Can SRS be considered medically necessary without dysphoria?

[Donna Elvira]

Like Missy, I'm a bit confused by the initial question. Assuming we are talking about an MtF who is already living as a woman (my own case before GRS) how can anyone imagine that there is not at least a minimum level of dysphoria just from the difficulties inherent in trying to live like any other woman with the "inconvenience" of having male genitals?
In my own case, the dsyphoria was at least partially a consequence of living full time and the ensuing consolidation of my female identity. After a year fulltime it just became obvious to me that I couldn't live out the rest of my life as a woman with the male parts still "hanging around" 

That doesn't mean I hated my male parts to any sort of extreme, it just means that they become totally incongrous and unpractical and
therefore needed to go.

My gender dysphoria is what drove my transition. For me, successfully completing that transition required GRS and on that basis alone I am pretty sure I would have qualified for GRS had I chosen to use the state financed system. This is because the main condition in the approval process is demonstating a consistant desire to live as a woman and for the people running the system, as a woman it is normal to prefer having a vagina to a penis. As it happens I didn't and paid for the surgery myself but that was for reasons of personal convenience.

In the context of the original question does my case qualify as dysphoria?

[suzifrommd]

Like Missy, I'm a bit confused by the initial question. Assuming we are talking about an MtF who is already living as a woman (my own case before GRS) how can anyone imagine that there is not at least a minimum level of dysphoria just from the difficulties inherent in trying to live like any other woman with the "inconvenience" of having male genitals?

Well, you're getting to the heart of the question. What is dysphoria? How do you measure it and how much do you have to have to justify medically necessary SRS? Is inconvenience enough?

One way of addressing this would be to define dysphoria "down". I.e. Make our understanding of dysphoria more expansive to include things like being bugged about tucking every now and then. At that point, one could claim that the term dysphoria wouldn't mean anything at all, since just about everything gets on one's nerves every now and then.

In the context of the original question does my case qualify as dysphoria?

I'm not sure anyone can answer this. Because everyone in the world has a different model in their brain of what dypshoria means.

Which is why I'm so dubious about using dysphoria as a criteria for medically necessary surgery, and why I started this thread to see what other people thought.

[Dee Marshall]

Like a lot of things, we have our day to day understanding and scientists, in this specific case psychiatrists who generated DSM V, have theirs. Rightly or wrongly, DSM V lists a specific list of criteria and the number of them that have to be met to qualify. Does this list match our commonsense understanding of dysphoria? No. Will it catch every instance with no false negatives? No, again. Since the only viable treatments are therapy, HRT, and SRS, and therapy isn't sufficient on its own, the only purpose of the GD diagnosis is to decide whether you'll be allowed HRT and SRS. The DSM was meant primarily to create billing codes for insurance but its used to regulate treatment as well.

Not what we want to hear, but there it is.

Do I think that others should be allowed SRS? Certainly. As a mental health professional, I have no clue how to include them other than, "I know it when I see it", which I do.

[Taka]

it's not medically necessary if there is no dysphoria at all. but the dysphoria might just be over not having a vagina, rather than having a penis... or it may be dysphoria over not fitting the norm, or social dysphoria triggeted by not having the "right" parts. limiting the definition of dysphoria too much won't do any good.

i can imagine a case where a person would want it for purely cosmetic reasons. but i'm not sure that case is likely to be found. maybe if someone joined in a political genderqurer sect who intentionally mix characteristics of both sexes or transition just to make a political statement. but i've seriously never heard of this ever happening. it seems much less likely than a man wanting a vagina. and he would have genital dysphoria of the same level as in any other gender dysphoria, so....

hm. wouldn't it be normal for doctors to do all they can to help a woman who wants to get malfunctioning genitals reshaped so they are usable for intercourse? it shouldn't matter whether the woman is cis or trans. neither should it be found a reason to deem her less female if she feels no need to fix her genitals, i'm sure a cis woman could convince her doctor that surgery isn't necessary if they are already damaged but not painful. or is society so sexist that it will try to force every woman to have a hole that perverted males can fantasize about using, or even force themselves into?

[Jessica Merriman]

or is society so sexist that it will try to force every woman to have a hole that perverted males can fantasize about using, or even force themselves into?

  Um, tread lightly with this type of statement please.

[EchelonHunt]

I do believe society and doctors can be sexist to a point...

In my situation, I was denied a mastectomy and hysterectomy because I was young, healthy cis-female, in the doctor's mind. The doctors feared I would regret the surgery and that if I desired to have children, that I wouldn't be able to (sterile from surgery) and they would get sued. Pfft, puh-lease! Having children is on my NOT-to-do list because it is a tumble down to Dysphoria-land for me. No thank you. I want to keep what's left of my sanity intact. 

Y'know, it's not like the sexist notion is that all women experience the maternal desire and drive to create a family, that all they exist for is to fall pregnant and give birth to biological children is not at all insulting to the diverse individuality of women everywhere.

There was also no "medical" reason for me to get a mastectomy or hysterectomy, despite that I was suffering from intense dysphoria and depression since puberty began, despite that I suffered violent mood swings prior to my periods - I strongly believe I was experiencing Premenstrual dysphoric disorder, just it went untreated because my symptoms went ignored and treated as "normal" PMS. Getting swarmed with intense suicidal tendencies two days before my period hits every single cycle that I begin to pick up the pattern leading up to it is definitely NOT normal! It was extremely debilitating and it took a toll on my relationship with my family, friends and worse of all, my mind. It was no wonder that suffering from PMDD for the many years of my adolescence that I struggled to see any future for myself.

I also feel that asking the doctors to remove my female genitalia, I suspect this caused discomfort within them because what body would I have afterwards? It certainly wouldn't be female nor male either. Mind you, back then, I wasn't thinking that far ahead, I was thinking, "Great, the sooner I can get these things off me, the better I will feel." than "Hm, what sex will I be?" Either way, the decision regarding my body was made for me by doctors - against my will. I had no say in the matter and I felt that was incredibly unfair because at the end of the day, it is MY body, if I cannot be allowed to modify it, what's the point of calling it my body if I cannot change it - especially to elevate dysphoria? If doctors are so concerned with getting sued, I will sign a letter or a waiver - I would not have to because the likelihood of me experiencing regret after the surgery is very slim. I had thought about the surgery for many years, even dreamed of it for many nights.

Funny how if you identify as a man, they will send you to a gender therapist who will write letters that will allow you to access the surgery that was denied to you as a biological woman because, oh no, we cannot remove your breasts and uterus unless you have cancer! What if the breasts and uterus may have well been cancer to my MIND? Nobody cared about enough about that, did they? They just looked at me like I put my head into a bucket of water and asked if I was wet. Why is a woman saying her breasts and periods cause her depression? That is not normal, she should be happy with her breasts and it is normal to be sad from periods - women don't particularly enjoy getting them anyway! That is what I think the doctors would be thinking to justify my behavior and conclude that I am female, just a very confused one.

It's a messed up society we live in. Doctors will find excuses and justifications for anything that goes against the binary system. God forbid, should someone have the right to modify their own body if they have been proven to be of sound mind, aside from experiencing distress from the said body parts they wish to remove.

This was probably severely off-topic - if it is, I will delete it.

[Tessa James]

Not to further derail but as a MAAB patient I have recently been denied genital surgery because it is "cosmetic, not a malignancy and will not improve function."  I have appealed this and will persist but please know we are in this rejection boat together.  What is different in my experience is that if a cis person has trouble getting an erection or has vaginal trauma from giving birth or a birth defect they will correct this problem without therapy letters or any of the falderal we go thru.  It is discrimination, unfair and wrong.

[Jessica Merriman]

It is discrimination, unfair and wrong.

Maybe so, but it is the law right now. Physicians have to follow established protocols or risk punishments themselves. No one disagrees that one should be able to do what they want with their bodies. That is not the problem at all. Having procedures in place for physicians to act on those request's is. The laws and protocols will change it just takes time. 

[missymay]

I heard of only one case where a man's genitals were so badly mangled in an accident yhat they offered him srs as the only sollution. But otherwise a man with no dysphoria woul not even need srs.

I heard about this option also, and SRS also being performed on burn victims.

[Tessa James]

Maybe so, but it is the law right now. Physicians have to follow established protocols or risk punishments themselves. No one disagrees that one should be able to do what they want with their bodies. That is not the problem at all. Having procedures in place for physicians to act on those request's is. The laws and protocols will change it just takes time. 

Well, yes and no.  In States such as California and Colorado and the District of Columbia law does not allow for this discriminatory exclusion of our medically necessary health care.  And then there are insurance companies, insurance policies, and clinics and providers in the USA that do support WPATH standards that since 2008 consider the exclusionary exemptions to be unethical.  My physicians and therapists have already declared that I meet the WPATH standards.  To deny us care is, again wrong and unfair and I urge any of us so denied, like you Jessica, to appeal and persist. 

[Taka]

I heard about this option also, and SRS also being performed on burn victims.

society also has a history of imposing this on infants, then trying to force them into a female gender role. not sure i agree with the practice.

  Um, tread lightly with this type of statement please.

if society is a group, then... but i view society as all groups together, and thus i'm not blaming any in particular.
it's also the most chaste way i could manage to express this feeling of being trampled upon, view as a reproductive organ and instrument of pleasure way before being seen as a human. treated like an existence doomed to motherhood and guaranteed to only find the greatest pleasures and purpose of life after learning to satisfy a man without complaint and experiencing all that has to do with pregnancy and childhood.
and it's not only men who do this to me. women have a tendency to be even worse, to other natal women. never asking what another woman wants, always assuming and pressuring in one direction. the perfecr marriage, the perfect man, pregnancy and childbirth, loving to be valued for one's secondary and primary sex characteristics, meekness, submissiveness, all the things people told me a woman was supposed to be.

i could continue my ramt for so long, and relating it to doctors' unwillingness to write that letter of libeation from crippling dysphoria, fear of the future, disdain from society, all the things a woman whi does not value her vagina and breasts will face. i'm nit speaking as a trans individual with body dysphoria right now. i am a woman, and have been for nearly 30 years of my life. and i gabe seen the lust in men's eyesthe expectations in women's, since i was barely 10.

it creeps me out.
and any feminist could express this all in words unfit for these forums.

it still is relevant to the topic too. srs or sterilization can be medically necessary for many more than just transgender people.
but this odd expectation that all people would be sexual beings whose greatest purpose in life is producing offspring, keeps the doctors from accepting our different forms of dysphoria as real.
not all doctors want that. many uae their own sound judgement. but most just follow what the system dictates, based on society's rules and norms rather than science and serious research.
we're still living in the old testament.

[suzifrommd]

I spent a lot of time thinking about this topic. The fact that I never had the sort of body dysphoria that so many have here but that I craved SRS anyway, set me to thinking about this. Should someone like me have my SRS covered by insurance?

At first my answer was, "of course not". I could comfortably live without surgery. The only negative effects would be tucking and the wish that my body were shaped differently.

Here's the problem with that line of thinking. If you have to have a certain level of unhappiness for your SRS to be considered medically necessary, won't that encourage A LOT of gatekeeping? Doctors deciding whether we meet the level while we tailor our stories so doctors won't turn us down?

I've changed my thinking. Here's where I am now with this:

Everyone has a right to be whole.

Whether you were born some type of physical deformity, or you've medically transitioned so that you're hormonally female, human beings have a medical right to bring their bodies in line with what other humans take for granted.

Thoughts?

[Taka]

as long as that right is not forced upon anyone.
and those whose "whole" is a little more or less than what other people take for granted, will they have the same right?

if a whole body is one without gender, for someone, will we recognize it as a medical right to grt their body in line with what they consoder whole and good?

i don' experience crippling dysphoria. but my wish to change aspects of my body is still strong enough that i'm willing to pay out of my own pocket for it. i believe my life will become better if i get to change these things. should i have a medical right to it?
there are others who experience much stronger dysphoria than me, and have considerably less money to spend. should they grt it for free even if they're not aiming to get their body in line with what everyone else takes for granted, but instead with their brain's expectations?

or are you defining what everybody else takes for granted, as having a body that fits one's mind? because that would b an equal right to all humans, and much easier for me to agree with unconditionally. anything else will make me feel left out and ask, why should you get it when i don't...

[Jenna Marie]

I agree with you, Suzi.

What keeps coming back to me is this essay I saw a while ago about how dysphoria doesn't always present as "classic"; the person can be depressed, have no hope for their life, feel like something amorphous is wrong, etc. but not know *themselves* that that's what's wrong. It's not until after they receive treatment that they look back and think "oh, so that's what that was."  What if one of the people denied is someone who has that sort of diffuse/undiagnosed genital dysphoria, and ends up in dire straits because they couldn't bring themselves to say the magic words to get surgery, because they thought it would be a lie? And how MUCH dysphoria do we need someone to demonstrate? Are we going to require that someone in the doctor's office be forced to take down their pants, look at their genitals, and have a panic attack/pass out/vomit before it's "enough"? (This sounds like sarcasm, but given that in the past trans women were required to present as perfectly feminine, claim to be straight, get divorced, and move across the country... never underestimate how high the medical establishment can set the bar.)

So while I don't recommend rearranging the genitals of people *against their will,* I don't see any reason why it should not be available to anyone who's a) confident it's what they want and b) informed of the risks. Anything less is treating trans people as if they have fewer rights than cis people to modify their bodies as they see fit.

[Taka]

the bar is still that high i norway, jenna.
i'd have to pretend being 130% male and agree to a full course which includes genital mutilation (it's mutilation if it's against someone's identity), if i want to transition within the established system.

of course i'll also have to pretend that men disgust me, i have crippling body dysphoria, getting a child was against all laws of nature and my own free will, and a whole lot of other things.

i'd even risk being performed surgery on without having been given oppostunity to consent, if i'm to believe stories of even recent years.

over half of the applicants for transition are denied because they aren't found trans enough. in a country where the people are generally tolerant and even accepting.

i don't have any medical rights in my country, and even many completely binary trans people experience the same.

medical right shouldn't be measured by levels of trans dysphoria. and tratment should be tailored to suit the patient's needs.

[Jenna Marie]

Taka : That is appalling. Things haven't improved all that long ago in the US, and in some states it's still pretty bad, but at least there's been *some* progress. I'm so sorry.

[EchelonHunt]

Taka, that is horrible. The next time I am anywhere near Norway's vicinity, I will protest in the streets, but that would probably get me arrested or kicked out.

We have rules here where you are not allowed to start hormones until you are 21, when the decision-making part of the brain finishes maturing. Yet, Australians are allowed to have sex at 16 and begin drinking alcohol at the age of 18, some drink underage even. There has been research to suggest that drinking heavily at young age can delay the brain's development so wouldn't this imply that the decision-making part of the brain could mature much later than 21...?

Just thought that situation was weird and interesting to note.

[mac1]

I heard of only one case where a man's genitals were so badly mangled in an accident yhat they offered him srs as the only sollution. But otherwise a man with no dysphoria woul not even need srs.

I heard about this option also, and SRS also being performed on burn victims.

Are you sure that they didn't offer him full nullification instead? I have heard of that being the option when the male genitals are severly damaged.

[Taka]

Taka, that is horrible. The next time I am anywhere near Norway's vicinity, I will protest in the streets, but that would probably get me arrested or kicked out.

We have rules here where you are not allowed to start hormones until you are 21, when the decision-making part of the brain finishes maturing. Yet, Australians are allowed to have sex at 16 and begin drinking alcohol at the age of 18, some drink underage even. There has been research to suggest that drinking heavily at young age can delay the brain's development so wouldn't this imply that the decision-making part of the brain could mature much later than 21...?

Just thought that situation was weird and interesting to note.

i don't think demonstrating would get you arrested. we're kind of liberal with those things.
interesting that people would think hrt is more damaging than biologically programmed puberty.
we should start telling stories of ruined youth and governmebtal blocking of the path to adulthood and a better life.

[JessicaH]

I think by definition that someone would have to be at least somewhat dysphoric to go through something as traumatic as SRS.