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

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

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