System Failure

- by Stacey Prince

Several clients in my practice who are transgender struggle with depression, anxiety, PTSD, and in some cases suicidality.  I believe that their transgender identity plays a large role in the difficulties they experience, but I say this not because I thnk being transgender is a disorder.  In fact, as discussed in an earlier blog article (Transcending Diagnosis, March 2010) I am highly in favor of revisions of the Diagnostic and Statistical Manual (DSM) so that transgender is no longer categorized as a "disorder," and so that people who fully transition can be diagnosis free.  I believe what is ailing these clients is not their transgender identity, per se, but a system around them that refuses to recognize the validity of their experience, harasses them for being different, and denies them the services and procedures that would set them free.

For many transgender individuals, the problems start at home.  For example, some parents continue to use their child’s birth name and gender pronouns rather than those consistent with their transitioned identity.  Other parents who have the financial means refuse to help with sex reassignment surgery (SRS) which costs upwards of $25,000 and is explicitly excluded from the list of covered services by most health insurance plans.  Other transgender individuals are fortunate enough to have supportive and understanding family members who help them access care, advocate for them, and explain gender dysphoria and transgender identity to extended family members.  

The second set of problems are systemic and economic.  As mentioned above, nearly all health insurance plans deem SRS "experimental" and/or "not medically necessary," and therefore deny coverage. Thankfully some plans do cover less expensive procedures such as hormone therapy that are critical to transitioning.  It is a contradiction that insurance companies seem unwilling to address that they deem some (much less expensive) procedures such as hormone treatment necessary, while SRS is denied.  Compounding the problem is the fact that many transgender individuals are underemployed, due to the being held back by anxiety or depressive symptoms, fear of discrimination, and in some cases transphobia.  Class issues are clearly embedded in this problem; some individuals with resources are able to raise the money for surgery themselves, and so bypass the need for insurance coverage.  Others choose to travel abroad to countries such as Thailand, where SRS is considerably less expensive but where they are far from their support network and their medical care for this very significant surgery is not always up to par.  

Also embedded in this is the problem of therapist "gatekeeping," wherein therapists are given the power to grant or deny procedures that transgender people request.  For example, a letter from one's therapist is required to begin hormone treatment, and two letters (one from the client's own therapist, and one from an independent evaluator) are required for SRS.  This system makes some sense in terms of evaluating whether a client is ready to undergo the tremendous physical, emotional and psychosocial stresses of transitioning.  However, sometimes the gatekeeper role is abused--either by therapists who mistake symptoms that are caused by transphobia and hopelessness for a more organic and permanent psychopathology, and therefore deny surgery, or worse, by therapists who are transphobic themselves and do not want to support transitioning.

The third set of problems has to do with interpersonal transphobia experienced not just in treatment settings, but in the workplace, schools, on the streets, on the bus, etc.  So many of my transgender clients have described "the look," a double take, sometimes followed by a sneer or at best a stare, as a stranger has difficulty reading their gender.  A recent study revealed that gender atypical behavior is one of the top triggers for bullying in the schools, and that those who experience bullying have higher rates of suicide ideation and attempts.  Even clients who get read as their transitioned geder most of the time live in fear of being discovered.  Many choose for a multitude of reasons not to reveal their transgender status, but then are subjected to people's anger or worse when it is discovered that they are transgender.  Further, despite the anti-discrimination law passed in 2005 in our state that includes gender identity, many individuals hold little confidence that they would have a legal leg to stand on if they were dismissed from a job or discriminated against in some other way due to transphobia.

There is hope.  Some universities are now paying for SRS for some of their transgender students.  Thirteen states plus D.C. now have anti-discrimination laws that include gender identity along with other targeted social memberships including ethnicity, sexual orientation, and religion.  The American Psychiatric Association has a task force working on developing best treatment guidelines for transgender individuals, which could in turn lead to insurance companies being forced to pay for transition procedures deemed necessary, including surgery.   And the American Psychological Association is considering getting rid of the stigmatizing "Gender Identity Disorder" diagnosis for the next revision of the DSM, replacing it instead with "Gender Incongruence," a diagnosis that sounds at once both more validating and more treatable.

In the meantime, I try to instill hope when my clients express their despair about their current situation and their future.  I try to help build resilience to deal with family members who still use the incorrect pronouns, managers at jobs who never call back, and medical staff who scold them for being "dishonest" when they finds that a client did not disclose their transgender status.  When necessary I advocate with staff, offering to come to their facility and do free workshops on working with transgender individuals with sensitivity and compassion.  I write letters to legislators when relevant bills are being considered, whether they are about transgender rights or bullying in the schools or coverage of medical procedures.  And I hope that my clients will perservere, until things get better.