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By Root 1906 0

in the DSM, as Kutchins and Kirk note in a chapter chronicling the review process that led to the decision. However, in medicine as in law, the transgendered were left behind when gays and lesbians entered the mainstream. Homosexuality may have been deleted from the DSM, but “gender identity disorder” has taken its place as the diagnosis most frequently assigned to children and adults who fail to conform to socially accepted norms of male and female identity and behavior. “When the DSM-III came out, the first edition without homosexuality, the gay community was so happy and so empowered that by the time the DSM-IV came out, nobody was watching anymore,” activist Dylan (nee Daphne) Scholinski told me in 2004. “Since then the category has just grown broader, mostly because they’ve combined all the old categories.”

The DSM serves as a kind of dictionary of psychopathologies. It is used both as a diagnostic tool and as a justification for insurance coverage. Without a DSM diagnosis, insurance companies will not reimburse mental health treatment, either inpatient or outpatient. “DSM is the psychotherapist’s password for insurance coverage,” note Kutchins and Kirk. “All mental health professionals must list a psychiatric diag-nosic label, accompanied by appropriate code number, on their claims for insurance reimbursement.” Since its inception in 1952, the DSM has been revised five times, though the 1980 publication of DSM-III is viewed as the most significant for a number of reasons. First, it is much more comprehensive than previous editions, with many more diagnoses. “The DSM-III Task Force was predisposed to include many new diagnostic categories,” say Kutchins and Kirk. The reason for this was twofold: The practice of psychiatry was moving out of the hospital and into outpatient settings, and practitioners were seeing a much broader range of problems. At the same time, third-party (insurance) coverage was becoming more common, and coverage required a diagnosis. These two factors working together account for the sudden increase in diagnostic categories in the DSM-III—suddenly many more people were susceptible to a DSM diagnosis (and thus eligible for insurance reimbursement for treatment) than previously.

Kutchins and Kirk’s analysis provides a clue to understanding why homosexuality was stricken from the DSM, while, first, transsexuality, and, later, gender identity disorder became part of the nosology, or system of classification. One of the many profound effects of the gay liberation movement was the sudden shift in the way that gay men and lesbians thought about themselves and their sexual orientation. After Stonewall and the activism that followed in its wake, many people who might once have sought out psychiatrists and therapists hoping to be “cured” of their desires achieved a level of self-acceptance they had previously lacked. They no longer needed the services of psychiatrists because they no longer perceived themselves as ill. Transsexual people faced a far more complicated situation, however. Even if they didn’t consider themselves “sick” per se, they still needed to secure the services of health care providers. They needed endocrinologists and surgeons but, according to the Benjamin Standards of Care, they first needed to spend up to a year in therapy in order to secure the all-important “letter” from their therapist recommending hormones or surgery. They remain locked into the health care system in a way that gays and lesbians are not.

Dr. Ben Barres of Stanford described this painful conundrum very succinctly in our conversation in 2001. “I have very mixed feelings about this. I think if gay people weren’t victims of societal ignorance and maltreatment, most would be very happy and well-adjusted, whereas I’m not sure that is true for transsexuals, at least most transsexuals that I’ve met who grow up feeling that they are the wrong gender. So there’s a certain amount of pathology. Nevertheless, I don’t think that transgendered people need to be in the DSM any more than gays do. It’s unfair, just as unfair as