of clinical work, the first three, i.e., mental health diagnostic assessment for GID, a minimum of three months of psychotherapy to confirm that the client has GID and real-life experience living in the social role of the opposite sex for one year, determine the client’s appropriateness for the last two, i.e., hormonal therapy and, perhaps, surgical therapy. To be referred for the latter two the client must have a letter from the psychotherapist and countersigned by a psychiatrist or psychologist stating that the client fits the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) diagnostic criteria for GID or the diagnosis of transsexualism outlined in the World Health Organization’s International Classification of Diseases, Tenth Revision (ICD-10) (Lev, 2004, p. 45 and Herman, 2006.)
Joanne Herman (2006), a transgendered member of the advisory board of the National Center for Transgender Equality, writes about the trans catch-22 faced by trannsexuals. “The SOC represents a “medicalized” approach, involving hormone therapy or surgery. And yet, because of the stigma from the DSM-IV, most health insurance plans will not pay for any treatment for a GID diagnosis code. This means that a patient who is diagnosed with GID may end up without access to treatment solely because he or she cannot afford to pay the costs out of pocket. The exclusion in health plans of all treatments related to SRS is terribly unfair and unjustifiable. Insurers will cover a hysterectomy for a female who has uterine cancer, but they won’t cover the same surgery for a female-bodied person who is transitioning to fit a deeply held male gender identity – even when it is recommended by a doctor for the psychological well-being of the transgendered patient…There’s another, more fundamental problem with the GID diagnosis…what if you don’t happen to desire hormone therapy or surgery to feel comfortable expressing your gender [variant] identity? You likely will not be diagnosed as having GID, meaning you too will be denied treatment. So why not remove GID from the DSM-IV? Aside from its existence as the linchpin of the SOC, some believe that its presence gives doctors a basis for providing hormones and surgery for us when they might fear being accused of malpractice otherwise. For those of us who truly need(ed) and want(ed) hormones and surgery, the prospect of having no doctors available to carry out the treatments is downright scary…”
It is worth noting at this point in the discussion that insurance reimbursement for SRS procedures has become extremely rare in the United States (Wilson, 2005.)
However, there is ongoing controversy as to whether the GID diagnosis should remain as the DSM-V is now going through the planning stages, especially since homosexuality, which was once included in the DSM, was deleted in 1973( Hausman, 2003, Herman, 2006; and Wilson, 2005.)
Some point out that American psychiatric perceptions of etiology, distress, and treatment goals for transgendered people are remarkably parallel to those for gay and lesbian people before the declassification of homosexuality from the DSM as a mental disorder in 1973 (Wilson, 2005, Herman, 2006.)
Darryl Hill, Ph.D., an assistant professor of psychology at Concordia University in Montreal, cites the lack of scientific reliability and validity studies supporting the GID diagnostic criteria and insists that GID is not a mental disorder, but that the criteria describes “the distress often experienced by parents” who have become “preoccupied with the negative aspects” of their son’s or daughter’s behavior as the child struggles to make sense of gender-related feelings. Thus, it is socially determined. In addition, Hill argues that “gender is not dichotomous” and everyone falls somewhere between the two poles, male and female (Hausman, 2003.)
In support of Hill’s argument, A. H. Devor, Ph.D. (2000) states in the abstract describing his work, “How Many Sexes? How Many Genders? When Two Are Not Enough,” that approximately a decade of his research with transgendered and transsexual persons is summarized in order to explore and illustrate some of the limitations in dualistic conceptualizations of gender, sex, and sexuality. In the process, he argues that increased descriptive power may be gained through the use of greater subtlety and nuancing of binary concepts of gender, sex, and sexuality. However he maintains that, ultimately, the dualistic paradigm is being stretched to the breaking point by the challenges raised by transgendered and transsexual people and that it is time for the development of new modes of thought.
Katherine Wilson, Ph.D., a founder of the San Diego-based organization GID Reform Advocates and former outreach director of the Gender Identity Center of Colorado, disagrees with Hill, insisting that it should remain in the DSM, but not as a disorder. She says that DSM fails to acknowledge that “many healthy, well-adjusted transsexual people exist”, and thus, GID should be replaced with a diagnosis of “unambiguously defined distress” rather than by “gender nonconformity. She would like to see GID replaced with a term like gender dysphoria, which would describe someone who is persistently distressed with his or her physical sex characteristics or with the limiting gender-based roles that society imposes on men and women (Hausman, 2003.)
Opposing the above arguments is Robert Spitzer, M.D., who chaired the work group that developed DSM-III and DSM-III-R. He maintains that cultures view gender as a dichotomy, certain behaviors “are part of being human – part of normal development” and it is legitimate for psychiatrists to identify a disorder in which persons of one gender reject these roles and behaviors and assume those of the opposite sex (Hausman, 2003.)
Also in opposition is Paul J. Fink, M.D., former APA president, professor of psychiatry at Temple University, and extensively experienced in working with transsexuals in the process of surgically changing their gender. He maintains that transsexualism is a valid psychiatric diagnosis, it “is not a normal sexual variant”, and although there may be a dearth of research on GID, he warns against correcting that situation by “legitimizing behaviors that are actually disadvantageous” to the person (Hausman, 2003.)
Ettner (1999, pp.61-73) offers diagnostic considerations regarding male-to-female issues. Only a certain percentage of individuals who disclose gender dysphoric feelings express a desire or intention to live full-time in the preferred gender. Many wish to maintain a partial or intermittent cross-gender presentation, or to live in an androgynous state. While some want or need only social or psychological interventions. Clinicians can help clients determine where they lie on the continuum of gender dysphoria. Many professionals have little knowledge about the nature of cross-dressing behaviors and assume they are entirely fetishistic in nature. Therefore, responsible diagnostic evaluation presupposes that the clinician thoroughly understand the difference between sex and gender…………………... …Female-to-male clients present far fewer diagnostic uncertainties than male-to-female ones. First and foremost, all female-to-male transsexuals “cross-dress”, but this behavior is not clinically remarkable as it does not violate social prohibitions. Neither is it fetishistic: Male items of clothing possess no erotic properties. Secondly, female-to-male transsexual persons often object to the term “transgendered”, which implies a periodicity or fluidity of the phenomenon, which they do not feel accurately describe the immutable nature of their experience.
As part of the psychiatric interview the psychiatrist asks Bree how she feels about her penis. Bree responds, “It disgusts me. I don’t even like looking at it.”
Dislike of the body and genitals is characteristic of gender dysphoria (Ettner, 1999, p.113.)
The scene ends by showing Bree at work as a dishwasher.
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