Toward a Resolution of GID, the Model of Disease, and the Transgender Community
The question whether transgenderism is a disease is hotly debated in both the medical and transgender community. This paper seeks to reconcile this question by defining disease, examining the moral meanings of classification as a disease, and with this model clarifying both what is meant by treatment and whether the state of being transgender is in fact a disease.
Disease: A clinically significant adverse effect or experience for an organism due to an interaction between one or more biological traits of that organism and the environment in which it resides.
This definition recognizes the fact that abstracted from its environment, whether a given genotype or phenotype is a disease cannot be accurately determined. An illustrative example is non-insulin dependent diabetes mellitus (NIDDM.) The genes (and proteins and cellular phenotype they produce) which in the developed world results in NIDDM are not a disease when abstracted from their environment. When examined independent of an environment that provides an abundance of food and a relatively sedentary lifestyle, this 'thrifty phenotype' that preserves energy, stores fat efficiently, and provides energy stores for times of famine can be a positive trait.
A phenotype only results in disease when an individual with that phenotype is in an environment where the interaction between organism and environment produces an adverse outcome or experience for the organism. Similarly the phenotype transgenderism is only a disease when it produces adverse effects or experiences for an individual due to the interaction of the transgendered person and the environment in which he lives.
Many in the trans-community have argued the following: since no dysphoria would exist in a transperson if he lived in a society which accepted his gender identity and expression, this implies transgenderism is not a disease. However, when applied to other states we accept as disease, the error of this thinking becomes apparent. It could similarly be said that in a perfect world, persons who in our society develop NIDDM would not develop the persistent hyperglycemia which produces adverse outcomes, therefor NIDDM is also not a disease. However, we do not live in a perfect society. In our society there is a surfeit of energy, less physical exertion required, and little tolerance for those who do not conform to the gender norms. So in our society, people with the 'thrifty phenotype' develop persistent hyperglycemia and resultant neuro-vascular disease and people with the transgender phenotype develop the dysphoria that is characteristic of Gender Identity Disorder.
However, this definition, while challenging the notion that transgenderism is not a disease state, does not imply many of the negative connotations that produce the visceral rejection of the disease label by the transgender community. Having the 'thrifty phenotype' is neither bad nor good. It provides a survival benefit in some environments and is a debilitating disease in others. Transgenderism is also neither bad nor good. In a society accepting of an individual's right to gender self-determination and self-expression, it is certainly not a negative and may in fact be a positive. In a transphobic society it is also a debilitating disease that causes depression, anxiety, and increased suicidality.
Moreover, this definition of disease implies neither that the primary causation of the adverse effect is the organism (rather than the environment) nor that the best means of treatment is in directly altering the organism (rather than the environment.) It simply recognizes the fact that all diseases – even those that we think of as being almost entirely genetic- are strongly influenced by environment. It recognizes that disease can no more be defined independently of an organisms environment than the height of an object can be defined independently of knowing the actual location of the ground. It also recognizes that specific etiology originating in the organism or the environment is far less important that the fact that an adverse effect or experience is present in the organism as a result of this interaction. Put simply, if the organism suffers from it, it matters little whether the genes or environment are largely to blame in the interaction that caused the suffering.
Even with that said, many in the trans-community continue to reject the label of disease because of the negative emotional connotations that are implied by that label. However, these implied conclusions are incorrect when applied to transgenderism/GID as they are when applied to the 'thrifty phenotype'/NIDDM. When disease is correctly viewed as a simple occurrence of an adverse outcome for the individual based on his phenotype and the environment in which he lives, the conclusions that transgender people are wrong, immoral, degenerate, inferior, or any other inappropriate assumption are patently incorrect.
An additional complaint voiced by some is that if the disease label is accepted, this implies that there is necessarily a cure to be had in changing transgender people (beyond the SRS and hormonal therapy individually chosen.) However, this is also not a correct conclusion. While it is the case that for many diseases, making alterations in the organism itself is the most effective way to alleviate a problem, this is by no means the only or even best way to ameliorate disease. Again, taking the example NIDDM, it is certainly the case that there are effective medications and other treatments that can be offered to patients with the 'thrifty phenotype'/NIDDM. However, medicine also realizes that the most effective means of treating the 'thrifty phenotype'/NIDDM may actually be to change the environment. Public health efforts aimed at decreasing the energy surplus that is present in our society may be more effective than simply offering a patient medications once hyperglycemia has developed. Similarly, the true treatment of transgenderism/GID is not necessarily in changing transgender individuals beyond their chosen medical/surgical interventions, but rather in changing society.
Just as NIDDM would cease to be a disease in a society that provided people with appropriate energy consumption and ample opportunity to expend that energy, so would GID cease to be a disease in a society that accepted an individual's right to self-determined his gender identity and expression. In those societies, individuals with the 'thrifty phenotype' or the 'transgender phenotype' would simply have benign traits that cause no significant adversity for the individual.
Lastly, while many recoil from the label 'disease,' if that label is accepted and understood fully it implies that transgender individuals are justified in their demand for adequate surgical and medical therapy (as conversion therapy is no more effective in GID than it is in homosexuality.) Moreover, this label also implies that the further demand for equality, respect, and acceptance from society is not only justified by the human rights argument, but also by the argument that all people have a right medical care. If part of the appropriate treatment for individuals with the transgender phenotype is changing their environment so that dysphoria no longer results from the interaction between their phenotype and society, then it is morally imperative to change society to promote that necessary acceptance.
Article 25 of the Universal Declaration of Human Rights states: “Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including... medical care and necessary social services.”
Transgender individuals certainly engender discomfort in some members of society. Acceptance of transgender individuals' rights to personal health, and thus if transgenderism/GID is a disease in our society, acceptance of their right to self-determine gender identity and expression may cause confusion, discomfort, and even anger in some. However, while we recognize the existence of certain fundamental human rights and freedoms, the right to be comfortable has never been among them. Just as the extreme discomfort felt by whites in the pre-civil rights south at sharing public accommodations with persons of color was not a justification for continuing to deprive persons of color of their basic human rights and dignity, so the discomfort of many in our society is not and never has been a morally sound justification to deny transgendered individuals their basic human rights and dignity.
Far from justifying the stigmatization of transgender individuals as immoral, unnatural, and intrinsically disordered, the label 'disease' does the exact opposite. It recognizes that transgender people experience sometimes extreme distress and pain in our society that drives some to suicide. It recognizes that NO ONE deserves to endure such pain if it is ameliorable by treatments of either the individual or society. It recognizes that not only is it the right of a transgender person to receive adequate medical and surgical care to provide reassignment of physical sex, but that it is the right of such individuals to live in a society that accepts them and thus does not cause the dysphoria that engenders their suffering.
NIDDM is a disease characterized by the body's global resistance to the uptake of glucose in response to insulin released by the pancreas. It is marked by a persistent elevations in blood sugar that causes multi-organ impairment predominantly by damaging nerves and blood vessels. Before modern times, NIDDM essentially did not exist as we know it. This is because individuals who are prone genetically to develop NIDDM will not do so unless they are exposed to an environment with a persistent surfeit of calories and a relative paucity of exercise. This 'thrifty phenotype' will consistently preserve energy for future times when energy may be scarce. While this was a survival benefit in the past, in a society where times of starvation are virtually non-existent, such a phenotype will result in the disease NIDDM.
Universal Declaration of Human Rights. United Nations General Assembly resolution 217 A (III) of 10 December 1948.