The trans
catch-22

As a transsexual woman, I have a mental disorder. Or so says the current Diagnostic and Statistics Manual of Mental Disorders, Fourth Edition (DSM IV) of the American Psychiatric Association. My diagnosis code is 302.85--Gender Identity Disorder of Adolescence or Adulthood (GID).

Gay men and lesbians used to have a mental disorder too. That was true until homosexuality was removed from the DSM in 1973. Why am I still in the big book of mental disorders 33 years after you were removed?

It's a very complicated matter, due in part to the existence of "The Standards of Care for Gender Identity Disorders" (SOC) of the Harry Benjamin International Gender Dysphoria Association (www.hbidga.org). HBIGDA, a group of medical doctors, psychologists, and other professionals, developed the SOC as a set of guidelines for diagnosing and treating people like me. The complication arises because the standards of care require that a person have a diagnosis of gender identity disorder as defined in the DSM IV in order to access treatment. Most ethical professionals in this and other countries use the SOC as a guide, so the DSM IV diagnosis is a necessary step on the road to transition.

Specifically, the SOC recommend a minimum of three months of psychotherapy before the therapist will write a letter permitting access to hormones. During that time the therapist confirms that the patient has GID and not something else. Once passing that hurdle, the SOC recommend that the patient live in the perceived gender for at least a year before the therapist writes a letter granting access to sex reassignment surgery, and that letter must be countersigned by a psychiatrist or Ph.D. psychologist.

Think of the SOC as a box that pops up on the computer screen of life, saying, "Are you really, really sure you want to change your gender?" This irks a lot of transsexual people, many of whom have (or had) felt at odds with our sex from a young age. We point out that what little research has been done suggests the incongruity originated while we were being carried in our mothers' wombs. Why is some costly "expert" required to confirm an uncomfortable reality that is not of our doing and that we've been living for all of these years? In the current social context, where gender difference is still seen as negative, a diagnosis of "mental illness" further stigmatizes transsexual people as sick and in need of a "cure" rather than equal civil rights.

Gender identity disorder is in the DSM IV in a way that includes those "who may or may not be transsexual and who may or may not be distressed or impaired," according to GID Reform Advocates on their informative resource www.gidreform.org. And the DSM IV also includes another diagnosis--302.3, called Transvestic Fetishism--that labels cross-dressing by heterosexual males as sexual fetish and "paraphilia." Through these two diagnoses, GID Reform Advocates write, a wide "segment of gender nonconforming youth and adults are potentially subject to diagnosis of psychosexual disorder, stigma and loss of civil liberty."

So the DSM IV succeeds in stigmatizing the entire gender-nonconforming population, not just transsexual or transgender people. This stigma leads to a big catch-22. The SOC represent essentially a medicalized approach, involving hormone therapy or surgery. And yet, because of the stigma from the DSM IV, most health insurance plan will not pay for any treatment for a GID diagnosis code. This means that a patient who is diagnosed with GID may end up without access to treatment solely because he or she cannot afford to pay the costs out of pocket.

The exclusion in health insurance plans of all treatments related to sex reassignment is terribly unfair and unjustifiable. Insurers will cover a hysterectomy for a female who has uterine cancer, but they won't cover the same surgery for a female-bodied person who is transitioning to fit a deeply held male gender identity--even when it is recommended by a doctor for the psychological well-being of the transgender patient. Costs are usually cited as the reason.

When a San Francisco ordinance expanded health care coverage for transgender employees in 2001, premiums for all city employees were raised to cover the feared spike in costs. Mark Leno, an ordinance sponsor who is now a California assemblyman, said after three years of the new coverage was instituted, "the revenues to pay for care exceeded costs by a factor of 25, demonstrating that concerns about spiraling costs were misplaced." Two corporations providing transgender health coverage during the same period, Avaya and Lucent, similarly experienced much lower than expected costs.

There's another, more fundamental problem with the GID diagnosis: It has the gender binary as a foundation. What if you define or express your gender in a way that doesn't quite fit the binary? Or what if you don't happen to desire hormone therapy or surgery to feel comfortable expressing your gender identity? You likely will not be diagnosed as having GID, meaning you too will be denied treatment.

So why not remove GID from the DSM IV? Aside from its existence as the linchpin of the SOC, some believe that its presence gives doctors a basis for providing hormones and surgery for us when they might fear being accused of malpractice otherwise. For those of us who truly need(ed) and want(ed) hormones and surgery, the prospect of having no doctors available to carry out the treatments is downright scary. So we remain in the DSM, many years after you left.

But really, isn't it the very presence of GID in the DSM IV in the first place that creates the stigma that leads to the fear of malpractice? If so, the issue is how to manage the transition out of the DSM IV in a way that allows trans people to access some level of treatment while the stigma slowly crumbles. It may be a while longer before this debate is settled.