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What's Up, Doc?

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Would removing transgender from the list of mental disorders do more harm than good?

The last word kelley winters would ever use to describe herself is disordered. But that's exactly how the medical profession describes her. Forget for a moment that Winters is a well-spoken Ph.D. in electrical engineering from the University of Idaho who went on to have an impressive 29-year career at Hewlett-Packard before retiring this June. Winters, who was born male, is transgender. And to receive the medical care she needed to transition, she had to be officially diagnosed with gender identity disorder -- the psychiatric term used to describe people who feel their gender identity doesn't match their birth gender.

Winters agreed to the GID diagnosis so that she could live her life as a woman, but she refused to accept it. Instead, she founded GID Reform Advocates, an organization committed to changing how psychiatrists view and classify transgender men and women. Her ultimate goal? To remove GID from the Diagnostic and Statistical Manual of Mental Disorders, the physician's bible for diagnosing mental health problems.

"The current diagnosis of GID," says Winters, "carries the same burden of social stigma that homosexuality did for gays and lesbians before 1973." When the American Psychiatric Association voted to remove the diagnosis of homosexuality from the DSM on December 15, 1973, it was a watershed for the gay rights movement. "With homosexuality no longer classified as a mental illness," says psychiatrist Jack Drescher, past chair of the APA's Committee on GLB Issues, "it removed the rationalization for discrimination, and it made the question about whether gays should be accepted as full citizens a moral one."

On the list

Whether removing gender identity disorder from the DSM would be a similar turning point for transgender rights has been cause for heated debate among trans people themselves. At its core, the dispute hinges on whether GID is truly an accurate classification for a person who is uncomfortable in his or her body. Some transgender advocates believe that the term GID incorrectly pathologizes being transgender, arguing that gender variance is as normal as homosexuality and therefore shouldn't be deemed a mental disorder. However, others point out that having GID in the DSM actually helps with specific legal and medical wrangling, so it's foolish to remove it. Still others propose a middle ground -- a place on the list but with a less stigmatizing diagnosis, such as gender dysphoria.

While the removal of gender identity disorder doesn't seem as clear-cut as homosexuality (at least in retrospect), parallels do exist. Says Winters: "Intolerant people don't make a distinction between gay, lesbian, bisexual, and transgender. In that respect the equation of difference with disorder, disease, and psychosexual perversion is very much the same for gender-variant people as it was for the gay and lesbian community."

But there is one important distinction: A gay or lesbian person doesn't require medical treatment because he or she is gay. In contrast, many transgender men and women seek out medical care, such as surgery and hormone therapy, which most will need for the rest of their lives. And depending on what type of surgeries they have, some transsexuals will always continue to require medical services related to their biological sex.

Shannon Price Minter, who has litigated a number of high-profile transgender cases as legal director for the National Center for Lesbian Rights, believes that removing GID from the DSM would be devastating because the diagnosis, whether it is fair or not, allows access to costly medical care. "The medical framework is enormously significant in legal advocacy," he says. "When we go to court to advocate for transsexual people to get medical treatment in a whole variety of circumstances, from kids in foster care to prisoners on Medicaid," the GID diagnosis is used to show that treatment is medically necessary. While removing GID from the DSM might be liberating for those who could pay out-of-pocket for hormones or sex-reassignment surgery, Minter says, it would simultaneously constrain medical options for many others.

And there are people who believe that the term GID is an accurate description of adults who seek mental health care for conflicts about their gender identity. "There is an inherent distress that some, but not all, people experience related to their gender identity conflict," says Walter O. Bockting, a psychologist who coordinates transgender health services at the University of Minnesota Department of Family Medicine and Community Health, and for them, "the GID diagnosis is appropriate." Of course, there is also distress due to stigma and to "not being fully accepted in our culture," he continues, which wouldn't be classified as gender identity disorder.

Physical or mental?

Becky allison, a cardiologist in Phoenix who is president-elect of the Gay and Lesbian Medical Association, argues that transsexuals should have a physical diagnosis, not a mental one. "There have been many attempts to correct the brain and the mind over the years," she says. "And they've all been unsuccessful. The only thing that works is changing the body -- and that's physical." A physical diagnosis would allow transsexuals to continue to receive medical care but eliminate the stigma of mental illness. Many in Allison's camp propose removing GID from the mental health realm of the DSM and instead inserting a category such as gender dysphoria into the International Classification of Diseases -- which doctors use to classify physical diseases and health problems.

However, Bockting questions whether there's enough physical evidence to warrant a new entry in the ICD. "There is no physical marker that a person has gender dysphoria. There's no physical test, as with diabetes" -- until a person has taken hormones and had surgery. "At that moment -- and this is an interesting idea -- it would be possible to physically assess if a person's chromosomes don't match their genitalia," he explains. "Perhaps an ICD classification could be used for people who have transitioned and continue to need hormone therapy."

Perhaps. But getting a diagnosis like gender dysphoria into the ICD would be a monumental effort. And given the progress LGBT people have made over the past 30 years in enacting laws and policies that address sexual orientation and gender identity, some question whether removing GID from the DSM is as critical as it was for homosexuality.

"There is a modern medical and mental health understanding that the way we are described in the DSM is just wrong," says Mara Keisling, executive director of the National Center for Transgender Equality. "But I think that whether we are in the DSM is irrelevant to whether or not we are going to make advances in access to medical care."

Not to mention advances in public opinion. Different factions among transgender people do find common ground on the potential benefits of replacing the term GID with one that carries less stigma, such as gender dysphoria, gender dissonance, or gender incongruity. For people like Minter, this would mean there would still be a DSM diagnosis capable of carrying legal weight, and those like Winters could shake off the shame associated with having a "disorder."

The APA plans to release a fifth edition of the DSM in 2012. It's a huge undertaking that requires a 27-member task force to review and assess the almost 400 disorders in the current version. It remains to be seen how receptive the APA will be to input from transgender people, but what's important to keep in mind, says psychiatrist Jack Drescher, "is that people invented these diagnostic systems and the medical categories. And what we learn when we use them is that there are limits to every system. We may need to find a new way of thinking."

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