Revisiting Flawed Research Behind the 80% Childhood Gender Dysphoria ‘Desistance’ Myth

Kelley Winters, Ph.D

 

 

In followup to the excellent WPATH Standards of Care, Version 8, meeting at the USPATH conference in February, I would like to re-share my presentation from the 2014 WPATH Symposium titled, “Methodological Questions in Childhood Gender Identity ‘Desistence’ Research.” I’ve formatted it as a video. It includes a specific recommendation to remove unsubstantiated and harmful statements on the statistical likelihood of non-birth assigned gender identity “persistence” in the section on Childhood Social Transition in the Standards of Care.

It is frequently repeated in mental health literature and popular media that the vast majority of children whose gender identity differs from their assigned birth-sex, or who are severely distressed by their birth-sex, will “desist” in their gender identities and gender dysphoria by adolescence. As a consequence, gender dysphoric children are pressed to remain in their birth-assigned roles throughout the world. But are gender dysphoria and diverse gender identities just a phase?

This presentation reexamines research in Canada and The Netherlands that underlies the “desistance” axiom, with respect to methodological rigor and validity of claims.

Please note corrections to slide 27 but not reflected in my original audio recording.

For more information, please see my original 2014 blog post about this presentation.

 

References
American Psychiatric Association (2014). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.

Byne, W., Bradley, S.J., Coleman, E., Eyler, A.E., Green, R., Menvielle, E.J., Meyer-Bahlburg, H.F.L., Pleak, R.R. & Tompkins, D.A. (2012). Report of the American Psychiatric Association Task Force on Treatment of Gender Identity Disorder. Archives of Sexual Behavior, 41(4):759-796.

Drescher, J. (2013) “Sunday Dialogue: Our Notions of Gender,” New York Times, June 29, http://www.nytimes.com/2013/06/30/opinion/sunday/sunday-dialogue-our-notions-of-gender.html

Drummond, Kelley D.; Bradley, Susan J.; Peterson-Badali, Michele; Zucker, Kenneth J. (2008), “A follow-up study of girls with gender identity disorder,” Developmental Psychology. Vol 44(1), Jan 2008, 34-45.

Kennedy, N. (2012) “Transgender children: more than a theoretical challenge,” Goldsmiths College, University of London, http://academia.edu/2760086/

Reed, B., Rhodes, S., Schofield, P., Wylie, K., (2009) “Gender variance in the UK. Prevalence, incidence, growth and geographic distribution,” GIRES – the Gender Identity Research and Education Society, http://www.gires.org.uk/assets/Medpro-Assets/GenderVarianceUK-report.pdf

Steensma, T.D., Biemond, R., de Boer, F. & Cohen-Kettenis, P.T. (2011). Desisting and persisting gender dysphoria after childhood: A qualitative follow-up study. Clinical Child Psychology & Psychiatry, 16(4):499-516.

Wallien, M.S.C. & Cohen-Kettenis, P.T. (2008). Psychosexual outcome of gender-dysphoric children. J American Academy Child & Adolescent Psychiatry, 47:1413-1423.

Winters, K. (2013) Response to Dr. Jack Drescher and the NY Times About Childhood Transition, GID Reform Weblog, July 5, https://gidreform.wordpress.com/category/childhood-social-transition/

World Professional Association for Transgender Health (2011), Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People: Author. http://www.wpath.org

Gender Madness in Psycho-Politics: Transgender Children Under Fire

A presentation to
Gender Infinity
Houston, Texas, USA
September, 2016
Kelley Winters, Ph.D.
GID Reform Advocates

Presentation Slides:  201609infinityg1

 

The Quadrumvirate of Anti-Trans Defamation:

My little taxonomy of false stereotypes about trans adults, adolescents and children, crediting the individuals responsible for searing them into public consciousness:

• Raymondian–alleging that trans women are “deceptive,” sexually “predatory” “men” whose existence poses a threat to the safety of others; and that trans men are “women” rather than authentic men. (Dr. Janice Raymond, University of Massachusetts in Amherst, 1979)
• McHughian–alleging that trans women are “delusional,” “confused,” “mentally ill” “men” (and vice-versa for trans men), and that accepting, respecting or providing transition medical care to trans  people in our authentic roles represents “collaboration” with “mental disorder.” (Dr. Paul McHugh, John Hopkins University, 1979)
• Blanchardian–alleging that most trans and transsexual women are psychosexually disordered “paraphilic” “men,” motivated only by sexual deviance/fetishism. Dr. Blanchard later included trans men to this false stereotype, by adding a so-called “autoandrophilia” specifier to his “transvestic disorder” in an early draft of the DSM-5. (Dr. Ray Blanchard, Clarke Institute of Psychiatry/Centre for Addiction and Mental Health, 1989)
• Zuckerian–alleging that gender dysphoria in the great majority, around 80%, of gender dysphoric children is a passing phase that will “desist” or “remit” by adolescence. Zucker has long promoted and practiced gender conversion “therapeutic intervention,” to enforce birth-assigned gender identities and expressions. (Dr. Kenneth Zucker, Clarke Institute of Psychiatry/Centre for Addiction and Mental Health, 1989)

These stereotypes have been weaponized by political extremist groups to inflict unprecedented systemic, strategic attacks on the human rights and medical care access of trans people and especially trans children.

 

Strategy of Anti-Trans Political, Social and Media Attack:

Coordinated legislation, litigation and misinformation aimed at:

• Eliminating access to Public Accommodation and Education
• Eliminating gender marker correction in official Documents & Records
• Eliminating access to transition medical care
• Legalizing and promoting Gender-Conversion Psychotherapy

 

Architects of systemic public policy attack:

• Family Research Council–authored the blueprint for anti-trans political, social and media attacks in 2013 that has been followed by US extremists nationwide
• Southern Baptist Convention Theological Seminary
• Heritage Foundation
• Republican Party

 

Strategic medical policy issues for the 20-teens:

my own priority list…

• WPATH: clarify and correct the childhood “desistance” myth statement in the SOC7
• WPATH: Issue a public policy statement discrediting the practice of gender-conversion psychotherapies that is consistent with the SOC7
• APA: clarify and correct the childhood “desistance” myth statement in the DSM-5
• APA: remove “Transvestic Disorder” category from the DSM-5
• WHO: initiate substantive conversation on converging the Adult/Adolescent Gender Incongruence categories in the proposed ICD-11 with the childhood category to refute the historical stereotype of childhood gender “confusion” and practice of gender conversion psychotherapies
• US Dept. of HHS: align transition related categories in ICD-10-CM to ICD-11 in 2018
• US Dept. of HHS/CMS: issue a National Coverage Determination for surgical transition care that is recognized as medically necessary by US and international medical authorities

 

A Call to Action

Attention to medical policy reforms that clarify evidence, reduce harm, and benefit health and mortality is as urgent in today’s world as ever. It is an essential step in fixing society for all of the Leelah Alcorns in our midst.

 

References

(under construction…)

Blanchard, R. (1989) “The Classification and Labeling of Nonhomosexual Gender Dysphoria,” Archives of Sexual Behavior, v. 18 n. 4, p. 322-323.

Brennan, C. and Hungerford, .E, (2011) “2011 Letter to the UN on ‘gender identity’ legislation,” http://sexnotgender.com/gender-identity-legislation-and-the-erosion-of-sex-based-legal-protections-for-females/

Drummond, Kelley D.; Bradley, Susan J.; Peterson-Badali, Michele; Zucker, Kenneth J. (2008), “A follow-up study of girls with gender identity disorder,” Developmental Psychology. Vol 44(1), Jan 2008, 34-45.

Ford, Z. (2014) “Three Days In Nashville Talking To Southern Baptists About Homosexuality,” Think Progress, Center for American Progress. http://thinkprogress.org/lgbt/2014/10/30/3586418/southern-baptist-erlc-homosexuality/

McHugh, Paul (1992). “Psychiatric Misadventures,” The American Scholar,
Autumn, http://www.lhup.edu/~dsimanek/mchugh.htm

P. McHugh (2004) “Surgical Sex,” First Things 147:34-38, http://www.firstthings.com/ftissues/ft0411/articles/mchugh.htm , http://www.firstthings.com/article/2004/11/surgical-sex

Raymond, Janice G. (1979) The Transsexual Empire: The Making of the She-male. New York: Teachers College,

Raymond, Janice G. (1980) “Technology on the Social and Ethical Aspects of Transsexual Surgery,” http://www.susans.org/reference/usts1-9.html

Stone, Sandy (1987) THE EMPIRE STRIKES BACK: A POSTTRANSSEXUAL MANIFESTO, http://sandystone.com/empire-strikes-back

Southern Baptist Convention (2014) “On Transgender Identity,” Resolution. http://www.sbc.net/resolutions/2250/on-transgender-identity

Williams, Cristen, (2013) “TERFs & Trans Healthcare [UPDATED],” http://theterfs.com/terfs-trans-healthcare/

Winters, K. (2008) “Disallowed Identities, Disaffirmed Childhood,” GID Reform Weblog, October, https://gidreform.wordpress.com/2008/10/28/disordered-identities-disaffirmed-childhood/

Winters, K. (2008) https://gidreform.wordpress.com/2008/11/10/autogynephilia-the-infallible-derogatory-hypothesis-part-1/

Winters, K. (2008) https://gidreform.wordpress.com/2008/11/19/autogynephilia-the-infallible-derogatory-hypothesis-part-2/

Winters, K. (2008) https://gidreform.wordpress.com/2008/07/01/the-horns-of-a-false-dilemma/

Winters, K. (2012) “These Aren’t the Droids You’re Looking For: Gender Diversity, Scapegoating and Erasure in Medicine and Media,” https://gidreform.wordpress.com/2012/04/21/these-arent-the-droids-youre-looking-for-gender-diversity-scapegoating-and-erasure-in-medicine-and-media/

Winters, K. (2013) “Response to Dr. Jack Drescher and the NY Times About Childhood Transition,” GID Reform Weblog, July 5, https://gidreform.wordpress.com/category/childhood-social-transition/

Winters, K. (2014) “Methodological Questions in Childhood Gender Identity ‘Desistence’ Research,” 23rd World Professional Association for Transgender Health Biennial Symposium, reposted GID Reform Blog, Feb. 25. https://gidreform.wordpress.com/2014/02/25/methodological-questions-in-childhood-gender-identity-desistence-research/

World Professional Association for Transgender Health (2011), Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People: Author. http://www.wpath.org

 

GID Reform in the DSM-5 and ICD-11: a Status Update

I prepared this presentation for the 2013 Philadelphia Transgender Health Conference but did not have the opportunity to attend. It is a summary of recent changes to gender related diagnostic categories in the DSM-5, published last month by the American Psychiatric Association, and proposed changes for the ICD-11, scheduled for publication in 2015 by the World Health Organization.  It is based on proposed revisions to the ICD-11 presented by Drs. Geoffrey Reed, Peggy Cohen-Kettenis and Richard Krueger at the National Transgender Health Summit in Oakland last month and on discussions at the Global Action for Trans* Equality (GATE) Civil Society Expert Working Group in Buenos Aires last April.

In my view, there are two primary issues in medical diagnostic policy for trans people. The first is harmful stigma and false stereotyping of mental defectiveness and sexual deviance, that was perpetuated by the former categories of Gender Identity Disorder (GID) and Transvestic Fetishism (TF) in the DSM-IV-TR. The second is access to medically necessary hormonal and/or surgical transition care, for those trans and transsexual people who need them. The latter requires some kind of diagnostic coding, but coding that is congruent with medical transition care, not contradictory to it. I have long felt that these two issues must be addressed together –not one at the expense of the other, or to benefit part of the trans community at the expense of harming another.

The DSM-5 Falls Short, Despite Some Significant Improvements

The new revisions for the Gender Dysphoria diagnosis in the DSM-5 are mostly positive. However they do not go nearly far enough. The change in title from Gender Identity Disorder (intended by its authors to mean “disordered” gender identity) to Gender Dysphoria (from a Greek root for distress) is a significant step forward. It represents a historic shift from  gender identities that differ from birth assignment to distress with gender assignment and associated sex characteristics 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. In another positive change, the Gender Dysphoria category has been moved from the Sexual Disorders chapter of the DSM to a new chapter of its own. Non-binary queer-spectrum identities and expression are now acknowledged in the diagnostic criteria, and the APA Working Group has rejected pressure to add an “autogynephilia” specifier to falsely stereotype and sexualize trans women. Children can no longer be falsely diagnosed with this mental disorder label, strictly on the basis of nonconformity to birth assignment.

However, the fundamental problem remains that the need for medical transition treatment is still classed as a mental disorder. In the diagnostic criteria, desire for transition care is itself cast as symptomatic of mental illness, unfortunately reinforcing gender-reparative psychotherapies which suppress expression of this “desire” into the closet. The diagnostic criteria still contradict transition and still describe transition itself as symptomatic of mental illness. The criteria for children retain much of the archaic sexist language of the DSM-IV-TR that psychopathologizes gender nonconformity. Moreover, children who have happily socially transitioned are maligned by misgendering language in the new diagnosis.

More troubling is false-positive diagnosis for those who have happily completed transition. Thus, the GD diagnosis, and its controversial post-transition specifier, continue to contradict the proven efficacy of medical transition treatments.  This contradiction may be used to support gender conversion/reparative psychotherapies– practices described as no longer ethical in the current WPATH Standards of Care.

Finally, the Transvestic Disorder category in the DSM-5 is even more harmful than its predecessor, Transvestic Fetishism. Punitive and scientifically capricious, it only serves to punish nonconformity to assigned birth roles and has no relevance to established definition of mental disorder. The Transvestic Disorder category has been expanded in the DSM-5 to implicate trans men as well as trans women, with a new specifier of “autoandrophilia,” apparently pulled from thin air without supporting research or clinical evidence.

The ICD-11, a Historic New Approach

The 11th Revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-11) is scheduled for publication in 2015 by the World Health Organization (WHO). It is a global diagnostic manual that contains chapters for both physical medical conditions and mental conditions. In contrast to the DSM-5, the ICD-11 holds promise for unprecedented forward progress on both issues of social stigma and barriers to medical transition care.  At the National Transgender Health Summit in Oakland last month, members of the ICD-11 Working Group for Sexual Disorders and Sexual Health confirmed proposals for  substantive changes in gender and transition related codings.

The Working Group has proposed a historic shift of transition related categories, now labeled “Gender Incongruence,”  out of the Mental and Behavioural Disorders chapter (called F-Codes) entirely. It is to be placed in a new, non-psychiatric chapter, called “Certain conditions related to sexual health.” The Incongruence title is distinct from DSM-5 dysphoria title, to clarify that this is no longer a mental disorder coding.  They have also proposed to eliminate victimless sexual paraphilia categories from the manual, including: F65.1: Transvestic fetishism. A similar category describing dual gender individuals, F64.1: Dual-role Transvestism, would be deleted as well. These changes have the potential for enormous progress in reducing both stigma and barriers to medical transition care, for those who need it. When implemented, they would effectively obsolete the new psychopathology categories of Gender Dysphoria and Transvestic Disorder in the DSM-5.

There are also questions and shortcomings in the current  ICD-11 proposals.  While the proposed children’s coding of  Gender Incongruence of Childhood is no longer a mental disorder label,  any pathologizing coding of happy gender nonconforming or socially transitioned children, who are too young to need any medical transition or puberty-blocking treatment, is highly controversial among clinicians, families and community members.  The diagnostic criteria for children, like those in the DSM-5, still emphasize nonconformity to anachronistic gender stereotypes as symptomatic of sickness. The adult and adolescent criteria have copied ambiguous language from the DSM-5 that cast desire for transition, in itself, as pathological. Worse yet, false-positive diagnosis of happy post-transition subjects inadvertently contradicts rather than supports medical transition care.

The ICD-11 Working Group for Sexual Disorders and Sexual Health should be commended for advancing these historic reforms. However, it is important that Group members listen to the remaining concerns of community members and supportive care providers.  Adults and adolescents needing access to medical transition care, or pubescent youth needing puberty blocking medications, require a clearer description of the problem to be treated. Young children, who may only need information, monitoring and support, have very different diagnostic needs and diagnostic risks than adults and adolescents.

Gender Dysphoria Diagnosis to be Moved Out of Sexual Disorders Chapter of DSM-5

Protest at 2009 APA Annual Meeting (photo Kelley Winters)

Dr. Jack Drescher,  a member of the subworkgroup on Gender Identity Disorders of the DSM-5 Workgroup on Sexual and Gender Identity Disorders, confirmed yesterday that the Gender Dysphoria Diagnosis will be removed from the sexual disorders chapter and placed in a separate category in the Diagnostic and Statistical Manual of Mental Disorders:

 GD is supposed to be placed in a chapter of its own, no longer linked with sexual dysfunctions and paraphilias (which will also have chapters of their own)

This reclassification, along with the change in title from Gender Identity Disorder to Gender Dysphoria, is a significant improvement in the diagnostic coding used for access to medical transition care, for trans and transsexual people who need it. Preceding diagnoses of Transsexualism/Gender Identity Disorders were grouped with “psychosexual” disorders in the DSM-III. They were briefly moved to the class of Disorders Usually First Evident in Infancy, Childhood or Adolescence in the DSM-III-R in 1987 but were returned to the sexual disorders chapter in the  DSM-IV, and DSM-IV-TR. Community advocates and supportive medical providers have long raised concern that this placement was clinically misleading and reinforced false stereotypes about gender diversity. Gender identity  is not specifically related to sexuality, sexual orientation or sexual dysfunction. Political and religious extremists have  exploited the sexual disorder grouping in the DSM to sexualize gender diversity and defame trans people as deviant. Trans and transsexual individuals have consequently lost their jobs, homes, families, children, and civil justice.

The DSM-5 working group responsible for sexual and gender diagnoses hinted at a possible change in diagnostic placement in February, 2010, stating

The subworkgroup questions the rationale for the current DSM-IV chapter Sexual and Gender Identity Disorders, which contains three major classes of diagnoses: sexual dysfunctions, paraphilias, and gender identity disorders… Various alternative options to the current placement are under consideration.

The decision to separate the revised Gender Dysphoria category from sexual disorders is consistent with a previous determination by the working group to remove sexual orientation specifiers from the diagnostic criteria. While many shortcomings remain in the proposed Gender Dysphoria diagnosis, this change in placement in the DSM represents forward progress for trans and especially transsexual individuals.

Unfortunately, the DSM-5 Task Force and APA Board of Trustees retained the Transvestic Disorder category in the sexual disorders chapter. Previous known as Transvestic Fetishism, it is grouped with paraphilic diagnoses such as pedophilia and exhibitionism and authored by Dr. Raymond Blanchard of the Toronto Centre for Addiction and Mental Health (formerly called the Clarke Institute of Psychiatry). This punitive and scientifically capricious category maligns many gender variant people, including transsexual women and men, as mentally ill and sexually deviant, purely on the basis of nonconforming gender expression. It is written to promote Blanchard’s unfounded theories of “autogynephilia” and “autoandrophilia” that conflate social and medical gender transition with fetishism. More than 7000 people have signed an online petition, sponsored by the International Foundation for Gender Education (IFGE), calling for the removal of this harmful diagnosis from the DSM.

Copyright © 2012 Kelley Winters, Ph.D., GID Reform Advocates

An Update on Gender Diagnoses, as the DSM-5 Goes to Press.

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

The American Psychiatric Association Issues Historic Position Statements on Trans Issues

Now don’t be sad
‘Cause two out of three ain’t bad
–Meat Loaf, 1977

On May 18, 2009, about 150 trans community members and allies gathered outside the Annual Meeting of the American Psychiatric Association in San Francisco to protest diagnostic policies that psychopathologize gender diversity. Bull horn in hand, I and others called upon the APA leadership to issue three public position statements in support of the dignity and health of trans and gender variant people:

1. That gender identity and expression which differ from assigned birth sex do not, in themselves, constitute mental disorder or impairment in judgment or competence.
2. That hormonal and/or surgical transition treatment, for those who need them, is medically necessary and should be covered by insurance and health care policies.
3. That the APA opposes discrimination on the basis of gender identity or expression and supports legal recognition of all people according to their gender identity and expression.

A month later, over 400 supporters endorsed a letter to APA President Alan Schatzberg and President-elect Carol Bernstein urging passage of these policy statements. The APA had, after all, issued numerous similar statements in support of other marginalized groups in past years but had never made a single position statement supporting civil justice and health care access for trans and gender variant people.

The response from APA officials was silence– three years of it.

Then last week, on August 16, the APA announced two of these position statements, authored by Drs. Jack Drescher and Ellen Haller and approved by votes of the Assembly and Board of Trustees. The first acknowledged the efficacy and medical necessity of hormonal and/or surgical transition treatment and the barriers to accessing this care faced by those who need it. Similar transition care policy statements were issued in 2008 by the American Medical Association, the American Psychological Association, and the World Professional Association for Transgender Health (WPATH).

Position Statement on Access to Care for Transgender and Gender Variant Individuals

Therefore, the American Psychiatric Association:

1. Recognizes that appropriately evaluated transgender and gender variant individuals can benefit greatly from medical and surgical gender transition treatments.
2. Advocates for removal of barriers to care and supports both public and private health insurance coverage for gender transition treatment.
3. Opposes categorical exclusions of coverage for such medically necessary treatment when prescribed by a physician.

The second position statement acknowledges harassment and discrimination that trans and gender variant people face in employment, education, parental rights and civil justice. It notes that trans people are frequently victimized in violent hate crimes and inappropriately assigned in gender-segregated facilities . Similar nondiscrimination statements were issued by the National Association of Social Workers in 1999, the American Psychological Association in 2008, and WPATH in 2010.

Position Statement on Discrimination Against Transgender and Gender Variant Individuals

Therefore, the American Psychiatric Association:

1. Supports laws that protect the civil rights of transgender and gender variant individuals
2. Urges the repeal of laws and policies that discriminate against transgender and gender variant individuals.
3. Opposes all public and private discrimination against transgender and gender variant individuals in such areas as health care, employment, housing, public accommodation, education, and licensing.
4. Declares that no burden of proof of such judgment, capacity, or reliability shall be placed upon these individuals greater than that imposed on any other persons.

Although the American Psychiatric Association lags years behind other leading medical and mental health associations in speaking out, these position statements represent an unprecedented shift in acceptance of human gender diversity by the APA leadership and membership. The background text to the discrimination statement notes:

In contrast to its strong affirmation of lesbian and gay civil rights since the 1973 decision to remove homosexuality from the DSM, APA has not issued position statements in support of transgender civil rights… Other organizations, including the American Medical Association and the American Psychological Association, have endorsed strong policy statements deploring the discrimination experienced by gender variant and transgender individuals and calling for laws to protect their civil rights .

The statement text reaffirms the role of advocacy in the APA mission: “ Speaking out firmly and professionally against discrimination and lack of equal civil rights is a critical advocacy role that the APA is uniquely positioned to take.”  Given the APA’s unique position in setting diagnostic policy that has been historically used to limit civil justice and transition care access for trans people, these position statements come far better late than never.

However, the APA statements fall short of debunking the false stereotype that gender difference is inherently pathological. The association’s ambivalence on the mental illness stereotype is reflected in the “Report of the American Psychiatric Association Task Force on Treatment of Gender Identity Disorder ,” published in June, 2012:

The Task Force could not reach a consensus regarding the question of whether or not persistent cross-gender identification sufficient to motivate an individual to seek sex reassignment, per se, is a form of psychopathology in the absence of clinically significant distress or impairment due to a self-perceived discrepancy between anatomical signifiers of sex and gender identity. 

In other words, this APA Treatment Task Force (a separate group from the DSM-5 Task Force) declined to refute the false stereotype of “disordered” gender identity. This is troublesome, because the proposed diagnostic criteria for the Gender Dysphoria category in the pending Fifth Edition of the APA’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5) continue to mischaracterize gender identities and expressions that do not conform to birth-assigned gender stereotypes as symptomatic of mental illness. By describing social and medical transition itself, or the desire for transition, as pathological, the new Gender Dysphoria diagnosis, like its controversial predecessor Gender Identity Disorder (GID), contradicts rather than supports the medical necessity of transition care that is affirmed in the new APA position statement. Even worse, the Transvestic Disorder category in the DSM-5 ascribes nonconforming gender expression and medical transition for many transsexual women and men to a defamatory false stereotype of sexual deviance and paraphilia. Ironically, the medical care statement acknowledges these contradictions in the DSM–

…the presence of the GID diagnosis in the DSM has not served its intended purpose of creating greater access to care–one of the major arguments for diagnostic retention .

Thankfully, there is evidence of change in attitudes toward gender diversity at the American Psychiatric Association. In 2010, the DSM-5 Task Force proposed to rename the widely despised Gender Identity Disorder title (intended to imply “disordered” gender identity) to Gender Incongruence and a further change in 2011 to Gender Dysphoria (from a Greek root for distress). These revisions were explained as a paradigm shift from diagnosing difference to a focus on incongruence or discrepancy that causes distress or impairment.

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.

The APA Position Statement on Discrimination contains the APA’s strongest statement to date that gender difference is not disease:

Being transgender gender or variant implies no impairment in judgment, stability, reliability, or general social or vocational capabilities; 

The fourth bullet point of the APA Position repeats this key principle:

Declares that no burden of proof of such judgment, capacity, or reliability shall be placed upon these individuals greater than that imposed on any other persons. 

This particular wording is historically significant; it is paraphrased from a 1973 quote by Dr. Robert Spitzer, chief editor of the DSM-III and DSM-III-R, arguing to depathologize same sex orientation:

In the past, homosexuals have been denied civil rights in many areas of life on the ground that because they suffer from a ‘mental illness’ the burden of proof is on them to demonstrate their competence, reliability, or mental stability.

Throughout his career, Spitzer has refused to apply this same reasoning to the plight of gender variant and especially transsexual people, who continue to bear a very similar burden.

Though long overdue, these position statements on Discrimination and Access to Care for Transgender and Gender Variant Individuals represent a historic step forward in reducing barriers to civil justice and transition care access. But they do not go far enough in deconstructing false stereotypes that equate gender diversity with mental sickness and sexual deviance. In the context of the proposed gender diagnoses in the DSM-5 and the recent treatment task force report, they represent a mixed message. In contrast, the World Professional Association for Transgender Health issued an unambiguous De-Psychopathologisation Statement in 2010 that provides a model for professional organizations that serve trans and gender diverse people:

The WPATH Board of Directors strongly urges the de-psychopathologisation of gender variance worldwide. The expression of gender characteristics, including identities, that are not stereotypically associated with one’s assigned sex at birth is a common and culturally-diverse human phenomenon which should not be judged as inherently pathological or negative. The psychopathologlisation [sic] of gender characteristics and identities reinforces or can prompt stigma, making prejudice and discrimination more likely, rendering transgender and transsexual people more vulnerable to social and legal marginalisation and exclusion, and increasing risks to mental and physical well-being.

Please join me in thanking Drs. Drescher and Haller and the American Psychiatric Association leadership for these policy statements that acknowledge the worth and dignity of trans and transsexual individuals. In addition, I urge the APA to issue a position statement that gender identity and expression which differ from assigned birth sex do not, in themselves, constitute mental disorder; to correct diagnostic criteria in the proposed Gender Dysphoria category that malign gender nonconforming expression and transition itself as pathological; and to delete the punitive and scientifically capricious Transvestic Disorder diagnosis from the DSM-5.

Copyright © 2012 Kelley Winters, Ph.D., GID Reform Advocates

Third Swing: My Comments to the APA for a Less Harmful Gender Dysphoria Category in the DSM-5

My objective for GID reform in DSM-5 is harm reduction– depathologizing gender identities, gender expressions or bodies that do not conform to birth-assigned gender stereotypes, while at the same time providing some kind of diagnostic coding for access to medical transition treatment for those who need it. I and others have suggested that diagnostic criteria based on distress and impairment, rather than difference from cultural gender stereotypes, offer a path for forward progress toward these goals. This post is an update to my earlier comments to the APA in June, 2011.

The  Gender Dysphoria (GD) criteria proposed by the Sexual and Gender Identity Disorders Work Group for the DSM-5 represent some forward progress on issues of social stigma and barriers to medical transition care, for those who need it. However, they do not go nearly far enough in clarifying that nonconformity to birth-assigned roles and victimization from societal prejudice do not constitute mental pathology. The improvements in the APA proposal so far include a more accurate title, removal of Sexual Orientation Subtyping, rejection of “autogynephilia” subtyping (suggested in the supporting text of the GID category in the DSM-IV-TR), recognition of suprabinary gender identities and expressions, recognition of youth distressed by anticipated pubertal characteristics, and reduced false-positive diagnosis of gender nonconforming children. However, the proposed GD criteria still fall short in serving the needs of transsexual individuals, who need access to medical transition care, or other gender-diverse people who may be ensnared by false-positive diagnosis.

The proposed Gender Dysphoria criteria continue to contradict social and medical transition by mis-characterizing transition itself as symptomatic of mental disorder and obfuscating the distress of gender dysphoria as the problem to be treated. The phrase “a strong desire,” repeated throughout the diagnostic criteria, is particularly problematic, suggesting that desire for relief from the distress of gender dysphoria is, in itself, irrational and mentally defective. This biased wording discourages transition care to relieve distress of gender dysphoria and instead advances gender-conversion psychotherapies intended to suppress the experienced gender identity and enforce birth-assigned roles. The World Professional Association for Transgender Health (WPATH) has stated that, “Such treatment is no longer considered ethical.” (SOC, Ver. 7, 2011)

Transitioned individuals who are highly functional and happy with their lives are forever diagnosable as mentally disordered under flawed criteria that reference characteracterics and assigned roles of natal sex rather than current status. For example, a post-transition adult who is happy in her or his affirmed role, wants to be treated like others of her/his affirmed gender, has typical feelings of those in her/his affirmed gender, and is distressed or unemployed because of external societal prejudice will forever meet criteria A (subcriteria 4, 5 and 6) and B and remain subject to false-positive diagnosis, regardless of how successfully her or his distress of gender dysphoria has been relieved. Once again, the proposed criteria effectively refute the proven efficacy of medical transition care. Political extremists and intolerant insurers, employers, and medical providers will continue to exploit these diagnostic flaws to deny access to transition care for those who need it. The World Professional Association for Transgender Health (WPATH) has affirmed the medical necessity of transition care for the treatment of gender dysphoria. (SOC, Ver. 7, 2011)

The criteria for children are slightly improved over the DSM-IV-TR, in that they can no longer be diagnosed on the basis of gender role nonconformity alone. However, the proposed criteria are unreasonably reliant on gender stereotype nonconformity. Five of eight proposed subcriteria for children are strictly based on gender role nonconformity, with no relevance to the definition of mental disorder. Behaviors and emotions considered ordinary or even exemplary for other (cisgender) children are mis-characterized as pathological for gender variant youth. This sends a harmful message that equates gender variance with sickness. As a consequence, children will continue to be punished, shamed and harmed for nonconformity to assigned birth roles.

A New Distress-based Diagnostic Paradigm.

An international group of mental health and medical clinicians, researchers and scholars, Professionals Concerned With Gender Diagnoses in the DSM, has proposed alternative diagnostic nomenclature based on distress rather than nonconformity (Lev, et al., 2010; Winters and Ehrbar 2010; Ehrbar, Winters and Gorton 2009). These include anatomic dysphoria (painful distress with current physical sex characteristics) as well as social role dysphoria (distress with ascribed or enforced social gender roles that are incongruent with one’s inner experienced gender identity) For children and adolescents, these alternative criteria include distress with anticipated physical sex characteristics that would result if the youth were forced to endure pubertal development associated with natal sex. For those who require a post-transition diagnostic coding for continued access to hormonal therapy, the criteria include sex hormone status. Psychologist Anne Vitale (2010) has previously described this distress as deprivation of characteristics that are congruent with inner experienced gender identity, in addition to distress caused directly by characteristics that are incongruent.

Building on this prior work, I propose that gender role component of gender dysphoria, including distress with a current incongruent social gender role and distress with deprivation of congruent social gender expression, can be more concisely described as impairment of social function in a role congruent with a person’s experienced gender identity. I believe it is also important to include other important life functions, such as sexual function in a congruent
gender role. This language would provide a clearer understanding of the necessity of social and medical transition for those who need them.

These alternative criteria acknowledge that experienced gender identity may include elements of masculinity, femininity, both or neither and are not limited to binary gender stereotypes. They also define clinically significant distress and impairment to include barriers to functioning in one’s experienced congruent gender role and exclude victimization by social prejudice and discrimination.

Suggested Diagnostic Criteria for Gender Dysphoria in the DSM-5

I would like to suggest the following diagnostic criteria for the Gender Dysphoria for adults/adolescents and children–

A. Distress or impairment in life functioning caused by incongruence between persistent experienced gender identity and current physical sex characteristics in adults or adolescents who have reached the earlier of age 13 or Tanner Stage II of pubertal development, or with assigned gender role in children, manifested by at least one of the following indicators for a duration of at least 3 months. Incongruence, for this purpose, does not mean gender expression that is nonconforming to social stereotypes of assigned gender role or natal sex. Experienced gender identities may include alternative gender identities beyond binary stereotypes.

A1. Distress or discomfort with one’s current primary or secondary sex characteristics,
including sex hormone status for adolescents and adults, that are incongruent with
experienced gender identity, or with anticipated pubertal development associated with
natal sex.
A2. Distress or discomfort caused by deprivation of primary or secondary sex
characteristics, including sex hormone status, that are congruent with experienced
gender identity.
A3. Impairment in life functioning, including social and sexual functioning, in a role
congruent with experienced gender identity.

B. Distress, discomfort or impairment is clinically significant. Distress, discomfort or
impairment due to external prejudice or discrimination is not a basis for diagnosis.

References

World Professional Association for Transgender Health (2011), Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People, http://www.wpath.org/documents/Standards%20of%20Care_FullBook_1g-1.pdf

Lev, A.I., Winters, K., Alie, L., Ansara, Y., Deutsch, M., Dickey, L., Ehrbar, R., Ehrensaft, D., Green, J., Meier, S., Richmond, K., Samons, S., Susset, F., (2010). “Response to Proposed DSM-5 Diagnostic Criteria. Professionals Concerned With Gender Diagnoses in the DSM.” Retrieved December 4, 2010 from: http://professionals.gidreform.org

Winters, K. and Ehrbar, R. (2010) “Beyond Conundrum: Strategies for Diagnostic Harm Reduction,” Journal of Gay & Lesbian Mental Health, 14:2, 130-139, April

Ehrbar, R., Winters, K., Gorton, N. (2009) “Revision Suggestions for Gender Related Diagnoses in the DSM and ICD,” The World Professional Association for Transgender Health (WPATH) 2009 XXI Biennial Symposium, Oslo, Norway, http://www.gidreform.org/wpath2009/

Vitale, A. (2010) The Gendered Self: Further Commentary on the Transsexual Phenomenon, Lulu, http://http://www.avitale.com/

 

Copyright © 2012 Kelley Winters, GID Reform Advocates

 

These Aren’t the Droids You’re Looking For: Gender Diversity, Scapegoating and Erasure in Medicine and Media

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

On the April 18th broadcast of The Rachel Maddow Show, Dr. Maddow reported an “explosive revelation” that Psychiatrist Robert Spitzer had rescinded his controversial 2001 claim that sexual conversion, or sexual reparative, psychotherapies can change sexual orientation in gay and lesbian people. Quoting an interview of Dr. Spitzer in The American Prospect, Maddow celebrated the historical significance of Spitzer’s reversal for the gay rights movement, calling it,

step one in what we’re now going to see as a real change, a real reckoning, in antigay politics.

Sadly, Dr. Maddow only told half of the story. For four decades, Robert Spitzer has played pivotal roles in mental health policies, not only on sexual orientation, but on gender diversity as well. This week, Rachel Maddow and other journalists turned a blind eye to Dr. Spitzer’s failure to retract a lifetime of trans psychopathologization, stereotyping gender identities and expression that differ from assigned birth roles as mental disease. This omission speaks to the marginal status of trans people within the GLbt rights movement and progressive media, as much as Spitzer’s omission speaks to trans marginalization by mental health policymakers. Shifting stigma from one oppressed class to a more oppressed class is not real change.

At the 1973 annual meeting of the American Psychiatric Association, Robert Spitzer played a central role in arguing for declassification of same-sex orientation as mental illness:

In the past, homosexuals have been denied civil rights in many areas of life on the ground that because they suffer from a ‘mental illness’ the burden of proof is on them to demonstrate their competence, reliability, or mental stability.

This led to the gradual deletion of sexual orientation categories from the Diagnostic and Statistical Manual of Mental Disorders (DSM) between 1973 and 1987. The DSM is published by the American Psychiatric Association and remains the medical and cultural definition of mental disorder in North America. As Chairman of the DSM-III and DSM-III-R Task Forces and chief editor of the diagnostic manual, Spitzer oversaw removal of the last major vestige of gay diagnosis, “Ego-dystonic Homosexuality,” from version III-R.

However, while depathologizing same-sex orientation, Dr. Spitzer simultaneously directed a massive expansion of trans-pathology diagnoses in the DSM. In 1980, a new category of Gender Identity Disorders (GID), including a Transsexualism (TS) diagnosis, was added to the class of Psychosexual Disorders in the DSM-III. The TS coding was paradoxical and controversial for many trans people. Many community advocates and medical providers agreed (and do today) that some kind of diagnostic coding was necessary to facilitate access to medical and/or surgical transition care for those trans and transsexual people who needed it.  On the other hand, defining a medical transition coding as a mental illness, rather than a treatable medical condition, contradicted access to hormonal and/or surgical transition care and encouraged gender conversion, or gender-reparative, psychotherapies— unsubstantiated treatments attempting to change gender identity and shame trans and TS people into the closets of their assigned birth roles.  Vulnerable trans and gender nonconforming youth were targeted and institutionalized as a consequence of diagnostic criteria based on nonconformity to birth-assigned stereotypes.

In the DSM III-R, Dr. Spitzer’s Task Force expanded the diagnostic criteria for children to emphasize gender role nonconformity for birth-assigned girls, including “persistent marked aversion to normative feminine clothing” (whatever that means).  Even more damaging, a new category was added, Gender Identity Disorder of Adolescence or Adulthood, Nontranssexual Type (GIDAANT), to psychopathologize for the first time the gender identities of trans people who did not need access to medical transition care.

The disorder of Transvestism in the DSM-III was renamed “Transvestic Fetishism” in the DSM-III-R, to further stigmatize crossdressing or gender nonconformity by birth-assigned males as sexual obsession. This change served to sexualize a diagnosis that did not clearly require a sexual context in its diagnostic criteria.  The DSM-IV Casebook, edited by Dr. Spitzer in 1994, went even further in pathologizing gender nonconformity, recommending a Transvestic Fetishism diagnosis for a self-accepting bigender male, whose crossdressing was not necessarily erotically motivated and whose primary distress was his spouse’s intolerance.

In 2001, Robert Spitzer tacked to the political right on sexual orientation, presenting a paper entitled,”Can Some Gay Men and Lesbians Change Their Sexual Orientation? 200 Participants Reporting a Change from Homosexual to Heterosexual Orientation,” to the Annual Meeting of the American Psychiatric Association. It was published in the Archives of Sexual Behavior two years later. Spitzer promoted sexual conversion, or sexual-reparative, psychotherapies as “a rational choice” and affirmed their efficacy, stating,

there is evidence that change in sexual orientation following some form of reparative therapy does occur in some gay men and lesbians.

Moreover, Spitzer denied mounting evidence that sexual-reparative psychotherapies cause harm and even criticized the American Psychiatric Association for denouncing the practice as unethical.  At the same time, he revealed his bias on gender diversity and gender conversion therapies, describing “a greater sense of masculinity in males, and femininity in females,” as a therapeutic “benefit.”

By 2003, Dr. Spitzer’s statements had drawn a firestorm of dissent from GLB communities and supportive mental health professionals. Wayne Besen, founder of Truth Wins Out, characterized Spitzer’s study as,

just the latest attempt by the political religious right to gain legitimacy for their arguments by teaming up with a supposedly unbiased scientist.

Indeed, antigay extremists, including the National Association for Research & Therapy of Homosexuality (NARTH), embraced the Spitzer paper as mainstream endorsement of their sexual-reparative psychotherapies:

These results would seem to contradict the position statements of the major mental health organizations in the United States, which claim there is no scientific basis for believing psychotherapy effective in addressing same-sex attraction. Yet Spitzer reports evidence of change in both sexes…

Spitzer’s response to mounting criticism of his scientific rigor was to backpedal from his “rational choice” position, clarifying, “Of course no one chooses to be homosexual and no one chooses to be heterosexual.” At the very same time, however, he doubled down on his characterization of trans people as mentally defective.

Sexual and Gender Identity Disorders symposium from the 2003 APA Annual Meeting. From the left, Drs. Karasic (speaking), Hill, Winters, Moser, Drescher, Spitzer (front), and Fink.

In May, 2003, Dr. Spitzer and I presented papers to a symposium entitled, “Sexual and Gender Identity Disorders: Questions for the DSM-V” at the Annual Meeting of the American Psychiatric Association. The only trans person and non-clinical scholar in the session, I sat on the left side of the stage table with presenters advocating reform of the Gender Identity Disorder (GID) and paraphilia diagnoses in the DSM-5. At the far right end of the table, Spitzer joined former APA President Dr. Paul Fink in defending the status quo. Spitzer wasted no time in invoking the worn stereotype of disordered gender identity:

Children normally develop a sense of gender identity. It is not taught—it just happens. I would argue that by itself, the failure to develop a gender identity that is congruent with biological gender is a dysfunction.

He continued, plodding down a path of cave-man essentialism:

In all cultures, young boys want to play with boys, Young girls want to play with girls… If you are interested in evolutionary psychology, you ask yourself could that have some survival value? The answer is yes. Thousands of years ago when men were more likely to be in hunting and women were more likely to be in the nurturing role, if you were a young boy you would do better if you spent your time with other boys with whom, when you were older, you would go to the hunt.

And Spitzer didn’t stop there, adding,  “…in all cultures, gender is recognized as a dichotomy.”

This could not be further from the truth. Global human history holds a great many indigenous cultures with more than two recognized sex and gender roles.  These include Tahitian and Hawaiian Mahu, Madagascar Sekrata, Hindu Tantric and Hijra Sects, Islamic Xanith, Khawal, and Sufi traditions and numerous Native American, or First Nation, Two Spirit traditions, and many others.

At the 2003 APA Meeting, Dr. Spitzer disparaged gender variant identities and expressions as pathological if they did not serve functions that he termed, “expected.” In my 2008 book, Gender Madness in American Psychiatry: Essays from the Struggle for Dignity, I questioned his evolutionary speculations,

who gets to decide what is ‘expected’? From whose perch of social privilege is American psychiatry to pass judgment upon the evolutionary worthiness of a class of people who have survived since human antiquity?

In the May, 2006, issue of Congressional Quarterly Researcher, Robert Spitzer debated UC San Francisco psychiatrist Dan Karasic on the question of GID as a mental illness. Spitzer used his most defamatory language to date to argue that well adjusted post-transition adults should continue to be regarded as mentally ill, so long as they deviate from their birth-assigned sex roles:

Granted that hormone therapy or surgery may now be the only treatment that we can now offer the adult with GID… But surely something remains profoundly wrong psychologically with individuals who are uncomfortable with their biological sex and insist that their biological sex is of the opposite sex. The only diagnosis that is appropriate for such cases is GID.

In issues of social discrimination, historic context matters. Cisgender GLB people had every right to their outrage at Spitzer’s 2001 attack on their dignity. This week, they had cause to celebrate his retraction. Wayne Besen noted that,

Spitzer just kicked out the final leg from the stool on which the proponents of ‘ex-gay’ therapy based their already shaky claims of success.

Perhaps, but trans and especially transsexual people are not celebrating. Dr. Spitzer and like-minded policymakers in American Psychiatry have long kicked the the legs from under our human legitimacy, and the rush to his redemption in progressive media has cast our issues aside once again.

We too have been injured by Robert Spitzer’s role in perpetuating defamatory stereotypes of mental “dysfunction” and deviance. Trans people continue to lose our jobs, homes, children, families, dignity and civil justice because of these stereotypes and continue to face predatory gender conversion psychotherapies. These stereotypes lie behind every extremist political campaign that demeans our most basic civil rights as “bathroom bills.” These stereotypes lie behind military discrimination and government policies that still malign us as “mentally unfit.” These stereotypes convince parents and school officials to dismiss trans youth as “confused” or going through “a phase.” Trans communities have waited more than two decades for a retraction or an apology from Dr. Spitzer. and we are still waiting.

Copyright © 2012 Kelley Winters, GID Reform Advocates

The Proposed Gender Dysphoria Diagnosis in the DSM-5

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

Last month, the American Psychiatric Association (APA) released a second round of proposed diagnostic criteria for the 5^th Edition of The Diagnostic and Statistical Manual of Mental Disorders (DSM-5). These include two diagnostic categories that impact the trans communities, Gender Dysphoria (formerly Gender Identity Disorder, or GID) and Transvestic Disorder (Formerly Transvestic Fetishism). For decades, the GID diagnosis has drawn protest from trans and transsexual communities, their allies and supportive medical and mental health professionals for its depiction of gender diversity, gender transition and medical transition care as mental illness and sexual deviance. The current diagnostic criteria for GID in the DSM-IV-TR cast difference from stereotypes of birth-assigned gender roles as pathological and are biased to favor harmful gender-reparative psychotherapies that enforce birth-role conformity. However, many community advocates and supportive medical professionals agree that some kind of diagnostic coding is necessary to facilitate access to medical and/or surgical transition care for those trans and transsexual people who need it. There is a need to replace the GID category with diagnostic nomenclature that is consistent with transition care, for those who need it, rather than contradicting transition care. There is a need for diagnostic nomenclature that does not harm those it is intended to help.

I urge trans community members, friends, care providers and allies to call upon the APA to clarify in the DSM-5 that nonconformity to birth-assigned roles and being victims of societal prejudice are not, in themselves, mental pathology. The current period for public comment to the APA ends June 15.

The APA Proposal Falls Short

The Sexual and Gender Identity Disorders Workgroup of the DSM-5 Task Force has partially responded to concerns about the GID diagnosis. For example, the derogatory title of Gender Identity Disorder (intended to imply, “disordered” gender identity) has been replaced with Gender Dysphoria, from a Greek root for distress. DSM-5 authors have expressed an willingness to focus on distress with incongruent physical characteristics and assigned gender roles, rather than on diagnosing difference (Ophelian 2010).

Moreover, the workgroup has articulated a historic shift in diagnostic focus away from the stereotype of “disordered” gender identity:

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 (APA 2011A)

However, the workgroup has not reflected these principles in the diagnostic criteria for Gender Dysphoria. They retain much of the flawed language from the DSM-IV, casting difference from birth-assigned roles and a desire for medical transition treatment, in themselves, as symptomatic of mental disorder. Worse yet, post-transition people who are happy with their bodies and affirmed roles remain entrapped by the diagnostic criteria and specifiers, permanently labeled as mentally and sexually disordered. The proposed diagnostic criteria and categorical placement in the DSM continue to contradict transition and describe transition itself as pathological.

Social Stigma.

The proposed Gender Dysphoria diagnosis describe identities and expressions that differ from assigned birth sex as mental illness and sexual deviance. Behaviors and emotions considered ordinary or even exemplary for other (cisgender) people are mis-characterized as madness for gender variant people and especially children. For example,

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 (APA 2011B)

In fact, five of the proposed subcriteria for children are strictly based on gender role nonconformity, with no relevance to the definition of mental disorder. As a consequence of similar criteria in the current DSM-IV-TR, children are punished and shamed for nonconformity to assigned birth roles.

Additionally, the Gender Dysphoria diagnosis is categorized with sexual disorders in the DSM. Although the work group noted that, “gender diagnoses will be separated from the sexual dysfunctions and paraphilias,” (APA 2011B). this decision falls short of addressing concerns about harmful stigma raised by clinicians, community advocates, and the World Professional Association for Transgender Health (2010A). Transwomen (those who identify as women and were birth-assigned male) are often maligned as crazy and sexually suspect “men” by the stigma of mental illness and sexual deviance that is perpetuated by these criteria and placement with sexual disorders, and vice versa for transmen. Gender variant and especially transsexual people lose jobs, homes, families, access to public facilities, and even custody and visitation of children as consequences of these false stereotypes.

Medical Transition Care Access.

The proposed Gender Dysphoria criteria continue to pose barriers for access to medically necessary hormonal and surgical transition treatment for those who need them. They contradict social and medical transition and mis-characterize transition itself as symptomatic of mental disorder. For example, four of six adult subcriteria describe a “strong desire” for social or medical transition as symptomatic of mental disorder (APA 2011A), without describing underlying distress or deprivation of life function that might underlie a desire for corrective treatment. This would be akin to classifying a desire for cancer treatment as pathological, rather than the cancer itself.

Transitioned individuals who are highly functional and happy with their lives are forever diagnosable as mentally disordered, according to the proposed criteria. For example, a post-transition person who wants to continue living in her or his affirmed role, wants to be treated like others of her/his affirmed gender, has typical feelings of those in her/his affirmed gender, and is distressed or unemployed because of societal prejudice will forever meet criteria A (subcriteria 4, 5 and 6) and B and remain diagnosable as mentally ill, regardless of how successfully her or his gender dysphoria has been ameliorated.

A new Post-transition specifier has been added to the proposed Gender Dysphoria criteria, which describes all individuals who have transitioned their gender roles full-time and have received hormonal and/or surgical transition care (APA 2011A). While this specifier is intended to aid continued access to hormonal care for post-transition people whose medical records do not yet reflect their affirmed gender, it is so broadly worded that it once again blocks exit from the diagnosis for everyone who has completed a social and medical transition. As written, this specifier contradicts transition treatment and describes social and medical transition in themselves as perpetually symptomatic of mental illness.

Like a roach motel, the proposed criteria and specifiers leave no way for a well adjusted transitioned person to exit diagnosis. As a consequence of diagnostic criteria that contradict proven treatments, the medical necessity of hormonal and surgical transition treatment is commonly denied by care providers, insurers and government agencies. In the US, access to surgical transition care is most often limited to the most financially privileged.

Punitive Gender-Reparative Therapies.

The American Psychiatric Association has often repeated that the DSM is a diagnostic manual and not a treatment guide (APA 2008). In truth, however, treatment and diagnostic nomenclature are inevitably intertwined. The efficacy of all medical and psychological treatments are judged by how well they ameliorate symptoms defined by diagnostic criteria (Winters 2008). Therefore, the wording of diagnostic criteria can have an enormous impact on treatments chosen by clinicians.

The proposed diagnostic criteria for Gender Dysphoria, like those of their GID predecessors, clench post-transition individuals who are happy and well adjusted with their bodies and affirmed roles even more tightly than they apply to pre-transition individuals suffering distress. Exit from diagnosis only exists for those transpeople who have beenshamed back into the closets of their birth-assigned roles. Thus, the current GID and proposed GD criteria implicitly promote punitive gender-reparative “treatments” intended to enforce conformity to assigned birth sex and suppress gender variant identities and expressions.

Criterion, B, which clarifies that distress or impairment should meet a clinical threshold for diagnosis, was recently reinstated by the APA in response to clinician concerns that distress should be emphasized over difference. However, the proposed language fails to exclude consequences of societal prejudice as a basis for diagnosis of mental disorder. As written, criterion B may be misinterpreted to imply that youth and adults who are victims of prejudice and exclusion are impaired and therefore mentally ill, simply because they are victims. Dr. Kenneth Zucker, co-author of the current GID diagnosis and Chairman of the DSM-5 Sexual and Gender Identity Disorders Workgroup, has used this interpretation of victimhood-as-pathology to promote gender-reparative psychotherapies for gender variant youth:

the standard of impairment in children with GID has been their poor same-sex peer relations, with attendant social ostracism.(Zucker 1999)

Zucker’s approach to gender-reparative “treatment” of a youth he diagnosed with GID was described in a chilling National Public Radio Interview in 2008:

Bradley would no longer be allowed to spend time with girls. He would no longer be allowed to play with girlish toys or pretend that he was a female character. Zucker said that all of these activities were dangerous to a kid with gender identity disorder. (Speigel 2008)

Why Not Remove All Gender Diagnosis?

Since the 1990s, some community advocates have called for the elimination of all gender-related diagnostic nomenclature in the DSM, in response to issues of stigma of mental disorder and sexual deviance. (Wilchins 1996; Park 2011) However, there is broad recognition among many community advocates and supportive medical professionals that some kind of diagnostic coding is necessary to facilitate access to medical and/or surgical transition care for those trans and transsexual people who need it. The World Professional Association for Transgender Health has stated that,

The use of a formal diagnosis is often important in offering relief, providing health insurance coverage, and guiding research to provide more effective future treatments (WPATH 2001)

Others have suggested that physical, medical, diagnostic nomenclature in the International Classification of Diseases (ICD) is more appropriate than diagnosis of mental disorder (NGLTF 1996; Lev 2004; Allison 2009).  However, such consensus within pediatric and endocrine medical specialties will not happen before publication of the DSM-5 in 2013. Because major revisions of the DSM are very infrequent, the DSM-5 will likely impact the lives, civil liberties and medical care of gender variant people through the 2020s. There is a fleeting opportunity to advocate reform, or harm reduction, of the GID category and removal of the defamatory Transvestic Fetishism category in the DSM-5 now. The objective of GID reform is to advance forward progress on both issues of social stigma and better access to medical transition care, for those who need it, and not one at the expense of the other, or to the benefit part of the transcommunity by harming another.

A New Distress-based Diagnostic Paradigm.

An international group of mental health and medical clinicians, researchers and scholars, Professionals Concerned With Gender Diagnoses in the DSM, has proposed alternative diagnostic nomenclature based on distress rather than nonconformity (Lev, et al., 2010; Winters and Ehrbar 2010; Ehrbar, Winters and Gorton 2009). These include anatomic dysphoria (painful distress with current physical sex characteristics) as well as social role dysphoria (distress with ascribed or enforced social gender roles that are incongruent with one’s inner experienced gender identity) For children and adolescents, these alternative criteria include distress with anticipated physical sex characteristics that would result if the youth were forced to endure pubertal development associated with natal sex. For those who require a post-transition diagnostic coding for continued access to hormonal therapy, the criteria include sex hormone status. Based on prior work by psychologist Anne Vitale (2010), this distress may also be described as deprivation of physical characteristics or social gender expression that are congruent with inner experienced gender identity. The resulting four-cornered definition of gender dysphoria, encompassing direct distress and deprivation distress around anatomic sex and ascribed/assigned gender, provides a cogent definition of the problem to be treated with medical transition care. It addresses prior false-positive and false-negative diagnostic concerns and does not contradict the treatment.

These alternative criteria acknowledge that experienced gender identity may include elements of masculinity, femininity, both or neither and are not limited to binary Western stereotypes. They also define clinically significant distress and impairment to include barriers to functioning in one’s experienced congruent gender role and exclude victimization by social prejudice and discrimination.

Suggested Diagnostic Criteria for Gender Dysphoria in the DSM-5

I would like to suggest that the APA adopt new diagnostic criteria for the Gender Dysphoria categories for children and adults/adolescents that are based on the following summary of work from the Concerned Professionals group–

A. A distressing sense of incongruence between persistent experienced or expressed gender and current physical sex characteristics or ascribed gender role in adults, adolescents (who have reached the earlier of age 13 or Tanner Stage II of pubertal development), or assigned gender role in children, manifested by at least one of the following indicators for a duration of at least 3 months. Incongruence, for this purpose, does not mean gender expression that is nonconforming to social stereotypes of assigned gender role or natal sex.

1. A distress or discomfort with living in the present gender or being perceived by others as the present gender, which is distinct from the experiences of discrimination or the societal expectations associated with that gender.

2. A distress or discomfort caused by deprivation of gender expression congruent with persistent experienced gender (or, for children, insistence that one has a gender that differs from the present gender). Experienced gender may include alternative gender identities beyond binary stereotypes.

3. A distress or discomfort with one’s current primary or secondary sex characteristics, including sex hormone status, that are incongruent with persistent experienced gender, or with anticipated pubertal development associated with natal sex.

4. A distress or discomfort caused by deprivation of primary or secondary sex characteristics, including sex hormone status, that are congruent with persistent experienced gender (including post-pubertal characteristics congruent with experienced gender, in the case of children and pre-adolescents).

B. Distress or discomfort is clinically significant or represents impairment in major life functions in a role congruent with experienced gender identity. Distress or impairment due to external prejudice or discrimination is not a basis for diagnosis.

Regardless of the wording chosen for the DSM-5, these alternative criteria for Gender Dysphoria may be used in clinical practice today to inform treatment by clarifying the problem that is being treated. These alternative criteria may serve to facilitate clearer communication between primary care, medical specialty and mental health providers, and they can enable patients and families of transitioning youth to make more informed decisions on treatment options.

What You Can Do Now

1. Ask the APA to reject diagnostic criteria and categorical placement for the Gender Dysphoria diagnosis that contradict transition or depict transition as symptomatic of mental disorder. Ask them to clarify that nonconformity to birth-assigned roles and being victims of societal prejudice are not, in themselves, mental pathology. Go to the APA DSM-5 web site (APA 2011), click on “register now,” create a user account and enter your statement in the box. The deadline for this second period of public comment is June 15.
2. Ask your local, national and international GLBTQ nonprofit organizations to issue public statements to clarify that nonconformity to birth-assigned roles and being victims of societal prejudice are not, in themselves, mental pathology.
3. Ask mental health and medical professionals who work with the transcommunity to voice their concerns to the APA.
4. Spread the word to your network of friends and allies.

For more information, see GID Reform Advocates (Winters, 2010)

APA: Proposed Diagnostic Criteria for Gender Dysphoria (in Adolescents or Adults)

(APA 2011A)

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: [2, 3, 4]

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) [13, 16]

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) [17]

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)

B. The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning, or with a significantly increased risk of suffering, such as distress or disability

Subtypes

With a disorder of sex development [14]

Without a disorder of sex development

See also: [15, 16, 19]

Specifier

Post-transition, i.e., the individual has transitioned to full-time living in the desired gender (with or without legalization of gender change) and has undergone (or is undergoing) at least one cross-sex medical procedure or treatment regimen, namely, regular cross-sex hormone treatment or gender reassignment surgery confirming the desired gender (e.g., penectomy, vaginoplasty in a natal male, mastectomy, phalloplasty in a natal female).

Note: Three changes have been made since the initial website launch in February 2010: the name of the diagnosis, the addition of the B criterion, and the addition of a specifier. Definitions and criterion under A remain unchanged.

APA: Proposed Diagnostic Criteria for Gender Dysphoria in Children

(APA 2011B)

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): [2, 3, 4]

1. a strong desire to be of the other gender or an insistence that he or she is the other gender (or some alternative gender different from one’s assigned gender) [5]

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 [6]

3. a strong preference for cross-gender roles in make-believe or fantasy play [7]

4. a strong preference for the toys, games, or activities typical of the other gender [8]

5. a strong preference for playmates of the other gender [9]

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 [10]

7. a strong dislike of one’s sexual anatomy [11]

8. a strong desire for the primary and/or secondary sex characteristics that match one’s experienced gender [12]

B. The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning, or with a significantly increased risk of suffering, such as distress or disability.

Subtypes

With a disorder of sex development [14]

Without a disorder of sex development]

See also [13, 15, 19]

Note: Two changes have been made since the initial website launch in February 2010: the name of the diagnosis and the addition of the B criterion. Definitions and criteria under A remain unchanged.

References

Allison, R. (2009) “Aligning Bodies with Minds: The Case for Medical and Surgical Treatment of Gender Dysphoria,” Annual Meeting of the American Psychiatric Association San Francisco, May 18, http://www.gidreform.org/blog2009May27.html

American Psychiatric Association (2011) “DSM-5 Development; Proposed Revisions, 302.3 Transvestic Fetishism,” http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=189#

American Psychiatric Association (2011A) “DSM-5 Development; Proposed Revisions, P 01 Gender Dysphoria in Adolescents or Adults,” http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=482

American Psychiatric Association (2011B) “DSM-5 Development; Proposed Revisions, P 00 Gender Dysphoria in Children,” http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=192

American Psychiatric Association (2008), “APA STATEMENT ON GID AND THE DSM-V,” http://www.psych.org/MainMenu/Research/DSMIV/DSMV/ APAStatements/APAStatementonGIDandTheDSMV.aspx , May 23

Ehrbar, R., Winters, K., Gorton, N. (2009) “Revision Suggestions for Gender Related Diagnoses in the DSM and ICD,” The World Professional Association for Transgender Health (WPATH) 2009 XXI Biennial Symposium, Oslo, Norway, http://www.gidreform.org/wpath2009/

Gigs, L. and Carroll, R. (2010) “Should Transvestic Fetishism Be Classified in DSM 5? Recommendations from the WPATH Consensus Process for Revision of the Diagnosis of Transvestic Fetishism,” International Journal of Transgenderism, 12:189-197.

Lev, A.I. (2004). Transgender emergence: Therapeutic guidelines for working with gender-variant people and their families. NY: Routledge, p. 180.

Lev, A.I., Winters, K., Alie, L., Ansara, Y., Deutsch, M., Dickey, L., Ehrbar, R., Ehrensaft, D., Green, J., Meier, S., Richmond, K., Samons, S., Susset, F., (2010). “Response to Proposed DSM-5 Diagnostic Criteria. Professionals Concerned With Gender Diagnoses in the DSM.” Retrieved December 4, 2010 from: http://professionals.gidreform.org

National Gay and Lesbian Task Force (1996), “Statement on Gender Identify Disorder and transgender people by the National Gay and Lesbian Task Force (NGLTF),”  http://www.gendertalk.com/articles/archive/ngltf1.htm

TransYouth Family Allies (2010) “Comments on the Proposed Revision to 302.6 Gender Identity Disorder in Children, Submitted to the American Psychiatric Association,” April 20, http://www.imatyfa.org/whatsnew/2010/10apr-commentsondsm-v.html

Vitale, A. (2010) The Gendered Self: Further Commentary on the Transsexual Phenomenon, Lulu, http://http://www.avitale.com/

Winters, K. (2008). Gender Madness in American Psychiatry: Essays from the struggle for Dignity, GID Reform Advocates, http://www.gendermadness.com

Winters, K. (2010) “Ten Reasons Why the Transvestic Disorder Diagnosis in the DSM-5 Has Got to Go,” GID Reform Advocates, Oct. 15, http://www.gidreform.org/blog2010Oct15.html

Winters, K. and Ehrbar, R. (2010) “Beyond Conundrum: Strategies for Diagnostic Harm Reduction,” Journal of Gay & Lesbian Mental Health, 14:2, 130-139, April

Ophelian, A (2010) Diagnosing Difference, documentary film, http://www.diagnosingdifference.com/

Park. P. (2011) “Transgender Health, Pathology & Human Rights,” Harvard University School of Public Health, April, http://www.paulinepark.com/index.php/2011/04/transgender-health-human-rights-harvard-4-20-11/

Speigel, A. (2008) “Two Families Grapple with Sons’ Gender Preferences,” National Public Radio, All Things Considered,”http://www.npr.org/templates/story/story.php?storyId=90247842

Wilchins, R. (1996). “TG Activisits Protest APA, Call for End to Gender Identity Disorder,” Transgender Forum, May, http://www.tgforum.com/

World Professional Association for Transgender Health (2001)“Standards of Care for Gender Identity Disorders,” Sixth Version,http://wpath.org/Documents2/socv6.pdf

World Professional Association for Transgender Health (2010). “Statement Urging the De-psychopathologisation of Gender Variance,” May 26,  http://wpath.org/publications_public_policy.cfm

World Professional Association for Transgender Health (2010A). “WPATH Reaction to DSM-V Criteria for Gender Incongruence,” May 25 ,http://www.wpath.org/documents/WPATH%20Reaction%20to%20the%20proposed%20DSM%20-%20Final.pd

Zucker, K. (1999) “Commentary on Richardson’s (1996) ‘Setting Limits on Gender Health,’” Harvard Rev Psychiatry, vol 7, p. 41.

Copyright © 2011 Kelley Winters, GID Reform Advocates

Transvestic Disorder, the Overlooked Anti-Trans Diagnosis in the DSM-5

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

On May 5^th, the American Psychiatric Association (APA) released a second round of proposed diagnostic criteria for the 5^th Edition of The Diagnostic and Statistical Manual of Mental Disorders (DSM-5). These include two diagnostic categories that impact the trans communities, Gender Dysphoria (formerly Gender Identity Disorder, or GID) and Transvestic Disorder (Formerly Transvestic Fetishism). While GID has received a great deal of attention in the press and from GLBTQ advocates, the second Transvestic category is too often overlooked. This is unfortunate, because the Transvestic Disorder diagnosis is designed to punish social and sexual gender nonconformity and enforce binary stereotypes of assigned birth sex. It plays no role in enabling access to medical transition care, for those who need it, and is frequently cited when care is denied (Winters 2010). I urge all trans community members, friends, care providers and allies to call for the removal of this punitive and scientifically unfounded diagnosis from the DSM-5. The current period for public comment to the APA ends June 15.

Like its predecessor, Transvestic Fetishism, in the current DSM, Transvestic Disorder is authored by Dr. Ray Blanchard, of the Toronto Centre for Addiction and Mental Health (CAMH, formerly known as the Clarke Institute). Blanchard has drawn outrage from the transcommunity for his defamatory theory of autogynephilia, asserting that all transsexual women who are not exclusively attracted to males are motivated to transition by self-obsessed sexual fetishism (Winters 2008A). He is canonizing this harmful stereotype of transsexual women in the DSM-5 by adding an autogynephilia specifier to the Transvestic Fetishism diagnosis (APA 2011) . Worse yet, Blanchard has broadly expanded the diagnosis to implicate gender nonconforming people of all sexes and all sexual orientations, even inventing an autoandrophilia specifier to smear transsexual men. Most recently, he has added an “In Remission” specifier to preclude the possibility of exit from diagnosis. Like a roach motel, there may be no way out of the Transvestic Disorder diagnosis, once ensnared.

What You Can Do Now

1. Go to the APA DSM-5 web site (APA 2011), click on “register now,” create a user account and enter your statement in the box. The deadline for this second period of public comment is June 15.
2. Sign the Petition to Remove Transvestic Disorder from the DSM-5 (IFGE 2010), sponsored by the International Foundation for Gender Education.
3. Demand that your local, national and international GLBTQ nonprofit organizations issue public statements calling for the removal of this defamatory Transvestic Disorder category from the DSM-5. Very few have so far.
4. Spread the word to your network, friends and allies.

For more information, see GID Reform Advocates (Winters, 2010)

References

American Psychiatric Association (2011) “DSM-5 Development; Proposed Revisions, 302.3 Transvestic Fetishism,” http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=189#

Ehrbar, R., Winters, K., Gorton, N. (2009) “Revision Suggestions for Gender Related Diagnoses in the DSM and ICD,” The World Professional Association for Transgender Health (WPATH) 2009 XXI Biennial Symposium, Oslo, Norway, http://www.gidreform.org/wpath2009/

International Foundation for Gender Education (2010) “Petition to Remove Transvestic Disorder from the DSM-5,” http://dsm.ifge.org/petition/

Lev, A.I., Winters, K., Alie, L., Ansara, Y., Deutsch, M., Dickey, L., Ehrbar, R., Ehrensaft, D., Green, J., Meier, S., Richmond, K., Samons, S., Susset, F., (2010). “Response to Proposed DSM-5 Diagnostic Criteria. Professionals Concerned With Gender Diagnoses in the DSM.” Retrieved December 4, 2010 from: http://professionals.gidreform.org

TransYouth Family Allies (2010) “Comments on the Proposed Revision to 302.6 Gender Identity Disorder in Children, Submitted to the American Psychiatric Association,” April 20, http://www.imatyfa.org/whatsnew/2010/10apr-commentsondsm-v.html

Winters, K. (2008). Gender Madness in American Psychiatry: Essays from the struggle for Dignity, GID Reform Advocates, www.gendermadness.com

Winters, K (2008A) Autogynephilia: The Infallible Derogatory Hypothesis, Part 1, GID Reform Advocates, November 10, http://www.gidreform.org/blog2008Nov10.html

Winters, K. (2010) “Ten Reasons Why the Transvestic Disorder Diagnosis in the DSM-5 Has Got to Go,” GID Reform Advocates, Oct. 15, http://www.gidreform.org/blog2010Oct15.html

Winters, K. and Ehrbar, R. (2010) “Beyond Conundrum: Strategies for Diagnostic Harm Reduction,” Journal of Gay & Lesbian Mental Health, 14:2, 130-139, April World Professional Association for Transgender Health (2010). “Statement Urging the De-psychopathologisation of Gender Variance,” May 26, http://wpath.org/publications_public_policy.cfm