Transgender Forum's Political Writes

The Debate Surrounding Removal of
Gender Identity Dysphoria (GID) from the DSM-IV


[The following was prepared as an informal briefing document for individuals and groups working on GID Reform. It is not intended as an official position statement of any participating person or organization.]

General Statement:
GID is a complex issue. Obviously some transpeople NEED medical reimbursement to get surgery and medical treatment. So rather than the end of *any* diagnosis, we favor a *replacement* of GID with a physical diagnosis, so that insurance (what limited insurance there is) can be granted on a diagnosis that does not pathologize people and undermine their human dignity.

In any case, we demand the APA immediately stop using GID against young people who are gender variant.

Finally, we recognize that whether GID is kept or eliminated, people will be hurt either way. The question is: which path is the one towards a progressive social movement, one which will end gender-intolerance and bigotry and empower the community? We think ending GID as we know it and its replacement with something less stigmatizing is the right way to begin.
Riki Anne Wilchins


The Debate

Pro: Riki Wilchins Con: JoAnn Roberts



Q: Won't getting rid of GID deprive transpeople of surgery?
PRO: No. It may keep *some* from getting reimbursement from their insurance companies. In any case, the high water mark on reimbursement was struck some time ago, and the tide on insurance coverage for Sex Reassignment Surgery (SRS) is clearly going out. Regardless of any action the APA takes over GID, it is clear that fewer and fewer transpeople will be getting surgery reimbursement in the future. CON: In their arguments for the removal of GID, activists focus on the end result of a journey -- sex reassignment surgery. They argue that removal of GID from the DSM would not cause serious financial hardship to very many people because very few insurance plans will cover reassignment surgery. True. However, almost all insurance plans cover prescriptions and psychological counseling, two important components in the therapy for transpeople. Many people simply need their counseling costs covered. Some also need the cost of hormones covered. Remove GID from the DSM and these people lose these benefits.



Q: Homosexuality was removed as a disorder [from the DSM], so why are gender [questioning youth] at risk?
PRO: Because GID is still used to pathologize behavior but not actual sexual activity. This means that it can and is used against kids who have no experience with sex, but who appear as queer to the homophobic & transphobic adults who use it to force them into treatment. CON: The use of GID against gender questioning youth is a sad and lamentable fact, but this is not the fault of the APA. The problem is ignorance and intolerance. The problem is the unethical therapist who abuses the DSM and GID to "pathologize" the child. If a baseball player attacks someone with a baseball bat, do we abolish all baseball bats? Do the GID activist really believe the abuse of gender questioning youth will stop if GID is no longer available? The "transphobes" will find another weapon to accomplish the same goal.



Q: Doesn't keeping [GID] a mental disorder help some transpeople get reimbursement now?
PRO: Reimbursement mainly helps those who are a) well off enough to have regular jobs and insurance coverage, but b) too poor to pay for it themselves. This is a very narrow slice of the community. Most transpeople who want surgery will endure some hardship saving towards it, but will eventually be able to afford surgery. In addition, even when reimbursement is available its subject to the usual coinsurance, deductibles, and exclusions, so part of any SRS *always* borne by the insured. CON: The SRS reimbursement issue was covered above. One point GID activists harp on is how demeaning and pathologizing it is to have the APA define you as having a mental disorder. However, it would seem that most GID activists have never actually read the DSM beyond the definition of GID. If they did, they would find the following in the Introduction, "Neither deviant behavior, nor conflicts that are primarily between the individual and society are mental disorders, unless the deviance or conflict is a symptom of a dysfunction in the person" The APA is saying if your behavior is simply one that conflicts with society's norms and you feel good about yourself despite that conflict, you do not have a mental disorder.



Q: Is GID the only avenue for SRS reimbursement?
PRO: Only for the present. Most transactivists don't just want to see GID eliminated. Instead, they'd like to see it *replaced* by a non-stigmatizing diagnosis as a *physical* condition like pregnancy, which is routinely reimbursed but is neither a mental or a physical disorder.

Also, please note that issues like reimbursement are always about power and legitimacy. For instance, sex-reassignment surgery for functional but intersexed (hermaphrodite) infant genitalia are routinely reimbursed, because *that's* a cosmetic genital procedure that society and medicine *want.*

CON: GID activists want to replace GID with a "physical" disorder and they liken GID to being pregnant. Unfortunately, there is absolutely no scientific evidence that GID is a physical disorder. If it was, there would be ways to test for it, just as one can test for pregnancy. Despite a great deal of scientific study, no one has ever been able to develop a test for transgender behavior.

Using an intersexed infant as an example of SRS reimbursement is specious.There is no therapy, nor diagnosis involved. Parents and doctors make these decisions. The infant has no choice in the matter. This is not considered sex reassignment surgery, nor is it anywhere near as expensive as SRS in an adult.



Q: Don't most transpeople *want* GID?
PRO: "Transpeople" or "transgendered people" are umbrella terms encompassing millions of Americans who are "genderqueer," i.e., differently gendered. Thus, GID is also applied to gay/les/bi youth, non-complaining crossdressers, drag people, and transgenders (who may want hormones, but not surgery). Transexuals are only one part of the larger group of "transpeople," and even among transexuals, many neither want or need SRS. CON: Many transpeople do not want the GID activists fooling around with the DSM. But, the issues surrounding GID have little to do with what "transpeople" want. We have to deal with reality here. In the scientific method it is not possible to prove something does not exist because all that is needed is one case to prove it does exist. The GID activists, no matter how hard they work at it, or wish for it, cannot prove GID does not exist as a mental disorder, and as long as the research evidence seems to indicate that it *is* a mental disorder, it should remain in the DSM.



Q: But isn't the bottom line that [you're] removing coverage some people already have?
PRO: Yes. But in balancing the costs and benefits, remember that this particular benefit is achieved only at the expense of pathologizing millions of Americans with a "mental disease."

In addition, part of the reason many people are so desperate for medical reimbursement is that transpeople face enormous employment discrimination. By depathologizing -- and ultimately destigmatize gender variance -- hopefully there will be a net *gain* in income into the community (and thus ability to pay) as more of us can work and keep our jobs.

CON: GID activists often resort to hyperbole to make their point. Neither the APA nor the DSM talk about "mental diseases." The DSM deals with mental disorders, not diseases. Who is doing the "pathologizing?"

The economic discrimination that many transpeople experience is distinct and separate from anything in the DSM. Destigmatizing gender variations is a worthwhile goal, but the problem is public perception, not counseling therapists. And, the problem is not simply one of gender variance, but also ageism, lookism and other perceptual issues.



Q: How will eliminating GID effect the cost of medical care?
PRO: It's impossible to predict that with any accuracy. However, in general when markets are deregulated, the cost of things go down, rather than up. We can reasonably hope that once the stigma of "deviance" goes away, and this is accepted (rightly or wrongly) as a normal "elective" or "cosmetic" procedure, more rather than fewer doctors will enter the pool, making costs more competitive.

In addition, the thousands of dollars spent on expensive and unnecessary psychotherapy by transpeople who are forced to obtain "surgery letters" attesting to their "mental illness" will probably be eliminated. And in the long run, we can also reasonably hope that "hidden costs," such as people losing their jobs, or even being forced to live full-time for a year before surgery (even if it means losing their job while trying to save for surgery) will gradually be eliminated.

Finally, if medical treatment is more accessible, more people -- including many crossdressers - may elect to take hormones, which could decrease costs there.

CON: This argument sounds like the folks who wanted to deregulate your cable television service. Does anyone have a cheaper CATV bill now than before deregulation? Probably not. Besides, what does GID diagnosis have to do with regulating medical costs? Nothing. This is a non-sequitur.

The Harry Benjamin International Association for Gender Dysphoria Association (HBIGDA) publishes a document known as the Standards of Care (SOC), a guideline for the treatment of what used to be called "transsexualism." Principle 8 of the SOC states: "...recommendation for hormonal and/or sex reassignment should, in part, be based upon an evaluation of how well the patient fits the diagnostic criteria for transsexualism as listed in the DSM..." So, here is the Catch-22 in transgender treatment. You may be a well-adjusted transsexual ready for the final surgery and the APA has no problem with you in that regard, but HBIGDA wants you to have been diagnosed with a mental disorder in order to have surgery. You're not crazy, but we won't approve your surgery unless you are. Here is one of the major problems with GID and the activists don't even mention it.



Q: But isn't it safer just to leave well-enough alone? Why force change now?
PRO: There are costs whether we keep GID or eliminate it. The current system effectively turns the shrinks into licensing agents, and in order to get "treatment" for your "mental disease," you must first spend $1-3,000 at up to $125/hour for therapy so they will write you diagnostic letters (also called "surgery letters"). In addition, the current system requires you to live "full time" for at least 1-2 years prior to surgery. This means many of us end up losing our jobs and on welfare at the *precise* moment we are trying to save money and move towards surgery. And we need to be sensitive that crossdressers and transpeople are routinely denied child custody - and even visitation rights to their own kids -- because under GID they are considered sexual deviants.

Finally, it's important to understand that although you have a slight chance of getting medical reimbursement under GID, you have no chance of ever obtaining individual medical or disability coverage again, because every insurance application asks: "Have you ever been diagnoses with a mental illness?" Once GID is in your records, you have to answer YES. And there is no known insurance company which will issue individual medical or disability coverage to a transexual. This means even those of us who can afford it, go uninsured.

CON: Transpeople don't lose their jobs because they must go through a Real Life Test. They lose their jobs because their employers and the public are ignorant of gender issues and fear differences. Transpeople will continue to lose their jobs whether GID is eliminated or not.

The activists routinely claim transpeople are denied child custody and even visitation rights to their own kids because under GID they are considered sexual deviants. There are at least two cases in most recent memory, one in Oklahoma and the other in Wyoming, where the transpersons were either granted unsupervised visitation or custody of the child. The world is not as stupid as the activists would have us believe.

The statement about being denied medical and/or disability insurance because of a prior mental disorder is simply untrue. I called CIGNA, one of the largest health care insurance providers in the U.S. and was told the following: An HMO cannot deny you medical covergae for any reason. They are required to take anyone. You might have a hard time getting independent medical insurance, but if you work for a large company, there should be no problem except that you might be denied long term disability coverage for the past diagnosis, in this case GID. It is unlikely that someone would claim. In other words, if you claim you are disabled because of GID, you cannot collect long term disability insurance.



Q: Aren't the abuses of gender [questioning] youth just a misuse of the diagnosis and not a problem of the diagnosis itself?
PRO: This is certainly one way to look at it. Another is that GID is less like a diagnostic category than a loaded gun, and if you leave a loaded cocked gun lying around genderphobes, it's going to go off and hurt someone. You can certainly argue that "guns don't shoot people, people shoot people," but it is undeniable that if you remove the gun the injuries stop CON: More hyperbole and rhetoric. Certainly the pen is mightier than the sword, but the pen motivates people to pick up the sword. I've yet to hear of a word which when spoken aloud causes death. Likening GID to a loaded gun is ludicrous.



Q: What effect will getting rid of GID have on gender rights, especially discrimination law?
PRO: [A]s we remove gender variance as a mental disease, we also remove the stigma of deviance and abnormality which prompts discrimination in the first place.

[The gay community's] experience with homosexuality is instructive here. It is beyond doubt that keeping homosexuality as a disorder would have allowed some gays to institute lawsuits over discrimination based on their "mental disease." On the other hand, what would be the chances of ENDA being close to passing, or the opening of immigration law, or the chances of legal gay marriage if homosexuality was still a mental disease? Probably none.

Keeping any identity a disability always helps a few people. On the other hand, it is also clearly impossible to mount a liberatory struggle to legitimize a group whose defining characteristic is that they have a mental disorder. The chances of the few to sue for discrimination if it's kept a disability must be weighed in the balance against the millions of transpeople who are stigmatized and who long for full legitimacy and participation in society in all its aspects: parental rights, marriage, military service and employment.

CON: This is a major flaw in the GID activists logic. The stigma will remain whether GID is eliminated or not. The only ways to eliminate the stigma is by education and getting transgender people included in a protected class by law.

GID activists point to the removal of homosexuality from the DSM and say they want the same treatment for transpeople. It's not quite the same issue. Homosexuals did not want healthy organ tissue removed from their bodies.The closest thing to having one's genitalia rearranged is obsessing about cosmetic surgery. And, that, perhaps is the only valid argument the activists could make; people have cosmetic surgery everyday without extensive counseling, why force transsexuals to go through it? Again, because a nose job doesn't break up a family or cost you your job. It's not even close as an issue.

A careful reading of the DSM shows that most transpeople are not mentally disordered, in spite of what the GID activists want you to believe. Their targeting of the APA and the DSM is misguided. What exactly the activists would effectively accomplish in their Quixotic quest to remove GID from the DSM is seriously in question.

What we desperately need is a comprehensive overhaul of sexuality education to include transgender issues for the public, for elementary and secondary school teachers and most importantly for youth.


Riki Wilchins is a co-founder of Transexual Menace and the current Executive Director of GenderPAC. JoAnn Roberts, PhD, is author of the Bill of Gender Rights. She is also a co-founder and current Managing Director of the Renaissance Education Assoc., Inc.



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