Is it time G.I.D. got the A.X.E.?

By Suzi Chase, 8/31/15

https://www.susans.org/2015/08/31/time-g-d-got-x-e/

It's been nearly 3 years since my diagnosis of GID, and the anger of that moment hasn't faded.

Only recently have I pried open my feelings to figure out why it angered me so. Wasn't that what I was after? Hadn't I known for months that I needed to transition, and finally a mental health professional was affirming that notion, albeit reluctantly and through gritted teeth? What more did I want?

QuoteWhat if we assumed people knew their own gender? If we decide we are male or female, our doctors and therapists take our word for it, the way they do with cisgender people.

If we didn't live in a society that so strongly codifies binary gender roles it would most probably be easier for everyone to know and express their gender. But we don't and as a result it does confuse a lot of people, we see it on this forum fairly regularly for those coming to us for help. A good therapist should be able to help unpick the layers of doubt that often surround gender confusion.

Actually, some of what you ask has come to pass, albeit not everywhere. At the Howard brown Center in Chicago they have an informed consent program for obtaining hormones.

In between, psychologists are useful in helping the person understand the dynamics of transition, especially the social dynamics. 

GCS? That's another issue. Until WPATH changes their SOC you probably won't see any movement away from two letters from qualified mental health professionals. To me this is a thornier issue. By opening up surgery to anyone who wants surgery, I think many more people would undergo a surgery they would later regret. On the other hand, shouldn't a person have the freedom to make choices for themselves. The downside that I see with this is more transition regretters which would only provide more fodder to those who fight against transgender people in the first place. Additionally, getting rid of the GID diagnosis may take it out of the realm of medically necessary procedures and insurance coverage which would place undue hardship on those who couldn't otherwise transition.

Hormones? - Yes
Counseling - Highly Recommended
Surgery on Demand? - I'm not sure. My mind is open for arguments, and definitely No if insurance coverage abates.

Honestly, in a lot of ways, I don't see the need for therapist approval all that much different from how other mental afflictions (I was trying to think of a nicer word than 'illness,' which is often thrown in our face) are treated via therapist/psychiatrist. Someone who firmly believes they are depressed can not simply walk into a pharmacy and order themselves antidepressants, and for good reason—hormones, while perhaps not as directly as antidepressants, alter our neurochemistry, and quite directly our biology in a lot of ways. Even cis, mentally affected persons have to at least attend a handful of sessions to obtain a strong diagnosis to ensure that the health professional has uncovered the root of the problem, rather than just a surface compensation, if that makes any sense. This isn't all too different from myself, being treated under WPATH.

Something I also noticed from the article that I found similar to what a cis person might experience if they presumed they had a mental affliction is that, Suzi, you mention that nearly all cases of GD (GID is actually outdated as of DSM-V as it implied we have an identity that just needs 'fixing') are self-diagnosed; I agree completely, but that isn't too much different from other people, who are often well aware of the fact that they likely have affliction X, Y, or Z before they ever make a therapy appointment. They don't get their meds willy-nilly either, and for some I think there's a lot of value in that, working through what makes you feel a certain way before prescribing meds to 'fix' it, so you understand what you're feeling perhaps from a different perspective, how certain instances of the affliction occur, and why you receive them at all.

I don't exactly know where I wanted to go with all this, I just think it's important to realise that we are not the only group of people that require the help (and I genuinely mean help) of a mental health professional before we are prescribed what we have likely known ourselves to need long before we step into that first appointment. I like to see it as less of a "gender-confirming session" and more of something along the lines of a self-analysis, where we can actually see ourselves for who we are and perhaps scratch at the surface of how this affects us daily, from the eyes of an outsider. Granted, this is the ideal, and health professionals that can actually professionally work with trans* clients are little more than a rarity, given just how many there are in the field. As always, I'm totally willing to hear out other opinions, but I just thought I'd throw in my two cents. Please take it with a grain of salt, as I actually did have a good therapy experience—short, sweet, to the point, and respectful of my wish to start HRT to confirm what I already knew.

I think GD should continue to exist as it accurately demonstrates the medical necessity of transitioning to the powers that fund. And that is really where I would like to see a divide.

I strongly believe in bodily autonomy. I do believe that for 95% of people, we know what we need and have our own best interests at heart in terms of transitioning when we have taken the time to do the research. Regardless of what you're doing to yourself, I believe you have a right to do it as long as it isn't negatively impacting someone else in a direct way. If someone has decided that they want to start HRT and perhaps have some kind of surgery to feel better about themselves, I believe that those options should be available to them regardless of the medical necessity of their choice.

But I don't believe that insurance should have to pay for it unless your case is medically necessary. I don't find WPATH standards to be unreasonable, especially for surgical procedures. I believe that informed consent for HRT should be more widely available in the United States, but even WPATH standards used by the right provider are not unreasonable.

I would say we need two things in terms of changing trans healthcare for the better:

• Certifications for working with trans people - Primarily for mental health professionals, but I could see an extension into primary care being relevant as well. This would limit the amount of negative experiences and instances of gatekeeping that people experience. WPATH should create an introductory course. You pay a fee, you take the course, take an exam, and get certified to work with trans people. Every year, you take a re-certification course that will update you to any changes in law or practice. It actually shocks me that we haven't made a push for this, considering that most people's bad experiences or feelings of negative stigma come from our interactions with the mental health community.
• Wholesale acceptance of WPATH Standards of Care by insurers - No more trans exclusions, no more vague wording about what is and isn't covered or what standards you have to meet to ensure coverage. Get everyone using the same standards. If every insurer requires us to meet the same standards AND every professional you have to work with along the way had to obtain a certification in order to work with you, I believe we'd see a lot fewer instances of people with genuine medical need having negative experiences.

Ftmax, your ideas sound good, but if a special certification was required to work with us I fear that our options would be even slimmer although the ones left might be of higher quality. It would be a hard sell for a therapist who saw one of us a year, if that. Therapy would only be available in big markets or from the few off us who are trained therapists.

As for insurance, government would have to be involved. If the companies could in any way manage it they would exclude any treatment excepting aspirin. Insurance is designed to spread the risk around and the overwhelming majority don't even know a transperson personally. Getting them to agree to even a $10 per year increase (which I believe is about right) without coercion would be tough.

Quote from: AndrewB on September 01, 2015, 09:18:06 AM
Honestly, in a lot of ways, I don't see the need for therapist approval all that much different from how other mental afflictions

My point is that being transgender is not a mental affliction. It is a perfectly normal, acceptable, reasonable way for a human being to experience gender.

The affliction is physical - that our body doesn't match our gender.

Quote from: traci_k on September 01, 2015, 07:56:58 AM
Until WPATH changes their SOC you probably won't see any movement away from two letters from qualified mental health professionals.

Agreed. This column (and some of my others) are aimed at WPATH and at the pressure our community should put on that organization and on the cisgender practitioners that insist upon following its guidelines.

I posted the following a few days ago in another thread, and I'll re-post an edited version here:
___

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. Insurance companies won't cover it if "diagnosis" is based solely on the patient's say-so.

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 the biologically based medical conditions they actually are.

By buying into the notion that ->-bleeped-<- shouldn't be in the DSM because "we're not like those people," we are contributing to the oppression of all people with "mental disorders." No one with any condition listed in the DSM deserves to be stigmatized for it.

Quote from: suzifrommd on September 01, 2015, 11:32:12 AM
My point is that being transgender is not a mental affliction. It is a perfectly normal, acceptable, reasonable way for a human being to experience gender.

The affliction is physical - that our body doesn't match our gender.

I don't know that I would use the word affliction if we're trying to remove negative stigma. But I would absolutely call it a mental condition. If there exists a disconnect between what your brain thinks your body is and what your body actually is, that is a mental condition that necessitates some kind of outside intervention.

As there isn't currently a way to alter the mind, doctors are forced to alter the body instead to relieve the symptoms of the condition. The root culprit remains the same. Having a female chest in itself was not my issue, my brain's response to having a female chest was.

I'm kind of mixed on this.

On the one hand, having it remain a medical diagnosis is good for us, because that's what being transgender is... a biological condition which requires medical treatment... it's medically-necessary. Declassifying it as a condition which needs treatment might give insurance companies and transphobes the liberty to say that it's not a medical procedure, it's an elective cosmetic procedure, and deny us care and deny us the ability to have our medical condition actually treated as a necessary medical condition instead of just as a "choice."

On the other hand, though, there is a BIG double-standard going on with access to surgery. Why can a cis woman decide with absolutely no mental health evaluation whatsoever that she wants to have gigantic breast implants, or silicone butt implants, or plastic surgery on her face, or people getting surgery to look like celebrities, with studies showing that up to 67% of the people who get those cosmetic surgeries will eventually regret them, and yet we just say "they're free to do what they want with their bodies, even if we don't understand it and even if it might be related to a mental disorder, and even if they regret it afterward," and you can also get Facial Feminization Surgery completely without any mental health evaluation whatsoever, and yet for some reason you need TWO mental health evaluations in order to get SRS? When 90%+ say it dramatically improves their lives? Yeah, I'm NOT okay with that. It's a horrible double-standard.

Now, I can absolutely understand the need for medical approval if you're expecting it to be covered by insurance, or covered by government health care programs, because then it's been proven that it's medically necessary, and thus is a medical treatment. That I'm totally fine with. But needing clearance just to have bodily autonomy? To have people telling you what you can and cannot do with your own body paying for it with your own money? Get out of my life and quit trying to police me. If cis people can get whatever freaking procedure they want even if they're going to regret it, why are we so worried about trans people regretting it?

Carrie Liz it's because, ... Shhhh!...., people think we're nuts!

Seriously. The average person thinks we're incompetent for wanting things they could never imagine they'd want themselves. "If I wanted that I would hope someone would stop me!"

A coworker asked me how I know I'm trans. I said, "imagine the doctor told you that they were going to cut off your testicles", and he looked horrified. I told him that I would be elated.

Education. It's the only thing that will work. It doesn't help that, until recently, we got no press unless we killed ourselves or were involved in something bizarre. That's why I'm totally out, and will ALWAYS be totally out even if by some miracle I eventually pass 100%. We have to be, in the words of a sitcom title, "The New Normal."

Quote from: Tysilio on September 01, 2015, 12:06:18 PM
I posted the following a few days ago in another thread, and I'll re-post an edited version here:
___

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. Insurance companies won't cover it if "diagnosis" is based solely on the patient's say-so.

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 the biologically based medical conditions they actually are.

By buying into the notion that ->-bleeped-<- shouldn't be in the DSM because "we're not like those people," we are contributing to the oppression of all people with "mental disorders." No one with any condition listed in the DSM deserves to be stigmatized for it.

Exactly.  I don't understand the stigmatization of people suffering from mental illnesses either.   Much like physical disabilities, mental illnesses can be absolutely debilitating.   Nobody chooses schizophrenia nor bipolar disorder, just as nobody chooses blindness nor paralysis.  On the flip side, the effects of both types of challenges can be mitigated and sometimes completely overcome.   Sadly, what happens is that people seem to be much more sympathetic to the people with a visible disability than an invisible one.

I see homeless people every day, many of whom have a disability that prevents them from working and forces them to panhandle in order to eat every day.  It makes me sad when I see individuals suffering from mental illnesses being met with "Get a job!" while others with visible disabilities are being handed more money per hour than most employees of the stores they sit outside of.

GID was clearly a hatchet job at classification, and I believe that GD was an improvement.   Removing GD from the DSM would be a big mistake at this time, as we currently need it there for insurance claims.  If there were no coding for GD, we would have no choice other than to pay out of pocket, just as we'd do for a tummy tuck.  Perhaps the medical establishment should consider classifying this as a physical condition in the ICD and placing it aside things such as menopause and hypogonadism the next time around.  After all, I seek relief from an endocrinologist, not a psychiatrist. 

Quote from: Jill FI don't understand the stigmatization of people suffering from mental illnesses either.

Jill, I think we both understand it well enough. The short version is that it's a holdover from the days when the mentally ill were believed to be possessed by demons. 

We haven't changed, as a culture, as much as we'd like to think.

QuotePerhaps the medical establishment should consider classifying this as a physical condition in the ICD and placing it aside things such as menopause and hypogonadism the next time around.

I like this idea, but there's still the problem of diagnosis. Both your examples can be diagnosed on the basis of physical changes, but I think we're a long way from having any physiological marker(s) for ->-bleeped-<-, and it's easy to see how pushing for the development of such could lead to even worse "gatekeeping" than we've had in the past.

Quote from: Carrie Liz on September 01, 2015, 12:47:05 PM
On the one hand, having it remain a medical diagnosis is good for us, because that's what being transgender is... a biological condition which requires medical treatment... it's medically-necessary. Declassifying it as a condition which needs treatment might give insurance companies and transphobes the liberty to say that it's not a medical procedure, it's an elective cosmetic procedure, and deny us care and deny us the ability to have our medical condition actually treated as a necessary medical condition instead of just as a "choice."

To be clear, the article is not suggesting it shouldn't be a diagnosis. The article suggests it should go from a psychological diagnosis (gender dysphoria) to a physical one (Body/Gender Dissynergia).