It doesn’t take much searching to find horror stories of what transgender people have to deal with when they seek medical care, ranging from everyday forms of embarrassment and humiliation to, in the worst cases, life-threatening ignorance. A lot of doctors are still unfamiliar with the needs of trans people and, as a result, just aren’t in a position to do a good job caring for them. This applies both to routine care — checkups and so on — and to the specific needs of trans people who choose to transition their gender via hormones therapy or surgery.
At the level of individual hospitals and clinics, that is slowly changing for the better — there are already pockets of the U.S. where trans people do have access to a fair number of doctors who know what they’re doing (assuming, of course, these potential patients have sufficient money, health insurance, and so on — all of which can be obstacles to getting good care).
It also seems to be changing at the level of the giant health organizations that in many ways set the tone of how doctors around the country and world do their jobs. Here’s one encouraging example: As Pam Belluck reported earlier this week in the New York Times, “The World Health Organization is moving toward declassifying transgender identity as a mental disorder in its global list of medical conditions, with a new study lending additional support to a proposal that would delete the decades-old designation.”
The process of updating the guidelines is a fairly winding one — it won’t be until May 2018 that the new guidelines are approved, Belluck notes. But she writes that there doesn’t appear to be much controversy within the organization that this is a change that should be made.
There is some controversy over the specifics, though: “Many, but not all, advocates favor the idea of keeping transgender in the codebook in some form because the designations are widely used for billing and insurance coverage of medical services and for conducting research on diseases and treatments,” Belluck writes. “But where should it go?”
This points to a catch-22 a lot of trans people face: they want or need services provided by doctors, but doctors (and insurance companies) will only provide those services if they’re doing so to “treat” something. But what is being “treated”? Trans people, like non-trans people, have a wide range of beliefs about their individual identities and experiences, but it’s safe to say that many of them feel they are seeking the services they are seeking to affirm who they already are. It isn’t about treating any sort of “disorder.” (A clear example of this is the preference some people have for terms like gender-affirming surgery over ones like gender-reassignment surgery.)
When the DSM, the “bible” of psychiatric disorders, was in the process of being updating to its fifth edition, which was released in 2013, the experts who wrote the guidelines had to grapple with all this. They ended up changing what used to be called “gender identity disorder” to “gender dysphoria,” and updating the diagnostic criteria as well. The working group responsible for coming up with the new dysphoria guidelines explained why it was seen as worthwhile to keep something pertaining to gender dysphoria in the DSM: “When it comes to access to care, many of the treatment options for this condition include counseling, cross-sex hormones, gender reassignment surgery, and social and legal transition to the desired gender,” its members wrote. “To get insurance coverage for the medical treatments, individuals need a diagnosis. The Sexual and Gender Identity Disorders Work Group was concerned that removing the condition as a psychiatric diagnosis—as some had suggested—would jeopardize access to care.” Also key: “It is important to note that gender nonconformity is not in itself a mental disorder. The critical element of gender dysphoria is the presence of clinically significant distress associated with the condition.”
So at the moment, there’s something of a shaky, uneasy compromise in place. For insurance purposes, and because the medical Establishment — an Establishment that doesn’t have a great track record in its treatment of LGBT folks — works in a certain way, trans people often have to accept a psychiatric diagnosis of gender dysphoria in exchange for access to medical care. It’s not ideal, but in the best cases it does at least “work” in the sense of getting trans people access to the care they need.