Diagnosis vs. Treatment: Psychosexual Stigma

Kelley Winters, Ph.D.

GID Reform Advocates




In the spring of 2003, I sat at a long table in the Grand Ballroom of the San Francisco Marriott with six men in suits and ties.  The only woman, the only transperson, the only scholar not a M.D. or mental health professional, I felt like the emissary from the dark side of the moon.  It was my second presentation at an annual meeting of the American Psychiatric Association, and I was fortunate for a place at the table.


We were presenting a symposium entitled, “Sexual and Gender Identity Disorders: Questions for the DSM-V” [1]. The moderators and organizers were Drs. Dan Karasic and Jack Drescher of the Association of Gay and Lesbian Psychiatrists, a division of the APA, who would later co-edit a book that followed [2].  On the left side of the table, Drs. Darryl Hill and Charles Moser joined me in advocating reform of the Gender Identity Disorder (GID) and paraphilia diagnoses in the next Diagnostic and Statistical Manual of Mental Disorders [3], published by the APA.  At the far right end of the table, former APA President Dr. Paul Fink and Dr. Robert Spitzer, Chair of the DSM-III and DSM-IIIR Task Forces and editor of the DSM-IV Casebook [4], defended the status quo.


After formal presentations from the left and rebuttals from the right, Dr. Fink uttered a remark that stunned clinicians in the audience who were supportive of their transitioning clients. Speaking of the GID diagnosis, he said,


“I think transsexualism is a diagnosis. … And it certainly doesn’t stigmatize anybody worse than the stigma they get every single day.” [5]


Having worked for NASA in a previous career, I couldn’t help but wonder — of life on which distant planet was he speaking?


Nearly five years later, I stood in a private school classroom in a conservative suburb where achievement was marked by enormous SUVs crowded between sprawling houses. The room was packed with angry parents and nervous staff. A group of us, consultants on gender diversity issues, had been asked to speak to their fears.  A stranger in a strange land, a remarkable young girl with a loving family had transitioned to her affirmed gender role in their midst.


One by one, voices around the room maligned this courageous child and condemned her parents, threatening to remove their own children from the school if she was not expelled.  As we tried to calm their panic, a hand shot in the air from one of the dominant men in the crowd, his eyes red with rage.  He demanded the other parents reject this innocent girl, hissing through clenched teeth,


“This is nothing more than mental illness, and the American Psychiatric Association says so.”


This was far from the first time that the diagnoses of Gender Identity Disorder and Transvestic Fetishism by the APA had been cited to justify intolerance and discrimination.  Virtually every aspect of transitioned life is impacted by these stereotypes of mental incompetence and sexual deviance.  We gender transcendent people are denied medical care, child custody, housing, employment, and public accommodation as a consequence.  Our very humanity in public discourse is dismissed as, “That’s nuts.” [6]


In 2007, the Maryland Montgomery County Public Schools introduced a health education curriculum including a lesson on “Respect for Differences in Human Sexuality” with an introduction to gender diversity.  In a lawsuit against the school district, opponents to the curriculum rallied around the DSM:


“the human sexuality lessons inaccurately portray ‘transgender’ as a ‘sexual variation’ when, transgenderism, gender dysphoria, and gender identity disorder actually constitute mental illness. American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).” [7]


Fortunately, the circuit court decided in favor of the school district early this year, but the same political extremists used GID to attack the Montgomery County gender identity nondiscrimination bill in November, 2007.  A public notice from Citizens for a Responsible Curriculum railed,


“You can stop this! The vote on this bill is November 13th. Urge the Montgomery County Council to exclude entry into female restrooms, showers and dressing rooms by male transgenders and vice versa. The American Psychiatric Association recognizes Gender Identity Disorder as a mental illness.” [6]


They ridiculed basic civil rights in public accommodation for gender variant people, invoking sensational maligning headlines of transitioned women as deviant males. The Montgomery County board passed the bill, but legal and public attacks continue to rely on the authority of the American Psychiatric Association.  For example, a Maryland political group dedicated an entire web page to denouncing transgender civil rights based on the DSM. It states,


“’Gender Identity Disorder’ is classified as a mental disorder by the American Psychiatric Association. Legal protection against discrimination based on mental illness is not provided for any other disorder, and there is no rational explanation why it should be offered for this one. Those who wish to assume a ‘gender identity’ contrary to their biological sex are in need of mental health treatment to overcome such disturbed thinking, not legislation to affirm it.” [8]


The GID and TF diagnoses are used by national as well as local political and religious groups to promote intolerance of gender variant people and even children.  For example, in an article entitled “A Gender Identity Disorder Goes Mainstream” the influential Traditional Values Coalition attacked the California Student and Violence Prevention Act of 2000 [9] by invoking the mental illness stereotype:


“In essence, this law gives sexually disturbed students the ‘right’ to self-identify their gender despite the biological reality of male and female. Under California state law, a boy who thinks he’s really a girl, is now protected from alleged ‘discrimination.’” [10]


They continued, “Gender confused individuals need long-term counseling, not approval for what is clearly a mental disturbance.”  The article cited the DSM to support the TVC’s derogatory characterizations, “Transgenders are mentally disordered . The American Psychiatric Association (APA) still lists Transsexualism and Transvestism as paraphilias or mental disorders in the Diagnostic and Statistical Manual (DSM-IV-TR)” [10].


Contrary to Dr. Fink’s denial of the problem, the role of psychiatric classification in perpetuating social stigma of mental incompetence and sexual deviance for gender variant individuals has been long recognized by scholars and clinicians across academic disciplines.  Anthropologist and author Ann Bolin noted in 1988, “The transsexual is labeled mentally ill and ipso facto in need of psychiatric care.  … The problems of stigma and the possible impact of the mental illness label are overlooked.” [11]


More recently, clinical social worker Arlene Istar Lev, author of Transgender Emergence, concluded, “Reform of  the GID diagnosis is necessary or the basic civil liberties for transgendered and transsexual people will remain elusive.”  [12]  Drawing parallels between the current GID diagnosis and the past classification of homosexuality in the DSM, psychologist Dr. Madeline Wyndzen observed, “I find that the mental illness label imposed on transsexuality is just as disquieting as the label that used to be imposed on homosexuality.” [13]


The American Psychiatric Association itself has acknowledged the potential harm of social stigma associated with a label of mental illness:


“Scientific data cannot be interpreted in a vacuum.  Sociological and other considerations must also be taken into account.   …we must consider instead how to balance the advantages of including the diagnosis in the DSM (e.g., increased detection of a treatable disorder with consequent reduction in morbidity and cost to the patient, his or her family, and to society at large) against the risks of making a false positive diagnosis (e.g., risk of stigmatization, cost and potential morbidity of unnecessary treatment, etc.).”  [14]


Undermining the legitimacy of social and medical transition in the title, diagnostic criteria and supporting text of the current Gender Identity Disorder diagnosis, the American Psychiatric Association has undermined the human dignity and civil justice of gender variant and especially transitioning people.  The Sexual and Gender Identity Disorders work group of the DSM-V Task Force has an opportunity to reconsider consequences of social stigma that have been overlooked in past editions.  Once again, it is time for diagnostic nomenclature that does not harm those it is intended to help.



[1] K. Housman, “Controversy Continues to Grow Over DSM’s GID Diagnosis,” Psychiatric News, Vol. 38 no. 14, July 2003.  http://pn.psychiatryonline.org/cgi/content/full/38/14/25 .   I was listed under pen-name Katherine Wilson in this article.  My presentation is summarized in K. Winters, “Gender Dissonance: Diagnostic Reform of Gender Identity Disorder for Adults,” Sexual and Gender Diagnoses of the Diagnostic and Statistical Manual (DSM),  Eds.  D. Karasic, and J. Drescher, Haworth Press, 2005;  co-published in Journal of Psychology & Human Sexuality, vol. 17 issue 3,  pp. 71-89,  2005. http://www.haworthpress.com/store/ArticleAbstract.asp?sid=DNFVJBXTSF848HQDMD0RDQAW67U17LP1&ID=67230


[2] D. Karasic and J. Drescher, Eds., Sexual and Gender Diagnoses of the Diagnostic and Statistical Manual (DSM), A Reevaluation, Haworth Press, 2005.


[3] American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, Washington, D.C., 2000.


[4] R. Spitzer, R., ed., DSM-IV Casebook, A Learning Companion to the Diagnostic and Statistical Manual of Mental Disorders (fourth edition). American Psychiatric Press, 1994.


[5] P. Fink, P., “Sexual and Gender Identity Disorders Discussion of Questions for DSM-V,” Journal of Psychology & Human Sexuality, Vol. 17, Nos. 3-4, February2006, pp. 117-123, http://www.ingentaconnect.com/content/haworth/jphs/2006/00000017/F0020003/art00008.


[6]  Citizens for a Responsible Curriculum, “Public Notice,”  Damascus MD, November 2007, http://www.mcpscurriculum.com/pdf/transgender_alert.pdf


[7]  Citizens for a Responsible Curriculum, et al. v. Montgomery County Public Schools, et al., Petitioners’ Memorandum, Civil Action No. 284980, Circuit Court for Montgomery County, MD, October 2007, p. 10, http://www.mcpscurriculum.com/pdf/Appellate_Brief_PFOX2.pdf


[8] Maryland Citizens for a Responsible Government, “Referendum to Repeal Bill 23-07,”  Gaithersburg MD,  http://www.notmyshower.net/gender_identity.shtml


[9]  Gay-Straight Alliance Network, “AB 537 Fact Sheet, California Student and Violence Prevention Act” http://www.gsanetwork.org/ab537/pdf/AB537.pdf


[10] Traditional Values Coalition, “A Gender Identity Disorder Goes Mainstream

Cross-dressers,Transvestites,And Transgenders Become Militants In The Homosexual Revolution,” Anaheim CA, pp. 2-3, http://www.traditionalvalues.org/pdf_files/TVCSpecialRptTransgenders1234.PDF


[11] A. Bolin, In Search of Eve, Bergin & Garvey, South Hadley MA, 1988. p53.


[12] A. Lev, Transgender Emergence, Therapeutic Guidelines for Working with Gender-Variant People and Their Families,  Haworth Press, 2004, p. 180.


[13] M. Wyndzen, M. H. “A Personal and Scientific look at a Mental Illness Model of Transgenderism.”  American Psychological Association Division 44 Newsletter, Spring 2004,  http://www.GenderPsychology.org/autogynephilia/apa_div_44.html


[14] American Psychiatric Association, “DSM-IV Frequently Asked Questions,” http://www.psych.org/MainMenu/Research/DSMIV/FAQs/WhatistheDSMandwhatisitusedfor.aspx


Copyright © 2008 Kelley Winters, GID Reform Advocates

About Kelley
Dr. Kelley Winters is a writer and consultant on issues of gender diversity in medical and public policy. She is the author of Gender Madness in American Psychiatry: Essays from the Struggle for Dignity (2008) and a past member of the International Advisory Panel for the World Professional Association for Transgender Health (WPATH) Standards of Care, the Global Action for Trans* Equality (GATE) Expert Working Group, and the Advisory Boards for TransYouth Family Allies (TYFA). She was recognized in the 2013 Trans 100 Inaugural List for work supporting the transgender community in the US. Kelley has presented papers and presentations on gender policy issues at annual conventions of the American Psychiatric Association, the American Psychological Association, the American Counseling Association and the Association of Women in Psychology. Kelley wanders the highways of America in an old Mazda, ever in search of comfort food.

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