Comments on Proposed Revisions to Gender Diagnoses in the DSM-5

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

This February, the American Psychiatric Association published its proposed draft revisions for the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) for public comment. The period of public review ends today.

Here are summaries for my comments for the proposed diagnostic categories of Gender Incongruence in Children (formerly Gender Identity Disorder), Gender Incongruence in Adults or Adolescents, and Transvestic Disorder (formerly Transvestic Fetishism).  The full text of my comments is available on the GID Reform Advocates site.  The draft diagnostic criteria from the DSM-5 Task Force are copied at the end of this post.

My comments here were developed to a large extent in prior collaborations and conversations with Dr. Randall Ehrbar , Dr. Nick Gorton,  Arlene Lev , Professionals Concerned With Gender Diagnoses in the DSM, and over 110 GID Reform Advocates.  I am deeply grateful to them for their passion and thoughtful contributions on these issues and all that they taught me.

Gender Identity Disorder in Children

Full Text

The current Gender Identity Disorder diagnosis imposes harmful stigma of mental illness and sexual disorder on gender variant and nonconforming children, regardless of the presence of gender dysphoria. Simultaneously, it poses barriers to social transition and access to puberty blocking or hormonal transition treatment at a later age, by describing transition itself as symptomatic of pathology. The proposed nomenclature for Gender Incongruence in Children for the DSM-5  contains a number of improvements in the title and diagnostic criteria intended to address both issues. However, these revisions fall short of clarifying that social or medical transition and other nonconformity to a birth- assigned gender  do not in themselves constitute mental illness.  These revisions obfuscate the clinically significant distress that may result from  physical sex characteristics or an assigned social gender role that are incompatible with experienced gender identity: distress that may require medical attention.  If there is a specific diagnostic category or criteria set for children in the DSM-5, it should be explicitly based on distress of anatomical or gender role dysphoria and not on gender role nonconformity.

Gender Identity Disorder in Adolescents or Adults

Full Text

The current Gender Identity Disorder diagnosis in the DSM-IV-TR imposes harmful stigma of mental illness and sexual deviance on gender variant and especially transsexual adults and adolescents. Simultaneously, it poses barriers to social transition and access to puberty blocking, hormonal and/or surgical transition care, for those who need them, by describing transition itself as symptomatic of pathology. The proposed nomenclature for Gender Incongruence in Adolescents or Adults for the DSM-5  contains a number of improvements in the title and diagnostic criteria intended to address both issues. However, these revisions fall short of clarifying that social or medical transition and other nonconformity to an assigned gender at birth do not in themselves constitute mental illness.  These revisions obfuscate the clinically significant distress that may result from  physical sex characteristics or an ascribed social gender role that are incompatible with experienced gender identity: distress that may require medical attention.  This diagnostic nomenclature should be explicitly based on distress of anatomical and/or gender role dysphoria (distress or discomfort) and not on gender role nonconformity.

Transvestic Fetishism

Full Text

The DSM-IV diagnostic category of Transvestic Fetishim in the DSM-IV is expanded by the proposed Transvestic Disorder diagnosis to remove exclusions of sexual orientation. It serves to punish gender expression that  differs from social expectations of male birth assignment and to worsen barriers to medical transition care for transsexual women who require it. A specifier of “With Autogynephilia” was added to implicate many  transsexual women, promoting the controversial theory and deeply offensive stereotype that transwomen transition to satisfy a sexual fetish rather than attain congruence with gender identity. This anachronistic condemnation of gender nonconformity fails to meet a modern definition of mental disorder and should be rejected by the APA and removed entirely from the DSM-5.

Proposed APA Diagnostic Criteria for Gender Incongruence in Adolescents or Adults

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:

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)
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)
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)

Subtypes

• With a disorder of sex development
• Without a disorder of sex development

Proposed APA Diagnostic Criteria for Gender Incongruence in Children

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):

1. a strong desire to be of the other gender or an insistence that he or she is the other gender
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
3. a strong preference for cross-gender roles in make-believe or fantasy play
4. a strong preference for the toys, games, or activities typical of the other gender
5. a strong preference for playmates of the other gender
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
7. a strong dislike of one’s sexual anatomy
8. a strong desire for the primary and/or secondary sex characteristics that match one’s experienced gender

Subtypes

• With a disorder of sex development
• Without a disorder of sex development

Proposed APADiagnostic Criteria for Transvestic Disorder

A. Over a period of at least six months, in a male, recurrent and intense sexual fantasies, sexual urges, or sexual behaviors involving cross-dressing.

B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specify if:

• With Fetishism (Sexually Aroused by Fabrics, Materials, or Garments)
• With Autogynephilia (Sexually Aroused by Thought or Image of Self as Female)

Why You Should Sign the Petition Opposing the Transvestic Disorder Diagnosis in the DSM-5

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

On January 10th, 2010, the American Psychiatric Association released proposed draft revisions for the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) for public comment through April 20th. The DSM is regarded as the medical and social definition of mental disorder throughout North America and strongly influences international psychiatric nomenclature. The DSM-5 proposal includes the diagnostic category Transvestic Disorder, expanding a previous diagnosis of Transvestic Fetishism.

Authored by Dr. Ray Blanchard, of the Toronto Centre for Addiction and Mental Health (CAMH, the former Clarke Institute of Psychiatry), the proposed Transvestic Disorder diagnosis is:

• Punitive: It punishes gender expression that differs from expectations of male birth-assignment and enforces conformity to masculine social stereotypes.
• Sexist: The diagnostic category is limited to those assigned male at birth, holding them to a stricter standard of conformity than birth-assigned females. It labels behaviours and gender expression that are ordinary or even exemplary for birth-assigned women as pathological for others.
• Stigmatizing: Transvestic Disorder is classified as a “paraphilic” sexual disorder, grouped with diagnoses of such harmful behaviors as pedophilia and exhibitionism. The resulting stereotypes of sexual deviance deny human dignity and civil justice to gender variant and transgender people.
• Ambiguous: murky language implicates sexual expression “involving” crossdressing as diagnosable. Thus, both erotic and nonerotic gender expression among bigender, dual-gender and genderqueer people may be diagnosed as “disordered.”
• Victim-blaming: The second diagnostic criterion requires clinically significant distress or impairment, but fails to exclude distress resulting from societal intolernce. This would promote false-positive diagnosis of victims of prejudice. For example, suffering job discrimination would be inferred as symptomatic of mental disorder.
• Needlessly Pathologizing: This diagnosis primarily pathologizes erotic crossdressing, a harmless consensual sexual expression, that does not meet any definition of mental illness.
• Harmful to Closeted or Self-rejecting Crossdressers: This diagnosis pathologizes crossdressers who are distressed by internalized shame and societal prejudice, very much as the previous diagnosis of Ego-Dystonic Homosexuality in the DSM-III pathologized victims of social homophobia.
• Harmful to Transsexual Women: This Transvestic Disorder category is not limited to crossdressers or male-identified people. It also targets transsexual women with a specifier of “autogynephilia,” a deeply offensive label to many transwomen, promoting an unfounded theory that transsexual women transition out of sexual fetishism rather than harmony with gender identity.
• Used to Deny Medical Transition Treatment for those who need it: For example, the predecessor Transvestic Fetishism diagnosis was cited by IRS attorneys against Rhiannon O’Donnabhainn in her recent landmark case in US Tax Court. They used the diagnosis to promote a false stereotype of fetishism to argue that corrective transition surgeries for transsexual women are not medically necessary.

Please add your name and voice, before April 20th, to the online petition to remove this defamatory Transvestic Disorder catagory from the DSM-5. It is sponsored by the International Foundation for Gender Education (IFGE) at dsm.ifge.org/petition/. You may also register and comment directly to the APA DSM-5 Task Force at www.dsm5.org. For more information, see the statement by Professionals Concerned With Gender Diagnoses in the DSM.