An Update on Gender Diagnoses, as the DSM-5 Goes to Press.
December 5, 2012 7 Comments
On December 1, the Board of Trustees for the American Psychiatric Association approved the final draft of the fifth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The most controversial DSM revision in more than three decades, the DSM-5 has drawn strong concerns, ranging from overdiagnosis and overmedication of ordinary everyday behaviors to poor diagnostic reliability in field trials. The transgender-specific categories of Gender Identity Disorder (GID) and Transvestic Fetishism (TF) have been especially contentious, beginning with the 2008 appointment of Drs. Kenneth Zucker and Raymond Blanchard of the Toronto Centre for Addiction and Mental Illness (CAMH) to lead the workgroup for sexual and gender identity disorders. They were key authors of the prior DSM-IV gender diagnoses and leading proponents of punitive gender conversion/reparative psychotherapies (no longer considered ethical practice in the current WPATH Standards of Care).
There are two major issues in transgender diagnostic policy. The first is a false stereotype that stigmatizes gender identities or expressions that differ from birth sex assignment with mental disease and sexual deviance. The second is access to medically necessary hormonal and/or surgical transition care, for those trans and transsexual people who need them. This access requires some kind of diagnostic coding, but not the current “disordered gender identity” label, which actually contradicts rather than supports medical transition care. It is necessary to address both issues together, to avoid harming one part of the trans community to benefit another.
Some of the proposed gender-related revisions in the DSM-5 are positive, however they do not go nearly far enough. The Gender Identity Disorder category (intended by its authors to mean “disordered” gender identity) is renamed to Gender Dysphoria (from a Greek root for distress) Though widely misreported today as “removal” of GID from the classification of disorders, this name change is in itself a significant step forward. It represents a historic shift from gender identities that differ from birth assignment to distress with current sex characteristics or assigned gender role as the focus of the problem to be treated. This message is reinforced by the August 2012 Public Policy Statement from the American Psychiatric Association affirming the medical necessity of hormonal and/or surgical transition care. Moreover, the sexual/gender disorders workgroup has stated a desire to move gender diagnoses away from the sexual dysfunctions and paraphilias group. (At this time of writing, it is not yet clear where they will be classified in the DSM-5.)
On the negative side, the proposed diagnostic criteria for Gender Dysphoria still contradict social and medical transition and describe transition itself as symptomatic of mental illness. The criteria for children are particularly troubling, retaining much of the archaic sexist language of the DSM-IV that pathologizes gender nonconformity rather than distress of gender dsyphoria. Moreover, children who have socially transitioned continue to be disrespected by misgendering language in the diagnostic criteria and dimensional assessment questions. There is very plainly no exit from the diagnosis for those who have completed transition and are happy with their bodies and lives. In other words, the only way to exit the GD label, once diagnosed, is to follow the course of gender conversion/reparative therapies, designed to shame trans people into the closets of assigned birth roles. While supportive care providers will continue to make the diagnosis work for their clients, intolerant clinicians will exploit contradictory language in the diagnostic criteria to deny transition care access and promote unethical gender conversion treatments.
A worse problem in the DSM-5 is the Transvestic Disorder (formerly Transvestic Fetishism) category. It is punitive and scientifically capricious— designed to punish nonconformity to assigned birth roles. It has been expanded to stigmatize even more gender-diverse people and should be removed entirely from the DSM.
Despite retention of the unconscionable Transvestic Disorder category, I believe that the Gender Dysphoria category revisions in the DSM-5 will bring some long-awaited forward progress to trans and transsexual people facing barriers to social and medical transition. I hope that much more progress will follow. In the longer term, I would like to see a non-psychiatric classification in the International Statistical Classification of Diseases and Related Health Problems (ICD, published by the World Health Association) for access to medical transition treatments for those who need them.
Copyright © 2012 Kelley Winters, Ph.D., GID Reform Advocates
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Reblogged this on One HuMan's Journey.
One thought I had… Does anyone at the top there who makes these decisions not see what’s wrong with assigning two straight men to decide the way in which the sexualities and genders of trans people are viewed? Moreover, has anyone within that board selection process stepped in to challenge the ethical and quality deficiencies of the research that those men did on this regard? Especially the work of Ray Blanchard? As far as I have seen, he sees everything relating to gender through the lens of “sexual paraphilia” in spite if research debunking his position, and even if said “trans person” is asexual. I just wish that there was people who actually understood gender and sex heading things things up, because quite frankly I consider Zucker and Blanchard to be quacks. If they were the last psychologist on the Earth, I’d never appoint them to a board that dealt with the way trans people are treated.
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I wrote here: http://clareflourish.wordpress.com/2012/12/10/naming-and-claiming/ about why I dislike the term “gender dysphoria” as a diagnosis: I found my dysphoria to be a sign of health, and not of sickness. It showed that I was sane, so sane that I could assert my true gender against all contrary evidence.
Thanks for the link to your thoughtful essay, Clare. I think I understand where you’re coming from– that the distress of gender dysphoria is a rational response to the underlying condition of physical characteristics that are incongruent to our gender identities, much as throbbing pain is a rational response to hitting our thumbs with a hammer. You argue that the underlying incongruence should be the focus of diagnosis, rather than it’s resulting distress. I took a similar path, supporting “dissonance” and “incongruence” as diagnostic titles in a paper to the 2003 APA Annual Meeting and a 2005 paper in the Journal of Psychology and Human Sexuality. However, I received feedback from folks in the trans community that “incongruence” was too ambiguous in a population as diverse as ours. Lots of trans people are perfectly OK with bodies that differ (according to social convention) from their inner gender identities and have no need of medical transition care. A label of incongruence could be inferred to wrongly pathologize their bodies and “diagnose difference.” We need diagnostic nomenclature that focuses, not on difference from social convention, but specifically on incongruence that is painful/distressing to the individual.
I now favor Gender Dysphoria, from a Greek root for distress, as a more descriptive title, but with a much more precise definition than proposed by the APA (see http://tinyurl.com/atk2png). It’s not a perfect term, but both “dysphoria” and “incongruence” are immensely better than Gender Identity Disorder, which was specifically intended by its key Clarke Institute authors to imply “disordered” gender identity– suggesting that our identities are in themselves pathological and represent confusion. The current GID title and diagnostic criteria were crafted to serve a business model of gender conversion/reparative psychotherapy.
I share your concern about mental disorder diagnosis for a medical problem with a medical solution. In the long term, I would like to see a new coding in a non-psychiatric section of the ICD that would obsolete the need for a DSM coding in North America (and the current psychiatric coding in the ICD).
Finally, it’s important to not forget the unconscionable Transvestic Disorder category in the DSM-5, which explicitly targets transsexual women and men and promotes Blanchard’s scientifically bankrupt theories of “autogynephilia” and “autoandrophilia.” This category needs to be deleted entirely.
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