In its Standards of Care for the Treatment of Gender Identity Disorder (SOC) in both adults and children, the Harry Benjamin International Gender Dysphoria Association notes that “the designation of Gender Identity Disorders as mental disorders is not a license for stigmatization or for the deprivation of gender patients’ civil rights. The use of a formal diagnosis is an important step in offering relief, providing health insurance coverage, and generating research to provide more effective future treatments.” However, it must be asked whether the present classification of gender identity disorder as a psychopathology meets these goals.
First, the designation of GID as a mental health problem does provide, and has provided, a license for stigmatization, and has undoubtedly contributed to the difficulty that gender-variant people have encountered in passing legislation protecting their civil rights. It is disingenuous to pretend that the deletion of the entry on homosexuality from the DSM has not greatly improved the status of gays and lesbians, or that the continued inclusion of gender-variant people in the DSM has not retarded their efforts to be recognized as healthy, functional members of society. Indeed, Dylan Scholinski says that since writing The Last Time I Wore a Dress and becoming an activist, he finds that “some of the toughest people to convince” that kids are still being institutionalized for gender identity disorder are gays and lesbians. “It’s like it brings up people’s worst fears,” he says. “People don’t want to believe that these kinds of things can happen now, they think that we’re beyond that. I tell them, ‘Well, maybe it didn’t happen to you, but it did happen to me.’”
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.