Stop Sexualizing Us!

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

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

We are here today to say, stop sexualizing us!

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

We say to the APA, stop sexualizing us!

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

We say to the APA, stop sexualizing us!

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

We say to the APA, stop sexualizing us!

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

We say to the APA, stop sexualizing us!

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

We say, to the APA, stop sexualizing us!

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

We say, to the APA, stop sexualizing us!

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

We say, to the APA, stop sexualizing us!

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

We say, to the APA, stop sexualizing us!

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

We say, to the APA, stop sexualizing us!

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

We say, to the APA, stop sexualizing us!

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

We say to the APA, stop sexualizing us!


About the Author:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Questions


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

Just as with microvascular angina, outcomes matter!

What constitutes a good outcome?

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

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

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

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

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

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

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

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

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

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

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

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

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

Transition works! Outcomes matter!

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

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

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

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

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

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

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

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

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

Published here with permission of the author

Copyright © 2009 Rebecca Allison

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

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

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

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

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

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

How can you help?

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

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

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

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


Contact Information:

Alan F. Schatzberg, President, American Psychiatric Association
Carol A. Bernstein, M.D., President-elect, American Psychiatric Association

American Psychiatric Association
1000 Wilson Boulevard
Suite 1825
Arlington, VA 22209
email in care of: apa@psych.org

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

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

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

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

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

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

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

Copyright © 2009 Kelley Winters, GID Reform Advocates

Beyond Conundrum: Strategies for Diagnostic Harm Reduction

summary of presentation given to the

Annual Meeting of the American Psychiatric Association

San Francisco, May 18, 2009

Kelley Winters, Ph.D., GID Reform Advocates

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

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

Recommendations for gender diagnoses in the DSM-V:

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

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

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

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

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

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

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

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

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

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


Recommendations for the Elected Leadership of the American Psychiatric Association

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

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

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

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

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

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

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

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

Further Reading:

GID Reform Advocates, http://www.GIDreform.org

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

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

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

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

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

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