New Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People

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

The World Professional Association for Transgender Health (WPATH) released it’s 7^th Version of Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People (SOC) in Atlanta today. The previous Version 6 was published in 2001. Overall, this newest SOC represents significant forward progress in respecting trans people and affirming the necessity of medical transition care for trans and transsexual individuals who need it. Although controversies and issues of transition care access remain in the SOC7, WPATH has announced a more frequent update process that will hopefully be more responsive to emerging evidence and clinical experience in the future.

First published in 1979, the SOC has provided clinical guidance to medical and mental health providers serving trans people, with an emphasis on transsexual individuals seeking hormonal and/or surgical transition care. In many parts of the world, particularly North America and Europe, the SOC has played a role in enabling access to medical transition care and in enabling medical and surgical practitioners to provide it. However, the SOC has been controversial among trans communities and supportive care providers. For example, prior versions have been critized for unreasonable barriers to medical transition care, pathologizing language of “disordered” gender identities and “gender‐disturbed children,” maligning pronouns and terms for transitioned individuals, and compulsory psychotherapy requirements. Fortunately, successive revisions of the SOC have trended toward greater respect for trans and transsexual people and fewer unjustified barriers to transition care. For example,  mandatory urological examinations were dropped from the 4^th Version in 1990, and mandatory psychotherapy requirements for those needing access to hormonal or surgical transition care were dropped from the 5^th SOC in 1998.

Gender Conversion Psychotherapies are Unethical

Perhaps the most historic change in the SOC7 appears in the section of ethical guidelines:

Treatment aimed at trying to change a person’s gender identity and lived gender expression to become more congruent with sex assigned at birth has been attempted in the past (Gelder & Marks, 1969; Greenson, 1964), yet without success, particularly in the long term (Cohen-Kettenis & Kuiper, 1984; Pauly, 1965). Such treatment is no longer considered ethical.

Though long overdue, this condemnation of gender-conversion or gender-reparative psychotherapies sets a new ethical standard for the mental health professions. Sexual orientation conversion therapies have been rejected by the American Psychiatric Organization, the American Psychological Association, the American Medical Association, the National Association of Social Workers and many other professional associations for over a decade. Yet the mental health and medical professions have maintained a double standard for trans, transsexual and gender nonconforming people victimized by analogous gender-reparative therapies that are equally harmful.

I commend the WPATH leadership and the SOC committees for taking this historic step and call upon the American Psychiatric Association and other professional associations to follow WPATH’s leadership on this important issue.

De-psychopathologisation of Gender Difference

The 7^th Version of the SOC goes further than prevous versions in employing respectful language and dispelling false myths that equate nonconformity to birth-assigned sex and gender roles with mental illness. A section entitled, “Being Transsexual, Transgender, or Gender Nonconforming Is a Matter of Diversity, Not Pathology,” prominently notes:

WPATH released a statement in May 2010 urging the de-psychopathologization of gender nonconformity worldwide (WPATH Board of Directors, 2010). This statement noted that “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 [that] should not be judged as inherently pathological or negative.”

We can only hope that the American Psychiatric Association and World Health Organizations will take guidance from this principle in future revisions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Statistical Classification of Diseases and Related Health Problems (ICD).

The de-psychopathologization principle is underscored by statements that, “Psychotherapy is not an absolute requirement for hormone therapy and surgery,” first introduced in Versions 5 and 6–

A mental health screening and/or assessment as outlined above is needed for referral to hormonal and surgical treatments for gender dysphoria. In contrast, psychotherapy – although highly recommended – is not a requirement.

The new standard clarifies gender dysphoria, from a greek root for distress, as the focus of treatment, replacing pathologizing language of “disordered” gender identity. Gender dysphoria is painful distress with one’s current physical sex characteristics or assigned or ascribed social gender role. Social role transition to a congruent, affirmed gender role and hormonal and/or surgical transition treatments (for those who need them) are well proven in relieving this distress. The SOC7 notes,

…transsexual, transgender, and gender nonconforming individuals are not inherently disordered. Rather, the distress of gender dysphoria, when present, is the concern that might be diagnosable and for which various treatment options are available.

The American Psychiatric Association has already proposed to replace the defamatory diagnostic title of “gender identity disorder” with Gender Dysphoria in the pending 5^th Edition of the DSM.

Other Positive Changes

The tone and language of the SOC7 are more positive than in previous versions, with more emphasis on care and less emphasis on barriers to care. Some highlights include:

• Concise and more cogent criteria for access to hormonal and surgical transition care.
• Relaxation of the age 18 restriction for access to hormonal transition care.
• Removal of the three month requirement for either “real life experience” (living in a congruent gender role) or psychotherapy before access to hormonal care.
• Clarification that “the presence of co-existing mental health concerns does not necessarily preclude access to feminizing/masculinizing hormones .”
• Removal of barriers to surgical care because of family intolerance or interpersonal issues.
• An expanded role for medical health professionals in granting access to hormonal therapies.
• Acknowledgement of informed consent model protocols, developed at community health centers worldwide for hormonal transition care.
• Emphasis of cultural competence and sensitivity for care providers.
• Expanded and clarified information on puberty delaying treatment for gender dysphoric adolescents.
• Clarification on the role of the SOC as flexible clinical guidelines that may be tailored for individual needs and local cultures.

Issues for Future Revisions

Although the 7^th Version of the SOC is significantly improved over previous versions, there remain issues of concern to trans communities and their allies. One issue is promotion of a widely held myth that gender dysphoria in children will persist in only a small minority by adolescence, in other words, that gender identity in children is malleable and impersistent. These statements in the SOC are based on studies that conflated mere nonconformity of gender expression in children with the distress of gender dysphoria: painful distress with born sex characteristics or assigned gender roles. Among a new generation of gender dysphoric children from supportive families, children who have actually transitioned to affirmed roles congruent with their gender identities, there is so far very little evidence of impersistence. Hopefully, future revisions of the Standards of Care will quickly incorporate research findings on these new populations of affirmed youth, as they become available.

Download the SOC Version 7

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

APA Releases 2nd Proposal to Replace GID in the DSM-5

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

The Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association, is the medical and social definition of mental disorder throughout North America and strongly influences international nomenclature. There is broad recognition 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. However, the current psychiatric classifications of Gender Identity Disorder (GID) and Transvestic Fetishism (TF) in the Fourth Edition, Text Revision of the DSM (DSM-IV-TR) fall short of meeting this need and actually contradict transition by describing transition itself as symptomatic of mental disorder.

Today, the Sexual and Gender Identity Disorders Workgroup of the DSM-5 Task Force released a second revision to proposed diagnostic criteria to replace the Gender Identity Disorder category in the DSM-5.

Most significant, the ambiguously defined title of Gender Incongruence has been replaced by Gender Dysphoria (from a Greek root for distress). The work group noted that,

Many commentators recommended ‘gender dysphoria’ as a semantically more appropriate term, because it expresses an aversive emotional component. In this regard, it should be noted that the term ‘gender dysphoria’ has a long history in clinical sexology (see Fisk, 1973) and thus is one that is quite familiar to clinicians who specialize in this area.

A number of trans health organizations and clinicians have advocated nomenclature focused on distress with the wrong physical sex characteristics or the wrong social gender role rather than difference from expectations of assigned birth-sex. Despite some confusion between dysphoria and dysmorphia (delusional self-image) in the press and in the transcommunity, I think dysphoria more clearly communicates distress as the diagnostic focus than alternative terms and represents a positive step forward.

This revised proposal also re-introduces a clinical significance criterion, B, which clarifies that diagnosis requires distress or impairment that meets a clinical threshold. This criterion is present in the DSM-IV but was removed from the first DSM-5 proposal. Clinicians and medical providers who work with  affirmed/transitioned youth have voiced concerns that removal of the clinical significance criterion would further obscure the medical necessity of puberty delaying medications for adolescents who need them, as well as hormonal and surgical transition care later in life. The American Medical Association, the American Psychological Association, and the World Professional Association for Transgender Health have issued public statements clarifying the medical necessity of hormonal and/or surgical  transition treatments for those who suffer distress caused by deprivation of physical characteristics congruent with their gender identity, within established standards of care.

However, the specific wording of the clinical significance criterion will likely be debated among community and medical advocates in coming weeks. For example, the proposed wording fails to exclude distress or impairment caused by societal prejudice as a basis for diagnosis. This omission has historically been used to justify gender-reparative therapies on gender nonconforming youth– with an inference that victimhood of intolerance is symptomatic of mental illness.

The first diagnostic criterion is unfortunately unchanged from the first DSM-5 proposal. It ambiguously describes gender identity and a desire for transition related treatment as foci of pathology. The corresponding criterion for children is especially problematic, as it describes gender expression that differs from assigned birth roles as symptomatic of mental illness.

The work group also added a Post-transition specifier, intended to aid continued access to hormonal care after the distress of gender dysphoria has been relieved by transition. However, it will certainly raise controversy by blocking exit from the diagnosis to those whose distress has been successfully relieved by transition related care.

Finally, the work group noted that, “gender diagnoses will be separated from the sexual dysfunctions and paraphilias.” This change in categorical placement of the Gender Dysphoria category would also represent forward progress in the DSM-5, although many advocates and care providers have pushed to move the new diagnosis out of the Sexual and Gender Identity Disorders section altogether.

The second gender category of Transvestic Disorder remains in the DSM-5 proposal, despite broad opposition from the transcommunity, care providers and allies.

The deadline for public comments on this revised proposal is now June 15, 2011. Unfortunately, this will pass before the Symposium of the World Professional Association for Transgender Health (WPATH) in September. WPATH played an active role in providing feedback on the previous proposal in 2010. The DSM-5 Task Force has announced a third round of revisions  and another period of public feedback to follow.

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

See http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=482#

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.

Proposed Diagnostic Criteria for Gender Dysphoria in Children

See http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=192

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.

Ten Reasons Why the Transvestic Disorder Diagnosis in the DSM-5 Has Got to Go

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

The classification of gender diversity and nonconformity to birth-assigned gender roles as mental illness by the American Psychiatric Association (APA) has drawn growing protest and outrage from transpeople and and allies worldwide. The Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the APA, is regarded as the medical and social definition of mental disorder throughout North America and strongly influences international diagnostic nomenclature. The fifth edition of the manual, the DSM-5, is in development and scheduled for publication in 2013. While the diagnostic category of Gender Identity Disorder (GID) has garnered most of the controversy, a second category of so-called Transvestic Fetishism (TF) has harmed transwomen, including transsexual women, as well as male-to-female crossdressers, dual gender and gender nonconforming people since the earliest days of the DSM. Trans and LGB advocates have been inexplicably quiet about the TF category, even after the APA proposed to expand the category in the DSM-5, renamed Transvestic Disorder, to implicate gender nonconforming people of all sexes and all sexual orientations.

The proposed DSM-5 diagnosis of Transvestic Disorder, even worse than its predecessor Transvestic Fetishism, labels gender expression not stereotypically associated with assigned birth sex as inherently pathological and sexually deviant. The diagnosis is punitive and scientifically capricious, serving to punish social and sexual gender nonconformity and enforce binary stereotypes of assigned birth sex. Here are ten reasons why the Transvestic Disorder diagnosis should be eliminated entirely from the DSM-5.

1. Diagnosis of Diversity

The World Professional Association for Transgender Health (WPATH), formerly the Harry Benjamin International Gender Dysphoria Association, (HBIGDA), publishes recognized standards of medical transition care for those who need it. In May, 2010, WPATH issued the following pivotal statement on de-psychopathologisation of gender variance,

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 [psychopathologisation] 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. WPATH urges governmental and medical professional organizations to review their policies and practices to eliminate stigma toward gender-variant people. 

Gender expression that differs from social expectations of assigned birth sex does not meet any medical or scientific definition of mental pathology. Difference is not disease.

2. Stigma of Sexual Deviance

Transvestic Disorder is classified as a “paraphilic” sexual disorder, grouped with diagnoses of such harmful behaviors as pedophilia and exhibitionism. The resulting stereotypes of sexual deviance deny human dignity and civil justice to transgender and gender variant people, including transsexual individuals, who consequently lose their jobs, homes, families, children, freedoms and access to public accommodation.

In the United States, these false stereotypes were exemplified in a full-page newspaper ad campaign in 2008 by Focus on the Family, a political extremist group opposed to civil rights for transpeople in the state of Colorado. A transwoman was depicted in a photo as a disheveled suspicious male in dirty work boots, lurking in a women’s restroom as a little girl stepped out of a stall. The ad contained the headline, “Colorado Just Opened Its Bathrooms to Either Sex!” with the phrase, “sexual predator.” The association of transwomen with sexual predation and threat to children was in reference to the association of transwomen with “paraphilia” in the DSM.

3. Denial of Civil Justice

In the DSM-III, the APA stated, “The crucial issue in determining whether or not homosexuality per se should be regarded as a mental disorder is not the etiology of the condition, but its consequences and the definition of mental disorder.” Tragically, the APA has neglected to apply this same logic to the consequences of psychopathologization of gender variance and nonconformity.

For example, Andrea Lafferty, of the extremist Traditional Values Coalition, exploited the TF and GID diagnostic categories to oppose national employment nondiscrimination legislation for GLBTQ Americans in a CBS News interview this year. Lafferty cited the APA while repeating that transpeople have “a serious mental disorder” and represent a threat to children. In fact, the current TF and GID nomenclature have played a pivotal role in the ongoing defeat of the Employment Nondiscrimination Act (ENDA) in the U.S. Congress, as opponents have focused on sensational false stereotypes of mental illness and sexual deviance rather than direct attack against gay and lesbian people.

4. Pathologization of Ordinary Behaviors.

The supporting text of the Transvestic Fetishism diagnosis describes behaviors that would be ordinary or even exemplary for cisgender women as symptomatic of mental disorder for transgender women and gender nonconforming males. These include wearing female clothing, dressing entirely as females, wearing makeup, expressing feminine mannerisms and appearing publicly in a feminine role. The text goes so far as to list “involvement in a transvestic subculture” among pathological “transvestic phenomena.” It is not clear how the very same behaviors and social/political affiliations can be pathological for one group of people and not for others.

5. Harm to Transsexual Women

The proposed Transvestic Disorder category is not limited to crossdressers or male-identified people. It also targets transsexual women with a specifier of “autogynephilia,” a deeply offensive label that sexualizes ordinary and customary social gender expression and promotes a poorly supported and socially defamatory theory that transsexual women transition to satisfy a sexual fetish rather than attain harmony with their experienced gender identity. The label of Transvestic Fetishism has also been used to deny medical transition treatment for transsexual indivicuals who need it. For example, the diagnosis was cited by Federal attorneys against Ms. Rhiannon O’Donnabhainn in her recent landmark case in U.S. Tax Court. They used the TF category to promote a false stereotype of fetishism to argue that corrective transition surgeries for transsexual women are not medically necessary.

6. Harm to Transmen

In June of this year, the phrase “in a male,” in reference to birth-assigned sex, was removed from criterion A for the proposed Transvestic Disorder without explanation. As a result, transmen and masculine or butch women may now be implicated with Transvestic Disorder because of the clothes they wear. A new specifier of “with autoandrophilia” was added to the diagnostic criteria to target transsexual men, much as the specifier of “autogynephilia” would target and defame transsexual women.

7. Harm to Non-erotically Motivated Crossdressers

Ambiguous language in Criterion A of the APA Transvestic Disorder proposal implicates sexual expression “involving” crossdressing, without evidence of causation. Thus, virtually any gender expression among bigender, dual-gender or genderqueer people that is coincident with any kind of a sex life may be inferred as diagnosable, whether erotically motivated or not.

It is apparent that DSM authors have long intended for the TF diagnosis to implicate non-erotic or ambiguously erotic crossdressing as a fetishistic psychopathology. For example, the DSM-IV Casebook recommended a Transvestic Fetishism diagnosis for a male-identified subject whose crossdressing was not necessarily sexually motivated.

8. Harm to Erotically Motivated Crossdressers

Crossdressing that is erotically motivated is a benign consensual sexual expression that does not rise to the definition of mental illness. There is no scientific justification for labeling this behavior as mentally or sexually pathological. The DSM-IV-TR states, “Neither deviant behavior … nor conflicts that are primarily between the individual and society are mental disorders unless the deviance or conflict is a symptom of dysfunction…”

9. Harm to Ego-Dystonic (self-unaccepting) Crossdressers

The APA proposal for Transvestic Disorder, pathologizes ego-dystonic crossdressers, who are distressed by internalized shame and societal transphobia, very much as the previous diagnosis of Ego-Dystonic Homosexuality in the DSM-III pathologized victims of social homophobia. Ego-Dystonic Homosexuality was removed entirely from the DSM-III-R in 1987, because it inexorably associated all same sex orientation with pathology and because “almost all people who are homosexual first go through a phase in which their homosexuality is ego-dystonic.” The very same logic should apply to the Transvestic Disorder diagnosis in the DSM-5. It would be tragic for the APA to perpetuate a diagnosis so analogous to Ego-Dystonic Homosexuality of the last century.

10. Implicit Endorsement of Gender-Reparative Therapies

In 2008, the American Psychiatric Association (APA) released public statements that, “…the DSM is a diagnostic manual and does not provide treatment recommendations or guidelines.” In fact, however, diagnostic nomenclature and treatment are inseparably related. The efficacy of all drug and psychotherapy treatments are judged according to specific diagnostic criteria listed in the DSM and ICD. The diagnostic criteria for the proposed Transvestic Disorder in the DSM-5 favor gender-reparative therapies that serve to repress gender nonconforming fantasies, urges and behaviors, described in criterion A. Bigender, dual gender or gender variant individuals who are not shamed into repression but are distressed by external societal intolerance, would perpetually meet the criteria regardless of how happy and functional they might otherwise be.
It is time to call upon the APA leadership to reject the proposed diagnostic category of Transvestic Disorder and remove nomenclature from the DSM that casts crossdressing and gender role nonconformity in themselves as mental disorder.

Appendix A: DSM-IV-TR Diagnostic Criteria for Transvestic Fetishism
(APA 2000)

A. Over a period of at least 6 months, in a heterosexual male, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving cross-dressing. 

B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning 

Specify if: With Gender Dysphoria: if the person has persistent discomfort with gender role or identity 

Appendix B: Proposed DSM-5 Diagnostic Criteria for Transvestic Disorder
(APA 2010)

A. Over a period of at least six months, recurrent and intense sexual fantasies, sexual urges, or sexual behaviors involving cross-dressing. 

B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.: 

Specify if:  

With Fetishism (Sexually Aroused by Fabrics, Materials, or Garments) 

With Autogynephilia (Sexually Aroused by Thought or Image of Self as Female) 

With Autoandrophilia (Sexually Aroused by Thought or Image of Self as Male) 

Specify if: 

In Remission (During the Past Six Months, No Signs or Symptoms of the Disorder Were Present) 

In a Controlled Environment 

References

American Psychiatric Association (1987). Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised, Washington, D.C., p. 426.

American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Washington, D.C., p. xxii.

American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, Washington, D.C., pp. xxxi, 574-5.

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

American Psychiatric Association (2010) “DSM-5 Development; Proposed Revisions, 302.3
Transvestic Fetishism,” http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=189

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

Cordes, N., CBS News (2010). “Washington Unplugged,” April 20 http://www.cbsnews.com/video/watch/?id=6414895n (audio excerpts of Andrea Lafferty, of the Traditional Values Coalition, repeating slurs of mental disorder are available at http://www.gidreform.org/cbslafferty1.mp3 )

DeCuypere, G., Knudson G., & Bockting, W. (2010). “Response of the World Professional Association for Transgender Health to the Proposed DSM 5 Criteria for Gender Incongruence,” http://www.wpath.org/documents/WPATH%20Reaction%20to%20the%20proposed%20DSM%20-%20Final.pdf

Focus on the Family Action (2008). Colorado Springs, CO, http://www.citizenlink.com. Photo available online at http://www.gidreform.org/2008FOFsb2006.jpg

Lev, A., Alie, L., Ansara, Y., Deutsch, M., Dickey, L., Ehrbar, R., Ehrensaft, D., Green, J., Meier, S., Richmond, K., Susset, F., Winters, K. (2010). Professionals Concerned With Gender Diagnoses in the DSM Statement on Transvestic Disorder in the DSM-5, http://gidconcern.wordpress.com/statement-on-transvestic-disorder-in-the-dsm-5/

Serano, J. (2009). “Autogynephilia’ and the psychological sexualization of MtF transgenderism,” International Foundation for Gender Education 2009 Conference, Alexandria VA, March, http://ai.eecs.umich.edu/people/conway/TS/IFGE2009/Disordered_No_More.html#Julia

Spitzer, R., editor (1994), DSM-IV Casebook, A Learning Companion to the Diagnostic and Statistical Manual of Mental Disorders (fourth edition), American Psychiatric Press, pp. 257-259.

Winters, K. (2008). Gender Madness in American Psychiatry: Essays from the Struggle for Dignity. CO: GID Reform Advocates, pp. 33-43.

Winters, K., (2010). “A Taxing Question of Medical Necessity,” GID Reform Advocates Essay Series on Gender Diagnoses in the DSM-V, Feb 6, http://www.gidreform.org/blog2010Feb06.html

Winters, K. (2010). “Comments on the Proposed Revision to 302.3 Transvestic Fetishism,” http://www.gidreform.org/201004APATFkwB.pdf

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

Comments on Proposed Revisions to Gender Diagnoses in the DSM-5

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

This February, the American Psychiatric Association published its proposed draft revisions for the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) for public comment. The period of public review ends today.

Here are summaries for my comments for the proposed diagnostic categories of Gender Incongruence in Children (formerly Gender Identity Disorder), Gender Incongruence in Adults or Adolescents, and Transvestic Disorder (formerly Transvestic Fetishism).  The full text of my comments is available on the GID Reform Advocates site.  The draft diagnostic criteria from the DSM-5 Task Force are copied at the end of this post.

My comments here were developed to a large extent in prior collaborations and conversations with Dr. Randall Ehrbar , Dr. Nick Gorton,  Arlene Lev , Professionals Concerned With Gender Diagnoses in the DSM, and over 110 GID Reform Advocates.  I am deeply grateful to them for their passion and thoughtful contributions on these issues and all that they taught me.

Gender Identity Disorder in Children

Full Text

The current Gender Identity Disorder diagnosis imposes harmful stigma of mental illness and sexual disorder on gender variant and nonconforming children, regardless of the presence of gender dysphoria. Simultaneously, it poses barriers to social transition and access to puberty blocking or hormonal transition treatment at a later age, by describing transition itself as symptomatic of pathology. The proposed nomenclature for Gender Incongruence in Children for the DSM-5  contains a number of improvements in the title and diagnostic criteria intended to address both issues. However, these revisions fall short of clarifying that social or medical transition and other nonconformity to a birth- assigned gender  do not in themselves constitute mental illness.  These revisions obfuscate the clinically significant distress that may result from  physical sex characteristics or an assigned social gender role that are incompatible with experienced gender identity: distress that may require medical attention.  If there is a specific diagnostic category or criteria set for children in the DSM-5, it should be explicitly based on distress of anatomical or gender role dysphoria and not on gender role nonconformity.

Gender Identity Disorder in Adolescents or Adults

Full Text

The current Gender Identity Disorder diagnosis in the DSM-IV-TR imposes harmful stigma of mental illness and sexual deviance on gender variant and especially transsexual adults and adolescents. Simultaneously, it poses barriers to social transition and access to puberty blocking, hormonal and/or surgical transition care, for those who need them, by describing transition itself as symptomatic of pathology. The proposed nomenclature for Gender Incongruence in Adolescents or Adults for the DSM-5  contains a number of improvements in the title and diagnostic criteria intended to address both issues. However, these revisions fall short of clarifying that social or medical transition and other nonconformity to an assigned gender at birth do not in themselves constitute mental illness.  These revisions obfuscate the clinically significant distress that may result from  physical sex characteristics or an ascribed social gender role that are incompatible with experienced gender identity: distress that may require medical attention.  This diagnostic nomenclature should be explicitly based on distress of anatomical and/or gender role dysphoria (distress or discomfort) and not on gender role nonconformity.

Transvestic Fetishism

Full Text

The DSM-IV diagnostic category of Transvestic Fetishim in the DSM-IV is expanded by the proposed Transvestic Disorder diagnosis to remove exclusions of sexual orientation. It serves to punish gender expression that  differs from social expectations of male birth assignment and to worsen barriers to medical transition care for transsexual women who require it. A specifier of “With Autogynephilia” was added to implicate many  transsexual women, promoting the controversial theory and deeply offensive stereotype that transwomen transition to satisfy a sexual fetish rather than attain congruence with gender identity. This anachronistic condemnation of gender nonconformity fails to meet a modern definition of mental disorder and should be rejected by the APA and removed entirely from the DSM-5.

Proposed APA Diagnostic Criteria for Gender Incongruence in Adolescents or Adults

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

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

Subtypes

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

Proposed APA Diagnostic Criteria for Gender Incongruence in Children

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

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

Subtypes

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

Proposed APADiagnostic Criteria for Transvestic Disorder

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

B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specify if:

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

Why You Should Sign the Petition Opposing the Transvestic Disorder Diagnosis in the DSM-5

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

On January 10th, 2010, the American Psychiatric Association released proposed draft revisions for the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) for public comment through April 20th. The DSM is regarded as the medical and social definition of mental disorder throughout North America and strongly influences international psychiatric nomenclature. The DSM-5 proposal includes the diagnostic category Transvestic Disorder, expanding a previous diagnosis of Transvestic Fetishism.

Authored by Dr. Ray Blanchard, of the Toronto Centre for Addiction and Mental Health (CAMH, the former Clarke Institute of Psychiatry), the proposed Transvestic Disorder diagnosis is:

• Punitive: It punishes gender expression that differs from expectations of male birth-assignment and enforces conformity to masculine social stereotypes.
• Sexist: The diagnostic category is limited to those assigned male at birth, holding them to a stricter standard of conformity than birth-assigned females. It labels behaviours and gender expression that are ordinary or even exemplary for birth-assigned women as pathological for others.
• Stigmatizing: Transvestic Disorder is classified as a “paraphilic” sexual disorder, grouped with diagnoses of such harmful behaviors as pedophilia and exhibitionism. The resulting stereotypes of sexual deviance deny human dignity and civil justice to gender variant and transgender people.
• Ambiguous: murky language implicates sexual expression “involving” crossdressing as diagnosable. Thus, both erotic and nonerotic gender expression among bigender, dual-gender and genderqueer people may be diagnosed as “disordered.”
• Victim-blaming: The second diagnostic criterion requires clinically significant distress or impairment, but fails to exclude distress resulting from societal intolernce. This would promote false-positive diagnosis of victims of prejudice. For example, suffering job discrimination would be inferred as symptomatic of mental disorder.
• Needlessly Pathologizing: This diagnosis primarily pathologizes erotic crossdressing, a harmless consensual sexual expression, that does not meet any definition of mental illness.
• Harmful to Closeted or Self-rejecting Crossdressers: This diagnosis pathologizes crossdressers who are distressed by internalized shame and societal prejudice, very much as the previous diagnosis of Ego-Dystonic Homosexuality in the DSM-III pathologized victims of social homophobia.
• Harmful to Transsexual Women: This Transvestic Disorder category is not limited to crossdressers or male-identified people. It also targets transsexual women with a specifier of “autogynephilia,” a deeply offensive label to many transwomen, promoting an unfounded theory that transsexual women transition out of sexual fetishism rather than harmony with gender identity.
• Used to Deny Medical Transition Treatment for those who need it: For example, the predecessor Transvestic Fetishism diagnosis was cited by IRS attorneys against Rhiannon O’Donnabhainn in her recent landmark case in US Tax Court. They used the diagnosis to promote a false stereotype of fetishism to argue that corrective transition surgeries for transsexual women are not medically necessary.

Please add your name and voice, before April 20th, to the online petition to remove this defamatory Transvestic Disorder catagory from the DSM-5. It is sponsored by the International Foundation for Gender Education (IFGE) at dsm.ifge.org/petition/. You may also register and comment directly to the APA DSM-5 Task Force at www.dsm5.org. For more information, see the statement by Professionals Concerned With Gender Diagnoses in the DSM.