Recently part of some thoughts I've had regarding the legality of transitioning.
It stems from the fact that decades ago, people fought to have homosexuality removed from the list of mental diagnoses over the span of 1973 to the late 80s, wherein the name of the 'diagnosis' of being gay has changed before it stopped being in the manual altogether.
I've only recently found a couple pdfs that share my view that part of getting the status of being transgendered is to have it removed from the manual and to have the process of changing one's legal name and gender marker to be a matter of choice than a matter of satisfying a diagnosis, and said reading material has also mentioned that a con would be the lack of insurance coverage for the physical treatment. Although I would certainly have no solutions myself, I could imagine that at least hormones and blood testing could be covered under the idea that once ovaries/testicles of the transgendered person have been rendered unable to provide hormones themselves, the HRT would be necessary for maintaining a healthy range of hormones for physical and mental stability.
The problem with this opinion I have is that I don't know of a lot of opinions of too many other transgendered people on this subject. There always seems to be only the argument between people who don't accept ->-bleeped-<- and people who want the diagnosis to be covered.
They should clearly be out of psychiatric section - which will happen in the edition of the ICD (not really familiar with the DSM structure). As far as treatment goes, the medical practitioners would be confused because they will have no code to refer when prescribing medications.... The contemporary trend is that GD is not mental condition, yet it is still medical condition and comparison with homosexuality is not very helpful here. Once somebody comes out as gay the consequences are mostly social. However, if somebody comes out as transsexual and intends to transition then there is only one known route at the moment, which is medical....
Under DSM, it's under the collective title 'gender dysphoria'.
I do know that I like the ICATH model, which I'm transitioning under, as it treats the decision to transition as a conscious decision being made by an adult and not as some dreadful last resort everyone wants to keep you from doing. The 'informed consent' model they follow for getting a legal hormone prescription might be the best approximation I've got.
I suppose a lot of it is that I'm sick of seeing both sides agree on this idea of surgery being 'mutilation' and the result of a disorder. Tattoos aren't considered mutilation driven by a disorder, it's considered something you consciously have done after (hopefully) some degree of forethought and a business transaction.
If you de-medicalize something, you remove the need for insurance companies to cover treatment.
I am all for removing the stigma of a mental health diagnosis, but only if we find a way for general practitioners to be comfortable making a diagnosis. I think informed consent could evolve to do this.
Quote from: Neshkav on August 16, 2015, 01:46:55 PM
Although I would certainly have no solutions myself, I could imagine that at least hormones and blood testing could be covered under the idea that once ovaries/testicles of the transgendered person have been rendered unable to provide hormones themselves, the HRT would be necessary for maintaining a healthy range of hormones for physical and mental stability.
HRT, in the interest of monitoring blood and keeping the levels in healthy ranges, could and would necessitate a degree of medicalization in the interest of the physical health of the individual at least. And I'd argue would make identity less within the need of a mental health diagnosis.
That avoids the question of medical necessity though, which is why insurance companies pay for things in the first place.
If you have a bad sore throat and go to the doctor, you might get a diagnosis for strep throat. They will then prescribe you medicine to clear this up. Your insurance will likely cover the cost of the medication because antibiotics are considered necessary in the treatment of strep throat.
You would first need to define why the administration of HRT is medically necessary to the individual in order to get to the point of making monitoring it a medical necessity.
Having a legal hormone prescription already requires blood work from between every few months to once a year under such things such as the ICATH model. If one for example has committed enough to physical transitioning to get bottom surgery, and would thus have no natural source of hormones if they quit using their prescription, there would be negative health consequences. That's a situation where insurance might be needed to cover hormones.
Which is what I stated above. Informed consent could evolve to take the place of a mental health diagnosis. But the responsibility would shift to require practitioners to make the call themselves, as opposed to having a mental health professional do it.
Even the situation you describe may not constitute a medical necessity to an insurer. Castration or a hysterectomy without the introduction of hormones can produce some uncomfortable side effects in people, but the medical community from what I've read seems torn on the subject in terms of its usefulness and necessity.
The biggest complication to your original question is the insurance system in the United States. If you want to remove the entity that they rely on to determine the necessity of transitional care, they're going to want something in its place to ensure that they aren't needlessly spending money and therefore losing profit.
And my answer to that is that, admittedly, one would not be using any insurance for things like surgeries. The surgeries would be a voluntary thing that an individual could do at their own choosing, but they would have to pay for it themselves. I would argue that the need for say, bottom surgery, could be determined by how well the individual could handle externally-recevied hormones after a given period (rather than the rather arbitrary "how well do you do in society" standard that mental health uses). Without being listed as a mental health diagnosis, proceedings with physical changes could instead simply be based on the fitness of the individual and whether or not there's much in the way of negative effects from the hormones. I mean frankly, that's what I thought the whole basis for waiting or bottom surgery was based on myself when I was getting myself started on testosterone.
That's one option, but it's by no means a viable solution if surgeries remain as financially inaccessible to most people as they are.
As one who earns just enough to be slightly above the poverty line, I find that taking the option of going to my doctor with "Here's a form to sign. Boom. Here's your hormone kit that costs $60 and lasts at least four months. Come back for blood work at this date." to be more financially viable and accommodating for saving up for surgeries then when I was previously arguing with a therapist for nearly a year who kept dodging the issue and telling me to watch this set or buy more clothes or travel to this group all the way in the next county or overall expecting me to spend my time and money on things that are beside the point.
Maybe splitting hairs, here. But my insurance covers gender dysphoria, not being diagnosed as transgender.
First, I'm sorry that your experience in therapy doesn't seem to have been good.
But your circumstances are your own. Many people would not be able to even dream of paying for surgeries or other parts of their medical transition without help from insurance. I make a fair amount of money and it will still take me several years of saving +$1000 per month in order to afford bottom surgery. For people that can't spare that much money per month, their wait stretches out indefinitely. Nevermind those moments when life happens and you have to clear out your savings because you got evicted or your car broke down, etc.
Ultimately, if we do see gender dysphoria come out of the DSM, I think the mental health barrier will be replaced by a greater degree of involvement on the part of the patient's doctor.
How is the involvement going to be any greater than under the ICATH model where the doctor just takes blood tests and explains what all the patient has to do if there's any sign a problem could arise?
Edit: Also,
Quote from: FriendsCallMeChris on August 16, 2015, 04:20:43 PM
Maybe splitting hairs, here. But my insurance covers gender dysphoria, not being diagnosed as transgender.
It still means transgendered people, if choosing WPATH, have to be diagnosed by a therapist who'll probably call you transphobic because you tell her, "No. I will not watch
Ma Vie En Rose. Especially not with my family. We're hippy/redneck hybrids, this will mean nothing to us. This movie has naught to do with you talking to a man in his mid 20s."
Coming into this conversation with a negative view of the mental health community colors your view of the situation. Not all therapists are like the ones you saw. There are some great professionals out there who genuinely care about our ability to transition of our own accord in a supportive environment.
Without a diagnosis, patients cannot get insurance coverage for transition related medical expenses. The only way I could see them removing gender dysphoria from the DSM while retaining the ability to diagnose is if we shift the responsibility of the diagnosis to another medical professional. That gives it the legitimacy needed for insurance companies.
I would argue that there wouldn't necessarily be a diagnosis, more that in the vain of ICATH they would have a form where you confirmed that you had your own understanding of the sociopolitical expectations and that your bloodwork pre-HRT showed that you were of satisfactory physical condition.
I've seen an argument between two people; one a guy who didn't understand and had issues with trans people having bottom surgery to transition. The person who was on the side that trans people should be allowed to transition honestly put forth the argument, "If there was a pill to okay with having a male body, I would take it, but there isn't, so surgery is what trans people have for treatment." If there's more pro-have-my-surgery-covered-by-insurance types of trans people with this view of themselves, I have to really wonder if having to get a therapist, or anyone's grant us permission to get a hormone prescription is doing us as much good as one would like it.
I see no benefit in having transgender removed. The reason homosexuality was removed is because it doesn't fit the qualifications of a disorder. It causes no harm or discomfort other than what society pressures.
Transgender people do not have this privilege. Gender dysphoria is not something that someone can just shrug off. It is a real mental distress. Due to this reason that is why it is in the DSM. Perhaps HRT qualifications could be more lax but having insurance companies cover that plus surgeries can only benefit. I dont know what benefit or justification you have for removing it from the DSM but it is clearly misguided
I think jargon has changed too much, and people are confusing things. Transexuals have dysphoria and suffer a medical condition that is alleviated through medical and often surgical transition. It is a condition that requires professional help.
Transgender is the umbrella term that covers all who's gender expression doesn't match the sex they were assigned at birth.
Transexuals don't want the it out of the DSM mostly to pay for treatment, but also so we are not just confused with people who dress for sexual fantasy fulfillment or any other reason not associated with dysphoria.
Quote from: Neshkav on August 16, 2015, 04:09:57 PM
As one who earns just enough to be slightly above the poverty line, I find that taking the option of going to my doctor with "Here's a form to sign. Boom. Here's your hormone kit that costs $60 and lasts at least four months. Come back for blood work at this date." to be more financially viable and accommodating for saving up for surgeries then when I was previously arguing with a therapist for nearly a year who kept dodging the issue and telling me to watch this set or buy more clothes or travel to this group all the way in the next county or overall expecting me to spend my time and money on things that are beside the point.
Right?
I can't afford treatment otherwise.
Quote from: Neshkav on August 16, 2015, 04:53:42 PM
It still means transgendered people, if choosing WPATH, have to be diagnosed by a therapist who'll probably call you transphobic because you tell her, "No. I will not watch Ma Vie En Rose. Especially not with my family. We're hippy/redneck hybrids, this will mean nothing to us. This movie has naught to do with you talking to a man in his mid 20s."
Huh?
Then just lie to your therapist if it's dumb stuff like that. I know women who do fight sports and only watch horror movies, are they not women or something :D ?
Neshkav, what you propose would eliminate being transgender from having any standing whatever as a medical condition that needs to be treated and put it squarely back in the realm of "lifestyle choices." It's taken years of struggle to begin to dent the attitude that gender-affirming surgery is medically necessary for some people, and it would be a tragedy if it were shoved back into the box of purely elective cosmetic surgery.
There are plenty of people for whom paying out of pocket even for safe, monitored hormone therapy will never be possible, and there are even more for whom paying for surgery is even more unattainable. This isn't any sort of moral failure or failure to "want it enough." It's the consequence of a truly effed-up social and economic system, in which things like race, class, education, and health status put vast numbers of people at a huge disadvantage.
It has taken a long time to get to the point we've now reached, where it's increasingly accepted that being transgender is a condition which, for many people, requires medical treatment and should therefore be covered by insurance. The problem is that the people qualified to give the medical treatment (surgeons, endocrinologists, and some primary care physicians) aren't qualified to make the diagnosis, which depends on psychological traits. This means that mental health professionals have to do that.
On the other hand, barriers to medical treatment, including financial ones, are among the major reasons trans folk suffer from psychological problems, with depression and self-harm, including suicide, among the most prevalent.
So, yes, treatment does need to be covered by insurance, and, no, gender dysphoria shouldn't be removed from the DSM. It's rational for insurers to want to be sure that treatment is actually needed, i.e. that this (or any other) condition is properly diagnosed, and this is the best mechanism we're likely to get.
To state the obvious, the reason some of us want gender id not to be in the DSM is that "mental disorders" in general are heavily stigmatized. Even those of us who should know better are scared by them; we often regard them as moral defects or personal failures rather than biologically based medical conditions -- which they actually are.
That is the basic problem here. By buying into the notion that ->-bleeped-<- shouldn't be in the DSM because "we're not like those people," we are contributing to their oppression. No one with any condition listed in the DSM deserves to be stigmatized for it.
Quote from: ftmax on August 16, 2015, 03:36:58 PM
Castration or a hysterectomy without the introduction of hormones can produce some uncomfortable side effects in people, but the medical community from what I've read seems torn on the subject in terms of its usefulness and necessity.
From what I've read and from chatting first hand with people suffering from hypogonadism (males with abnormally low testosterone production), and from chatting with some DES daughters who've experienced premature menopause, having insufficient sex hormones causes you to develop all sorts of chronic health problems as you get older, as well as completely destroying your quality of life.
It's true there is quite a large faction within the medical community who are of the opinion that hormones are an optional accessory, but then not so long ago, doctors were telling people that bloodletting was the cure for all ills, and that there was no need for them to wash their hands or practice any kind of hygiene because "a gentleman's hands can't carry disease". Most of what doctors do isn't based on science at all, but rather on "expert opinion" (which all too often later turns out to be completely wrong). This is just another example.
http://www.ncbi.nlm.nih.gov/pubmed/18567642
Androgen deprivation therapy, insulin resistance, and cardiovascular mortality: an inconvenient truth.
"Prostate cancer (PCa) is the most common cancer in men. Androgen deprivation therapy (ADT) is used in the treatment of locally advanced and metastatic PCa. Although its use as an adjuvant therapy has resulted in improved survival in some patients, ADT has negative consequences.
Complications like osteoporosis, sexual dysfunction, gynecomastia, and adverse body composition are well known. Recent studies have also found metabolic complications in these men. Studies show that short-term ADT (3-6 months) results in development of hyperinsulinemia without causing hyperglycemia.
Studies of men undergoing long-term (>or=12 months) ADT reveal higher prevalence of diabetes and metabolic syndrome compared with controls. In addition, men undergoing ADT also experience higher cardiovascular mortality. "
(Androgen Deprivation Therapy is the medically induced suppression of testosterone production in men)
If you look at the full text of the study, it's not just a small increase in metabolic disorders and mortality in the androgen deprived group either.
"The results showed that 55% of the men in the ADT group had metabolic syndrome, compared to 22% and 20% in the non-ADT and control groups, respectively."
"men receiving ADT were 2.6 times more likely to have cardiovascular mortality than non-ADT controls"
Although I don't know of any actual studies off hand in women, I've been told that much the same applies there too (except the hormone involved is estradiol rather than testosterone obviously).
This is why trans women shouldn't put up with being underdosed with estradiol by their doctors. It doesn't just give you poor results as far as feminization and overall feelings of wellbeing are concerned, it's actually putting your health and your life in danger.