcome this challenge to the stigma faced by certain minority groups. The gains in terms of rights, status and visibility made by lesbian and gay people since homosexuality has been expunged from the ICD is to be celebrated, and psychiatry is right to distance itself from its history of involvement with conversion therapy. However, it is difficult to regard treatment of gender dysphoria as equivalent, unless medical and surgical transition is held to be the ideal end goal. We note that ICD-11 has dropped gender dysphoria from its chapter on mental and behavioural disorders, and moved it to the chapter on sexual health (1). What then, is the exact nature of this sexual health disorder? Are children necessarily prescribed puberty blockers and cross sex hormones because they suffer from a sexual health issue?

The conflation of ‘transgender’ with ‘gender non-conformity’ is also surprising. Most people would consider ‘gender’ a straightjacket, and celebrate scrapping the regressive and repressive stereotypes associated with either sex. King seems to suggest that should someone reject these stereotypes, the correct response is to embark on complex, painful medical intervention as an attempt to pass as the opposite sex. Any attempt for a clinician to affirm a patient’s gender-nonconformity whilst allowing for acceptance of their sexed body, is presumably considered ‘conversion therapy’ (2).

King describes the role of psychiatry in gatekeeping transgender treatment as ‘controlling’. However, no mention is made of the exponential rise (25-fold since 2009) in referrals to the Tavistock Gender Identity Disorder Service (3). The majority of these are young natal females who now comprise 75% of referrals. Although published research in this group is sparse, it has been demonstrated that there are high rates of mental illness, with self-harm, autism and depression all significant associations (4,5). In addition, many are same-sex attracted, which raises the question as to the status of lesbians in the young LGBTQ+ community. The ever-growing number of detransitioners cite complex mechanisms underpinning their initial desire to transition, and identify a worrying lack of sensitive explorative therapy available to deal effectively with their gender dysphoria (6).

1. International Advisory Group for the Revision of ICD-10 Mental and Behavioural Disorders. A conceptual framework for the revision of the ICD-10 classification of mental and behavioural disorders. World Psychiatry Off J World Psychiatr Assoc WPA. 2011 Jun;10(2):86–92.

2. Supporting transgender and gender-diverse people: PS02/18. Royal College of Psychiatrists; 2018.

3. Referral figures from GIDS [Internet]. Available from: http://gids.nhs.uk/number-referrals

4. Kaltiala-Heino R, Sumia M, Työläjärvi M, Lindberg N. Two years of gender identity service for minors: Overrepresentation of natal girls with severe problems in adolescent development. Child Adolesc Psychiatry Ment Health. 2015 Dec;9(1):9.

5. Holt V, Skagerberg E, Dunsford M. Young people with features of gender dysphoria: Demographics and associated difficulties. Clin Child Psychol Psychiatry. 2016 Jan;21(1):108–18.

6. Female detransition and reidentification: Survey results and interpretation [Internet] 2016. Available from: http://guideonragingstars.tumblr.com/post/149877706175/female-detransition-and-reidentification-survey

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Conflict of interest: None declared

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Stigma around sexuality and gender

David Curtis, Retired consultant psychiatrist, RCPsych
16 July 2019

King draws parallels around the attitudes towards sexual orientation and gender identity. The issue which he ducks is this. Nowadays there is a widespread view that the appropriate therapeutic approach to homosexuality is affirmation. However in the case of people with what he refers to as "so-called gender identity disorders" he refers to therapies which aim to help them feel comfortable as they are as "conversion therapies". He conveys the sense that he is pleased that gender identity disorder has been dropped by ICD-10 but also that he thinks that people who are transgender should receive treatment to transition. Many medical professionals will be troubled by the idea that people who do not have a disorder should nevertheless be subject to medical and surgical interventions. The issues are clearly complex but it should be clear that one cannot simply use homosexuality as a paradigm to inform the correct approach to dealing with gender identity. In the one case we say "You're fine as you are" and in the other we say "You're not fine but we can fix you". In fact, many health professionals doubt that this is always the correct response and that some people with concerns about gender identity might also benefit from a more affirmative approach. It might be unhelpful to equate this therapeutic approach with the discredited attempts to change sexual orientation by referring to it simply as conversion therapy. Nor should exploring such options necessarily be regarded simply as inappropriate professional gate-keeping. ... More

Conflict of interest: None declared

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