1. I have mused over this same topic on numerous occasions, and to date been unable to come to a resolution in my own head around the notion of whether or not there needs to be a diagnostic category in the DSM and/or ICD.

    But, then, I have been less troubled by the existence of the diagnosis itself for two very key reasons:

    1) Unlike GLB people, there are legitimate medical procedures that transsexuals in particular need access to. While removing the homosexuality diagnosis did not change the ability of a GLB person to access needed medical treatment, doing so could have serious consequences for transsexuals.

    2) Early on in my own journey, I came to the understanding that the DSM was “descriptive, not prescriptive”. That is to say it serves primarily to provide a language that the treatment community can readily use to communicate with each other.

    This isn’t to say that I was oblivious to the political and social implications of the diagnosis, but rather that I had come to the conclusion that those who used the diagnosis itself as a weapon against transsexuals in the struggle for rights did so through an erroneous understanding of what a diagnosis in fact means.

    In no other circumstance is a diagnosis used to deny a competent person full access to their civil rights, and this is wrong. In part, I believe that this is because the mental health practitioners as a whole have not done an effective job of explaining the purpose and intent of the DSM to the world as a whole, which leaves the public in a bit of a vacuum which gets filled with all kinds of bogeyman imagery.

    When I come around to the ethical and legal considerations that a doctor or surgeon must engage with when providing treatment to any patient, I fail to see how the removal of a diagnostic category serves the long term interests of the transsexual community. There are too many risks for them, especially in the litigious environment of the United States, but Canada is little better in this respect.

    Most surgeons do not feel that they are qualified to adequately assess whether or not someone is ready for a surgery that is as life-changing as GRS, and are legitimately hesitant about getting pulled into owning that responsibility. (and in truth, the same concern exists for GPs or Endocrinologists providing hormones)

    Like it or not, I think we are doomed to the existence of diagnostic categories for the foreseeable future. What we need to do is work with our allies in the treatment community to educate the world around us about what a diagnosis really means, and what it should mean. Further, being more active with the groups that create these formalized languages and working with them to develop diagnostic language that actually has exit criteria (probably the most interesting criticism of the DSM-IV language I have encountered is the lack of exit criteria).

    • dentedbluemercedes
    • October 31st, 2012

    Well, there needs to be a categorization in the ICD. Everything’s in the ICD. If you break your arm, that’s in the ICD. In many places, that’s how all the billing is cross-referenced & reconciled. It just doesn’t need to be under a mental health chapter.

    “those who used the diagnosis itself as a weapon against transsexuals in the struggle for rights did so through an erroneous understanding of what a diagnosis in fact means.”

    That, exactly. That, and a bias against or else willingness to exploit biases against mental health in general.

    • I think the treatment community as a whole would still argue that there is a legitimacy to having it under a mental health designation for several reasons:

      1) There is a lack of conclusive evidence as to physiological origins. (Lots of very promising research results, but nothing that could be used for a diagnosis)

      2) The very real likelihood that other mental health conditions can be at the root of trans* related symptoms.

      I would point out that there is a lot in the DSM that is quite surprising (including tobacco addiction), that most would not consider a “mental illness” per se, so I’m not entirely convinced that removal from the DSM would have the desired effect.

      Additionally, the growing concerns around those who detransition (and unfortunately seem all too willing to assign blame to the treatment community …). Those concerns alone are making some of the treatment community quite jumpy as it is increasing the risk of a practitioner finding themselves caught in a lawsuit.

      As much as we might like less gatekeeping, I think this latter issue is going to increase it as a natural reaction to the changing landscape. There will be a lot of pressure within the treatment community to ensure that they are only providing surgery to those who are ready for it and fully understand the direction they are taking.

        • dentedbluemercedes
        • October 31st, 2012

        1) Agreed, that continues to be a problem. Which is why it’s probably more feasible to push for an active and urgent investigation into the development of an alternative, if anything.

        It’s interesting that you suggest change could result in more gatekeeping. I just had the same conversation last night, how scarcity and limited options can make people even more dependent. The media hasn’t covered it, but that’s had a lot to do with how Aubrey Levin managed since the mid 1990s here, too, without getting caught. It’s speculative, but certainly possible that delisting could create more of that same vulnerability.

    • Cristina
    • October 31st, 2012

    I couldn’t find your email, so I wanted to leave this link here to see if you could cover our boycott concering RuPaul’s blatant transsexual-phobia last night on their show, thanks, also, if you have an email, we would greatly appreciate it, I really like your articulate articles, Cristina

    http://themagnetsource.blogspot.com/2012/10/magnet-boycotts-rupauls-ongoing.html

  2. Mercedes,

    I’m well aware that almost all transsexual persons feel indignant, and often outraged, over requirements imposed by gatekeepers, particularly those related to psychiatric diagnosis…

    I have a different perspective on these issues, and find myself agreeing strongly with what MgS has stated in their comments here… in large part part due to having been brought into treacherous straits through psychiatric treatment…

    If a diagnosis of Gender Dysphoria is not included in the DSM, therapists and clinicians – who are usually trained to work from the book, and are driven to attach diagnoses to persons seeking help for psychological distress through the pressures of obtaining payments for their services through insurance billings – will look for other diagnoses for those persons who are suffering from gender dysphoria.

    And horrible though it is to relate, if a therapist sees someone who presents with issues related to self-image and self-identity related to severe gender issues without being led to view this “Gender Dysphoria” as a separate diagnostic entity, they’re likely to resort to the dreaded Borderline Personality Disorder label…

    The primary features of BPD are unstable interpersonal relationships, affective distress, marked impulsivity, and unstable self-image.

    Manipulation and deceit are viewed as common features of BPD by many of those who treat the disorder as well as by the DSM-IV.

    Oh does this stink – and apparently tagging a client with BPD is already a common ploy among therapists who disapprove of transitioning. (I’m sorry that I can provide no citations here, but I have seen this noted.)

    And then… just who is going to be assessing those seeking medical treatment for transgender or transsexual conditions? Professionals in psychology are always going to be involved in some capacity, to reassure endos and surgeons that such a person is not just engaging a shallow whim (which happens, viz. Sam Hashimi/Samantha/Charles Kane) that will bring them into public conflict with a publicity-happy nutjob – Kane again!…

    “I thought going back to being a man would be the end of the story, but it’s not. Becoming a man again has been much harder than I ever imagined.”
    “After what I’ve been through, I now think that sex-change operations shouldn’t be allowed. They should be banned.”

    (facepalm)

    Neurologists are not going to want to be tasked with the chore of assessing “some quality” or qualities of brain differentiation that can be presumed to establish transsexualism until there is a LOT of hard evidence providing specifics and parameters of such variation… and that may not be truly desirable resolution to these problems.

    At any rate, I view the recent adoption by the American Psychiatric Association of the Position Statement strongly supporting medical treatment for transgender persons as a great step forward. The DSM-V diagnostic criteria for Gender Dysphoria are pretty pathetic, in my view, but… “things could be worse”.

    thanks,
    – bonzie anne

      • dentedbluemercedes
      • November 1st, 2012

      You’re correct about the possibility of the usage of alternate diagnoses. I mentioned TF here, but am also aware of BPD and Dissociative Identity Disorder used as alternate or overriding diagnoses in Alberta. I’m also aware of ECT having been used to treat, as recently as (IIRC) 2006, under the guise of treating depression.

      With regard to Charles Kane (and Walt Heyer, etc), there’s a weird dissonant double-standard among the far right who use their stories, in which people are expected to take responsibility for themselves when it comes to paying for trans-related medical processes, and yet everyone else is responsible in the rare regret cases. Even if those people (Kane and Heyer included) rushed their transitions, deliberately deceived their doctors, etc.

      To me, that completely reverses priority: that as a collective community, we should recognize the need to make available procedures that improve enfranchisement and quality of life, but the individual has to take responsibility for pursuing them and being certain of the need. Because no matter how many obstructions are put up for surgery, there will always (provided they have the ca$h) be a Walt Heyer. But each obstruction will be an additional hardship for hundreds of people who genuinely need it, and are not as economically privileged.

  3. Mercedes, everything you write is too long, making mistakes more likely, and response far more difficult. The latter is especially true in this important and complex matter, which really deserves several postings on different aspects. As it is one hardly knows where to start. So I shall just pick a few.

    But first I want to thank you for posting this here instead of only on the Bilerico site where comments are only allowed by those who have so little concern for privacy that they are members of Facebook.

    Although it would be good to have our medical interventions listed in the non-mental sections of the ICD it is wrong to say that is essential, wrong to say it must be done before the mental listings are removed, wrong to say every other medical intervention is listed, and wrong to say causes need to be listed. Many medical interventions are not listed, and many medical conditions still are of unknown cause. All those are false excuses for retention of the mental illness lie.

    The APA and WHO never consult “communities”, especially ones they presently list as mentally ill. Besides, how would that be done, bearing in mind that those who have mental disorders tend to be easily visible to use as excuses for retention. But please let me inform you that despite the Spanish-initiated anti-pathologisation campaign, which was supposedly taken up by ILGA, public removal from some national versions, and a resolution in the parliament of the European Union, I am told that there has never been a proposal to the ICD group to remove the listings. Furthermore there is an ICD committee to change the listings but the only member of it I know for certain is a member of the APA DSM committee that has advocated retaining the listings (and totally ignored all our responses to their consultations); a gay man who refuses to reply to queries on the ICD committee, and, having been a prime mover in banning reparative therapy on gays and lesbians, sees no problem in its use on transsexual people. So my guess is we are being shafted.

    The intention has been for some years to automatically incorporate the new DSM as the revised mental illness section of the ICD. Because of that the US government’s Department of Health and Human Services (HHS) – under the Bush administration, which was transphobic – funded and provided manpower to allow the APA start a revision. The transphobic balance of the relevant revision committee was established at the start and has not been revised during the more friendly Obama administration. In fact the Obama HHS, as a funding provider, has the ability to intervene in the DSM revision in line with its stated pro-trans policies right up until publication, but seems determined to not do so. This is highly questionable. Moreover, the ICD is an international enterprise in which US representatives play important roles, and the State Department and, again, Health and Human Services, which both have avowedly pro-trans policies could have intervened, and still could, but seem not to wish to so do. That too is highly questionable. Again my guess is that we are being shafted.

    I have tried very hard to get the government of my own country to act on this, both to speak with US HHS, and to act at the WHO. It is clear that – despite them also having avowedly pro-trans policies – they listen instead to the mental health professionals who say we are mentally ill, and to the trans activists who wrongly believe the listings need to remain.

    Those who keep arguing for continued inclusion in the DSM & ICD on any grounds at all must bear much blame for the lack of success. We need total removal of the sex- and gender-identity minorities in one, highly publicized step, so that the message is noticed. Anything else will enable the association with mental illness to continue.

    Any professional claiming they need their patients to be falsely labelled as mentally ill so that they can earn money should be disbarred. This is especially true with children, where the libel is then also used to deny them the right to consent to the medical interventions they need, which ruins lives permanently. We are normally quite as mentally healthy as the general population, but those of us who aren’t, at any time, will benefit from their therapists being able to use the standard listings for those conditions. At present such people often don’t get the necessary help because therapists often expect anyone with transsexualism to be mentally unwell because it is listed in the DSM and ICD.

    That’s more than enough for now.

    • helen
    • November 5th, 2012

    There is a lot in this issue……..I would argue de-pathologisation at the moment , without more, would be net loss to trans people generally.

    Finding medical practitioners who are willing and able to treat is not always easy…….at the moment the one route which protects those practitioners from litigation starts with the DSM catagorisation and a psychiatric assessment.

    The drugs/hormones used aren’t approved by FDA (or alternative jurisdictions’ corresponding Drug Authorities ) for cross gender usage, there aren’t clinical trials establishing this usage, any practtioner prescribing these drugs/hormones is at significant risk of being sued. The protection is the DSM criteria, and a psychiatric/ psychological assessment. Without this formalised , medically mandated template , not only would there be few Drs who would take the risk, there would be even less medical indemnity insurers who would insure them, or alternatively, the lack of an adequate medical diagnosis would mean the treatment by the pysician would be an exclusion from the policy.

    Additionally, if you read the development of the jurisprudence of trans issues, every legal precedent starts from the evidence (almost always placed before the court) that trans issues engage a medically diagnosed condition, legitimised by the inclusion in the DSM. Courts like to tie their decisions to well documented evidence . At the moment that comes in form of medical opinion that there is defined & diagnosed condition , legitimised by placement in the DSM. In one sense, Courts rarely try to resolve an actual scientific/ medical issue as a matter of objective reality, they look to the established viewpoint within the experts within that field of knowledge. As an example, I would suggest there would be little hope of successfully running cases requiring medical treatment of trans prisoners without the Diagnosis.

    Even if the inclusion is stigmatising, and dubious, I believe , for the moment, more is gained by its rention than by its removal.

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