Transgender Health, Pathology & Human Rights
Pauline Park, Ph.D.
Harvard University School of Public Health
20 April 2011
I’m honored by the invitation to speak here at the Harvard University School of Public Health and I’d like to thank the members of the Queer Student Alliance for that invitation. I’d especially like to thank Ankit Raskogi for organizing my appearance here.
Let me begin by describing the work that I’m doing in New York on health care access for members of the transgender community and relate health care access to human rights by way of a discussion of the pathologization of gender variance and transgender identity.
The New York Association for Gender Rights Advocacy is the first statewide transgender advocacy organization in New York. NYAGRA is working in partnership with the Transgender Legal Defense & Education Fund (TLDEF) and the Gender Identity Project of the LGBT Community Center of New York City on the Transgender Health Initiative of New York, a project whose mission is to enhance access to health care for transgendered and gender-variant people.
In the 7 years since we started the Transgender Health Initiative, THINY (as we call it) and its members have worked tirelessly to try to open up health care to members of our community in New York, who face significant impediments to accessing quality health care, just as they do throughout the country. In July 2009, NYAGRA published the first directory of transgender-sensitive health care providers in New York City and the metropolitan area, which is now available on nyagra.com. This was the first directory of transgender-sensitive health care providers for New York City and the metropolitan area ever published, and to my knowledge, it was the first such directory for any city published in a print edition anywhere in the United States. We are now updating it continuously as we identify more transgender-sensitive providers in the area.
In 2006, I did a series of trainings with Michael Silverman (the executive director of TLDEF) for St. Vincent’s Hospital, which was one of the largest hospitals in New York City, and a hospital with one of the largest transgender patient populations.
Sadly enough, St. Vincent’s went bankrupt last year and closed after failing to resolve a situation in which the hospital had accumulated over a billion dollars in debt. Sad, too, because these were the first transgender sensitivity trainings for any major hospital in the city and they were as much of an eye opener for us as they were for the nurses, techs, and other health care professionals we trained. Participants ranged from hostile to indifferent to open-minded to genuinely supportive in short, a microcosm of society and its attitudes towards the transgendered. Only a few of the nurses were openly hostile and even (in at least two cases) somewhat disruptive. But most of the nurses and other providers we did trainings for at the very least listened politely.
The real problem was the lack of both knowledge of the challenges facing transgendered people as they try to access health care as well as the lack of sensitivity on the part of some of these providers. With regard to the former lack of knowledge one of the big problems facing our community is that among those who think about transgender access to health care and there are far too few who think about this issue at all most imagine that the main challenge we face is accessing hormones and sex reassignment surgery (SRS). While that is a challenge, the biggest challenge for transgendered people really is accessing healthcare for all of those medical issues unrelated to gender transition.
And that leads me to the central theme of my talk today. The ‘gateway’ diagnosis required to access to hormone replacement therapy (HRT) and SRS since 1974 has been gender identity disorder (GID), introduced into the fourth edition of the Diagnostic & Statistical Manual of Mental Disorders (DSM IV), published by the American Psychiatric Association (APA). While GID is usually thought of as the diagnosis by which adult transsexual and transgendered people gain access to HRT and SRS, the true significance of GID is much larger. First, a change of legal sex designation the ‘gender marker’ on identification documents that assigns us to either male or female sex in most jurisdictions requires at the very least documentation of an intent to go for SRS, if not actually proof of completion of surgery (as is the case in New York City).
While there is no necessary connection between a change of legal sex designation and a change of legal name, in many if not most cases, transitioning transsexuals pursue these two changes simultaneously. The truth is that most transgendered people frequently or even consistently present in a gender that does not match their ID, which causes problems in a multitude of situations. Since 911, most large buildings in New York City require photo ID even to enter the building. And so the apparent discrepancy between ID and either ‘gender marker’ and/or gendered name and/or gender presentation in a photocan constitute a barrier to employment, housing, and public accommodations as well as to accessing health care and social services.
But if the apparent ’solution’ is to go for a change of legal sex designation as well as name, and if the former change – and in some cases, effectively, the latter – requires the diagnosis of GID; then in effect, the ability to access health care as well as employment, housing, and public accommodations requires a diagnosis of GID as well. I personally find it outrageous that transgendered people in the United States and elsewhere have to have themselves declared mentally ill in order to access health care or to get or to keep a job. We must commit to finding means by which transgendered people can access forms of medical intervention such as HRT and SRS without having to subject themselves to the degradation of being declared mentally ill simply by virtue of their gender identity.
GID not only undergirds the Harry Benjamin Standards of Care (SOC) and the protocols for gender transition in this society, this diagnosis – what I call the GID ‘regime’ – constitutes the very basis for American society’s understanding of transgender. Even in relatively more sympathetic portrayals of transgendered characters such as those in “TransAmerica” and on “All My Children” and “Ugly Betty,” the discourse through which those characters are understood is a medical model of transsexuality based fundamentally on the concept of gender dysphoria. My own work as a transgender activist is informed by a feminist conception of gender and a commitment to challenging and dismantling the sex/gender binary that is at the root of our oppressionas women and as men as well as transgendered men and women. Our goal as a movement must therefore be nothing less than the transformation of society’s understanding of gender. And if we are committed to that goal, we must also be commited to dismantling the ‘GID regime’ that undergirds this system of gender regulation and control.
I fully understand the practical implications of GID for accessing hormones and surgery, but I reject the notion that we must accept thepathologizing of all gender variance as mental illness in exchange for the ostensible benefits that flow from the diagnosis. The reality is thathardly anyone nowadays is getting SRS paid for by private insurance anyway, so the practical argument for retaining GID with regard to insurance payment is no longer persuasive. Many transgendered people have no health insurance at all, and those who do have either Medicaid – which in New York and many other states prohibits payment for HRT and SRS – or health insurance through health maintenance organizations (HMOs), most of which now have explicit clauses written into their policies excluding coverage of any service related to gender transition. As I have stated, we must certainly find a way for those members of our community who seek hormones and surgery to obtain them as well as coverage for them. I do not have the time here to go into a discussion of the details of possible alternatives to GID. But I must say that I am personally rather skeptical of the notion of merely ‘reforming’ GID. It simply makes no sense to propose to the APA that they change GID to a non psychiatric medical diagnosis or condition, given that the DSM is a Diagnostic & Statistical Manual of Mental Disorders.
But I have spoken so far only of the implications for adults. It is important for us to recognize that the pernicious effects of GID extend far beyond simply the instrumental necessity for adult transsexuals to obtain the diagnosis in order to access hormones and surgery. According to one report, three quarters of all those diagnosed with GID are diagnosed with GID in childhood and adolescence. These are for the most part gender variant children whose parents take them to a psychiatrist because Johnny is playing too often with dolls or Janie is climbing too many trees. The parents conflate homosexuality with transgender and hope that the psychiatrist can ‘cure’ or at least ‘prevent’ homosexuality in their chil dren. There may well be a significant segment of the psychiatric profession that uses the diagnosis in precisely this fashion to try to ‘cure’ or ‘prevent’ homosexuality in children and youth – this, despite the removal of homosexuality from the DSM in 1974.
Many of these psychiatrists, such as Charles Socarides and George Rekers, are associated with the religious right and in fact advocate re introduction of homosexuality in the DSM. Rekers, who is on the faculty of the School of Medicine at the University of South Carolina, has in fact received over half a million dollars from the National Institute of Mental Health (NIMN) to study ways to ‘treat’ and ‘cure’ such ‘deviant’ behavior, including ‘at ypical gender identity,’ ‘atypical sex roles,’ and ‘pre transsexual behavior.’
One of the leading organizations advocating re introduction of homosexuality in the DSM is the National Association for Research & Therapy of Homosexuality. NARTH and their co conspirators in homophobia see removal of GID as having the potential to eliminate the ability of psychiatry and homophobic and transgenderphobic parents to police and enforce the gender boundaries that they wish to impose on their children as well as on adults to the extent possible.
I have an Asian American lesbian friend in Queens whose nephew is transgendered. When he told his parents that he felt himself to be a girl, his mother and stepfather had him institutionalized, on the basis of a diagnosis of GID. He is currently at Cinnamon Hills, which despite its charming name, is in effect a prison for youth located in the middle of the desert in southern Utah. Perhaps the most famous such case of institutionalization of a youth with GID is that of Daphne (now Dylan) Scholinski, who now identifies as a transman. At fifteen years old, Scholinski identified as a butch lesbian and was committedto a mental institution by parents who were determined to ‘cure’ her ofthe mental illness with which she was diagnosed. The Last Time I Wore A Dress is only the most famous account of a gender-variant youth subjected to behavior modification therapy for a gender identity that is no disorder and that cannot be cured.
What many people evenwithin the transgender community do not realize is that legal minors can be committed to a mental institution and subjected to behavior modification therapy up to and including electroshock therapy. In fact, even adults can be institutionalized against their will if they are diagnosed with GID, which is precisely what happened to the renowned economist Deirdre McCloskey, when family members decided that she was ‘insane’ after she told them of her intention to transition (as she writes in Crossing: a Memoir, University of Chicago Press, 1999). It seems to me that what is ‘insane’ is forcibly institutionalizing a brilliant economist simply because she has informed her family that she wishes to live her life consistent with her internal sense of gender identity. What is insane is the diagnosis of GID itself.
The pernicious effects of GID extend by implication indirectly to the intersexed as well. Intersex genital mutilation (IGM) certainly requires no diagnosis of GID, and in fact, the intersex ‘condition’ is explicitly excluded as a criterion for GID, but the rigid insistence on the sex/gender binary articulated by the GID diagnosis that is officially recognized by the psychiatric profession through its inclusion in the DSM gives implicit support to the practice of IGM.
The influence of GID also extends into the sphere of public policy as well, impeding the fight for transgender rights. We have made enormous progress as a community and as a movement over the course of the last two decades, but while 95 jurisdictions including nine states and the District of Columbia – now have enacted legislation explicitly prohibiting discrimination based on gender identity or expression, it is a sad fact that 41 states have no such protection in their state laws. However, every state has included disability in its human rights law, and it is that rubric that litigators are using to obtain legal redress for transgendered plaintiffs across the country, and they often win on that basis. But the argument that such litigators proffer usually follows along these lines: my client is mentally ill by virtue of his/her gender identity disorder and therefore is protected under state disability law. I should make clear that I have nothing but admiration for the hard working lawyers who represent transgendered clients – often pro bono – with limited time and resources. And in those 41 states without explicit inclusion of gender identity and expression in state human rights law, appeal to disability by way of GID may well be the only practical way of obtaining legal redress for discrimination against a transgendered client. But I think we need to recognize how sharp the horns of that dilemma may be.
As a non lawyer who works on legislation, I can tell you that the genuine happiness that I feel for the transgendered client who wins such a case is diminished by the realization that the victory for that individual undercuts the very arguments that we need to make in the legislative arena. Because it is precisely GID that gives the religious right and other opponents of transgender rights legislation their most powerful ammunition.
Consider Vermont, where activists are trying to get the state legislature to pass a transgender rights bill against the opposition of right -wing organizations such as Vermont Renewal, which describes itself as “a grassroots organization with the primary goal of promoting and defending traditional family and moral values based on the Judeo- Christian worldview that Vermont and the entire United States were founded upon” (www.vermontrenewal.org). In an op-ed in the Burlington Free Press for Vermont Renewal, Stephen Cable writes,
“Under the banner of equality, the Vermont Legislature seeks to protect transgender behavior (i.e. transvestite and transsexual) from discrimination (bills S.51 and H.228)… Despite good intent, there are major problems with this legislation. First, such behavior is associated with a treatable mental disorder. However, we question efforts which, under the pretext of equality, actually favor one mental disorder for protections to the exclusion of all others, such as depression, anorexia, kleptomania, etc. The Common Benefits Clause of the Vermont Constitution forbids such preferential treatment…”
“There are, of course, serious pitfalls associated with efforts to protect behavior associated with mental disorders. Perhaps the largest would be inadvertently sending a message that such illness is healthy, or even desirable, rather than encouraging treatment and recovery – thereby trapping people within this disorder. Equally important, however, is the danger that, by affording too much protection to the sufferer, government may actually become the oppressor, creating unforeseen hardship and complexity for businesses, schools, and the common person…” Now, there are certainly many responses to Cable’s uninformed and bigoted screed, including a critique of the way in which he misconstrues disability law and how it works. And one can also respond to Cable by pointing out that there is no evidence that the GID diagnosis was intended to be used as an argument against non-discrimination legislation. But we simply cannot ignore the fact that the religious right not only in Vermont but across the country has latched onto GID as the core of its argument against transgender rights legislation at the local, state and national levels; to that extent, the removal of GID from the DSM would disable their core argument (pun intended). And any student of LGBT history would be conscious of how the removal of homosexuality from the DSM in 1974 advanced the gay and lesbian movement from that point onwards.
Among the most influential of the organizations on the religious right is the Traditional Values Coalition. TVC attacked the settlement that I reached in April 2005 in my discrimination case involving restroom access at the Manhattan Mall. Ironically enough, given that I coordinated the campaign for Int. No. 24, I became the first person (along with my friend and colleague, Justine Nicholas) to successfully pursue a discrimination claim under the transgender rights law enacted by the New York City Council in 2002, ably represented as I was by Michael Silverman of the Transgender Legal Defense & Education Fund. In response to the report by the New York Times of our settlement, the Traditional Values Coalition declared on April 7 of 2005,
“The New York Association of Gender Rights Advocacy has won a victory over restroom use by individuals who believe they are a member of the opposite sex… The victory involves a settlement from a security guard company that allegedly discriminated against transgender activist Pauline Park when he [sic] used a woman’s restroom in a Manhattan mall in April, 2004. Park wears women’s clothing and identifies as a woman but has not had a sex change operation. Park is still anatomically a male but calls himself [sic] a ‘male-bodied woman’… This decision means that men who think they are women and are still anatomically males can use women’s restrooms in New York City…”
The April 7 TVC news report is entitled, “Ladies Restrooms: Who is That Male-Bodied Woman In the Next Stall?” That report concludes, “In a society where rational thought still existed, Pauline Park would be institutionalized for insanity or be given intense therapy to overcome his [sic] serious gender identity disorder. Instead, he has imposed his own mental illness upon the city of New York — and Michael Bloomberg has been a willing accomplice…”
(photo courtesy Anh Ðao Kolbe)
What I would say to the Traditional Values Coalition is this: I do not have a gender identity disorder; it is society that has a gender identitydisorder. I must admit it was a bit of a shock to be subjected to personal attack by one of the largest religious right organizations in the country, but I have taken the advice of a friend of mine who encouraged me to wear it as a badge of honor. Now that I’ve been declared a public enemy by the likes of TVC that I have ‘arrived.’
But the point I would like to make here is not so much about the TVC bull’s eye on my forehead; it is the ammunition that the discourse of mental pathology gives to opponents of transgender rights. In TVC’s report, “A Gender Identity Disorder Goes Mainstream” (also issued in April 2005), the organization declares, “These are deeply troubled individuals who need professional help, not societal approval or affirmation.”
Elsewhere in its ‘report,’ TVC describes “this mental illness and how it is being normalized in our culture.” In fact, the very title of the TVC ’special report’ is “A Gender Identity Disorder Goes Mainstream,” followed by the sub head, “Cross dressers, transvestites, and transgenders become militants in the homosexual revolution.” And TVC is not the only such organization pursuing this line of argument, however specious. The religious right is now so panicked about the growing acceptance of gay men and lesbians in this societythat they are increasingly focusing on the diagnosis of GID not only to oppose transgender rights legislation, but also non discrimination andhate crimes legislation that includes sexual orientation as well.
And that is why I say that every victory for a transgendered plaintiff whose lawyer uses disability to win a discrimination case compromises our ability to work in the legislative arena – hence my profound ambivalence about the GID-based arguments being used in such cases. A few years ago, I had a conversation with a transgender activist from another state for whom I have great respect. She insisted that the way forward for the transgender movement was the disability route. I insisted with equal vehemence that the ‘disability track’ was the wrong path to pursue. I cited the clause in the Americans with Disabilities Act that explicitly excludes ‘transvestism and transsexualism’ from coverage under the terms of the 1990 federal disability rights law, thanks to Jesse Helms. The notoriously bigoted senator from North Carolina made certain that thepath to transgender rights through federal disability law would be closed, and there is little if any chance that that path will be opened anytime soon.
But the issue of federal disability law aside, the larger strategic question for our community and for our movement must be this: is ourgoal only litigation and legislation or are we pursuing something bigger? The whole critique of the queer left of the mainstream gay and lesbian movement is that it has for far too long focused narrowly on juridical rights. Now, I happen to believe that we should pursue non-discrimination legislation and that we must ensure that all transgendered and gender variant people – indeed, all LGBT people – gain equal rights under federal as well as state and local law in every area of activity, including marriage. But I also believe that our movement must have at its core a vision of social justice and social change. And that vision must be premised on the goal I articulated earlier. Our objective must be nothing less than the transformation of society’s understanding of gender. And so the removal of GID from the DSM must be a goal of our movement; it simply cannot be otherwise. We must discard a medical model of transsexuality that is a disease model of mental illness; we must reject any suggestion that our goal as a community and as a movement is simply to find a place within a normalizing discourse of the existing sex/gender binary, expanded ever so slightly to accommodate us – or at least those of us who can comfortably fit within a governing regime of heteronormativity. In its stead, we must embrace a vision in which all forms of transgender are seen simply asnatural variants in gender identity and expression and in which all transgendered and gender variant people will be accepted as fully equal to their conventionally gendered family members, friends, colleagues, and neighbors.
What I would like to suggest as an alternative is to put a concept of wellness at the center of transgender health. I am arguing here for the removal of GID from the DSM and a comprehensive rejection of the pathologizing of transgender and gender variance. Just as homosexuality is now viewed by mainstream psychiatrists and psychologists as simply a natural variance in sexual orientation, so transgender would be viewed simply as a natural variance in gender identity and expression – no more or less natural than conventional gender identities.
The objection to such a conception coming from certain quarters no doubt would be that it would render hormone replacement therapy and sex reassignment surgery as ‘elective’ procedures, thus making itimpossible to get insurance payment for HRT and SRS as ‘medically necessary.’ But the reality is that very few people now are getting hormones or surgery covered by private health insurance. Many transgendered people are completely uninsured, and most those whodo have health insurance – like most non transgendered people – get it through HMOs – what are called ‘managed care’ but what I call ‘mismanaged care.’ Many states – including New York – prohibit Medicaid payment for hormones or SRS, and the exclusion of ‘transvestism’ and ‘transsexualism’ from the Americans with Disabilities Act (ADA), as mentioned earlier, precludes a challenge to such exclusion under federal disability law. In other words, very few transgendered people are getting hormones paid for and even fewer are getting SRS paid for anyway, so the ostensible ‘loss’ of coverage by embracing this concept of transgender health will be a small one for our community. In my view, the gain will more than offset such a loss. Instead of viewing ourselves as having been born with a ‘birth defect,’ we would see ourselves as being fully ‘normal,’ fully natural, and fully human, just as in fact we are.
In this conception, the various technologies that some of us use to modify our anatomy and biology would be viewed as technologies of self-determination, used to configure our bodies to conform to our internal sense of gender identity. In other words, HRT and SRS, breast reduction and breast augmentation, metoidioplasty, tracheal shaves, and other forms of plastic surgery would be technologies we can use to make ourselves feel more comfortable in our own skin – technologies that we can use to enhance our sense of well-being. In such a conception, would hormones, surgery and the like be elective? Yes, and by reconceptualizing such technologies as elective, we would reclaim our sense of self determination. The truth is that the argument for SRS as currently conceived makes no sense whatsoever. For what mental illness is surgery on a part of the body other than the brain indicated or prescribed? I know of none. The usual objection to SRS is that it involves the removal (in most cases) of perfectly healthy tissue, and that is in fact usually the case. There is nothing diseased in the sex organs of most transsexual or transgendered people who seek SRS. But surgery will enhance the well-being of those who elect it. And by reconceptualizing surgery – including and above all SRS – as elective, we reclaim our sense of agency. The notion that SRS is medically necessary cannot be advanced except by way of an argument that pathologizes our bodies and our minds – that pathologizes our very identities.
The truth is that SRS is rafely if ever medically necessary in the conventional sense of the term. Rather, SRS can be a very effective way of enhancing the well-being of those who elect it, and as such, should be readily available without any psychiatric evaluation or diagnosis to those who choose to elect it. And just as private insurance pays for hormone replacement therapy for post menopausal non transgendered women, it should pay for HRT for transgendered women and men as well as for SRS for both. The crucial point is that we as transgendered individuals have to move towards acceptance of ourselves. And we as a transgender community have to reject the idea that the body of a transgendered person is a diseased body. Even more importantly, we must reject thenotion that the mind of a transgendered person is a diseased mind. The ‘problem’ of ‘gender dysphoria’ is not to be found in the mind of a transgendered person. Rather, the problem is to be found in the society that is too rigid to allow for those born male to identify as women or those born female to identify as men – or to allow those born male, female, or intersexed to identify as something other than men or women.
And so I say that what we need to do is to reconceptualize pathology as the problem and not the solution to our problems. The solution is, instead, a (w)holistic concept of wellness informed by feminist consciousness that locates the problem at the level of society and not the individual who resists the dictates of an overly gender-rigid society. As I see it, my work as a transgender activist is not about helping a small number of post-operative transsexuals to fit more easily into existing boxes but rather about helping all of us to break out of all of the boxes so that we can all be whoever and whatever we feel ourselves to be. In my view, the task facing us as a community is not to shore up regressive notions of mental pathology but rather to challenge and dismantle the GID regime and the larger sex/gender binary of which it is a part and which is the source of our oppression as transgendered and gender variant people. We must set as our objective nothing less than the transformation of society’s understanding of gender, as part of a movement for social justice for all. I urge you to join me in that struggle. Thank you.
Pauline Park is chair of the New York Association for Gender Rights Advocacy (NYAGRA), the first statewide transgender advocacy organization in New York (www.nyagra.com), which she co-founded in June 1998. She also serves as vice-president of the board of directors of the Transgender Legal Defense & Education Fund (TLDEF). Park led the campaign for the transgender rights law enacted by the New York City Council (Int. No. 24, enacted as Local Law 3 of 2002). She served on the working group that helped to draft guidelines – adopted by the Commission on Human Rights in December 2004 – for implementation of the new statute.
Park negotiated inclusion of gender identity and expression in the Dignity for All Students Act (DASA), a safe schools bill currently pending in the New York state legislature, and the first fully transgender-inclusive legislation introduced in that body. She also serves on the steering committee of the coalition that secured enactment of the Dignity in All Schools Act by the New York City Council in September 2004. Park has written widely on LGBT issues and has conducted transgender sensitivity training sessions for a wide range of social service providers and community-based organizations. She has a Ph.D. in political science from the University of Illinois at Urbana-Champaign.