American Psychiatric Association Tolerates, Largely Ignores Feedback on Teh Trans

by Shaker EastSideKate, a feminist teacher/scholar/mother/partner/derbygirl from Upstate New York.

The American Psychiatric Association recently issued proposed revisions to be included in the upcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). The bit that many transsexual* and gender non-conforming** people have been waiting for is the Gender Identity Disorder entry (the part of the book that says that we're mentally ill because of who we are). Callen-Lorde Community Health Center (New York City's LGBT medical center) and the LGBT Community of Center of New York City have written a response, which lots of other folks signed on to. Helen's posted the full letter at Trans Group Blog, and I highly recommend it.

Let me highlight two points (emphasis mine):

...We appreciate the APA's proposed "Gender Incongruence"(GI) diagnosis is an effort intended to de-stigmatize gender non-conformity and improve transgender-identified people's access to mental health care. We agree with the intention behind this effort; however, we endorse an alternative viewpoint, based on our years of collective practice knowledge. We believe GI will continue to inappropriately pathologize gender non-conformity, maintain barriers to medically necessary health care, and lend justification to gender based stigmatization and discrimination...

...The November 2008 Report of the DSM-V Sexual and Gender Identity Disorders Work Group indicates that the "sub-work group has addressed feedback from interested advocacy groups and other stakeholders. Surveys were sent to more than 60 organizations." While other agencies have provided feedback in this process, we are concerned that the institutions that provide the bulk of medical and mental health services to transgender people nationwide were not asked for input. We have reached out to LGBT community health centers and LGBT community centers; none of these key, high-volume, client-centered, community-driven stakeholders seem to have been included in the research or vetting process...

Now, a couple of points relevant to the letter…

1) Stakeholders.

Stakeholder: n. 4. A person or organisation with a legitimate interest in a given situation, action or enterprise.

Stakeholder: n. 3. One who is involved in or affected by a course of action.

Okay, stakeholders. I can think of one hugely important group of stakeholders when it comes to pathologizing trans people. We're hardly a homogeneous group, but I'd wager that most trans people do not want to be classified as mentally ill on the basis of 'gender incongruence.' There have been vocal trans people who have said as much. I don't see how these proposed criteria address our feedback.

Who else is a stakeholder in the eyes of the APA? The earliest conventions (which are still influential) I'm aware of for transitioning from male-to-female*** sought to minimize the disturbance to stakeholders, as defined as cissexual people who would be disturbed if they were aware of the existence of people like me. The most desirable candidates were women who were: heterosexual, were beautiful (as defined by heterosexual male gatekeepers) yet non-remarkable, and were willing to cut all ties from friends and families. They couldn't have children or spouses (again, there are gatekeepers that still informally enforce these standards). The medical establishment viewed these conventions as a way of protecting stakeholders. I'm not so interested in addressing the concerns of such stakeholders.

Aside from trans people, let me take a look at who the working group didn't address. I'm honestly surprised (and incredibly indignant) that Callen-Lorde wasn't consulted. They're kinda a big deal. Without going into too much of the present and historical tensions within GLBT communities, and between health care providers and trans people, in my estimation LGBT health centers are the frequently some of the best (and only) hopes for many American trans people to get our medical needs met.

When I first tried getting hormones, I spent months trying to track down doctors willing to a)see me and b) treat me like a human being. I finally ended up making regular 3 hour (one way) drives to Howard Brown, the LGBT health center in Chicago, because there was one practitioner there that everyone I encountered within driving distance of Chicago recommended as the person to see. The Mazzoni Center in Philadelphia sponsors the only health conference in America run for and by trans people.

LGBT health groups would have been among the first organizations I would have contacted, were I looking to find out something about the well being of trans people.

2) Access to Care.

I'm not a big fan of how professional psychiatry manages mental illness. However, trans people find ourselves in a double bind. There are any number of medical interventions that trans people may require to happily live our lives. The APA continues to classify us as mentally ill. This does not encourage health insurers to cover the procedures we require, nor does it protect the needs of trans people from becoming political foosballs in places with ostensibly more rational health care systems.

I've had problems with my lungs, my joints. Each time, I, insured American, went to the doctor, providers took care of my health concerns (and insurers paid for some of the care). My experiences in the US haven't been as fabulous as my experiences living in Finland (where everyone, including foreign students got free health care), but they're not comparable to my struggles obtaining medical services related to transsexuality.

I remember the cold winter day I finally got up to call up a professional to tell him "I had GID." It's over five years later now. I'm really privileged to have had a job and health insurance for all of those five years, yet I'm still constantly battling to have essential medical needs me, and the double bind the APA created is partly responsible. I also remember the Spring day I found out that I had lost an acquaintance, in part due to the hopelessness she felt in her attempts to access health care. Our welfare is not a trivial issue. I wish the APA would try to see the issue of trans health care from the viewpoint of those of us with the most at stake.

3) The binary, it burns.

Okay, the working group does use the phrase "the other gender (or some alternative gender different from one's assigned gender)." This is an improvement over DSM-IV. Still, "A strong conviction that one has the typical feelings and reactions of the other gender"? WTF does this mean? You know, as a lesbian who loves football, I'm compelled to point out the obvious: I'm a woman. By the way, I was seriously tormented for years and years by the fact that I knew I wasn't a boy, yet was attracted to girls and liked football. There are girls like that. And thanks to previous work, the APA no longer classifies some of such women as mentally ill! The APA is sending a message that young me wasn't really who I thought I was. And that current me isn't who I say I am. It's also implying that lots and lots of people are deviating from the "typical", from the way they naturally should be. Seriously APA, you're hurting a ton of folks here, and not just the trans ones.

FWIW, today is the last day the APA is soliciting feedback on the draft.

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*I use the term to mean people who identify as the gender not assigned to them at birth.

**"Gender non-conforming" is the best term I've heard for referring to folks who either identify outside of the false male/female dichotomy, or who otherwise express themselves in a manner substantially inconsistent with societal expectations for a person of their assigned gender. The idea here is that you don't need to identify as "transsexual" to get caught up in transphobia.

***I'm not as familiar with the way the psychiatric establishment treats (and has treated) trans men. I suspect this stems from a parallel unfamiliarity on the part of the psychiatric establishment.