A New Understanding Of The Normal And The Ordinary

The one, dependable constant in life changes. Change can be seen in how humans have progressed from hunter-gatherers to farmers, monarchical governments to democracies, accepting those ethnically different, and gender and identity. As humanity expands its knowledge of the gender binary (male or female), new understandings of gender and identity come to the mainstream, what the majority deems normal and conventional. Since the late 1800s, society has grown its understanding of transgender, individuals born of one sex but identify as another; intersex, individuals born with a variation of both sexes; and agender, individuals that do not identify either male or female.

The research and studies done in the 1900s helped generate the stigma and systemic oppression the American transgender community experiences today. However, before exploring the current state of the transgender community, let’s review a story thousands of years old.

During the rule of Augustus, Emperor of Rome, with the rolling over of the calendar from Before Common Era (BCE) to the Common Era (CE), lived Publius Ovidius Naso from Sulmona, Italy.

Publius, better known as Ovid, was a poet who published several works well known to us today; one of these was Metamorphoses. Metamorphoses is an epic recounting Greek mythology adapted for the Roman Empire telling tales of transformation. Greek and Roman mythology, for the most part, were overlapping and maintained the substance of their stories except for the changing of the gods’ names. This was mostly done to keep in line with the stories while simultaneously creating their mythology by appropriating the names.

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The subject of Ovid’s Metamorphoses, translated by Brookes More, is Caenis, daughter of Elatus (mother). Caenis was a beautiful Thessalian woman, coveted by many for her beauty. Caenis was walking along the shore when Neptune (Poseidon to the Greek) asserted his lust and power over Caenis for he, too, coveted her beauty. After Neptune took what he wanted using rape, he offered Caenis one wish she would not be refused. Caenis wished to become a man so as never to be harmed the way Neptune had just inflicted. By the time Caenis finished rendering her wish, she was speaking with the full force of a man. Neptune had granted her wish. Along with transforming Caenis into a man, Neptune also provided her with impenetrable skin so that no weapons may do her any harm. With this new power, Caenis ventured forth across Thessalia as a warrior under his new name, Caeneus. (More, stanza 189)

The story of Caenis suggests that transgender individuals, or at least the idea, existed before any medical or psychological studies began to understand why some people have a transgender experience. Since this mythology originates within Greek society, it can be estimated that it took nearly 2300 years before attempts began to understand this psychological phenomenon. Two of the major publications used internationally today are the International Classifications of Diseases (ICD) and the Diagnostic and Statistical Manual of Mental Disorders (DSM). While classifications began during the 19th century, it was not until 1900 that the ICD was first published. And then, half a century later, the DSM. Both of which are used primarily for statistical analysis. Arguments could be made that medical coding exists, today, solely for insurance companies so that services may be rendered. In America, a diagnosis is required to provide treatment or care.

The ICD is used for the diagnosis in all areas of medical need. However, the DSM is used specifically within psychology and psychiatry for the diagnosis of mental disorders and illnesses. The DSM introduced the term Gender Identity Disorder (GID) within the third edition of the DSM, published in 1980. Leading up to its inception in 1900, the ICD had been focused on causes of death. Although, after its publication, the ICD started incorporating other diseases and illnesses that contribute to a person’s health. The DSM took on the same task of updating a periodic timetable. Until recently, these two were separate, operating as independent manuals. The ICD and DSM now work together to ensure that diagnoses are accurately reflected in each manual, and work to balance concerns regarding “… access to care and perpetuating the stigma associated with a mental disorder diagnosis.” (Drescher 137) The history of updates to the ICD and DSM has shown how GID/GD has constantly been replaced and renamed.

GID/GD diagnoses did not appear until just after the middle of the 20th century, due to the extensive work done to understand the psychopathological reasons contributing to the transgender experience. Richard Freiherr von Krafft-Ebing, an Austro-German psychiatrist, published Psychopathia Sexualis in 1886 in which he linked the mental status of those with thoughts of changing genders to sexual perversion. The publication of Psychopathia Sexualis helped introduce many of the sexual terminologies today including homosexuality, same-sex attraction; pedophilia, sexual relationships with children; and Beastiality, sexual relationships with animals. These terms helped the medical community diagnose sexual deviancy as a mental disorder. Krafft-Ebing’s work continued into the 20th century when a Jewish, Gay, and German had coined the term transvestite and started the gay rights movement. Magnus Hirschfield worked to separate homosexuality and transsexuality through his studies and research during the early years of the 1900s. In 1919, Hirschfield opened the first institute devoted to the study of sex: the Institute for Sexual Science. With Hirschfield making advancements within sexology, the medical community at large was still slow to recognize his work. The majority of physicians still held onto the idea that all forms of sexuality not deemed normal by society were forms of sexual deviancy. And in the 1960s, this is how the first classifications were entered into the ICD.

However, over time, these terms were refined, developed, and understood with the assistance of additional research. Within the ICD, ‘Sexual Deviations’ became ‘Psychosexual disorders’ in a revision to ICD-9. The 1990 publication of ICD-10 further refined the classification to ‘Gender Identity Disorder’, and then the 2003 publication of the last revision to ICD-10 saw the term change again to its current classification of Gender Dysphoria. ICD-11 is not yet released but will be presented in May 2019 at the next World Health Assembly. ICD-11 has taken the classification a step further by removing it from mental disorders altogether and into a category for sexual health conditions as a new term: Gender Incongruence. The World Health Organization (WHO) acknowledges that gender dysphoria is not a mental disorder and classifying it as such “… can cause enormous stigma for people who are transgender, …” (WHO 2018) thus reinforcing that being transgender is not a mental disability.

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The United States (US) maintains the status of a global leader in many fields (business, democracy, military) but fails in others (technology, science, math). Some may say, one of these failed areas is that of the private healthcare sector. The US is built as a capitalistic society in that its citizens may form privatized corporations for financial gain by providing a service or product. However, the benefit of capitalism is a fair-market economy. As long as monopolies, a single company existing as the sole source of a product or service, are prevented from forming, the competition between related corporations helps to keep costs low. Basic economics does play an important role in that supply versus demand. Privatized healthcare, within the US, comprises hospitals, clinics, insurance companies, and state and federal agencies. There exists an abundance of bureaucracy that decreases the efficiency of maintaining a healthy population.

Without the ability to work efficiently and cohesively, the process of creating an easy-to-use, standardized healthcare system becomes burdensome to those it is meant to serve, the people. The Centers for Medicare and Medicaid Services (CMS) is one example of a system designed to help facilitate the ease of payments due for medical treatment and care. CMS oversees the legality to which all privatized corporations must adhere for financial reimbursement of services rendered. Before the creation of CMS by President Lyndon B. Johnson in 1965, the Social Security Act (SSA) of 1935 helped to formalize the legality of medical payments. The SSA established the baseline for patients to receive care in their definition of medical necessity. Section 1862(a)(1)(A) of the SSA defines the medical necessity for payments under Medicare Parts A and B, that those services to diagnose treatments of illness or injury should be fair and necessary. (US Gov’t) This definition has threaded together the existence of the ICD and DSM, and the need to diagnose patients so that their care can be provided. Without it, transgender individuals would not be able to receive the care they need to control the depth of their transition, from a federal perspective.

Privatized health insurance companies may choose to cover anything they deem necessary. However, to remain competitive, most large insurance companies include some sort of mental health coverage. The Affordable Care Act, or Patient Protection and Affordable Care Act, (ACA) of 2010 assures that ten categories must be covered when an individual purchases health insurance through a federal marketplace. One of these categories is dedicated to treatments for mental and behavioral health. There also exists the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 that helps include mental health coverage under private insurance plans. Insurance companies that provide mental and behavioral health coverage must provide that coverage as robustly as traditional medical coverage. Insurance companies are not allowed to undercharge or provide inferior, coverage for mental and behavioral health. With many companies turning to automated, computerized systems, the need to safeguard data becomes apparent.

Technology has altered the landscape of all institutions that gather patient data. Most healthcare providers now upload patient data for analytical and access purposes. The Health Insurance Portability and Accountability Act (HIPAA), signed by the 42nd president of the US, President Bill Clinton, in 1996, was created for the explicit protection of shared data amongst the many who may be involved with a patient’s care and treatment. HIPAA limits who may have access to a patient’s information based on either the direct need for treatment or at the request of the patient. The US Office of Civil Rights enforces HIPAA with penalties ranging from small civil penalty fines up to a criminal fine of $250,000 and ten years in prison. HIPAA also includes special rules and regulations regarding mental health and psychiatry.

The explicit limitations on the release of mental health and psychiatry information directly reflect the idea that these are sensitive areas that may cause the patient undue complications if released to the wrong entity or person. Dr. Ronald M. Salomon, the doctor with the Department of Psychiatry, Vanderbilt University School of Medicine in Nashville, Tennessee, quoted a survey conducted by the California HealthCare Foundation in which it found that nearly half of the 2100 patients that were victims of misused and improperly released mental health information were harmed or embarrassed outside of their healthcare provider’s office. (Salomon et. al)

Thanks to the ACA, MHPAEA, and HIPAA, transgender identifying patients have more access and security than ten years ago. However, a study led by Sari Reisner, MD, ScD, with the Department of Epidemiology of Harvard School of Public Health and The Fenway Institute, shows that female-to-male (FTM) transitioning adults experience enacted and anticipated stigma, 14.1% and 32.1% of 2578 self-reported respondents respectively, within medical care. (Reisner et. al) Enacted stigma is when a health professional expresses their discrimination explicitly against an individual currently seeking care. As an example: an FTM person shows up to their appointment, and their doctor refuses to see them after learning they are transgender. Anticipated stigma occurs before seeing a health professional in that the individual delays or refuses to seek care due to fears of not being provided care because of how the patient identifies.