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

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

The Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association, is regarded as the medical and social definition of mental disorder throughout North America and strongly influences the The International Statistical Classification of Diseases and Related Health Problems (ICD). The current psychiatric classifications of Gender Identity Disorder (GID) and Transvestic Fetishism (TF) in the Fourth Edition Text Revision of the DSM (DSM-IV-TR) inflict great harm to gender variant, and especially transsexual, people in three ways:

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

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

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

The DSM-V.

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

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

Further Reading.

GID Reform Advocates, www.gidreform.org

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

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

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

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

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