Blinded Me With Science: Sampling Error

 

Kelley Winters, Ph.D.

GID Reform Advocates

http://www.gidreform.org

 

On May 28th, the American Psychiatric Association issued a “Statement on GID and the DSM-V” that emphasized,

 

“The APA’s goal is to develop a manual that is based on sound scientific data…”[1]

 

But has the APA met this standard with the Gender Identity Disorder diagnosis in the current edition IV-TR of the Diagnostic and Statistical Manual of Mental Disorders? [2] Where is the “sound scientific data” to suggest, as do the title, diagnostic criteria and supporting text of the GID category, that gender variant identities and expressions are intrinsically “disordered?”

 

The eminent physicist Bertrand Russell said of scientific method,

 

“A habit of basing convictions upon evidence, and of giving to them only that degree of certainty which the evidence warrants, would, if it became general, cure most of the ills from which this world is suffering.” [3]

 

The cornerstone of empirical science is elimination of bias by sampling data that is representative of the population under study.  Unfortunately, the APA track record for scientific vigor in the DSM is spotty.  For decades, the classification of same-sex orientation as mental disorder was justified by “research” of subjects limited to clinical populations.  Psychologist Evelyn Hooker noted in 1957 and earlier that gay and lesbian people seeking psychiatric help or incarcerated in prisons and hospitals did not constitute representative populations.

 

“…few clinicians have ever had the opportunity to examine homosexual subjects who neither came for psychological help nor were found in mental hospitals, disciplinary barracks in the Armed Services, or in prison populations. It therefore seemed important, when I set out to investigate the adjustment of the homosexual, to obtain a sample of overt homosexuals who did not come from these sources” [4]

 

Astonishingly, another 16 years passed before psychiatric policy makers began to take note. Psychiatrist Judd Marmor, urging removal of homosexuality from the DSM in 1973, argued,

 

“if our judgment about the mental health of heterosexuals were based only on those whom we see in our clinical practices we would have to conclude that all heterosexuals are also mentally ill” [5]

 

The authors of the GID diagnosis in the DSM-IV and current revision IV-TR employed similarly unrepresentative data to conclude that all gender variant people, whose gender identity or expression vary from their assigned birth sex roles, are mentally ill.  For example, the GID authors relied upon their own clinical populations from the “Sissy Boy” studies at UCLA [6] and the Clarke Institute of Psychiatry (currently the Centre for Addiction and Mental Health, CAMH, in Toronto) in developing the diagnostic criteria for children:

 

“Currently, the authors are analyzing data sets from Green’s (1987) study and from the database of the Child and Adolescent Gender Identity Clinic at the Clarke Institute of Psychiatry, Toronto, Canada, to examine the similarities and differences between children referred for gender identity concerns who do and do not verbalize the wish to be of the opposite sex.”  [7]

 

Moreover, clinical populations in mental health care, at least in the case of transvestic fetishism, were pre-judged a priori as impaired by Drs. Kenneth Zucker and Ray Blanchard of CAMH, members of the Sexual and Gender Identity Disorders work groups for the DSM-IV and DSM-V editions.  They stated in 1997 that individuals,  “…who consult mental health professionals are presumably, in some respect, distressed or impaired by their condition.” [8]  Their reasoning seems strangely reminiscent of Alice’s experience in Wonderland:

 

“Said the Cheshire Cat: ‘We’re all mad here. I’m mad. You’re mad.’
’How do you know I’m mad?’ said Alice.
’You must be,’ said the Cat, ‘or you wouldn’t have come here.”[9]

 

And what of non-clinical populations of gender variant people? There is little evidence that follow-up studies, suggesting overwhelmingly positive outcomes for transsexual individuals whose gender dysphoria had been relieved by transition and corrective surgeries, were considered by the GID authors in the DSM-IV. [10] A unique controlled 1990 study of the benefit of genital surgery for (MTF) transsexual women by Mate-Kole, et al. [11], and a comprehensive 1992 review of 80 case studies spanning 30 years by Pfäfflin and Junge [12] are absent from the DSM-IV Sourcebook citations.  Pfäfflin and Junge concluded that, “… we found most of the desired changes in the areas of partnership and sexual experience, mental stability and socio-economic functioning level.”   This data would have been helpful in refuting stereotypes of inherent psychological pathology that were embodied in the GID diagnostic criteria and supporting text.

 

To gain “sound scientific data,” it is necessary to understand the demographics of the population under study in order to access its members.  To this end, the DSM-IV-TR cites the prevalence of GID as, “… roughly 1 per 30,000 adult males and 1 per 100,000 adult females seek sex-reassignment surgery” [p. 579]  These estimates are based on studies by Wålinder [13] and Hoenig [14] in the 1960s and 70s of patients who sought help in gender clinics in Sweden and the U.K.  Last year, Professors Femke Olyslager and Lynn Conway presented an analysis to the World Professional Association for Transgender Health (WPATH) that revealed startling flaws in these figures [15].  For example, prevalence in the Hoenig study is understated by more than a factor of six, based on the study’s own data, if the relevant general populations of birth-assigned males and females are corrected for appropriate age.

 

Aggregating a number of earlier studies, and accounting for general population demographics and conflation of prevalence with incidence in the early years of available surgical treatments, Olyslager and Conway reported that the prevalence of corrective surgical transition procedures was much higher than previously acknowledged in psychiatric literature. Their re-analysis of data from prior studies suggests a lower bound of 1:2900 to 1:5800 of the total population that has had or will have corrective surgery in support of transition, and they reported an even higher rate based on data from surgeons. Dr. Mary Ann Horton independently reported a similar surgical prevalence of 1:3100 per lifetime among US citizens. [16]  As only a subset of transsexual individuals require or obtain surgical treatment, Olyslager and Conway went on to estimate the lower bound on prevalence of transsexualism at 1:500. [15]  Moreover, transsexual individuals represent a subset of those meeting the current diagnosis of Gender Identity Disorder in the DSM-IV-TR, which relies heavily on gender role nonconformity rather than specific distress or incongruence with assigned birth sex.

 

These recent studies raise a crucial question, how can the American Psychiatric Association claim that the current GID diagnosis is based on “sound scientific data,” representative of the gender variant population, when they are unaware of the existence of as much as 99% of that population?  Conway noted,

 

“Such a truly egregious error presents a direct challenge to the psychiatric profession’s credibility in the entire area of transsexualism.” [17]

 

Where is this hidden silent majority of gender variant people who are not to be found in clinical populations?   Conway has compiled a collection of photos and stories for over 200 transitioned transsexual man and women living full lives, ordinary and extraordinary:

 

“They are successes in living ‘life in the large.’ We see it in the happy faces, and sense it in between the lines of their stories. These are the successes of women who have survived and corrected their earlier transsexualism, and gone on to find joy and comfort and peace in their lives.” [18]

 

Transsexual people are only the tip of the iceberg of gender variant adults and youth currently implicated as mentally ill. In more than two decades that I have been active in the trans-community, I have been honored to meet hundreds of remarkable individuals who defy anachronistic stereotypes of mental impairment – people who have transitioned into very ordinary conventional male and female roles and into unique roles that defy convention, people who live in “stealth,” quietly assimilated into society, and those who are out and proud as advocates and role models. I have heard their narratives, stories of grace and courage in the face of adversity that would likely overwhelm most other people. These are real people in the real world with little resemblance to the doctrine of “disordered” gender identity perpetuated in the current DSM-IV-TR.

 

What Dr. Evelyn Hooker noted of gay men a half-century ago is perhaps even more true for gender variant individuals today:

 

“But what is difficult to accept (for most clinicians) is that some homosexuals may be very ordinary individuals, indistinguishable, except in sexual pattern, from ordinary individuals who are heterosexual. Or – and I do not know whether this would be more or less difficult to accept – that some may be quite superior individuals, not only devoid of pathology (unless one insists that homosexuality itself is a sign of pathology) but also functioning at a superior level.”[4]

 

The current diagnosis of Gender Identity Disorder in the DSM allows no possibility for the existence of countless well-adjusted transsexual and gender variant people already in society.  The Sexual and Gender Identity Disorders work group has an opportunity to replace stereotype with science in the DSM-V, to base diagnostic nomenclature on sound data that is representative of real gender variant people from non-clinical populations.

 

 

[1] American Psychiatric Association, “APA Statement on GID and the DSM-V,” http://www.psych.org/MainMenu/Research/DSMIV/DSMV/APAStatements/APAStatementonGIDandTheDSMV.aspx , May 23, 2008.

 

[2] American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, Washington, D.C., 2000.

 

[3] Bertrand Russell, http://www.skepticreport.com/medicalquackery/camufo.htm

 

[4] E. Hooker, E., “The Adjustment of the Male Overt Homosexual,” Journal of Projective Techniques, #21, p.18, 1957.

 

[5] R. Stoller, J. Marmor, I. Beiber, et al.,”A Symposium: Should Homosexuality be in the APA Nomenclature?” American Journal of Psychiatry, vol. 130, pp. 1208-1209, 1973.

 

[6] R. Green, The “Sissy Boy Syndrome” and the Development of Homosexuality, Yale University Press, New Haven CT, 1987.

 

[7] T. Widiger, et al., eds., DSM-IV Sourcebook, Vol. 3, American Psychiatric Association, 1997, p. 320.

 

[8] K. Zucker and R. Blanchard, “Transvestic Fetishism: Psychopathology and Theory,” in D. Laws and W. O’Donohue (Eds.), Sexual Deviance: Theory and Application, Guilford Press, New York, 1997, p. 258.

 

[9] Charles Dodgson {Lewis Caroll}, Alice’s Adventures in Wonderland, 1865.

 

[10] Note: One post-operative follow-up study cited in the DSM-IV Sourcebook by Blanchard, et al., was cited to support a remark in the text of the DSM-IV and DSM-IV-TR that transsexual women attracted to other women and transitioning in adulthood are “less likely to be satisfied after sex-reassignment surgery.” [p. 580]  This statement has posed barriers to surgical transition care for transsexual women, maligned as “males” in the supporting text, on the basis of their sexual orientation.  R. Blanchard, B. Steiner, L. Clemmensen, R. Dickey, “Prediction of Regrets in Postoperative Transsexuals,” Can. J. Psychiatry, 34, pp.43-45, 1989.

 

[11] C. Mate-Kole, M. Freschi , and A. Robin, “A controlled study of psychological and social change after surgical gender reassignment in selected male transsexuals.” Brit J Psychiat 157: pp. 261-264, 1990.

 

[12] F. Pfäfflin, A. Junge , Sex Reassignment: Thirty Years of International Follow-Up Studies after SRS — A Comprehensive Review, 1961-1991. 1992, English translation 1998.  available on the Internet at <http://209.143.139.183/ijtbooks/pfaefflin/1000.asp&gt;.

 

[13] J. Wålinder, Incidence and Sex Ratio of Transsexualism in Sweden , British

Journal of Psychiatry, vol. 119, pp. 195-196, 1971.

 

[14] J. Hoenig and J.C. Kenna, “The prevalence of transsexualism in England and Wales,”

British Journal of Psychiatry, vol. 124, pp. 181-190, 1974.

 

[15] F.  Olyslager and L.Conway, “On the Calculation of the Prevalence of Transsexualism,” WPATH 20th International Symposium, Chicago, Illinois, 2007. http://ai.eecs.umich.edu/people/conway/TS/Prevalence/Reports/Prevalence%20of%20Transsexualism.pdf , Submitted for publication in the International Journal of Transgenderism (IJT).

 

[16] M. Horton, “The Cost of Transgender Health Benefits,” Transgender at Work, http://www.tgender.net/taw/thbcost.html .

 

[17] L. Conway, “The Numbers Don’t Add; Transsexual Prevalence,” http://www.gidreform.org/gid30285.html .

 

[18] L. Conway, “Transsexual Women’s Successes: Links and Photos,” http://ai.eecs.umich.edu/people/conway/TSsuccesses/TSsuccesses.html ;

“Successful TransMen: Links and Photos,”  http://ai.eecs.umich.edu/people/conway/TSsuccesses/TransMen.html

 

 

Copyright © 2008 Kelley Winters, GID Reform Advocates

Top Ten Problems with the GID Diagnosis

 

Kelley Winters, Ph.D.

GID Reform Advocates

www.gidreform.org

 

What are the problems with the Gender Identity Disorder diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (DSM) [1]?  How are overarching issues of psychiatric stigma and access to medical transition procedures related to specific flaws in the diagnostic criteria [2] and supporting text? The philosopher Jiddu Krishnamurti said,

 

If we can really understand the problem, the answer will come out of it, because the answer is not separate from the problem. [3]

 

This is my personal list of the most egregious problems with the current Gender Identity Disorder diagnosis. While far from comprehensive, it is perhaps a starting point for dialogue about how harm reduction of gender nomenclature might be possible in the DSM-V.

 

1.      Focus of pathology on nonconformity to assigned birth sex in disregard to the definition of mental disorder, which comprises distress and impairment.

 

Recent revisions of the DSM increasingly target gender identity and expression that differ from natal or assigned sex as disordered.  The current diagnostic criteria for GID in the DSM-IV-TR are preoccupied with social gender role nonconformity, especially for children. Identification with the “other sex,” meaning other than assigned birth sex, is described as symptomatic regardless of our satisfaction and happiness with that identification [p.581].

 

2.      Stigma of mental illness upon emotions and expressions that are ordinary or even exemplary for non-transgender children, adolescents and adults.

 

Criterion A for Gender Identity Disorder highlights a desire to be treated as, or “frequently passing as,” our affirmed gender as pathological.  For children, criteria A and B stress ordinary masculine or feminine expression in clothing, play, games, toys, and fantasy as symptoms of mental “disturbance” [p.581]. The supporting text disparages innocent childhood play as disorder, including Barbie dolls, playing house, Batman and “rough-and-tumble” activity, if they violate stereotypes of assigned birth sex [pp. 576-577]. Incredulously, knitting is implicated as a focus of sexual perversion for adult transwomen in the supporting text [p.579].

 

3.      Lacks clarity on gender dysphoria, defined here as clinically significant distress with physical sex characteristics or ascribed gender role [4].

 

The distress of gender dysphoria that necessitates medical intervention is inadequately described in criterion B of the GID diagnosis in the DSM-IV-TR as “discomfort” or “inappropriateness.”  For children, this often-debilitating pain is obfuscated in the diagnostic criterion, which emphasizes nonconformity to gender stereotypes of assigned birth sex rather than clinically significant distress.  Adolescents and adults who believe that we were “born in the wrong sex” meet criterion B on the basis of their belief, even if our gender dysphoria has been relieved by transition or related medical procedures [p.581].

 

4.      Contradicts transition and access to hormonal and surgical treatments, which are well proven to relieve distress of gender dysphoria. 

 

Social role transition, living and passing in our affirmed gender roles, and desiring congruent anatomic sex characteristics are listed as “manifestation” of mental pathology in criterion A of Gender Identity Disorder.  Requests for hormonal or surgical treatment to relieve gender dysphoria are disparaged as “preoccupation” in criterion B and supporting text rather than medical necessity [p. 581].  Evidence of medical transition treatment, such as breast development for transwomen or chest reconstruction for transmen, are described in a negative context as “associated features and disorders” of mental illness in the supporting text [p.579].

 

5.      Encourages gender-conversion therapies, intended to change or shame one’s gender identity or expression.

 

The DSM is intended as a diagnostic guide without specific treatment recommendations [p. xxxvii]. Nevertheless, the current GID diagnostic criteria are biased to favor punative gender-conversion “therapies.”   For example, gender variant youth, adolescents or adults who have been shamed into the closet, forced into concealing our inner gender identities, no longer meet the diagnostic criteria of Gender Identity Disorder and are emancipated from a label of mental illness.

 

6.      Misleading title of  “Gender Identity Disorder,” suggesting that gender identity is itself disordered or deficient.

 

The name, Gender Identity Disorder, implies “disordered” gender identity — that the inner identities of gender variant individuals are not legitimate but represent perversion, delusion or immature development.   In other words, the current GID diagnosis in the DSM-IV-TR implies that transwomen are nothing more than mentally ill or confused “men” and vice versa for transmen [5].

 

7.      Maligning terminology, including “autogynephilia,” which disrespects transitioned individuals with inappropriate pronouns and labels.

 

Maligning language labels gender variant people by our assigned birth sex in disregard of our gender identity.  In other words, affirmed or transitioned transwomen are demeaned as “he” and transmen as “she.”  It appears throughout the diagnostic criteria and supporting text of the GID diagnosis in the current DSM-IV-TR, where affirmed roles are termed “other sex” [p.581], transsexual women are called “males” and “he” [p. 577], and transsexual men as “females” [p. 579].  Such demeaning terms deny our social legitimacy and empower defamatory social stereotypes like “a man in a dress,” in the press, the courts, our workplace and our families. 

 

8.      False positive diagnosis of those who are no longer gender dysphoric after transition and of gender nonconforming children who were never gender dysphoric.

 

There is no exit clause in the diagnostic criteria for individuals whose gender dysphoria has been relieved by transition, hormones or surgical treatments, regardless of how happy or well adjusted with our affirmed gender roles.  The diagnosis is implied “to have a chronic course” for adults [p. 580], despite  transition status or absence of distress. Children may be diagnosed with Gender Identity Disorder, solely on the basis of gender role nonconformity, without evidence of gender dysphoria. Criterion A requires only four of five listed attributes, and four of those describe violation of gender stereotypes of assigned birth sex.  The fifth, describing unhappiness with birth sex, is not required to meet criterion A. Criterion B may be met by “aversion toward rough-and-tumble play and rejection of male stereotypical toys…” for natal boys  and “aversion toward normative feminine clothing” for natal girls [p.581].

 

9.      Conflation of impairment caused by prejudice with distress intrinsic to gender dysphoria.

 

Criterion D of the GID diagnosis, the clinical significance criterion [p. 581], was intended to require clinically significant distress or impairment to meet the accepted definition of mental disorder [p. xxxi].  Unfortunately, it fails to distinguish intrinsic distress of gender dysphoria from that caused by external societal intolerance.  Lacking clarity in criterion D, prejudice and discrimination can be misconstrued as psychological impairment for gender variant individuals who are not distressed by our physical sex characteristics or ascribed gender roles.

 

10.  Placement in the class of sexual disorders.

 

In 1994, Gender Identity Disorders were moved from the class of “Disorders Usually First Evident in Infancy, Childhood or Adolescence,” to the section of sexual disorders in the DSM-IV, renamed “Sexual and Gender Identity Disorders” [6].  This reinforces stereotypes of sexual deviance for gender variant people.

 

The DSM-V Task Force has an opportunity to address these shortcomings in the current GID diagnosis.  I hope that this list can help provide a way to evaluate proposals for less harmful diagnostic nomenclature in the Fifth Edition of the DSM.

 

 

[1] American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, Washington, D.C., 2000, pp. 576-582.

 

[2] DSM-IV-TR Diagnostic criteria for Gender Identity Disorder of Adults and Adolescents are available online at http://www.gidreform.org/gid30285.html and for children at http://www.gidreform.org/gid3026.html .

 

[3] “Krishnamurti Quotes,”  http://www.krishnamurti.org.au/articles/krishnamurti_quotes.htm

 

[4] Working definition of Gender dysphoria by Dr. Randall Ehrbar and I, following our panel presentations at the 2007 convention of the American Psychological Association. It is defined in glossary of the DSM-IV-TR as “A persistent aversion toward some of all of those physical characteristics or social roles that connote one’s own biological sex.” (p. 823)

 

[5] K. Winters, “Gender Dissonance: Diagnostic Reform of Gender Identity Disorder for Adults,” Sexual and Gender Diagnoses of the Diagnostic and Statistical Manual (DSM),  Ed.  Dan Karasic, MD. and Jack Drescher, MD., Haworth Press, 2005;  co-published in Journal of Psychology & Human Sexuality, vol. 17 issue 3,  pp. 71-89,  2005.

 

[6] American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, 1994

 

Copyright © 2008 Kelley Winters, GID Reform Advocates

 

Disordered Identities: The Focus of Pathology

 

Kelley Winters, Ph.D.

GID Reform Advocates

http://www.gidreform.org

 

Two weeks after the American Medical Association passed a historic resolution supporting health insurance coverage for gender confirming endocrine and surgical care [1], Dr. David Stevens of the Christian Medical & Dental Associations slurred this medically necessary care as “mutilation” by stereotyping transsexual women and men as mentally ill,

 

“…mutilation of the body is wrong, and it’s sad that these people have this psychological disorder — but it should be treated from a psychological perspective,” [2]

 

What is truly sad, this derogatory stereotype is rooted in flaws of the classification of Gender Identity Disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association (APA).  Indeed, the focus of pathology in successive revisions of the DSM has shifted further from gender dysphoria (defined here as a persistent distress with one’s current or anticipated physical sexual characteristics or current ascribed gender role [3]) toward nonconformity with assigned birth sex [4]. Consequently, barriers to social legitimacy and access to transition related medical care remain insurmountable for many gender dysphoric individuals.

 

Gender identity disorders first appeared in the class of Psychosexual Disorders in the DSM-III [5, p. 261] with more focus on gender dysphoria than today. The Transsexualism diagnosis was defined by a persistent sense of discomfort and inappropriateness about one’s anatomic sex and desire to live as a member of the “opposite” (affirmed) sex [p. 263]. Gender Identity Disorder of Childhood was characterized by a strong and persistent stated desire to be, or insistence that one is of, the other (affirmed) sex. For natal males only, diagnostic criteria included nonconformity to gender stereotypes [p.265].

 

In the DSM III-R [6] Gender Identity Disorders were moved out of Psychosexual Disorders to the class of Disorders Usually First Evident in Infancy, Childhood or Adolescence [p. 71] in recognition of gender identity origin in early life [p.424]. Although this reclassification was a positive change, the diagnostic criteria for children were broadened to include gender role nonconformity for natal girls, such as “persistent marked aversion to normative feminine clothing” [p.73].  Worse yet, a new category was added, Gender Identity Disorder of Adolescence or Adulthood, Nontranssexual Type (GIDAANT) [p. 76], defined by discomfort about one’s assigned birth sex and gender expression outside of the assigned role in fantasy or actuality [p. 77].  For the first time, non-transsexual gender variant individuals comfortable and well adjusted in cross-sex roles full time or part-time were classified as mentally ill under a Gender Identity Disorder.

 

In the DSM-IV [7], Gender Identity Disorders were once again classified as sexual disorders, now called Sexual and Gender Identity Disorders [p. 493], rekindling the stereotype of sexual deviance. A single expanded Gender Identity Disorder diagnosis combined the DSM-III categories of Transsexualism, Gender Identity Disorder of Childhood and GIDAANT.  Unlike prior editions, the DSM-IV encouraged concurrent diagnoses of GID and Transvestic Fetishism (TF) [p. 536], making the stigma of fetishism a social issue for male-to-female transsexual women. Gender Dysphoria was obfuscated in criterion B by the phrase, “Or a belief that he or she was born the wrong sex.” [p.581]  Thus, transitioned adults no longer gender dysphoric would be pathologized by their belief rather than their distress. Diagnostic criteria for children were again broadened to place a greater emphasis on nonconformity to social sex stereotypes. These implicated as mentally ill children with no evidence of gender dysphoria [8]. 

 

A clinical significance criterion was added to GID, TF and most diagnoses in the DSM-IV, well intended to require clinically significant distress or impairment to meet the accepted definition of mental disorder [7, p.7].  Unfortunately, it failed to distinguish intrinsic distress of gender dysphoria from that caused by external societal prejudice and intolerance, what Dr. Evelyn Hooker termed “ego defensive” response [9].  Therefore, the clinical significance criterion failed to counter the stereotype that all gender variance is disordered. The criterion was brushed aside by Drs. Kenneth Zucker and Ray Blanchard (members of the Sexual and Gender Identity Disorders subcommittees for the DSM-IV and DSM-V editions) as “muddled” and having “little import” [10]. However this position appears to conflict with the APA’s definition of mental disorder:

 

“a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress… or disability… or with a significantly increased risk of suffering, pain, disability, or an important loss of freedom… Whatever its original cause, it must currently be considered a manifestation of a behavioral, psychological, or biological dysfunction in the individual.”  [11, p. xxxi]

 

The shift in focus from gender dysphoria to gender nonconformity in the DSM has implicated a growing number of gender variant people with mental disorder and sexual deviance who meet no standard of “dysfunction in the individual.” It has exacerbated barriers to medical care and social intolerance. It has poorly served the purpose of diagnostic nomenclature given by the current World Professional Association for Transgender Health (WPATH) Standards of Care:

 

“The use of a formal diagnosis is often important in offering relief, providing health insurance coverage, and guiding research to provide more effective future treatments” [12]

 

In sharp contrast to the American Psychiatric Association policy, the American Medical Association last month reinterpreted GID as “a serious medical condition” rather than mental or sexual disorder, characterized by distress rather than nonconformity to assigned birth role:

 

“a persistent discomfort with one’s assigned sex and with  one’s primary and secondary sex characteristics, which causes intense  emotional pain and suffering;” [1]

 

Moreover, the American Psychological Association Task Force on Gender Identity, Gender Variance and Intersex Conditions stated in 2006,

 

“Many transgender people do not experience their transgender feelings and traits to be distressing or disabling, which implies that being transgender does not constitute a mental disorder per se.” [13]

 

In the DSM-V, there is opportunity for the American Psychiatric Association to realign with contemporary attitudes about gender diversity among its peer organizations, to refocus the GID diagnostic criteria on distress with physical sex characteristics or distress with assigned birth role or ascribed social role that are incongruent with inner gender identity.  There is an opportunity for the APA to clarify in the supporting text and in public policy statement that, in the absence of dysphoria, gender identity and expression that vary from assigned birth sex are not, in themselves, mental disorder.

 

 

[1] 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 , June 2008.

 

[2] C. Butts, “Transgenderism — purely psychological?” OneNewsNow,  http://www.onenewsnow.com/Culture/Default.aspx?id=161948 , July 2, 2008.

 

[3] Working definition of Gender dysphoria by Dr. Randall Ehrbar and I following our panel presentations at the 2007 convention of the American Psychological Association. It is defined in glossary of the DSM-IV-TR as “A persistent aversion toward some of all of those physical characteristics or social roles that connote one’s own biological sex.” (p. 823)

 

[4] K. Winters, “Gender Dissonance: Diagnostic Reform of Gender Identity Disorder for Adults,” Sexual and Gender Diagnoses of the Diagnostic and Statistical Manual (DSM),  Ed.  Dan Karasic, MD. and Jack Drescher, MD., Haworth Press, 2005;  co-published in Journal of Psychology & Human Sexuality, vol. 17 issue 3,  pp. 71-89,  2005.

 

[5] American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Third Edition, 1980

 

[6] American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised, 1987

 

[7] American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, 1994

 

[8] K. Winters, under pen-name K. Wilson,  “The Disparate Classification of Gender and Sexual Orientation in American Psychiatry,” 1998 Annual Meeting of the American Psychiatric Association, Workshop IW57, Transgender Issues, Toronto, Ontario Canada, June 1998. This paper is a revised and expanded version of a previous article of the same title, published in Psychiatry On-Line, The International Forum for Psychiatry, Priory Lodge Education, Ltd., April, 1997, www.priory.co.uk/psych.htm. The original article is available on-line at www.priory.com/psych/disparat.htm.

 

[9] E. Hooker, E., “A Preliminary Analysis of Group Behavior of Homosexuals.” Journal of Psychology. #41, p. 219, 1956

 

[10] K. Zucker and R. Blanchard, “Transvestic Fetishism: Psychopathology and Theory,” in D. Laws and W. O’Donohue (Eds.), Sexual Deviance: Theory and Application, Guilford Press, New York, 1997, p. 258.

 

[11] American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, Washington, D.C., 2000.

 

[12] World Professional Association for Transgender Health (formerly Harry Benjamin International Gender Dysphoria Association) “Standards of Care for Gender Identity Disorders,” Sixth Version, http://wpath.org/Documents2/socv6.pdf , 2001

 

[13] American Psychological Association, “Answers to Your Questions About Transgender Individuals and Gender Identity,”   APA Task Force on Gender Identity, Gender Variance and Intersex Conditions, http://www.apa.org/topics/transgender.html, 2006.

 

Copyright © 2008 Kelley Winters, GID Reform Advocates

Diagnosis vs. Treatment: The Horns of a False Dilemma

Kelley Winters, Ph.D.

GID Reform Advocates

www.gidreform.org

 

 

The transgender community has been divided by fear that we must chose between access to corrective hormonal and surgical procedures to support transition and the stigma of mental illness imposed by the current diagnosis of Gender Identity Disorder(GID)[1] This schism has allowed little dialogue and no progress on GID reform in nearly three decades. However, the GID diagnosis has failed our community on both points. Transsexual individuals are poorly served by a diagnosis that both stigmatizes us as mentally deficient and sexually deviant and at the same time undermines the legitimacy of social transition and medical procedures that are often dismissed as “elective,””cosmetic,” or as reinforcing mental disorder.

 

Gender Identity Disorder in the Diagnostic and Statistical Manual of Mental Disorders[2] has imposed stigma of mental illness and sexual deviance upon people who meet no scientific definition of mental disorder[3]. It does not acknowledge the existence of many healthy, well-adjusted transsexual and gender variant people or justify why we are labeled as mentally ill. 

 

I have heard countless narratives of suffering inflicted by the stereotype of mental illness and “disordered” gender identity, and I have experienced it myself. We lose our families, our children, our homes, jobs, civil liberties, access to medical care and our physical safety. With each heartbreak, we’re almost invariably told the same thing – that we’re “nuts,” that our identities and affirmed roles are madness and deviance. The following statement by Dr. Robert Spitzer at the 1973 annual meeting of the American Psychiatric Association remains as true today for transgender people as it was for gay and lesbian people then:

 

“In the past, homosexuals have been denied civil rights in many areas of life on the ground that because they suffer from a “mental illness” the burden of proof is on them to demonstrate their competence, reliability, or mental stability.”[4]

 

The current GID diagnosis places a similar burden of proof upon gender variant individuals to prove our competence, with consequences of social stigma and denied civil rights.  It harms those it was intended to help. For example, 

 

“Transsexuals suffer from ‘mental pathologies,’ are ineligible for admission to Roman Catholic religious orders and should be expelled if they have already entered the priesthood or religious life,” the Vatican says in new directives.”[5]

 

Simultaneously, GID in the DSM-IV-TR undermines and even contradicts social transition and the medical necessity of hormonal and surgical treatments that relieve the distress of gender dysphoria, defined here as a persistent distress with one’s current or anticipated physical sexual characteristics or current ascribed gender role [6]. For example, Paul McHugh, M.D., former psychiatrist-in-chief at Johns Hopkins Hospital, used GID diagnosis as a key reason to eliminate gender confirming surgeries there:

 

 “I concluded that to provide a surgical alteration to the body of these unfortunate people was to collaborate with a mental disorder rather than to treat it.”[7]

 

Dr. Paul Fedoroff of the Centre for Addiction and Mental Health (formerly the Clarke Institute of Psychiatry) cited the psychiatric diagnosis to urge elimination of gender confirming surgeries in Ontario in 2000,

 

“TS [transsexualism, in reference to the GID diagnosis] is also unique for being the only psychiatric disorder in which the defining symptom is facilitated, rather than ameliorated, by the ‘treatment.’ … It is the only psychiatric disorder in which no attempt is made to alter the presenting core symptom.”[8]

 

Paradoxically, the GID diagnosis has been defended as necessary for access to hormonal and surgical transition procedures.  It is required by Standards of Care of the World Professional Association for Transgender Health [9], and GID is cited in legal actions to gain access to these procedures.  Attorney Shannon Minter, head counsel for the National Center for Lesbian Rights was quoted in The Advocate,

 

“’When we go to court to advocate for transsexual people to get medical treatment in a whole variety of circumstances, from kids in foster care to prisoners on Medicaid,’ the GID diagnosis is used to show that treatment is medically necessary.”[10]

 

Dr. Nick Gorton echoed longstanding fears that access to hormonal and surgical procedures would be lost if the GID were removed entirely,

 

“Loss of the DSM diagnostic category for GID will endanger the access to care, psychological well being, and in some cases, the very life of countless disenfranchised transgender people who are dependent on the medical and psychiatric justification for access to care.”[11]

 

Gender dysphoric transpeople have therefore assumed that we must suffer degradation and stigma by the current GID diagnosis or forfeit lifesaving medical transition procedures. But has our community been impaled on the horns of a false dilemma?

 

Are hormonal and surgical procedures available to transitioning individuals because of the current diagnosis of “disordered” gender identity or in spite of it? Because the GID criteria and supporting text are tailored to contradict transition and pathologize birth-role nonconformity[3], affirming and tolerant professionals are burdened to re-construe GID in more positive and supportive way for transitioning clients. For example, last month the American Medical Association passed a historic resolution, “Removing Financial Barriers to Care for Transgender Patients.” It reinterpreted GID to emphasize distress and de-emphasize difference:

 

“… a persistent discomfort with one’s assigned sex and with  one’s primary and secondary sex characteristics, which causes intense emotional pain and suffering.” [12]

 

The AMA statement is perhaps a model for what the GID diagnosis should become.

 

The current GID diagnosis and its doctrine of “disordered” gender identity have failed the trans-community on both issues of harmful psychosexual stigma and barriers to medical care access. The DSM-V Sexual and Gender Identity Disorders work group has an opportunity to correct both failures with new diagnostic nomenclature based on scientific standards of distress and impairment rather than intolerance of social role nonconformity and difference from assigned birth sex. 

 

 

 

[1]  This essay is expanded from K. Winters, “Harm Reduction for Gender Disorders in the DSM-V,” Philadelphia Trans Health Conference, May 2008.

 

[2] American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, Washington, D.C., 2000.

 

[3] K. Winters, “Gender Dissonance: Diagnostic Reform of Gender Identity Disorder for Adults,” Sexual and Gender Diagnoses of the Diagnostic and Statistical Manual (DSM),  Ed.  Dan Karasic, MD. and Jack Drescher, MD., Haworth Press, 2005;  co-published in Journal of Psychology & Human Sexuality, vol. 17 issue 3,  pp. 71-89,  2005.

 

[4] R. Spitzer, “A Proposal About Homosexuality and the APA Nomenclature: Homosexuality as an Irregular Form of Sexual Behavior and Sexual Orientation Disturbance as a Psychiatric Disorder,” American Journal of Psychiatry, Vol. 130, No. 11, November 1973 p.1216

 

[5] N. Winfield, Associated Press, “Vatican Denounces Transsexuals,” Newsday, Jan 2003.

 

[6] Working definition of Gender dysphoria by Dr. Randall Ehrbar and I following our panel presentations at the 2007 convention of the American Psychological Association. It is defined in glossary of the DSM-IV-TR as “A persistent aversion toward some of all of those physical characteristics or social roles that connote one’s own biological sex.” (p. 823)

 

[7] P. McHugh, “Surgical Sex,” First Things 147:34-38, http://www.firstthings.com/ftissues/ft0411/articles/mchugh.htm , 2004.

 

[8] J. Fedoroff, “The Case Against Publicly Funded Transsexual Surgery,” Psychiatry Rounds, Vol 4, Issue 2, April 2000.

 

[9] World Professional Association for Transgender Health  (formerly HBIGDA), “Standards of Care for The Hormonal and Surgical Sex Reassignment of Gender Dysphoric Persons,” http://wpath.org/Documents2/socv6.pdf , 2001 

 

[10] S. Rochman, “What’s Up, Doc?” The Advocate, http://www.advocate.com/issue_story_ektid50125.asp , Nov 2007.

 

[11] R.N. Gorton,  “Transgender as Mental Illness: Nosology, Social Justice, and the. Tarnished Golden Mean,”  www.Nickgorton.org/misc/work/private_research/transgender_as_mental_illness.pdf , 2006.

 

[12] 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, June 2008.

          

Copyright © 2008 Kelley Winters, GID Reform Advocates

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