Update: Statement on Gender Identity Disorder and Transvestic Fetishism in the DSM-V

Kelley Winters, Ph.D.
GID Reform Advocates
www.gidreform.org

The Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association, is regarded as the medical and social definition of mental disorder throughout North America and strongly influences the The International Statistical Classification of Diseases and Related Health Problems (ICD). The current psychiatric classifications of Gender Identity Disorder (GID) and Transvestic Fetishism (TF) in the Fourth Edition Text Revision of the DSM (DSM-IV-TR) inflict great harm to gender variant, and especially transsexual, people in three ways:

Unfair Social Stigma. The GID and TF diagnoses falsely label identities and expressions that differ from assigned birth sex as mental illness and sexual deviance. Behaviors and emotions considered ordinary or even exemplary for other (cisgender) people are mis-characterized as madness for gender variant people. Transwomen (those who identify as women and were birth-assigned male) are consequently maligned as crazy and sexually suspect “men” by this stereotype and vice versa for transmen. The defamatory classification of Transvestic Fetishism particularly targets transwomen, including a great many transsexual women (whose gender identities are dramatically incongruent with born physical sex characteristics), as “paraphiliac” or sexually perverse. Across North America, these diagnoses are cited directly when gender variant people are denied human dignitiy, civil justice, and legal recognition in their affirmed gender roles. Gender variant people lose jobs, homes, families, access to public facilities, and even custody and visitation of children as consequences of these false stereotypes.

Medical Care Access. GID and TF pose barriers to access to medically necessary hormonal and surgical transition treatment for those who need them.  The diagnostic criteria, supporting text and categorical placement of GID and TF contradict social and medical transition and mis-characterize transition itself as symptomatic of mental disorder. Transitioned individuals who are highly functional and happy with their lives are forever diagnosable as mentally disordered, according to the current diagnostic criteria. As a consequence, the medical necessity of hormonal and surgical transition treatments are not commonly recognized by care providers, insurers and government agencies. In the US, only the financially privileged have access to surgical care, with scant few exceptions.

Gender-Reparative Therapies. GID and TF implicitly promote cruel and harmful gender-reparative psychiatric “treatments” intended to enforce conformity to assigned birth sex and suppress gender variant identities and expressions into the closet. Once diagnosed with GID or TF, the only way a transperson can be released from the current diagnostic criteria is to completely hide his or her gender identity and deny his or her authentic self. Children and adults, already at risk from undeserved guilt and shame, are subjected to more guilt, shame, torturous aversion therapies, drugs and even incarceration with these diagnoses.

The DSM-V.

I urge reform and redefinition of the Gender Identity Disorder diagnosis to simultaneously address both issues of unfair social stigma and medical necessity of hormonal and surgical transition treatments. I believe this can best be accomplished in the upcoming Fifth Edition of the DSM (DSM-V) by replacing GID with nomenclature emphasizing painful distress with born physical sex characteristics or ascribed social gender role that are incongruent with gender identity, rather than nonconformity to assigned birth-sex. I am encouraged by a recent report from Drs. Peggy Cohen-Kettenis and Friedemann Pfafflin , of the Gender Identity Disorders Subcommittee of the DSM-V Task Force. They acknowledge many of the GID issues described here and recommend a diagnostic focus on distress and exclusion from diagnosis of gender variant people who meet no scientific definition of mental disorder. However, I am concerned about their use of the word, “desire,” in their proposed diagnostic criteria, which would ambiguously implicate desire for medical transition treatment in itself as symptomatic of mental illness.

I strongly urge elimination of the scientifically capricious and socially punitive Transvestic Fetishism diagnosis from the DSM-V. I am especially troubled by a September report from Dr. Raymond Blanchard, chairman of the Paraphilias Subcommittee of the DSM-V Task Force. He proposes to retain the TF diagnosis, renamed “Transvestic Disorder” with its existing diagnostic criteria that ambiguously label all “behaviors involving cross-dressing” by those assigned male at birth as sexually deviant on the basis of their sexual orientation. Moreover, Dr. Blanchard proposes to add the deeply offensive and inflammatory term, “autogynephilia,” as a specifier to the diagnosis. I ask the DSM-V Task Force and elected officials of the American Psychiatric Association to reject his proposal.

Further Reading.

GID Reform Advocates, www.gidreform.org

Winters, K. (2008). Gender Madness in American Psychiatry: Essays from the struggle for Dignity, GID Reform Advocates, www.gendermadness.com

Ehrbar, R., Winters, K., Gorton, N. (2009) “Revision Suggestions for Gender Related Diagnoses in the DSM and ICD,” The World Professional Association for Transgender Health (WPATH) 2009 XXI Biennial Symposium, Oslo, Norway, http://www.gidreform.org/wpath2009/

Winters, K., Ehrbar, R. (2009) “Beyond Conundrum: Strategies for Diagnostic Harm Reduction,” Annual Meeting of the American Psychiatric Association, San Francisco, CA, http://www.gidreform.org/blog2009May18.html

Cohen-Kettenis, P. T., & Pfafflin, F. (2009). “The DSM diagnostic criteria for gender identity disorder in adolescents and adults.” Archives of Sexual Behavior, doi: 10.1007/s10508-009-9562-y. http://www.springerlink.com/content/c54551hj463111j1/

Blanchard, R. (2009). “The DSM Diagnostic Criteria for Transvestic Fetishism,” Archives of Sexual Behavior, doi: 10.1007/s10508-009-9541-3, http://www.springerlink.com/content/9267212375m4n40r/

Revision Suggestions for Gender Related Diagnoses in the DSM and ICD

Ehrbar, Randall D., Psy.D.
Winters, Kelley, Ph.D.
Gorton, R. Nicholas, M.D

a synopsis of the presentation to

The World Professional Association for Transgender Health (WPATH)
2009 XXI Biennial Symposium
June 19, 2009
Oslo, Norway

For the complete presentation text, please see www.gidreform.org/wpath2009/

Starting with different beliefs and assumptions about appropriate diagnoses for transgender and gender variant individuals suffering from gender dysphoria, the members of this panel have reached similar conclusions about desirable changes to diagnostic categories in the next version of the DSM and ICD. Important points of agreement are that revised versions of diagnoses such as GID, Transsexualism, and GID in children 1) should center on gender dysphoria, which is distress associated with sexed characteristics of the body and/or social gender role, 2) should be large enough to encompass all of those who need it including those with non-binary gender identities, and those who do not wish to fully medically or socially transition to the “opposite” gender, 3) should be narrowly defined to only include those who are experiencing gender dysphoria (and are therefore presumably in need of treatment), not to those who are merely gender non-conforming. We will discuss the different premises and constructs on which the three authors base their conclusions and explore how despite these significant epistemological differences, the same conclusions become apparent. We will also discuss placement of diagnostic categories, nomenclature, “exit clauses” for trans-people who no longer experience gender dysphoria, cultural and sociopolitical significance of diagnostic categories and discourses around such categories, and appropriate diagnosis of distress primarily due to discrimination and oppression rather than gender dysphoria.

Introduction:

We come at this issue from a variety of different backgrounds and viewpoints differing on whether there should be a diagnosis at all or what kind of diagnosis it should be. When I first approached Dr. Nick Gorton and Dr. Kelley Winters they both were a bit skeptical, in fact, because they perceived that the other had very different viewpoints. Yet we agree about fundamental principles of treatment and rights for trans people. We may just differ in the ways that we think these things can best be accomplished. In the process of working on this talk we discovered that not only do we share common basic principles, but even had some common ground about utility of having a diagnosis and what such a diagnosis should look like if there is a diagnosis. . We were also able to generate compromises that could accommodate those areas where we do have fundamental differences. One of the first things we did in preparing for our talk was to write in 30 words or less our fundamental beliefs about diagnosing transgender people with an illness and what that does for the community.

What We Think:

• Winters – Individuals whose gender identity or expression differ from assigned birth-sex are labeled mentally disordered in the DSM-IV-TR, inflicting harmful social stigma and barriers to transition care.
• Ehrbar – Practically, diagnosis is needed for access. Conceptually, it makes sense to categorize gender dysphoria as a mental health disorder.
• Gorton – GID (by any name) belongs in DSM-V. Revisions can foster acceptance among consumers without compromising scientific accuracy. Diagnosis facilitates insurance coverage and disability protections.

We also explicitly identified our common ground is with regard to access to care, non-discrimination, social justice, and civil rights. We have a good deal of common ground about how we think the world should be. In fact, we suspect that most if not all of the folks here at WPATH share these fundamental beliefs. , I It’s worth reminding ourselves that we do agree that trans and gender variant people shouldn’t be subject to discrimination, should have access to health care and should have civil rights and protections.

The Authors’ Shared Vision:

• End discrimination on the basis of gender identity and expression
• Gender identity and expression that differ from assigned birth sex do not, in themselves, constitute a mental disorder or an impairment in competence
• Hormonal and/or surgical transition treatments to relieve gender dysphoria are medically necessary
• Insurance and health care coverage for medically prescribed transition treatment
• Legal recognition/documentation for all people that is consistent with their gender identity and expression.
• Reform must fit everyone’s needs, but as a social justice movement we must weigh more heavily the needs of those least enfranchised.

Summary of Proposed Diagnosis:

• Dx Criteria – Both A and B

A: Strong and persistent distress with physical sex characteristics, or ascribed social gender role, that is incongruent with persistent gender identity.

B: Distress is clinically significant or causes impairment in social, occupational, or other important areas of functioning, when this distress or impairment is not solely due to external prejudice or discrimination.

• GD in remission

No longer meets criteria, needs treatment to maintain remission

• ‘Exit clause’

No longer meets criteria, doesn’t need treatment to maintain remission

Key Points:

• It’s about Dysphoria, not difference from assigned birth sex
• Respectful Language
• Not too Big; Not too Little; but Just Right
• Accurate Classification Placement
• Remove Tranvestism/Fetishism Categories

Our main points are: 1) gender dysphoria is the conceptual center of the diagnosis, 2) use respectful language in nomenclature and description of individuals, 3) include those who are in need of inclusion, do not include those who should not be, 4) move the diagnosis out of the sexual and gender identity disorders chapter, 5) and remove transvestic fetishim.

About the Authors:

Randall Ehrbar is a clinical psychologist with extensive training and experience working with transgender clients. He has also been actively involved in the American Psychological Association’s efforts to address transgender concerns.

Kelley Winters is a writer and consultant on gender diversity issues in medical, employment and public policy.

Nicholas Gorton is a medical doctor who provides primary care to many transgender clients at Lyon Martin Health Services

Copyright © 2009 Randall Ehrbar, Kelley Winters, Nicholas Gorton

Stop Sexualizing Us!

A Guest Essay by Julia Serano, Ph.D.
Presented at a Protest Rally at the
Annual Meeting of the
American Psychiatric Association
San Francisco, May 18, 2009

For decades, the general public, and especially the media, have had a lurid fascination with trans people’s bodies and sexualities. From talk shows like Jerry Springer, to reality shows like There’s Something About Miriam, novels like Myra Breckinridge, and the countless movies that portray trans women almost exclusively as either sex workers, sexual predators and sexual deviants. This hypersexualization of transgenderism predominantly targets trans women and others on the trans feminine spectrum—because in a world where women are routinely objectified, and where a woman’s worth is often judged based on her sexual appeal, it is no surprise that many people presume that those of us who were assigned a male sex at birth, but who identify as women and/or dress in a feminine manner, must do so for primarily sexual reasons.

We are here today to say, stop sexualizing us!

This sexualization of trans feminine gender expression also runs rampant in psychiatry. In the current version of the DSM, there is a diagnosis called Transvestic Fetishism, which specifically targets “male” expressions of femininity. When nontransgender women wear traditionally feminine clothing, they are viewed as healthy. But when the same behavior occurs in people assigned a male sex at birth, the APA deems it psychopathology. This is hypocrisy!

We say to the APA, stop sexualizing us!

And while crossdressing by men is often an expression of femininity, or of an inner gender identity, Transvestic Fetishism presumes that the act of wearing feminine clothing must (in and of itself) be an expression of aberrant sexuality.

We say to the APA, stop sexualizing us!

Studies have shown that, “Cross-dressers…are virtually indistinguishable from non-cross-dressers.” Despite the empirical lack of evidence that crossdressing is associated with psychopathology, the APA continues to mischaracterize crossdressing as a mental disorder.

We say to the APA, stop sexualizing us!

And if that wasn’t bad enough, Transvestic Fetishism has been categorized in the Paraphilias section of the DSM—the category that used to be called Sexual Deviations. This section used to be home to diagnoses like Homosexuality and Nymphomania—societal double standards that for decades were reified in the DSM as mental disorders. Like its predecessors, crossdressing is a harmless, consensual activity that is unnecessarily stigmatized in both the culture at large and within psychiatry. We are here to call for the removal of all forms of crossdressing and transvesticism from the DSM.

We say to the APA, stop sexualizing us!

And while there are many psychologists who understand the distinction between gender and sexuality, who understand that trans people’s identities, personalities and sexual histories are infinitely varied, the APA passed over such people, and instead tapped Ray Blanchard to chair of the sub-working group for the next DSM’s Paraphilia section.

We say, to the APA, stop sexualizing us!

Blanchard is the inventor of the controversial theory of autogynephilia, which claims that all transgender women are sexually motivated in our transitions. Despite the overwhelming scientific and experiential evidence that contradicts his theory, it has gained traction in the psychological literature—including a mention in the current DSM—precisely because it reifies hypersexualized stereotypes of trans women.

We say, to the APA, stop sexualizing us!

Blanchard views trans feminine spectrum individuals the way most movie producers do. To him, we are all either gay men who become women in order to attract straight men, or we are male perverts who become women in order to fulfill some kind of bizarre sex fantasy.

We say, to the APA, stop sexualizing us!

Blanchard not only believes that we are sexually deviant, but in the psychological literature, he has forwarded his belief that those people who are attracted to us—our lovers, partners and spouses—must also suffer from a paraphilic disorder.

We say, to the APA, stop sexualizing us!

Blanchard’s theories have been challenged by a majority of trans activists, allies, advocates and countless trans-knowledgeable psychologists and therapists. Yet, the APA selected him to play a lead role in rewriting trans feminine gender expression back into the DSM.

We say, to the APA, stop sexualizing us!

When you sexualize someone, you invalidate them. That’s why feminists have worked so hard to put an end to sexual harassment in the workplace, and it’s why we as trans activists seek an end to the psychiatric sexualization of trans feminine gender expression.

We say, to the APA, stop sexualizing us!

Clothing choice does not constitute a psychopathology. We call for the complete removal of crossdressing and Transvesticism (in any form) from the DSM.

We say to the APA, stop sexualizing us!

About the Author:
Julia Serano is an Oakland, California-based writer, spoken word performer, trans activist, and biologist. Julia is the author of Whipping Girl: A Transsexual Woman on Sexism and the Scapegoating of Femininity (Seal Press, 2007), a collection of personal essays that reveal how misogyny frames popular assumptions about femininity and shapes many of the myths and misconceptions people have about transsexual women. Julia has gained noteriety in transgender, queer, and feminist circles for her unique insights into gender. She has a Ph.D in Biochemistry and Molecular Biophysics from Columbia University and is currently a researcher at UC Berkeley in the field of Evolutionary and Developmental Biology.

Published here with permission of the author
Copyright © 2009 Julia Serano

ALIGNING BODIES WITH MINDS: THE CASE FOR MEDICAL AND SURGICAL TREATMENT OF GENDER DYSPHORIA

A Guest Essay by
Rebecca Allison, M.D., FACC, FACP
Chair, American Medical Association Advisory Committee
On Gay, Lesbian, Bisexual, and Transgender Issues
President-Elect, Gay and Lesbian Medical Association

A presentation given to the
Annual Meeting of the American Psychiatric Association
San Francisco, May 18, 2009

As a physician who has successfully completed the process of transition from male to female, I find it strange and inappropriate that I may still be considered “mentally ill” by those who would take literally the diagnosis of “gender identity disorder” in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). I believe such a diagnosis is incorrect, and submit this review to support my belief.

I’d like to begin by offering an example from my medical practice in support of the idea that “outcomes do matter” – that a favorable clinical outcome, reproducible from one patient to the next, validates the medical and/or surgical treatment prescribed for the diagnosis.

I intend to show that a cardiologist may initiate a course of treatment based on a patient’s reported symptoms, despite a lack of objective findings to support the working diagnosis; and that the accuracy of such a diagnosis is confirmed by the favorable response to what some might consider “empiric” treatment.

So much of my practice centers on a relatively small number of diseases of the cardiovascular system. One of the most common conditions I see is called angina pectoris.

Angina Pectoris is simply Latin for “Chest Pain.” But it’s a specific type of discomfort: mid-chest; radiates to the neck, jaw, or left arm; worse with physical or emotional stress. It’s relieved by rest or by the medication nitroglycerin.

When I see a patient with such typical symptoms, I know that it’s very likely he or she has interference with blood flow to the heart through clogged coronary arteries. I begin a series of tests including electrocardiograms, stress testing, and cardiac catheterization. Usually – over 95 percent of the time – the blockages are identified and managed appropriately with medications or surgery.

However, a small number of persons will have completely normal testing – no blockages at all. Even the electrocardiograms and stress testing do not indicate a physical cause for their symptoms. My next step for these persons is to look for other causes for their pain, with evaluation of the esophagus, GI tract, or musculoskeletal system. Even after this evaluation is complete, there will remain a group of people who have no discoverable cause for their pain, yet it is very real, severe, and sometimes disabling. What to do then?

I can tell you that what a cardiologist does then is treat the patient. We treat with medications, just as we would use for a patient with documented coronary artery disease. We give long acting nitroglycerin, calcium channel blockers, and aspirin. And our treatment works! The patients report prompt improvement. They are able to go about their normal lives without the anxiety and fear of the disabling pain. Outcomes do matter!

Numerous review articles in the cardiology literature confirm the effectiveness of medical therapy for the “syndrome of chest pain with normal coronary arteries.”

It has been suggested that this syndrome may be due to coronary vascular spasm, particularly in the small vessels of microscopic size. This is not a condition which can be objectively documented with any ease or safety, and so we do not perform provocative tests to induce spasm and “prove” our diagnosis, since such induced spasm could be harmful to the patient. We accept the diagnosis based on the response to our treatment. We name the condition “Cardiac Syndrome X,” which simply shows cardiologists aren’t very imaginative when it comes to original names. If we are more creative, we call it “microvascular angina,” and either way we give it an ICD Code of 413.9.

Notice that we do not call microvascular angina a mental disorder, although it has been reviewed frequently in the psychiatric literature, due to the high prevalence of serious anxiety in persons suffering from this condition. (I dare say, if I had frequent, severe, chronic chest pain, I’d be anxious too.) IF we use anti-anxiety medications, they are secondary to the primary medical treatment, and we would not prescribe them in lieu of nitroglycerin.

So, let’s just suppose someone comes to see me in my office, and he tells me, “Dr. Allison, I keep having these chest pains.” Suppose, after going through the complete evaluation, I tell him, “There’s nothing physically wrong. Perhaps we just need to help you adapt to your current circumstances. Let me give you a benzodiazepine [a mild tranquilizer].” What will he say? He most likely would tell me, “Listen here, either you give me some nitroglycerin, or I am going to find someone who will.” And he would be entirely correct. Because he knows that nitroglycerin will give him a good outcome, and he knows that outcomes matter.

Like microvascular angina, Gender Identity Disorder (or Gender Variance) is a diagnosis which is not based on objective findings. There’s no blood test for Gender Variance. There’s no chromosome analysis, no radiographic diagnosis, no nuclear scan. Pathologic changes in the hypothalamus, such as the “bed nucleus of the stria terminalis” or BSTc, are of academic interest but cannot be applied to living patients.

Some have suggested that a magnetic resonance image of the brain may show an appearance of the corpus callosum in male-to-female persons which is similar to genetic females. Even if a statistically significant correlation were to be proven, however, it would not have one hundred per cent sensitivity, meaning that some persons with true Gender Variance would have negative findings on MRI examination.

The best diagnosis remains subjective, the history as reported by the patient: a constant awareness of a sense of self which is not congruent with one’s physical body and the expected social role associated with that body.

Or, if you prefer, “a strong and persistent cross-gender identification;” and “persistent discomfort about one’s assigned sex or a sense of inappropriateness in the gender role of that sex.” You may recognize these as Criteria A and B of Gender Identity Disorder in the DSM-IV.

What about Criterion D, you ask? I maintain that “Clinically significant distress or impairment in social, occupational, or other important areas of functioning” should not be a necessary criterion for a diagnosis of Gender Variance. Many young persons are blessed with enlightened parents who facilitate their transition and help them avoid all the distress and impairment which was unavoidable for those of us who transitioned years ago. That is not to say that persons with Gender Variance no longer experience distress. We still do, but it is not a primary component of Gender Variance. It is secondary to the rejection we experience from family, friends, employers, and religious organizations.

Questions

What should be the appropriate treatment for persons who experience Gender Variance?

Just as with microvascular angina, outcomes matter!

What constitutes a good outcome?

Surely it is a well adjusted person, able to function socially and professionally, with no incongruity between sense of self and physical body.

What treatment results in a good outcome?
Does behavior modification result in a good outcome?

“Reparative Therapy”? Aversion therapy? Electroconvulsive therapy? Antipsychotic drugs? What data suggest that persons undergoing such treatments and remaining in their birth sex role experience a good outcome? I would suggest that no such data exist.

What about psychotherapy? Is it helpful as an isolated treatment modality, in persons who are not going through transition?

On a more positive note, does psychotherapy, or any long term counseling relationship, help produce a good outcome in persons who are going through transition? Even so, do some persons who complete transition without the need of therapy experience equally good outcomes?

Numerous published studies document the outcomes of transition, and these studies are consistent in their findings.

Cohen-Kettenis and colleagues (Journal of the American Academy of Child and Adolescent Psychiatry, 1997) interviewed 22 consecutive adolescent patients of their Netherlands gender clinic who underwent sex reassignment surgery. Postoperatively they reported no gender dysphoric symptoms and were socially functioning well. None of the patients expressed any feelings of regret over transition.

From the same clinic, Smith and colleagues (Psychological Medicine, 2005) followed 162 adults (146 male to female, 76 female to male) who completed medical and surgical reassignment in the course of transition. They found that body image scores and psychological functioning were significantly improved. Only 1.6% of patients expressed any regrets.

Krege and colleagues at the University of Essen (BJU International, 2001) found no regrets among 66 male to female persons followed between 1995 and 2000.

Lawrence (Archives of Sexual Behavior, 2003) evaluated 232 male to female patients who had sex reassignment surgery between 1994 and 2000. No patient reported outright regret. Interestingly, compliance with the requirements for sex reassignment surgery as outlined in the WPATH Standards of Care was not associated with more favorable subjective outcomes.

At its 2008 Annual Meeting, the American Medical Association adopted Resolution 122 regarding treatment of Gender Identity Disorder. The AMA noted, among other concerns, that “An established body of medical research demonstrates the effectiveness and medical necessity of mental health care, hormone therapy and sex reassignment surgery as forms of therapeutic treatment for many people diagnosed with GID,” and “Health experts in GID, including WPATH, have rejected the myth that such treatments are ‘cosmetic’ or ‘experimental’ and have recognized that these treatments can provide safe and effective treatment for a serious health condition.” The document notes “Delaying treatment for GID can cause and/or aggravate additional serious and expensive health problems, such as stress-related physical illnesses, depression, and substance abuse problems, which further endanger patients’ health.”

The AMA concluded with the Resolution “That our American Medical Association support public and private health insurance coverage for treatment of gender identity disorder as recommended by a physician.”

As I review these documents, I see evidence of the effectiveness of the transition process. Persons who complete transition are more likely to be well-adjusted, successful in work and with social relationships, and without regrets. Our own life experiences, as well as those of our friends and colleagues, confirm these successful outcomes.

Transition works! Outcomes matter!

The effectiveness of medical and surgical treatment for Gender Variance should mandate a medical diagnosis and inclusion in the ICD, rather than the DSM. Again, this does not imply that persons with Gender Variance do not benefit from behavioral health care. Many such persons experience depression, anxiety, or adjustment reactions due to the stress of rejection. These conditions are not, however, central to the diagnosis of Gender Variance. They are identical to the same conditions seen in persons who do not have Gender Variance. They will likely respond to appropriate counseling and/or medical management, but such treatment is adjunctive to the primary concern of working to achieve successful transition.

If Gender Variance were not a psychiatric diagnosis, then what other roles can the psychiatrist or psychologist play in the care of persons with Gender Variance?

We feel that one important role a therapist can perform is differential diagnosis. While the large majority of persons begin the transition process appropriately, there are a few who may have other psychological conditions which they confuse with Gender Variance. If these persons can be identified and directed to more appropriate courses of action before they take irreversible steps, we will not read about them as examples of regret for transition.

As we know, the WPATH Standards of Care require letters of approval from a behavioral health practitioner before a person may have sex reassignment surgery. While all North American surgeons, and most surgeons in Europe, require such letters, there are many doctors in other parts of the world who do not have such a requirement. The numbers of persons with Gender Variance who travel to these surgeons without going through a therapy relationship are increasing. In the future we may expect to see outcome studies relative to satisfaction or regret for transition without therapy.

IN CONCLUSION, I have used a common example from my practice of cardiology to illustrate that a diagnosis can be correctly made, and treatment can be successfully initiated, based on subjective symptoms as reported by the patient, without confirmation by specific diagnostic testing. Using the example of microvascular angina as my model, I contend that the same principles may be applied to the condition I call Gender Variance (rather than Gender Identity Disorder). It is not necessary to achieve certain measurements on a diagnostic image of the brain to know that a physical condition exists and is treatable by physical (medical and surgical) measures. The results of treatment are obvious and measurable. Hormone therapy works. Surgery to modify primary and secondary sex characteristics works. Transition works. Transition produces good outcomes, and outcomes matter.

In a perfect world, a diagnosis of Gender Variance, which does not carry the stigma of “disorder,” might exist as a medical condition in the ICD. Medical doctors could treat such persons with appropriate hormone management; surgeons could perform the operations essential for a normal life in the appropriate gender; and all such treatments would be covered by health insurance.

In a perfect world, psychiatrists and psychologists would appropriately manage the anxiety, depression, or other emotional conditions which occur in persons who have Gender Variance. These conditions would have appropriate codes in the DSM, but Gender Variance would not.

In a perfect world, psychiatrists might still treat persons WITH Gender Variance; but they would not treat persons FOR Gender Variance.

About the Author:
Dr. Allison is a Phoenix, Arizona cardiologist, Chairwoman of the American Medical Association Advisory Committee On Gay, Lesbian, Bisexual, and Transgender Issues, President-Elect of the Gay and Lesbian Medical Association. An advocate for the transcommunity, she created www.drbecky.com , a resource for medical, legal and spiritual information for trans people.

Published here with permission of the author
Copyright © 2009 Rebecca Allison

Call to Action to Urge Trans-Affirming Position Statements by the APA

Kelley Winters, Ph.D.
GID Reform Advocates
www.gidreform.org

On May 18, I presented a paper to the Annual Meeting of the American Psychiatric Association on the diagnostic categories of Gender Identity Disorder (GID) and Transvestic Fetishism (TF) in the Diagnostic and Statistical Manual of Mental Disorders (DSM). Coauthored by San Francisco psychologist and community advocate Dr. Randall Ehrbar, our presentation stressed the need to address two issues in the upcoming Fifth Edition of the DSM. First, the GID and TF diagnoses inflict harmful stigma of mental illness and sexual deviance on all trans, gender variant and queer identified individuals who do not conform to their assigned birth-sex, either by inner identity or outer social expression. Second, the GID diagnosis fails to support the medical necessity of hormonal or surgical transition care for those transsexual individuals who need them. In fact, the current GID diagnostic criteria and supporting text contradict both medical and social transition.

In addition to the case for reforming GID and removing the defamatory TF diagnosis in the DSM-V, we also urged the elected leadership of the APA to issue three public position statements in support of human dignity and medical care for trans and gender variant people.

We would like to ask the trans-community, our LGB and straight allies and especially our supportive medical and mental health providers to join us in calling for position statements that gender difference is not disorder, affirming the medical necessity of transition care, and recognizing social gender transition. The American Psychiatric Association has an opportunity today to reclaim its compassion for human dignity and its mandate to do no harm.

In 1973, the American Psychiatric Association made a historic step toward the ultimate declassification of same sex orientation as mental illness in the Diagnostic and Statistical Manual of Mental Disorders (DSM). Although the actual removal of the homosexuality diagnosis from the DSM occurred in incremental revisions over the following fourteen years, the elected leadership of the APA issued a Position Statement on “Homosexuality and Civil Rights” that had a profound impact on public opinion and defamatory stereotypes. Tragically, the APA has never issued a similar position statement in support of trans and gender variant people.

How can you help?

Please send letters to the President and Board of Trustees of the APA and the President of the Association of Gay and Lesbian Psychiatrists with the following requests:¹

1– We ask the elected leadership and Board of Trustees of the American Psychiatric Association to affirm in a position statement that gender identity and expression which differ from assigned birth sex do not, in themselves, constitute mental disorder and imply no impairment in judgment or competence.

2– We also ask the APA to follow the example of the American Medical Association, the American Psychological Association, and the World Professional Association for Transgender Health (WPATH) by issuing a statement clarifying the medical necessity of hormonal and/or surgical transition treatments for those who suffer distress caused by deprivation of physical characteristics congruent with their gender identity. We call on the APA to urge insurance and healthcare coverage for medically prescribed transition treatment as well as ongoing and ordinary medical and mental health care. ²

3– Finally, we ask the American Psychiatric Association to follow the example of the American Psychological Association, the National Association of Social Workers and WPATH in opposing discrimination on the basis of gender identity or expression and encouraging legal recognition of all people that is consistent with their gender identity and expression. We ask the APA to affirm in a position statement the dignity and legitimacy of individuals who have transitioned their social gender roles, regardless of their physical anatomy or assigned birth sex.

Contact Information:

Alan F. Schatzberg, President, American Psychiatric Association
Carol A. Bernstein, M.D., President-elect, American Psychiatric Association
American Psychiatric Association
1000 Wilson Boulevard
Suite 1825
Arlington, VA 22209
email in care of: apa@psych.org

Board of Trustees, American Psychiatric Association
in care of: Thomas Graham
Senior Governance Specialist – Board of Trustees
email: tgraham@psych.org

Copy to Ubaldo Leli, M.D., President, Association of Gay and Lesbian Psychiatrists
email: uleli@aglp.org

Please send copies of your letters to me at kelley@gidreform.org. Include the phrase “APA Gender Position Statements” in your email header.

Update: My letter of June 22, 2009, to APA officials, with names of over 400 online endorsements and copies of letters received by GID Reform advocates, is available at www.gidreform.org/200906APAstatementsA.pdf

Finally, if you are a Facebook member, please consider adding your name to this Facebook Group to Urge the American Psychiatric Association to Publicly Affirm Human Dignity and Access to Medical Care for Trans and Gender Variant People. See www.facebook.com/home.php?ref=home#/group.php?gid=92915546212

1. Statement text updated May 31 and June 2, 2009 to clarify the distress of anatomic gender dysphoria, acknowledge organizations that previously issued similar statements and call for a statement to oppose discrimination. My deep thanks to Randall Ehrbar, Becky Allison, Jamison Green, Dan Karasic, Arlene Lev and Anne Vitale for their insight and input.

2. Based on input from clinicians and friends in the community, “and mental health” care was added to the second position statement request. At issue: those transpeople who do suffer depression or anxiety face unusual barriers to care that result from the stereotype that our gender identities are defective or “disordered.” All too often, care givers may ignore these conditions because they are preoccupied with “fixing” our gender identities; or insurers may deny claims altogether once they are aware that transition has started. For a thoughtful discussion of some of these issues, see the sent(a)mental project, founded by author Dylan Scholinski, at apps.facebook.com/causes/203944/14856704.

Copyright © 2009 Kelley Winters, GID Reform Advocates

Beyond Conundrum: Strategies for Diagnostic Harm Reduction

summary of presentation given to the

Annual Meeting of the American Psychiatric Association

San Francisco, May 18, 2009

Kelley Winters, Ph.D., GID Reform Advocates

Randall Ehrbar, Psy.D., New Leaf Services for Our Community

Since Gender Identity Disorders were first introduced in the DSM-III in 1980, the focus of what constitutes psychopathology in successive revisions of the DSM has shifted further away from distress with one’s assigned or birth sex toward a greater focus on gender identity or gender expression that differ from one’s birth sex. The consequences of conceptualizing gender identity as “disordered” include barriers to transition and related medical care, burdens of social stigma associated with psychiatric disorder or sexual deviance, loss of civil liberties and social legitimacy, and false positive diagnoses of individuals who meet no other definition of a mental illness. The publication of the DSM-V is an opportunity for APA to affirm that, in the absence of dysphoria, gender identity and expression that vary from assigned birth sex are not, in themselves, grounds for diagnosing a mental disorder.

Recommendations for gender diagnoses in the DSM-V:

• Clarify the focus of Pathology on Gender Dysphoria, defined as chronic distress with physical sex characteristics or current ascribed gender role that are incongruent with persistent gender identity. Includes distress with anticipated sex characteristics for prepubescent youth.

• Option: Limit focus of pathology to anatomic gender dysphoria, defined as chronic distress with physical sex characteristics, including anticipated sex characteristics for prepubescent youth, that are incongruent with persistent gender identity.

• Rename “Gender Identity Disorder,” which suggests that gender identities differing from birth-sex assignment are themselves disordered or deficient.

• Make diagnostic criteria and supporting text congruent, rather than contradictory to, medical and social transition steps that are proven to relieve distress of gender dysphoria.

• Remove maligning terminology in diagnostic criteria and supporting text which disrespects transitioned individuals with inappropriate pronouns and labels.

• Eliminate false positive diagnosis of those who are no longer gender dysphoric after social or medical transition.

• Adress false positive diagnosis of gender nonconforming children who were never gender dysphoric. Remove all reference to gender nonconforming expression by children in diagnostic criteria and supporting text.

• Clarify impairment in the clinical significance criterion to exclude sequelae of societal intolerance, prejudice and discrimination.

• Reduce false stereotype of sexual deviance by moving gender related diagnoses from class of sexual disorders to a new class of gender dysphoria/dissonance diagnoses.

• Remove the derogatory category of Transvestic Fetishism (TF), in the Paraphilias section.

Recommendations for the Elected Leadership of the American Psychiatric Association

We ask the elected leadership and Board of Trustees of the American Psychiatric Association to affirm in a public statement that gender identity and expression which differ from assigned birth sex do not, in themselves, constitute mental disorder and imply no impairment in judgment or competence.

We also ask the APA to follow the example of the American Medical Association and the American Psychological Association with a statement clarifying the medical necessity of hormonal and surgical transition treatments for those who suffer painful distress with their physical sex characteristics that are incongruent with their persistent gender identity.

Finally, we ask the American Psychiatric Association to follow the example of the American Psychological Association in encouraging legal and social recognition of all people that is consistent with their gender identity and expression. We ask the APA to publicly affirm the dignity and legitimacy of individuals who have transitioned their social gender roles, regardless of their physical anatomy or assigned birth sex.

Recommendations for Diagnostic Criteria of an Incongruent Gender Dissonance* Category to Replace GID in the DSM-V

A. Strong chronic distress with physical sex characteristics, including anticipated characteristics for prepubescent youth, or current ascribed gender role** that are incongruent with persistent gender identity. Ascribed gender role includes current social gender expression or the gender role that is assigned or imposed by others.

B. Distress or resulting impairment in social, occupational, or other important areas of functioning is clinically significant. Distress or impairment resulting from discrimination or intolerance by others is excluded and not a basis for diagnosis.

* or similar title that does not associate gender identity per se with mental disorder.

** Optionally, criterion A may be narrowed to Anatomic Gender Dysphoria, or distress with current or anticipated physical sex characteristics without reference to social gender role. This would treat the distress of Social Gender Dysphoria (distress with current ascribed gender role) as analogous to closeted or repressed expression of sexual orientation, which is not classified as mental disorder. Social gender transition to a congruent role, like coming out as gay or lesbian, does not in itself require medical or mental health treatment.

Further Reading:

GID Reform Advocates, www.GIDreform.org

Professionals Concerned with Gender Diagnoses in the DSM, www.Professionals.GIDreform.org

K. Winters, Gender Madness in American Psychiatry: Essays from the Struggle for Dignity, GID Reform Advocates, 2008

D. Karasic & J. Drescher, eds., Sexual and Gender Diagnoses of the DSM: A Reevaluation, Haworth Press, 2005

American Psychological Association, “Resolution on Transgender and Gender Identity and Gender Expression Non-Discrimination,” 2008, http://www.apa.org/governance/CPM/chapter12b.html

American Medical Association, “Resolution 122: Removing Financial Barriers to Care for Transgender Patients”, http://www.ama-assn.org/ama1/pub/upload/mm/16/a08_hod_resolutions.pdf

Transvestic Disorder and Policy Dysfunction in the DSM-V

Kelley Winters, Ph.D.
GID Reform Advocates
www.gidreform.org

At the Annual Meeting of the Society for Sex Therapy and Research this month, a “Provisional Report by the DSM-V Workgroup on Sexual and Gender Identity Disorders,” was presented by Chairman Kenneth Zucker and a panel of workgroup members.¹ Ray Blanchard, who chairs the Paraphilias Subcommittee, summarized proposals for “Pedohebehpilic Disorder” and “Transvestic Disorder” in the DSM-V.² While Charles Moser, Ph.D., M.D., and others have long raised concern about all paraphilia diagnoses in the DSM,³ the current diagnostic category of Transvestic Fetishism is particularly stigmatizing and defamatory for male-to-female (MTF) cross-dressers as well as many transsexual women.⁴ Unfortunately, Dr. Blanchard’s proposal of Transve6stic Disorder offers little to allay these concerns.

First, Dr. Blanchard broadly expanded the definition of paraphilia to include,

“any intense and persistent sexual interest other than sexual interest in genital stimulation or preparatory fondling with phenotypically normal, consenting adult human partners.”

This would appear to implicate masturbation and erotic stimulation without a partner as paraphilia and sexual deviance: a proscription rooted in religious dogma rather than science. Moreover, no clarification is given for “phenotypically normal” Although Blanchard notes that he would exclude same-sex adult partners from his paraphilia definition, it is not clear whether anyone attracted to a trans or intersex partner with atypical physiology or social role would be labeled as paraphilic under this definition.

Blanchard did however make a distinction between paraphilia as sexual phenomena and paraphilic disorder in diagnostic nomenclature. The latter, he noted, “causes distress or impairment to the individual or harm to others,” If applied to the DSM-V, this would narrow the scope of paraphilic diagnostic nomenclature to a degree by tying it to the definition of mental disorder.

Second, Dr. Blanchard proposed that the diagnosis of Transvestic Fetishism in the DSM-IV-TR be renamed Transvestic Disorder. While somewhat less pejorative than the current title, Transvestic Disorder would still imply that all cross-dressing represents mental disorder. It would continue to perpetuate this defamatory stereotype.

Unfortunately, Dr. Blanchard proposed to retain the current diagnostic criteria⁵ for Transvestic Fetishism:

A. Over a period of at least 6 months, in a heterosexual male, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving cross-dressing.

B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Criterion A is grammatically ambiguous⁶. The phrase, “or behaviors involving cross-dressing,” implies that all cross-dressing, whether or not it is erotically motivated, represents paraphilia and mental disorder. Criterion B fails to make any distinction between distress or impairment directly caused by cross-dressing from those caused by social intolerance and prejudice. Thus, all transwomen, including transsexual women, who are birth-assigned male, attracted to women, wear clothing that is typical or ordinary for other women, and are distressed by social or familial prejudice would perpetually meet both diagnostic criteria. Under Blanchard’s proposal they would be subject to diagnosis with Transvestic Disorder for the rest of their lives, regardless of how happy and well adjusted they might be with their lives and gender expression.

Furthermore, these diagnostic criteria define the proposed Transvestic Disorder as a gender-reparative therapy diagnosis, engineered to facilitate psychological “treatment” to suppress gender expression that differs from assigned birth sex. Only by hiding gender nonconforming expression deep into the closet, may a gender variant individual be emancipated from these criteria and paraphilic diagnosis.

Finally, Dr. Blanchard proposes to change the Specifier Options to the diagnosis. The current Transvestic Fetishism diagnosis has a single specifier, “With Gender Dysphoria: if the person has persistent discomfort with gender role or identity.”⁷ Blanchard’s proposal would replace this with a specifier of “Autogynephilia (Sexually Aroused by Thought or Image of Self as Female).”

The term, autogynephilia was coined by Blanchard in 1989⁸, not merely to describe a phenomenon of human sexuality, but rather to promote his derogatory theory that all lesbian, bisexual and asexual transsexual women were motivated to transition by a narcissistic sexual obsession.⁹ This word was subsequently associated by author J. Michael Bailey with profoundly defamatory remarks and stereotypes in his 2003 book, The Man Who Would be Queen: The Science of Gender-Bending and Transsexualism.”¹⁰

It is difficult to imagine how a term that has become so offensive and so damaging to the dignity of transwomen¹¹ could serve any constructive clinical purpose in the DSM-V.¹²

To summarize, Dr. Blanchard’s proposal for Transvestic Disorder in the DSM-V fails to address serious issues of unfair social stigma and stereotyping that surround the current Transvestic Fetishism diagnostic category. Moreover, it would worsen these concerns by adding the pejorative term “autogynephilia” as a specifier to the diagnosis.

I ask the elected leadership and Board of Trustees of the American Psychiatric Association to affirm in a public statement that gender identity and expression which differ from assigned birth sex do not, in themselves, constitute mental disorder and imply no impairment in judgment or competence. I ask the DSM-V Task Force to honor this principle in the DSM-V by removing the current category of Transvestic Fetishism and rejecting Dr. Blanchard’s proposal to replace it with Transvestic Disorder. Finally, I invite members, allies and affirming care providers of the transcommunity to voice their concerns by publishing comments to this essay at gidreform.wordpress.com. I will forward these postings to the APA and DSM-V Task Force at the APA Annual Meeting in May.

¹ Society for Sex Therapy and Research, “Program Schedule: SSTAR 2009,” April 2009, http://www.sstarnet.org/download/20090402ProgramSchedule.pdf

² R. Blanchard, “DSM-IV Paraphilias Options: General Diagnostic Issues, Pedohebephilic Disorder, and Transvestic Disorder,” Annual Meeting of the Society for Sex Therapy and Research, Alexandria VA, April 2009, http://individual.utoronto.ca/ray_blanchard/index_files/SSTAR.html

³ C. Moser and P. Kleinplatz, “DSM-IV-TR and the paraphilias: An argument for removal.” Journal of Psychology and Human Sexuality 17(3/4), also published in Sexual and Gender Diagnoses of the Diagnostic and Statistical Manual (DSM),  Eds.  D. Karasic, and J. Drescher, Haworth Press, 2005, p. 106.

⁴ K. Winters, “Disordered Identities: The Ambiguously Sexual Fetish,” GID Reform Advocates, November 2008, http://www.gidreform.org/blog2008Nov02.html, http://gidreform.wordpress.com/2008/11/02/disordered-identities-the-ambiguously-sexual-fetish/

⁵ American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, Washington, D.C., 2000, p. 575.

⁶ K. Winters (published under pen-name Katherine Wilson) and B. Hammond, “Myth, Stereotype, and Cross-Gender Identity in the DSM-IV,” Association for Women in Psychology 21st Annual Feminist Psychology Conference, Portland OR, 1996,  http://www.gidreform.org/kwawp96.html.

⁷ DSM-IV-TR, 2000, p. 574.

⁸ R. Blanchard, “The Classification and Labeling of Nonhomosexual Gender Dysphoria,” Archives of Sexual Behavior, v. 18 n. 4, 1989, p. 322-323.

⁹ K. Winters, “Autogynephilia: The Infallible Derogatory Hypothesis, Part 1,” GID Reform Advocates, November 2008, http://www.gidreform.org/blog2008Nov10.html

¹⁰ J. Bailey, The Man Who Would Be Queen: The Science of Gender-Bending and Transsexualism, Joseph Henry Press, 2003, pp. xii, 172, 178, 183-185, 206.

¹¹ J. Serano, “Autogynephilia’ and the psychological sexualization of MtF transgenderism,” International Foundation for Gender Education 2009 Conference, Alexandria VA, March 2009, http://ai.eecs.umich.edu/people/conway/TS/IFGE2009/Disordered_No_More.html#Julia

¹² K. Winters, “Autogynephilia: The Infallible Derogatory Hypothesis, Part 2,” GID Reform Advocates, November 2008, http://www.gidreform.org/blog2008Nov19.html

Book Announcement: Gender Madness in American Psychiatry, Essays from the Struggle for Dignity

Kelley Winters, Ph.D.
GID Reform Advocates, 2008
$17.99 USD
ISBN-10: 1-4392-2388-2
ISBN-13: 9781439223888
Paperback: 220 pages

Foreword by Dan Karasic, M.D.

 For more information, see www.gendermadness.com

 Available for order at:

 International Foundation for Gender Education (IFGE) Bookstore, www.ifge.org/catalog/;
Amazon.com;
AbeBooks.com;
Alibris.com;
BookSurge.com

 
More than three decades after the American Psychiatric Association voted to remove the classification of homosexuality as a mental disorder, those who do not conform to their assigned birth-sex, either by inner identity or outer social expression, are labeled mentally ill in the Diagnostic and Statistical Manual of Mental Disorders (DSM).  Resulting stereotypes of psychiatric disorder and sexual deviance pose grave consequences to their human dignity and civil liberties. For transsexual individuals, the current diagnostic categories of Gender Identity Disorder (GID) and Tranvestic Fetishism also pose barriers to access to medical transition procedures. As the APA works toward its fifth revision of the DSM in 2012, these gender diagnoses provoke growing controversy while failing to explain the existence of countless well-adjusted transsexual, gender queer and gender transcendent people who have contributed to society for millennia.

Gender Madness in American Psychiatry: Essays from the Struggle for Dignity provides an overview of the literature and attitudes behind the current diagnostic nomenclature and a historical snapshot of the issues and challenges faced by gender transcendent people on the eve of publication of the Fifth Edition of the DSM. This book contains a collection of essays from the struggle for transgender dignity and health care access. They are expanded from pieces posted to the GID Reform Advocates web site in 2008 and incorporate the generous feedback and discussion from advocates and critics.

For students of psychology, sociology, anthropology and gender studies curricula, this book provides an overview of the literature and social context that led to the current diagnostic nomenclature. It offers a historical snapshot of the issues and challenges faced by the trans-community on the eve of publication of the DSM-V. For gender transcendent people, this book is a call for respect and celebration of the broad diversity that exists within our community. Yet, it is also a call for unity and solidarity in demanding change for psychiatric policies and stereotypes that harm all trans-people. For mental health clinicians who work with transitioning clients, this book is intended to provide some insight, from a trans-perspective, into the barriers to social legitimacy and access to medical care that are posed by the categories of current Gender Identity Disorder and Transvestic Fetishism.

Kelley Winters is a writer on issues of gender diversity in public and medical policy, founder of GID Reform Advocates (www.gidreform.org), and a member of the World Professional Association for Transgender Health as wells as advisory boards for the Matthew Shepard Foundation and Trans-Youth Family Allies. She has presented papers on mental health policy issues to the American Psychiatric Association, the American Psychological Association and the American Counseling Association and has authored chapters in two books.

What is the Body Capable of? What is the Body for?

 

A Guest Essay by

j/j hastain, MFA

www.jjhastain.com

 

 

 

 

In Kelley Winter’s essay Maligning Terminology in the DSM: the Language of Oppression she states:

 

“I’m speaking of affirmed transwomen being called “he” and transmen being called “she.” I use the term Maligning Language to describe this specific kind of verbal violence.” (1)

 

I wonder what an authentic replacement to this verbal violence (concerning gender and identity) that Kelley refers to would look like…I wonder what types of spaces would necessarily evolve, if we as a species were somehow more precisely able to focus our gestures and efforts on the continued re-structuring and imagining of the places where these violences take place.

 

The following outpour is a phantasmagoria built off of questions. It is a document to dream through. It is a grouping of inquiries rooted in belief that it is possible to proceed in our work with gender and embodiment practices, in ways that are more involved, more evolved, more interested and more creative.

 

The following is a place to begin.

 

There will always be some sort of a future to reckon with–to recognize through. I find that there are some very real questions that need to be asked concerning how to create a future that makes all beings want to be here for that future.

 

What would it mean if we were to truly gesture toward the future of health for all persons?

 

In order for this future to truly occur, there need be inquiry into what and how

gender variant bodies can most accurately be referred.

 

This future would also need to obviously use accurate pronouns. By accurate I do not mean correct in terms of the polarist options of typical patriarchal categoricism

(e.g. he/she). I am speaking of an accuracy that would be dependent on the person utilizing the pronouns (as reference) actually inquiring of whom they are referring, how they wish to be referred. For example:

 

Do you wish to be referred to as he or she?    Or is there something else that you more deeply identify as?

 

What would it be to engage intimacies and accuracies rather than binary induced categorization? What would it be to replace traditional notions of categorization with  fundamental openness and curiosity? And what effects would these particular revolutions have on our bodies as we continue?

 

Perhaps the authentic replacement that I am referring to would look like many spaces of uninhibited imagination, overlapping and commingling. Spaces that are not typical or traditional. Spaces that emphasize specificity and precision concerning the vitalities of the individual.

 

Perhaps this replacement would emerge as spaces wherein the body is no longer seen in terms of how an exterior position would categorize it–but instead is seen as a space for forms to move through. A space that needs to be seen, acknowledged and named in terms of awe and enigma.

 

Imagine what it would be like if we were to treat each body as if it were an ever original, non-debatable conglomerate. An always developing compound. Always perfect. Always amidst. And always continuing.

 

I propose that it is possible that we make a neoteric future. I believe that a future such as this will need be based on extreme invention and vision. It will require new realms of interactivity where language is engaged in as action, activism and opportunity to touch the most inner places in bodies.

 

In this future we will name our own realities based in what it is that actually anitmates us–what it is that brings us to life. A future where we reach to understand others’

self-named realties with excitement and vigor rather than fear or complacency.

 

This will be a future that requires that we not fear differentiation. This will be future that demands that we understand variance.

 

In this future we will necessarily transmogrify the polarizing issue of exteriority.

Traditional categorizations and misperceptions will be further specified, because there will be space made for variant bodies to speak their accuracies concerning them.

 

In this future, in the place of patriarchal history we will implant shining, myriad glossaries of exactness.

 

As Lyn Hejennian states:

 

“a work that is not a closed symmetrical whole, but an unfolding dynamic integrity.”(2)

 

This future is a work that we allow to progress through models of motility.

 

If we consider perceiving in terms of its limits and we admit those limits and are willing to extend further than our own perceptions in order to expand, I believe it is possible for us to progress into this future with deeper and more profound notions of respect.

 

If we engaged in these ways, then perhaps what we would construct as methodologies to engage with the very bodies to which were are referring  would be that much more developed in terms of space, capacity to understand and willingness to offer.

 

This future would no longer be dominated by rhetoric that incites fear or exteriorly deterministic frames of acceptability that demand social normatively. This future would be a place where we as a species, take pride in the study and active progressing of axiological tendencies concerning aptitude.

 

In this future, where previous histories and categorical imperatives, are seen and understood as insufficient (in their representation of all bodies) and are thereby in need of extreme imagination:

 

A place of beautiful distinctions and descriptions where we admit to one another:

I know you are not solvable. I will not try to control you or limit you.

 

A place from there we engage the following questions together:

What is the body capable of    What is the body for?

 

“I can only begin a posteriori, by perceiving the world as vast and overwhelming; each moment stands under an enormous vertical and horizontal pressure of information. Potent with ambiguity, meaning-full, unfixed and certainly not complete. What saves this from becoming a vast undifferentiated mass of data and situation is one’s ability to make distinctions.”(3)

 

This is my hope for a future of personal, infused sites for accurate, limitless imaginations and motilities.

 

This future engages languages which attend and adhere to the body as a multifarious site of motions along an unending spectra. This future that prides itself in the urgencies of inclusion, that honor and recognize gender variant or gender transcendent (4) bodies: bodies that are not currently, thoroughly or accurately represented in the context of patriarchal historicity.

 

Our future that sees the body as subjective matter in desperate need of spaces to declare itself, within a social context that allows those declarations to be accurate, full and visible.

 

To consider our bodies as one would the following question:

 

Is there an answer for bread?

 

In this future we would become the work we engage in. A work that is reaching to itself by breaking open/discovering and accumulating spaces for its future.

 

This future would be the inherent reversal of Dylan Scholinski’s question:

 

“have you ever been so false your skin is your enemy” (5)

 

At cadences of ritual and nourishment, honor and vivisection

 

where we become what it is that moves us

 

 

our voices increasing halo

 

supplying new types of verdant

 

 

as ever unconditional fields for us to plant in.

 

 

 

References:

 

(1) Maligning Terminology in the DSM: The Language of Oppression (Kelley Winters)

 

(2) The Language of Inquiry (Lyn Hejenian)

 

(3) The Language of Inquiry   (Lyn Hejenian)

 

(4) the following italicized term is a term used in both essays and conversation with Kelley Winters

 

(5) The Last Time I Wore a Dress (Dylan Scholinski)

 

 

 

 

 About the Author:    j/j hastain is a performance artist, photographer, musician,

gender-revolutionary and phonic-theorist. j/j’s poetry, essays and chapbooks have appeared in publications both online and in print: Cliterature, Hot Whiskey, Mappemunde, MiPOesias, slumgullion, Fact-Simile, hotmetalpress Poetry Prize 2008, etc.   j/j published a book with livestock editions. j/j has a book coming out with BlazeVox.   j/j received a BA in poetry, music, gender and cultural studies, and an MFA in contemporary poetics.

 

j/j defines as trans (which is different than transgendered, though not at all discounting it).   j/j is interested in the differentiated usages of the prefix trans (when it is utilized in ways that are not at all related to previously determined models with binary derived bases).   j/j’s life work involves embodying/inhabiting the body as one would a neoteric space—through ways and methods that are not related to previously prescribed shapes that are based in limit.

 

j/j lives outside Boulder, CO with j/j’s Beloved.   contact j/j at: www.jjhastain.com

 

 

Published here with permission of the author
Copyright © 2008 j/j hastain

 

DES’s Other Daughters: Neglected Evidence of Prenatal Gender Development

 

A Guest Essay by

Dana Beyer, M.D.

www.danabeyer.com

 

 

 

I spent the first half century of my life searching for the reason I was assigned, reared, and living as a man even though I knew I was female. As a child it was utterly confusing, and when coming out to my parents led to threats of incarceration in the state mental hospital, being the smart little kid that I was, I went silent and focused on trying to determine the causes of my misery. I could never imagine, in my wildest dreams or fantasies, ever transitioning and living full-time as myself; I couldn’t even imagine spending even a day in public as a woman. So I focused my attention on an academic future, scouring all the major libraries in the northeast, reading everything I could about gender variant behavior, trying to understand how I became who I was.

 

My cover being near perfect, I could do this research without arousing suspicion. I could even ask my mother questions about her pregnancy with me, and my brother, and try to tease out some information that might help me. One day she mentioned having taken the drug, DES, or diethylstilbestrol, to prevent miscarriage. Having miscarried her first time around, and being the dutiful woman that most were back in the early 50’s, she took this drug which had come highly touted from the Harvard labs. She told me she was always concerned about her exposure, but could never really learn anything about it, and was afraid to speak out. I, however, as a medical student, was under no such constraints. So I learned that the drug had been banned by the FDA in 1971 after having been tied to a cluster of eight cases of vaginal adenocarcinoma in very young women. This been unheard of in the Boston area, epidemiologists eventually traced the tumor to DES exposure in utero, and the drug was pulled.

 

Eventually I learned about additional long-term consequences of DES exposure, but the vast majority of them were in those assigned female. Even female homosexuality was recognized as a complication, along with breast cancer in the mothers as well as daughters, and an epidemic of infertility. A group, DES Action, sprang up in the 1970’s, fueled by the young women’s movement and books such as “Our Bodies, Our Selves.”  Lawsuits were filed and won, Congress got into the act, and DES was eventually recognized as the worst drug disaster in American history. 5 million women were poisoned, and while the vaginal tumor developed in only 1:1000, it was still a true tragedy.

 

But what about those assigned as male? Nothing. While males were part of the few long-term follow-up studies, nothing more than a whisper of testicular cancer or a variety of genito-urinary tract anomalies popped up. DES Action put a man with brain cancer as the front for a DES Sons group, yet he didn’t even have internet or email capabilities, effectively shutting down any effective advocacy for those men.

 

We all know men are uncomfortable with their bodies, and don’t like to talk about their medical problems. The DES researchers, generally men, were not investigating issues of human sexuality either, so it became very easy to announce that the drug has no effects on male offspring. This in spite of the fact that DES was a super-estrogen, capable of crossing the placental and blood-brain barriers, and bathing the developing male brain with an overdose of estrogen before neurodevelopment had progressed very far. Those dosages of estrogen sure seemed to be capable of overwhelming the testosterone produced by the fetus’s testes, but the possibility was not taken seriously. Except by basic science researchers, such as Professor John McLachlan of Tulane University, who studied DES’ effects on rodents.

 

At a Congressional hearing on DES in 2001 I bumped into the good Professor and recounted my personal history. He told me that my medical history was classic for DES exposure, referred me to his papers, and I finally had my answers. Funny thing, by that time I had decided I could no longer live as a male and had decided to transition, so it no longer mattered to me existentially. But I had the answer.

 

As the medical advisor to Dr. Scott Kerlin’s DES Sons International Listserve, I had been toying with outing myself as transgender. Finally, I came out, and that opened the door to hundreds of other exposed DES “Sons.” Strange how things happen. That flood inspired Scott to start collecting data online, leading to his presentation of a paper at the e.hormone conference at Tulane in 2004, and my presentation, along with the nationally renowned intersex expert, Dr. Milton Diamond, of an expanded version of the paper, at the International Behavioral Development Symposium in Minot, North Dakota, in 2005. All the heavy hitters were there – Bailey, Blanchard, Zucker, Meyer-Bahlburg -  and while they were able to ignore the paper because of our lack of proof in medical histories which had been destroyed decades earlier, the younger and more open-minded researchers accepted our thesis. Shortly thereafter Shanna Swan published her paper proving, for the first time in humans, that endocrine disruptors, of which DES is the paradigmatic compound, caused feminization of male fetuses. This past summer Congress banned the importation and sale of children’s toys containing one of the more ubiquitous EDCs, a class of molecules called phthalates.

 

Progress may come slowly, in fits and starts, but it does come. It will come, if people will it to happen.

 

 

 

 

References:

 

Berkson, D. Lindsey (2000). Hormone Deception, Contemporary Books.

 

Meyer-Bahlburg, H. F. L., Erhardt, A. A.,  Rosen, L., Gruen, R., Veridiano, V. F. H., and Neuwalder, H. F. (1995). Prenatal estrogens and the development of homosexual orientation. Developmental Psychology 31: 12.

 

McLachlan, J. A., Newbold, R. R. , Burow, M. E. and Li, S. (2001). From malformations to molecular mechanisms in the male: three decades of research on endocrine disrupters. APMIS 109 (4): 263.

 

Beyer, D., Kerlin, S. and Diamond, M. (2005), The Presence of Gender Dysphoria, Transsexualism, and Disorders of Sexual Differentiation in Males Prenatally Exposed to Diethylstilbestrol: Evidence from a 5-Year Study. Presentation to the International Behavioral Development Symposium, Minot, ND, August 2005.

 

Swan, S., Main, K. M., Liu, F., Stewart, S. L., Kruse, R. L., Calafat, A. M. , Mao, C.S, Redmon, J.B., Ternand, C.L., Sullivan, S., Teague, J.L. and the Study for Future Families Research Team. (2005). Decrease in anogenital distance among male infants with prenatal phthalate exposure. Environmental Health Perspectives 113 (8): 1056.

 

 

About the Author: Dr. Dana Beyer is a retired ophthalmic surgeon and physician and is currently a senior advisor to Maryland Montgomery County Council Member, Duchy Trachtenberg.  A vice-president of Equality Maryland, Dana was instrumental to a recent effort that successfully defended a transgender civil rights law in Montgomery County. In a historic 2006 campaign, Dr. Beyer ran for the Maryland General Assembly.