standardizing the child and adolescent GID definitions and reexamining the protocol for intersex conditions around the world, as well as the protocols for intervention in GID.” She admits that there are problems with current definitions. “Sometimes the language is archaic, and I apologize for that,” she says. However, the essential point to remember when discussing the value or lack of value of the diagnosis, she says, is that “something has to be wrong in medicine in order [for it] to be fixed.”
Dylan Scholinski articulates this conundrum from the perspective of the trans activist, admitting that whereas “initially most people were advocating the straight-out removal of GID from the DSM,” a more nuanced position is now developing because “you don’t want to fuck with people’s access to health care, not till there’s something else in place. You can’t just leave the community with nothing.”
Not only does the GID diagnosis ensure continued access to surgery and hormones for those who require them (even if they are not covered by insurance), but it is also used as a legal tool. Those states that permit transsexual people to change their sex of record on birth certificates, driver’s licenses, and other legal documents often require letters from psychotherapists and other health care providers attesting to the medical validity of the claim. Some require proof of genital surgery; others do not. The broad definition of GID ensures that even those who have not undergone genital surgery (as most FTMs do not) qualify for such legal remedies. Attorneys Collin Vause, Shannon Minter, and Karen Doering relied heavily on the medical model in the case
In the trial, which was shown in its entirety on Court TV, Linda and her attorneys argued that Michael should be considered legally female, that their ten-year marriage should be deemed void, and that Michael should be stripped of his parental rights and prevented from seeing the children. Judge O’Brien ruled otherwise, partly on the basis of extensive medical evidence presented by Walter Bockting, Ph.D., a clinical psychologist and former president of the Harry Benjamin International Gender Dysphoria Association; Ted Huang, M.D., a surgeon; and Collier Cole, Ph.D., a professor in the Department of Psychiatry and Behavioral Sciences at the University of Texas, Gal-veston. One of the major issues disputed in the case was Michael Kan-taras’s decision not to undergo phalloplasty (surgical construction of a penis). Linda Kantaras’s attorneys argued that Michael’s lack of a penis indicated that he was not a man, and that the marriage was therefore invalid. The medical experts testified that gender identity disorder was a legitimate medical condition and that Michael Kantaras had followed the Standards of Care of the Harry Benjamin International Gender Dysphoria Association for the treatment of gender identity disorder. Kantaras actually relocated to Galveston for two years in order to carry out his transition under the care of the Gender Identity Clinic there. (He met Linda shortly after his return to Florida.) The doctors pointed out that most female-to-male transsexual people do not opt for phalloplasty, because of its great expense and uncertain outcome, and that Michael Kantaras’s decision was therefore congruent with prevailing treatment norms. They also testified that most married transmen enjoyed satisfying marital relations with their wives irrespective of their genital status, and that they did so as men, in the male role.
Most observers agree that the medical testimony was crucial in establishing an outcome favorable to Michael Kantaras. Previous court cases in which the legality of marriages contracted by a transsexual person were at issue did not rely as heavily on the testimony of expert medical witnesses. In two of the four U.S. cases
Under the circumstances, many transsexual and transgendered people and their allies are understandably wary of any attempt to eliminate the GID classification without replacing it with a medical diagnosis. The solution to the GID issue, and to many of the other medical and legal challenges that confront the transgender community, they argue, is research. “Basically, we know squat about our community,” says Julie Maverick, a university professor in the physical sciences who heads the research subcommittee of the National Transgender Advocacy Coalition (NTAC). (Like many cross-dressers, Maverick is closeted and has requested anonymity.) In 2002, Maverick and colleagues at NTAC requested that Congress allocate funds to the National Institutes of Health for new and expanded efforts in the collection of medical and demographic information on transgendered and gender-variant people. “The transgendered community, including transsexuals, cross-dressers, and the intersexual, is believed to represent as much as 2 percent of the American populace and has specific needs regarding mental and physical health,” Maverick and NTAC point out in their request for research funding. “They have the highest suicide rate for any demographic group, a very high incidence of depression and other mental health problems and a very high incidence of substance abuse. They have unique medical needs associated with hormonal therapy (breast cancer in genetic males, for example), sexual reassignment surgery and misdiagnosis of ailments (like ovarian cancer in female to male transsexuals).” Transgendered sex workers are also a “critical vector” for the transmission of HIV, as the request notes. Surveys carried out in Washington, D.C., San Francisco, Los Angeles, New York, and Philadelphia found high rates of HIV infection among trans sex workers in those cities.
Despite the serious health problems confronted by transgendered people, they remain a largely invisible and untreated population for a number of reasons. Some fear exposure, many lack health insurance, and more than a few have encountered hostility, ridicule, and rejection from health care providers when they have sought treatment. “Trans-gendered people commonly receive substandard or inadequate medical treatment due to discrimination, ignorance, confusion and loss of health insurance due to job loss,” the NTAC request for funding notes. To a certain extent, the difficulties that transgendered people encounter are shared by other members of the LGBT community. “Most physicians get no training at all” with respect to treating transgendered patients, says Dr. Ben Barres, but “this is related to an even bigger problem, because let’s face it, transgendered people are very rare, but homosexuals are very common, a couple percent of the population, and there’s no training in medical school about that. For example, most physicians are very insensitive to that issue when they do a history and physical. They’ll ask a person if they use birth control before they’ve even ascertained whether they are gay or not.”
Speakers at the American Medical Students Association’s 2001 conference concluded that “LGBT patients face many barriers to adequate health care. These problems range from poor physician access to a lack of awareness in the medical community about the health concerns of LGBT patients, not to mention the failure to address these health issues in most medical school curricula.” The failure of medical schools to train future physicians to treat LGBT patients is yet another consequence of the lack of research on the specific health care needs of these populations. Research on LGBT issues typically begins and ends with AIDS research. AIDS remains a significant problem, to be sure— rates of HIV infection among male-to-female transsexuals in cities remain shockingly high. But the circumstances that drive those high rates of infection—needle-sharing among users of black-market hormones, sex work, substance abuse, and possibly depression—remain understudied, and therefore largely invisible. This lack of research has very large consequences for the transgender community, even beyond the basic but somewhat esoteric question of the etiology (cause) of gender variance.
“In this culture, and in most of the civilized world today, research data is used to determine public policy, to determine legislation, making cases in court, is used in determining protocols in medicine and psychiatry. Virtually every place you touch, people are coming up against this system where research data would be helpful,” says Kit Rachlin, a psychotherapist with a doctorate in applied research who has worked with transgendered clients since 1990. “Everything from the quality of the medical care I get to whether I can get custody or adopt children, or have my license changed to reflect my gender—all of the services people want to be there for them, they don’t realize that for it to be there for them in a consistent way, in a supportive way, you need to have research data, and the data has to be of a certain quality. And it will have to come from outside the community, if the community hasn’t yet grown its own researchers.”
In her plenary lecture at the 2001 True Spirit Conference, Rachlin focused on the mistrust many transpeople
