Dr. Torrey Might Have A Good Idea, But What Does It Mean For LGBT People?

This morning, I caught a segment of C-Span's Washington Journal in which Libby Casey interviewed psychiatrist and schizophrenia researcher Dr. E. Fuller Torrey.  

Recently, Dr. Torrey wrote about John F. Kennedy's proposal, 50 years ago, that the Federal government would fund community mental health centers (CMHCs) to replace big mental hospitals run by the states.  (Willowbrook in Staten Island, New York was one of the most infamous examples.)  At the time, most people thought this was a good idea because institutions like Willowbrook were, in essence, warehouses for the mentally ill that often made their patients worse.  Also, the first effective treatments for mental illnesses were becoming available around that time.

However, as Dr. Torrey pointed out, the nature of some of those illnesses--including schizophrenia and bipolar disorder--were not understood as the brain diseases they are rather than as problems that could be talked away through therapy.  So, the de-institutionalization of thousands of mental patients that resulted from JFK's proposal had a terrible, if unintended, consequence:  Many people who need treatment are homeless, in prison or, worse, committing violent crimes.  (He said, in essence, that the last few episodes of mass murder, including the Newtown and Aurora massacres, were "predictable".)  He asserts--correctly, I believe--that some mentally ill people need to stay in a hospital or some similar setting, at least for some period of time and that they need medication or some other form of treatment.  Also, CMHCs were not interested in (and, in many cases, didn't have the wherewithal for) treating the severely ill patients who were released when large state mental hospitals closed down.  Rather, they focused on helping what are sometimes called "the worried well".

Dr. Torrey believes that the Federal government should get out of the business of treating mentally ill people and turn that responsibility back to the states.  He believes that because mental illnesses such as schizophrenia are better understood than they were 50 years ago, and better treatments are available, the states now have the know-how to do a better job than they did back then.  He does advocate Federal oversight, but thinks the states should run the programs.

On the surface, this sounds like a good idea.  However, I find one potential problem.  I'm not quite sure that I completely agree with Dr. Thomas Szaz's notion that there's no such thing as mental illness, but I agree that, at least to some degree, it's whatever people define it to be.  The DSM is an example of this:  According to the DSM-IV, I am mentally ill, but in the upcoming DSM-V, I am not.  

So, if transgenderism--or male homosexuality, or lesbianism--could be re-classified from one edition to another of a reference guide used by clinicians and insurers, who's to say that different states won't have their own definitions of "mental illness"?  Many LGBT people who aren't much older than I am can recall friends, siblings or colleagues who were committed--and even received electroshock treatments--for expressing their love for people of their own gender, or the fact that they aren't the genders indicated on their birth certificates.  In fact, at least two I know personally were institutionalized and were subjected to shock  and drug "therapies".  Who's to say that such things won't happen again--or that we won't be criminalized outright and incarcerated, at least in some states. 

I don't think I'm expressing irrational fears, or even far-out fantasies: After all, sodomy and even wearing things that are considered inappropriate for one's gender are illegal in some jurisdictions.  Dr. Torrey might respond that Federal oversight might ensure consistent standards.  He might be right, but I can envision certain states resisting, in whatever ways they can, any Federal incursion into what they believe to be their domains.

In any event, I think his ideas are certainly worth exploring.  For the most part, I agree with him when he says the states can't do worse than the Federal government has done on the issue.  At least, I know some states can and will do better.  Given its track record before JFK's proposal, I'm not sure that New York, where I life, is one of those states

What The DSM-V Won't, And Can't, Address

Yesterday I discussed, briefly, the possible implications and effects of removing "transgender" from the list of mental disorders for the upcoming DSM-V.

As I mentioned, this de-classification of us as mentally ill may not turn out to be an entirely good thing unless other changes are made.  In the post, I talked about the fact that some medical and psychiatric care is available to us on the premise that our identity is a "disorder". The good news is that while changing such a circumstance won't be easy, it can at least be done through a few very specific actions, such as changing some health care, governmental and insurance policies.

On the other hand, there's another problem that will take longer and could prove even more difficult:  changing the attitudes of some health professionals and others on whom we depend.  While efforts to educate them about homosexuality have eliminated or lessened at least some of the homophobia found among such professionals, there is still some bigotry against non-heterosexual people.  And, where there's homophobia, there's usually even more transphobia.

Fortuanately for me, I have not experienced transphobia from health care professionals since the time, early in my transition, a group of nurses at the New York Eye and Ear Infirmary mocked me when I came in for an appointment.  I was ready to walk out and file a complaint when the doctor with whom I had the appointment walked in, apologized for the nurses' behavior and treated me with courtesy and respect.  While that incident turned out well and I have not had difficulty with health care professionals since then, many other trans people are not so fortunate.

As an example, a trans man I know told me about an LGBT health fair he attended.  One of the presenters was a doctor with a large number of transgender patients.  In fact, he was my first doctor when I started my transition.  According to this friend--and others who attended that fair--this doctor disparagingly compared trans people to Michael Jackson and even said, in essence, that there's not much that can be done to help trans people; all anyone can do is to medicate them.

Now, if a doctor with transgender patients can make such comments, you can only imagine how much transphobia still exists, even if it's less openly expressed.  It can be mitigated, of course, through education:  Some aspiring doctors are learning about trans issues as part of their training.  Others are doing residencies or internships with clinics and other institutions that serve large numbers of LGBT people.  And, of course, some experienced doctors and nurses are open to change, or weren't bigoted to begin with.  But while I am confident that others  can and will change, de-classifying us in the DSM-V won't be enough.

How Much Of A Victory Will The DSM-V Be For Transgenders?

If you're not LGBT, or not a medical or psychiatric professional, or an actuary, you've probably never looked at the Diagnostic And Statistical Manual (DSM).

However, even if you haven't, it probably has a greater impact on your life than you realize.  Doctors, psychiatrists and researchers in those fields depend on it because it provides a common nomenclature and has, by and large, standardized the categories used to classify various psychiatric issues.  Perhaps even more important to most people, health policy makers as well as pharmaceutical and insurance companies use it in a variety of ways.  

That last fact is one reason why removing "transgender" from the list of mental disorders--one of the many revisions in the upcoming DSM-V, due to be released in May--may not be as much a cause for celebration as some would believe.

To be sure, it would remove much of the stigma of being a transgendered person, just as the subtraction of homosexuality from the list of disorders in the seventh edition of DSM-II did much to help gay men and lesbians.  One result was that serious medical and psychiatric practitioners would no longer sanction the use of electroshock, lobotomies and other horrific "therapies" that were employed in the hope of "curing" a person's attraction to other people of his or her own gender. (In its place, we got "reparative" "therapies" and ministries.)  In turn, that would lead to the greater availability of appropriate medical and psychological care for members of the LGBT community.

However, there is one major difference between the situation of gays before and after changes to the DSM-II and that of trans people.  Most of the care we now receive has been made available to us based on the assumption that we do indeed have a "disorder" that needs treatment.  The few insurance plans that paid for psychotherapy, surgery, hormones and other treatments did so because transgenderism was seen as a disease, as it were.  

So I wonder:  Could the change in DSM-V actually make it more difficult for many trans people to get the care we need?  And would it give insurance companies a rationale for continuing to see gender reassignment surgery as "cosmetic" and refusing to cover the costs of it?

On one hand, I am glad that we will no longer be classified as mentally ill.  But, as we all know, you don't have to be ill to need treatment.