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”

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