Gender Madness in Psycho-Politics: Transgender Children Under Fire

A presentation to
Gender Infinity
Houston, Texas, USA
September, 2016
Kelley Winters, Ph.D.
GID Reform Advocates

Presentation Slides:  201609infinityg1

 

The Quadrumvirate of Anti-Trans Defamation:

My little taxonomy of false stereotypes about trans adults, adolescents and children, crediting the individuals responsible for searing them into public consciousness:

• Raymondian–alleging that trans women are “deceptive,” sexually “predatory” “men” whose existence poses a threat to the safety of others; and that trans men are “women” rather than authentic men. (Dr. Janice Raymond, University of Massachusetts in Amherst, 1979)
• McHughian–alleging that trans women are “delusional,” “confused,” “mentally ill” “men” (and vice-versa for trans men), and that accepting, respecting or providing transition medical care to trans  people in our authentic roles represents “collaboration” with “mental disorder.” (Dr. Paul McHugh, John Hopkins University, 1979)
• Blanchardian–alleging that most trans and transsexual women are psychosexually disordered “paraphilic” “men,” motivated only by sexual deviance/fetishism. Dr. Blanchard later included trans men to this false stereotype, by adding a so-called “autoandrophilia” specifier to his “transvestic disorder” in an early draft of the DSM-5. (Dr. Ray Blanchard, Clarke Institute of Psychiatry/Centre for Addiction and Mental Health, 1989)
• Zuckerian–alleging that gender dysphoria in the great majority, around 80%, of gender dysphoric children is a passing phase that will “desist” or “remit” by adolescence. Zucker has long promoted and practiced gender conversion “therapeutic intervention,” to enforce birth-assigned gender identities and expressions. (Dr. Kenneth Zucker, Clarke Institute of Psychiatry/Centre for Addiction and Mental Health, 1989)

These stereotypes have been weaponized by political extremist groups to inflict unprecedented systemic, strategic attacks on the human rights and medical care access of trans people and especially trans children.

 

Strategy of Anti-Trans Political, Social and Media Attack:

Coordinated legislation, litigation and misinformation aimed at:

• Eliminating access to Public Accommodation and Education
• Eliminating gender marker correction in official Documents & Records
• Eliminating access to transition medical care
• Legalizing and promoting Gender-Conversion Psychotherapy

 

Architects of systemic public policy attack:

• Family Research Council–authored the blueprint for anti-trans political, social and media attacks in 2013 that has been followed by US extremists nationwide
• Southern Baptist Convention Theological Seminary
• Heritage Foundation
• Republican Party

 

Strategic medical policy issues for the 20-teens:

my own priority list…

• WPATH: clarify and correct the childhood “desistance” myth statement in the SOC7
• WPATH: Issue a public policy statement discrediting the practice of gender-conversion psychotherapies that is consistent with the SOC7
• APA: clarify and correct the childhood “desistance” myth statement in the DSM-5
• APA: remove “Transvestic Disorder” category from the DSM-5
• WHO: initiate substantive conversation on converging the Adult/Adolescent Gender Incongruence categories in the proposed ICD-11 with the childhood category to refute the historical stereotype of childhood gender “confusion” and practice of gender conversion psychotherapies
• US Dept. of HHS: align transition related categories in ICD-10-CM to ICD-11 in 2018
• US Dept. of HHS/CMS: issue a National Coverage Determination for surgical transition care that is recognized as medically necessary by US and international medical authorities

 

A Call to Action

Attention to medical policy reforms that clarify evidence, reduce harm, and benefit health and mortality is as urgent in today’s world as ever. It is an essential step in fixing society for all of the Leelah Alcorns in our midst.

 

References

(under construction…)

Blanchard, R. (1989) “The Classification and Labeling of Nonhomosexual Gender Dysphoria,” Archives of Sexual Behavior, v. 18 n. 4, p. 322-323.

Brennan, C. and Hungerford, .E, (2011) “2011 Letter to the UN on ‘gender identity’ legislation,” http://sexnotgender.com/gender-identity-legislation-and-the-erosion-of-sex-based-legal-protections-for-females/

Drummond, Kelley D.; Bradley, Susan J.; Peterson-Badali, Michele; Zucker, Kenneth J. (2008), “A follow-up study of girls with gender identity disorder,” Developmental Psychology. Vol 44(1), Jan 2008, 34-45.

Ford, Z. (2014) “Three Days In Nashville Talking To Southern Baptists About Homosexuality,” Think Progress, Center for American Progress. http://thinkprogress.org/lgbt/2014/10/30/3586418/southern-baptist-erlc-homosexuality/

McHugh, Paul (1992). “Psychiatric Misadventures,” The American Scholar,
Autumn, http://www.lhup.edu/~dsimanek/mchugh.htm

P. McHugh (2004) “Surgical Sex,” First Things 147:34-38, http://www.firstthings.com/ftissues/ft0411/articles/mchugh.htm , http://www.firstthings.com/article/2004/11/surgical-sex

Raymond, Janice G. (1979) The Transsexual Empire: The Making of the She-male. New York: Teachers College,

Raymond, Janice G. (1980) “Technology on the Social and Ethical Aspects of Transsexual Surgery,” http://www.susans.org/reference/usts1-9.html

Stone, Sandy (1987) THE EMPIRE STRIKES BACK: A POSTTRANSSEXUAL MANIFESTO, http://sandystone.com/empire-strikes-back

Southern Baptist Convention (2014) “On Transgender Identity,” Resolution. http://www.sbc.net/resolutions/2250/on-transgender-identity

Williams, Cristen, (2013) “TERFs & Trans Healthcare [UPDATED],” http://theterfs.com/terfs-trans-healthcare/

Winters, K. (2008) “Disallowed Identities, Disaffirmed Childhood,” GID Reform Weblog, October, https://gidreform.wordpress.com/2008/10/28/disordered-identities-disaffirmed-childhood/

Winters, K. (2008) https://gidreform.wordpress.com/2008/11/10/autogynephilia-the-infallible-derogatory-hypothesis-part-1/

Winters, K. (2008) https://gidreform.wordpress.com/2008/11/19/autogynephilia-the-infallible-derogatory-hypothesis-part-2/

Winters, K. (2008) https://gidreform.wordpress.com/2008/07/01/the-horns-of-a-false-dilemma/

Winters, K. (2012) “These Aren’t the Droids You’re Looking For: Gender Diversity, Scapegoating and Erasure in Medicine and Media,” https://gidreform.wordpress.com/2012/04/21/these-arent-the-droids-youre-looking-for-gender-diversity-scapegoating-and-erasure-in-medicine-and-media/

Winters, K. (2013) “Response to Dr. Jack Drescher and the NY Times About Childhood Transition,” GID Reform Weblog, July 5, https://gidreform.wordpress.com/category/childhood-social-transition/

Winters, K. (2014) “Methodological Questions in Childhood Gender Identity ‘Desistence’ Research,” 23rd World Professional Association for Transgender Health Biennial Symposium, reposted GID Reform Blog, Feb. 25. https://gidreform.wordpress.com/2014/02/25/methodological-questions-in-childhood-gender-identity-desistence-research/

World Professional Association for Transgender Health (2011), Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People: Author. http://www.wpath.org

 

GID Reform in the DSM-5 and ICD-11: a Status Update

I prepared this presentation for the 2013 Philadelphia Transgender Health Conference but did not have the opportunity to attend. It is a summary of recent changes to gender related diagnostic categories in the DSM-5, published last month by the American Psychiatric Association, and proposed changes for the ICD-11, scheduled for publication in 2015 by the World Health Organization.  It is based on proposed revisions to the ICD-11 presented by Drs. Geoffrey Reed, Peggy Cohen-Kettenis and Richard Krueger at the National Transgender Health Summit in Oakland last month and on discussions at the Global Action for Trans* Equality (GATE) Civil Society Expert Working Group in Buenos Aires last April.

In my view, there are two primary issues in medical diagnostic policy for trans people. The first is harmful stigma and false stereotyping of mental defectiveness and sexual deviance, that was perpetuated by the former categories of Gender Identity Disorder (GID) and Transvestic Fetishism (TF) in the DSM-IV-TR. The second is access to medically necessary hormonal and/or surgical transition care, for those trans and transsexual people who need them. The latter requires some kind of diagnostic coding, but coding that is congruent with medical transition care, not contradictory to it. I have long felt that these two issues must be addressed together –not one at the expense of the other, or to benefit part of the trans community at the expense of harming another.

The DSM-5 Falls Short, Despite Some Significant Improvements

The new revisions for the Gender Dysphoria diagnosis in the DSM-5 are mostly positive. However they do not go nearly far enough. The change in title from Gender Identity Disorder (intended by its authors to mean “disordered” gender identity) to Gender Dysphoria (from a Greek root for distress) is a significant step forward. It represents a historic shift from  gender identities that differ from birth assignment to distress with gender assignment and associated sex characteristics 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. In another positive change, the Gender Dysphoria category has been moved from the Sexual Disorders chapter of the DSM to a new chapter of its own. Non-binary queer-spectrum identities and expression are now acknowledged in the diagnostic criteria, and the APA Working Group has rejected pressure to add an “autogynephilia” specifier to falsely stereotype and sexualize trans women. Children can no longer be falsely diagnosed with this mental disorder label, strictly on the basis of nonconformity to birth assignment.

However, the fundamental problem remains that the need for medical transition treatment is still classed as a mental disorder. In the diagnostic criteria, desire for transition care is itself cast as symptomatic of mental illness, unfortunately reinforcing gender-reparative psychotherapies which suppress expression of this “desire” into the closet. The diagnostic criteria still contradict transition and still describe transition itself as symptomatic of mental illness. The criteria for children retain much of the archaic sexist language of the DSM-IV-TR that psychopathologizes gender nonconformity. Moreover, children who have happily socially transitioned are maligned by misgendering language in the new diagnosis.

More troubling is false-positive diagnosis for those who have happily completed transition. Thus, the GD diagnosis, and its controversial post-transition specifier, continue to contradict the proven efficacy of medical transition treatments.  This contradiction may be used to support gender conversion/reparative psychotherapies– practices described as no longer ethical in the current WPATH Standards of Care.

Finally, the Transvestic Disorder category in the DSM-5 is even more harmful than its predecessor, Transvestic Fetishism. Punitive and scientifically capricious, it only serves to punish nonconformity to assigned birth roles and has no relevance to established definition of mental disorder. The Transvestic Disorder category has been expanded in the DSM-5 to implicate trans men as well as trans women, with a new specifier of “autoandrophilia,” apparently pulled from thin air without supporting research or clinical evidence.

The ICD-11, a Historic New Approach

The 11th Revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-11) is scheduled for publication in 2015 by the World Health Organization (WHO). It is a global diagnostic manual that contains chapters for both physical medical conditions and mental conditions. In contrast to the DSM-5, the ICD-11 holds promise for unprecedented forward progress on both issues of social stigma and barriers to medical transition care.  At the National Transgender Health Summit in Oakland last month, members of the ICD-11 Working Group for Sexual Disorders and Sexual Health confirmed proposals for  substantive changes in gender and transition related codings.

The Working Group has proposed a historic shift of transition related categories, now labeled “Gender Incongruence,”  out of the Mental and Behavioural Disorders chapter (called F-Codes) entirely. It is to be placed in a new, non-psychiatric chapter, called “Certain conditions related to sexual health.” The Incongruence title is distinct from DSM-5 dysphoria title, to clarify that this is no longer a mental disorder coding.  They have also proposed to eliminate victimless sexual paraphilia categories from the manual, including: F65.1: Transvestic fetishism. A similar category describing dual gender individuals, F64.1: Dual-role Transvestism, would be deleted as well. These changes have the potential for enormous progress in reducing both stigma and barriers to medical transition care, for those who need it. When implemented, they would effectively obsolete the new psychopathology categories of Gender Dysphoria and Transvestic Disorder in the DSM-5.

There are also questions and shortcomings in the current  ICD-11 proposals.  While the proposed children’s coding of  Gender Incongruence of Childhood is no longer a mental disorder label,  any pathologizing coding of happy gender nonconforming or socially transitioned children, who are too young to need any medical transition or puberty-blocking treatment, is highly controversial among clinicians, families and community members.  The diagnostic criteria for children, like those in the DSM-5, still emphasize nonconformity to anachronistic gender stereotypes as symptomatic of sickness. The adult and adolescent criteria have copied ambiguous language from the DSM-5 that cast desire for transition, in itself, as pathological. Worse yet, false-positive diagnosis of happy post-transition subjects inadvertently contradicts rather than supports medical transition care.

The ICD-11 Working Group for Sexual Disorders and Sexual Health should be commended for advancing these historic reforms. However, it is important that Group members listen to the remaining concerns of community members and supportive care providers.  Adults and adolescents needing access to medical transition care, or pubescent youth needing puberty blocking medications, require a clearer description of the problem to be treated. Young children, who may only need information, monitoring and support, have very different diagnostic needs and diagnostic risks than adults and adolescents.

Gender Dysphoria Diagnosis to be Moved Out of Sexual Disorders Chapter of DSM-5

Protest at 2009 APA Annual Meeting (photo Kelley Winters)

Dr. Jack Drescher,  a member of the subworkgroup on Gender Identity Disorders of the DSM-5 Workgroup on Sexual and Gender Identity Disorders, confirmed yesterday that the Gender Dysphoria Diagnosis will be removed from the sexual disorders chapter and placed in a separate category in the Diagnostic and Statistical Manual of Mental Disorders:

 GD is supposed to be placed in a chapter of its own, no longer linked with sexual dysfunctions and paraphilias (which will also have chapters of their own)

This reclassification, along with the change in title from Gender Identity Disorder to Gender Dysphoria, is a significant improvement in the diagnostic coding used for access to medical transition care, for trans and transsexual people who need it. Preceding diagnoses of Transsexualism/Gender Identity Disorders were grouped with “psychosexual” disorders in the DSM-III. They were briefly moved to the class of Disorders Usually First Evident in Infancy, Childhood or Adolescence in the DSM-III-R in 1987 but were returned to the sexual disorders chapter in the  DSM-IV, and DSM-IV-TR. Community advocates and supportive medical providers have long raised concern that this placement was clinically misleading and reinforced false stereotypes about gender diversity. Gender identity  is not specifically related to sexuality, sexual orientation or sexual dysfunction. Political and religious extremists have  exploited the sexual disorder grouping in the DSM to sexualize gender diversity and defame trans people as deviant. Trans and transsexual individuals have consequently lost their jobs, homes, families, children, and civil justice.

The DSM-5 working group responsible for sexual and gender diagnoses hinted at a possible change in diagnostic placement in February, 2010, stating

The subworkgroup questions the rationale for the current DSM-IV chapter Sexual and Gender Identity Disorders, which contains three major classes of diagnoses: sexual dysfunctions, paraphilias, and gender identity disorders… Various alternative options to the current placement are under consideration.

The decision to separate the revised Gender Dysphoria category from sexual disorders is consistent with a previous determination by the working group to remove sexual orientation specifiers from the diagnostic criteria. While many shortcomings remain in the proposed Gender Dysphoria diagnosis, this change in placement in the DSM represents forward progress for trans and especially transsexual individuals.

Unfortunately, the DSM-5 Task Force and APA Board of Trustees retained the Transvestic Disorder category in the sexual disorders chapter. Previous known as Transvestic Fetishism, it is grouped with paraphilic diagnoses such as pedophilia and exhibitionism and authored by Dr. Raymond Blanchard of the Toronto Centre for Addiction and Mental Health (formerly called the Clarke Institute of Psychiatry). This punitive and scientifically capricious category maligns many gender variant people, including transsexual women and men, as mentally ill and sexually deviant, purely on the basis of nonconforming gender expression. It is written to promote Blanchard’s unfounded theories of “autogynephilia” and “autoandrophilia” that conflate social and medical gender transition with fetishism. More than 7000 people have signed an online petition, sponsored by the International Foundation for Gender Education (IFGE), calling for the removal of this harmful diagnosis from the DSM.

Copyright © 2012 Kelley Winters, Ph.D., GID Reform Advocates

An Update on Gender Diagnoses, as the DSM-5 Goes to Press.

On 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