KYLA: We are having the wrong conversation(s). This is the conclusion I came to after attending an amazing community dialogue on Gender Identity Disorder (GID) in the Diagnostic and Statistical Manual (DSM).  Part of the NYC Quorum Forum, the dialogue explored how language is used in ongoing debates around GID to “distance gender expression/experiences from other experiences currently described in the DSM.”

This was far from the first time I’ve thought about the DSM within my work on transgender legal protections.  Indeed, when discussing various legal strategies for employment discrimination recourse, I often bring up the article written by Levi and Klein in Transgender Rights on using disability law to protect transgender workers.  I have also done a lot of reading on the pathologization and stigmatization caused by a diagnosis of GID and engaged in conversations on the removal of this diagnosis or its transference to a medical rather than psychiatric diagnosis.  And I’ve chewed on Andrew Sharpe’s point about how the GID excludes members of the transgender and gender non-conforming population whose identities do not fit into the narrow narrative the DSM has established as the “right” narrative for accessing treatment and care.

Despite all of this, my brain never quite connected these two conversations – the pathologization of DSM diagnoses and the connections between transgender and disability rights.  But thanks to the folks who gathered in Bluestockings for this dialogue and demanded more from our community/movement/whatever you want to call it, my brain is working in new directions now.  And these directions feel darn exciting.

As much as I appreciate the advocacy people are conducting around the upcoming revision of the DSM, I don’t believe talking about a removal of GID is the right conversation at this time.  The fact is access to health care and coverage often hinges on a diagnosis.  DSM diagnoses are also used in courts to prove the legitimacy of a transgender plaintiff who is bringing forward a discrimination claim.  Now, do I think either of these things are right?  NO!  But these are currently the structures we are operating under.

Now, let’s definitely talk about changing the way our legal system works and expanding its overly narrow definitions of who fits into protected categories and who isn’t deserving of protection.  And let’s definitely continue the fight for universal affordable quality healthcare that includes the specific healthcare needs of trans communities.  But it is my belief that we need to work towards these goals first before considering the removal of GID from the DSM.

In the meantime, we can learn a lot from the disability rights movement.  Like how a diagnosis or a disability is not necessarily the sum total of your being.  Rather, it is part of who you are – and for some, it can be an empowering part.  Let’s challenge the rampant stigmatization around psychiatric and medical diagnosis. I believe that in engaging in this work and these conversations our movement for collective liberation* will only be made stronger.

* Thanks to Dickerson for introducing me to this term!

AVORY: Thanks so much for bringing this topic up, Kyla!  As our readers are about to learn, I have a lot to say on the subject…

There are two basic strains to the diagnosis question, as I see it.  One is the narrow definition of what “transition” means.  The other is the connection you’ve identified between transgender identity and (dis)ability.

First, what is transition?

There is one fairly well recognized, if not well understood medical model that involves a cognitive distance between gender identity and “physical sex,” followed by therapy, GID diagnosis, and physical transition from one binary gender to the other through some combination of hormones and surgery.  In this process, some might argue that there is a clear end point to transition, that once a person has completed surgery/ies and is living as the “opposite” gender, he or she “has transitioned.”  Of course, there are attendant social and legal elements to this–friends and family recognizing the transition, gender marker being changed on ID documents, etc.

Of course, this isn’t exactly what everyone who is MTF or FTM and chooses to medically transition goes through.  Some do all these steps but don’t identify with their gender exactly the way their therapist wants.  Not everyone who completes these steps considers transition “complete” or wants to pass as cisgender.  Moving out from this narrow definition, there then those who choose limited or no surgical intervention, but do take hormones.  There are those who do not take hormones.  There are those who are perfectly happy with what others perceive as a “male” body while using a female name, pronouns, and identity (and vice versa).  And there are non-binary folks like me, or binary trans folks who aren’t quite comfortable with the straight-line transition narrative from one gender to the “opposite.”

The point of all this is that the GID diagnosis, and the recognized standards of care around that diagnosis, narrow the cultural and legal understanding of “transition.”  Most trans people know that there are many ways to transition, but those outside the community may continue to see transition very narrowly, and reject those who do not fit the model.  Lawmakers also tend to make law based on what medicine says about trans people, so in some cases the GID definition limits ability to legally transition.

GID also privileges certain forms of gender expression, and certain transition paths, over others.  In order to get a GID diagnosis, some trans people have to drastically alter their authentic gender presentation to “convince” a therapist or be eligible for medical intervention.  Some non-binary people, for example, would be more comfortable having chest surgery, but in order to convince a doctor that this surgery is needed, have to fit into an FTM or MTF mold.

The second issue, as Kyla points out, is the connection between transgender and (dis)ability.

What is disability?  Often, it is an inability to do things in the “normal” way.  Most people perceive things through sight and sound, so those who cannot see or hear are seen as “disabled.”  Most people move through the world by walking on their feet, so those who use prosthetic limbs or roll down the street in a chair are seen as “disabled.”  There wouldn’t be a concept of disability without a concept of ability, or the “normal” way of doing things.

This frame doesn’t only apply to things we think of as disability-related.  Some examples:

- It’s “weird” to talk with your hands instead of your mouth

- It’s “weird” to express yourself very emotionally, or to express yourself very infrequently

- It’s “weird” not to think and feel within a certain realm of acceptable thoughts and feelings

- It’s “weird” to prefer the same sex

- It’s “weird” to have multiple partners

- It’s “weird” to have a gender that doesn’t culturally “match” chromosomal or physical “sex”

Those who are perceived as “weird” often form distinct communities based on different ways of doing things.  Because of privilege, the majority doesn’t generally question its view of what’s “normal” and what’s “weird,” but those in a particular community may consider their version perfectly normal.  For example, in the Deaf community, communicating through sign language is not considered a “disability.”  Many transgender people, similarly, don’t see themselves or their friends as having a “disorder.”

These differing perceptions, unsurprisingly, tend to create rifts between communities.  The idea of “ability” or “normality” is used by the majority as a protective mechanism.  If you’re weird, I’m okay.  There’s a discomfort with different ways of doing things, because if those ways are normal, the majority has to question its own ways.  Both the disability model and the gender binary are a kind of line-drawing that makes the majority comfortable.  I am on one side of the line, you are on the other.

From the perspective of someone on the “other” side of the line, these categories may seem quite arbitrary.  For example, I recently read a post on Sociological Images about two runners who use prostheses.  There is a resistance to allowing disabled runners to compete alongside those running on their natural legs, explained by the possibility of some advantage being conferred by the prosthesis.  A prosthesis is seen as an “unnatural” advantage, but we don’t say the same about very tall basketball players or very short gymnasts.  Similarly, we have no problem with people being beautiful, happy, or comfortable in their gender without surgery or hormones, but those who need medical intervention to reach this state are seen as “wrong.”

The fact is, there’s nothing inherently wrong or unnatural about having a gender that doesn’t “correspond” in our cultural understanding to chromosome makeup or birth genitalia.  It’s difficult to be transgender because of stigma, social harm, lack of access to care, and other reasons.  Many of the justifications for putting transgender in the DSM are based on the social response to trans identities and the harm it causes to trans people, rather than on the simple state of being transgender.  It’s a disorder because society defines order.

This is not to minimize what it’s like to live in a body that feels wrong.  Even if these societal harms didn’t exist, if we were correctly gendered no matter what our bodies looked like, there would likely still be dysphoria and some people would still need surgery to feel right in their bodies.  But it is unclear why we should treat this need for surgical correction as indicating a disorder.  Is having wisdom teeth a disorder?  Are the cultural and ritual changes that take place in many other areas indicative of a disorder?  When we look at it this way, the norm of having the same sex characteristics throughout life seems rather arbitrary, kind of like talking with our mouths rather than our hands.

Like people with disabilities, transgender people are harmed by others not understanding the way we perceive the world, by lack of education, and by difficulty finding affirming community.

This brings us back to the question of the GID diagnosis, and the benefits Kyla points out–access to healthcare and the use of GID in discrimination claims.  Those benefits are real, and I agree that there are big changes we need to make before taking transgender out of the medical sphere entirely will benefit trans people.  However, I would argue that there should be a change in the DSM to less stigmatizing vocabulary.  The DSM-V criteria under consideration offer a mostly workable concept of gender dysphoria.

I’m not an expert in diagnostic criteria, and so I can’t guess what the implications of the revision being considered would be.  However, I do think it makes sense to frame gender transition as something (covered by insurance) that some need and some don’t.  A condition doesn’t have to be a stigmatized disorder to ensure access and insurance coverage.  For example, near-sightedness isn’t a stigmatized problem–you just get glasses.  Birth control for contraceptive purposes is covered as a legitimate form of preventive care.  I can even imagine framing transition as preventive care–not a sign of a disorder, but something that is necessary to prevent later health problems.

The bottom line for me is that we have to have a serious paradigm shift as a society, and I think the DSM-V provides at least one opportunity to start making that change.

KYLA: I love the idea of using conversations around DSM revisions as an opportunity for paradigm shifts!  That is such an exciting re-framing of what has typically been a very painful conversation.

I also want to use this opportunity to contextualize coverage for birth control.  Yes, it’s fantastic that about 9 in 10 employer-sponsored insurance plans now cover a full range of prescription contraceptions.  But this is only thanks to over two decades of hard core activism, a history which may be too easily forgotten.  Gloria Feldt lays out this strategy in her final chapter of The War on Choice and the National Women’s Law Center has a handy-dandy timeline of this push for coverage of contraceptives.  You can also read about the first big victory in 1998 where activists successfully used insurance coverage of Viagra to point out the absurdity of not covering birth control.  It’s important to remember this history, especially in light of the backlash to President Obama’s recent mandate for birth control coverage and this week’s no-girls-allowed Congressional hearing on birth control.

When it comes to insurance, there are many battle fronts to fight on.  Perhaps this is another opportunity to use the collective liberation strategy to push for real change that leaves no one behind.