Transvestic Disorder and Policy Dysfunction in the DSM-V
April 22, 2009 24 Comments
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, https://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
About Kelley
GID Reform Weblog by Kelley Winters 
The war between the psychological and physiological, Bio-Neurological and Chromosomal, causes are soon to be vetted and accepted across the AMA and most scientific organizations. Dr. M Diamond and others have made tremendous research advancements. They are compiling research that demonstrates that Intersex (DSD) and Transsexuality are closely associated and affect 1/100 births to date. I would suspect that the Freudian clones will think of some new hucksterism’s so they can continue to shrink everyone’s brain.
I’m reminded that it really is not all that long since psychiatry used to pathologise a healthy normal interest in sex by women as a ‘disorder’.
The victims change as society grows more sophisticated but some psychiatrists seem to have a kind of addictive need to find groups of people whom they can label, stigmatise and control.
“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.”
How can this be considered a mental illness for straight men, but not gay or bisexual men? What objective standard requires this distinction? Are there other diagnoses that that apply only to straight, gay or bisexual men? Or is this just an attempt to enforce cultural expectations for men based upon their sexual orientation?
Assuming the validity of the category – what metric was used to determine the 6 month criteria?
I am weary of hearing psych folks saying that they wish to base the changes in the DSM on “science” knowing they are entertaining support of stereotype and stigma without anything that could rise to the level of science. It would be comical if it weren’t so harmful.
Margaret McGhee makes an excellent case for the role of our personnal narrative in transitioning at http://www.geocities.com/margimcghee/Articles/AG.htm .
Also see http://scienceblogs.com/cortex/2009/04/confabulations.php in which Jonah Lehrer explains the importance of narrative in words much like Ms. McGhee.
My impression of Ray Blanchard is he is intolerant of personal narratives that do not support his opinions.
Ray Blanchard is fortunately on the wrong side of human history.
Increasing diversity and tolerance is a sign of progress. His views are a sign of the past. My hope is Ray Blanchard will become progressive and not repressive. If not he will simply remain a bully.
As a trans psychiatrist, I am profoundly disappointed and ashamed of my organization and profession. The proposed categories are markedly defamatory and will have a very stigmatizing affect on transpeople. Specifically, identifying transfolk as suffering from a paraphilia. Unfortunately, psychiatric diagnoses are used by the wider society who are not cognizant of the problems with categorizing a given condition as within the purvue of psychiatry. Who could doubt the disastrous effect of such a diagnosis upon a trans person fighting for custody of their children? I had hoped that my profession had progressed.
I find it disturbing that the science is not given more scrutiny. If the terms such as ‘Transvestic Fetishism’ and ‘paraphilia’ are added to the DSM they will certainly be enormously damaging to Trans and gender queer. Perhaps given the potential for harm the DSM should be opened for a wider, open and international review before publication. If the DSM is to be taken seriously it should not contain pseudoscience and should transcend cultural and social norms. I hope that if published with these terms, similar actions to those in the 1970’s are taken when Homosexuality was removed under pressure.
These views are seriously archaic. While I recognize that social distress can affect the body (personal or social), and cause “dysfunction” to ones self and/or others, when is research going to move in the logical direction of the more profound human harm / damage done by the practice and effects of labeling people who are different – dis-ordered?
The discomfort that affects bodies has to do with so-called “normals” being supported by our religious, legal, medical, and other powerful institutions in their failing to come to terms with people who are sexually different. When is failing to come to terms with human diversity going to be considered a psychological disorder? It seems to me that if we must label, that label is seriously overdue, and certainly based in a form of hetero-masculine narcissism.
Instead of researching the gendered and sexual dysfunction that causes THAT sort of EXCESSIVE hetero-policing of the social spaces that create and reproduce their own bodies, we instead cause more harm to the already stigmatized and erect protections around a very disordered hetero-worldview (and, hetero-masculinity and its helpers are excessive).
It’s very hard for me to understand how these psychological opinions fall under the medical requirement to do no harm. These views cause a lot more harm than they do alleviate hurt. Creating the intellectual “resources” necessary to continue to justify one’s hate based on discourses of normality/non-normality does nobody any good.
It’s relieving to know, however, that as a femme-looking lesbian (not trying to pass, thank you), that on those days that I have an ambiguously erotically charged need to wear cargo-pants and a “wife-beater” (when is that going to enter the DSM as a gender disorder?), that it is, in fact, an obsession-based, narcissistic, sexual disorder that I am signifying. If I had known that sooner, I would have found reason to “get-off” on that faster and wear them more frequently. And I think I will now do that.
What a ridiculous shame this makes of our “psychological” community.
Tara
How can being a trannsexual be a mental disorder when having surgery cures you? It is very obvious that these Dr’s have no clue about being trans.
As a trans woman, I am totally in agreement with Dr. Winters views on this matter. In particular, the autogynephilia hypotheses has been so discredited by the lived experience of so very many trans women – and men! – as to make it absurd to even consider including it in the DSM.
By playing the masturbation card Blanchard is doing what he knows how to do best – prey on people’s misplaced feelings of guilt. I believe he is hoping that anyone who is entertaining thoughts of dissenting from his opinions will be intimidated by the threat of being associated with a common practice, the extent of which can never be known because of decency and the respect for privacy. It is a tactic that worked so well for J Edgar Hoover who, for years, was placated by people who wished to see his accusing finger pointed anywhere but at them. Blanchard strikes me as a predator stalking the herd, chasing the most vulnerable while the rest runs to safety.
I don’t know why, of all the things I have posted on line, this quote seems to get the most hits. When I Google my name it is the second entry on the Google page. It must be the sensationalism of the words “transvestic” a “masturbation”. I wish my comment could be removed. I don’t regret what I had to say. Blanchard’s DSM-V proposals are offensive for more reasons than the one I give in my comment, I could have said more, I suppose. The weight of the words “transvestic” and “masturbation” are misleading. They actually distract from the point I was trying to make. I am sure those words have caused misconceptions for anyone doing a cursory search of my name, particularly people who are not familiar with Blanchard’s very biased research.
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Clearly they are trying to keep themselves in work.
You may be interested to know that Blanchard’s new definition of paraphilia now appears at the head of the Wikipedia entry for that concept, where the source provided is Cantor, J. M., Blanchard, R., & Barbaree, H. E. (2009). Sexual disorders. In P. H. Blaney & T. Millon (Eds.), Oxford textbook of psychopathology (2nd ed.) (pp. 527–548). New York: Oxford University Press, p.527. If I knew enough about the subject I’d be tempted to do a little editing!
May I also suggest that you look at what it has to say on p.530, about “Erotic Identity Disorders” (it is available through Google Books). As a 2009 statement of Blanchard’s current views, it makes for chilling reading.
And the main editor at Wiki who continuously deletes all reference to biological causes when it comes to trans issues is… one James Cantor.
I really appreciate this dialogue and this community – and have brought up similar concerns I’ve had with these disorders in my classes when learning the DSM-IV as a social worker.
It seems that the important specifier that is overlooked is that a diagnosis of TF requires the person to have resulting impairment in functioning. It’s a behavior that it causing behavioral/psychological distress. This part – I get. However, if we accept this, should we/can we classify ALL behaviors that cause impairment in functioning and psychological distress as mental disorders? What’s so special about cross-dressing? And…why can only straight men have this disorder?
The hope that a rational and compassionate treatment protocol for GID people in my life time is dashed. They don’t want us killing ourselves, but they still deprive us of even a tiny semblance of dignity in an already difficult life.
Khadijah
Also found on my blog:
“any intense and persistent sexual interest other than sexual interest in genital stimulation or preparatory fondling with phenotypically normal, consenting adult human partners.”
Are you transgender, genderqueer, a cross dresser, someone with ambiguous genitalia, someone with a non-typical gender presentation, or anything else that differs from the expected ideas of male and female traits, beauty, and role? Then that quote up there is how Dr. Ray Blanchard wants to define you.
As a queer psychologist, I stand at an interesting and uncomfortable crossroads. Psychology is bloody. Psychology has much to answer for. Like medicine, it was only recently that psychology began to help more than it hurt.
Queer people are one of the groups often marginalized and shut out by the mental health community. One need only look at pray away the gay style ‘therapies,’ the fact that being gay remained a mental illness in the DSM—called the Bible of mental disorders—until the seventies.
But psychology has done a singular job of erasing, tormenting, and even killing transgendered people, and those with nontraditional gender presentation like crossdressers. (transgender is used here as an umbrella term here to describe anyone who rejects their assigned gender role, and/or the genital-personality connection) The nightmarish images in popular culture of sadistic nurses applying electrodes to patients who won’t comply is not all fiction. For decades, transgender people have found their ‘therapy’ to be little more than torture.
Now, as we emerge from the darkness, a single entry threatens to undo all the battles we’ve won. Dr. Ray Blanchard proposes that Tranvestic Disorder be included in the DSM-V.
I hardly need to mention the deep sadness engendered in me when men like this, with a clear most probably religious agenda—do not let the fact that he chairs the Paraphilia Subcommittee escape you—wield their power to harm instead of heal.
We are psychologists. We are, ultimately, service people. We took up this mantle because we believed, somewhere in our hearts (idealistic, no matter how battered), that we could help shine a light on an otherwise dark and tangled path. When a man like this deliberately takes a wrong turn because of his wrong-headed notions about what constitutes an illness, it isn’t simply ignorance. In an ideal world, we would point and laugh at him just before dismissing him utterly for his ridiculousness. Instead, this man holds lives in his hands.
Mental health is about saving lives. There are many people out there who don’t understand this yet, because the inner workings of the mind are not always written on the body in ways we can easily see. But make no mistake, when we allow this kind of change, we make demons and monsters, we create a false Other who embodies not human struggles and needs and feelings, but our fears. We strip a person of their humanity and replace it with transphobia, with misunderstandings, with hate. We make a person in to a black hole, meant to absorb abuse.
Being transgender does indeed cause challenges, but this proposed change is the same logic that allows our society to say don’t get raped instead of don’t rape. Don’t get bullied instead of don’t bully. It puts the onus on the transgendered person, or the crossdresser, or any person that deviates from a rigid notion of what it is to be normal and properly gendered.
What we should really be saying, as psychologists, as people tuned in to the human condition, is don’t be transphobic.
It’s trans woman. Not “transwoman”. Trans is an adjective. “Transwoman” implies trans women are some sort of pseudo woman, something separate and distinct from a woman. I’m not a brownhairedwoman or an Englishwoman. Being trans has no affect on my, nor any other trans woman’s womanhood, it’s incredibly insulting to insinuate otherwise.
Thank you for your comment, Happy. You are correct. I posted this essay in 09 and have long since spelled trans women and trans men as two separate words, for the reasons you suggest. For the record, my spelling in this post is incorrect.
–Kelley Winters
How would the rest of society like it if these so called experts constantly defined and redefined them as “ill”, “abnormal” or (insert negative label)?! All based on obscure personal theories to support personal or politically motivated agendas. People should be looked at as people! Normal is not a reality, but a theory!!!
Reality is that all people are multifaceted, ever changing, natural beings that are part of an infinite spectrum of natural possibilities and combinations!
It’s things like this which make me upset that I chose to do a psychology degree. This wreaks of ignorance of the highest order. They claim to be using empirical evidence to support any changes in the definition and criteria for their diagnoses but every change seems to be caused by a personal pet hypothesis or some kind of political agenda.
The fact that society has been unable to move on from type-casting and stereotyping straight men as having to conform to x behaviour and yet having different standards for heterosexual, bisexual or pansexual males shows a lack of understanding on the part of the population as a whole. But when a psychologist/psychiatrist can’t even understand the thought processes that these people have it truly saddens me. These people are supposed to be experts in the field that is the human experience yet are so used to diagnosing people as abnormal and are so quick to see any difference in character as a disorder that they miss the reality of the situation and as a result are too quick to come up with new labels to fit to that which they don’t understand.
/rant