Response to Dr. Jack Drescher and the NY Times About Childhood Transition: Part 2, by Arlene Istar Lev

Coy Mathis

GID Reform Advocates respond to the question, “When a child identifies with the other gender, what to do?” Dr. Jack Drescher’s commentary on the Coy Mathis Civil Rights Case in Colorado appeared in the Sunday Dialogues Feature of the June 29, 2013 New York Times. Here is the discussion that the Times did not publish.

A Guest Post by Arlene Istar Lev LCSW-R, CASAC
Albany New York
Social Worker, Family Therapist, Gender Specialist, Activist
Choices Counseling and Consulting

To the Editor:

Thank you for opening this dialogue and recognizing the importance of public discourse on the issue of transgender children and their civil rights.

My colleague, Dr. Drescher, is correct that “no one knows” whether Coy will identify as a girl or boy when she matures; however, the same can be said for Coy’s classmates. He is also correct that theories abound in this newly emerging field and that experts are engaged in heated discussions about how to best support gender dysphoric children and their families. The concept of children transitioning gender in elementary is clearly a recent, and controversial, phenomenon, one which is increasingly being supported by mental health specialists, school policies, and legal decisions.

Dr. Drescher states that most “children like [Coy] grow up to be gay, not transgender.” This is a misleading statement for a number of reasons. First of all, the research he is referring to is a few decades old; gender atypical children who are now gay adults matured into their identities before transgender expression was a viable social option (especially for children!), and in the early days of the gay liberation movement. More options exist in the modern world for exploration of gender identity and expression, as well as the freedom to live an out gay life. This research also examined gender non-conforming children, not necessarily those who were gender dysphoric, a distinction that may appear academic, but is crucial to understanding the experiences and potential trajectories of children’s emerging gender identities.

Gender non-conforming behavior can exist in a wide-range of children, and can cause distress since our culture can (still!) be extremely rigid about gender roles and rules, especially for boys. One can imagine a gender atypical boy, particularly one who might be aware of attractions to other boys, might be struggling psychologically. Gender dysphoria is, however, markedly different from the social and identity challenges of a gender non-conforming child who will grow up to be gay. Transgender children are suffering in an intensely personal way, with a body and a social world that is at odds with their deepest sense of self.

I am not saying it is always easy to determine what is happening within a young child’s psyche, not as a therapist, and not as a parent. I agree with Dr. Drescher that parents must educate themselves on all the treatment approaches, and recognize the current limitations of science. I also believe that parents can see the difference between a profoundly suffering little boy and a happy contented little girl. A child who is not transgender would simply not adjust to a gender transition with a lessening of mental health symptoms, and an increasing satisfying social life. A boy, no matter how atypical his gender might be, has no interest in using the girls’ bathroom. For a child who is a girl, it is an essential part of her identity.

Thank you Colorado for recognizing this obvious truth. Thank you to Dr. Drescher for initiating respectful public and professional dialogue on this controversial subject. Thank you to Coy and her parents, for allowing their personal family struggles to be a guiding light to others.

Sincerely,
Arlene Istar Lev

Arlene Istar Lev, LCSW, CASAC
info@choicesconsulting.com
http://www.choicesconsulting.com

Arlene Lev is a social worker, family therapist, educator, and writer whose work addresses the unique therapeutic needs of lesbian, gay, bisexual, and transgender people. She is the Founder and Clinical Director of Choices Counseling and Consulting in Albany, New York, providing family therapy for LGBTQ people and is on a Lecturer at the University at Albany, School of Social Welfare, and an adjunct at Empire College. She is also the Founder and Clinical Director of TIGRIS, The Institute for Gender, Relationships, Identity, and Sexuality, a post-graduate training program serving people seeking greater relational and sexual intimacy, people who identify as sexual minorities, and those interested in exploring sexuality, gender, and identity issues. Arlene is the author of The Complete Lesbian and Gay Parenting Guide andTransgender Emergence: Therapeutic Guidelines for Working with Gender-Variant People and their Families, winner of the American Psychological Association Distinguished Book Award, 2006. She serves on the editorial Boards of theJournal of GLBT Family StudiesThe Journal of Lesbian Studies, and the Journal of Transgenderism. Arlene is the organizer of Professionals Concerned with Gender Diagnoses in the DSM.

Response to Dr. Jack Drescher and the NY Times About Childhood Transition: Part 1, by Kelley Winters

Coy Mathis

GID Reform Advocates respond to the question, “When a child identifies with the other gender, what to do?” Dr. Jack Drescher’s commentary on the Coy Mathis Civil Rights Case in Colorado appeared in the Sunday Dialogues Feature of the June 29, 2013 New York Times. Here is the discussion that the Times did not publish.

Kelley Winters, Ph.D.
GID Reform Advocates

The Sunday Dialogue feature of the June 30 edition of the New York Times responded to the recent Colorado Human Rights Division ruling in favor of Coy Mathis, a six year old transgender girl who sought the same equal treatment and facilities access as other girls at her public school. The Times editors turned to Dr. Jack Drescher, a New York psychiatrist who served on the Work Group on Sexual and Gender Identity Disorders for the DSM-5, the diagnostic manual of mental disorders published by the American Psychiatric Association. Dr. Drescher  could have taken this opportunity to acknowledge young Ms. Mathis’ remarkable courage and tenacity. He could have taken this teachable moment to note the barriers of intolerance and injustice that transgender people face as children, both in and out of the closet. But, instead, Dr. Drescher said this:

Actually, no one knows whether Coy will continue to feel that she is a girl when her body develops further, since most children like her grow up to be gay, not transgender.

Although Coy has identified as a girl, lived happily as a girl and attended school as a girl since kindergarten, Drescher’s statement impugns her legitimacy as a girl and suggests that her strong sense of gender identity is a likely just a passing phase. The statement not so subtly passes judgement on the Mathis family for allowing Coy to be herself as she sees herself. Although the “passing phase” mantra is heard frequently among psychiatric policy makers and institutional researchers in recent years, serious questions remain. Is this prediction based on scientific evidence? And, what exactly is meant by, “children like her”?

Conflating Gender Expression with Gender Identity

Young children, like Coy, who strongly, consistently and persistently identify as other than their birth-assigned sex, and who have fully lived in their affirmed gender roles, have been criticized while left unstudied by researcher/policymakers who publish literature on gender variant youth. Since the early 90s, most study populations have instead been selected by much broader diagnostic criteria for Gender Identity Disorder in Children (GIDC) from the DSM-IV and IV-TR, published in 1994 and 2000. Under these controversial criteria, children could be diagnosed with GIDC strictly on the basis of gender nonconforming behavior, with no evidence that they identified as other than their birth-assigned gender. Therefore, children who were intensely distressed by their birth-sex or assigned gender roles (gender dysphoria) were not distinguished from larger numbers of effeminate male-identified boys or masculine female-identified girls. Under these criteria, gender expression that differed from birth-assigned roles was deemed psychopathological, no matter how happy, functional and well adjusted the child. Moreover, children who conformed to birth-assigned stereotypes were exempt from GIDC diagnosis, no matter how gravely distressed with those roles and even if conformity was compelled under duress or physical punishment.

In 2000, Bartlett, et al., noted shortcomings in the GIDC criteria:

…it appears that a minority of children diagnosed with GID have a sense of discomfort with their biological sex.

Concerns about broad false-positive diagnosis of children who were never actually transgender and potential therapeutic abuse of youth suspected of being “pre-gay” led to revision of the Gender Dysphoria in Children category in the DSM-5 in 2013. Its criteria were tightened to resemble the prior DSM-III and DSM-III-R GIDC categories, requiring evidence of desire or insistence of other than the birth-assigned gender. In other words, the childhood diagnosis was restricted in the DSM-5 to gender dysphoric children in conflict with their birth-sex or assigned role, not merely gender nonconforming. However, sample bias resulting from old diagnostic flaws in the DSM-IV and IV-TR was not subsequently acknowledged by researchers who based their studies on GIDC diagnosis. Dr. Drescher’s remark about Coy Mathis was informed by dated research and old attitudes that conflated gender nonconformity with gender dysphoria, not controlled studies of children who actually resembled Coy.

The Doctrine of Desistence

Medical and public policy have long been influenced by research, suggesting that gender variance from birth-assigned roles in young children will most likely “desist” by adolescence and adulthood, when they will identify with their birth-assigned sex. Dr. Kenneth Zucker, of the Toronto Centre for Addiction and Mental Health (CAMH) and chairman of the DSM-5 Work Group on Sexual and Gender Identity Disorders, is the most prolific proponent of the 80%-desistence assumption. In 2006, he remarked to the New York Times:

80 percent [of preadolescent gender variant children] grow out of the behavior, but 15 percent to 20 percent continue to be distressed about their gender and may ultimately change their sex.

This “it’s just a phase” stereotype, has been repeated for many years and has underpinned policies that keep gender dysphoric children in the closets of their birth-assigned gender.  It is based primarily on studies at Dr. Zucker’s own practice at CAMH and at VU University Medical Center in Amsterdam. Since 1994, sample selection for these studies has relied on diagnostic criteria for Gender Identity Disorder in Children (GIDC) in the DSM-IV and IV-TR. In fact, Zucker and his colleagues at CAMH were instrumental in defining these criteria. As discussed earlier, these criteria required only gender nonconforming behavior for diagnosis, and not necessarily evidence of gender dysphoria  (persistent distress or incongruence with birth-sex or birth-assigned gender role). Gender dysphoric subjects in the resulting study samples were diluted by gender nonconforming children who were not gender dysphoric.

Therefore, much of this research actually suggests that the majority of children who are merely gender nonconforming, and meet the overinclusive GIDC criteria in the DSM-IV and IV-TR, will not be gender dysphoric later in life and will identify with their birth-assigned gender. However, some researcher/policymakers have inexplicably interpolated the 80%-desistance assumption to a smaller subset of children who are gender dysphoric. They have arbitrarily substituted “gender dysphoria” for “gender identity disorder” or “gender variance” in their literature, even though these terms have widely disparate definitions. As a consequence, there are concerns that these studies have scooped up large proportions of gender nonconconforming kids who were never actually gender dysphoric, found them still not gender dysphoric at puberty, and then declared them “desistent” in the literature.

In his NY Times commentary, Dr. Drescher went further still, applying the desistence doctrine to an even smaller subset of extremely gender dysphoric children like Coy Mathis, who have surmounted formidable barriers to live a real life experience in their affirmed gender roles at school. However, the Toronto and Amsterdam studies  discouraged  real life experience social transition before puberty and therefore lacked validity for “children like her.”

While mental health researchers and policymakers may not know Coy’s inner gender identity, there is a real chance that she does. Unlike those of past generations, Coy has been given a chance at a childhood, a life, without closets, without shame and without punishment for behaviors and expression that would be ordinary or even exemplary for other children. The real questions are, whether this chance should be taken away from her, and on what scientific basis?

In his response comment in the Times, Dr. Drescher called for “less polemics and fewer opinions presented as hard facts.” We might start with closer scrutiny of the 80%-desistence doctrine. In the meantime, Coy Mathis is busy defying false stereotypes, political attacks and media sensationalism by being herself in her Colorado first grade classroom. American psychiatry could learn a lot from this brave little girl.

© 2013 Kelley Winters, GID Reform Advocates

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)

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.

ImageOn 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

Kelley outside the 2009 Annual Meeting of the APANow 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

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

 

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