Second, the diagnosis of gender identity disorder does not facilitate insurance coverage of medical or surgical procedures for people desiring hormonal or surgical treatment; it does not guarantee coverage of anything other than mental health treatment by a psychiatrist or a psychologist. “DSM is a red herring. It barely covers anybody,” says Dr. Dana Beyer, a retired surgeon who underwent sex-reassignment surgery in 2003. “Why we feel the need for this crutch is beyond me. This DSM crutch. But it’s the only recognition that it’s medical—it just happens to be in the psychiatric field, which causes more problems than it’s worth. So why can’t we just shift it from the psychiatric problem to congenital or genetic or developmental or whatever? That should be easy. But again it becomes a turf war. The psychiatrists don’t want to give it up. You’d think they’d want to get rid of us. But no, they don’t want to do that. As far as insurance goes, that’s a crock; it doesn’t cover anybody.”
Finally, rather than “generating research” or research funding, the classification of GID as a mental disorder seems instead to have limited the research done on physiological mechanisms for gender variance, or on the intriguing connections between GID and prenatal exposure to DES and other exogenous estrogens and androgens. Christine Johnson, an engineer who is using systems theory to analyze the connections between environmental estrogens and gender variance, says that available data simply do not support the theory that GID is a psychiatric disorder. “There’s all this empirical data, exceptional data, data that doesn’t fit their [psychiatric] theory. The U.S. military, for example, has generated a whole set of body measurements that include about thirty different things that they’ve characterized over a large population, and they have curves that describe what the distributions look like for height, for proportion, for all these various body measurements. For 90 percent of them I’m right on the female mean. Now, I’ve yet to see any psychologist explain how it is that I managed to change my skeleton if this [transsexualism] is in fact due to some sort of a mental pathology. The fact is that I’m an exception, an anecdote, and they are not willing to explain it. They are treating me as an exception, and that’s fine, but it still doesn’t support their theory. If there’s unexplainable data, that’s something they need to address.”
High rates of polycystic ovary syndrome (PCOS) in female-bodied persons diagnosed with GID are another anomaly that cannot be explained using the psychopathology paradigm. PCOS is an endocrine disorder affecting women of reproductive age and has been associated with excess production of androgens by the ovary. Researchers currently view PCOS as a developmental disorder in which fetal or pre-pubertal overproduction of androgen causes “hypoandrogenism” in adulthood. Though most women with PCOS are not gender-variant, the fact that many female-bodied persons diagnosed with GID have a history of PCOS would seem to indicate that the two conditions are related and may have a common etiology. Such suggestive connections and potential avenues for research are masked by the common view that GID is a psychopathology, however. The same is true of the overlap between various intersex conditions and GID; I know of at least two transmen who were diagnosed with congenital adrenal hyperpla-sia (CAH) in childhood, for example. In CAH, excess androgens create ambiguous genitalia in XX babies, who are born with an enlarged clitoris and a fused labia. However, the literature provided to parents of CAH babies fails even to mention the possibility that prenatal exposure to excess androgens may affect gender identity.
The DSM has nothing at all to say about the etiology, or causes, of the various psychopathologies it describes; it is a purely descriptive nosology. Moreover, its overall validity and reliability are questioned by people who are not particularly supportive of transgender activists’ agenda. Just because something is in the DSM, that doesn’t make it a real disease, they say. “Listen, there are things in the DSM that are false. The DSM is only a nomenclature,” says Dr. Paul McHugh, retired chief of psychiatry at Johns Hopkins Hospital. “This is a dictionary in which various experts have been given the license by the American Psychiatric Association to say ‘what are the criteria by which they choose to call this’ and they get the names up. If we still believed in witches, witches would be in DSM-IV! Because these are operational criteria. That’s the whole point. You can put anything in, if you can get enough guys to agree that it exists without any other proof than that you think it exists in the way that you claim.”
For all of the reasons noted above, many people argue that the GID diagnosis should be either revised or retired. “I think that it [gender identity disorder] should not be in the DSM any more than homosexuality should be in the DSM,” says Dr. Ben Barres, of Stanford. “I think that it’s offensive. I don’t think I need a DSM diagnosis. I think that I’m perfectly healthy. I did need some medical help to deal with my transition, but there are lots of things requiring medical help where you don’t need to be in a book of mental pathologies.”
“To the extent that it is in the DSM, I don’t think that it should be applied to everybody,” said a male-to-female attorney I interviewed in New York City in 2001. “Though it hasn’t been my experience, I think that there are people who perhaps experience it as a disorder, for whom it makes life uncomfortable and miserable, just as there are probably certain gay and lesbian people for whom homosexuality is ego-dystonic, as the psychiatrists term it. But I think that there are many, many people for whom this is not a disorder; it does not disorder their lives.”
The great majority of the people whom I encountered while doing the research for this book did not appear to suffer from any kind of mental pathology or derangement. They were competent and productive people with homes, families, and jobs they enjoyed. This is particularly true of those who had completed the process of transition or who were post-transition. Those who are still working through transition, on the other hand, often suffer enormous stress as they attempt to renegotiate relationships with family and significant others, with co-workers, and with their own sense of self. This is a years-long process, which does eventually end. But there is no “exit clause” in the DSM, as Katharine Wilson and others have pointed out, by which someone who experiences a high degree of discomfort and distress prior to transition is considered cured afterward.
Indeed many people, including those who chose not to undergo surgery and/or take hormones at all, experience relief after admitting to themselves and others that they are transgendered. Accepting and integrating this new identity and seeking out a community of people who love and accept them despite their “difference,” some find their gender dysphoria transformed to gender “euphoria,” as they are released from the bonds of shame and secrecy. “Brad” described his first visit to the Tom Waddell Center, in San Francisco, to me as a kind of homecoming. “It was a wonderful situation, because it was through the city health plan and it was free and they totally understood me and supported me. Even though when I first went there, I was sitting in a hallway with all of these really ugly women, I mean really ugly, some of the freakiest fucking scary women you’ve ever seen in your life and some really strange-looking men. But I was at home. They accepted me for who I was even though I still had not transitioned yet.”
Many people who argue that GID should be removed from the DSM support a reclassification as a medical diagnosis. “Louis Gooren, one of the major Dutch researchers on transsexuality, was finally asked just in the last year to contribute a chapter to one of the major endocrinology textbooks about transsexuality, which is I think the proper place for it,” says Ben Barres. This perspective was shared by most of the trans physicans and scientists whom I interviewed for the book. “It’s not as if there is no data,” says Dr. Dana Beyer, who, like Dr. Barres, was exposed to a synthetic hormone in utero.
Many of my transsexual sources were extremely reluctant to support the deletion of GID from the DSM, however, until a formal medical reclassification had taken place—possibly in the I CD (International Statistical Classification of Diseases) produced by the World Health Organizat
ion. The ICD is used internationally to track morbidity and mortality of diseases, and unlike DSM, it is updated yearly. All of the diagnostic codes in the DSM-IV (published in 1994) and the DSM-IV TR (published in 2000) were selected to match valid ICD-9 codes. However, as the ICD is updated yearly and the DSM-V will not be published until 2010, there will be discrepancies. A reclassification of gender identity disorder from a psychiatric to an endocrinological condition in the ICD would have a major impact—but as that reclassification has not yet occurred, some argue that it is important to retain the DSM diagnosis for both medical and political reasons despite its flaws. The DSM diagnosis affirms the legitimacy of gender variance and at the same time pathologizes it—making gender variance something more than the perverse lifestyle choice that fundamentalist Christian and other critics believe it to be. More important, this diagnosis legitimizes the range of hormonal and surgical interventions developed over the years that have provided relief for thousands of transsexual and transgendered people. Activists who argue that the “medical model” of gender variance “pathologizes human diversity” tend to miss this point. Without some sort of diagnosis, sex reassignment becomes nothing more than a kind of extreme cosmetic surgery/ body enhancement, or in the view of critics like Paul McHugh, a fad, a fashion, a “craze.”
“If you talk to post-op transpeople, most are what you would call conservative on this question,” says Chelsea Goodwin of Transy House. “I’m conservative in the sense that I accept the medical model but I believe that anybody who needs to see a doctor should, and anyone who needs surgery should be able to have it reimbursed. I’m a pragmatist really. In the 1970s and 1980s the argument was that the transsexual community looked down on cross-dressers because transsexuals got legitimacy from the Benjamin medical model. Well, that legitimacy made it possible for us to exist. Nobody likes to look at the fact that Christine Jorgensen managed to do this [sex reassignment] at the height of the McCarthy era. There was still this incredible respect for scientists among the public back then. If a doctor at a time when medicine was the most respected profession in America said that this was okay, then the public believed it. That was the only way that this revolutionary act of sex change could be done at the time. To throw that legitimacy away now is crazy.”
Therapists and other professionals who work with gender-variant clients express many of the same reservations. Christine Wheeler says, “My fear is that it [the GID diagnosis] will get thrown out of the DSM because of some of the strident views coupled with malpractice issues that continue to frighten physicians. I’m afraid that we will see a time when people won’t be able to get the help they need.” Wheeler, who is on the APA task force for DSM-IV and is one of the drafters of the HBIGDA Standards of Care, says that both committees are “looking at standardizing the child and adolescent GID definitions and reexamining the protocol for intersex conditions around the world, as well as the protocols for intervention in GID.” She admits that there are problems with current definitions. “Sometimes the language is archaic, and I apologize for that,” she says. However, the essential point to remember when discussing the value or lack of value of the diagnosis, she says, is that “something has to be wrong in medicine in order [for it] to be fixed.”
Dylan Scholinski articulates this conundrum from the perspective of the trans activist, admitting that whereas “initially most people were advocating the straight-out removal of GID from the DSM,” a more nuanced position is now developing because “you don’t want to fuck with people’s access to health care, not till there’s something else in place. You can’t just leave the community with nothing.”
Not only does the GID diagnosis ensure continued access to surgery and hormones for those who require them (even if they are not covered by insurance), but it is also used as a legal tool. Those states that permit transsexual people to change their sex of record on birth certificates, driver’s licenses, and other legal documents often require letters from psychotherapists and other health care providers attesting to the medical validity of the claim. Some require proof of genital surgery; others do not. The broad definition of GID ensures that even those who have not undergone genital surgery (as most FTMs do not) qualify for such legal remedies. Attorneys Collin Vause, Shannon Minter, and Karen Doering relied heavily on the medical model in the case oiKantaras v. Kantaras, a child custody lawsuit argued in the state of Florida in 2002. In this groundbreaking case, Florida Circuit Court judge Gerard O’Brien ruled in February 2003 that Michael Kantaras, a transman, was legally male, and that his marriage to Linda Kantaras was legally valid. The court awarded custody of the two children that Michael and Linda had raised together during their marriage to Michael, who is the biological uncle of the youngest child, who was conceived through artificial insemination of Linda with sperm donated by Michael’s brother. The elder child was three months old when Linda and Michael married in 1989, and Michael adopted the child shortly afterward. Linda was aware of Michael’s history when the couple married, but neither child knew about Michael’s past until Linda revealed the details after the couple’s separation.
In the trial, which was shown in its entirety on Court TV, Linda and her attorneys argued that Michael should be considered legally female, that their ten-year marriage should be deemed void, and that Michael should be stripped of his parental rights and prevented from seeing the children. Judge O’Brien ruled otherwise, partly on the basis of extensive medical evidence presented by Walter Bockting, Ph.D., a clinical psychologist and former president of the Harry Benjamin International Gender Dysphoria Association; Ted Huang, M.D., a surgeon; and Collier Cole, Ph.D., a professor in the Department of Psychiatry and Behavioral Sciences at the University of Texas, Gal-veston. One of the major issues disputed in the case was Michael Kan-taras’s decision not to undergo phalloplasty (surgical construction of a penis). Linda Kantaras’s attorneys argued that Michael’s lack of a penis indicated that he was not a man, and that the marriage was therefore invalid. The medical experts testified that gender identity disorder was a legitimate medical condition and that Michael Kantaras had followed the Standards of Care of the Harry Benjamin International Gender Dysphoria Association for the treatment of gender identity disorder. Kantaras actually relocated to Galveston for two years in order to carry out his transition under the care of the Gender Identity Clinic there. (He met Linda shortly after his return to Florida.) The doctors pointed out that most female-to-male transsexual people do not opt for phalloplasty, because of its great expense and uncertain outcome, and that Michael Kantaras’s decision was therefore congruent with prevailing treatment norms. They also testified that most married transmen enjoyed satisfying marital relations with their wives irrespective of their genital status, and that they did so as men, in the male role.
Most observers agree that the medical testimony was crucial in establishing an outcome favorable to Michael Kantaras. Previous court cases in which the legality of marriages contracted by a transsexual person were at issue did not rely as heavily on the testimony of expert medical witnesses. In two of the four U.S. cases {Gardiner, Littleton v. Prange), the marriages were ruled invalid. “To our knowledge this is the first transgender marriage case in the U.S. in which extensive medical evidence was presented, including testimony from three of the foremost experts on transsexualism in the country,” attorney Shannon Minter said in a statement when the Kantaras ruling was announced. “As the court has recognized, the medical evidence overwhelmingly favors recognizing that the law should accommodate transgender people so they can be productive, functioning members of society. This includes permitting transgender people to marry and have children.”
Under the circumstances, many transsexual and transgendered people and their allies are understandably wary of any attempt to eliminate the GID classification without replacing it with a medical diagnosis. The solution to the GID issue, and to many of the other medical and legal challenges that confront the transgender community, they argue, is research. “Basically, we
know squat about our community,” says Julie Maverick, a university professor in the physical sciences who heads the research subcommittee of the National Transgender Advocacy Coalition (NTAC). (Like many cross-dressers, Maverick is closeted and has requested anonymity.) In 2002, Maverick and colleagues at NTAC requested that Congress allocate funds to the National Institutes of Health for new and expanded efforts in the collection of medical and demographic information on transgendered and gender-variant people. “The transgendered community, including transsexuals, cross-dressers, and the intersexual, is believed to represent as much as 2 percent of the American populace and has specific needs regarding mental and physical health,” Maverick and NTAC point out in their request for research funding. “They have the highest suicide rate for any demographic group, a very high incidence of depression and other mental health problems and a very high incidence of substance abuse. They have unique medical needs associated with hormonal therapy (breast cancer in genetic males, for example), sexual reassignment surgery and misdiagnosis of ailments (like ovarian cancer in female to male transsexuals).” Transgendered sex workers are also a “critical vector” for the transmission of HIV, as the request notes. Surveys carried out in Washington, D.C., San Francisco, Los Angeles, New York, and Philadelphia found high rates of HIV infection among trans sex workers in those cities.
The Riddle of Gender Page 27