When the National Gay and Lesbian Task Force—a national advocacy group that's been around since 1973—issued a strongly worded statement in 1996 calling for the American Psychiatric Association to eliminate gender identity as a mental disorder in the diagnostic manual, it sparked vociferous protest.
And much of it came from people and groups sympathetic to transgendered people.
E-mails and postings to newsgroups like alt.transgendered decried the elimination of the diagnosis "by which transsexuals receive health care and legal recognition of their new gender," saying such an action would "end sex-reassignment surgery in the United States, end the legal availability of hormones for transsexuals, and eliminate existing legal protection."
"Gender Identity Disorder" (GID) is the description in the Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association. Reforming GID remains a debatable issue in the trans community, but the consensus has shifted in recent years.
"Some folks will say we need to have that diagnosis because it rationalizes and provides a way for us to get medical treatment," says Daniel Gould, a transman and director of health programs for the FTM Alliance of Los Angeles. "Well, at the moment, most health insurance companies restrict coverage based on GID.
"Many transpeople experience profound distress in their struggle to understand and to find understanding about their gender. I don't want to take that away. That distress is real," he adds. "Sometimes it can be a relief for people to have a name for what's going on for them. But it stigmatizes and pathologizes. I wish I thought that GID was a useful concept, but I don't."
During her tenure as director of health services at Mazzoni Center in Philadelphia, an LGBT health organization, Alison Gerig built a transgender health program. She strongly supports getting rid of Gender Identity Disorder.
"I'm a psychotherapist and deal with the shame and trauma that comes with having to be in the world as a transperson. I do a lot of work around coming to terms with it themselves and negotiating the world. If and when I have to use that diagnosis," she says, "the client and I have a really long conversation about what it means to me to be using it, and I really separate that out from how I see them—and that I don't see it as a disorder. My approach is not to pathologize people at all. I'm very transparent about when I have to use it and why."
Moonhawk River Stone, a transman and psychotherapist in the Albany, N.Y., area, puts it bluntly: "Using a psychiatric diagnosis to help people access health care is like calling a plumber when you need an electrician. 'Gender Identity Disorder' is an inadequate and inappropriate descriptor of transgender experience.
"My approach as an original thinker on this issue is not to storm the barricades of the DSM but to get people to change their thinking," he adds. "Developing a new paradigm that allows people access to health care and to be able to move on productively with their lives is what's really important. I think it's more fitting for transgender people to access health care through development of an overarching ICD-9 medical diagnosis"—a more general clinical description—"that would allow people access to care."
Kelley Winters, a transwoman, founded GID Reform Advocates to push for changes in transgender medical policy. "People in the trans community who are concerned about these issues have different strategies and different tactics that they advance. Some people in the community are focused on reforming the standards of care," she says. "It's a chicken or egg kind of scenario when you talk about reforming the standards of care versus reforming the diagnostic category.
"Because a subset of the trans community experiences gender dysphoria—and I define that as an intense persistent distress with one's physical sex characteristics or assigned social sex roles—the issue of access to medical procedures is a very crucial one," Winters says. "We do need a diagnostic coding to facilitate access to that. But the current diagnostic category of disordered gender identity has failed the trans community on both the issue of social stigma and on the issue of medical necessity, evidenced by the fact that virtually no insurers or employers recognize the legitimacy of these procedures.
"My proposal is to replace GID with a new diagnosis that is strictly based on distress, strictly based on gender dysphoria as I described it," she says. "There's a great deal of precedence for diagnostic category based on chronic pain, whether or not there is a clear understanding of where that pain comes from. I would remove all references to social gender role conformity. That simply is not relevant to the issue of distress or access to medical care."