1973 Homosexuality and civil rights
1984 Homosexual issues concerning the military
1988 Statement on discrimination based on gender or sexual orientation
1990 Homosexuality and the armed services
1998 Sexual orientation, psychiatric treatment
Approved December 2013 by the APA Board of Trustees
APA Position: While recognizing that the scientific understanding is incomplete and often distorted because of societal stigma, the American Psychiatric Association holds the following positions regarding same-sex attraction and associated issues.
It is the American Psychiatric Association’s position that same-sex attraction, whether expressed in action, fantasy, or identity, implies no impairment per se in judgment, stability, reliability, or general social or vocational capabilities. The American Psychiatric Association believes that the causes of sexual orientation (whether homosexual or heterosexual) are not known at this time and likely are multifactorial including biological and behavioral roots which may vary between different individuals and may even vary over time. The American Psychiatric Association does not believe that same-sex orientation should or needs to be changed, and efforts to do so represent a significant risk of harm by subjecting individuals to forms of treatment which have not been scientifically validated and by undermining self-esteem when sexual orientation fails to change. No credible evidence exists that any mental health intervention can reliably and safely change sexual orientation; nor, from a mental health perspective does sexual orientation need to be changed.
The American Psychiatric Association opposes discrimination against individuals with same-sex attraction whether it be in education, employment, military service, immigration and naturalization status, housing, income, government services, retirement benefits, ability to inherit property, rights of survivorship, spousal rights, family status, and access to health services. The American Psychiatric Association recognizes that such discriminations, as well as societal, religious, and family stigma, may adversely affect the mental health of individuals with same-sex attraction necessitating intervention by mental health professionals, for which, the American Psychiatric Association supports the provision of adequate mental health resources to provide that intervention. The American Psychiatric Association supports same-sex marriage as being advantageous to the mental health of same-sex couples and supports legal recognition of the right for same-sex couples to marry, adopt and co-parent.
Issue: Significant and long-standing medical and psychiatric literature exists that demonstrates clear benefits of medical and surgical interventions to assist gender variant individuals seeking transition. However, private and public insurers often do not offer, or may specifically exclude, coverage for medically necessary treatments for gender transition. Access to medical care (both medical and surgical) positively impacts the mental health of transgender and gender variant individuals.
The APA’s vision statement includes the phrase: “Its vision is a society that has available, accessible quality psychiatric diagnosis and treatment,” yet currently, transgender and gender variant individuals frequently lack available and accessible treatment. In addition, APA’s values include the following points:
best standards of clinical practice
patient-focused treatment decisions
scientifically established principles of treatment
advocacy for patients
Transgender and gender variant individuals currently lack access to the best standards of clinical practice, frequently do not have the opportunity to pursue patient-focused treatment decisions, do not receive scientifically established treatment and could benefit significantly from APA’s advocacy.
Therefore, the American Psychiatric Association:
Recognizes that appropriately evaluated transgender and gender variant individuals can benefit greatly from medical and surgical gender transition treatments.
Advocates for removal of barriers to care and supports both public and private health insurance coverage for gender transition treatment.
Opposes categorical exclusions of coverage for such medically necessary treatment when prescribed by a physician.
Authors: (component and/or members developing the Position Statement)
Jack Drescher, MD
Ellen Haller, MD
APA LGBT Caucus
BACKGROUND ON PROPOSED APA POSITION STATEMENT REGARDING ACCESS TO CARE FOR TRANSGENDER AND GENDER VARIANT INDIVIDUALS
Transgender and gender variant people are frequently denied medical, surgical and psychiatric care related to gender transition despite significant evidence that appropriately evaluated individuals benefit from such care. It is often asserted that the DSM (and ICD) diagnoses provide the only pathways to insurance reimbursement for transgender individuals seeking medical assistance. However, to date, the APA has issued no treatment guidelines for gender identity disorder (GID) in either children or adults. This omission is in contrast to an increasing proliferation of APA practice guidelines for other DSM diagnoses (1).
The absence of a formal APA opinion about treatment of a diagnosis of its own creation has contributed to an ongoing problem of many health care insurers and other third party payers claiming that hormonal treatment and sex reassignment surgery (SRS) are “experimental treatments,” “elective treatments,” or “not medically necessary,” and, therefore, not reimbursable or covered under most insurance plans. The lack of consistency in how a transgender condition is defined by some institutions further marginalizes these individuals based on their subjective, surgical and hormonal status (2). In addition, treatment is not always accessible to wards of governmental agencies, such as transgender and gender variant individuals in foster care and prison systems. In other words, the presence of the GID diagnosis in the DSM has not served its intended purpose of creating greater access to care--one of the major arguments for diagnostic retention (1).
Lack of access to care adversely impacts the mental health of transgender and gender variant people, and both hormonal and surgical treatment have been shown to be efficacious in these individuals (3, 4, 5, 6, 7). Practice guidelines have been developed based on peer-reviewed scientific studies and are published and available for clinicians to access (3, 8, 9). The American Medical Association and the American Psychological Association both have position statements stating the critical importance of access to care for transgender and gender variant individuals (10, 11).
Being transgender gender or variant implies no impairment in judgment, stability, reliability, or general social or vocational capabilities; however, these individuals often experience discrimination due to a lack of civil rights protections for their gender identity or expression. As a result, transgender and gender variant persons face challenges in their marriage, adoption and parenting rights, are regularly discharged from uniformed services or are rejected from enlisting due to their gender identity, and have difficulty revising government identity documents. Incarcerated transgender and gender variant persons suffer risks to their personal safety and lack of access to comprehensive healthcare. Further, transgender and gender variant individuals may be inappropriately assigned space in gender-segregated facilities such as inpatient psychiatric units and residential treatment programs. Transgender and gender variant people are frequently harassed and discriminated against when seeking housing or applying to jobs or schools and are often victims of violent hate crimes.
The APA declares in its vision statement that it is, “the voice and conscience of modern psychiatry.” Thus, this position statement is relevant to the APA because discrimination and lack of equal civil rights is damaging to the mental health of transgender and gender variant individuals. In addition, APA’s values include “advocacy for patients.” Speaking out firmly and professionally against discrimination and lack of equal civil rights is a critical advocacy role that the APA is uniquely positioned to take.
Therefore, the American Psychiatric Association:
Jack Drescher, MD
Ellen Haller, MD
APA LGBT Caucus
BACKGROUND ON PROPOSED APA POSITION STATEMENT REGARDING DISCRIMINATION AGAINST GENDER VARIANT OR TRANSGENDER INDIVIDUALS
In 1973, the American Psychiatric Association removed the diagnosis of homosexuality from the DSM-II (1, 2) and issued a position statement of support of gay and lesbian civil rights (3). In subsequent years, APA continued to expand its public positions regarding gay and lesbian civil rights. In 1990, APA issued a statement opposing “exclusion and dismissal from the armed services on the basis of sexual orientation” (4). In 1992, APA called on “all international health organizations, psychiatric organizations, and individual psychiatrists in other countries to urge the repeal in their own countries of legislation that penalizes homosexual acts by consenting adults in private” (5).
In 2000, following Vermont’s passage of civil union laws, APA endorsed “the legal recognition of same-sex unions and their associated legal rights, benefits and responsibilities” (6). In 2002, APA approved a position statement supporting “initiatives which allow same-sex couples to adopt and co-parent children and supports all the associated legal rights, benefits, and responsibilities which arise from such initiatives” (7).
In 2005, after Massachusetts’ 2004 legalization of marriage equality, APA issued a statement supporting “the legal recognition of same-sex civil marriage with all rights, benefits and responsibilities conferred by civil marriage, and opposes restrictions to those same rights, benefits, and responsibilities” (8).
In contrast to its strong affirmation of lesbian and gay civil rights since the 1973 decision to remove homosexuality from the DSM, APA has not issued position statements in support of transgender civil rights. The APA Committee on Gay, Lesbian, and Bisexual Issues often functioned as the default clearinghouse for queries to the APA about trans issues.
Gender variant and transgender individuals must cope with multiple unique challenges. They face significant discrimination, prejudice and hatred and the potential for victimization from violent hate crimes (9). In the workplace, bias may impact transgender people as part of the application process or during their employment precipitated by the individual coming out as transgender (either on their own or by being “outed” by others), or transitioning while an employee. These individuals also need to navigate numerous expensive and complex legal issues such as changing their identity documents including, in part, their social security, driver’s license, and passport (10). They often experience discrimination when accessing non-gender transition-related health care and are denied numerous basic civil rights and protections (11). Gender variant and transgender people have no federal protection against discrimination on the basis of their gender identity or expression in public accommodations, housing, credit, education, or federally-funded programs.
The mental health of gender variant and transgender people is hypothesized to be adversely impacted by discrimination and stigma. For example, gender-based discrimination and victimization were found to be independently associated with attempted suicide in a population of transgender individuals, 32% of whom had histories of trying to kill themselves (12). And, in the largest survey to date of gender variant and transgender people with an N of 6,450, 41% reported attempting suicide (13).
Other organizations, including the American Medical Association and the American Psychological Association, have endorsed strong policy statements deploring the discrimination experienced by gender variant and transgender individuals and calling for laws to protect their civil rights (14, 15).
1. Bayer, R. (1981). Homosexuality and American psychiatry: The politics of diagnosis. New York: Basic Books.
2. Drescher, J., & Merlino, J. P. (Eds.). (2007). American psychiatry and homosexuality: An oral history. New York: Harrington Park Press.
9. National Gay and Lesbian Task Force. Injustice at Every Turn: A report of the National Transgender Discrimination Survey. Accessed on May 16, 2011, from: http://www.thetaskforce.org/downloads/reports/reports/ntds_full.pdf
10. Transgender Law Center. The State of Transgender California Report. Accessed on May 16, 2011, from: http://www.transgenderlawcenter.org/pdf/StateTransCA_report_2009Print.pdf
11. National Transgender Discrimination Survey Report on health and health care, Accessed online May 16, 2011, from: http://www.thetaskforce.org/downloads/reports/reports/ntds_report_on_health.pdf
12. Kristen Clements-Nolle PhD, MPH, Rani Marx PhD, MPH &
Mitchell Katz MD (2006): Attempted Suicide Among Transgender Persons, Journal of
Homosexuality, 51:3, 53-69 http://dx.doi.org/10.1300/J082v51n03_04
13. Grant, Jaime M., Lisa A. Mottet, Justin Tanis, Jack Harrison, Jody L. Herman, and Mara Keisling. Injustice at Every Turn: A Report of the National Transgender Discrimination Survey. Washington: National Center for Transgender Equality and National Gay and Lesbian Task Force, 2011. http://endtransdiscrimination.org/PDFs/NTDS_Report.pdf
14. American Medical Association policies: Continued Support of Human Rights and Freedom, Nondiscrimination Policy, and Civil Rights Restoration. Accessed online May 16, 2011, from: http://www.ama-assn.org/ama/pub/about-ama/our-people/member-groups-sections/glbt-advisory-committee/ama-policy-regarding-sexual-orientation.page?
15. American Psychological Association. APA Policy Statement: Transgender, Gender Identity & Gender Expression Non-Discrimination. Accessed online May 16, 2011, from: http://www.apa.org/about/governance/council/policy/transgender.aspx
Approved by the Assembly, May 2005
Approved by the Board of Trustees, July 2005
"Policy documents are approved by the APA Assembly and Board of Trustees…These are … position statements that define APA official policy on specific subjects…" -- APA Operations Manual.
As physicians who frequently evaluate the impact of social and family relationships on child development, and the ability of adults and children to cope with stress and mental illness, psychiatrists note the invariably positive influence of a stable, adult partnership on the health of all family members. Sustained and committed marital and family relationships are cornerstones of our social support network as we face life’s challenges, including illness and loss. There is ample evidence that long-term spousal and family support enhances physical and mental health at all stages of development.
This position statement is about the legal recognition of same-sex civil marriage, not religious marriage, and it does not pertain to any organized religion’s view of same-sex marriage.
Heterosexual relationships have a legal framework for their existence through civil marriage, which provides a stabilizing force. In the United States, with the exception of Massachusetts, same-sex couples are currently denied the important legal benefits, rights and responsibilities of civil marriage. Same-sex couples therefore experience several kinds of state-sanctioned discrimination that can adversely affect the stability of their relationships and their mental health.
The children of unmarried gay and lesbian parents do not have the same protection that civil marriage affords the children of heterosexual couples. Adoptive and divorced lesbian and gay parents face additional obstacles. An adoptive parent who is lesbian or gay is often prejudicially presumed as unfit in many U.S. jurisdictions. Furthermore, when unmarried couples do adopt, usually one parent is granted legal rights, while the other parent may have no legal standing. These obstacles occur even though no research has shown that the children raised by lesbians and gay men are less well adjusted than those reared within heterosexual relationships.
As the population ages, the denial of legal recognition of civil marriage has consequences for increasing numbers of older adults in same-sex relationships who face age-related health and financial concerns. Excluding these adults from civil marriage protections of survivorship and inheritance rights, financial benefits, and legal recognition as a couple in health care settings increases the psychological burden associated with aging.
The American Psychiatric Association has historically supported equity, parity, and non-discrimination in matters that have an impact on mental health. APA has also supported same-sex civil unions and the right of same-sex couples to adopt and co-parent children. This is because APA has a longstanding interest in civil rights and legal issues that affect mental health as well as a code of ethics that supports and respects human dignity. Educating the public about lesbian and gay relationships and supporting efforts to establish legal recognition of samesex civil marriage is consistent with the Association’s advocacy for minority groups.
Civil marriage is associated with a unique set of benefits that provide legal and economic protections to adults in committed relationships and to their children. Equal access to the institution of civil marriage is consistent with the APA’s opposition to discrimination based on sexual orientation. Therefore be it resolved that:
"In the interest of maintaining and promoting mental health, the American Psychiatric Association supports the legal recognition of same-sex civil marriage with all rights, benefits, and responsibilities conferred by civil marriage, and opposes restrictions to those same rights, benefits, and responsibilities.” Supporting Documents:
American Psychiatric Association (1973), Position statement on homosexuality and civil rights. American J. Psychiatry, 1974, 131:497.www.psych.org/edu/other_res/lib_archives/archives/730010.pdf
American Psychiatric Association (1990), Position statement on homosexuality and the armed services. www.psych.org/edu/other_res/ lib_archives/archives/900013.pdf
American Psychiatric Association (1991), Position statement:
Homosexuality and the Immigration and Naturalization Service. American J. Psychiatry, 148:1625.
American Psychiatric Association Committee on Gay, Lesbian, and Bisexual Issues (1993), Position statement on homosexuality. American J. Psychiatry, 150:686. www.psych.org/edu/other_res/ lib_archives/archives/ 730010.pdf
Resource Document on Controversies in Child Custody: Gay and Lesbian Parenting; Transracial Adoptions; Joint v. Sole Custody and Custody Gender Issues: Approved by Board of Trustees, December 1997.
Resource Document on Same Sex Marriage: Approved by the Board of Trustees, December 1998.
American Psychiatric Association (1998), Position statement on psychiatric treatment and sexual orientation. American J. Psychiatry, 1999; 156:1131. www.psych.org/edu/other_res/ lib_archives/archives/ 980020.pdf
American Psychiatric Association (2000), Commission on Psychotherapy by Psychiatrists (COPP): Position statement on therapies focused on attempts to change sexual orientation (Reparative or conversion therapies). American J. Psychiatry, 157:1719-1721. www.psych.org/edu/other_res/ lib_archives/archives/200001.pdf
American Psychiatric Association (2000), Position statement on same sex civil unions. December 2000American Psychiatric Association (2002),
Position Statement on Adoption and Co-Parenting of Children by Same Sex Couples. November 2002.
Brief for Amici Curiae in the case of Lawrence and Garner v. Texas (signed by American Psychiatric Association), January 2003. www.psych.org/edu/other_res/lib_archives/archives/amicus/02-102.pdf
American Psychological Association (2004), Resolution on Sexual Orientation and Marriage. http://www.apa.org/pi/lgbc/policy/marriage.pdf
Amended APA Resource Document on Same Sex Marriage;
Approved by the Board of Trustees, December 2004.
American Psychiatric Association: Position statement on same sex civil unions (revised); Approved by Board of Trustees, December 2004.
Position paper of the Massachusetts Psychiatric Society on Gay Marriage, November 2004
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Approved December 2000 by the APA Board of Trustees
The APA expresses a valid interest in the well being of heterosexual married couples in such areas as children's mental health and other aspects of family life. Heterosexual relationships have a legal framework for their existence, which provides a stabilizing force.
In the United States, with the recent exception of Vermont, same sex partners are currently denied the important benefits and responsibilities of legal marriage. Same sex couples therefore experience several kinds of state-sanctioned discrimination that affect the stability of their relationships.
The children of gay and lesbian parents do not have the same protection that legal marriage affords the children of heterosexual couples. Adoptive and divorced lesbian and gay parents face additional obstacles. An adoptive parent who is lesbian or gay is presumed unfit in many U.S. jurisdictions. Furthermore, when couples do adopt, usually one parent is granted legal rights, while the other parent may have no legal standing. These obstacles occur even though research has shown that the children raised by lesbian and gay men are as well adjusted as those reared within heterosexual relationships.
The American Psychiatric Association has historically supported equity, parity, and non-discrimination regarding legal issues affecting mental health. Educating the public about lesbian and gay relationships and supporting efforts to establish same sex legal unions is consistent with the Association's advocacy for other disadvantaged minority groups.
"The American Psychiatric Association supports the legal recognition of same sex unions and their associated legal rights, benefits, and responsibilities".
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On June 15, the American Medical Association became the latest organization to call for equal parenting rights for same-sex couples. Learn more about supportive policy statements of the following organizations:
[ http://www.hrcactioncenter.org/ct/mpzcUY115BTt/ ]American Academy of Child and Adolescent Psychiatry
[ http://www.hrcactioncenter.org/ct/mdzcUY115BTv/ ]American Academy of Family Physicians
[ http://www.hrcactioncenter.org/ct/EdzcUY115BTb/ ]American Academy of Pediatrics
[ http://www.hrcactioncenter.org/ct/m7zcUY115BT5/ ]American Anthropological Association
[ http://www.hrcactioncenter.org/ct/j7zcUY115BT4/ ]American Bar Association
[ http://www.hrcactioncenter.org/ct/E1zcUY115BTg/ ]American Medical Association
[ http://www.hrcactioncenter.org/ct/E7zcUY115BT6/ ]American Psychiatric Association
[ http://www.hrcactioncenter.org/ct/EpzcUY115BTO/ ]American Psychoanalytic Association
[ http://www.hrcactioncenter.org/ct/U1zcUY115BTW/ ]American Psychological Association
[ http://www.hrcactioncenter.org/ct/UdzcUY115BTI/ ]Child Welfare League of America
[ http://www.hrcactioncenter.org/ct/m1zcUY115BTf/ ]National Association of Social Workers
[ http://www.hrcactioncenter.org/ct/jpzcUY115BTr/ ]North American Council on Adoptable Children
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