Question Fifteen: How is being trans different from a delusion stemming from a mental health condition?

April 15, 2013 § 7 Comments

A really interesting question today, and I’m sure one that many people have thought about – panel bios here.


Question Fifteen

I don’t mean this to sound prejudiced or bigoted so please take it in the spirit it is intended.
 So I have suffered from schizophrenia and psychosis. At various times I have had an absolute cast iron conviction that:
 a) that I was a messianic prophet figure, an example to mankind of how they could cast aside their differences and live life in peace. That my life was showing mankind the way to universal harmony
 b) that everybody else in the world had a small glass bowl in which they could observe me and hear my thoughts.
 So obviously if I had come to you with either of the two scenarios above you would have (hopefully) said: ‘I think you have a mental health problem. You should see a psychiatrist.’ 
But if I had come to you and said that I believed I was a woman, would your response be different?
 So my question is, how do distinguish between the kind of delusions I have described and being trans? Is there some sort of empirical test?



Naith: I’m no mental health professional, but as far as I understand it, delusions relating to psychosis usually respond to treatment – so if you get treatment, they’re likely to go away. However the only treatment for a trans person who strongly knows themselves to be the sex other to that which they were assigned, is to transition. It is the only thing that “cures” it. So I would suggest that shows it isn’t a “delusion” but a fact. And as far as distinguishing the two – gender dysphoria is going to be long term, whereas delusions from psychosis will change over time. One of the first things you have to do when going through transition is a psychiatric assessment to check you don’t have any other mental health problems.



Maeve: I suspect that the trans people on the panel with personal experience of the health system may be better placed to answer this, but I will say that in my understanding of the process of gender reassignment, ensuring that an individual is not suffering from such delusions, and that any other mental health issues are under control, is a key part of accessing treatment. The NHS treatment pathway does involve referral to a psychiatrist prior to accessing medical treatment, and there are criteria that individuals have to meet prior to treatment being granted.

     The delusions that you have described are objectively not true, they could be proved to anyone who was able to think rationally about the scenario. A person’s gender identity, however, is something internal, and up until this point in time the only way that we could know about somebody else’s identity was to ask them. Emerging research is beginning to explore physical causes of gender dysphoria, so there may come a time when we could have an ‘objective’ medical test. Here’s a quote from a 2010 review of the research:

“We conclude that biological factors, especially prenatal androgen levels, play a role in the development of a gender-variant identity and it is likely that psychosocial variables play a role in interaction with these factors.”

Veale, Clarke, Lomax, Biological and psychosocial correlates of adult gender-variant identities: A review; Personality and Individual Differences, Volume 48, Issue 4, March 2010, Pages 357–366 



Roz: If I met someone who said they were Napoleon, I might be skeptical. If Marshals of France turned up, and asked his advice about Waterloo, I’d take my skepticism under advisement. Seriously, everyone worries a bit too much about this hypothetical person whose mental illness takes the form of their thinking wrongly they are trans. Look at the happy fulfilled lives of most trans people if left alone to get on with it. Whereas most megalomaniacs I have known do not have a good time with it.



Natacha: This is simple; if you were a messianic prophet you would know that you were rather than believe you were. In addition you would know that people do not have receptacles that can hear your every word. I doubt that Jesus, Buddha or Mohammed ever had such delusions and it is difficult, from examining what is written by or about them to ascertain any evidence of schizophrenia. In addition schizophrenia of this sort is, in some senses a natural reaction of the brain to the feeling of powerlessness, that is a feature of modern capitalist society, and indeed  something which those in positions of power in modern capitalist society would like everyone to feel.

    On the other hand trans people have existed in every society and civilization going back 40,000 years, and this has been well documented by cultural historian Marjorie Garber. Indeed before the renaissance trans people were accepted in Europe and there is plenty of evidence that they were accepted in native American society up until only around 100 years ago. The Indian Nation’s representative in Washington in the 1880s when Grover Cleaveland was president, was a transwoman named Zuni Weiwha, who was in effect one of the most powerful and trusted members of her race. Transwomen often led armies and were tribal leaders in native American society, especially in the Plains Indians.

    In addition trans people usually do not require psychiatric treatment in the same way that people with schizophrenia do. Indeed the encounter trans people have with psychiatrists is usually nothing more than a gatekeeping exercise, it is certainly not a genuine consultation. Many trans people obtain surgery abroad without seeing a psychiatrist at all, and trans people who do not require surgery usually never see one at all.

    There is no treatment for being trans other than for others to change their beliefs to accept trans people. In the end it is not us who are suffering from a problem it is the rest of society that is labouring under a culture known as Cisgenderism; a delusion that gender is always equated with physical manifestations of the body. This was identified by Susan Stryker as caused by a culture of materiality that developed in Europe during the renaissance and which situated the physical as more important than the spiritual or psychological.

     In contrast to schizophrenia, which can severely impair the individual sufferer and cause then to be unable to function in society, being transgender does not have any such effects. Simply permitting trans people to live according to their own self-designated gender, rather than being forced to conform to other people’s ideas of how they should be, is usually enough. In other words it is others who have to change not us. Indeed the psychologist Harry Benjamin, one of the early researchers into trans people in the 1950s concluded that for many trans people it is society that needed to change not them. In many cases a simple physical operation is enough to allow them to live happily, especially if those around them are accepting. 



CN: I think the rest of the panel have already said everything that I could hope to say, apart from one small point. I have Obsessive Compulsive Disorder, as well as being bipolar – when I was younger and not on medication/not on correct medication/in between treatment, the obsessions could become so bad, so out of control that they became more like hallucinations. Obviously, OCD is not schizophrenia, and there’s always that duality of being utterly convinced by the obsessions and, simultaneously, knowing that they’re delusional. But they have always been totally unlike both my physical dsyphoria and my intellectual and emotional objections to a binary gender/sex system. I would be very interested to hear trans people with schizophrenia talk about differences and (potentially) any similarities.



§ 7 Responses to Question Fifteen: How is being trans different from a delusion stemming from a mental health condition?

  • anon says:

    I can’t speak for schizophrenics but I have had psychotic episodes in the past that have involved delusions and auditory hallucinations. The confusing thing is that the delusions often stem from anxieties, and as anyone who’s dipped into Freud would know, those anxieties are often of a sexual nature so it’s worth saying that they interact with gender issues in rather bizarre ways. And the paranoia of stepping out also sucks of course, although I’m not sure that on medication and with adequate treatment that I find it generally any worse than for anyone else. One thing I will say on a positive note is that medical professionals have actually been pretty good at not interpreting my gender issues as delusions, and the last professional I saw was confident in making the case that I would cost the NHS less money by seeking treatment for them. So noone should ever feel discouraged.

  • […] Question Fifteen: How is being trans different from a delusion stemming from a mental health conditi…. […]

  • anon says:

    Glad to be of service Lester. I think I should also have a stab at anwering your and the enquirer’s question about the differences.
    Firstly there is predictably no empirical test to distinguish gender dysphoria from delusions, but I don’t have to leave that at a frustrating ‘only you can discover that’ platitude. Delusions feel like manias, they feel thrilling and intoxicating but often extremely frightening and never in my experience comfortable. Living in my desired gender feels much more calming and actually sedates the feelings of paranoia that are always somewhat present in delusions. In this way one of the comments on Facebook about denial being a delusion is kind of accurate, although that is a different thing- perhaps a passive slow-release delusion of some kind- more an inability to accept the truth than to create an aggrandising false one.
    I did find it very hard to separate out delusions of a psychotic kind from some quite wild and ecstatic visions of being the gender of my choice, and it’s kind of a shame to lose those! But over time, and it can take a long time, I got more accustomed to seeing myself as female and it became more pleasant and salving. A therapist many years ago told me that RD Laing thought psychosis was ‘the mind telling the person it needed to change’, and I think that has a ring of truth, in his theory that is quite an understandable response to being put in an impossible situation.

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