Content Warning: This article discusses transphobia and arguments used by transphobic people to invalidate the existence of folks with trans and gender expansive identities. If you are affected by this type of content, please feel free to click away. Additionally, The Trevor Project is an organization aimed toward LGBTQ+ folks aged 25 and under and has support hotlines in the form of calling, texting or online chatting. Please look through their resources and consider their hotlines if you are LGBTQ+ and need support.
Welcome back to this series of open letters proving transphobic arguments wrong with facts and evidence! This week’s letter is about the medical history and practices of transgender and gender expansive folks. We will talk about the DSM and its history of labeling the experiences of trans people as mental illness, and what the appropriate terminology is. We will conclude this letter by exploring some resources for transgender friendly and gender affirming healthcare.
I recommend reading the Open Letter, Part 0.5: An Introduction to Trans+ Identities and Language if you haven’t already, as I define many vocabulary terms that are used when discussing trans+ identities and concepts of gender and sex that I will be using here. And if you missed the last open letter about the historical and cultural existence of more than two genders, I definitely recommend reading it after you finish this article!
Transgender Identity and the Mental Health Field
Gender identity and the field of mental health and psychology haven’t exactly had the best track record, historically speaking. The first mention of gender in the Diagnostic and Statistical Manual (DSM) was in the third edition, published in 1980. The DSM III entered the diagnosis “Transsexualism” and “Gender Identity Disorder of Childhood” under the diagnostic category “Sexual Deviations” (source). The word transsexual was, at the time, the term used to describe people who we would now identify as transgender, although this term is not appropriate today. The concerns with listing these diagnoses as a sexual deviance is that, among other things, deviance has a negative connotation, and the exploration of gender identity should not be viewed as a negative occurrence. In the DSM III-R (1987), these two diagnoses were maintained, but instead were labeled under the diagnostic category “Disorders Usually First Evident in Infancy, Childhood, or Adolescence,” acknowledging the reality that gender identity often begins to form in childhood (source).
In 1994, the DSM IV was published, which shifted these prior gender diagnoses into one overarching diagnosis of Gender Identity Disorder within the diagnostic category of Sexual and Gender Identity Disorders (source). This category also held sexual dysfunctions and paraphilias, which compares exploring one’s gender identity with dysfunctions from normal behavior (sexual dysfunctions) and abnormal sexual preferences (paraphilias). This is obviously not what exploring gender identity should be compared to, which brings us to the DSM V (2013).
In the fifth edition of the DSM, Gender Identity Disorder was redefined as Gender Dysphoria, which is what we are familiar with today. This shift highlights a move from the stigmatizing label of “disorder” and places an emphasis on dysphoria, rather than gender identity, as a target symptom for treatment (source). The diagnosis of Gender Dysphoria is given to an individual who is experiencing psychological distress that results from an incongruence in their gender identity and their sex assigned at birth (source).
Beyond the existence of a validating diagnosis for gender dysphoria, another issue that transgender and gender expansive folks experience is finding a therapist that is familiar with mental health issues related to exploring one’s gender identity, including gender dysphoria. While not documented much, it’s a well known fact within the transgender and gender expansive community that finding mental health services that specialize or even have a basic understanding of gender identity concerns and issues is difficult.
A term you might know in relation to transgender identity is that of “transitioning.” There are actually two types of transitioning: social transition, which involves using new pronouns, using a new name, dressing in a different way to express your gender, etc.; and medical transition, which is a collection of many things that medically change your body to reflect a different gender, like hormone therapy and reconstructive surgeries. This section will largely focus on medical transitioning and the different aspects within it.
Neither form of transitioning is necessary or required to identify as transgender or gender expansive. That being said, if a gender expansive person chooses to medically transition, it can involve any of the following procedures:
Hormone Replacement Therapy (HRT): This is the process of taking either testosterone or estrogen to develop secondary sex characteristics that our society perceives as either masculine or feminine. Methods of receiving HRT are through shots, patches, gels or pills. The method depends on the hormone you are receiving, your general health and your personal preferences.
Top Surgeries: “Top Surgeries” can involve either a mastectomy (removal of the breasts) or a mammoplasty (breast augmentation or “boob job”). These procedures are done to help create an appearance that many people may recognize as more feminine or masculine, depending on the procedure.
Genital Reconstruction or Removal: Common feminizing procedures include the orchiectomy (removal of testicles), vaginoplasty (creation of a vagina and vulva and removal of the penis and testicles), and vulvoplasty (creation of a vulva and removal of the penis and testicles). Common masculinizing procedures include metoidioplasty (the elongation of a clitoris into a penis), phalloplasty (creation of a penis and scrotal sacs) hysterectomy (removal of the uterus and potentially a portion or all of the fallopian tubes), and oophorectomy (removal of one or both of the ovaries and fallopian tubes)
All forms of medical transitioning can be very costly, and often aren’t covered by insurance companies. Many cite these treatments and procedures as cosmetic or not medically necessary, which is discriminatory and causes unequal access to transgender healthcare. If an insurance company does cover aspects of medical transition, they often require a diagnosis of gender dysphoria in order to prove medical necessity. This is a barrier not only for those who do not feel the intense discomfort with their gender that is required of a gender dysphoria diagnosis, but for those who don’t have access to or feel comfortable seeking mental health treatment. Thankfully, more insurance companies are covering gender affirming surgeries and other types of medical transition for their transgender and gender expansive patients, including Medicare.
Resources for Trans Positive Health Care
Trillium Health: Trillium Health is a Rochester-based LGBTQ+ oriented healthcare facility that specializes in LGBTQ+ and trans+ healthcare. They provide trans friendly healthcare, mental health services and hormone therapy.
Golisano Children’s Hospital (University of Rochester Medical Center): The Gender Health Services wing provides youth and young adults access to several forms of gender expansive healthcare and medical transition procedures, including hormone replacement therapy, surgical services, and fertility services.
United States Based
Planned Parenthood: Many of Planned Parenthood’s locations offer hormone therapy! Check to see if it’s offered at a location near you using their “Find a Health Center” search option.
Human Right Campaign (HRC): HRC’s Healthcare Facilities Search Function is a wonderful search engine to find healthcare services and providers in your area that provide trans and gender expansive friendly healthcare and services.
The next, and last, letter focuses on the impact of transphobia and anti-trans rhetoric on trans+ and gender expansive folks.
Read More of the Open Letter Series
An Open Letter, Part 3: Myths about Trans+ Medical Care (this article)
An Open Letter Part 4: Transphobia’s Impact on Trans+ People (now published)