On Saturday, the Board of the American Psychiatric Association (APA) approved changes to the newest addition of the Diagnostic & Statistical Manual on Mental Disorders (DSM), including changes to the diagnostic criteria for Gender Identity Disorder (GID). After years of pushing the APA to re-evaluate the inclusion of GID in the DSM, many trans advocates celebrated changes to the diagnostic criteria as a victory and a step towards full elimination of GID and related diagnoses from the DSM altogether. However, there are also many trans and disability advocates who have raised important questions about what this change will mean for trans communities and how to frame our advocacy moving forward.
It seems like there are two distinct but related questions being raised in response to the APA's approval of new language regarding the inclusion of "Gender Identity Disorder" and related/updated diagnoses in the upcoming DSM-V. First, there are questions about the effects of this change on the ability of individuals, especially low-income trans people and trans people of color, to continue to access discrete benefits under the new diagnostic regime. Second, there are questions about how our conversations about the DSM and GID implicate larger questions of trans and disability justice and the ways in which medicalization and stigma frame our understanding of the role of the DSM in our resistance strategies.
Like all diagnoses, framed and constrained by medical and mental health providers, GID is limited in its scope, fails to account for the range of experiences of gender and gender dysphoria, and places power in medical "professionals" to shape and control the availability of treatment and recognition for TGNC individuals. The medical control over the meaning of the normal and the deviant to advance white patriarchal capitalist interests is central to the construction of all diagnoses but the diagnoses themselves can also serve as sites of resistance to those same interests.
For many people, especially trans people of color and low income and incarcerated trans people, the diagnosis of Gender Identity Disorder has become a tool to resist medical and other forms of state control. In prison, for example, access to all medical and mental health care is controlled by prison staff and often deliberately denied to individuals who need the care to survive. It is the very denial of health/care that serves to create one of the central axes of control over individuals in prison. The Prison Industrial Complex (PIC) -- including prisons, jails, immigration detention centers, homeless shelters, and psychiatric hospitals -- decides when and how an individual can utilize medication and treatment to self-determine their bodily needs; this can mean that people are medicated against their will, denied access to medication, or told that they fail to meet the criteria of need to access care that they have long-depended on to survive. The law as tool to challenge practices implemented to shorten the lives of people incarcerated by the PIC is limited and reactionary. It takes a denial and an injury to even precipitate a potential legal challenge and even then, legal barriers such as the Prison Litigation Reform Act and state and federal rules of civil procedure, make accessing the courts nearly impossible and winning cases, even more elusive. That being said, for incarcerated transgender individuals, the availability of a GID diagnosis creates an important framework for meeting Eighth Amendment and statutory requirements for challenging the deliberate indifference of prison medical staff. The recognition and disordering of gender through the DSM has been a vital tool for incarcerated individuals to access hormones, surgery and other trans health care.
The change in language in the DSM-V may set back decades of legal challenges brought by incarcerated transgender individuals, mostly transgender women of color without counsel, that created avenues for treatment and and gender self-determination for people in prisons, jails, detention centers and various other sites of civil commitment. Prisons and courts may argue that the case law and policies that do exist are premised on the diagnostic regime under the DSM-IV TR and that the change in language from a disorder to a condition no longer meets the requirements under the law for a "serious medical need." What may appear to be an aesthetic change may become a substantive change under legal rules that are designed to make it impossible for incarcerated transgender individuals to survive. The better (although still terrible) policies of jails and prisons regarding the treatment of transgender individuals require a diagnosis of GID to initiate all forms of affirming care. We may see the loss of important tools of resistance, hard-won by our incarcerated trans community members.
In the related context of Social Security benefits, another state-controlled system designed to subject the bodies of some -- low-income, disabled, people of color -- to scrutiny over the meaning of their bodies, experiences and health needs, changes in diagnostic criteria and conversations about those criteria may create new barriers to benefits for our community members. Access to Supplemental Security Income (SSI) is already limited and the benefits themselves completely insufficient for anyone to survive (usually the most being $761/month). For transgender individuals, a GID diagnosis rarely itself can serve as the basis for receipt of SSI (although some eople have received benefits solely based on a GID diagnosis and related experiences) but it has been an important argument for people to raise in their cases.
Our benefits system is deeply flawed and worsening every day. We cannot rely on SSI or other so-called benefits to support our community members whose work, identity, history and existence is erased by the very systems put in place to supposedly "help." However, in the meantime it is important to recognize that our advocacy strategies and ideological positions may serve to cut off the only cash benefits available to people. Someone like me -- a white, wealthy attorney -- may feel very comfortable arguing that my trans identity is not a "Disorder" that inhibits my ability to work in a set of publicly regulated jobs that the state deems legitimate while many other individuals who are existing under the constant scrutiny of multiple state regulatory regimes may experience their trans identities as the very definition of a disability for purposes of SSI. A change in language under the DSM may make it harder for our community members with disabilities to access needed benefits. Often it is the presentation of multiple medically-legitimized diagnosis that create a "successful" SSI case (i.e., a case that results in the awarding of benefits). Fears of mental illness, disability and difference combined with notions of productivity and utility permeate our conversations about diagnoses, benefits and need.
The pushback from trans people around the inclusion of GID in the DSM seems to fail to incorporate a larger assessment of why we are so afraid of "disorder" and who enjoys the benefit of avoiding stigma and pathologization. I want to think about the DSM and other medical and medicalizing tools in a way that asks what we want from them in a set of systems that takes away survival chances from the most vulnerable in our communities rather than looking to the DSM to define my own or anyone's identity; I would rather ask, how can the DSM be utilized to create the best distributive outcomes and benefits for our communities members. To shift our thinking in this way, it makes sense to first explore what fears have been raised about inclusion of GID and related diagnoses in the DSM.
The following concerns are regularly articulated in arguments against including GID in the DSM or in advocacy to alter the present diagnostic language: it is stigmatizing to have your identity consider "disordered", it allows for the medical control over trans bodies and access to care, trans people aren't crazy, shifting the GID to a medical rather than a mental health diagnosis will reduce stigma and increase access to care. Each of these critiques raises important questions about the DSM and the failure of medical and mental health systems to provide affirming and supportive care to people living with mental illness, trans people, and people with disabilities. However, the elimination of GID from the DSM will likely only eliminate these concerns for some people while exacerbating the same or related sets of concerns for others. For example, if we understand "dis-order" as a disjunction with clear categories of meaning and prevailing understandings of an orderly identity, then more trans people might gravitate towards the notion that within the framework of order or categorical neatness, our identities and experiences might be dis-ordered. Similarly, medical control over trans bodies and lives will always be most dangerous and violent for our community members in prison, jail, detention, homeless shelters and psychiatric hospitals and institutions. The removal of GID or its changing construction might help to further distance some (most likely white, wealthy, male-identified) trans people from external control over their access to affirming care, while simultaneously subjecting other trans people (low-income, incarcerated, people of color, female-identified) to enhanced control.
Access to trans health care has very little to do with the DSM and much more to do with access to resources. Conversations about overall access to gender affirming care, though related to this conversation, are still separate in most contexts. The place where the DSM has the most control over access to trans healthcare is in prisons and for that reason, it seems that we should focus most on the needs of our incarcerated community members when thinking about the most useful set of diagnoses we want included in the DSM and ICD. Our fears about stigma, pathologization, forced institutionalization and other enhanced controls, should be framed in relation to the systems of state power that implement those controls. Many people will have choices over whether or not to identify with GID, the DSM and then how to access treatment. It is in the context of state definitional and distributive systems that people will not have those choices when prisons, jails, Medicaid agencies, homeless services, and children's services enforce and withhold diagnoses and care. There are no easy answers or solutions to challenging the ways in which trans people, especially trans people in prison, homeless trans people and trans people of color, experience violence because of stigmas and pathologization related to mental illness, disability and poverty.
I, personally, believe that eliminating GID from the DSM and our conversations about that elimination will ultimately do more harm to our communities and move us further from our goals of building resistance and self-determination.
One example raised of how de-pathologization can lead to broader insurance coverage and wider access to care was pregnancy and birth. I actually think this example highlights the ways in which de-pathologization is an elusive concept and that advocacy along those lines within a framework that will always pathologize some people can be incredibly damaging. Non-trans women outside of prison with access to financial resources may experience pregnancy and birth in a non-pathologizing way and access care accordingly. However, in prison, homeless shelters, and public assistance systems, pregnancy and birth are highly pathologized and care is very much unavailable. In contexts where pregnancy is less-pathologized and access to medical care more available, it can be incredibly damaging for people who are expected to meet work-related productivity standards while experiencing mental and physical health constraints incompatible with those expectations. In the pregnancy context, as in the GID context, it is helpful to think about what we want from the law and discrete benefits systems and advocate from that standpoint centering the most vulnerable in our communities rather than looking to those systems to reflect our identities back to us in ways that is most affirming.