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 Proposed Gender Dysphoria Diagnosis in the DSM-5

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

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

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

The APA Proposal Falls Short

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

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

We have proposed a change in conceptualization of the defining features by emphasizing the phenomenon of “gender incongruence” in contrast to cross-gender identification per se (APA 2011A)

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

Social Stigma.

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

in boys, a strong preference for cross-dressing or simulating female attire; in girls, a strong preference for wearing only typical masculine clothing and a strong resistance to the wearing of typical feminine clothing (APA 2011B)

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

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

Medical Transition Care Access.

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

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

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

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

Punitive Gender-Reparative Therapies.

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

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

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

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

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

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

Why Not Remove All Gender Diagnosis?

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

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

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

A New Distress-based Diagnostic Paradigm.

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

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

Suggested Diagnostic Criteria for Gender Dysphoria in the DSM-5

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

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

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

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

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

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

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

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

What You Can Do Now

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

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

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

(APA 2011A)

A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested by 2 or more of the following indicators: [2, 3, 4]

1. a marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or, in young adolescents, the anticipated secondary sex characteristics) [13, 16]

2. a strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or, in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics) [17]

3. a strong desire for the primary and/or secondary sex characteristics of the other gender

4. a strong desire to be of the other gender (or some alternative gender different from one’s assigned gender)

5. a strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender)

6. a strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender)

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

Subtypes

With a disorder of sex development [14]

Without a disorder of sex development

See also: [15, 16, 19]

Specifier

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

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

APA: Proposed Diagnostic Criteria for Gender Dysphoria in Children

(APA 2011B)

A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested by at least 6* of the following indicators (including A1): [2, 3, 4]

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

2. in boys, a strong preference for cross-dressing or simulating female attire; in girls, a strong

preference for wearing only typical masculine clothing and a strong resistance to the wearing of typical feminine clothing [6]

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

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

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

6. in boys, a strong rejection of typically masculine toys, games, and activities and a strong avoidance of rough-and-tumble play; in girls, a strong rejection of typically feminine toys, games, and activities [10]

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

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

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

Subtypes

With a disorder of sex development [14]

Without a disorder of sex development]

See also [13, 15, 19]

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

References

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Copyright © 2011 Kelley Winters, GID Reform Advocates

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

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

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

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

What You Can Do Now

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

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

References

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

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

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

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

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

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

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

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

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

An Inflection Point for Gender Diversity in Mental Health Policy

Kelley Winters, Ph.D.
Keynote Speech,
Colorado Gold Rush Conference,
Denver, CO
February 2010

Thank you so much for inviting me to spend this time with you, and thanks to everyone at the Gender Identity Center of Colorado for organizing this wonderful event that has brought all of together. I would also like to thank the staff here at the Renaissance Hotel, who have made us so welcome in this space.

Most of all, I am grateful to all of you here tonight for lending your support to me. The Gender Identity Center is my personal home in the transcommunity. This is where I go when I need support, advice and inspiration. More than 23 years have passed since I tiptoed into my very first support group meeting, right here in Denver, when the Center was up on 32nd street. For the first time in my life that evening, I discovered community – I discovered in the first person that I was not alone. The support, love, sisterhood and brotherhood that I found in this organization saved me then as they sustain me today. From the bottom of my heart, thank you for this very special and very resilient community.

Earlier this year, I was honored to finally meet one of my personal heroes, Miss Major, a trans community leader and activist for over 40 years and a veteran of the Stonewall Riots. How many of you saw the screening yesterday of the movie, Diagnosing Difference? One of the speakers interviewed in the film, Miss Major reminded us that—

“We have to look out for one another, because we’re all we got”

More than 15 years ago, I felt a need to give something back to this community that had given so much to me. But I soon discovered what most all community advocates learn– how overwhelming is the work to be done and the barriers to be overcome. I looked at the history of the gay and lesbian movement for examples of where individuals made a difference, where small groups of people were able to impact the course of history. I found two such inflection points: the Stonewall riots of 1969 and the declassification of same-sex orientation as mental disorder in the 1970s and 80s. Having back problems, thrown off a few too many horses in my youth, I decided that flipping over burning cop cars was probably not my best calling. I focused on psychiatric policy issues instead.

There are currently two categories in the Diagnostic and Statistical Manual of Mental Disorders that impact our community: Gender Identity Disorder (GID), very much intended to imply that our gender identities are in themselves disordered, and Transvestic Fetishism, targeted specifically at transwomen.

There are two major issues in these diagnoses that confront us today:

First, the stigma of mental disorder and sexual deviance for all who differ in gender identity or gender expression from expectations of their assigned birth-sex.

And second, for that portion of our community distressed by our physical sex characteristics, barriers to access hormonal and surgical treatment that are proven to relieve this distress.

Unlike cisgender gay and lesbian folks, who were emancipated from the classification of mental illness a generation ago, gender identities and gender expression that differ from expectation of assigned birth sex remain very much classified as mental disorder and sexual deviance by the American Psychiatric Association. The consequences of this undeserved stigma to our human dignity, social legitimacy in our affirmed roles are enormous and devastating. We lose our jobs, our homes, our families, our children, our civil justice and our access to medical care to defamatory stereotypes that place an unfair burden of proof upon all gender transcendent people to continually demonstrate our sanity, our competence and our human worth.

For example, as people of color in my rural southern home town were singled out for humiliation, denied access to public facilities under Jim Crowe policies, many of us are similarly denied the basic human dignity of access to facilities appropriate to our gender identities today because of these false stereotypes.

Transsexual individuals, those of us with a medical need for hormonal and/or surgical treatment, have long been told that we must choose between forever suffering this stigma and losing what little access we currently have to medical transition care. I reject the premise that we must choose between human dignity and access to transition care for those who need it. We have been manipulated, fooled, into believing a false dichotomy — when in fact the current diagnostic nomenclature has failed us on both issues of stigma and transition care access.

The current diagnostic criteria of GID and TF describe transition itself as symptomatic of mental illness, especially so for gender nonconforming children and transwomen. This burdens our supportive medical and mental health providers to re-spin, to repackage, this flawed nomenclature as congruent with social and medical transition, when in fact it was written to contradict transition. As a consequence, only a privileged portion of us who need access to hormonal and/or surgical care are afforded access. Worse yet, trans youth and even adults remain subject to psychological gender reparative and cruel aversion “therapies” intended to shame affirmed gender identities into dark and solitary closets.

The Fifth Edition of the DSM is scheduled for publication by the American Psychiatric Association in 2013. It is the first major revision since 1994. Critical decisions for the diagnostic categories and criteria have already been considered, and the DSM-5 work group authoring the sex and gender categories was sadly stacked to favor bias intolerant of gender diversity. After a period of unprecedented secrecy, draft language for proposed gender diagnoses were disclosed on February 10th for a period of public review and comment through April 20.

This is a pivotal point in the history of our community, as the DSM-5 will likely impact the lives, civil liberties and medical care of all gender-transcendent people through the 2020s.

In spite of the barriers that we face with mental health policymakers, I have hope for positive change in the DSM-5. The proposed Gender Incongruence diagnoses for adults, adolescents and children (formerly called Gender Identity Disorder) represent some forward progress on both issues of stigma and barriers to medical transition care– the first forward progress that we have seen in 30 years of DSM revision.

Most significant, is a statement of explanation by the subcommittee that for the first time refutes the false myth of “disordered” gender identity:

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

This clarification that diverse gender identities are not in themselves the focus of mental pathology is historically unprecedented, since the introduction of Transsexualism to the DSM in 1980. This statement alone provides a powerful educational tool to advocates for our community.

Moreover, the proposed Gender Incongruence category for children has been reformed so that children must show dissatisfaction with birth-sex assignment to meet the criteria and can no longer be diagnosed strictly on the basis of gender role nonconformity. Again, this is an unprecedented step forward for kids who transition in their social roles and for gender nonconforming kids who are not trans but were pathologized in the past.

However, much work is needed to clarify these new criteria so that they do not continue to diagnose difference. For example:

  • “Incongruence” is not clearly defined to mean incongruence as experienced by the subject. It could still be misrepresented to mean nonconformity to cultural gender stereotypes.
  • The new criteria have retreated from clinically significant distress as a focus of diagnosis, which supports the medical necessity of treatment.
  • Ambiguous language continues to misrepresent transition and desire for medical transition care as symptomatic of mental illness.
  • The offensive term “Disorder of Sex Development” is used to describe people born with intersex conditions.
    For children, nonconformity to anachronistic gender stereotypes is still emphasized as symptomatic of mental disorder.
  • These categories are placed in the DSM section of Sexual Disorders, though describing emotions and behaviors that are not necessarily sexual.

In spite of these, I am for the first time optimistic that the DSM subcommittee authoring these Gender Incongruence diagnoses may be willing to listen to our concerns for positive reform.

However, the socially punitive and scientifically capricious diagnosis of Transvestic Fetishism was expanded to Transvestic Disorder in the DSM-5 draft proposal, removing exclusions of sexual orientation. It punishes gender expression that differs from social expectations of male birth assignment. It plays no role in access to medical transition care, but can worsen barriers to it. Worse yet, a specifier of “Autogynephilia” was added to implicate many transsexual women– promoting an unsupported and offensive theory by its author that transwomen transition for purposes of sexual deviance and not gender identity.

In my view, this Transvestic Disorder category is an affront to our MTF crossdresser, dual gender, bigender, genderqueer and transsexual communities alike and should be rejected by the APA. I ask you to join me in calling for the removal of all so-called “transvestic” diagnosis from the DSM-5.

Denise Leclair of the International Federation for Gender Education (IFGE) and others are working to pull together a coalition of allies and organizations to speak to these concerns before the April 20th APA deadline for public comment. Please stay tuned to ifge.org and our GID Reform Advocates site, gidreform.org, for updates. Most urgently, I am advocating a large scale petition drive on the specific issue of removing the defamatory transvestic fetishism disorder from the DSM-5 and urge you to add your names and voices to it, when it becomes available.

[Update: Denise has posted this petition at dsm.ifge.org/petition/. Please add your name to this effort and spread the word]

It is especially important that supportive mental health professionals get involved. Author and social work professor Arlene Lev has long worked to organize Professionals Concerned with Gender Diagnoses in the DSM. I urge you to check with the concerned professionals site at professionals.gidreform.org in coming weeks.

I believe that we stand at our own inflection point in the history of an affirming trans movement, one that our youth in this room will look back upon as adults.

In the words of the great Captain, Jack Aubrey, “There is not a moment to lose.”

As brothers and sisters in the community, as parents and allies, as medical and mental health providers, please lend your attention and your voices to issues of social stigma and transition medical care access that are rooted in these mental health policy decisions.

After all,

“We have to look out for one another, because we’re all we got”

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.

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