This section includes eighty-six short original essays commissioned for the inaugural issue of TSQ: Transgender Studies Quarterly. Written by emerging academics, community-based writers, and senior scholars, each essay in this special issue, “Postposttranssexual: Key Concepts for a Twenty-First-Century Transgender Studies,” revolves around a particular keyword or concept. Some contributions focus on a concept central to transgender studies; others describe a term of art from another discipline or interdisciplinary area and show how it might relate to transgender studies. While far from providing a complete picture of the field, these keywords begin to elucidate a conceptual vocabulary for transgender studies. Some of the submissions offer a deep and resilient resistance to the entire project of mapping the field terminologically; some reveal yet-unrealized critical potentials for the field; some take existing terms from canonical thinkers and develop the significance for transgender studies; some offer overviews of well-known methodologies and demonstrate their applicability within transgender studies; some suggest how transgender issues play out in various fields; and some map the productive tensions between trans studies and other interdisciplines.
The International Statistical Classification of Diseases and Related Health Problems (ICD) is, as the name states, a collection of diseases and health problems compiled by the World Health Organization (2012). At the same time, it is also the basis for payments for health care in virtually all countries in the world. And therein lies the problem for trans* people.1
The current edition, ICD-10, lists “Gender Identity Disorders” in the section covering “Disorders of Adult Personality and Behaviour,” in the chapter “Mental and Behavioural Disorders.” Other disorders that can affect trans* people and that are listed in the same section are “Disorders of Sexual Preference” and “Psychological and Behavioural Disorders Associated with Sexual Development and Orientation.” As many trans* activists have pointed out, trans* people's identities are not diseases and should not be pathologized (GATE 2012a; Winters 2008, 2012a, 2012b; STP, International Campaign Stop Trans Pathologization 2012). At the same time, some trans* people want and need access to trans*-specific healthcare. This is one issue that comes up again and again in research on problems faced by trans* people: access to healthcare, and especially access to transition-related healthcare (Winter 2012; Grant et al. 2011; Council of Europe 2011; Motmans 2009; Kisia and Wahu 2010; Whittle, Turner, and Al-Alami 2007; Keuzenkamp 2012; Bones Rocha et al. 2009; Alisheva, Aleshkina, and Buhuceanu 2007; Human Rights Commission Te Kāhui Tika Tangata 2007).
These needs are a seeming contradiction; the ICD is a gateway for some trans* people to access rights such as funded transition-related healthcare, which relies on an ICD code, while preventing others (or even the same people) from accessing other rights, because the ICD acts as a gatekeeper, such as with access to legal gender recognition, which is often dependent on a diagnosis of gender identity disorder (Balzer and Hutta 2012, Transgender Europe 2012). A best-practice model solving the seeming contradiction at the national level is the Argentinian Gender Identity Law, especially Articles 4 and 11.2
On top of that is the critique of the view of trans* people's transition-related healthcare needs as a disorder versus a variation of the human race that may or may not need medical attention. As large parts of the medical field are based on the assumption of disorder (as the International Classification of Disorders certainly is), this is a continuing ideological struggle between, on one hand, the label “disorder” with the usual power imbalance that accompanies it (doctors get to put the label of disorder on patients, for example—and never the other way around), and on the other hand, criticism of that imbalance from critical health care voices and users of health services.
The current diagnostic codes used for trans* people are also subject to abuse: in some countries (for example, Norway [Helsedirektoratet 2012]), only trans* people diagnosed with the code F64.0, “Transsexualism,” are allowed to access treatment, while others (for example, people diagnosed with F64.8—“Other Gender Identity Disorders”) are not. The diagnosis itself can take bizarre forms; for example, a month-long hospitalization in a mental health hospital (Insight NGO 2010).
One of the most challenging issues is the very need to include trans* health issues in the next ICD edition, ICD-11. That inclusion must be a reference or a set of references not based in illness and, at the same time, able to create a path to health care, public or private insurance coverage, and legal recognition of trans* people's identities.
Taking into account this last and seemingly unavoidable connection between diagnosis and health care coverage, other questions arise: what kind of diagnosis would be needed?
There are several, sometimes conflicting, demands on what a future ICD code must be able to achieve. On one hand, it must be phrased in neutral language to be usable in places where transphobia in health cost reimbursements is rampant, where any reference to trans* issues could lead to an automatic exclusion of the procedure or the person from coverage. On the other hand, in other places, trans*-specific codes are either needed for legal gender recognition or could be useful for scientific purposes (i.e., research into side effects or long-term effects of hormone use). A code must be broad enough to cover those trans* people who need access to specific services while procedures get refined and needs may change over time, yet it must not be so broad as to cover all trans* people irrespective of their actual need for health care. Some codes also need to give clues for treatment to those doctors who are willing to help trans* people but do not know how.
In order to fulfill all these requirements, GATE (Global Action for Trans* Equality) proposed what we called a starfish model, which we described as a decentralized system of codes that can be used together or independently, depending on the local situation (GATE 2012a). We named it for the starfish, which has a decentralized nervous system. Essentially, a trans*-specific code would be placed in a section of the ICD that also houses uncomplicated pregnancy and other factors influencing health and health status. This code would then refer out to other, non–trans*-specific codes in, for example, the endocrinologic and genitourinary parts of the ICD, codes that could be used for trans* people but also for other patients. One example would be “Testosterone Deficiency” or “Absence/Presence of Vagina.” These nonspecific codes could be used either as stand-alone codes or in combination with the trans* specifier, depending on the local conditions.
I would like to acknowledge the work of GATE's codirector Mauro Cabral in developing many of the concepts on which this text is based as well as his help in drafting this text and his leadership in GATE's work on the ICD reform. Furthermore, I would like to thank the members of GATE's ICD working group for their critical thinking and input in GATE's work.
1. The international trans* organization Global Action for Trans* Equality (GATE) uses the term trans* to name those people who identify themselves in a different gender than that assigned to them at birth and/or those people who feel they have to, prefer to, or choose to present themselves differently from the expectations associated with the gender role assigned to them at birth—whether by clothing, accessories, cosmetics, or body modification. This includes, among many others, people who identify as transsexual and transgender, transvestite, travesti, hijra, cross-dresser, fa'afafine, two-spirit, no gender, third sex, or genderqueer. The term trans* should be understood as a political umbrella term that encompasses many different and culturally specific experiences of embodiment, identity, and expression. The asterisk aims to make its open-ended character explicit.
2. A translation of the law was provided by GATE (2012b).