DSM-V Task Force Releases Proposed Diagnostic Criteria

After months of delay, the American Psychiatric Association released proposed diagnostic criteria for the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) at www.dsm5.org. A period of public review and comment begins today and ends April 2oth.  Readers may register and post comments to the dsm5 site through that date.  It is especially important that mental health clinicans who work with transitioning clients are heard in this process.

The publication date for the DSM-5 is now scheduled for May, 2013.

The proposed list of gender related diagnoses in the DSM-V is:

• 302.6 Gender Identity Disorder in Children, renamed Gender Incongruence (in Children)
• 302.85 Gender Identity Disorder in Adolescents or Adults, renamed Gender Incongruence (in Adolescents and Adults)
• 302.6 Gender Identity Disorder Not Otherwise Specified
• 302.3 Transvestic Fetishism, renamed Transvestid Disorder

Preliminary Remarks

At first glance, the proposed changes to the GID criteria offer some forward progress on issues of dignity and barriers to medical transition care. For example, the title of Gender Incongruence is intended to be more descripitive and less stigmatizing. The authorsnoted a significant departure from the prior DSM editions:

We have proposed a change in conceptualization of the defining features by emphasizing the phenomenon of “gender incongruence” in contrast to cross-gender identification per se

However, these revisions don’t go far enough in clarifying distress as the focus of diagnosis, rather than difference from expectations of assigned birth sex. Without this clarification, the change in title to Gender Incongruence loses much of its potential benefit. The phrase, “a strong desire,” in four of the subcriteria for adolescents or adults depict a “desire” to transition in itself as symptomatic of mental illness. This wording obfuscates the distress of gender dysphoria as the clinical problem and implies in its stead that only crazy people would wish to transition. Moreover, the clinical significance criterion, requiring a clinically significant degree of distress or impairment, has been removed entirely. This broadens the scope of diagnosis to people who do not meet the accepted definition of mental disorder or even necessarily suffer gender dysphoria (defined as distress with current physical sex characteristics, and/or ascribed gender role that is incongruent with persistent gender identity). While the DSM-IV clinical significance criterion was flawed in failing to exclude distress/impairment caused by societal prejudice, deleting it entirely undermines the medical necessity of transition treatments and could excascerbate barriers to accessing them. The authors expressed a good intention to provide an exit clause to diagnosis for those whose gender dysphoria has been relieved by transition. However, ambiguous language in subcriteria 5 and 6,

5. a strong desire to be treated as the other gender…
6. a strong conviction that one has the typical feelings and reactions of the other gender…

still allow post-transition and even post-operative individuals to remain diagnosed, however happy and well adjusted they are in their affirmed roles (where “other gender” may be infered in the context of assigned birth-role and not affirmed present role).

Childhood diagnosis is also improved over the DSM-IV-TR. By requiring subcriterion 1A for diagnosis,

A strong desire to be of the other gender or an insistence that he or she is the other gender,

children can no longer be diagnosed purely on the basis of gender role nonconformity. However, the language of Gender Incongruence in Children remains far too focused on arcane gender stereotypes, sexist inequities between masculine and feminine expession, and maligning terms (“boys” and “girls”) based on assigned birth sex rather than experienced or expressed identities. Most important, it is not clear why young children, not yet concerned with access to puberty-delaying treatment, need any diagnosis at all.

Dimensional diagnosis (based on those comedic severity questions) across the entire DSM-V has raised concern by community advocates and two past chairmen of DSM Task Forces. Blurring the boundaries around who is disordered and who is not could potentially implicate huge populations of people not diagnosable under previous DSM editions as mentally ill.

Finally, Transvestic Fetishism, expanded to “Transvestic Disorder” with a particularly offensive specifier of “autogynephilia” to target transsexual women, remains a punitive and defamatory retribution against nonconformity to male birth-assignment. I hope that removing this clothing-focused paraphilia nomenclature entirely from the DSM-V will become a priority for transcommunities and allies in coming weeks and months.

Proposed Diagnostic Criteria for Gender Incongruence in Adolescents or Adults

A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested by 2* or more of the following indicators:

1. a marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or, in young adolescents, the anticipated secondary sex characteristics)
2. a strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or, in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics)
3. a strong desire for the primary and/or secondary sex characteristics of the other gender
4. a strong desire to be of the other gender (or some alternative gender different from one’s assigned gender)
5. a strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender)
6. a strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender)

Subtypes

• With a disorder of sex development
• Without a disorder of sex development

Proposed Diagnostic Criteria for Gender Incongruence in Children

A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested by at least 6* of the following indicators (including A1):

1. a strong desire to be of the other gender or an insistence that he or she is the other gender
2. in boys, a strong preference for cross-dressing or simulating female attire; in girls, a strong preference for wearing only typical masculine clothing and a strong resistance to the wearing of typical feminine clothing
3. a strong preference for cross-gender roles in make-believe or fantasy play
4. a strong preference for the toys, games, or activities typical of the other gender
5. a strong preference for playmates of the other gender
6. in boys, a strong rejection of typically masculine toys, games, and activities and a strong avoidance of rough-and-tumble play; in girls, a strong rejection of typically feminine toys, games, and activities
7. a strong dislike of one’s sexual anatomy
8. a strong desire for the primary and/or secondary sex characteristics that match one’s experienced gender

Subtypes

• With a disorder of sex development
• Without a disorder of sex development

Proposed Diagnostic Criteria for Transvestic Disorder

A. Over a period of at least six months, in a male, recurrent and intense sexual fantasies, sexual urges, or sexual 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.

Specify if:

• With Fetishism (Sexually Aroused by Fabrics, Materials, or Garments)
• With Autogynephilia (Sexually Aroused by Thought or Image of Self as Female)

This essay is also posted in part at The Bilerico Project: daily experiments in LGBTQ .

Copyright © 2010 Kelley Winters, GID Reform Advocates