Blinded Me with Science: Devolution of the DSM

Kelley Winters, Ph.D.

GID Reform Advocates

www.gidreform.org

 

At the 2003 Annual Meeting of the American Psychiatric Association, Dr. Robert Spitzer, Chair of the DSM-III and DSM-IIIR Task Forces, defended the categories of Gender Identity Disorder (GID) and paraphilias such as Transvestic Fetishism (TF) in the Diagnostic and Statistical Manual of Mental Disorders (DSM) [1].  He declared the inherent pathology of gender identities that vary from assigned birth sex,

 

“Children normally develop a sense of gender identity.  It is not taught—it just happens.  I would argue that by itself, the failure to develop a gender identity that is congruent with biological gender is a dysfunction.” [2, p.116]

 

He based this premise not on empirical data but upon a theory of evolutionary essentialism, “the view that some ‘things’ (like being human) have properties or qualities that are invariable and represent the true essence of the ‘thing.’ In this context, Spitzer defined a medical disorder as “some biological function that is expected—that is part of being a human being – that is not working.” [p. 113].  He disparaged gender variant identities and expressions as pathological, because they do not serve what is “expected,” because they are incongruent to biological function of the born body.  But who gets to decide what is “expected?”  From whose perch of social privilege is American psychiatry to pass judgment upon the evolutionary worthiness of a class of people who have survived since human antiquity?

 

Dr. Spitzer’s reasoning is very reminiscent of essentialist theories that upheld the classification of same-sex orientation as mental illness in previous editions of the DSM [3].   In the early 1960s, psychoanalyst Dr. Sandor Rado stated that “every individual is either male or female” based on reproductive anatomy, that the only healthy sexual adaptation is male-female pair bonding [4].  Dr. Charles Socarides, co-founder of the anti-gay National Association for Research and Therapy of Homosexuality (NARTH), asserted, “heterosexual object choice is determined by two and a half billion years of human evolution” [5]. Psychoanalyst Dr. Irving Bieber echoed these views of biological heteronormativity. Arguing to retain homosexuality as a diagnosis in the DSM, he stated, “humans born with normal gonads and genitals are biologically programmed for heterosexual development” [6, p.1209].

 

Ironically, Dr. Spitzer was himself instrumental in removing the diagnosis of homosexuality from the DSM between 1973 and 1987 and was strongly opposed by Socarides and his NARTH cohorts.  Spitzer refuted essentialist arguments for homosexual pathology, noting that the purpose of the DSM is to list disorders, not human functioning that is judged “less than optimal.”  He explained,

 

“ if failure to function optimally in some important area of life, as judged by either society or the profession, is sufficient to indicate the presence of a psychiatric disorder, then we will have to add to our nomenclature the following conditions: celibacy (failure to function optimally sexually), revolutionary behavior (irrational defiance of social norms), religious fanaticism (dogmatic and rigid adherence to religious doctrine), racism (irrational hatred of certain groups), vegetarianism (unnatural avoidance of carnivorous behavior), and male chauvinism (irrational belief in the inferiority of women). [6, p1215]

 

Stanford evolutionary biologist Dr. Joan Roughgarden challenged assumptions of adaptive unfitness for gender diversity in her 2004 book, Evolution’s Rainbow: Diversity, Gender, and Sexuality in Nature and People [7]. She concluded,

 

“Diversity allows a species to survive and prosper in continually changing conditions,”  [p.21]

 

emphasizing that the occurrence of sexual and gender diversity across species and its prevalence among human beings across many cultures are inconsistent with stereotypes of pathology.

 

Roughgarden cited many examples of animal and plant species with more than two distinct genders and others with abilities to change sex from female to male and vice versa. A tropical ginger plant can change sex mid-day, making pollen in the morning and receiving pollen in the afternoon. A coral reef fish, the bluehead wrasse, has three genders, including large and small types of males.  The larger type begins life as female and is aggressive toward the smaller males born male.  A male clown fish can turn into a female, and hamlets, producing both sperm and eggs, switch roles several times as they mate. Gobies can crisscross sexes several times in their lives to relieve shortages of males or females.  Forty-two species of hummingbirds exhibit “transgender expression,” with females having masculine coloration and characteristics and vice-versa [pp. 32-35,102].

 

Regarding sexual orientation, Roughgarden cited ninety-four bird species known to mate in same-sex pairs.  Geese can mate for life in male-male pairs, with some couples documented together over fifteen years. (A span that most American heterosexual marriages might envy.)  Male and female homosexual behavior has been found in over 100 mammalian species, including wild and domestic sheep, hyenas, kangaroos, squirrels, seals, sea lions, dolphins and whales.  Among primates, bonobos (along with chimpanzees) are our closest genetic relatives. Male and female same-sex encounters are very common for bonobos, and they even use a set of hand signals to communicate the kind of sex they wish [pp. 136-149].

 

Among humans, Dr. Roughgarden proposed that transsexualism occurs too frequently to be explained by random mutation pruned by natural selection alone and therefore does not imply significant adaptive disadvantage [p. 287]. As cited in an earlier essay, Olyslager and Conway estimated the lower bound on prevalence of transsexualism at around 1:500, based on mathematical correction of prior studies and survey of surgical data [8], nearly 100 times greater than figures cited in the DSM [1, p.579].  Roughgarden noted this is consistent with estimates from the U.K and the Hijra in India of around 1:1000 [7, p. 286].  She compared the prevalence of transsexualism to a 99.9 percentile score on a college entrance exam or an IQ of 130, stating that such relatively common traits “can only be consistent with a tiny and undetectable loss of fitness.” [p. 282] 

 

Is social Darwinism in American psychiatry rooted in science or social bias? At the 2003 APA meeting, Dr. Spitzer echoed evolutionary psychologists who seemed to project rigid contemporary sex stereotypes (dominant, hunting males vs. passive, nurturing, gathering females) upon ancestral cultures [9,10]. He speculated:

 

“In all cultures, young boys want to play with boys, Young girls want to play with girls… If you are interested in evolutionary psychology, you ask yourself could that have some survival value?  The answer is yes. Thousands of years ago when men were more likely to be in hunting and women were more likely to be in the nurturing role, if you were a young boy you would do better if you spent your time with other boys with whom, when you were older, you would go to the hunt.” [2, p115]

 

He went on, “…in all cultures, gender is recognized as a dichotomy.” 

 

All cultures? Anthropological research has revealed a long list of non-European cultures with more than two recognized sex and gender roles. Traditions of social gender role transition independent of birth sex include the Tahitian and Hawaiian Mahu, The Madagascar Sekrata, Hindu Tantric and Hijra Sects, Islamic Xanith, Khawal, and Sufi Traditions and others. [11, 12, 13, 14].   Native American scholars now use the term Two Spirit to describe sex and gender traditions, common among First Nations, that are beyond dichotomy[15].

 

Here in Colorado where I write today, Two-Spirit (male-to-female) women, such as the Navajo Nadle, the Lakota Winkte and the Cheyenne He man eh [16], held respected roles in healing and spiritual leadership. Gender transcendence was not only a normal variation of human life but sacred, a sign of a person especially close to the spirits.  As a young boy, the great Chief Crazy Horse of the Lakota Sioux was blessed by a Winkte shaman in a secret naming ceremony. Possessing a secret Winkte name marked social status and conferred spiritual protection, good health and long life [14, p.37].  Later, he married at least one Winkte wife, in addition to his wives born female [p. 112].

 

Like the coral reef fish, these proud Native American nations thrived for millennia, apparently unaware of any “adaptive disadvantage.”  That was, perhaps, until European intolerance appeared on the plains in the form of the Seventh Cavalry and compulsory missionary and reservation schools, which drove these ancient traditions into the closet [14, pp.177-196]. Among human societies, the anomaly is not the existence of gender diversity but the repression of it, isolated to relatively few cultures, including our own. It seems astonishing that such a large, relevant body of social science has been ignored by previous authors of the Diagnostic and Statistical Manual of Mental Disorders.

 

In our modern global economy, as among the native nations of the Colorado plains, humans live and compete in communities.  Adaptation and survival mean success of the tribe, perhaps more than individual breeding. Economist Richard Florida stated that in today’s world, “Human creativity is the ultimate economic resource.” [17, p. xiii].  In his book, The Rise of the Creative Class, he tracked the growth of the “creative class,” those doing creative work for a living, from less than 10 percent in 1900 to nearly a third in the year 2000 – a class generating as much wage and salary income as the manufacturing and service sectors combined [p. xiv].  Surprising to many, he found strong correlations between the most diverse US communities and those with the highest creative class share.  Five of the top ten metropolitan regions ranked for diversity, Seattle, Boston, Minneapolis, San Francisco, Austin, and Denver, also ranked in the top ten of creative class share [pp. xxi, 244]. Four of these, San Francisco, Austin, Seattle and Boston, were in the top five regions for gay and lesbian population share, a component of the diversity ranking.  And three of these, San Francisco, Boston and Seattle respectively, were the top three regions for high-technology industry.  Dr. Florida concluded that lowering barriers to inclusion fosters creative ecosystems –

 

“Habitats open to new people and ideas, where people network easily and offbeat ideas are not stifled but are turned into new projects, companies and growth. Regions and nations that have such ecosystems are likely to do the best job of tapping the diverse creative talents of the most people, and thus gain competitive advantage.”  [p. xx]

 

Although Florida’s analysis utilized gay and lesbian census data, where gender variant populations are not counted, gender transcendent people are a vibrant and increasingly visible component of lesbian, gay, bisexual, transgender (GLBT) and straight communities – especially in urban centers.  For example, of the top ten large metropolitan regions for creative class share in Florida’s survey, seven prohibit employment discrimination based on gender identity — according to the Human Rights Campaign. These include Washington, D.C., Boston, Austin, San Francisco, Minneapolis, Denver, and Seattle. Nine of the top ten high-technology communities, all but Phoenix, have trans-inclusive civil rights ordinances. [17 pp .244, 251; 18]  Lowering barriers to gender diversity in these communities is associated with creative human capital and economic potential.

 

While correlation does not imply causality, there is growing evidence that gender diversity is far from a “dysfunction” in human communities. Diversity of gender identity and expression can contribute adaptive advantages in unique breadth of perspective and creative viewpoint to the cultural and economic success of communities, ancestral and modern. 

 

Derogatory stereotypes that equate gender diversity with evolutionary unfitness and psychiatric pathology, like those of same-sex orientation that preceded them, are contradicted by the pervasive reality of gender diversity throughout nature and human culture.  As Dr. Joan Roughgarden observed,

 

“When scientific theory says something’s wrong with so many people, perhaps the theory is wrong, not the people.”  [7, p.1]

 

I hope that the Sexual and Gender Identity Disorders work group of the DSM-V Task Force will reexamine the evidence that difference in itself is not disease. [16]

 

 

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

 

[2] R. Spitzer, “Sexual and Gender Identity Disorders: Discussion of Questions for DSM-V,” Journal of Psychology & Human Sexuality, Vol. 17, Nos. 3-4, February2006, pp. 111-116, http://www.ingentaconnect.com/content/haworth/jphs/2006/00000017/F0020003/art00008.

 

[3] K. Winters (published under pen name Katherine 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 Canada, June 1998. http://www.gidreform.org/kwapa98.html

 

[4] S. Rado, Psychoanalysis of Behavior II. New York: Grune and Stratton, 1962.

 

[5] C. Socarides, The Overt Homosexual. New York: Basic Books, 1962.

 

[6] R. Stoller, J. Marmor, I. Beiber, et al.,”A Symposium: Should Homosexuality be in the APA Nomenclature?” American Journal of Psychiatry, vol. 130, pp. 1208-1215, 1973.

 

[7] J. Roughgarden, Evolution’s Rainbow: Diversity, Gender, and Sexuality in Nature and People, Univ. of CA Press, 2004.

 

[8] 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).

 

[9] G. Alexander, “An Evolutionary Perspective of Sex-Typed Toy Preferences: Pink, Blue, and the Brain,” Archives of Sexual Behavior, Vol. 32, 2003, 1991, pp. 7-17.

 

[10] J. Benenson, “Sex Differences in Children’s Investment in Peers,” Human Nature, vol 9 no 4, 1998, pp. 369-390.

 

[11] C. Ford and F. Beach, F., Patterns of Sexual Behavior. New York, Harper and Brothers, 1951.

 

[12] A. Bolin, In Search of Eve, Bergin & Garvey, 1988.

 

[13] V. Bullough and B. Bollough, Cross Dressing, Sex, and Gender, University of Pennsylvania Press, 1983.

 

[14] W. Williams, The Spirit and the Flesh: Sexual Diversity in American Indian Culture. Boston, Beacon Press, 1986.

 

[15] S. Jacobs, W. Thomas, S. Lang, Two-Spirit People, Univ of Illinois Press, 1997.

 

[16] 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.

 

[17] R. Florida, The Rise of the Creative Class: And How It’s Transforming Work, Leisure, Community and Everyday Life, Basic Books, 2003.

 

[18] Human Rights Campaign, “Cities and Counties with Non-Discrimination Ordinances that Include Gender Identity” April 2008, http://www.hrc.org/issues/workplace/equal_opportunity/9602.htm.

 

Copyright © 2008 Kelley Winters, GID Reform Advocates

Diagnosis vs. Treatment: Psychosexual Stigma

Kelley Winters, Ph.D.

GID Reform Advocates

kelley@gidreform.org

 

 

In the spring of 2003, I sat at a long table in the Grand Ballroom of the San Francisco Marriott with six men in suits and ties.  The only woman, the only transperson, the only scholar not a M.D. or mental health professional, I felt like the emissary from the dark side of the moon.  It was my second presentation at an annual meeting of the American Psychiatric Association, and I was fortunate for a place at the table.

 

We were presenting a symposium entitled, “Sexual and Gender Identity Disorders: Questions for the DSM-V” [1]. The moderators and organizers were Drs. Dan Karasic and Jack Drescher of the Association of Gay and Lesbian Psychiatrists, a division of the APA, who would later co-edit a book that followed [2].  On the left side of the table, Drs. Darryl Hill and Charles Moser joined me in advocating reform of the Gender Identity Disorder (GID) and paraphilia diagnoses in the next Diagnostic and Statistical Manual of Mental Disorders [3], published by the APA.  At the far right end of the table, former APA President Dr. Paul Fink and Dr. Robert Spitzer, Chair of the DSM-III and DSM-IIIR Task Forces and editor of the DSM-IV Casebook [4], defended the status quo.

 

After formal presentations from the left and rebuttals from the right, Dr. Fink uttered a remark that stunned clinicians in the audience who were supportive of their transitioning clients. Speaking of the GID diagnosis, he said,

 

“I think transsexualism is a diagnosis. … And it certainly doesn’t stigmatize anybody worse than the stigma they get every single day.” [5]

 

Having worked for NASA in a previous career, I couldn’t help but wonder — of life on which distant planet was he speaking?

 

Nearly five years later, I stood in a private school classroom in a conservative suburb where achievement was marked by enormous SUVs crowded between sprawling houses. The room was packed with angry parents and nervous staff. A group of us, consultants on gender diversity issues, had been asked to speak to their fears.  A stranger in a strange land, a remarkable young girl with a loving family had transitioned to her affirmed gender role in their midst.

 

One by one, voices around the room maligned this courageous child and condemned her parents, threatening to remove their own children from the school if she was not expelled.  As we tried to calm their panic, a hand shot in the air from one of the dominant men in the crowd, his eyes red with rage.  He demanded the other parents reject this innocent girl, hissing through clenched teeth,

 

“This is nothing more than mental illness, and the American Psychiatric Association says so.”

 

This was far from the first time that the diagnoses of Gender Identity Disorder and Transvestic Fetishism by the APA had been cited to justify intolerance and discrimination.  Virtually every aspect of transitioned life is impacted by these stereotypes of mental incompetence and sexual deviance.  We gender transcendent people are denied medical care, child custody, housing, employment, and public accommodation as a consequence.  Our very humanity in public discourse is dismissed as, “That’s nuts.” [6]

 

In 2007, the Maryland Montgomery County Public Schools introduced a health education curriculum including a lesson on “Respect for Differences in Human Sexuality” with an introduction to gender diversity.  In a lawsuit against the school district, opponents to the curriculum rallied around the DSM:

 

“the human sexuality lessons inaccurately portray ‘transgender’ as a ‘sexual variation’ when, transgenderism, gender dysphoria, and gender identity disorder actually constitute mental illness. American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).” [7]

 

Fortunately, the circuit court decided in favor of the school district early this year, but the same political extremists used GID to attack the Montgomery County gender identity nondiscrimination bill in November, 2007.  A public notice from Citizens for a Responsible Curriculum railed,

 

“You can stop this! The vote on this bill is November 13th. Urge the Montgomery County Council to exclude entry into female restrooms, showers and dressing rooms by male transgenders and vice versa. The American Psychiatric Association recognizes Gender Identity Disorder as a mental illness.” [6]

 

They ridiculed basic civil rights in public accommodation for gender variant people, invoking sensational maligning headlines of transitioned women as deviant males. The Montgomery County board passed the bill, but legal and public attacks continue to rely on the authority of the American Psychiatric Association.  For example, a Maryland political group dedicated an entire web page to denouncing transgender civil rights based on the DSM. It states,

 

“’Gender Identity Disorder’ is classified as a mental disorder by the American Psychiatric Association. Legal protection against discrimination based on mental illness is not provided for any other disorder, and there is no rational explanation why it should be offered for this one. Those who wish to assume a ‘gender identity’ contrary to their biological sex are in need of mental health treatment to overcome such disturbed thinking, not legislation to affirm it.” [8]

 

The GID and TF diagnoses are used by national as well as local political and religious groups to promote intolerance of gender variant people and even children.  For example, in an article entitled “A Gender Identity Disorder Goes Mainstream” the influential Traditional Values Coalition attacked the California Student and Violence Prevention Act of 2000 [9] by invoking the mental illness stereotype:

 

“In essence, this law gives sexually disturbed students the ‘right’ to self-identify their gender despite the biological reality of male and female. Under California state law, a boy who thinks he’s really a girl, is now protected from alleged ‘discrimination.’” [10]

 

They continued, “Gender confused individuals need long-term counseling, not approval for what is clearly a mental disturbance.”  The article cited the DSM to support the TVC’s derogatory characterizations, “Transgenders are mentally disordered . The American Psychiatric Association (APA) still lists Transsexualism and Transvestism as paraphilias or mental disorders in the Diagnostic and Statistical Manual (DSM-IV-TR)” [10].

 

Contrary to Dr. Fink’s denial of the problem, the role of psychiatric classification in perpetuating social stigma of mental incompetence and sexual deviance for gender variant individuals has been long recognized by scholars and clinicians across academic disciplines.  Anthropologist and author Ann Bolin noted in 1988, “The transsexual is labeled mentally ill and ipso facto in need of psychiatric care.  … The problems of stigma and the possible impact of the mental illness label are overlooked.” [11]

 

More recently, clinical social worker Arlene Istar Lev, author of Transgender Emergence, concluded, “Reform of  the GID diagnosis is necessary or the basic civil liberties for transgendered and transsexual people will remain elusive.”  [12]  Drawing parallels between the current GID diagnosis and the past classification of homosexuality in the DSM, psychologist Dr. Madeline Wyndzen observed, “I find that the mental illness label imposed on transsexuality is just as disquieting as the label that used to be imposed on homosexuality.” [13]

 

The American Psychiatric Association itself has acknowledged the potential harm of social stigma associated with a label of mental illness:

 

“Scientific data cannot be interpreted in a vacuum.  Sociological and other considerations must also be taken into account.   …we must consider instead how to balance the advantages of including the diagnosis in the DSM (e.g., increased detection of a treatable disorder with consequent reduction in morbidity and cost to the patient, his or her family, and to society at large) against the risks of making a false positive diagnosis (e.g., risk of stigmatization, cost and potential morbidity of unnecessary treatment, etc.).”  [14]

 

Undermining the legitimacy of social and medical transition in the title, diagnostic criteria and supporting text of the current Gender Identity Disorder diagnosis, the American Psychiatric Association has undermined the human dignity and civil justice of gender variant and especially transitioning people.  The Sexual and Gender Identity Disorders work group of the DSM-V Task Force has an opportunity to reconsider consequences of social stigma that have been overlooked in past editions.  Once again, it is time for diagnostic nomenclature that does not harm those it is intended to help.

 

 

[1] K. Housman, “Controversy Continues to Grow Over DSM’s GID Diagnosis,” Psychiatric News, Vol. 38 no. 14, July 2003.  http://pn.psychiatryonline.org/cgi/content/full/38/14/25 .   I was listed under pen-name Katherine Wilson in this article.  My presentation is summarized in K. Winters, “Gender Dissonance: Diagnostic Reform of Gender Identity Disorder for Adults,” Sexual and Gender Diagnoses of the Diagnostic and Statistical Manual (DSM),  Eds.  D. Karasic, and J. Drescher, Haworth Press, 2005;  co-published in Journal of Psychology & Human Sexuality, vol. 17 issue 3,  pp. 71-89,  2005. http://www.haworthpress.com/store/ArticleAbstract.asp?sid=DNFVJBXTSF848HQDMD0RDQAW67U17LP1&ID=67230

 

[2] D. Karasic and J. Drescher, Eds., Sexual and Gender Diagnoses of the Diagnostic and Statistical Manual (DSM), A Reevaluation, Haworth Press, 2005.

 

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

 

[4] R. Spitzer, R., ed., DSM-IV Casebook, A Learning Companion to the Diagnostic and Statistical Manual of Mental Disorders (fourth edition). American Psychiatric Press, 1994.

 

[5] P. Fink, P., “Sexual and Gender Identity Disorders Discussion of Questions for DSM-V,” Journal of Psychology & Human Sexuality, Vol. 17, Nos. 3-4, February2006, pp. 117-123, http://www.ingentaconnect.com/content/haworth/jphs/2006/00000017/F0020003/art00008.

 

[6]  Citizens for a Responsible Curriculum, “Public Notice,”  Damascus MD, November 2007, http://www.mcpscurriculum.com/pdf/transgender_alert.pdf

 

[7]  Citizens for a Responsible Curriculum, et al. v. Montgomery County Public Schools, et al., Petitioners’ Memorandum, Civil Action No. 284980, Circuit Court for Montgomery County, MD, October 2007, p. 10, http://www.mcpscurriculum.com/pdf/Appellate_Brief_PFOX2.pdf

 

[8] Maryland Citizens for a Responsible Government, “Referendum to Repeal Bill 23-07,”  Gaithersburg MD,  http://www.notmyshower.net/gender_identity.shtml

 

[9]  Gay-Straight Alliance Network, “AB 537 Fact Sheet, California Student and Violence Prevention Act” http://www.gsanetwork.org/ab537/pdf/AB537.pdf

 

[10] Traditional Values Coalition, “A Gender Identity Disorder Goes Mainstream

Cross-dressers,Transvestites,And Transgenders Become Militants In The Homosexual Revolution,” Anaheim CA, pp. 2-3, http://www.traditionalvalues.org/pdf_files/TVCSpecialRptTransgenders1234.PDF

 

[11] A. Bolin, In Search of Eve, Bergin & Garvey, South Hadley MA, 1988. p53.

 

[12] A. Lev, Transgender Emergence, Therapeutic Guidelines for Working with Gender-Variant People and Their Families,  Haworth Press, 2004, p. 180.

 

[13] M. Wyndzen, M. H. “A Personal and Scientific look at a Mental Illness Model of Transgenderism.”  American Psychological Association Division 44 Newsletter, Spring 2004,  http://www.GenderPsychology.org/autogynephilia/apa_div_44.html

 

[14] American Psychiatric Association, “DSM-IV Frequently Asked Questions,” http://www.psych.org/MainMenu/Research/DSMIV/FAQs/WhatistheDSMandwhatisitusedfor.aspx

 

Copyright © 2008 Kelley Winters, GID Reform Advocates

Diagnosis vs. Treatment: Barriers to Medical Care

Kelley Winters, Ph.D.

GID Reform Advocates

kelley@gidreform.org

 

The psychiatric classification of gender variance as Gender Identity Disorder (GID) in the Diagnostic and Statistical Manual of Mental Disorders (DSM) [1] has long been cited as necessary to provide access to medical transition procedures for transsexual individuals who need them. According to Dr. Ira Pauly of the DSM-IV Subcommittee on Gender Identity Disorders,

 

“Research in the field has been facilitated by having standardized criteria available for correctly diagnosing individuals with GID…. This has greatly increased our knowledge and understanding of GID, and has resulted in improved and more standardized treatment protocols.”  [2]

 

Standards of Care of the World Professional Association for Transgender Health continue to require a GID diagnosis for access to hormonal or surgical transition procedures [3].  Many fear that hormonal and surgical procedures might be withheld without some kind of diagnosis to validate their medical necessity and justify their risks.  While the existence of a diagnostic coding has helped affirming, supportive care providers to make transition procedures available to some transitioning individuals, the specific diagnostic criteria and supporting text of the current Gender Identity Disorder category support the opposite approach – punitive gender-conversion or gender-reparative therapies intended to change or suppress gender identity or expression which differ from assigned birth sex roles [4].

 

However unintended, the consequences of the doctrine of “disordered” gender identity in the latest DSM-IV-TR include barriers to medical care for transitioning individuals far beyond the scope of transition itself. The following examples of disparate health benefit coverage are common among large corporate employers [5] and would apply to transitioning intersex as well as transsexual employees.  Similar barriers exist within government health benefits, small business health plans and private insurance policies.

 

Denied Coverage for Corrective Surgical Procedures

Transsexual individuals who suffer distress with their physical sex characteristics or ascribed social gender role (defined here as gender dysphoria [6]) are singled out by many employers for exclusion from coverage for corrective procedures that are commonly covered for cis-gender or non-trans employees. 

 

Medically necessary surgical treatment for gender dysphoria does not necessarily require expanded or special coverage, but often employs the same or similar procedures already commonly covered for non-transsexual employees for a wide variety of congenital and endocrine conditions. [7]

 

Surgical Procedures Performed on Transsexual and Non-TS Individuals

Associated Conditions

In Non-Transsexual Individuals

Vaginoplasty,

Labia Construction

Congenital androgen insensitivity syndrome,

Congenital adrenal hyperplasia,

Vaginal agenesis, Vaginal atresia,

Mayer-Rokitansky syndrome

Reduction mammoplasty,

Chest Reconstruction

Gynecomastia

Metoidioplasty,

Scrotoplasty

Urethral Extension

Congenital micropenis,

Congenital Buried Penis Syndrome,

Epispadias,

Hypospadias

 

These surgical procedures correct the same physiology and function for non-transsexual people and transitioning people alike and are not broadly excluded in health benefits for employees who are not transsexual. However, transitioning employees at many corporations are singled out for denial of coverage with a broad exclusion such as,

 

“All expenses related to gender reassignment, including those related to complications arising from such services.”  [8]

 

This discrimination is based solely on gender identity, often in violation of corporate and state equal opportunity policies.

 

Denied Coverage for Endocrine Specialty Care

There is much confusion around coverage for hormone replacement therapy (HRT) for gender dysphoric employees or those who have completed physical transition.  At my employer, one woman was covered for HRT while employed, but then she was denied coverage under post-employment, or Cobra, benefit after she was terminated in the course of her transition. Non-trans men and women who require HRT for treatment of androgen or estrogen deficiencies are covered under most benefit plans; while the same or similar treatment for transitioning employees is explicitly excluded by many plans under the phrase, “All expenses related to gender reassignment.” [8]  Such policy can be used to prevent any transitioning or transitioned employee from equitable access to hormone replacement therapy.

 

Denied Coverage for Conditions Prevalent among Females

Natal cis-gender (non-trans) women are typically covered for a variety of conditions prevalent among women. However, transitioned women (male-to-female, or MTF) fear denial of coverage for conditions like breast cancer or osteoporosis at many employers, which exclude any conditions that might be construed as a “complication” of the transition process or hormone therapy.  At these employers there is no assurance of equal coverage for these potentially fatal conditions.

 

Moreover, transitioning or transitioned men (FTM) may possess atypical physiology with the possibility of conditions prevalent among natal women, such as cervical or ovarian cancer.  Transmen may be singled out for denial of coverage for these fatal conditions at many employers for treatments “not appropriate based on the gender of the patient.”  [11] The award-winning documentary, Southern Comfort chronicles the tragic death of Mr. Robert Eads, a trans-man who was similarly refused treatment for ovarian cancer. [9]

 

Denied Coverage for Conditions Prevalent among Males

Conversely, natal men are typically covered for conditions unique or prevalent among men.  However, transitioned men (FTM) may be denied treatment for conditions covered for other men by many employers if they are construed as “complications” of the transition process or hormone therapy.

 

Transitioning or transitioned women (MTF) may possess atypical physiology susceptible to conditions unique or common to natal men, such as prostate cancer.  While prostate cancer risk is much lower for transitioned women than natal men, cases have been reported [10], and regular examination and PSA screening are recommended.  Such care is currently denied under many benefit policies, which deems it “not appropriate based on the gender of the patient.”  [11]

 

Denied Mental Health Benefit Coverage

There is also a great deal of confusion about mental health care benefits for transitioning employees. Recognized medical standards of care for treatment of gender dysphoria and correction of physical sex characteristics are defined by the World Professional Association for Transgender Health (WPATH).  While there is no scientific basis for casting gender diversity in itself as mental illness, gender dysphoria (persistent distress with one’s physical sex characteristics or ascribed social role [6]) is effectively treated with medical transition procedures.

 

However, the current standards require evaluation by a mental health professional with specialized knowledge of gender dysphoria and gender diversity issues prior to prescription of hormone replacement therapies.  For those who require surgical correction of sex characteristics, a period of 12 months of full-time “real-life experience” in their affirmed gender role is necessary for eligibility. An evaluation by a mental health professional is required for reduction mammoplasty and chest reconstruction for transmen, and evaluation by two mental health professionals is required for genital surgery eligibility for transmen and transwomen. [12]

 

However, benefit coverage for mental health evaluation and any psychotherapy specific to hormonal or surgical treatments may be denied under broad exclusions common to many employers, “All expenses related to gender reassignment.” [8]

 

This exclusion could be used to deny any transitioning employee access to mental health assessments that are required by standards of care in the course of physical transition.

 

Maligning Stereotypes of Mental Illness

At many employers, the only mental health benefits explicitly covered for gender dysphoric employees are those not “related to gender reassignment.”  Psychological treatments known as gender-conversion or gender-reparative therapies, which attempt to reverse innate gender identity or sexual orientation, fail to relieve distress of gender dysphoria and are considered extremely offensive to the transgender community.  Unfortunately, benefit coverage at many employers for these damaging psychotherapies, and simultaneous denial of hormonal and surgical medical care, combine to reinforce these defamatory stereotypes.  The message implied by these benefits policies has contributed to a hostile work environment for transgender employees.  In recent years, a transsexual woman at my employer was mocked and ridiculed as mentally disordered by her supervisor, who told her,

 

“I don’t know why a ‘man’ would want to cross-dress. You know, the company will pay to fix this condition.”  [13]

 

She was terminated in the course of her transition.

 

The 2008 Corporate Equality Index  [14] from the Human Rights Campaign surveyed 11,369 major U.S. businesses for policies and practices pertinent to GLBT employees, consumers and investors. Of these, less than one percent, 109, offer health benefit coverage for medically necessary surgical procedures to transitioning employees and their families.

 

The attitudes behind this epidemic transsexual health care discrimination are perhaps revealed by looking at those employers most publicized for their “equal opportunity” policies.  The HRC awarded 195 employers with perfect 100% scores, denoting the very “best” workplaces for GLBT people.  A disgraceful sixty percent of these, 117, specifically exclude transition surgical procedures.  An important clue is found in nearly 80% of this group, 93, which cover “mental health counseling” for transitioning individuals while denying surgical benefits. Their intention to promote gender-conversion or gender-reparative psychotherapies in lieu of transition for those who suffer gender dysphoria seems clear.  In my view, this is evidence that prevalent transsexual health benefit discrimination is based on a false stereotype of “disordered” gender identity that equates gender difference with mental illness – a stereotype grounded in the DSM.

 

The current diagnosis of Gender Identity Disorder has contributed to derogatory stereotypes of mental illness and sexual deviance, creating barriers to medical care for transsexual and other gender variant people before and after transition. The DSM-V Sexual and Gender Identity Disorders work group has an opportunity to refute these stereotypes with diagnostic criteria and supporting text that are affirming of transition rather than promoting punitive gender-conversion therapies.  It is time for mental health policies that do not harm those they are intended to help. [15]

 

  

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

 

[2] I. Pauly, “Terminology and Classification of Gender Identity Disorders,” Interdisciplinary Approaches in Clinical Management, New York: Haworth Press, 1992.

 

[3] 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 

 

[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] Examples of health benefit inequity updated from K. Winters, “Issues of Transgender Health Benefit Inequity in the Corporate Equality Index,” Seminar presented to the Human Rights Campaign, Washington, D.C., June 2008.

 

[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] Thanks to Becky Allison, M.D., Gary Alter, M.D., and Marci Bowers, M.D., for input and information on these procedures and common health coverage practice.  This table is far from exhaustive but illustrates examples of corrective surgical procedures, often denied to transsexual individuals, that are analogous to those covered for patients who are not transsexual.  While not all health plans cover all of these procedures for cis-gender (non-transitioning) individuals, broad exclusions to their coverage are not common.

 

[8] This language is used by my own employer, a Fortune 20 corporation, to deny coverage for all transition-related medical expenses in health plans administered by Aetna, UnitedHealthcare, and BlueCross BlueShield.  It is representative of common language I have heard in employee and private health plans.

 

[9] Southern Comfort,  New Video Group, 2001. It may be viewed online at http://www.logoonline.com/shows/dyn/southern_comfort/videos.jhtml.

 

[10] R. Miksad, G. Bubley, et. al, “Prostate Cancer in a Transgender Woman 41 Years After Initiation of Feminization,” Letter to the Journal of the American Medical Assoc., v. 296 no. 19, Nov. 2006.  http://jama.ama-assn.org/cgi/content/full/296/19/2316

 

[11] This language is currently used by UnitedHealthcare to exclude coverage of care for post-transition individuals at my employer that is unrelated to transition itself. It is representative of language I have heard in other employee and private health plans.

 

[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] GID Reform Advocates, Advocates’ Statements, http://www.gidreform.org/advocate.html.

 

[14] Human Rights Campaign, Corporate Equality Index, 2008.  http://www.hrc.org/issues/workplace/cei.htm.

 

[15] K. Wilson (former pen-name for Kelley Winters), “Gender as Illness: Issues of Psychiatric Classification,” 6th Annual ICTLEP Transgender Law and Employment Policy Conference, Houston, Texas, July 1997. Reprinted in Taking Sides – Clashing Views on Controversial Issues in Sex and Gender, E. Paul, Ed., Dushkin McGraw-Hill, Guilford CN, 2000, pp. 31-38.  http://www.gidreform.org/kwictl97.html

 

Copyright © 2008 Kelley Winters, GID Reform Advocates 

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