DSM-V Task Force Releases Proposed Diagnostic Criteria

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

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

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

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

Preliminary Remarks

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

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

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

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

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

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

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

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

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

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

Proposed Diagnostic Criteria for Gender Incongruence in Adolescents or Adults

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

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

Subtypes

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

Proposed Diagnostic Criteria for Gender Incongruence in Children

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

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

Subtypes

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

Proposed Diagnostic Criteria for Transvestic Disorder

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

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

Specify if:

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

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

Copyright © 2010 Kelley Winters, GID Reform Advocates

A Taxing Question of Medical Necessity

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

Many trans and especially transsexual Americans were relieved this week by the U.S. Tax Court decision to reverse earlier IRS positions and allow costs of hormonal and surgical transition care to be deducted as medical expenses. The ruling concluded:

Petitioner has shown that her hormone therapy and sex reassignment surgery treated disease within the meaning of section 213 and were therefore not cosmetic surgery. Thus petitioner’s expenditures for these procedures were for “medical care” as defined in section 213(d)(1)(A), for which a deduction is allowed under section 213(a).

However, this recognition of the legitimacy of medical transition came at a cost to the dignity of transsexual women and men. It relied on the flawed diagnostic nomenclature of Gender Identity Disorder (GID) in the Diagnostic and Statistical Manual of Mental Disorders (DSM) and its implication of mentally “disordered” gender identity. Paradoxically, this case fueled opposition to medical transition access, based on the current wording of the very same GID classification and its more virulent companion diagnosis of Transvestic Fetishism. While the Tax Court decision underscored the utility of some kind of diagnostic coding for those who need access to hormonal or surgical transition care, it also illustrated the urgency of reforming the GID diagnosis and removing the Transvestic Fetishism category in the next revision of the DSM, published by the American Psychiatric Association (APA).

Ms. Rhiannon O’Donnabhain underwent corrective genital surgery in 2001 and claimed a tax deduction for surgical and hormonal treatment expenses as well as the cost of a breast augmentation procedure. Her courageous nine year battle with the IRS to affirm the medical legitimacy of her transition care took a tortuous off-again, on-again path among the potholes of politics and prejudice.

Although the IRS initially issued a full refund to Rhiannon, a tax examiner denied her deduction in July, 2002. He declared her surgical and hormonal care to be “cosmetic” and therefore excluded as a deductible medical expense under section 231(d)(9) of the Internal Revenue Code. She appealed, represented by Gay and Lesbian Advocates and Defenders (GLAD). Attorney Karen Loewy argued that,

Any notion that medical treatment for a transgender person is purely cosmetic is based on misunderstanding and prejudice, not medical science.

In November, 2004, the IRS reversed the examiner’s decision and allowed Rhiannon to deduct her surgical expenses as medically necessary and professionally prescribed. However, political extremist groups responded by pressuring the Bush Administration to deny tax deductions for all medical transition care. They based their arguments on the same psychiatric classification of GID that GLAD cited to win the appeal. The following month, Rev. Louis Sheldon, chairman of the Traditional Values Coalition (TVC), wrote IRS Commissioner Mark Everson:

[B]y giving this tax deduction, your agency will be encouraging other mentally disturbed individuals to consider such surgery as an unneeded surgical procedure for what is a troubled mind–not a troubled body.

The IRS caved to political pressure in October, 2005. IRS Branch Chief Thomas Moffitt issued a Memorandum of Chief Counsel Advice that reversed the decision of the appeals officer and once again denied Rhiannon’s deduction of medical transition expenses. Moffitt demeaned Rhiannon with maligning pronouns of her assigned birth sex and concluded,

In light of the Congressional emphasis on denying a deduction for procedures relating to appearance in all but a few circumstances and the controversy surrounding whether GRS is a treatment for an illness or disease, the materials submitted do not support a deduction.

Astonishingly, Moffit based his ruling, not on respected medical literature, but on a political magazine called First Things, published by the Institute on Religion and Public Life. He cited an article by psychiatrist Paul McHugh, known for employing false stereotypes of mental pathology to terminate gender confirming surgeries at John Hopkins Hospital in the 1970s . McHugh mocked post-operative transsexual women as “caricatures” and invoked the current classification of mental disorder to discredit medical transition care:

Once again I concluded that to provide a surgical alteration to the body of these unfortunate people was to collaborate with a mental disorder rather than to treat it.

Finally, Chief Moffit erected an addition political barrier, unprecedented for other minorities, to transsexual citizens seeking equal treatment under the tax code:

Only an unequivocal expression of Congressional intent that expenses of this type qualify under section 213 would justify the allowance of the deduction in this case.

Civil justice advocates were outraged at such tactics by the Bush Administration. Professor Lynn Conway noted,

To deny such people medical deductions for the medical correction of their bodies – people who often face extreme financial and employment difficulties during their transitions – is unfair and inhumane. The claim that such people require a special “act of Congress” before being treated fairly exudes not only ignorance and intolerance, but also open Executive Branch hostility towards gender variant people.

Berkeley tax attorney Donald Read commented in the San Francisco Chronicle

The IRS should not allow religious views to impact the administration of our tax laws… We all should be concerned about the politicization of the IRS, not only against gay and transgender people, but in all its forms.

Rhiannon’s suit was heard by the U.S. Tax Court in July, 2007. She was again represented by the GLAD legal staff as well as co-counsel from the Boston firm of Sullivan & Worcester.

Senior IRS attorney John Mikalchus repeated the party line from the TVC and Paul McHugh that transition in itself represents psychopathology, citing the current GID diagnosis. He stated that surgery, hormones and other transition treatments do not cure cross-gender identification but “reinforce” it.

Mikalchus also invoked the second gender diagnosis of Transvestic Fetishism, speculating that many transsexual women seeking corrective transition surgeries are afflicted with a paraphilic sexual preoccupation with dressing as women. The APA fueled this false stereotype with publication of the DSM-IV in 1994, where TF was expanded to specifically include transsexual women who are attracted to other women. Mikalchus further belittled Rhiannon with the term, “autogynephilia,” an unsupported derogatory theory promoted by Toronto sexologist Raymond Blanchard, associating male-to-female transition with a narcissistic sexual arousal at “the thought or image of oneself as a woman.” Dr. Blanchard was largely responsible for the current Transvestic Fetishism diagnosis in the DSM-IV. As chairman of the APA’s Paraphilias Subcommittee for the pending DSM edition, he has recently proposed expanding the TF diagnosis with the title, Transvestic Disorder, and adding “Autogynephilia” as a diagnostic specifier.

Despite these barriers, the Tax Court ultimately rejected the IRS portrayal of transition as pathological and its associated medical care as “cosmetic.” On February 2, 2010, the Court ruled that Rhiannon’s hormonal and surgical transition treatments –

were for the treatment of disease within the meaning of § 213(d)(1)(A) & (9)(B), I.R.C. and thus not “cosmetic surgery” excluded from the definition of deductible “medical care” by § 213(d)(9)(A), I.R.C. [paraphrased]

A 69 page majority opinion, authored by Judge Joseph Gale, once again reversed the IRS denial and allowed Rhiannon to deduct her expenses for hormonal medications and corrective genital surgery (although it denied a deduction for her breast augmentation expenses). Their decision rested upon an interpretation of the GID diagnosis as “a serious, psychologically debilitating condition,” rather than a demeaning indictment of “disordered” gender identity. Although political extremists and the IRS attempted to exploit conflicting and ambiguous language in the current GID nomenclature, the GLAD legal team and expert witness Dr. George Brown successfully clarified that severe persistent distress with current physical sex characteristics (often termed anatomical dysphoria) is the true focus of medical transition treatment. In spite of the shortcomings of the current Gender Identity Disorder and Transvestic Fetishism diagnoses, they persuaded the Court that the necessity and efficacy of these treatments in relieving this debilitating distress is well established. Jennifer Levi, Director of GLAD’s Transgender Rights Project, noted,

In this landmark ruling, the Tax Court affirmed the consensus position of the medical establishment that transition-related medical care is essential for many transgender people.

However, the political fragility of this ruling and the contradictory role of the GID and TF diagnoses in establishing the medical necessity of transition treatments are underscored by the dissenting opinion (p. 119-139) of Judge David Gustafson. Joined by four other judges, he opposed allowing a deduction for transition surgeries, stating:

One could analyze the GID patient’s problem in one of two ways: (1) His anatomical maleness is normative, and his perceived femaleness is the problem. Or (2) his perceived femaleness is normative, and his anatomical maleness is the problem. If one assumes option 2, then one could say that SRS does “treat” his GID by bringing his problematic male body into simulated conformity (as much as is possible) with his authentic female mind. However, the medical consensus as described in the record of this case is in stark opposition to the latter characterization and can be reconciled only with option 1: Petitioner’s male body was healthy, and his mind was disordered in its female self- perception.

In its present form, the diagnostic criteria and supporting text of the GID diagnosis can all too easily be inferred in Gustafson’s second context of “disordered” gender identity, in contradiction to the medical necessity of hormonal and surgical transition treatments. If the intention of the Internal Revenue Service was to punish transsexual people for nonconformity to their assigned birth roles, the American Psychiatric Association, inadvertently or not, handed them blunt instruments of oppression with the current GID and TF diagnoses. Rhiannon herself said it best,

It’s a Catch-22. I have to accept the stigma of being labeled as having a disorder [or] a mental condition … in order to get benefits. I haven’t liked this diagnosis from the very beginning. But I’ve got to play the game.

This week, on February 10, the American Psychiatric Association is scheduled to release draft diagnostic criteria for the Fifth Edition of the DSM for public review. In the DSM-V, the APA has an opportunity to correct the shortcomings and ambiguities of the GID diagnosis that pose barriers to civil justice and access to medical care: (1) clarifying distress as the diagnostic focus rather than nonconformity to assigned birth sex roles; (2) excluding from diagnosis those who suffer no distress or impairment with their bodies or ascribed social gender; (3) clarifying that transition is therapeutic and not pathological; and (4) removing maligning pronouns and terms that disrespect the affirmed identities of transitioned individuals. The APA also has an opportunity to remove the Transvestic Fetishism category that is purely punitive and defamatory to many transwomen.

An American hero in the struggle for dignity and equality, Rhiannon O’Donnabhain deserves better from mental health policymakers. We all do.

Update: Statement on Gender Identity Disorder and Transvestic Fetishism in the DSM-V

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

The Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association, is regarded as the medical and social definition of mental disorder throughout North America and strongly influences the The International Statistical Classification of Diseases and Related Health Problems (ICD). 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) inflict great harm to gender variant, and especially transsexual, people in three ways:

Unfair Social Stigma. The GID and TF diagnoses falsely label 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. Transwomen (those who identify as women and were birth-assigned male) are consequently maligned as crazy and sexually suspect “men” by this stereotype and vice versa for transmen. The defamatory classification of Transvestic Fetishism particularly targets transwomen, including a great many transsexual women (whose gender identities are dramatically incongruent with born physical sex characteristics), as “paraphiliac” or sexually perverse. Across North America, these diagnoses are cited directly when gender variant people are denied human dignitiy, civil justice, and legal recognition in their affirmed gender roles. Gender variant people lose jobs, homes, families, access to public facilities, and even custody and visitation of children as consequences of these false stereotypes.

Medical Care Access. GID and TF pose barriers to access to medically necessary hormonal and surgical transition treatment for those who need them.  The diagnostic criteria, supporting text and categorical placement of GID and TF contradict social and medical transition and mis-characterize transition itself as symptomatic of mental disorder. Transitioned individuals who are highly functional and happy with their lives are forever diagnosable as mentally disordered, according to the current diagnostic criteria. As a consequence, the medical necessity of hormonal and surgical transition treatments are not commonly recognized by care providers, insurers and government agencies. In the US, only the financially privileged have access to surgical care, with scant few exceptions.

Gender-Reparative Therapies. GID and TF implicitly promote cruel and harmful gender-reparative psychiatric “treatments” intended to enforce conformity to assigned birth sex and suppress gender variant identities and expressions into the closet. Once diagnosed with GID or TF, the only way a transperson can be released from the current diagnostic criteria is to completely hide his or her gender identity and deny his or her authentic self. Children and adults, already at risk from undeserved guilt and shame, are subjected to more guilt, shame, torturous aversion therapies, drugs and even incarceration with these diagnoses.

The DSM-V.

I urge reform and redefinition of the Gender Identity Disorder diagnosis to simultaneously address both issues of unfair social stigma and medical necessity of hormonal and surgical transition treatments. I believe this can best be accomplished in the upcoming Fifth Edition of the DSM (DSM-V) by replacing GID with nomenclature emphasizing painful distress with born physical sex characteristics or ascribed social gender role that are incongruent with gender identity, rather than nonconformity to assigned birth-sex. I am encouraged by a recent report from Drs. Peggy Cohen-Kettenis and Friedemann Pfafflin , of the Gender Identity Disorders Subcommittee of the DSM-V Task Force. They acknowledge many of the GID issues described here and recommend a diagnostic focus on distress and exclusion from diagnosis of gender variant people who meet no scientific definition of mental disorder. However, I am concerned about their use of the word, “desire,” in their proposed diagnostic criteria, which would ambiguously implicate desire for medical transition treatment in itself as symptomatic of mental illness.

I strongly urge elimination of the scientifically capricious and socially punitive Transvestic Fetishism diagnosis from the DSM-V. I am especially troubled by a September report from Dr. Raymond Blanchard, chairman of the Paraphilias Subcommittee of the DSM-V Task Force. He proposes to retain the TF diagnosis, renamed “Transvestic Disorder” with its existing diagnostic criteria that ambiguously label all “behaviors involving cross-dressing” by those assigned male at birth as sexually deviant on the basis of their sexual orientation. Moreover, Dr. Blanchard proposes to add the deeply offensive and inflammatory term, “autogynephilia,” as a specifier to the diagnosis. I ask the DSM-V Task Force and elected officials of the American Psychiatric Association to reject his proposal.

Further Reading.

GID Reform Advocates, www.gidreform.org

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

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/

Winters, K., Ehrbar, R. (2009) “Beyond Conundrum: Strategies for Diagnostic Harm Reduction,” Annual Meeting of the American Psychiatric Association, San Francisco, CA, http://www.gidreform.org/blog2009May18.html

Cohen-Kettenis, P. T., & Pfafflin, F. (2009). “The DSM diagnostic criteria for gender identity disorder in adolescents and adults.” Archives of Sexual Behavior, doi: 10.1007/s10508-009-9562-y. http://www.springerlink.com/content/c54551hj463111j1/

Blanchard, R. (2009). “The DSM Diagnostic Criteria for Transvestic Fetishism,” Archives of Sexual Behavior, doi: 10.1007/s10508-009-9541-3, http://www.springerlink.com/content/9267212375m4n40r/

Revision Suggestions for Gender Related Diagnoses in the DSM and ICD

Ehrbar, Randall D., Psy.D.
Winters, Kelley, Ph.D.
Gorton, R. Nicholas, M.D

a synopsis of the presentation to

The World Professional Association for Transgender Health (WPATH)
2009 XXI Biennial Symposium
June 19, 2009
Oslo, Norway

For the complete presentation text, please see www.gidreform.org/wpath2009/

Starting with different beliefs and assumptions about appropriate diagnoses for transgender and gender variant individuals suffering from gender dysphoria, the members of this panel have reached similar conclusions about desirable changes to diagnostic categories in the next version of the DSM and ICD. Important points of agreement are that revised versions of diagnoses such as GID, Transsexualism, and GID in children 1) should center on gender dysphoria, which is distress associated with sexed characteristics of the body and/or social gender role, 2) should be large enough to encompass all of those who need it including those with non-binary gender identities, and those who do not wish to fully medically or socially transition to the “opposite” gender, 3) should be narrowly defined to only include those who are experiencing gender dysphoria (and are therefore presumably in need of treatment), not to those who are merely gender non-conforming. We will discuss the different premises and constructs on which the three authors base their conclusions and explore how despite these significant epistemological differences, the same conclusions become apparent. We will also discuss placement of diagnostic categories, nomenclature, “exit clauses” for trans-people who no longer experience gender dysphoria, cultural and sociopolitical significance of diagnostic categories and discourses around such categories, and appropriate diagnosis of distress primarily due to discrimination and oppression rather than gender dysphoria.

Introduction:

We come at this issue from a variety of different backgrounds and viewpoints differing on whether there should be a diagnosis at all or what kind of diagnosis it should be. When I first approached Dr. Nick Gorton and Dr. Kelley Winters they both were a bit skeptical, in fact, because they perceived that the other had very different viewpoints. Yet we agree about fundamental principles of treatment and rights for trans people. We may just differ in the ways that we think these things can best be accomplished. In the process of working on this talk we discovered that not only do we share common basic principles, but even had some common ground about utility of having a diagnosis and what such a diagnosis should look like if there is a diagnosis. . We were also able to generate compromises that could accommodate those areas where we do have fundamental differences. One of the first things we did in preparing for our talk was to write in 30 words or less our fundamental beliefs about diagnosing transgender people with an illness and what that does for the community.

What We Think:

• Winters – Individuals whose gender identity or expression differ from assigned birth-sex are labeled mentally disordered in the DSM-IV-TR, inflicting harmful social stigma and barriers to transition care.
• Ehrbar – Practically, diagnosis is needed for access. Conceptually, it makes sense to categorize gender dysphoria as a mental health disorder.
• Gorton – GID (by any name) belongs in DSM-V. Revisions can foster acceptance among consumers without compromising scientific accuracy. Diagnosis facilitates insurance coverage and disability protections.

We also explicitly identified our common ground is with regard to access to care, non-discrimination, social justice, and civil rights. We have a good deal of common ground about how we think the world should be. In fact, we suspect that most if not all of the folks here at WPATH share these fundamental beliefs. , I It’s worth reminding ourselves that we do agree that trans and gender variant people shouldn’t be subject to discrimination, should have access to health care and should have civil rights and protections.

The Authors’ Shared Vision:

• End discrimination on the basis of gender identity and expression
• Gender identity and expression that differ from assigned birth sex do not, in themselves, constitute a mental disorder or an impairment in competence
• Hormonal and/or surgical transition treatments to relieve gender dysphoria are medically necessary
• Insurance and health care coverage for medically prescribed transition treatment
• Legal recognition/documentation for all people that is consistent with their gender identity and expression.
• Reform must fit everyone’s needs, but as a social justice movement we must weigh more heavily the needs of those least enfranchised.

Summary of Proposed Diagnosis:

• Dx Criteria – Both A and B

A: Strong and persistent distress with physical sex characteristics, or ascribed social gender role, that is incongruent with persistent gender identity.

B: Distress is clinically significant or causes impairment in social, occupational, or other important areas of functioning, when this distress or impairment is not solely due to external prejudice or discrimination.

• GD in remission

No longer meets criteria, needs treatment to maintain remission

• ‘Exit clause’

No longer meets criteria, doesn’t need treatment to maintain remission

Key Points:

• It’s about Dysphoria, not difference from assigned birth sex
• Respectful Language
• Not too Big; Not too Little; but Just Right
• Accurate Classification Placement
• Remove Tranvestism/Fetishism Categories

Our main points are: 1) gender dysphoria is the conceptual center of the diagnosis, 2) use respectful language in nomenclature and description of individuals, 3) include those who are in need of inclusion, do not include those who should not be, 4) move the diagnosis out of the sexual and gender identity disorders chapter, 5) and remove transvestic fetishim.

About the Authors:

Randall Ehrbar is a clinical psychologist with extensive training and experience working with transgender clients. He has also been actively involved in the American Psychological Association’s efforts to address transgender concerns.

Kelley Winters is a writer and consultant on gender diversity issues in medical, employment and public policy.

Nicholas Gorton is a medical doctor who provides primary care to many transgender clients at Lyon Martin Health Services

Copyright © 2009 Randall Ehrbar, Kelley Winters, Nicholas Gorton

Stop Sexualizing Us!

A Guest Essay by Julia Serano, Ph.D.
Presented at a Protest Rally at the
Annual Meeting of the
American Psychiatric Association
San Francisco, May 18, 2009

For decades, the general public, and especially the media, have had a lurid fascination with trans people’s bodies and sexualities. From talk shows like Jerry Springer, to reality shows like There’s Something About Miriam, novels like Myra Breckinridge, and the countless movies that portray trans women almost exclusively as either sex workers, sexual predators and sexual deviants. This hypersexualization of transgenderism predominantly targets trans women and others on the trans feminine spectrum—because in a world where women are routinely objectified, and where a woman’s worth is often judged based on her sexual appeal, it is no surprise that many people presume that those of us who were assigned a male sex at birth, but who identify as women and/or dress in a feminine manner, must do so for primarily sexual reasons.

We are here today to say, stop sexualizing us!

This sexualization of trans feminine gender expression also runs rampant in psychiatry. In the current version of the DSM, there is a diagnosis called Transvestic Fetishism, which specifically targets “male” expressions of femininity. When nontransgender women wear traditionally feminine clothing, they are viewed as healthy. But when the same behavior occurs in people assigned a male sex at birth, the APA deems it psychopathology. This is hypocrisy!

We say to the APA, stop sexualizing us!

And while crossdressing by men is often an expression of femininity, or of an inner gender identity, Transvestic Fetishism presumes that the act of wearing feminine clothing must (in and of itself) be an expression of aberrant sexuality.

We say to the APA, stop sexualizing us!

Studies have shown that, “Cross-dressers…are virtually indistinguishable from non-cross-dressers.” Despite the empirical lack of evidence that crossdressing is associated with psychopathology, the APA continues to mischaracterize crossdressing as a mental disorder.

We say to the APA, stop sexualizing us!

And if that wasn’t bad enough, Transvestic Fetishism has been categorized in the Paraphilias section of the DSM—the category that used to be called Sexual Deviations. This section used to be home to diagnoses like Homosexuality and Nymphomania—societal double standards that for decades were reified in the DSM as mental disorders. Like its predecessors, crossdressing is a harmless, consensual activity that is unnecessarily stigmatized in both the culture at large and within psychiatry. We are here to call for the removal of all forms of crossdressing and transvesticism from the DSM.

We say to the APA, stop sexualizing us!

And while there are many psychologists who understand the distinction between gender and sexuality, who understand that trans people’s identities, personalities and sexual histories are infinitely varied, the APA passed over such people, and instead tapped Ray Blanchard to chair of the sub-working group for the next DSM’s Paraphilia section.

We say, to the APA, stop sexualizing us!

Blanchard is the inventor of the controversial theory of autogynephilia, which claims that all transgender women are sexually motivated in our transitions. Despite the overwhelming scientific and experiential evidence that contradicts his theory, it has gained traction in the psychological literature—including a mention in the current DSM—precisely because it reifies hypersexualized stereotypes of trans women.

We say, to the APA, stop sexualizing us!

Blanchard views trans feminine spectrum individuals the way most movie producers do. To him, we are all either gay men who become women in order to attract straight men, or we are male perverts who become women in order to fulfill some kind of bizarre sex fantasy.

We say, to the APA, stop sexualizing us!

Blanchard not only believes that we are sexually deviant, but in the psychological literature, he has forwarded his belief that those people who are attracted to us—our lovers, partners and spouses—must also suffer from a paraphilic disorder.

We say, to the APA, stop sexualizing us!

Blanchard’s theories have been challenged by a majority of trans activists, allies, advocates and countless trans-knowledgeable psychologists and therapists. Yet, the APA selected him to play a lead role in rewriting trans feminine gender expression back into the DSM.

We say, to the APA, stop sexualizing us!

When you sexualize someone, you invalidate them. That’s why feminists have worked so hard to put an end to sexual harassment in the workplace, and it’s why we as trans activists seek an end to the psychiatric sexualization of trans feminine gender expression.

We say, to the APA, stop sexualizing us!

Clothing choice does not constitute a psychopathology. We call for the complete removal of crossdressing and Transvesticism (in any form) from the DSM.

We say to the APA, stop sexualizing us!

About the Author:
Julia Serano is an Oakland, California-based writer, spoken word performer, trans activist, and biologist. Julia is the author of Whipping Girl: A Transsexual Woman on Sexism and the Scapegoating of Femininity (Seal Press, 2007), a collection of personal essays that reveal how misogyny frames popular assumptions about femininity and shapes many of the myths and misconceptions people have about transsexual women. Julia has gained noteriety in transgender, queer, and feminist circles for her unique insights into gender. She has a Ph.D in Biochemistry and Molecular Biophysics from Columbia University and is currently a researcher at UC Berkeley in the field of Evolutionary and Developmental Biology.

Published here with permission of the author
Copyright © 2009 Julia Serano

ALIGNING BODIES WITH MINDS: THE CASE FOR MEDICAL AND SURGICAL TREATMENT OF GENDER DYSPHORIA

A Guest Essay by
Rebecca Allison, M.D., FACC, FACP
Chair, American Medical Association Advisory Committee
On Gay, Lesbian, Bisexual, and Transgender Issues
President-Elect, Gay and Lesbian Medical Association

A presentation given to the
Annual Meeting of the American Psychiatric Association
San Francisco, May 18, 2009

As a physician who has successfully completed the process of transition from male to female, I find it strange and inappropriate that I may still be considered “mentally ill” by those who would take literally the diagnosis of “gender identity disorder” in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). I believe such a diagnosis is incorrect, and submit this review to support my belief.

I’d like to begin by offering an example from my medical practice in support of the idea that “outcomes do matter” – that a favorable clinical outcome, reproducible from one patient to the next, validates the medical and/or surgical treatment prescribed for the diagnosis.

I intend to show that a cardiologist may initiate a course of treatment based on a patient’s reported symptoms, despite a lack of objective findings to support the working diagnosis; and that the accuracy of such a diagnosis is confirmed by the favorable response to what some might consider “empiric” treatment.

So much of my practice centers on a relatively small number of diseases of the cardiovascular system. One of the most common conditions I see is called angina pectoris.

Angina Pectoris is simply Latin for “Chest Pain.” But it’s a specific type of discomfort: mid-chest; radiates to the neck, jaw, or left arm; worse with physical or emotional stress. It’s relieved by rest or by the medication nitroglycerin.

When I see a patient with such typical symptoms, I know that it’s very likely he or she has interference with blood flow to the heart through clogged coronary arteries. I begin a series of tests including electrocardiograms, stress testing, and cardiac catheterization. Usually – over 95 percent of the time – the blockages are identified and managed appropriately with medications or surgery.

However, a small number of persons will have completely normal testing – no blockages at all. Even the electrocardiograms and stress testing do not indicate a physical cause for their symptoms. My next step for these persons is to look for other causes for their pain, with evaluation of the esophagus, GI tract, or musculoskeletal system. Even after this evaluation is complete, there will remain a group of people who have no discoverable cause for their pain, yet it is very real, severe, and sometimes disabling. What to do then?

I can tell you that what a cardiologist does then is treat the patient. We treat with medications, just as we would use for a patient with documented coronary artery disease. We give long acting nitroglycerin, calcium channel blockers, and aspirin. And our treatment works! The patients report prompt improvement. They are able to go about their normal lives without the anxiety and fear of the disabling pain. Outcomes do matter!

Numerous review articles in the cardiology literature confirm the effectiveness of medical therapy for the “syndrome of chest pain with normal coronary arteries.”

It has been suggested that this syndrome may be due to coronary vascular spasm, particularly in the small vessels of microscopic size. This is not a condition which can be objectively documented with any ease or safety, and so we do not perform provocative tests to induce spasm and “prove” our diagnosis, since such induced spasm could be harmful to the patient. We accept the diagnosis based on the response to our treatment. We name the condition “Cardiac Syndrome X,” which simply shows cardiologists aren’t very imaginative when it comes to original names. If we are more creative, we call it “microvascular angina,” and either way we give it an ICD Code of 413.9.

Notice that we do not call microvascular angina a mental disorder, although it has been reviewed frequently in the psychiatric literature, due to the high prevalence of serious anxiety in persons suffering from this condition. (I dare say, if I had frequent, severe, chronic chest pain, I’d be anxious too.) IF we use anti-anxiety medications, they are secondary to the primary medical treatment, and we would not prescribe them in lieu of nitroglycerin.

So, let’s just suppose someone comes to see me in my office, and he tells me, “Dr. Allison, I keep having these chest pains.” Suppose, after going through the complete evaluation, I tell him, “There’s nothing physically wrong. Perhaps we just need to help you adapt to your current circumstances. Let me give you a benzodiazepine [a mild tranquilizer].” What will he say? He most likely would tell me, “Listen here, either you give me some nitroglycerin, or I am going to find someone who will.” And he would be entirely correct. Because he knows that nitroglycerin will give him a good outcome, and he knows that outcomes matter.

Like microvascular angina, Gender Identity Disorder (or Gender Variance) is a diagnosis which is not based on objective findings. There’s no blood test for Gender Variance. There’s no chromosome analysis, no radiographic diagnosis, no nuclear scan. Pathologic changes in the hypothalamus, such as the “bed nucleus of the stria terminalis” or BSTc, are of academic interest but cannot be applied to living patients.

Some have suggested that a magnetic resonance image of the brain may show an appearance of the corpus callosum in male-to-female persons which is similar to genetic females. Even if a statistically significant correlation were to be proven, however, it would not have one hundred per cent sensitivity, meaning that some persons with true Gender Variance would have negative findings on MRI examination.

The best diagnosis remains subjective, the history as reported by the patient: a constant awareness of a sense of self which is not congruent with one’s physical body and the expected social role associated with that body.

Or, if you prefer, “a strong and persistent cross-gender identification;” and “persistent discomfort about one’s assigned sex or a sense of inappropriateness in the gender role of that sex.” You may recognize these as Criteria A and B of Gender Identity Disorder in the DSM-IV.

What about Criterion D, you ask? I maintain that “Clinically significant distress or impairment in social, occupational, or other important areas of functioning” should not be a necessary criterion for a diagnosis of Gender Variance. Many young persons are blessed with enlightened parents who facilitate their transition and help them avoid all the distress and impairment which was unavoidable for those of us who transitioned years ago. That is not to say that persons with Gender Variance no longer experience distress. We still do, but it is not a primary component of Gender Variance. It is secondary to the rejection we experience from family, friends, employers, and religious organizations.

Questions

What should be the appropriate treatment for persons who experience Gender Variance?

Just as with microvascular angina, outcomes matter!

What constitutes a good outcome?

Surely it is a well adjusted person, able to function socially and professionally, with no incongruity between sense of self and physical body.

What treatment results in a good outcome?
Does behavior modification result in a good outcome?

“Reparative Therapy”? Aversion therapy? Electroconvulsive therapy? Antipsychotic drugs? What data suggest that persons undergoing such treatments and remaining in their birth sex role experience a good outcome? I would suggest that no such data exist.

What about psychotherapy? Is it helpful as an isolated treatment modality, in persons who are not going through transition?

On a more positive note, does psychotherapy, or any long term counseling relationship, help produce a good outcome in persons who are going through transition? Even so, do some persons who complete transition without the need of therapy experience equally good outcomes?

Numerous published studies document the outcomes of transition, and these studies are consistent in their findings.

Cohen-Kettenis and colleagues (Journal of the American Academy of Child and Adolescent Psychiatry, 1997) interviewed 22 consecutive adolescent patients of their Netherlands gender clinic who underwent sex reassignment surgery. Postoperatively they reported no gender dysphoric symptoms and were socially functioning well. None of the patients expressed any feelings of regret over transition.

From the same clinic, Smith and colleagues (Psychological Medicine, 2005) followed 162 adults (146 male to female, 76 female to male) who completed medical and surgical reassignment in the course of transition. They found that body image scores and psychological functioning were significantly improved. Only 1.6% of patients expressed any regrets.

Krege and colleagues at the University of Essen (BJU International, 2001) found no regrets among 66 male to female persons followed between 1995 and 2000.

Lawrence (Archives of Sexual Behavior, 2003) evaluated 232 male to female patients who had sex reassignment surgery between 1994 and 2000. No patient reported outright regret. Interestingly, compliance with the requirements for sex reassignment surgery as outlined in the WPATH Standards of Care was not associated with more favorable subjective outcomes.

At its 2008 Annual Meeting, the American Medical Association adopted Resolution 122 regarding treatment of Gender Identity Disorder. The AMA noted, among other concerns, that “An established body of medical research demonstrates the effectiveness and medical necessity of mental health care, hormone therapy and sex reassignment surgery as forms of therapeutic treatment for many people diagnosed with GID,” and “Health experts in GID, including WPATH, have rejected the myth that such treatments are ‘cosmetic’ or ‘experimental’ and have recognized that these treatments can provide safe and effective treatment for a serious health condition.” The document notes “Delaying treatment for GID can cause and/or aggravate additional serious and expensive health problems, such as stress-related physical illnesses, depression, and substance abuse problems, which further endanger patients’ health.”

The AMA concluded with the Resolution “That our American Medical Association support public and private health insurance coverage for treatment of gender identity disorder as recommended by a physician.”

As I review these documents, I see evidence of the effectiveness of the transition process. Persons who complete transition are more likely to be well-adjusted, successful in work and with social relationships, and without regrets. Our own life experiences, as well as those of our friends and colleagues, confirm these successful outcomes.

Transition works! Outcomes matter!

The effectiveness of medical and surgical treatment for Gender Variance should mandate a medical diagnosis and inclusion in the ICD, rather than the DSM. Again, this does not imply that persons with Gender Variance do not benefit from behavioral health care. Many such persons experience depression, anxiety, or adjustment reactions due to the stress of rejection. These conditions are not, however, central to the diagnosis of Gender Variance. They are identical to the same conditions seen in persons who do not have Gender Variance. They will likely respond to appropriate counseling and/or medical management, but such treatment is adjunctive to the primary concern of working to achieve successful transition.

If Gender Variance were not a psychiatric diagnosis, then what other roles can the psychiatrist or psychologist play in the care of persons with Gender Variance?

We feel that one important role a therapist can perform is differential diagnosis. While the large majority of persons begin the transition process appropriately, there are a few who may have other psychological conditions which they confuse with Gender Variance. If these persons can be identified and directed to more appropriate courses of action before they take irreversible steps, we will not read about them as examples of regret for transition.

As we know, the WPATH Standards of Care require letters of approval from a behavioral health practitioner before a person may have sex reassignment surgery. While all North American surgeons, and most surgeons in Europe, require such letters, there are many doctors in other parts of the world who do not have such a requirement. The numbers of persons with Gender Variance who travel to these surgeons without going through a therapy relationship are increasing. In the future we may expect to see outcome studies relative to satisfaction or regret for transition without therapy.

IN CONCLUSION, I have used a common example from my practice of cardiology to illustrate that a diagnosis can be correctly made, and treatment can be successfully initiated, based on subjective symptoms as reported by the patient, without confirmation by specific diagnostic testing. Using the example of microvascular angina as my model, I contend that the same principles may be applied to the condition I call Gender Variance (rather than Gender Identity Disorder). It is not necessary to achieve certain measurements on a diagnostic image of the brain to know that a physical condition exists and is treatable by physical (medical and surgical) measures. The results of treatment are obvious and measurable. Hormone therapy works. Surgery to modify primary and secondary sex characteristics works. Transition works. Transition produces good outcomes, and outcomes matter.

In a perfect world, a diagnosis of Gender Variance, which does not carry the stigma of “disorder,” might exist as a medical condition in the ICD. Medical doctors could treat such persons with appropriate hormone management; surgeons could perform the operations essential for a normal life in the appropriate gender; and all such treatments would be covered by health insurance.

In a perfect world, psychiatrists and psychologists would appropriately manage the anxiety, depression, or other emotional conditions which occur in persons who have Gender Variance. These conditions would have appropriate codes in the DSM, but Gender Variance would not.

In a perfect world, psychiatrists might still treat persons WITH Gender Variance; but they would not treat persons FOR Gender Variance.

About the Author:
Dr. Allison is a Phoenix, Arizona cardiologist, Chairwoman of the American Medical Association Advisory Committee On Gay, Lesbian, Bisexual, and Transgender Issues, President-Elect of the Gay and Lesbian Medical Association. An advocate for the transcommunity, she created www.drbecky.com , a resource for medical, legal and spiritual information for trans people.

Published here with permission of the author
Copyright © 2009 Rebecca Allison

Call to Action to Urge Trans-Affirming Position Statements by the APA

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

On May 18, I presented a paper to the Annual Meeting of the American Psychiatric Association on the diagnostic categories of Gender Identity Disorder (GID) and Transvestic Fetishism (TF) in the Diagnostic and Statistical Manual of Mental Disorders (DSM). Coauthored by San Francisco psychologist and community advocate Dr. Randall Ehrbar, our presentation stressed the need to address two issues in the upcoming Fifth Edition of the DSM. First, the GID and TF diagnoses inflict harmful stigma of mental illness and sexual deviance on all trans, gender variant and queer identified individuals who do not conform to their assigned birth-sex, either by inner identity or outer social expression. Second, the GID diagnosis fails to support the medical necessity of hormonal or surgical transition care for those transsexual individuals who need them. In fact, the current GID diagnostic criteria and supporting text contradict both medical and social transition.

In addition to the case for reforming GID and removing the defamatory TF diagnosis in the DSM-V, we also urged the elected leadership of the APA to issue three public position statements in support of human dignity and medical care for trans and gender variant people.

We would like to ask the trans-community, our LGB and straight allies and especially our supportive medical and mental health providers to join us in calling for position statements that gender difference is not disorder, affirming the medical necessity of transition care, and recognizing social gender transition. The American Psychiatric Association has an opportunity today to reclaim its compassion for human dignity and its mandate to do no harm.

In 1973, the American Psychiatric Association made a historic step toward the ultimate declassification of same sex orientation as mental illness in the Diagnostic and Statistical Manual of Mental Disorders (DSM). Although the actual removal of the homosexuality diagnosis from the DSM occurred in incremental revisions over the following fourteen years, the elected leadership of the APA issued a Position Statement on “Homosexuality and Civil Rights” that had a profound impact on public opinion and defamatory stereotypes. Tragically, the APA has never issued a similar position statement in support of trans and gender variant people.

How can you help?

Please send letters to the President and Board of Trustees of the APA and the President of the Association of Gay and Lesbian Psychiatrists with the following requests:¹

1– We ask the elected leadership and Board of Trustees of the American Psychiatric Association to affirm in a position statement that gender identity and expression which differ from assigned birth sex do not, in themselves, constitute mental disorder and imply no impairment in judgment or competence.

2– We also ask the APA to follow the example of the American Medical Association, the American Psychological Association, and the World Professional Association for Transgender Health (WPATH) by issuing a statement 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. We call on the APA to urge insurance and healthcare coverage for medically prescribed transition treatment as well as ongoing and ordinary medical and mental health care. ²

3– Finally, we ask the American Psychiatric Association to follow the example of the American Psychological Association, the National Association of Social Workers and WPATH in opposing discrimination on the basis of gender identity or expression and encouraging legal recognition of all people that is consistent with their gender identity and expression. We ask the APA to affirm in a position statement the dignity and legitimacy of individuals who have transitioned their social gender roles, regardless of their physical anatomy or assigned birth sex.

Contact Information:

Alan F. Schatzberg, President, American Psychiatric Association
Carol A. Bernstein, M.D., President-elect, American Psychiatric Association
American Psychiatric Association
1000 Wilson Boulevard
Suite 1825
Arlington, VA 22209
email in care of: apa@psych.org

Board of Trustees, American Psychiatric Association
in care of: Thomas Graham
Senior Governance Specialist – Board of Trustees
email: tgraham@psych.org

Copy to Ubaldo Leli, M.D., President, Association of Gay and Lesbian Psychiatrists
email: uleli@aglp.org

Please send copies of your letters to me at kelley@gidreform.org. Include the phrase “APA Gender Position Statements” in your email header.

Update: My letter of June 22, 2009, to APA officials, with names of over 400 online endorsements and copies of letters received by GID Reform advocates, is available at www.gidreform.org/200906APAstatementsA.pdf

Finally, if you are a Facebook member, please consider adding your name to this Facebook Group to Urge the American Psychiatric Association to Publicly Affirm Human Dignity and Access to Medical Care for Trans and Gender Variant People. See www.facebook.com/home.php?ref=home#/group.php?gid=92915546212

1. Statement text updated May 31 and June 2, 2009 to clarify the distress of anatomic gender dysphoria, acknowledge organizations that previously issued similar statements and call for a statement to oppose discrimination. My deep thanks to Randall Ehrbar, Becky Allison, Jamison Green, Dan Karasic, Arlene Lev and Anne Vitale for their insight and input.

2. Based on input from clinicians and friends in the community, “and mental health” care was added to the second position statement request. At issue: those transpeople who do suffer depression or anxiety face unusual barriers to care that result from the stereotype that our gender identities are defective or “disordered.” All too often, care givers may ignore these conditions because they are preoccupied with “fixing” our gender identities; or insurers may deny claims altogether once they are aware that transition has started. For a thoughtful discussion of some of these issues, see the sent(a)mental project, founded by author Dylan Scholinski, at apps.facebook.com/causes/203944/14856704.

Copyright © 2009 Kelley Winters, GID Reform Advocates