Two a years ago, it was not possible to be transgender with good mental health – at least according to International Association of Diseases, the largest reference book that doctors around the world use to evaluate their patients. Over the years, “transsexualism” and “childhood gender identity” have been closely associated with personality disorders and paraphilias, or sexual preferences, ICD‘s mental illness section.
Finally, in the edition that came into force last year, gender-related diseases were changed to sex-related diseases, which led to the stigmatization of violations. At the same time, the World Professional Association of Transgender Health (WPATH) changed its guidelines on the treatment of transgender people to no longer recommend a full psychological evaluation before receiving hormones or gender reassignment surgery. “There is an abandonment of old models that see mental illness as something to be questioned and ‘cured,'” said Laura Erickson-Schroth, chief medical officer at the Jed Foundation, which contributed to the initiative.
But just as the medical profession has moved in one direction, political groups are pushing in another direction. In April, Missouri’s attorney general introduced an emergency law that would have required all gender-certified health care providers to screen their patients for autism and make sure they don’t have “psychiatric symptoms.” Patients would also have to receive about two years of treatment to identify their identity.
The emergency order, which represented a direct attack on the medical autonomy of adults amid the recent flood of anti-trans policies, was eventually blocked by a judge. But by focusing specifically on autistic trans people and people who may have mental illness, it shows a powerful rhetoric in the anti-trans movement. Some studies have shown that trans people are more likely than their cis counterparts to be autistic or suffer from mental illness, an idea that anti-trans campaigners have called into question the validity of trans identity. They say that some people are “genetically defective” or “mentally ill” and may not respond well to gender reassignment therapy—medical procedures such as hormone therapy and surgery to confirm whether they are male or female.
While it’s possible that people with autism or other mental illnesses may have a harder time than their non-neurological peers after receiving gender-affirming treatment – there’s little evidence either way. But Florence Ashley, an assistant professor of law at the University of Alberta, says a lack of evidence can’t be used to stop people from choosing care for themselves. “The problem is not with trans people to justify the need for gender-affirming care,” they say. “It’s up to those who want to impose barriers to care, or remove access to gender-affirming services, to prove it’s necessary.”
Missouri’s emergency law cites documented links between diagnosis and rates of mental illness or autism—but no research has shown that mental illness or autism results in negative outcomes in gender-affirming care. There is a good reason for this: there are no such studies. One study found that people with and without mental illness were less likely to complete their gender-affirming education, but they didn’t see why — and factors unrelated to medical problems, such as financial problems, may play a role. One study found that teens with autism were no more likely than non-autistic teens to change their request for gender-affirming care, but the group was too small to show anything definitive.
