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

Protest at 2009 APA Annual Meeting (photo Kelley Winters)

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.

ImageOn 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

The American Psychiatric Association Issues Historic Position Statements on Trans Issues

Kelley outside the 2009 Annual Meeting of the APANow don’t be sad
‘Cause two out of three ain’t bad
–Meat Loaf, 1977

On May 18, 2009, about 150 trans community members and allies gathered outside the Annual Meeting of the American Psychiatric Association in San Francisco to protest diagnostic policies that psychopathologize gender diversity. Bull horn in hand, I and others called upon the APA leadership to issue three public position statements in support of the dignity and health of trans and gender variant people:

  1. That gender identity and expression which differ from assigned birth sex do not, in themselves, constitute mental disorder or impairment in judgment or competence.
  2. That hormonal and/or surgical transition treatment, for those who need them, is medically necessary and should be covered by insurance and health care policies.
  3. That the APA opposes discrimination on the basis of gender identity or expression and supports legal recognition of all people according to their gender identity and expression.

A month later, over 400 supporters endorsed a letter to APA President Alan Schatzberg and President-elect Carol Bernstein urging passage of these policy statements. The APA had, after all, issued numerous similar statements in support of other marginalized groups in past years but had never made a single position statement supporting civil justice and health care access for trans and gender variant people.

The response from APA officials was silence– three years of it.

Then last week, on August 16, the APA announced two of these position statements, authored by Drs. Jack Drescher and Ellen Haller and approved by votes of the Assembly and Board of Trustees. The first acknowledged the efficacy and medical necessity of hormonal and/or surgical transition treatment and the barriers to accessing this care faced by those who need it. Similar transition care policy statements were issued in 2008 by the American Medical Association, the American Psychological Association, and the World Professional Association for Transgender Health (WPATH).

Position Statement on Access to Care for Transgender and Gender Variant Individuals

Therefore, the American Psychiatric Association:

  1. Recognizes that appropriately evaluated transgender and gender variant individuals can benefit greatly from medical and surgical gender transition treatments.
  2. Advocates for removal of barriers to care and supports both public and private health insurance coverage for gender transition treatment.
  3. Opposes categorical exclusions of coverage for such medically necessary treatment when prescribed by a physician.

The second position statement acknowledges harassment and discrimination that trans and gender variant people face in employment, education, parental rights and civil justice. It notes that trans people are frequently victimized in violent hate crimes and inappropriately assigned in gender-segregated facilities . Similar nondiscrimination statements were issued by the National Association of Social Workers in 1999, the American Psychological Association in 2008, and WPATH in 2010.

Position Statement on Discrimination Against Transgender and Gender Variant Individuals

Therefore, the American Psychiatric Association:

  1. Supports laws that protect the civil rights of transgender and gender variant individuals
  2. Urges the repeal of laws and policies that discriminate against transgender and gender variant individuals.
  3. Opposes all public and private discrimination against transgender and gender variant individuals in such areas as health care, employment, housing, public accommodation, education, and licensing.
  4. Declares that no burden of proof of such judgment, capacity, or reliability shall be placed upon these individuals greater than that imposed on any other persons.

Although the American Psychiatric Association lags years behind other leading medical and mental health associations in speaking out, these position statements represent an unprecedented shift in acceptance of human gender diversity by the APA leadership and membership. The background text to the discrimination statement notes:

In contrast to its strong affirmation of lesbian and gay civil rights since the 1973 decision to remove homosexuality from the DSM, APA has not issued position statements in support of transgender civil rights… Other organizations, including the American Medical Association and the American Psychological Association, have endorsed strong policy statements deploring the discrimination experienced by gender variant and transgender individuals and calling for laws to protect their civil rights .

The statement text reaffirms the role of advocacy in the APA mission: “ Speaking out firmly and professionally against discrimination and lack of equal civil rights is a critical advocacy role that the APA is uniquely positioned to take.”  Given the APA’s unique position in setting diagnostic policy that has been historically used to limit civil justice and transition care access for trans people, these position statements come far better late than never.

However, the APA statements fall short of debunking the false stereotype that gender difference is inherently pathological. The association’s ambivalence on the mental illness stereotype is reflected in the “Report of the American Psychiatric Association Task Force on Treatment of Gender Identity Disorder ,” published in June, 2012:

The Task Force could not reach a consensus regarding the question of whether or not persistent cross-gender identification sufficient to motivate an individual to seek sex reassignment, per se, is a form of psychopathology in the absence of clinically significant distress or impairment due to a self-perceived discrepancy between anatomical signifiers of sex and gender identity. 

In other words, this APA Treatment Task Force (a separate group from the DSM-5 Task Force) declined to refute the false stereotype of “disordered” gender identity. This is troublesome, because the proposed diagnostic criteria for the Gender Dysphoria category in the pending Fifth Edition of the APA’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5) continue to mischaracterize gender identities and expressions that do not conform to birth-assigned gender stereotypes as symptomatic of mental illness. By describing social and medical transition itself, or the desire for transition, as pathological, the new Gender Dysphoria diagnosis, like its controversial predecessor Gender Identity Disorder (GID), contradicts rather than supports the medical necessity of transition care that is affirmed in the new APA position statement. Even worse, the Transvestic Disorder category in the DSM-5 ascribes nonconforming gender expression and medical transition for many transsexual women and men to a defamatory false stereotype of sexual deviance and paraphilia. Ironically, the medical care statement acknowledges these contradictions in the DSM–

…the presence of the GID diagnosis in the DSM has not served its intended purpose of creating greater access to care–one of the major arguments for diagnostic retention .

Thankfully, there is evidence of change in attitudes toward gender diversity at the American Psychiatric Association. In 2010, the DSM-5 Task Force proposed to rename the widely despised Gender Identity Disorder title (intended to imply “disordered” gender identity) to Gender Incongruence and a further change in 2011 to Gender Dysphoria (from a Greek root for distress). These revisions were explained as a paradigm shift from diagnosing difference to a focus on incongruence or discrepancy that causes distress or impairment.

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.

The APA Position Statement on Discrimination contains the APA’s strongest statement to date that gender difference is not disease:

Being transgender gender or variant implies no impairment in judgment, stability, reliability, or general social or vocational capabilities; 

The fourth bullet point of the APA Position repeats this key principle:

Declares that no burden of proof of such judgment, capacity, or reliability shall be placed upon these individuals greater than that imposed on any other persons. 

This particular wording is historically significant; it is paraphrased from a 1973 quote by Dr. Robert Spitzer, chief editor of the DSM-III and DSM-III-R, arguing to depathologize same sex orientation:

In the past, homosexuals have been denied civil rights in many areas of life on the ground that because they suffer from a ‘mental illness’ the burden of proof is on them to demonstrate their competence, reliability, or mental stability.

Throughout his career, Spitzer has refused to apply this same reasoning to the plight of gender variant and especially transsexual people, who continue to bear a very similar burden.

Though long overdue, these position statements on Discrimination and Access to Care for Transgender and Gender Variant Individuals represent a historic step forward in reducing barriers to civil justice and transition care access. But they do not go far enough in deconstructing false stereotypes that equate gender diversity with mental sickness and sexual deviance. In the context of the proposed gender diagnoses in the DSM-5 and the recent treatment task force report, they represent a mixed message. In contrast, the World Professional Association for Transgender Health issued an unambiguous De-Psychopathologisation Statement in 2010 that provides a model for professional organizations that serve trans and gender diverse people:

The WPATH Board of Directors strongly urges the de-psychopathologisation of gender variance worldwide. The expression of gender characteristics, including identities, that are not stereotypically associated with one’s assigned sex at birth is a common and culturally-diverse human phenomenon which should not be judged as inherently pathological or negative. The psychopathologlisation [sic] of gender characteristics and identities reinforces or can prompt stigma, making prejudice and discrimination more likely, rendering transgender and transsexual people more vulnerable to social and legal marginalisation and exclusion, and increasing risks to mental and physical well-being.

Please join me in thanking Drs. Drescher and Haller and the American Psychiatric Association leadership for these policy statements that acknowledge the worth and dignity of trans and transsexual individuals. In addition, I urge the APA to issue a position statement that gender identity and expression which differ from assigned birth sex do not, in themselves, constitute mental disorder; to correct diagnostic criteria in the proposed Gender Dysphoria category that malign gender nonconforming expression and transition itself as pathological; and to delete the punitive and scientifically capricious Transvestic Disorder diagnosis from the DSM-5.

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

Third Swing: My Comments to the APA for a Less Harmful Gender Dysphoria Category in the DSM-5

DSM-5

My objective for GID reform in DSM-5 is harm reduction– depathologizing gender identities, gender expressions or bodies that do not conform to birth-assigned gender stereotypes, while at the same time providing some kind of diagnostic coding for access to medical transition treatment for those who need it. I and others have suggested that diagnostic criteria based on distress and impairment, rather than difference from cultural gender stereotypes, offer a path for forward progress toward these goals. This post is an update to my earlier comments to the APA in June, 2011.

The  Gender Dysphoria (GD) criteria proposed by the Sexual and Gender Identity Disorders Work Group for the DSM-5 represent some forward progress on issues of social stigma and barriers to medical transition care, for those who need it. However, they do not go nearly far enough in clarifying that nonconformity to birth-assigned roles and victimization from societal prejudice do not constitute mental pathology. The improvements in the APA proposal so far include a more accurate title, removal of Sexual Orientation Subtyping, rejection of “autogynephilia” subtyping (suggested in the supporting text of the GID category in the DSM-IV-TR), recognition of suprabinary gender identities and expressions, recognition of youth distressed by anticipated pubertal characteristics, and reduced false-positive diagnosis of gender nonconforming children. However, the proposed GD criteria still fall short in serving the needs of transsexual individuals, who need access to medical transition care, or other gender-diverse people who may be ensnared by false-positive diagnosis.

The proposed Gender Dysphoria criteria continue to contradict social and medical transition by mis-characterizing transition itself as symptomatic of mental disorder and obfuscating the distress of gender dysphoria as the problem to be treated. The phrase “a strong desire,” repeated throughout the diagnostic criteria, is particularly problematic, suggesting that desire for relief from the distress of gender dysphoria is, in itself, irrational and mentally defective. This biased wording discourages transition care to relieve distress of gender dysphoria and instead advances gender-conversion psychotherapies intended to suppress the experienced gender identity and enforce birth-assigned roles. The World Professional Association for Transgender Health (WPATH) has stated that, “Such treatment is no longer considered ethical.” (SOC, Ver. 7, 2011)

Transitioned individuals who are highly functional and happy with their lives are forever diagnosable as mentally disordered under flawed criteria that reference characteracterics and assigned roles of natal sex rather than current status. For example, a post-transition adult who is happy in her or his affirmed role, wants to be treated like others of her/his affirmed gender, has typical feelings of those in her/his affirmed gender, and is distressed or unemployed because of external societal prejudice will forever meet criteria A (subcriteria 4, 5 and 6) and B and remain subject to false-positive diagnosis, regardless of how successfully her or his distress of gender dysphoria has been relieved. Once again, the proposed criteria effectively refute the proven efficacy of medical transition care. Political extremists and intolerant insurers, employers, and medical providers will continue to exploit these diagnostic flaws to deny access to transition care for those who need it. The World Professional Association for Transgender Health (WPATH) has affirmed the medical necessity of transition care for the treatment of gender dysphoria. (SOC, Ver. 7, 2011)

The criteria for children are slightly improved over the DSM-IV-TR, in that they can no longer be diagnosed on the basis of gender role nonconformity alone. However, the proposed criteria are unreasonably reliant on gender stereotype nonconformity. Five of eight proposed subcriteria for children are strictly based on gender role nonconformity, with no relevance to the definition of mental disorder. Behaviors and emotions considered ordinary or even exemplary for other (cisgender) children are mis-characterized as pathological for gender variant youth. This sends a harmful message that equates gender variance with sickness. As a consequence, children will continue to be punished, shamed and harmed for nonconformity to assigned birth roles.

A New Distress-based Diagnostic Paradigm.

An international group of mental health and medical clinicians, researchers and scholars, Professionals Concerned With Gender Diagnoses in the DSM, has proposed alternative diagnostic nomenclature based on distress rather than nonconformity (Lev, et al., 2010; Winters and Ehrbar 2010; Ehrbar, Winters and Gorton 2009). These include anatomic dysphoria (painful distress with current physical sex characteristics) as well as social role dysphoria (distress with ascribed or enforced social gender roles that are incongruent with one’s inner experienced gender identity) For children and adolescents, these alternative criteria include distress with anticipated physical sex characteristics that would result if the youth were forced to endure pubertal development associated with natal sex. For those who require a post-transition diagnostic coding for continued access to hormonal therapy, the criteria include sex hormone status. Psychologist Anne Vitale (2010) has previously described this distress as deprivation of characteristics that are congruent with inner experienced gender identity, in addition to distress caused directly by characteristics that are incongruent.

Building on this prior work, I propose that gender role component of gender dysphoria, including distress with a current incongruent social gender role and distress with deprivation of congruent social gender expression, can be more concisely described as impairment of social function in a role congruent with a person’s experienced gender identity. I believe it is also important to include other important life functions, such as sexual function in a congruent
gender role. This language would provide a clearer understanding of the necessity of social and medical transition for those who need them.

These alternative criteria acknowledge that experienced gender identity may include elements of masculinity, femininity, both or neither and are not limited to binary gender stereotypes. They also define clinically significant distress and impairment to include barriers to functioning in one’s experienced congruent gender role and exclude victimization by social prejudice and discrimination.

Suggested Diagnostic Criteria for Gender Dysphoria in the DSM-5

I would like to suggest the following diagnostic criteria for the Gender Dysphoria for adults/adolescents and children–

A. Distress or impairment in life functioning caused by incongruence between persistent experienced gender identity and current physical sex characteristics in adults or adolescents who have reached the earlier of age 13 or Tanner Stage II of pubertal development, or with assigned gender role in children, manifested by at least one of the following indicators for a duration of at least 3 months. Incongruence, for this purpose, does not mean gender expression that is nonconforming to social stereotypes of assigned gender role or natal sex. Experienced gender identities may include alternative gender identities beyond binary stereotypes.

A1. Distress or discomfort with one’s current primary or secondary sex characteristics,
including sex hormone status for adolescents and adults, that are incongruent with
experienced gender identity, or with anticipated pubertal development associated with
natal sex.
A2. Distress or discomfort caused by deprivation of primary or secondary sex
characteristics, including sex hormone status, that are congruent with experienced
gender identity.
A3. Impairment in life functioning, including social and sexual functioning, in a role
congruent with experienced gender identity.

B. Distress, discomfort or impairment is clinically significant. Distress, discomfort or
impairment due to external prejudice or discrimination is not a basis for diagnosis.

References

World Professional Association for Transgender Health (2011), Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People, http://www.wpath.org/documents/Standards%20of%20Care_FullBook_1g-1.pdf

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

Winters, K. and Ehrbar, R. (2010) “Beyond Conundrum: Strategies for Diagnostic Harm Reduction,” Journal of Gay & Lesbian Mental Health, 14:2, 130-139, April

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/

Vitale, A. (2010) The Gendered Self: Further Commentary on the Transsexual Phenomenon, Lulu, http://http://www.avitale.com/

 

Copyright © 2012 Kelley Winters, GID Reform Advocates

 

Final Public Comment Period For Proposed DSM-5 Criteria Ends June 15

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

The American Psychiatric Association announced a third and final period of public comment on proposed diagnostic criteria for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), ending June 15.  Criteria for the draft diagnostic categories of Gender Dysphoria in Children and Gender Dysphoria in Adolescents or Adults (formerly Gender Identity Disorder, or GID) are unchanged from the second round proposal in May, 2011. The Sexual and Gender Identity Disorders Workgroup of the DSM-5 Task Force only partially responded to concerns raised about the GID diagnosis by community advocates, allies and care providers. Their specific diagnostic criteria continue to characterize gender identities and expressions that differ from birth-assigned roles as pathological and therefore contradict access to medical transition care, for those who need it, rather than lower its barriers.

Worse yet, the punitive and scientifically capricious diagnosis of Transvestic Disorder (formerly Transvestic Fetishism) offers no medical justification for its continued inclusion in the diagnostic manual, despite growing insistence on its removal. Many in the trans and allied communities are outraged at defamatory “autogynephilia”/”autoandrophilia” specifiers in this diagnosis that falsely stereotype many transsexual women and men as self-obsessed sexual fetishists. An online petition, sponsored by The International Foundation for Gender Education (IFGE) now has over 6,700 signatures, calling for complete removal of the Transvestic Fetishism/Disorder category from the DSM.

What You Can Do Now

  1. Ask the APA to fix the Gender Dysphoria diagnosis– rejecting diagnostic criteria and categorical placement that currently contradict transition or depict transition itself as symptomatic of mental disorder. Ask them to clarify that nonconformity to birth-assigned roles and being victims of societal prejudice are not, in themselves, mental pathology. Demand that the APA remove the defamatory Transvestic Disorder diagnosis entirely. Go to the APA DSM-5 web site, click on “register now,” create a user account and enter your statement in the box. The deadline for this third period of public comment is June 15.
  2. Sign the IFGE sponsored petition to remove the cruelly hurtful Transvestic Disorder category from the DSM-5.
  3. Ask your local, national and international GLBTQ nonprofit organizations to issue public statements to clarify that nonconformity to birth-assigned roles and being victims of societal prejudice are not, in themselves, mental pathology.
  4. Ask mental health and medical professionals who work with the transcommunity to voice their concerns to the APA.
  5. Spread the word to your network of friends and allies.

These Aren’t the Droids You’re Looking For: Gender Diversity, Scapegoating and Erasure in Medicine and Media

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

On the April 18th broadcast of The Rachel Maddow Show, Dr. Maddow reported an “explosive revelation” that Psychiatrist Robert Spitzer had rescinded his controversial 2001 claim that sexual conversion, or sexual reparative, psychotherapies can change sexual orientation in gay and lesbian people. Quoting an interview of Dr. Spitzer in The American Prospect, Maddow celebrated the historical significance of Spitzer’s reversal for the gay rights movement, calling it,

step one in what we’re now going to see as a real change, a real reckoning, in antigay politics.

Sadly, Dr. Maddow only told half of the story. For four decades, Robert Spitzer has played pivotal roles in mental health policies, not only on sexual orientation, but on gender diversity as well. This week, Rachel Maddow and other journalists turned a blind eye to Dr. Spitzer’s failure to retract a lifetime of trans psychopathologization, stereotyping gender identities and expression that differ from assigned birth roles as mental disease. This omission speaks to the marginal status of trans people within the GLbt rights movement and progressive media, as much as Spitzer’s omission speaks to trans marginalization by mental health policymakers. Shifting stigma from one oppressed class to a more oppressed class is not real change.

At the 1973 annual meeting of the American Psychiatric Association, Robert Spitzer played a central role in arguing for declassification of same-sex orientation as mental illness:

In the past, homosexuals have been denied civil rights in many areas of life on the ground that because they suffer from a ‘mental illness’ the burden of proof is on them to demonstrate their competence, reliability, or mental stability.

This led to the gradual deletion of sexual orientation categories from the Diagnostic and Statistical Manual of Mental Disorders (DSM) between 1973 and 1987. The DSM is published by the American Psychiatric Association and remains the medical and cultural definition of mental disorder in North America. As Chairman of the DSM-III and DSM-III-R Task Forces and chief editor of the diagnostic manual, Spitzer oversaw removal of the last major vestige of gay diagnosis, “Ego-dystonic Homosexuality,” from version III-R.

However, while depathologizing same-sex orientation, Dr. Spitzer simultaneously directed a massive expansion of trans-pathology diagnoses in the DSM. In 1980, a new category of Gender Identity Disorders (GID), including a Transsexualism (TS) diagnosis, was added to the class of Psychosexual Disorders in the DSM-III. The TS coding was paradoxical and controversial for many trans people. Many community advocates and medical providers agreed (and do today) that some kind of diagnostic coding was necessary to facilitate access to medical and/or surgical transition care for those trans and transsexual people who needed it.  On the other hand, defining a medical transition coding as a mental illness, rather than a treatable medical condition, contradicted access to hormonal and/or surgical transition care and encouraged gender conversion, or gender-reparative, psychotherapies— unsubstantiated treatments attempting to change gender identity and shame trans and TS people into the closets of their assigned birth roles.  Vulnerable trans and gender nonconforming youth were targeted and institutionalized as a consequence of diagnostic criteria based on nonconformity to birth-assigned stereotypes.

In the DSM III-R, Dr. Spitzer’s Task Force expanded the diagnostic criteria for children to emphasize gender role nonconformity for birth-assigned girls, including “persistent marked aversion to normative feminine clothing” (whatever that means).  Even more damaging, a new category was added, Gender Identity Disorder of Adolescence or Adulthood, Nontranssexual Type (GIDAANT), to psychopathologize for the first time the gender identities of trans people who did not need access to medical transition care.

The disorder of Transvestism in the DSM-III was renamed “Transvestic Fetishism” in the DSM-III-R, to further stigmatize crossdressing or gender nonconformity by birth-assigned males as sexual obsession. This change served to sexualize a diagnosis that did not clearly require a sexual context in its diagnostic criteria.  The DSM-IV Casebook, edited by Dr. Spitzer in 1994, went even further in pathologizing gender nonconformity, recommending a Transvestic Fetishism diagnosis for a self-accepting bigender male, whose crossdressing was not necessarily erotically motivated and whose primary distress was his spouse’s intolerance.

In 2001, Robert Spitzer tacked to the political right on sexual orientation, presenting a paper entitled,”Can Some Gay Men and Lesbians Change Their Sexual Orientation? 200 Participants Reporting a Change from Homosexual to Heterosexual Orientation,” to the Annual Meeting of the American Psychiatric Association. It was published in the Archives of Sexual Behavior two years later. Spitzer promoted sexual conversion, or sexual-reparative, psychotherapies as “a rational choice” and affirmed their efficacy, stating,

there is evidence that change in sexual orientation following some form of reparative therapy does occur in some gay men and lesbians.

Moreover, Spitzer denied mounting evidence that sexual-reparative psychotherapies cause harm and even criticized the American Psychiatric Association for denouncing the practice as unethical.  At the same time, he revealed his bias on gender diversity and gender conversion therapies, describing “a greater sense of masculinity in males, and femininity in females,” as a therapeutic “benefit.”

By 2003, Dr. Spitzer’s statements had drawn a firestorm of dissent from GLB communities and supportive mental health professionals. Wayne Besen, founder of Truth Wins Out, characterized Spitzer’s study as,

just the latest attempt by the political religious right to gain legitimacy for their arguments by teaming up with a supposedly unbiased scientist.

Indeed, antigay extremists, including the National Association for Research & Therapy of Homosexuality (NARTH), embraced the Spitzer paper as mainstream endorsement of their sexual-reparative psychotherapies:

These results would seem to contradict the position statements of the major mental health organizations in the United States, which claim there is no scientific basis for believing psychotherapy effective in addressing same-sex attraction. Yet Spitzer reports evidence of change in both sexes…

Spitzer’s response to mounting criticism of his scientific rigor was to backpedal from his “rational choice” position, clarifying, “Of course no one chooses to be homosexual and no one chooses to be heterosexual.” At the very same time, however, he doubled down on his characterization of trans people as mentally defective.

2003 APA Annual Meeting

Sexual and Gender Identity Disorders symposium from the 2003 APA Annual Meeting. From the left, Drs. Karasic (speaking), Hill, Winters, Moser, Drescher, Spitzer (front), and Fink.

In May, 2003, Dr. Spitzer and I presented papers to a symposium entitled, “Sexual and Gender Identity Disorders: Questions for the DSM-V” at the Annual Meeting of the American Psychiatric Association. The only trans person and non-clinical scholar in the session, I sat on the left side of the stage table with presenters advocating reform of the Gender Identity Disorder (GID) and paraphilia diagnoses in the DSM-5. At the far right end of the table, Spitzer joined former APA President Dr. Paul Fink in defending the status quo. Spitzer wasted no time in invoking the worn stereotype of disordered gender identity:

Children normally develop a sense of gender identity. It is not taught—it just happens. I would argue that by itself, the failure to develop a gender identity that is congruent with biological gender is a dysfunction.

He continued, plodding down a path of cave-man essentialism:

In all cultures, young boys want to play with boys, Young girls want to play with girls… If you are interested in evolutionary psychology, you ask yourself could that have some survival value? The answer is yes. Thousands of years ago when men were more likely to be in hunting and women were more likely to be in the nurturing role, if you were a young boy you would do better if you spent your time with other boys with whom, when you were older, you would go to the hunt.

And Spitzer didn’t stop there, adding,  “…in all cultures, gender is recognized as a dichotomy.”

This could not be further from the truth. Global human history holds a great many indigenous cultures with more than two recognized sex and gender roles.  These include Tahitian and Hawaiian Mahu, Madagascar Sekrata, Hindu Tantric and Hijra Sects, Islamic Xanith, Khawal, and Sufi traditions and numerous Native American, or First Nation, Two Spirit traditions, and many others.

At the 2003 APA Meeting, Dr. Spitzer disparaged gender variant identities and expressions as pathological if they did not serve functions that he termed, “expected.” In my 2008 book, Gender Madness in American Psychiatry: Essays from the Struggle for Dignity, I questioned his evolutionary speculations,

who gets to decide what is ‘expected’? From whose perch of social privilege is American psychiatry to pass judgment upon the evolutionary worthiness of a class of people who have survived since human antiquity?

In the May, 2006, issue of Congressional Quarterly Researcher, Robert Spitzer debated UC San Francisco psychiatrist Dan Karasic on the question of GID as a mental illness. Spitzer used his most defamatory language to date to argue that well adjusted post-transition adults should continue to be regarded as mentally ill, so long as they deviate from their birth-assigned sex roles:

Granted that hormone therapy or surgery may now be the only treatment that we can now offer the adult with GID… But surely something remains profoundly wrong psychologically with individuals who are uncomfortable with their biological sex and insist that their biological sex is of the opposite sex. The only diagnosis that is appropriate for such cases is GID.

In issues of social discrimination, historic context matters. Cisgender GLB people had every right to their outrage at Spitzer’s 2001 attack on their dignity. This week, they had cause to celebrate his retraction. Wayne Besen noted that,

Spitzer just kicked out the final leg from the stool on which the proponents of ‘ex-gay’ therapy based their already shaky claims of success.

Perhaps, but trans and especially transsexual people are not celebrating. Dr. Spitzer and like-minded policymakers in American Psychiatry have long kicked the the legs from under our human legitimacy, and the rush to his redemption in progressive media has cast our issues aside once again.

We too have been injured by Robert Spitzer’s role in perpetuating defamatory stereotypes of mental “dysfunction” and deviance. Trans people continue to lose our jobs, homes, children, families, dignity and civil justice because of these stereotypes and continue to face predatory gender conversion psychotherapies. These stereotypes lie behind every extremist political campaign that demeans our most basic civil rights as “bathroom bills.” These stereotypes lie behind military discrimination and government policies that still malign us as “mentally unfit.” These stereotypes convince parents and school officials to dismiss trans youth as “confused” or going through “a phase.” Trans communities have waited more than two decades for a retraction or an apology from Dr. Spitzer. and we are still waiting.

Copyright © 2012 Kelley Winters, GID Reform Advocates

New Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People

Kelley Winters, Ph.D.
GID Reform Advocates
www.gidreform.org
kelley@gidreform.org

The World Professional Association for Transgender Health (WPATH) released it’s 7th Version of Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People (SOC) in Atlanta today. The previous Version 6 was published in 2001. Overall, this newest SOC represents significant forward progress in respecting trans people and affirming the necessity of medical transition care for trans and transsexual individuals who need it. Although controversies and issues of transition care access remain in the SOC7, WPATH has announced a more frequent update process that will hopefully be more responsive to emerging evidence and clinical experience in the future.

First published in 1979, the SOC has provided clinical guidance to medical and mental health providers serving trans people, with an emphasis on transsexual individuals seeking hormonal and/or surgical transition care. In many parts of the world, particularly North America and Europe, the SOC has played a role in enabling access to medical transition care and in enabling medical and surgical practitioners to provide it. However, the SOC has been controversial among trans communities and supportive care providers. For example, prior versions have been critized for unreasonable barriers to medical transition care, pathologizing language of “disordered” gender identities and “gender‐disturbed children,” maligning pronouns and terms for transitioned individuals, and compulsory psychotherapy requirements. Fortunately, successive revisions of the SOC have trended toward greater respect for trans and transsexual people and fewer unjustified barriers to transition care. For example,  mandatory urological examinations were dropped from the 4th Version in 1990, and mandatory psychotherapy requirements for those needing access to hormonal or surgical transition care were dropped from the 5th SOC in 1998.

Gender Conversion Psychotherapies are Unethical

Perhaps the most historic change in the SOC7 appears in the section of ethical guidelines:

Treatment aimed at trying to change a person’s gender identity and lived gender expression to become more congruent with sex assigned at birth has been attempted in the past (Gelder & Marks, 1969; Greenson, 1964), yet without success, particularly in the long term (Cohen-Kettenis & Kuiper, 1984; Pauly, 1965). Such treatment is no longer considered ethical.

Though long overdue, this condemnation of gender-conversion or gender-reparative psychotherapies sets a new ethical standard for the mental health professions. Sexual orientation conversion therapies have been rejected by the American Psychiatric Organization, the American Psychological Association, the American Medical Association, the National Association of Social Workers and many other professional associations for over a decade. Yet the mental health and medical professions have maintained a double standard for trans, transsexual and gender nonconforming people victimized by analogous gender-reparative therapies that are equally harmful.

I commend the WPATH leadership and the SOC committees for taking this historic step and call upon the American Psychiatric Association and other professional associations to follow WPATH’s leadership on this important issue.

De-psychopathologisation of Gender Difference

The 7th Version of the SOC goes further than prevous versions in employing respectful language and dispelling false myths that equate nonconformity to birth-assigned sex and gender roles with mental illness. A section entitled, “Being Transsexual, Transgender, or Gender Nonconforming Is a Matter of Diversity, Not Pathology,” prominently notes:

WPATH released a statement in May 2010 urging the de-psychopathologization of gender nonconformity worldwide (WPATH Board of Directors, 2010). This statement noted that “the expression of gender characteristics, including identities, that are not stereotypically associated with one’s assigned sex at birth is a common and culturally-diverse human phenomenon [that] should not be judged as inherently pathological or negative.”

We can only hope that the American Psychiatric Association and World Health Organizations will take guidance from this principle in future revisions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Statistical Classification of Diseases and Related Health Problems (ICD).

The de-psychopathologization principle is underscored by statements that, “Psychotherapy is not an absolute requirement for hormone therapy and surgery,” first introduced in Versions 5 and 6–

A mental health screening and/or assessment as outlined above is needed for referral to hormonal and surgical treatments for gender dysphoria. In contrast, psychotherapy – although highly recommended – is not a requirement.

The new standard clarifies gender dysphoria, from a greek root for distress, as the focus of treatment, replacing pathologizing language of “disordered” gender identity. Gender dysphoria is painful distress with one’s current physical sex characteristics or assigned or ascribed social gender role. Social role transition to a congruent, affirmed gender role and hormonal and/or surgical transition treatments (for those who need them) are well proven in relieving this distress. The SOC7 notes,

…transsexual, transgender, and gender nonconforming individuals are not inherently disordered. Rather, the distress of gender dysphoria, when present, is the concern that might be diagnosable and for which various treatment options are available.

The American Psychiatric Association has already proposed to replace the defamatory diagnostic title of “gender identity disorder” with Gender Dysphoria in the pending 5th Edition of the DSM.

Other Positive Changes

The tone and language of the SOC7 are more positive than in previous versions, with more emphasis on care and less emphasis on barriers to care. Some highlights include:

  • Concise and more cogent criteria for access to hormonal and surgical transition care.
  • Relaxation of the age 18 restriction for access to hormonal transition care.
  • Removal of the three month requirement for either “real life experience” (living in a congruent gender role) or psychotherapy before access to hormonal care.
  • Clarification that “the presence of co-existing mental health concerns does not necessarily preclude access to feminizing/masculinizing hormones .”
  • Removal of barriers to surgical care because of family intolerance or interpersonal issues.
  • An expanded role for medical health professionals in granting access to hormonal therapies.
  • Acknowledgement of informed consent model protocols, developed at community health centers worldwide for hormonal transition care.
  • Emphasis of cultural competence and sensitivity for care providers.
  • Expanded and clarified information on puberty delaying treatment for gender dysphoric adolescents.
  • Clarification on the role of the SOC as flexible clinical guidelines that may be tailored for individual needs and local cultures.

Issues for Future Revisions

Although the 7th Version of the SOC is significantly improved over previous versions, there remain issues of concern to trans communities and their allies. One issue is promotion of a widely held myth that gender dysphoria in children will persist in only a small minority by adolescence, in other words, that gender identity in children is malleable and impersistent. These statements in the SOC are based on studies that conflated mere nonconformity of gender expression in children with the distress of gender dysphoria: painful distress with born sex characteristics or assigned gender roles. Among a new generation of gender dysphoric children from supportive families, children who have actually transitioned to affirmed roles congruent with their gender identities, there is so far very little evidence of impersistence. Hopefully, future revisions of the Standards of Care will quickly incorporate research findings on these new populations of affirmed youth, as they become available.

Download the SOC Version 7

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