Austen Crowder

All eyes on disordered taxes

Filed By Austen Crowder | February 07, 2010 1:00 PM | comments

Filed in: Living, Transgender & Intersex
Tags: GID, juvenile, medical, retinoschisis, tax, transition

Above all else, I always try to be a practical woman. Maybe it's my Hoosier upbringing; maybe it's my family's small-business, by-the-bootstraps mentality; or maybe it's just my interactions with money in a time of recession; but I have always thought of things in terms of practicality over all else. Abstract concepts are nice, but there's something about the down, the dirty, and the practical that always catches my attention.eye[1].jpg

I've seen a lot of brouhaha about the recent tax court decision to make transition-related expenses tax deductible, and to be honest I don't get the uproar. Namely, I read one article in particular here on Bilerico that springboards from the tax court decision into a call to move the transgender treatment and identity from a disease model to an identity model. My primary contention with the position is the assertion that transgender people should be seen as a salient identity instead of a medical condition; thus the tax court decision is a bad precedent that codifies GID as a medical condition, complete with all the issues that come with being labeled as diseased. I disagree with this position; the very foundation of a trans identity - at least in the classical, medical-model sense - is that of a disorder that needs correction.

What's so bad about needing medical help?

For sake of argument and comparison, I don't want to start by talking about my views on transition, medical gatekeepers, and our position within society's gender binary. See, this isn't my first time to the medical-disorder rodeo, and I think that talking about my other disorder may give us a new framework with which to explore the issue of transition, medical disorders, and our identities.

I have a visual handicap caused by a little-known genetic disorder called X-linked Juvenile Retinoschisis, and it has shaped the way I approach transition.

What is XLRS?

X-Linked Juvenile Retinoschis is a rare eye disorder, passed along the x-chromosome, that affects vision from an early age. Cysts form between the retina and optic nerve and fill with fluid, eventually separating the rods and cones from the nerve. This macular degeneration is slow and progressive, and eventually causes severe visual impairment. The only treatment at this time is observation and low vision aids: no cure for the disorder exists.xlrs_odb.jpg

What does this mean for me? I'm 25 and I wear progressive lenses. I need a letter from my ophthalmologist when I try and get a new license, as I sometimes fail the vision test. All in all, I have 20/70 vision with my glasses on, and have to make some significant adjustments to my workspaces to to make basic, everyday tasks livable. A few examples:

  • My computer monitor is positioned approximately 9 inches from my face, and my entire desk is arranged around that setup. (Any further and I find myself leaning in close to read the screen.)
  • My living room has chairs for everyone else, and then a chair for me near the television.
  • My friends know to read far-away texts for me - however, most times I simply listen to conversation and try to figure out the text by context clues.
  • I had large-print books and tests in elementary school. (Once I got better about adjusting my behaviors for daily tasks I moved to regular-print books.)
  • I avoid driving at night whenever possible.
  • I have been told on multiple occasions to consider my vision when looking at potential careers. ("You may have trouble with that when your eyes start to go.")
  • I live with the eventuality of going blind. (Point of fact: I'm actually overdue for a loss of acuity, according to case studies I've seen.)

People act strangely when they discover you have a visual impairment. Some of this is curiosity - what can you see? - and some of this is simply trying to understand what you need to get by. However, there's a strand of pity running through the reactions of many people. I tire of hearing the "you poor thing!" chorus whenever my impairment gets brought up: I'm not a poor thing, and if I didn't tell you that I have 20/70 vision they wouldn't have been any the wiser. I have a visual impairment, yes, but I don't want to identify as visually impaired.

I don't want pity. I want equality. Thus, I don't often tell people I'm visually handicapped. I'll tell people if they ask, but it's not something I offer up on a daily basis.

Transgender through an "impairment" framework

Asking around, I find that there are two major ways to approach transgender identities. On one hand: transgender is an identity to be proud of. Often found in online groups, trans-exclusive spaces, and other sympathetic avenues, these people see our transition as exempt from the medical model, and wish that more decision-making power could be put into the hands of the transitioner. On the other hand, we have the medical model, where therapists, doctors, and care-givers act as gatekeepers to transition resources, and the goal is to correct a sort of "cosmic irony" such that the transitioner can lead a mainstreamed, normal life in the role of their chosen gender. Both models have their merits, and both models have their downfalls.

I've talked to a few sympathetic medical professionals about this debate, and the answers are quite telling of the climate this conversation has brought to bear. Few people are willing to wade into the discussion - there is far less tolerance of lexicological missteps in trans-related conversations than there are in more mainstream issues. (As I said to a friend: in trans debate, stick yourself out there and there's a good chance you'll get cut down to size.)

However, the conversation about visual impairments acts as a great metaphor for this discussion. I never wanted to be visually impaired. I never wanted to deal with the eventual fact that I'll be legally blind, or that my entire workspace has to be modified to accommodate my vision needs. In much the same way as a visually impaired person never wanted their condition, I never wanted to be trans in the first place. I am, and yes it's part of my identity, but if I'd had my druthers I'd have been born female. Simple as that.

Reality, however, dictates that I need medical help to achieve my transition goals. Do I like it? No. Is it cheap? No. However, practicality rules the day here. This isn't my first time to the "It's not fair!" rodeo, and I'm sure it won't be my last. I don't want to buy expensive progressive lenses, or look ahead to expensive low-vision aids, or consider braille lessons, but that's the way my cookie crumbles. More and more, I see transition in a similar way: a necessary evil, predicated on medical gatekeeping, with the end of being a run-of-the-mill girl in mind.

My agreement or disagreement with the GID diagnosis is immaterial to tax breaks, psychology scholarship, or my medical treatment. By the same token, I'd love to hear about a cure for XLRS, but I fully understand that there just isn't enough need for a cure to finance the research. In the meantime I simply accept that some things will be more expensive for me, and while that's not morally okay it's just the way things work right now.

Going back to practicality, I have spent a lot of money on my transition, from hair removal to hormones to wardrobe, not to mention the long-term losses that unfortunately come with the disparity between male and female pay rates. I've played by the medical gatekeepers' rules, gone through my pain and suffering, and I have just as much right to define my trans status as a disorder as others have to define it as an identity. Furthermore, I feel that I've earned the right to be low-key about my transition; I don't wear the "I'm trans!" pin everywhere I go, and for the most part I get along just fine as a woman.

I am visually impaired, but I am loathe to center my identify on this fact. The same applies to my trans status. My goal from the very start of my transition was to be a woman. It always has been, and always will be my ideal end result. While transgender is part of my identity, it is not me: I am not third gender, and despite the fact that our medical establishment requires the diagnosis of a disorder to meter treatment I am not a "broken" person because of the diagnosis.

"Disordered" doesn't mean broken

The tl;dr here is simple: the system sucks, but that's not going to change just because we lament the sentiment of transgender as a disorder. By society's medical, legal, and financial definitions, we are disordered: we are people whose gender doesn't match our sex and whose condition requires medical correction. That's the definition of disorder: something that is out of order. Plain and simple, clear as crystal. Does the fact that our condition is a disorder mean that we, as people, are disordered? As a genetic-disorder laden, visually-handicapped woman, I say no.

People sometimes ask me why trans people can't get it together, lobby-wise. I think part of the answer lays in the definitions of the group: some of us never wanted to be trans in the first place. Many will find ways to come out of the end of the tunnel, completely mainstreamed and comfortable with being their target sex, despite their history. For many - myself included - that is the end-goal: integration, not salient identity. I'm a half-blind girl that used to be a boy, if you have to know, but we don't talk about it that often.

Are we perfect in the gender of our choosing? Hardly. But then again, nobody in this world can afford be so blind as to ignore their imperfections.

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Hi Austen,

Maybe I'm wrong but I would bet you are younger and have never been married to a woman. The names Bailey, Blanchard and Green kept appearing over and over to make a case for Rhiannon. The implications, right there, are too much for me to bear. For a younger person the implications are that you are not authentic but simply a gay man who's gone off the deep end.

Most of the treatments I had involve my endocrine system including surgery. I did go to an electrologist. I became very friendly with her but I know women with PCOS who have had to rely on electrology treatments as well as spironolactone and premarin to keep from masculinizing who have had to deal with hirsuitism, etc.

I had no trouble getting a diagnosis that stated I needed genital surgery as an adolescent. No one needs a psychological diagnosis to have their sex of rearing reinforced. I don't think you need one to obtain treatment for your eyes. It is only when a person's self knowledge tells them that they have been forced into a system that insists everyone fit into a two sex system based on reproductive paradigms they can't conform to that their mental health is called into question.

Someone remarked on an earlier thread that the reason it is so difficult to locate a single etiology for transsexualism is because there are probably so many different ways people are affected by biological conditions that lead to a sense of self that is in opposition to their sex of rearing. There is no single kind of male or female. That is what makes Kurt Freundian, John Money-esque models of sex orientation and "gender identity" so wrong.

It is good to get treatment. It is good that there is a possibility insurance providers may have to offer it as part of their plans. The large question looming overhead is how the law will perceive our sex, gender or whatever word you want to use and how that will fit us or keep us from fitting in with the rest of society.

I agree, disorder should NOT an insult unless it's an excuse for oppression and exclusion. I would say, as someone who was pretty much laid off as an elementary school teacher because of transition, that a disorder which has an imagined sexual component to it can prove a big impediment to anyone working with children or in adoption/foster and parenting custodial situations. But it's the way sexuality is projected onto the disorder, not the word "disorder" itself.

I agree with your logic there, Gina, and while I hadn't thought to use an ableism argument in my article I wish I had thought of it sooner. Looking at it this way makes me realize that the "fear of being disordered" vein of the "not-a-disorder" crowd really bothers me about this whole yarn; being disordered is little more than a definition. I could see haggling over whether trans-related treatment was approached medically or psychologically, yes, as our medical system is set up to handle the two categories in completely different ways, but that doesn't detract from the fact that we have a condition that needs fixing.

Yes, there are perceptions that paint us as deeply troubled, sexually confused beings, but that is not a result of the marking of "disorder" so much as it is the perception that we're just a scary variant of gay people. It's a sentiment that is completely disconnected from our medical treatment, from what I can see, and something that will not go away if we change the way the medical community treats trans people.

But ableism... I like that argument. :)

...and I'm now realizing that I actually crossed my signals a little bit here regarding ableism. Sorry about that, Gina. :)

The "sexualized disordering" of trans women (I can't speak for trans men... I really do think it's different) goes well beyond any gay identities and into something which is made into a paraphilia. In fact, from what I've read in the past decade, gay men have relatively few issues with child custody (although they do with adoption and fostering) and I don't know of any recent case of gay men or lesbians being fired from teaching younger children (in fact, a large percentage of men teaching elementary school are gay). Which is the "sexual paraphilia" nature which is projected specifically onto trans women which makes our continued issues in certain kinds of employment and child custody cases highly unique.

I greatly miss teaching younger children (although I do occasionally sub in my district). The sad irony is, I was basically blackballed from a career (in a highly progressive city) which is 90% comprised of women, while had I worked in, say, IT (a job which is 90% male) there would have likely been no issue.

I don't know of any recent case of gay men or lesbians being fired from teaching younger children

There was me, in 2005. Although I wasn't a teacher exactly, I was working with small children. Turns out they still don't want homos!

I've always been bothered a bit by the knee jerk response to not have trans stuff associated with disability. There's a legitimate concern there, but it seems to be fueled at least in part by ableism and a sense that having a disability is one of the worst kinds of things possible.

As far as thinking about being trans as a disorder, I think the issues vary wildly depending on what exactly is seen as the disorder. Usually it's discussed as either,

1 - A psychological delusion that someone thinks they are ____ when they are really ____.

2 - A physical defect in prenatal development that needs to be corrected.

Obviously, the first interpretation goes greatly against our interests. I think folks get nervous around the second interpretation (myself included) because it's occasionally implied that there are exactly two ways of being sexed/gendered and any deviation needs to be corrected. And as a sociologist reared on 2nd wave feminism, I'm wary of the suggestion that biology will dictate things such as who wants or doesn't want to wear dresses, use makeup, shave legs, etc.

But when it comes down to it, I've got to take hormones for the rest of my life. I require a prescription for that, and usually that requires a diagnosis, even if all it says is that my hormone levels aren't what they should be. Any cis woman producing the amount of hormones I do would be diagnosed with an endocrine disorder, and in my push for equal treatment, I don't see a problem with receiving such a diagnosis myself.

I guess your last paragraph sort of encompasses my approach to the situation. Like I said in the article I'm a practical girl with a GTD attitude; I'll be happy to have philosophical debate about gender identity and the evils of binaries, but last I checked Foucault didn't buy me any hormones or teach me how to get by as a woman. Insofar as my transition is concerned I treat it like I treat my visual impairment: part of my identity, but not my entire identity. I'd rather it not become what everyone remembers about me when I'm out and about with friends, if that makes any sense.

coming back to this post, I see how much I have missed.

You mention that you are twenty-five first of all, Austen. If I had looked before I leaped I would have picked up on that. I have a fuller picture of the reality you experience. If I were twenty-five, I don't think I would be able to comprehend because my eyesight was so sharp then. I just had cataract surgery. I am not that old. I realize, now, what it is like, to some degree, to have to compensate because of the way my vision has deteriorated over the years. Beyond what I personally have experienced, I have to rely on you to tell me what yours is like.

We share something in common beyond the way you experience the way you perceive the world through your eyes, however. I don't know how analogous the two experiences are. If you compared yourself to someone else with X-Linked Juvenile Retinoschis who felt she or he belonged with the sex/gender assigned to her/him do you think the person could understand what you have to go through?

I read what Gina wrote. Don't you think it is heartbreaking to have been laid off because even though she might have been well suited to care for children, she lost trust by transitioning? That kind of understanding kept me in the closet for a long time. I had children. My life was not the only one at stake.

I think we can parse out the experiences of gender and vision into separate categories. If I talked to another person with low vision in their youth I'm sure we could make some great connections over large print books, the evil of fast food menus, tips on getting by in low-light situations, etc. Granted, there'd be a huge disconnect in experience when gender came into the picture, but I'm all about finding similarity instead of pointing out exemptions.

As for Gina's situation, yes. It is heartbreaking. I taught for a while myself and it is hard to accept that present social mores would not allow me back into a small-town Indiana high school classroom. However, Gina also correctly identifies this issue as separate to the issue at hand: disorders don't drive discrimination. That is a separate category of issue that must be tended to in its own way.

To put forth an analogy: is discrimination against a deaf person because of their deafness or because of people's reaction to their deafness? I know it's splitting hairs a bit but I think the distinction is important to make.

Hi Austen,

The reservations I have about the term disorder does not have anything to do with a fear of having something that needs treatment labeled as disordered. When the label is applied to something that doesn't need treatment it makes me fearful. It is for that reason there are so many intersex people upset over the expression "disorders of sex development" ("DSD"). I don't think those concerns should be met with dismissiveness or suspicion of prejudice. For that matter there are many people who are misdiagnosed with with bipolar disorder. I don't see any problem with having reservations about the accuracy of certain diagnoses.

The only ability issue involved with transsexualism is the ability to reproduce. That is the potent issue surrounding the problem of transsexualism. The expression the tax court decision uses is "mentally defective". What is it the court thinks is mentally defective about her? I think the danger involved with the possibility that the court, or anyone else, framing this as a matter of disability rights, is that it makes it an easy a way out of acknowledging her self perception as female.

battybattybats battybattybats | February 7, 2010 10:13 PM

Austen, I am physically disabled with CFS. Thats definately a medical problem. I have transsexual friends who require medical procedures. It's not hard to characterise that as a medical problem in that they have a need requiring medical treatment.

But I am also Transgender. With a bi-gender identity. Currently the only medical treatment i have sought or considered relating to that has been:

1. government paid for brief set of psychological counselling sessions which touched on internalised issues with transgender as well as relationship problems with a partners transphobia though this was a minor aspect as the majority of this was actually intended for and used for pain and other symptom management for my CFS.

2. combating hereditary hair loss.

That does not seem to be so easilly classifiable as a medical problem even if it may be biological in causation. And lets not forget that the bi-genders, crossdressers, genderqueer et al are the largest proportion of the Sex and Gender Diverse population.

Too often these debates are put into an either/or format with unspoken or veiled biases flung about with wild abandon. It does a disservice to those who need medical treatment - to varying degrees of amount of it as well as imediacy of need - to insist their is no medical component of their experience however it is equally problematic for those who have no direct need of medical treatment to insist they have a medical problem.

And there is no easy splitting them all into two camps either because not only do both groups share cultural and historical and human rights issues connections but there are plenty with varying degrees of medical need whose needs change over time and often with self-realisation.

Pushing one side as the sole truth of transgender could mean ignoring everyone's medical needs and the other could mean coercive legislation that requires unneccessary medical treatment in order to obtain basic civil rights. Neither of these is valid.

Clearly the Sex and Gender Diverse population include people who need medical treatment, people who should no longer have medical treatment forced upon them without their own consent, people who should have the option of medical treatment who may or may not choose it all based on the exact same human rights of access to healthcare and bodily autonomy and all of whom are discriminated against in society and the law across the vast majority of the globe for the same reasons.

You're kind of painting my piece into a corner with this response. In no way was I trying to claim ownership of the entireity of transgender experience: I was simply explaining how my approach to transition has been affected by my experience with visual impairment, and then made an attempt to explain how it could inform the system. The article was in response to a guest blog here on Bilerico, which springboarded from the recent tax court decision on GID to say that we need to remove the "disorder" label entirely from transgender identities, a position I happen to disagree with.

Am I trying to wipe the slate clean of bi-gender identities? Of course not. I think there's room for everyone in the umbrella. That I happen to adhere pretty closely to the gender binary is my decision, and I don't think that expousing it here erases bi-gender identies. It's an opinion site, and there are plenty of people writing in support of gender fluidity/bi-gender identity/etc.

All I really wanted to say here is "the label of disorder isn't a terrible thing." I wasn't trying to corner the market of transgender ideas, and if my piece came off that way I apologize.

battybattybats battybattybats | February 8, 2010 12:19 PM

I agree disorder should not be a bad word. And your personal transition experiences and choices are valid by default.

That this is an ongoing issue accross the entire Sex and Gender Diverse community well beyond most peoples definition of Transgender and right into Intersex too as well as across into other groups with medical issues too does rather suggest that much could be gained from looking at the ways these issues cross across wide swathes of the oppressed diverse population.

Medical issues may arise for any group of S&GD. The common threads are important.

If I may, I think that several important aspects have been a bit confused, perhaps. This was not about the entire transgender umbrella, it was very much about a very specific and small subset, those who want and need medical intervention to correct their bodies. Any argument that applies the discussion of mental disorder verses medical correction to transgender subsets other than transsexuals is simply not valid.

Tobi, regarding the wearing of dresses, shaving of legs and make up, I think that you are dead-on. Those are purely social constructs of gender role. However, it's also irrelevant as the discussion is not about gender roles or trans identity. In this case we actually *are* talking about biology, specifically physiology. Hormones and hair growth and organs of various sorts. They are the "other" parts of gender that are intrinsic and expressed before gender role is even learned. Our gender roles are as varied as any other man or woman and we have a basic right to be able to choose and celebrate them.

And lest I be accused of being binary, I might agree except that we are not trying to have our M/F sex obscured or entirely removed or blended together. But, it is also true that not everyone needs every available intervention. The need for various medical corrections is a set of overlapping bell curves. However, few if any of those curves extend out past the classification of transsexual and into the rest of the transgender umbrella. And none determine expressive identity as male, female, trans-x, y-fluid, z-sexual or any other variation of gender expectation transgression. Simply put, there is a fundamental, unique identity to each group and one can be a member of more than one group. It makes for a beautiful,complex tapestry of humanity.

The solution for transsexuals is simple: Remove the condition from the realm of psych disorders, but as the AMA recommended, cover those procedures with insurance as being medically necessary.

The primary arguments for the current diagnosis of GID is that it:

-Protects surgeons from liability that would otherwise discourage them from offering SRS/GRS. It's rare, but occasionally someone has surgery that regrets it afterwards. If this argument held water, the therapist would've been sued instead and they would be discouraged from offering their services.

-Allows qualified professionals with the most knowledge and experience to determine whether a patient requires medical intervention. I think time and time again the APA has proved otherwise, that's all I'll say about this one.

-Provides for insurance coverage of treatment. This case showed that this is not necessarily true. Common knowledge shows it to rarely be true. We hope that a tax court decision will influence insurance coverage in the future but there is no guarantee, it will have to initially be fought on a case by case basis and the appeal to authority could have just as easily come from the AMA as the APA.

I can accept my condition being labelled a medical disorder, but not a mental one especially considering the qualifications of those with the power to label me. The APA has done enough profitable harm to us over the years and it is time for that to come to an end.

You win the cookie. *presents a plate*

I could get behind the AMA taking control of medical transition, and you make a good argument here as to why the APA isn't the ideal group to take charge of these needs.

battybattybats battybattybats | February 8, 2010 12:39 PM

Every part of Sex and Gender Diversity may encounter medical rights issues.

Just cause someone has a bi-gender identity that doesn't mean they will be happy with all secondary sexual characteristics they may face from body-hair to baldness to breast-size these can still be serious issues for people that can cause profound disstress. And no i'm not sayting thats as bad as what most transsexuals experience but that doesn't prevent the need to consider the reality of it.

Ensuring any legislative changes not only do not coercively require medical treatment in order to obtain basic rights should not be allowed to prevent those needing medical treatment from receiving it and vice versa. But we must also ensure that any protection for doctors and surgeons will not also allow for the performing of uneccessary and potentially disasterous surgeries on Intersex Infants.

The interaction across different parts of S&GD is vitally important for us to be more aware of, the way that legislation to help one group if poorly thought out could harm, increase harm or perpetuate harm of one or more others.

I know what its like to have a medical disorder misslabeled as a mental one as the medical disability i've had half my life (CFS) still gets labelled mental from time to time. But then the only problem with that is when a harmful treatment is erroneously rescribed based on that labelling which instead worsens the condition.

Every part of the Sex and Gender Diverse population may have medical human rights issues.

rapid butterfly | February 8, 2010 9:10 AM

thanks, Austen, for another well-thought out article which offers a fresh take on the issues by drawing parallels not previously or at least not often drawn - you're very good at that. :-) I agree - we may have a condition which calls for certain treatments - but so stating does not make us "broken" as people.

I would quibble slightly with the notion that there is some future point at which you, or I, will be a woman, after a transition process (I don't say this is a central thesis of your article at all, just a possible implication of some of what you have written). I think it is dangerous and for me, at times demoralizing, to define my identity in the reactions of others or to make it contingent on this or that medical treatment. I have no doubt that I am a woman, nor do those closest to me; I am blessed in that as I transition, the circle of people who view me as a woman is expanding, but my self-knowledge of my gendered identity is something that is not subject to the whims of others or contingent on any particular medical treatment.


I think there are both internal and external components to experiencing gender. Gender identity is certainly internal (and, contrary to what some theorists claim, I believe one is overwhelmingly born with it). Gender Attribute (how other people respond to your perceived gender) is a function of people reacting to you, your physical appearance, voice, presentation, etc. It also has a profound influence on one's gendering within society. To use an extreme example, a male assigned person who feels internally female but hasn't transitioned will still be treated as some kind of male by others. As a result, they aren't experiencing that part of their life as a woman and aren't really living a life which fits within the broad scope of "women's lives". My example is a more extreme one, but it's certainly one most trans women have gone through at some point in their lives.

I think what Austin was suggesting is fair, that without some form of physical, vocal or even medical transition, the likelihood a male-assigned person will be viewed as female is slim (especially in the broad variety of woman-defined social situations). They might be viewed as a bi-gender person or as gender fluid (which may or may not be to their liking) but for those who don't identify as GQ, they might also well be upset, clinically depressed even suicidal they aren't identified as female. So I what Austen said makes a lot of sense to me.

rapid butterfly | February 8, 2010 3:32 PM


Yes, I take your point, and to the extent yours is (part of) Austen's, hers as well. We don't live in a vacuum, and how we are gendered by others is an important part of our gendered life - and thus, of our happiness. I certainly agree that physical and other changes I have experienced and am experiencing are helping more folks gender me as female.

But I guess I think the identity is probably the most important part, at least for me, and it is the rock on which the rest is built. How we are viewed by others is important; but tying too much of our happiness as women of trans history to what others think is, I still think, a potentially serious mistake. YMMV, of course, and probably has. :-)