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