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Gender Identity Disorder: What To Do?
Can we eliminate GID without decreasing TS health care access?
The debate in the transgender community over whether or not Gender Identity Disorder (GID) should be de-pathologized has raged for some time. However, recent activity from within the larger queer community adds a new dimension to the debate, and even threatens to overwhelm those transgenders who favor continuation of GID as a bona fide psychiatric diagnosis. For the sake of furthering reasonable discourse, and in hopes of promoting a solution that disadvantages none of us, I will try to present clearly here some of the considerations, and one possible solution.
The most vocal supporters of continuing GID as a recognized pathological condition seem to be transsexuals who seek insurance payment for their SRS expense. Insurance companies generally require requests for any medical expense reimbursement to include the DSM-coded diagnosis for which treatment was provided. Those who reimburse for SRS specifically require this DSM-compliant diagnosis of GID. The removal of GID from the DSM threatens these transexuals with loss of insurance repayment for their surgery expense. Those TS folk I've spoken with who advocate for continuation of GID believe that insurance coverage is the only way to cover the cost of their surgery.
There's a claim that GID may be useful for averting employment discrimination, but I haven't seen a successful case of it's application in this way. It may, I suppose, benefit the crossdresser who seeks to end his distress over the practice through psychiatric help. I'll ignore those who find ways to use it to their financial advantage, like service providers who try to "cure" people of gender non-conformance.
On the other side, some CDs, TSs and TGs would like to see GID eliminated as a mental illness, in order to further reduce the stigmatization of transgender folk. This is the logical continuation of the movement towards greater individual freedom of expression which has previously de-pathologized homosexuality and transvestism. Many activists believe that this is a necessary step towards acquisition of full rights and respect for transgender folk.
The ongoing debate on this issue has recently taken a new tack, as gay and lesbian activists joined the call for an end to GID because of its use as a basis for incarceration and abuse of gender-variant, "potentially homosexual" youth. The book Gender Shock by Phyllis Burke is probably the leading vehicle for this interest. It successfully dramatizes the plight of gender-variant youth, providing a disturbing collection of case histories of boys and girls mistreated in the name of normalcy. Many of them are incarcerated in mental institutions and "treated" with what are clearly abusive regimens, ranging from gross psychological manipulation to routine application of drugs and electroshock -- often without supporting psychotherapy or counseling. Ms. Burke also relates interviews with contemporary practitioners of such "therapies" who continue to this day to prescribe abusive and ineffective treatment for transgenderism most often, apparently, in futile effort to ward of future homosexuality. The call by Gender Shock for an end to GID diagnoses is compelling. To this transgender reader, the book is extremely disturbing, and highlights the needed reform of both our psychiatric services and our children's upbringing and very rights. It remains to be seen just how great will be the reach of this work, but it will surely advance the cause of those who argue for the abolition of GID.
Most transgender folk I've spoken with agree that the greatest damage is done to us when we are young, at the mercy of parents, teachers, and peers. Without that abuse and repression, we would surely reach our middle years in much better shape than we do currently, and be much less in need of reparative services. Indeed, I suspect that the demand for SRS might decrease if genitals ceased to be a reason for social discrimination, but that is pure speculation on my part.
There is no doubt that the acceptance and even encouragement of young people's gender variation would yield much happier transgender (and non-TG) adults. An obvious component of that change in attitude is a change in the assignment of pathology in cases of gender transgression. Clearly, it is the parents whose own guilt and fear for their gender appropriateness causes them to ignore the hurt they cause their children in blaming them for the pathology. It is their insecurity as parents and their mistaken beliefs which cause them to hurt their children in the name of "normalcy" and "good parenting". Likewise, it is the doctor's homo- and gender-phobia that makes them accomplices in the evil acts performed in the "child's best interests".
As more transgender people become visible, we are presented with more examples of transgender people whose lives are not ruined by their transgenderism. We are accumulating evidence that transgenderism itself is not a problem. It is becoming increasingly clear that the problem is other people's treatment of transgender folk. In response to this clarity, we need to relocate the pathology from the gender-transgressive individual to the person upset by that transgression. To fail to do so would be to continue the insane practice of blaming the victim for failing to satisfy the bully's demands.
At the same time, what about the person young or old who will clearly benefit from surgical intervention, but who cannot by themselves muster the resources needed to accomplish the feat? Currently, surgery on intersexed young people to make them "more normal" is a mostly unquestioned insurance reimbursement. While this practice deserves, like GID "therapy", to be exposed for the butchery it most often is, it shows the willingness of insurers to pay for gender-corrective measures. Clearly, insurance companies are willing to pay for surgery which is beneficial to a person's welfare, even when the problem to be corrected is not life-threatening. At the same time, they draw the line at cosmetic surgery: No matter how ugly you are, they will not pay for a nose job or face lift performed for strictly cosmetic reasons. Here, then, we have found an inconsistency in policy. Because a nose job or face lift or liposuction or whatever can in some cases demonstrably improve the quality of one's life. This is the same goal as that of SRS and intersexual surgery. Why is intersexual surgery reimbursed when cosmetic surgery is not? Because it's been medically established as a bona fide need, while the need for a nose job has not been. Part of that established need occurs because intersexuality is mysterious and involves unmentionables, while a nose job is as plain as what's between your eyes. The mystery and fear allow the doctors greater latitude in diagnosing a disorder and performing a procedure for which they will get paid.
SRS, on the other hand, got a bad name a few years back, thanks mostly to some doctors at Johns Hopkins. They conducted a study that showed that TSs were no happier after surgery than before. Of course, they were just as closeted - by the advice of their doctors - as before. As we are now learning, out is generally (if not always) happier than not, so it's no surprise that closeted post-ops (at increased personal risk/paranoia) weren't a lot happier than pre-ops. But the researchers conducting the study overlooked that detail (and others, no doubt). The insurance companies followed their lead, and SRS has become mostly regarded as "elective", "experimental" and "of questionable benefit" and thus non-reimbursable. However, the new transgender activism has reversed the direction of the pendulum on this one.
So the current situation is, insurance companies won't pay for cosmetic surgery, but they will pay for quality of life intervention for a diagnosed condition, such as surgery on intersexed genitals. If we want them to pay for SRS, we need to give them a diagnosis.
In fact, transexuality is not a gender disorder, it's a physiological sexual disorder. It's a need for a physical intervention, a surgery. To insist on the retention of GID as a means of obtaining coverage of SRS is like insisting that my neighbor not cut down his apple tree even though the apples are killing his dog which is allergic to them, because some of the apples fall in my yard and I enjoy them. Instead, if I want apples, I should grow a tree of my own.
In order to provide insurance coverage of SRS for transsexuals, it would seem reasonable for us to create a DSM diagnosis of "transexuality". It could support the various surgeries that transexuals want or need. This would allow the elimination of GID without hurting those transsexuals who need our help. A specific diagnosis of transexuality could provide a basis for specific body-altering procedures such as mastectomy and phalloplasty and vaginoplasty and orchiectomy and such.
Is the elimination of GID and establishment of diagnosable transexuality achievable? If we seek out and work with sympathetic medical authorities, if we go about it reasonably and with open minds, if we do our share of the legwork, if we persist until we succeed� it becomes not just possible, but inevitable.
Nancy Nangeroni 11/96