42 Journal of Personality Assessment, 1983, 47.1 An MMPI Subscale (Gd): To Identify Males with Gender Identity Conflicts Stanley E. Althof, Leslie M. Lothstein Department of Psychiatry Case Western Reserve University School of Medicine PAUL JONES and JOHN SHEIN Department of Biometry Department of Psychiatry Case Western Reserve University School of Medicine Abstract: This study reported on the development and cross-validation of a 31-item MMPI Gender Dysphoria subscale (Gd) which accurately discriminates between gender identity patients and matched controls, and identifies males with gender dysphoria syndrome. Both the validity and reliability of the Gd scale has been demonstrated and there is every expectation that the scale has excellent potential for clinical usage. In the construction of the Gd scale, we have addressed the major methodological problems of previous studies which have used psychological tests to assess gender role and identity disturbances: small criterion groups, a lack of an appropriate control group, and prediction of too many false positives. The clinical disorder of transsexualism has historical roots in ancient civilizations (Green, 1969) and was first medically documented at the beginning of the 19th century (Friedreich, 1830).It wasn't until the publication of Psychopathia Sexualis (Kraft-Ebing,1894), however, that the condition was considered worthy of medical investigation. Initially, transsexualism was seen as a rare disorder characterized by a compulsive belief or wish to become a member of the opposite sex (I am a man/woman trapped in a woman's/man's body) and an insistent request for sex reassignment surgery (SRS). Fisk (Note 2) introduced the term "gender dysphoria syndrome" in 1973, as an alternative to the now accepted diagnosis of Transsexualism (DSM-III-302.5x). The concept of gender dysphoria syndrome is broader than that of transsexualism in that it includes all individuals who are distressed about their gender roles and identities, but may not desire SRS. Thus, the term gender dysphoria more accurately described the clinical variants who present with gender role and identity disturbances. It is estimated that there are currently 30,000 patients with gender role and identity disturbances who have labeled themselves transsexuals; a sizeable minority of these patients have received Sex Reassignment Surgery (Berger, Green, Laub, Reynolds, & Walker, & Wollman, Note 1). Early estimates of the prevalence of gender identity disorders involving requests for SRS in the United States were: 1/100,000 for males and 1/130,000 for females (Pauly, 1969). It is now apparent that these are conservative figures (Berger et al., Note 1), as increasing numbers of gender dysphoria patients requesting SRS are being seen in outpatient psychiatric clinics (Volkin, 1979). An objective diagnostic instrument, used in conjunction with a clinical interview, would be of great assistance to mental health professionals in assessing gender dysphoria. Moreover, there are many patients whose initial clinical presentation of atypical depression and mixed psychotic symptoms are confusing-and it is only much later that their gender identity disturbances are recognized. Because gender dysphoria patients may be willing to talk about their wishes to be of the opposite sex (related to their fears of being stigmatized), it is often difficult to appropriately diagnose them. A diagnostic test which could bypass their defensive proc- 01-02307 S.E. ALTHOF, L.M. LOTHSTEIN, P. JONESS and J. SHEN 43 esses and identify their possible gender dysphoria, would provide clinicians with the basis for making appropriate clinical interventions. Psychological Testing No single measure, or standardized battery of tests, has ever been consistently employed to compare groups of gender dysphoric patients from different geographical, racial, and socio-economic backgrounds. The published studies have reported on either group or individual data from diverse measures as: Thematic Apperception Test (Doorbar, 1969;Hill,1980); Rorschach Inkblot Test (Nachbahr,1977); Draw-A-Person (Doorbar, 1969); Fleming, Koocher & Nathans,1979; Hill,1980; Money & Wang,1966); Body Image Scale (Pauly & Lindgren,1976); Feminine Gender Identity Scale (Freund, Langevin, Satterberg & Steiner,1977); Wechsler Adult Intelligence Scale (Doorbar,1969; Hill,1980); Tennessee Self-Concept Scale (Roback, Staesberg, McKee, & Cunningham,1977; Sadoughi, Jayaram & Bush,1978); Sexual Functioning Inventory (Derogatis, Meyer, & Vazquez,1978; Nachbahr,1977); and the Bender Gestalt (Hill,1980). The MMPI, however, has shown the most promise as a clinical instrument for identifying and predicting gender dysphoria. The published studies have used the MMPI to: (a)determine psychiatric diagnosis (Finney, Brandsma, Tondow, & LeMaestre,1975); (b)describe a mean MMPI patient profile (Lothstein,1980; Lothstein, Althof, Jones, & Shen, Note 3; Paitich, Note 4);(c)contrast gender dysphoria patients with other patient groups, using mean profiles (Lothstein et al., Note 3); and (d)contrast the patient's pre- and post treatment scores on a single measure (Fleming, Cohen, Salt, Jones, & Jenkins,1981; Hill,1980). The results of these studies respectively indicate: (a)a preponderance of hysterical diagnoses; (b)elevations on Scale 5, with the most prevalent two-point clinical codes being 5-4/4-5 and 5-8/8-5; (c)the mean profiles of gender patients suggest less psychopathology than those of outpatients in control groups; (d)treatment significantly lowers patients' scores on MMPI clinical scales. A diagnosis of "gender dysphoria syndrome," based on elevated Scale 5 and/or clinical profiles 5-4/4-5 or 5-8/8-5, would yield large numbers of false positives. In addition, methodological problems in the development of Scale 5 preclude its being used as the sole basis for the diagnosis of gender dysphoria. In this study we set out to expand the above findings to determine if an MMPI gender dysphoria scale for males could be constructed. It was hoped that such a scale would not only be of theoretical interest but also of practical clinical importance. It was recognized that such a study would have to meet the major methodological objections to the published studies (that is, employing small criterion groups, and yielding too many false positive diagnoses of gender dysphoria using mean profile scores). With these considerations in mind, the following study was designed with the aim of developing a clinically usable MMPI gender dysphoria subscale for males. Subjects The item selection phase of this study included criterion and control groups. Group I, the criterion group, included 52 males (35 whites; 17 blacks) who applied to the Case Western Reserve University Gender Identity Clinic for SRS between 1975 and 1978. White patients had a mean age of 30 and 12 years of education; Blacks had a mean age of 25 and 11 years of education. The Whites were predominantly from working class backgrounds as opposed to the lower class backgrounds of Blacks. Group II, the control group, included 52 male psychiatric outpatients. They were matched with the criterion group for age, sex, and race. These patients were chosen from lists of patients with completed MMPIs on file at two psychiatric outpatient facilities in Cleveland. 01-02308 78 THE SEXUALLY UNUSUAL 2. Fetishistic TV. This is the transvestite usually ranging from exclusively to mostly heterosexual (Kinsey Scale 0-2). This individual dresses periodically in clothing of the opposite sex, usually wearing garments under male clothing. Transvestites, as described by Benjamin, are almost entirely male. 3. True transvestite (ranging from 0-2 on the Kinsey Scale) often dresses in women's clothing and may actually live as a female. This individual is heterosexual except when cross dressed. 4. Nonsurgical transsexual. This person ranges from 1-4 on the Kinsey Scale and cross-dresses, often with insufficient relief of the gender dysphoria from the cross-dressing. The sense of gender discomfort in this individuals because of their ambivalence. 5. True transsexual, moderate. This person ranges between 4 and 6 on the Kinsey Scale(usual to exclusive homosexuality). He or she lives and works as a member of the opposite sex, if possible, but may have tried to adapt to the normal sex roles of the biological gender and may have married and had children. Usually surgery is indicated in this individual. 6. True transsexual, intense. this person tends to be exclusively homosexual, as defined by the biological gender, although they see themselves as heterosexual. Their gender discomfort is intense, and they get very little relief from cross-dressing. These individuals are usually clinically evident at an early age and truly believe themselves to be trapped in the wrong body. The "true transsexual" will likely give an early childhood history of wishing to be a member of the opposite sex, often from earliest memory. Cross-dressing usually begins quite early in life and is usually accompanied by stereotypical cross-gender play and the choice of playmates of the opposite gender. For the biological male, this often involves playing with dolls or playing house, and for the biological female, this usually involves a reluctance to wear dresses or to play with dolls or other sedentary play. Girls typically will seek out rough and tumble play, whereas gender dysphoric 01-02309 Part II: Noncoercive Sexually Unusual Expression boys will avoid it. Usually at some point, the gender dysphoric male is labeled a "sissy" and is often socially ostracized because of this. the gender dysphoric female is likely to be labeled a "tomboy" but is less likely to suffer negative social consequences and may actually be rewarded for this behavior. The transvestite typically has a later onset of cross-dressing, often at puberty. Cross-dressing is usually fetishistic in nature and is accompanied by sexual arousal to the cross-dressing itself. The transsexual, on the other hand, tends to be more asexual and is so aversive to the genitals that there is often a reluctance to masturbate by touching them. Although they are usually attracted to members of the same biological gender, they see themselves as heterosexual since they themselves are in the wrong body. They may also be homosexual or bisexual but are most likely to be heterosexual. It should be noted that in the mid-thirties, a transvestite is frequently observed to become ore gender dysphoric and may actually lose the fetishistic nature of masturbation. It is not uncommon that individuals previously diagnosed as transvestite later in life request sex reassignment surgery and may be appropriate for it. EGODYSTONIC HOMOSEXUAL It should be pointed out that individuals suffering from genetic or hormonal abnormalities demonstrated by an ambiguous genitalia should first be treated by procedures commonly accepted for those medical conditions. It is likely that patients with Klinefelter's Syndrome will have a higher incidence of gender dysphoria than the normal population, and may be candidates for a gender treatment program, after appropriate medical treatment. Psychological conditions which are commonly confused with transsexualism include schizophrenia, multiple personality disorder, and dissociative conditions. Occasionally, a patient who has been sexually abused will consciously decide to be a member of the opposite gender in an attempt to avoid sexual abuse in the future (Satterfield, 1984). This usually occurs in females. Males with a very poor self-image have been misdiagnosed as transsexual because they feel that their passivity and lack of stereotyped male behavior is inconsistent with 01-02310 other staff there is a right of return to their old jobs. Two cases are known to have been dealt with by British Gas. At British Airways there is an agreed policy that transexuals may remain in employment. British Airways employs such people as female (or male) prior to the operation. After the operation they are reclassified under their new gender. They are however, usually moved from their existing posts. Following the operation the employee is kept on his or her existing salary until a new post is found for which they must complete in the normal way. Until a new post is found, no increments are paid. It is understood that these policies date back to a meeting of the nationalized industries chairmen and personnel directors groups in the early 1980's. In local authorities, the policy is usually to keep the transexual in employment in the existing post. There are at least four known cases in London boroughs. A case in the court service led to a justices clerk taking early retirement instead of remaining in employment. The Civil Services treats each case on its merits but clearly security considerations are taken into account. The agreed Civil Services policy is to keep the transexual in employment but to redeploy after surgery has been performed. There are believed to have been at least 20 cases in the Civil Services in the last decade. In the National Health Services administrative staff and annual workers are kept in post after gender changes there are three known examples. In the case of nursing staff, the transexual is taken off duty before the operation, but may be reemployed after surgery. There are two known cases of nurses changing gender. In the education field, transexuals are normally not employed in the period before the operation but are reemployed afterwards. Six cases are known. In the universities, two academics are known to have changed gender without any major problems. In the private sector there are wide variations in practice. The approach is often sympathetic when it involves staff at lower levels though this is less common in smaller companies. At the more senior level, it is usual for the employee to leave but some organizations have given help to individuals in setting up their own business. Employment law as it relates to transvestites and transexuals is largely an uncharted are. This is probably because the individuals concerned usually wish to avoid the publicity and trauma which legal action entails. Many do not feel able to face the reaction of their employer and their workmates, preferring to resign quietly and take the risk of looking for another job. Unfair dismissal An employee with at least two years of continuous services who is dismissed because he is a transvestite may be able to claim unfair dismissal on the basis that his off-duty behavior is of no concern to the employer. In many cases this would be a powerful argument. However, in some situation, the employer might be able show substantial reason for dismissal under section 57 (1b) of the Employment Protection (Consolidation) Act and persuade the tribunal that dismissal was a reasonable response to the circumstances. For example, dismissal of a senior employee in a position of trust, on discovery that he is a transvestite might be found largely a manager's ability to control his subordinates might be undermined if they found out about his transvestism. Another possible substantial reason for dismissal might be pressure to dismiss from the transvestite's fellow employees, or from an important customer. In such a case the tribunal would probably expect a reasonable employer to seek to protect the employee from irrational bigotry, and to consider whether it is possible to transfer him to an alternative post among unprejudiced colleagues. However, a tribunal would probably find that as a last resort, dismissal was a genuine attempt to protect business interests and consequently within the range of the responses available to a reasonable employer. Similar considerations would apply to unfair dismissal claims by transexuals. in Calvin Standard Telephones and Cables Inc., a sex discrimination case brought by a pre-operative transexual, the company argued that there would be "organizational" problems in employing such an individual. For example, it would be embarrassing for employees or visitors to the factory to see an individual entering the male toilets wearing female clothes and it was impracticable to provide separate toilet facilities. In an unfair dismissal case, such matters would probably be found to amount to a substantial reason for dismissal. Unfair dismissal law therefore provides limited protection to transvestites and transexuals. But what about sex discrimination law? The problem here is that under the Sex Discrimination Act 1975 an applicant has to show that he or she has suffered discrimination "on the ground of his (or her) sex." The case of White v British Sugar Corporation concerned a woman who had for many years treated herself as if she were a man. BSC employed here assuming that she was a man and she used the men's toilet rooms and changing facilities. Rumors began to circulate and she was soon dismissed. Her sex discrimination claim failed. The tribunal found that the company had not treated here less favorably than they would have treated a man who held himself out to be a woman, who had been employed as such and who used the women's toilets. in Calvin v STC (see above) a male job applicant did not hide the fact that he was preparing to change sex. but the tribunal similarly found that it was not unlawful sex discrimination for the company to refuse to interview him because a pre-operative female transexual would not have been interviewed either. By contrast a male employee (or prospective employee) who suffers inferior treatment because he is a transvestite may stand a greater chance of succeeding in a sex discrimination claim, on the basis that a female cross-dresser would have been treated better (it is generally thought that it is easier for a woman to pass dressed as a man than vice verse). Where a transexual continues in employment after undergoing a change of gender, there may be problems of reclassification as the opposite sex. This may be relevant for certain contractual purposes. In Corbett v Corbett a court decided that a person who was born a male but had undergone a sex change operation was not a woman who could validly marry a man. However, an employer and employee can get around this by expressly agreeing on which sex the latter is to be for contractual purposes. But if the employee was subsequently to bring a sex Reproduced with permission of copyright owner. Further reproduction prohibited. 01-02312 Eric Matusewitch, New York City Health and Hospitals Corp. New York, NY LABOR RELATIONS THE LEGAL STATUS OF TRANSSEXUALS IN THE WORKPLACE Hundreds of Americans undergo sex reassignment each year. it is well documented that these individuals referred to as transsexuals are misunderstood and scorned by society. As a matter of fact, "questions of sexual deviation and sexual abnormalities probably provoke more emotional responses to society generally than almost any other subject." many employers, influenced by harmful stereotypes, perceive transsexuals as unstable or incapable of performing their jobs. The result of this attitude is that transsexuals are refused employment or terminated from jobs upon discovery of their status. Because of this treatment, the courts have been grappling with the employment difficulties of transsexuals. In simplest terms, transsexualism (or gender identity disorder) is the enduring, pervasive, compelling desire to be a person of the opposite sex. The American Psychiatric Association (PA), which has classified transsexualism as a mental disorder since 1980's, states that transsexuals suffer from moderated to severe personality disturbances and frequently experience considerable anxiety and depression, attributable to their inability to live in the role of the desired sex. In these instances, "depression is common, and can lead to suicide attempts." Although transsexuals are often confused with homosexuals and transvestites, the three types of individuals are considered distinct by most legal and medical authorities. Transsexuals are individuals who suffer from gender identity disorders; homosexuals are individuals who are attracted sexually to members of their own sex; and transvestites are primarily heterosexual men who experience psychological relief and sexual arousal by dressing in women's clothes. Both homosexuals and transvestites are content with the sex into which they were born. The treatment programs for transsexual patients typically require cross dressing as long as two years while undergoing hormonal treatments, psychotherapy and psychosocial adjustment training. If the attending psychiatrist concludes that the patient is psychologically and physically ready, the sex-reassignment surgery is performed. Postoperative follow-up is aimed at the total assimilation of the individual not society in the new sex role. Estimates on the number of male-to-female transsexuals outnumber female-to-male transsexuals by a ratio of as high as eight to one, and as low as two to one. Preoperative and postoperative transsexuals have unsuccessfully challenged employment discrimination under Title VII of the Civil Rights Act of 1964. That statue prohibits discrimination on the basis of race, color, religion, sex and national origin. With the exception of one trial court, no federal court has held that Title VII's ban on sex discrimination protects transsexuals. The most recent case, Ulane vs. Eastern Airlines, Inc., is representative of how these courts have resolved transsexual claims. For a decade, Karen Ulane had been a male pilot with an excellent employment record at Eastern Airlines. An increasing desire to become a woman led Ulane to undergo female hormone treatment. Ulane continued to fly until finally taking a leave of absence to undergo gender-reassignment surgery. After surgery, she was given permission to resume flying by the Federal Aviation Administration. Eastern, however, refused to reemploy Ulane as a pilot. The airline contended that Ulane was too much of a psychiatric risk to vest with the responsibility of piloting a commercial aircraft. Ms. ulane filed suit in the US District Court for the Northern District of Illinois. In a bench trial, the district court held that Eastern had violated Title VII of the Civil Rights Act of 1964 by discriminating against Ms. Ulane as a transsexual and as a female. The US Court of Appeals for the Seventh Circuit reversed the district court's ruling and relied on reasons to support its holding that Title VII did not protect transsexuals. First, the appeals court held that the word sex in Title VII meant a man or woman, not an individual suffering from a sexual-identity disorder. Second, the court found that the legislative his- PERSONNEL JOURNAL/ AUGUST XXXX 01-02313 60 Bozman and Beck Apfelbaum, B., and Apfelbaum, C. (1985). The egoanalytic approach to sexual apathy. In Goldberg, D.C. (ed.). Contemporary Marriage: Special Issues in Couples Therapy, Dorsey, Homewood, IL. Bancroft, J. (1983). Human Sexuality and Its Problems, Churchill, Livingstone, London. Barfield, R. and Sachs, B. (1968). Sexual behavior: Stimulation by painful electric shock to skin in male rats. Science 161: 392-395. Barlow, D. H. (1977). Assessment of sexual behavior. In Ciminero, A., Calhoun, K., and Adams, H. (eds). Handbook of Behavioral Assessment, Wiley, New York. Barlow, D. H., Becker, R., Leitenberg, H., and Agras, W. S. (1970). A mechanical strain gauge for recording penile circumference change. J. Appl. Behav. Anal. 3: 73-76. Barlow, D. H., Sakheim, D. K., and Beck, J. G. (1983). Anxiety increases sexual arousal. J. Abn. Psychol. 92: 49-54. Beck, J. G. and Barlow, D. H. (1984). Current conceptualizations of sexual dysfunction. A review and an alternative perspective. Clin. Psychol. Rev. 4: 363-378. Beck, J. G., Barlow, D. H., Sakheim, D. K., and Abrahamson, D. J. (1987). Shock threat and sexual arousal: The role of attention, thought content, and affective states. Psychophysiology 24: 165-172. Fisher, W. A., Byrne, D., and White, L. A. (1983). Adolescent contraception. In Byrne, D., and Fisher, W. A. (eds). Adolescents, Sex and Contraception, Erlbaum, Hillsdale, NJ. Hoon, E. F., and Chambless, D. (1988). Sexual Arousability Inventory (SAI) and Sexual Arousability Inventory-Expanded (SAI-E). In Davis, C. M., Yarber, W. L., and Davis, S. L. (eds). Sexuality-Related Measures. Lake Mills: Graphic Publishing. Hoon, E., Hoon, P., and Wincze, J. (1976). An Inventory for the measurement of female sexual arousability: the SAI. Arch. Sex. Behav. 5: 291-300. Hoon, P., Wincze, J., and Hoon, E. (1977). A test of reciprocal inhibition: Are anxiety and sexual arousal in women mutually inhibitory? J. Abn. Psychol. 86: 65-74. Kaplan, H. S. (1977). Hypoactive Sexual Desire. J. Sex Marital Ther. 3: 3-10. Kaplan, H. S. (1979). Disorders of Sexual Desire. Brunner/Mazel, New York. Kaplan, H. S. (1984). The Evaluation of Sexual Disorders. Brunner/Mazel, New York. Leiblum, S. R., and Rosen, R. C. (1988). Sexual Desire Disorders. Guilford, New York. Levine, S. B. (1984). An essay on the nature of sexual desire. J. Sex Marital Ther. 10: 83-96. Lief, H. L. (1977). Inhibited sexual desire. Med. Aspects Hum. Sex. 7: 94-95. Masters, W. H., and Johnson, V. E. (1970). Human Sexual Inadequacy. Little Brown, Boston. McNair, D. M., Lorr, M., and Droppleman, L. F. (1971). Profile of Mood States, Educational and Industrial Testing Service, San Diego, CA. Norusis, M. J. (1986). SPSS/PC+: SPSS for the IBM PC/XT/AT, SPSS Inc., Chicago. Schwartz, G. E., and Weinberger, D. A. (1980). Patterns of emotional responses to affective situations: Relations among happiness, sadness, anger, fear, depression, and anxiety. Motiv. Emot. 4: 175-191. Singer, B., and Toates, F. M. (1987). Sexual motivation. J. Sex. Res. 23: 481-501. Vasey, M. W., and Thayer, J. F. (1987). The continuing problem of false positives in repeated measures ANOVA in psychophysiology: A multivariate solution. Psychophysiology 24: 479-486. Wincze, J., Hoon, P., and Hoon, E. (1976). Sexual arousal in women: A comparison of cognitive and physiological responses by continuous measurement. Arch. Sex. Behav. 5: 121-133. Wincze, J. P., Venditti, E., Barlow, D., and Mavissakalian, M. (1980). The effects of a subjective monitoring task on the physiological measure of genital response to erotic stimulation. Arch. Sex. Behav. 9: 533-547. Wolchik, S. A., Beggs, V., Wincze, J. P., Sakheim, D. K., Barlow, D. H., and Mavissakalian, M. (1980). The effects of emotional arousal on subsequent sexual arousal in men. J. Abn. Psychol. 89: 595-598. Zilbergeld, B. (1978). Maale Sexuality. Little Brown, Boston. 01-02314 Archives of Sexual Behavior, Vol. 20, No. 1, 1991 Transsexual Healing: Medicaid Funding of Sex Reassignment Surgery Eric B. Gordon, MD., J.D. Federal requirements for state Medicaid programs are surveyed, and case law regarding Medicaid funding of sex reassignment surgery is reviewed. State have attempted to exclude sex reassignment surgery (SRS) from Medicaid coverage on various bases, concluding for example, that the procedure constituted "cosmetic surgery." Judicial scrutiny of such exclusions has usually resulted in the state action being found violative of the federal Medicaid statute and accompanying regulations. In those cases upholding the state exclusion, the primary judicial obstacle to funding has been a determination that SRS is "not medically necessary" or is "experimental." The author explores the recent scientific literature concerning long-term outcomes following SRS and concludes that the procedure, for purposes of Medicaid funding, is neither "unnecessary" nor "experimental," and that the categorical exclusion of SRS from Medicaid determinations of eligibility for Medicaid Funding, utilizing the standards of care promulgated by the Harry Benjamin International Gender Dysphoria Association. KEY WORDS: gender dysphoria; Medicaid, sex reassignment surgery; Social Security; transsexualism. THE MEDICAID SCHEME Medicaid, Title XIX of the Social Security Act, was enacted in 1965. Reflecting the concept of "cooperative federalism," Medicaid gives each state broad discretion in devising a program to best suit the needs and To whom all correspondence should be addressed at McDermott, Will and Emery, 2029 Century Park East, Los Angeles, California 90067. 61 01-02315 it substituted its own medical judgement based upon its own notion of the significance of a treating physician's mental status examination. While the court's holding was limited, by its terms to the facts of the case, the decision in reality permitted a categorical denial of funding by the Department of Social Services. This conclusion is reflected in the reasoning of the lower court dissent in Denise R. v. Lavine (1975): "the Legislature certainly never intended to authorize the payment of substantial public funds for the dubious sex change operation here in question... Such claims were never within the contemplation of the lawmakers." Several subsequent cases have held a state regulation precluding funding for SRS void as violative of 42 C.F.R. section 440.230(c). In Doe v. Department of Public Welfare (1977), the Minnesota Supreme Court held void an absolute exclusion of SRS from Medicaid reimbursement. The plaintiff in Doe had applied for Medicaid funding for SRS and was denied. She appealed to Phe county welfare department, which found the surgery medically necessary and granted the benefits. The state welfare department reversed, holding that (I) funding of SRS was absolutely prohibited under agency provisions, and (ii) the petitioner had not proved that "if she has the surgery, her psychological problems will be alleviated to the point that she will no longer be disabled and will become self-supporting." The trial court affirmed the state welfare department's decision. On appeal, the Minnesota Supreme Court found, first, that the absolute exclusion violated 45 C.F.R. section 249.10 [now 42 C.F.R. section 440.230(c)]. noting that "[I] there was no explicit provision appearing in the Federal statues that would prohibit the payment of medical benefits for impatient hospital care for transsexual surgery." Second, the court held invalid the state welfare department's requirement that treatment found it unreasonable to require the applicant to prove that an operation would be successful; it noted that the "self-supporting" requirement, uniformly applied, would serve to deny palliative treatment to terminally ill patients. The court ruled that future applications for SRS would need to be decided by the state agency on a case by case basis involving a "thorough, complete and unbiased medical evaluation" to determine the medical necessity of the requested operation. Because the record before it disclosed an uncontroverted finding of medical necessity by the county hearing officer, the court ordered the state welfare department to fund Doe's surgery. In Pinnek v. Preisser (1980), the Eighth Circuit held Iowa's absolute exclusion of Medicaid coverage for SRS void. The court found that "from this record, it appears that radical sex conversion surgery is the only medical 01-02316 treatment available to relieve or solve problems of a true transsexual." Thus, it ruled that a state plan absolutely excluding the only available treatment known at this stage of the art for a particular condition must be considered an arbitrary denial of benefits based solely on the "diagnosis, type of illness, or condition" and therefore contrary to 42 C.F.R. section 440.230(c). The court further held that Iowa's policy, which established an irrebuttable presumption of non-necessity without any formal rule making proceedings or hearings, was contrary to the objectives of the Medicaid statue and that the decision as to medical necessity should rest with the recipient's physician "and not with clerical personnel or government officials." This latter holding has been criticized on the ground that it invests too much power it the treating physician, an interested party in the decision as to funding. However, Pinneke may be reasonably interpreted as holding only that the initial determination of medical necessity must be made by the treating physician; this determination would then be subject to medical review by the state agency and the courts. The Pinneke court's concern was that the Iowa policy created an absolute preclusion on an administrative, and not a medical basis. "This approach reflects inadequate solitude for the applicant's diagnosed condition, the treatment prescribed by the applicant's physicians, and the accumulated knowledge of the medical community. The Supreme Court has emphasized the importance of a professional medical judgement in this contest." A similar result was reached by the district court in Rush v. Parham (1980). The court held that an express exclusion of SRS from the Georgia State Plan was void; "Judgements of medical necessity must be made for individual patients and what may be cosmetic, experimental, palliative, or unnecessary for some, may be deemed essential for another. It follows that the state may not administer a State Plan which irrebuttably denies coverage of any services or procedures within the five required categories (ILLEGIBLE). Similarly, the state may not deny any medical services solely because (ILLEGIBLE) diagnosis, type of illness or condition." The court ruled that states (ILLEGIBLE) provide all medically necessary services; the power to determine (ILLEGIBLE) was vested solely in the treating physician. The Fifth Circuit (ILLEGIBLE) and remanded, finding the case "unripe for summary disposition." (ILLEGIBLE) held that the state should have been permitted to show at trial (ILLEGIBLE) Georgia's Medicaid program had a ban against reimbursing ex-(ILLEGIBLE) treatment because such treatment is unnecessary and (ii) that (ILLEGIBLE) surgery is experimental or (iii) that the Medicaid plan provided (ILLEGIBLE) reimbursement but denied payment to plaintiff on an individual- 01-02317 314 Rowan, R. L., and Gillett, P. J. (1978). The Gay Health Guide. Little, Brown. Boston. Scott, D. H. (1976). Walter C. Alvarez - American Man of Medicine. Van Nostrand Reinhold, New York. Simodynes, E. (1981). Preoperative shock secondary to severe hypokalemia and hypocalcemia from recreational enemas. Anesth. Analg. 60: 762. Smith, D. W., and Gips, C. D. (1963). Care of the Adult Patient. J. B. Lippincott, Philadelphia. Sohn, N., and Robilotti, J. G. Jr. (1977). The gay bowel syndrome. Am. J. Gastroenterol. 67: 478. Sohn, N., Weinstein, M. A., and Gonchar, J. (1977). Social injuries of the rectum. Am. J. Surg. 134: 611. Sonnabend, J., Witkin, S. S., and Purtilo, D. T. (1983). Acquired immunodeficiency syndrome, opportunistic infections, and malignancies in male homosexuals. J. Am. Med. Assoc. 249: 2370. Steinbach, H. L., Rousseau, R., McCormack, K. R., and Jawetz, E. (1960). Transmission of enteric pathhogens by barium enemas. J. Am. Med. Assoc. 174: 1207. Sullivan, E. E., and Garnjobst, W. M. (1978). Pruritus anl: A practical approach. Surg. Clin. N. Am. 58: 505. Szunyogh, B. (1958). Enema injuries. Am. J. Proctol. 9: 303. Tillery, B., and Bates, B. (1966). Enemas. Am. J. Nursing 66: 534 Ziskind, A., and Gellis, S. S. (1958). Water intoxication following tap- water enemas. Am. J. Dis. Child. 96: 699. 01-02318 Archives of Sexual Behavior, Vol. 15, No. 4, 1986 The Gender Identity Movement: A Growing Surgical-Psychiatric Liaison Ira B. Pauly, M.D. and Milton T. Edgerton, M.D. The evaluation and treatment of individuals with gender identity problems has resulted in an interesting and productive collaboration between several specialties of medicine. In particular, the psychiatrist and surgeon have joined hands in the management of these fascinating patients who feel they are trapped in the wrong body and insist upon correcting this cruel mistake of nature by undergoing sex reassignment surgery. Over the last two decades, some 40 centers have emerged in which interdisciplinary teams cooperate in the evaluation and treatment of these gender dysphoric patients. The model for this collaboration began at The John Hopkins Hospital, where the Gender Identity Clinic began its operation in 1965 (Edgerton, 1983; Pauly, 1983). This "gender identity movement" has brought together such unlikely collaborators as surgeons, endocrinologists, psychologists, psychiatrists, gynecologists, and research specialists into a mutually rewarding arena. This paper deals with the background and modern era of research into gender identity disorders and their evaluation and treatment. Finally, some data are presented on the outcome of sex reassignment surgery. This interdisciplinary collaboration has resulted in the birth of a new medical subspecialty, which deals with the study of gender identification and its disorders. KEY WORDS: transsexualism; interdisciplinary; gender identity; genital surgery; sex change. This paper was presented at the Eighth International Gender Dysphoria Association Meeting, in Bordeaux, France, on September 16, 1983. Department of Psychiatry and Behavioral Science, University of Nevada School of Medicine, Reno, Nevada 89557. Department of Plastic and Maxillofacial Surgey, University of Virginia Medical Center, Charlottesville, Virginia 22908. 315 01-02319