Antonia D'orsay

Compromise 3 - Analysis of the DSM-V PRs

Filed By Antonia D'orsay | February 15, 2010 6:00 PM | comments

Filed in: The Movement, Transgender & Intersex
Tags: Cohen-Kettenis, Columbia, DSM V, Gender Incongruence, ICD-10, ICD-11, psychiatry, Psychology, trans, trans awareness, trans kids, trans portrayals, trans youth, transgender, transgender counseling, UN, United Nations, WHO, World Health Organization

I have looked at some of the more simple aspects of the PR's thus far in the first and second parts of this series.

This time around, I will look at the little things in there that are both good and bad, and examine some of the potential social impacts of the changes. In the last segment, which will follow in a couple days, I will look at three other listings of criteria, and compare and contrast how they are intended to function, how they are likely to function, and some of the issues around them.

Because where this is a compromise, the others are an ongoing battle....

One of the changes that has people somewhat fearful is the change of all references from sex to gender.  The rationale for this is as follows:

The term "sex" has been replaced by assigned "gender" in order to make the criteria applicable  to individuals with a DSD (Meyer-Bahlburg, 2009b).

The citation here is of this work: Meyer-Bahlburg, H. F. L. (2009b). Variants of gender differentiation in somatic disorders of sex development: Recommendations for Version 7 of the World Professional Association for Transgendered Health's Standards of Care. International Journal of Transgenderism, 11, 226-237.

Note that this cited article discusses proposed treatments.  This tells us that treatments are being considered throughout the process of writing this.

The ostensible reason for doing this is to provide those IS folks who are reared in a gender that conflicts with their sex and/or gender identity a way to correct that, making them, essentially, both IS and TS at the same time. This is a questionable thng in terms of internal community politics, as there are a sizeable number of IS folks who want there to be zero linkage between trans folk and IS folk.  Indeed, to many IS folk being linked is considered an insult.  That's not universally held mind you, but it's fairly critical, as, right now, they are still considered separate conditions.

This is important because what it does is depathologize the transition process, and pathologize the rearing of the children - in short, it's all the parent's fault.  Still not ideal, from a trans perspective, but from an IS perspective a hell of a lot better a result given the issues with DSD overall.

Among the studies cited in the paper there are others done by the same researcher, such as:

Gender development in women with congenital adrenal hyperplasia as a function of disorder severity. Meyer-Bahlburg HF, Dolezal C, Baker SW, Ehrhardt AA, New MI. Arch Sex Behav. 2006 Dec;35(6):667-84. Epub 2006 Aug 11.

What explains discrepant gender identity outcome in 46,XX individuals with 11-hydroxylase deficiency? Meyer-Bahlburg HF. Ann Saudi Med. 2007 May-Jun;27(3):216-7. No abstract available.

Late diagnosed 46,XX child with congenital adrenal hyperplasia (CAH): deciding the gender of rearing. Meyer-Bahlburg HF. J Natl Med Assoc. 2008 Jun;100(6):759-60. No abstract available.

So this is directly related to the problem that was created by the resistance to forced surgery of infants with visible genitalia variance - what do you raise them as when no one can tell you what they are?

Another interesting aspect is the so called "exit clause" (see Kelley Winters' comment on my analysis part 2 for an explanation there). This is a reflection of the intent of the authors involved, and it means that "corrected" persons are, in effect, no longer trans.  (on a side note, this also means that the so called "classic transsexuals" are no longer transsexuals, they are now just classic, and, therefore, not being spoken for or on behalf of by most activists who are working on behalf of persons for the most yet to enter treatment or currently in it, as well as those who do not have the ability to "blend in".)

And yes, I did just have to get that in there.

The exit clause reflects certain legal aspects of transition, as well as pragmatic considerations, but it further makes it absolutely clear that the treatment processes are intended to be a cure, whatever final form they may take.

It's also an indication, yet again, that they are paying close attention to the work they are doing here.  This is important because the new criteria are so substantially different from the old ones that a great deal more broadly structured treatment outline will need to be considered and ultimately created.  As I noted last column, there are no treatment guidelines in the DSM, and this is by intent. Treatment guidelines will have to come from a different organization: WPATH.

Atlanta, Georgia, in 2011, is hosting the biennial meeting of WPATH.  Given the timing of all of this, the symposium will most likely focus heavily on determining the nature and extent of the new treatment guidelines for the Standards of Care.  It's my personal opinion that any trans person who has any interest in making changes beneficial to more than merely transsexual persons make a point of getting into that area and making yourself known by then.

I also suggest to all trans folk that you take some time to sit with your therapist and make sure they know about this information now. Send then the links to the information and/or print out the rationales and new criteria and *talk with your care provider* -- not as an adversary or someone hostile to your transition (for I hope if your therapist is hostile, that you've fired them, seeing as how they are your employee), but as someone who can benefit from this and who's input here is extremely valuable and of great importance.

Conversely, avoid telling Dr. Phil about it.

This is extremely important, as their input will carry great weight in comparison to the weight of individual trans folk.  They are the one's who will be using this, and the introduction of dimensional analysis (read, a test for gender incongruence) will affect very dramatically how they approach the methods of treatment they use.

It's here that the third tab - Severity - enters into the whole fracas, and this tab is extremely important, for it is, in the end, a test for what kind of trans person are you.  The practical use for it will be as such, and as a dimensional measure (that is, checking a whole bunch of factors and plotting them as a kind of 3D graph) it will also begin to provide data that will inevitably be used to classify and subtype along a more accurate means (indeed, I used a dimensional model in my "What is Trans*" article).

The Severity tab contains some example questions.  The primary testing example of this tool has been called the GIDYQ, with -AA for adolescents and adults typically used as a modifier. It has two versions, one for females, one for males. It's based on a continuum structure - male at one end and female at the other - and uses the questions to determine where a person falls along that scale, in a similar manner to some of the dimensional tests based on the Kinsey scale.

The items were developed by the North American Task Force on Intersexuality Research Protocol Working Group (S. J. Kessler, H. F. L. Meyer-Bahlburg, J. M. Schober, and K. J. Zucker). They were generated based on clinical experience in working with patients with gender dysphoria (both with and without somatic intersexuality), the DSM-IV-TR criteria for GID, and wording modifications from both Cohen-Kettenis and van Goozen (1997) and Docter and Fleming (2001). An effort was made to capture a range of subjective (n : 13 items), social (n = 9 items), somatic (n = 3 items), and sociolegal (n = 2) indicators of gender identity/ gender dysphoria that could be answered in parallel form by both males and females. Each item was rated on a 5-point response scale, with the past 12 months as the time frame. The response options were Always (coded as 1), Often (2), Sometimes (3), Rarely (4), or Never (5).

Items 1, 13, and 27 were reversed scored. For adolescents <18 years of age, the words woman and man were changed to girl and boy, respectively. Items 1-2, 5-10, 16, and 24-27 were considered to be subjective indicators of gender identity/gender dysphoria; Items 3-4, 11, 13-15, and 17-19 were considered social indicators; Items 20-22 were considered somatic indicators; and Items 12 and 23 were considered sociolegal indicators.

As noted in the DSM-V Rationales:

For the current analysis, we coded a symptom as present if the participant endorsed one of the two most extreme response options (frequently or always) and as absent if the participant endorsed one of the three other options (never, rarely, sometimes). This yielded a true positive rate of 94.2% and a false positive rate of 0.7%. Because the wording of the items on the GIDYQ is not identical to the wording of the proposed indicators, further validational work will be required during field trials.

I've provided an example of it on my own site.

You can also purchase one of the studies through amazon.

This assessment is something completely new in terms of the DSM and trans folk, and has significant importance for the day to day lives of the therapists involved (and, therefore, in persons who are trans).

What they do not provide in the DSM is what the scores mean, and a good part of that is because right now, they will mean one thing, while in ten years they may well mean something else. With scoring ranges of between 27 and 135, there's some significant leeway in there, and as has been noted previously, there will be some studies to determine which questions are of the most value and which one's are not - as well as there being new and slightly differently worded questions, made clear in the opening of the Severity Tab and the Rationales tab (as quoted above).

One of the things that's notable is that the test is extremely accurate. There are dimensional measures that are decades old that don't have the accuracy of it.

As such, the final form will replace many of the tools already in use (such as the MMPI) in terms of dealing with trans folk and make the process of getting a diagnosis much easier.  However, there is a continued risk that the habit of "figuring out the right answers" will continue in the community, and people will work against the value of the test, fearing that they might somehow be classified wrong (and, in some cases, justly).

So, in closing, when it comes to adolescents (which, in terms of the treatment on a practical basis are the start of puberty as measured by hormonal development, or for general measure, the age of 13) and adults, the new DSM-V PRs have much to be excited about, and much to be concerned about in terms of practical, day to day use, as well as their repercussions in politics.

Most of which will be better known when the more important Standards Of Care are released, since one often overlooked factor here is that the current standards of care won't work worth a damn with these new criteria.

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Nobody seems to want to listen to this point:

The inclusion of intersex / "DSD" as a qualifier potentially does something that should be concerning. I do think a mental health model needs to be maintained until the science of trans is developed enough to establish a medical model outside the framework of the DSM. But should physical origins be clearly demonstrated and accepted, this simply moves transsexuals from the "without a DSD" subcategory to "with a DSD." (in addition to previously mentioned concerns about established intersex conditions being annexed and DSD terminology being used)

Whether one wants GI/GID removed from the DSM in due time or wants delisting tomorrow, this inclusion opens the possibility that even when the physical science is better understood and that medical model can be more clearly developed, psychiatry retains full province over the diagnosis and treatment.

This seems to me to be hugely important.

Hi Mercedes,

While there is that potential, the science doesn't show cause, so it would be done on the part of soeone defying both medical ethical conventions. (not that such doesn't happen and often, given that surgery on infants still occurs to this day).

As a subtype, the structure is such that it says *with* a DSD or not, and the literature supporting it and the practice in dealing with DSD's specifically seeks to avoid that unless the examples I've noted come to pass -- that an individual with a DS who has been raised in one manner has a Sex and/or Gender Identity that is different from the assigned gender of reaering.

Furthermore, since even if a precise physical causation is found it would not result in transsexuals having a DSD, it owuld simply move them out of the category, as DSD's are not a psychiatric or psychological issue in and of themselves (just as the authors note expressly about it not belonging in the same category with paraphilias).

Lastly, Psychiatry does not have full province over the treatment, even now, and has not for some time. All they have full province over is the diagnosis, and even that is shared, since the ICD is out of their control. Treatment falls predomininatly in the hands of sociologists, social workers, and psychologists, endocrinologists, and assorted other specialties who make up the WPATH (with few psychiatrists in residence there), not to mention more than a few transsexuals.

Influence, then (even strong), but not control.

Atlanta, Georgia, in 2011, is hosting the biennial meeting of WPATH. Given the timing of all of this, the symposium will most likely focus heavily on determining the nature and extent of the new treatment guidelines for the Standards of Care. It's my personal opinion that any trans person who has any interest in making changes beneficial to more than merely transsexual persons make a point of getting into that area and making yourself known by then.

I also suggest to all trans folk that you take some time to sit with your therapist and make sure they know about this information now....This is extremely important, as their input will carry great weight in comparison to the weight of individual trans folk. They are the one's who will be using this, and the introduction of dimensional analysis (read, a test for gender incongruence) will affect very dramatically how they approach the methods of treatment they use.

Unfortunately therein lies the Catch-22 for many non-transitioning trans people, like myself, who generally don't see therapists for trans-related issues -- because we don't need sign-off for surgical changes -- but who are still going to be affected, given that cross-dressing is still defined as a paraphilia.

The changes from GID to GI are encouraging. The discussion around the newly renamed "Transvestic DIsorder"... not so much. As Time magazine noted: "the DSM still seems to have a problem with cross-dressing." Particularly since Ray Blanchard seems to have been given free rein to push his unsubstantiated autogynephilia theory within this section, which not uncoincidently expresses the same sort "doctor knows best" disregard of the voices of those it seeks to diagnose.

I'd be more than happy to try to educate, but with Blanchard in charge of the sub-work group it seems pretty futile. To paraphrase Upton Sinclair: It is difficult to get a man to understand something, when his professional career depends upon his not understanding it.


While Blanchard may in charge of the working group, he is not in charge of the WPATH, and has, in fact, relatively little influence there of late.

He also has no say over the Board or the Assembly, and the board and the assembly are the bodies that make the final decision about what goes in and what goes out.

He's done all he can do at this point.

My biggest objection to the criteria was the it included a question about sexual orientation. Sexual orientation should have absolutely no bearing on a diagnosis of gender incongruence. Including it only serves to provide homophobic psychologists an excuse to not help transgender people who identify as gay or lesbian in their identified gender ie. 'straight-women' who would be transitioning into gay men.

From paragraph two section #2. under Rationale for 302.85 Gender Identity Disorder in Adults and Adolescents:

"The term “sex” has been replaced by assigned “gender”. . .This resolves the problem that, in the DSM-IV-TR, there was a lack of an “exit clause,” . . . For instance, a natal male living in the female role and having regrets experiences an incongruence between the “newly assigned” female gender and the experienced/expressed (still or again male) gender."

The last part of this quote seems to reflect a concern for what happened to David Reimer more than anything else; whose case tragically demonstrates that gender identity is more than a social construct. The facts surrounding the Reimer case are thought by many to point to a biological causation for "brain sex" or self identification which, when not congruent with the absence or presence of a "y" chromosome, would seem to be something that would be catalogued as a DSD under the current regime deciding these matters, if it were proven that the brain possesses sex characteristics as other parts of the body do.

I also have to say that I am not giddy over the prospect of an exit clause. The only thing it seems to imply is that treatment for a disorder has been successfully completed. It doesn't imply entry into new category where one would be congruent with one's gender identity. My darkest thoughts on this occur when I recall what the backgrounds of some of those working in "Sexual and Gender Identity Disorders" workgroup are and what successful treatment might mean to them if it means the same as it did for colleagues of theirs who worked with people like Alan Turing.

As far as the APA and the DSM are involved with people like me are concerned, I am reminded what people like David Lane and David Healy have to say about their profession and what drives the research. I am pretty sure I was mis-diagnosed with a co-morbid condition, which I am still angry about because of all the implications involved. Last Saturday I happened to catch Ethan Watters on the radio who captured my sentiments fairly well with a lot of what he had to say:

". . .Watters writes of Japanese beliefs before 2000. Despite Japanese thinking to the contrary, GlaxoSmithKline saw a huge potential market for Paxil and mounted a massive marketing campaign that combined savvy marketing and questionable scientific research."

In retrospect, I think I should have bought my hormones on line, self medicated, paid a psychiatrist for three visits, written my own evaluation, then headed to Thailand the way someone I know did.

I don't know anyone who has had to endure the invasive scrutiny I have had to. I don't think it is right.


I apologize to everyone on this thread. I did not mean for any of my comments to follow in the order they did. My computer did not shut down last night and a window with this thread on it was left open. Again, this morning I went back to this thread without closing the window. I missed all the comments that came in in the meantime on both occasions.

I am sorry for interrupting the train of thought. All this happened because I prudently decided not to post what I had written last night. I wish I had been as prudent this morning.

Angela Brightfeather | February 16, 2010 10:23 AM


On every blog I have commented to about why the celebration seems to be hollow about DSM changes because it does nothing for the person who is not seeking surgery, or about 90% of the Trans Community, I have been ignored and not given any answers or argument.

There seems to be an aversion to giving a straight answer that might dispose people to throw a bit of water on this celebration. I don't know how long people are going to try and get away with "mum's the word" about the revisions to DSM when it comes to the other 90% of the gender diverse part of the community and when people commenting on these changes like yourself are going to come clean on the fact that there is little or nothing that will change the lives and the discrimination of that 90%. But isn't it time that we start to demand some respect for people's choices in our community instead of going along with things like Blanchards thoughts about us that seem riveted and cast in concrete about 90% of the Trans Community having a parphilia that will continue to be used against them to discriminate and deprive them of their rights? Or is this all about the 5% to 10%.

While everyone is happy about any progress, I don't think that we should get lost in the facts. Which clearly seem to state that for 90% of those out there in the community who are not looking for surgical or complete identity changes, nothing is going to improve in the way of respect or being able to live our lives without being discriminated against, or be cast in the light of the anchor that is weighing down the 10% from progressing.

Exactly how is the DSM addressing this?

90% not seeking surgery is *very* different from what I see in Alberta, although this may be a result of regional quirks. Alberta had the clearest path for people who were surgery-tracked (until last year), so we had some influx of people for that reason. Somewhere more liberal (i.e. California) might attract people who are out, proud and not as surgery-tracked; places where health care is not a reality will also have people who are more strongly forced to consider forgoing it. I did notice in BC that for a period when they delisted health care coverage, many in the Van community had a shift in thinking for awhile, away from surgery -- which might have been a result with coming to terms with the availability (plus a more liberal social climate).

Still, I understand and respect the choice not to have surgery (and also remember those who can't). From my perspective, the choice to have GRS should ideally reside primarily in whether one experiences so much squick and anxiety about their body that they have to, but until there is major social change, there will also be those who do so for resolution with regards to ID, relationships and other gender binary issues.

I see some consideration of this in the diagnostic revisions, but not enough to allay concerns that those who are not looking for GRS might be shifted to a diagnosis of Transvestitic Fetish/Disorder and then find roadblocks with regards to hormones, identification and such. As long as TF/D is in there, it will be an issue.

In the US, a significant majority of trans folk are of a non-anglo background, and the impact of racism and classism prevalent here create a situation where they are the least likely to achieve the wherewithal to get surgery, plus there are cultural factors at play (including surgery, the use of the term "tranny", and more, all of which do not carry near the same value they do in the anglo population *overall*).

In needs assessments done in Los Angeles and Phoenix that I'm aware of and have had access to, the number of trans folk who are people of color is about twice the number of trans folk who are white.

And that's *just* transsexuals. The Trans Community, itself, is significantly larger than just transsexuals, and this particular set of criteria are there to recognize that.

One of the problems here, though, is that a great many trans folk do not present for diagnosis -- so in this case, the diagnosis is somewhat ahead of the curve, and will almost certainly have some legal ramifications associatied with it.

That's the thing about universal health care: it's equal opportunity. And it's because of that potential that the DSM matters. It's just one factor, but it's a big one.

Hi Antonia,

On a reread, I notice that I missed what you were trying to say here:

"Furthermore, since even if a precise physical causation is found it would not result in transsexuals having a DSD, it owuld simply move them out of the category, as DSD's are not a psychiatric or psychological issue in and of themselves (just as the authors note expressly about it not belonging in the same category with paraphilias)."

This is so difficult to sort out. DSD's ARE in the DSM. I think there are gender identities sorted out among the variations listed in the DSD nomenclature. Is someone who has a verifiable "DSD" only considered to have a gender identity disorder if they have a gender identity not associated with their genetic variation?

I doubt a "precise physical causation" will ever be found for transsexualism ( a term that seems to me to be a lot less pathologizing than GID just as intersex is for DSD). It seems fairly obvious, going back to the work of Harry Benjamin and the forty some odd percent of his patients who were hypogonadal that it is probably the result of complex interactions between someone's biology and their social environment which makes pinning down a causation so elusive.

Why can't the existence of transsexualism simply be accepted like so many other variations of the human condition and together with them be kept from being pathologized? Why can't these sorts of things stay in the medical realm when treatment is required?

Angela Brightfeather | February 16, 2010 3:53 PM

Thank you Mercedes!!!!!

I really do appreciate your perspective on it, the first I have really gotten, and I think that I was most likely being generous when saying that the DSM changes will affect 10% of what will previously have been the Transgender/Trassexual Community in general.

What I have been trying to get to is....what is going to be done about all this.

It seems obvious that there needs to be some dirt kicked in the face of the DSM committees who think that that they can now separate people into one of two areas....either classic Trassexual or parphiliac. The first deserving of a life and the second having to continue to live with fear and discrimination. I think that after the fact in 2012 and the new DAM manual comes out, I'm hardly going to see a lot of Classic Transsexuals doing the great job they hav been doing over the past 20 years regarding activism. I might be wrong about that because they are good people and God just keep son making people like us despite what Friends of the Family try to do about it. But I know there will be fewer working at helping to get that 90% some kind of fair treatment and equality.

What is going to be done? Well, it's open to community feedback at for a limited time. Diagnosis discussion will of course be forwarded to the relevant work groups, so GID/GI to Dr. Cohen-Kettennis et al, and TF/TD feedback to Blanchard & co. At this point, I don't see any likelihood of changes in work group direction, unfortunately.

Feedback will probably be somewhat contextualized by who it's from -- more credence given to medical professionals and scholars and far less to folks in the community. I wrote elsewhere about how I believe that's a tragically wrong approach (and it may be inappropriate to post the link here), but that has been the clear indication to me in the past.

That doesn't mean that we give up. We just have to be smarter about how we approach the reply. Kicking dirt will just give us a one-way ticket to the trash folder. It has to be detailed and balanced dissection.

Angela Brightfeather | February 17, 2010 12:36 AM

"And that's *just* transsexuals. The Trans Community, itself, is significantly larger than just transsexuals, and this particular set of criteria are there to recognize that.

One of the problems here, though, is that a great many trans folk do not present for diagnosis -- so in this case, the diagnosis is somewhat ahead of the curve, and will almost certainly have some legal ramifications associatied with it."

And there you have it!!!!

The fact that many Trans folks do not present for diagnosis, is due to the fact that they don't need it. certainly we can agree that not every Trans person nees to be sorted out and convinced that they need help from a psychiatrist. After all, this is what a lot of Trans folks have been saying for years. In fact, the vast majority of them.

When the average Trans person who is gender diverse learns about being Transgender, they find out the first thing they need to address is their "problem". That keeps literally millions of them in the closet or confined to small groups, at best, but it just enlarges their closets a bit and never allows them to breath healthy air.

With non-Transgender people thinking that "men in dresses" are in need of psychiatric help, and classic TS's thinking the same thing, is it any wonder why the DSM committees feel free to classify the vast majority of gender ddiverse people as having a problem and thus keeping them in their closets?

If the number of gender diverse people out there could actually express themselves without being classified as unhealthy or inbalanced, a lot of things would have to change and there would be far fewer BMW's parked outside of psychiatric offices across this country.

For over a decade I have tried to tell you, Helms, Abernathey, Sandeen and Lena and all your TG buds this day of Judgment was coming and the collective response was to personally attack me in every possible manner.

People formerly known as transsexuals just got Raptured out of the transgender religious construct leaving you and yours to live in the Tribulation of pathologized incongruence until the end of time.

I told you so...... directly starting two years ago right here on Bilerico...exactly how in fact.

And while I had sympathy for your plight years ago, over the progression of attempts to destroy every aspect of my life and reputation you all pretty much erased that bit by bit.

You, and the names you can easily name so I don't have to, have no one to blame but yourselves. I hope the legions of now and in the future transgender people correctly hold you and your activist friends directly accountable. You deserve it. You caused it, you gave all the post corrected women in a position to soften or change this zero reason not to wash their collective hands of you, and they did. You see every post corrected woman you attacked and insulted represented hundreds who read and never commented and learned who you were and the exact nature of neogynophobia you expressed so openly. You demonstrated to the professionals who do read these blogs that AGP is real as an end stage of transvestic fetishism and classic transsexuality was something entirely different. You made our case for us.

You were warned not to make war on the women you tried to co-opt...but you just had to do it. Now you live with the results.

I am beginning to understand how out of place my comments are.

I would strongly agree that "Transvestic Fetishism" has no place in the APA's diagnostic code.

That said, I have to say I strongly disagree with assumptions about "communities" and who belongs with which one. If there actually is such a thing as "90 percent" it should more accurately be described as "100 percent".

There is no "transsexual community". Transsexualism has nothing to do with "classic" or "non classic" or elitism. Access to surgery is an entirely separate issue where wealth and health are an impediment. So are human rights and the right to self expression.

Only a total lack of understanding of what it is like to be transsexual would allow a thoughtful and sensitive person to separate a someone who is transsexual from the general population and deny them the authenticity of their self identification by shoving them into a category that is as disparate as the population of New York City.

Transsexualism is simply an existential fact, a biological variation and a lonely place to be. Yes, a transsexual person will seek the treatments it will take to end physical dissonance. I believe most of the misunderstanding surrounding transsexualism arises from the fact that sex, and I mean physical sex, is misconstrued as a strictly binary phenomenon that is also something etched in stone. It is not. We are human. We are flesh and blood.

I enthusiastically support a person's right to form relationships with whomever they please, marry who they please, serve in the military regardless of who they choose to form relations with and express their gendered feelings however they please.
Having a transsexual background doesn't have anything to with that, however.

I probably shouldn't try to comment here. I was drawn here through the Ron Gold controversy, someone who would characterize a person like me as a gay man in denial. It is so wrong to do that. It is becoming obvious that there are those who would make my gender expression an issue when my feminine expression should be totally appropriate to my legal identity in the jurisdictions where I currently reside. Appropriate sex markers on documents and legal sex are my concerns, not appropriate gender expression.

In my situation, marriage equality and discrimination because of sexual orientation should be the constituency I am lumped together with. For someone whose sexual orientation is different than mine, there might be nothing to draw them to sites such as this one except for the fact they might find themselves shanghaied into a demographic for political purposes at what could be the expense of having legal rights they currently enjoy taken away because of false associations created by those with their own distinct political needs. It is very dismissive of the realities of transsexualism imply for people who are trying to put their transsexual history behind them that shouldn't be so. Transsexualism is not like an issue of racial or ethnic loyalty. Even those issues have racist, nationalistic and culturally chauvinistic pitfalls one has to be wary of when working against oppression.