John:

We already did that and we ended up throwing people out on the streets who were completely unable to take care of themselves.

Allowing people to leave when they want to leave is not the same thing as “throwing people out on the streets.” If someone is completely unable to take care of herself, it’s fine in my book for you to try to help them out. What’s not fine is forcing your “help” on her against her will.

We also filled our prisons with the mentally ill.

Transferring people from one prison to another is not what I advocate.

Deinstitutionalization was one of the biggest crimes of the last 50 years.

Compared to camphor-shock therapy? Electroconvulsive therapy? The ice-pick lobotomy?

Bullshit.

Eric Hannekan:

Hm. It sounds like he’s suggesting “mental therapy vouchers,” dispensed by a judge to those he deems mentally ill.

No, I’m suggesting that involuntary commitment be abolished, and that judges and other government officials be removed from the psychotherapeutic process entirely.

If you want to get together a voluntarily-funded charity or mutual aid society that covers the costs of psychotherapy, possibly including hospitalization in a psychiatric ward, then you should be free to do so, but one of the chief points that I’m trying to stress is that government officials and political power need to be kept as far away from psychiatry as possible.

Tacos:

One of the issues that arises in treatment of the mentally ill is that many patients have little or no insight into their own illness. You can’t expect all mentally ill people to recognize that they are even ill, much less recognize that they need to seek help.

Many people with diabetes or human papilloma virus have little or no insight into their own illness, and many may not even recognize that they are ill. Yet very few people are willing to imprison diabetics or HPV carriers and force “treatment” on them without their consent.

This might be seen as an improvement on the surface, but in reality if the patient is convinced that pyschiatrists are trying to implant a transmitter in his brain, his ability to choose between facilities might be somewhat impaired.

Ah, paternalism.

I know of some cases of people with cancer who chose to go for quack “therapies” rather than submitting to the usual regimen of treatment. Sometimes at the cost of their own lives, and often on the basis of beliefs that are no less irrational than the delusions common among certain people labeled as “schizophrenic.” Yet people who believe stupid or crazy things about magic cancer cures are not forced to undergo chemotherapy or radiation therapy against their will. If they were it would be more or less universally considered an atrocity, even if putatively forced on them “for their own good.”

What, if anything, do you think explains this difference in treatment? What, if anything, do you think justifies it?

piny,

I didn’t mean to suggest that adolescents never consider or make a physical transition, or to attribute to Michelle the claim that there ought to be therapeutic intervention to “correct” GID in young kids because a failure to do so would lead to them ending up gay. I didn’t infer from her mention of the “outcome” statistics that that’s what she believes. If I did inadvertently suggest that, I apologize for being unclear.

The point I was trying to make about age is that, as I understand it, an issue that’s unlikely to come up at the age of 7 or 8 in a case like this one. A few years later, closer to adolescence, sure, but at that point we’re moving rapidly away from the diagnostic territory of “GID in Children” anyway, and towards “GID in Adolescents and Adults.” My understanding may be mistaken; if so I retract that claim, but I’d still make the more specific claim that it doesn’t have much to do with what this particular kid and her mother say they’re concerned about at this particular moment, or with the details of how the school is dealing with them. And I’d also fall back on the other argument against the basic problem with the way that the medical establishment holds medical aids to transition hostage to medicalized labels and “disorder” diagnoses.

The stuff about “outcome” statistics wasn’t meant to suggest that Michelle personally believed that there was something wrong with adolescents being gay. Rather that if one believes that there’s nothing wrong with being gay, nothing wrong with not being gay, nothing wrong with being trans, and nothing wrong with not being trans (which for all I know is what Michelle believes; otherwise I would have been arguing about that rather than just asserting it), then that correspondingly undermines the claim that there’s anything that ought to be called “disordered” or of “clinical interest” here, and to that extent it’s unclear why you’d need a diagnostic category for it, let alone a diagnostic category that’s used to justify psychotherapeutic intervention (at least not for children who don’t actively seek it out for themselves, rather than being shoved into it by anxious adults), let alone a diagnostic category that’s counted as a mental “disability” for legal purposes.

If I had to guess at Michelle’s motives I’d be very unlikely to guess that it had to do with personal attitudes of homophobia or transphobia, and much more likely to guess that they have to do with the tendency in our culture to elevate professionalized psychiatry and medicine as the primary or only way to understand the things that are most important to our lives, and the “mission creep” for medicalized labels that this inevitably leads to, no matter how ill-founded or inappopriate that model may be in a given area. But that’s just speculation, and I’ll happily take it all back if I’m wrong.

Rosehiptea,

As Holly mentions, the major distinction in types of treatment has to do with whether the diagnosis is made in childhood or later in life. Shrinks are generally respectful enough of their adults patients’ wishes and strongly held convictions, at least on this specific point, not to simple-mindedly force them into efforts to “correct” their transgenderism. Not so for children, where all kinds of nasty behavioral therapy are commonly employed to “cure” them.

Michelle,

I think that when the common features of “diagnostic category” are explicitly described “symptoms,” while the thing itself is explicitly labeled a “disorder” and it is classified as an Axis I Clinical Disorder, it’s a bit odd to suggest that the purpose of the diagnostic category is primarily descriptive, rather than prescriptive. When professional medical practitioners describe a set of behaviors and attitudes in terms that are directly and deliberately taken from the medical study of disease, and describes them as causes for “clinical attention,” it is pretty strongly suggested that there’s something wrong with people who have that “disorder.”

As for the professional ethics in sex-reassignment surgery, it has basically nothing to do with the use of Gender Identity Disorder as a “diagnostic category” in eight year old children, which was the context of the discussion. However, I think that if the sole raison d’etre for this diagnostic category is in order to pander to the prejudices of doctors who can only be persuaded to acknowledge their trans patients’ considered judgment when said patients can get another doctor to sign off on it in the form of an Official Diagnosis certifying that they’re “disordered,” that’s a pretty slender reed to lean on. I’d hope that maybe we can start talking about changes that are important for our lives without first having to get a medical label slapped on it.

As for the study of “outcomes” in children labeled as having GID, cf. Speck’s reply. (Incidentally, last I checked, the DSM-IV TR says that 3/4 of anatomical boys diagnosed with GID end up living as homosexual or bisexual males in their late adolescence; the corresponding figure for anatomical girls diagnosed with GID are said to be unknown.)

But, moreover, I don’t see what the point of bringing this up is in the first place. If 3/4 of GID-diagnosed kids turn out to be gay, then so what? There’s nothing wrong with being gay and there’s nothing wrong with not being gay. There’s nothing wrong with wanting to live as a girl (or boy) when you’re 8 and then deciding you want to live as a gay man (or lesbian) when you’re 16. There’s nothing wrong with wanting to live as a girl (or boy) when you’re 8 and then deciding that you want to continue living as a woman (or man) when you’re 16. There’s nothing wrong with changing the gender you want to live as every four months, if you feel like it. If only a few kids diagnosed GID end up seeking sex-reassignment surgery as adults, what of clinical interest follows from that? It’s certainly not any kind of argument for therapeutic intervention with the kids with strong, persistent cross-gender identification (either potential outcome–remaining trans or not remaining trans–is fine, so what’s the big deal?). Nor is it an argument for trying to get the government to treat 8 year old kids with strong, persistent cross-gender identification as if they had a mental “disability.”

ThickRedGlasses,

“The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.” . . . People with Gender Identity Disorder are going to be significantly distressed by being in the wrong body, even if the social stigma goes away.

A significant part of my point is that the criteria having to do with “impairment in social [or] occupational … functioning” are basically bogus. They’re a way of shifting the responsibility for other people’s discrimination and bullying onto the victims of the discrimination and bullying. In reality, insofar as there’s a “disorder” here, it’s because other people have a problem, not because kids labeled as having GID have a problem.

As far as “clinically significant distress” goes, as far as I know, there’s been no positive evidence presented to the effect that the little girl in question feels that way, and I see little reason to assume that she does. Not everybody who wants to live as a member of a gender different from the one they were assigned at birth is especially concerned about the anatomical details of their body, especially not when they are still years away from puberty.

If, on the other hand, she does feel that way, then in any case that’s a separate issue from the accommodations that the school should or shouldn’t make for her. They don’t have much control over her personal feelings about her genitals. The issue at hand is how they will or won’t deal with the questions about her immediate social environment–whether or not teachers and classmates call her by her chosen name, allow her to to come to school dressed as a girl, do or don’t harass her, etc.

From a clinical standpoint, I’d question the utility of creating a gender-specific diagnostic category if the only purpose is to group together people who are (1) trans and (2) depressed or anxious or dysphoric about their bodies. There’s nothing wrong with (1) per se, and there’s already a ton of different diagnostic categories to cover (2), so why come up with a new one just to single out the fact that one subgroup of people who develop (2) are also (1)?

Holly:

Thank you for posting this. I love how the genital correctness blowhard brigade keeps falling back on the idea that anyone who doesn’t go out of their way to make life unpleasant for this kid (e.g. by refusing to call her by her chosen name, or by harassing or punishing her for wearing the “wrong” set of clothes to school) must, therefore be “bending over backwards” to suit her delicate sensibilities. Rather than, you know, just not going out of their way to be obnoxious to an eight-year-old kid in the name of heteropatriarchal social engineering.

ThickRedGlasses:

Wouldn’t this child be considered disabled under the Americans with Disabilities Act? Gender Identity Disorder is considered considered a mental disorder, so shouldn’t this girl be covered by ADA?

I think we’d be better off not going there.

So-called “Gender Identity Disorder” is a basically political, not medical diagnosis. It’s been used repeatedly as an excuse for quack psychiatrists and anxious or controlling parents to inflict all kinds of torture, mislabeled “therapy,” in the name of “curing” their trans kids, or even mildly gender-deviant kids, of their “disorder”. In fact there is absolutely nothing wrong or crazy or disordered about a kid born anatomically male who wants to live as a girl (or vice versa), and I think it would be a serious mistake to reinforce and institutionalize the notion that there is, whatever short-term advantages you might hope to gain from it.

A few decades ago, Homosexuality was considered a mental illness and included as a category in the DSM. But if that diagnosis were still on the books, I think it would be counterproductive, to say the least, for gay liberationists to try and use it to get accommodations under the ADA.

How would you know how much or how little of “the research” on this topic I have read? The short answer is that you have no idea, because you haven’t begun to engage with the arguments at hand. If you want to demonstrate that there are important facts of which I am not aware you will have to, you know, actually point them out, and not just wave your hands at The Science and The Research without discussing any concrete findings.

Jonathan: For example, because the study of race was used in the past for nefarious purposes, discount any current data on race, even if it means potentially more effective medications for people of certain races.

This is a strawman. Nobody suggested that you should “discount any current data” on so-called “mental illness.” I said that the history of psychiatric abuse is a good reason for caution in appeals to consensus, which is something different. Similarly, people certainly should be cautious of research on racial difference, given the history of racialist pseudoscience. The epistemic authority of a scholarly community depends (in part) on its reliability in getting to the truth, and when there’s a long history of pseudoscience being promoted in order to provide ideological cover for prejudice, there is nothing logically askew in exhibiting a healthy degree of skepticism.

This is hardly ancient history. For example, Homosexuality was a recognized “disorder” until 1974, and so-called “Gender Identity Disorder” remains in the DSM to this day. Walter Freeman was still cutting up people’s brains not 40 years ago.

Of course, if you have an actual argument or empirical data to present, rather than just an appeal to The Science, then that argument and that data can and should be evaluated on its own merits, independently of whatever historical worries one may have. But since you have produced nothing of the sort, there is nothing to be assessed on its own merits; we have only the appeal to authority.

Jonathan: I’m not making an appeal to authority or scientific consensus.

Dismissing an argument on the grounds of an assertion, without further evidence, that its conclusion is “backwards, anti-science, and ignorant” is one of two things. Either it’s (1) an appeal to authority, which can sometimes be a cogent form of argument in the right context, or (2) simple abuse in place of an argument, which never is. I took the more charitable interpretation of supposing that you intended for your remarks to be (1), and so gave an argument as to why the appeal is misplaced, in this context.

If I misunderstood you, and should have adopted the less charitable interpretation, well, I guess I apologize.

Micha,

Two things.

1. You write: “If people who suffer from mental illnesses believe (or are convinced by believing friends and family) that mental illness is a myth, they may not get the help they need, and suffer greatly as a result.”

But Szasz’s views, if implemented, would not deprive the people currently labeled “schizophrenic,” “bipolar,” “depressed,” etc. from “getting help” for their problems. The notion that it would is based on a common but extremely careless misreading of Szasz’s argument. Szasz is quite explicit that the symptoms on which a diagnosis of these pseudo-“diseases” are based are quite real, and pose real problems for people’s lives. What he objects to is the philosophical and political leap of organizing the understanding and “treatment” of those symptoms under pseudomedical terms like “schizophrenia,” “bipolar disorder,” “depression,” etc., which ultimately have a lot more to do with the legal requirement that someone have a diagnosed “disease” in order to get most drugs, than they do with any real scientific basis for the claim that all these symptoms trace to a single, identifiable disease.

In Szasz’s ideal society, people who are suffering from what is now mistakenly called “mental illness” would in fact have far more access to help than they have now, since the abolition of pharmaceutical laws and government licensure laws would remove a couple of the major barriers to entry and price floors on psychiatric “help.”

Szasz also believes that psychiatrists should not have the power to force “help” onto their “patients” against those patients’ wills. But the power to force “help” on unwilling “beneficiaries” is quite a different issue from the ability to “get help” when one needs it.

1. You write: “But shouldn’t one of our goals be truth?”

Sure. But summary dismissal of an argument based on an unsubstantiated assertion that it is “backwards, anti-science, and ignorant” is not, as I see it, a reliable method of getting to the truth. Especially not when there are specific historical reasons to be cautious of “consensus” in the field in question, and when the person whose arguments are being thus dismissed without discussion is in fact a dissenter within the same community of experts whose authority is supposedly being referred to. (In this respect, Szasz’s position, as a professionally trained medical psychiatrist, is quite different from that of creationists who have no training in paleontology and evolutionary biology, or Holocaust deniers who have no training in history. That makes an appeal to authority, rather than an critical engagement with Szasz’s specific arguments, rickety in the extreme.)

Well, hell, if someone in a white lab coat says it, it must be true.

Certainly there is no reason to be cautious of appeals to scientific consensus in this field. There are certainly no prominent examples of appeals to scientific authority, or to psychiatry in particular, that had little to do with science and lots to do with providing cover for coercive normalization, inhuman “treatment” of so-called “patients,” or torture and brain damage posing as “cures.” No need to think for yourself, citizens; the experts have already done it for you.

Meanwhile, we can just safely ignore Szasz’s actual arguments, ignore the extent to which common criticism and “embarassment” over Szasz is based on easily refuted strawmen (such as the claim that he believes that hallucinations are “made up”), and substitute an appeal to authority and an ad hominem (abusive form).

The wikipedia entry on Szasz clearly states he believes schizophrenia is a “fake disease.”

Yes, he does, as do I. But you seem to have grossly misunderstood what that means.

Szasz does not deny that there are people who really have hallucinations. As a practicing psychiatrist he has often treated people who had persistent hallucinations. What he denies is the popular pseudomedical theory that mainstream psychiatrists use to explain those experiences–the theory that they are “symptoms” of a single, identifiable disease, called “schizophrenia.”

Back in the 19th century, psychiatrists believed that there was a mental illness called “hysteria,” which they used to explain all kinds of experiences that many women of a certain class reported having — emotional fragility, psychosomatic reactions, inability to enjoy sex, etc. Nowadays most psychiatrists regard “hysteria” as a bogus diagnosis. That doesn’t mean that they deny that many woman experienced certain kinds of emotional fragility, or psychosomatic reactions, or were unable to enjoy sex. Rather, they now realize that there were various explanations for these experiences, some personal, some medical, and some cultural, and that these experiences were not best understood as common symptoms of some single, identifiable disease. Szasz believes the same thing about “schizophrenia,” and in fact about the category of “mental illness” broadly.

I don’t want to be rude, but Szasz has spent a great deal of time making this point carefully in his writing, both in articles and in book-length treatments of the topic. Maybe you would be better off engaging with what he says there, rather than trying to puzzle out his views from the brief descriptions in a WikiPedia article?

or, he believes seeing spiders that aren’t there isn’t a disease (or symptomatic of a disease).

The claim that hallucinations aren’t necessarily symptoms of an underlying disease is certainly not ridiculous; in fact it’s true, and easily demonstrated. For example, you can get hallucinations right now, without having anything that could be identified as a “disease.” For example, by depriving yourself of sleep for a long period of time, or by consuming a lot of liquor.

Now, for all I know, and for all that Szasz says, it may well be that there is some neural disease that explains Tiffany Sitton’s hallucinations. But if so, then it’s incumbent on those who propose that explanation to give a description of the disease, its etiology, and its causes, and to give some evidence that Tiffany Sitton has it. For the reasons I explained, just saying “schizophrenia” doesn’t count as such giving such a description. “Schizophrenia” is defined in such a way that that does no more explanatory work than if you had said, “Tiffany Sitton has hallucinations because she has the hallucination-causing disease.”

My point remains that seeing spiders that aren’t there is not, as Caplan claims, merely “bad behavior.” Do you, or Szasz, disagree?

This is a crude strawman. Caplan doesn’t claim that having hallucinations is “bad behavior.” If you think that he has, you have misread him very badly. What he suggested is that “schizophrenia is a linguistic excuse for bad behavior.” Again, the issue here is the use of the category “schizophrenia,” not the specific experiences that she reports having. What he’s challenging is the use of a psychiatric diagnosis to excuse specific behaviors (e.g. drug abuse and inflicting emotional suffering on her mother). Not the claim that she really does have hallucinations about spiders.

Scheule: Even if one girl lies about hearing demons, it’s nonsense to believe this explains the entirety of diagnosed schizophrenics.

I can’t vouch for Caplan’s views, but certainly Thomas Szasz has never claimed anything of the sort.

Scheule: Alternatively, Caplan thinks the girl is telling the truth but doesn’t want to call it a disease–but c’mon, she feels non-existent spiders itching around subdermally. If that’s not an illness, please, what is?

Smallpox is a disease. Feeling non-existent spiders itching around under your skin is a hallucination, not a disease.

Depending on the breaks, the hallucination may be a symptom of some identifiable neural disease. Or it may not be. Lots of well-defined neuropathologies can result in hallucinations, such as Parkinson’s disease, or brain tumors, or for that matter the syndromes that result from certain kinds of drug abuse. But lots of unpleasant things can also happen to your body without being to anything that you could call a “disease.” If you intend to bring in the medical model, it’s up to you to explain what the disease actually is and produce some evidence that it’s present in this case.

You might say, “Oh, well, the disease here is schizphrenia.” But just referring back to a term explicitly defined through a grab-bag of loosely-related symptoms, rather than in terms of etiology, doesn’t cut much ice. Since schizophrenia is defined in terms of things like the experience of hallucinations, citing it as the explanation for hallucinations is either tightly circular, or at best an unbacked promissory note for a physiological explanation, rather than the explanation itself. It’s hard for me to see what function, if any, pseudomedical terms like “schizophrenia” serve in helping us to understand what’s going on with someone like Tiffany Sitton.