A reader writes: “The DSM-V is coming out at the end of the year, and the big question of whether or not gender identity disorder will appear is being decided now, I believe. I heard something about that they gave the revision of this part to the wrong people, and that something terrible could come out of it.
“My main question, though, is: Is it good or bad to remove ourselves from the DSM at this point in time? I know that seeing being trans as a mental disorder is not proper – that I know from living through it. But not everyone else understands.
“I fear that if transsexuality is no longer in the medical books, we will be seen in both the medical and rest of the community as feigning illness. And especially for the former, I see free license to discriminate. I think it shouldn’t be in there, but at this point, when many people still think trans people are just really gay people, what do we gain and lose from taking ourselves off a respected list?”
The debate about whether or not Gender Identity Disorder (GID) (or some other language that represents a similar “condition”) should be in the DSM (Diagnostic and Statistical Manual of Mental Disorders) has been going on for at least as long as I have been in the community. I first learned of the debate when I began transition fifteen years ago.
The DSM-V is scheduled to be released in May of 2013, and at this point, it appears that Gender Identity Disorder will now be called Gender Dysphoria, but I don’t think it’s as simple as a name change. There are various pieces of the diagnosis that have been changed or moved to different categories within the DSM-V, and there have been other changes in language.
Some people feel that these changes are positive, while others want certain categories out of the DSM altogether. However, my understanding is that it will appear as Gender Dysphoria in the DSM-V.
There are people far more knowledgeable on this subject than I am, and I hope that they comment on this post, because I have not studied this issue in depth, and I can only offer the most basic of overviews, along with my opinion.
One source that I recommend for in-depth information is Dr. Kelley Winters of GID Reform Advocates. Her website has a lot of information and analysis on this issue. She has also written a book, Gender Madness in American Psychiatry, that is an important read for those interested in this issue. There are other sources out there as well, offering differing positions. I hope readers will suggest them, so those interested in studying this further can examine all sides of the debate.
But in the limited space of a blog, with the knowledge that I have, we can look at your question: “Is it good or bad to remove ourselves from the DSM at this point in time?”
It turns out to be a moot point, because Gender Dysphoria will be in the DSM-V. However, the arguments at their most basic level are:
> We should be in the DSM, because if we are not, we will not be seen as having a legitimate condition that requires medical intervention. We will be seen as “choosing” transition, and we will not be taken seriously. Any strides that we have made with regard to insurance paying for transition procedures will stall. We need the backing of the medical and psychiatric communities in order to realize full rights and full equality.
> We should not be in the DSM, because we do not have a mental health disorder. If anything, we have a medical condition that was present at birth and is possibly due to hormonal fluctuations during pregnancy or we do not have any kind of “condition” at all, and we are simply one of many ways to be as human. By virtue of our humanity, we are equal to all other humans, and by virtue of a strongly demonstrated need to align our body with our gender identity, we should be able to transition with informed consent and with the understanding from insurance companies and medical professionals that transition is a medical necessity.
Now these arguments as I have worded them here are very basic and simplistic, and they are not the only two. There are many variations within these themes, and many complications and intricacies that are not addressed by the language above. But these very basic components make sense, and I understand both sides of the argument.
When I first started transition, I was pretty anti-therapy, even though I loved my own therapist. I did not, and still don’t, like the “oversight” component of therapy with regard to transition. I think that therapy can be very helpful, and I think that it can be especially beneficial when dealing with the “reality checks” that I think are necessary for transition, as well as offering support and ideas with social-role and adjustment issues that can come with transition.
I’ve always thought that the “gatekeeper” aspect of the therapist’s role with regard to approval for hormones and surgery can interfere with a truly beneficial therapeutic relationship. On the other hand, a good therapist, working with a healthy trans person with realistic expectations, can result in a positive experience.
Unfortunately, a lot of trans people have suffered at the hands of ill-prepared, misinformed, or just plain uncaring therapists who have required a lot of jumping through unnecessary hoops, which does not bode well for a valuable relationship. And there are a lot of therapists out there who still believe that gender issues can be “cured,” particularly in childhood (one of the concerns of the community was that one of the doctors on the DSM-V revision committee was known for “treating” children who exhibited gender issues by forcing them into stereotypical gender roles associated with their birth sex).
My own opinion is that I would like to see Gender Identity Disorder, Gender Dysphoria, or whatever psychiatric label comes about for people whose gender identity does not align with their physical sex (or sex assigned at birth) removed from the DSM. I don’t think that my “condition” is a mental health issue.
Research has demonstrated that transition, a series of medical procedures, can reduce or eliminate the suicidal ideation and other emotional difficulties that many trans people experience. Therefore, I believe that this is a medical issue and should be treated as such. However, there are some trans people who think that even that is too pathologizing, and that transition procedures should be available as on-demand procedures, with the idea that we know our own bodies and minds and should have the right to make our own decisions about care.
I agree with this as well, and this is where I am torn. I believe that I am responsible for my own body, and that I am capable of making decisions about it. I don’t think that I should have to jump through a bunch of someone else’s hoops to do what is best for me. But if gender issues are not part of either a psychiatric or a medical diagnosis, and transition procedures can be issued upon request, then transition becomes a series of “elective” procedures, not considered medically necessary, not covered by insurance or other medical programs, and not recognized as a life-saving intervention.
“Homosexuality” was removed from the DSM in 1973, and the new volume in 1974 reflected that. Since that time, gay and lesbian people have made great strides in rights and acceptance, although, almost forty years later, gay men and lesbians still do not have equal rights. However, the removal of homosexuality from the DSM did not hurt that community in any way that I can see, and probably helped them, because there’s no way that homophobes can turn to the DSM and say, “See? This is a documented mental health issue.”
In that way, it would be quite similar for us, although the difference is that many of us do require medical interventions, whereas gay men and lesbians do not, so while I think that GID/Gender Dysphoria should be removed from the DSM sooner rather than later, there also needs to be provisions in place that will enable those who need to transition to access hormones and surgery in a timely, reasonable, and safe manner.
I would love to hear opinions on this from readers, as well as more detailed information that I don’t have. Thanks in advance for thoughts, comments, and info.
(A quick aside about language: I generally say “we are in the DSM” or “I am in the DSM” simply for ease of communication. The truth is that we are not in the DSM and I am not in the DSM. I am diagnosed with a “condition” that appears in the DSM. I think it’s an important distinction, at least when thinking about yourself as a trans person. We are not our diagnosis.)
I’ve never really understood the notion that removing GID from the DSM would delegitimize it as a medical condition needing of health care. The DSM is for mental health issues, not all health issues. I had pneumonia last year, and my doctor took it seriously even though it wasn’t in the DSM. I get a pap smear every year or so, but cervical cancer isn’t in the DSM. My doctor prescribes testosterone for me, not a psychiatrist, and regardless of if I’m even seeing a counselor at all. In fact, she checks all of my blood levels to make sure I’m healthy and on a good dose at the same time she does my pap. Seems like those things should have something in common, like not being in the DSM
“Transgenderism” is not yet an accepted physiological condition/entity described in any medical paper in any form. Research has been done in the area as I’m sure you know, but there is no other medically accepted model. Getting GID out of the DSM does nothing to make it a physiological condition. Taking it out of the DSM would simply erase it from medical literature altogether, and that is why it’s not desirable at the moment. The new WPATH Standards of Care are steering the attention more in the physiological arena by depathologizing it. When we have a physiological model, GID et al can then safely be removed from it.
Speaking as the parent of a teenager who is quite literally suffering from dysphoria due to the discomfort of living in his female body, i am happy to see this change. I don’t think the gender identity is a “disorder” or any sort of mental illness or medical concern, but the dysphoria and depression and resulting problems that arise from being miserable in the “wrong” body before being able to medically transition (for those who suffer from this and for whom a medical transition is part of their plan) are definitely a concern, and a medical diagnosis that accurately reflects the problem is important and will hopefully make it easier for transgender folks to find doctors willing to provide hormone treatment and surgery and perhaps for insurance companies to cover it. I guess to put it in a nutshell: i think the gender issue is a medical condition (body doesn’t match the brain so the body needs to be fixed medically); the resulting dysphoria and depression is a mental health issue. The mental health issue can be partly or perhaps fully resolved by correcting the medical issue.
At this junction I think we should leave it in the DSM, but remove the necessity for letters of recommendation for hormone and surgical treatment required by doctors. Until more of the general populous recognizes a gender spectrum instead of a gender binary, it gives us a level of legitimacy as human beings. By that I mean that at least the mental health community recognizes that we exist and it is okay for us to exist. We don’t do his by choice, we do this because we are here and we live in a state of discomfort that needs medical intervention. I may not like having a condition in the DSM, but because I do, I can get medical treatment. It is baby steps to change most of the time.
Thanks, Matt, for turning your attention to this important topic.
In a nutshell, (bad pun, I know) there are two issues, which I feel 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 first is hurtful stigma and false stereotypes of mental defectiveness and sexual deviance promoted by the current classification. The second is access to medically necessary hormonal and/or surgical transition care, for those transsexual people who need them. The latter requires some kind of diagnostic coding, but not the current “disordered gender identity” nomenclature, which actually contradicts rather than supports medical transition care. In the long term, I would like to see a non-psychiatric classification in the ICD (published by the World Health Assoc) for access to transition treatments. In the short term, I have worked with others to propose harm reduction strategies for replacing GID with a distressed based Gender Dysphoria coding in the DSM-5. Dysphoria is from a Greek root for distress, and gender dysphoria, if properly defined, describes painful distress with current or impending physical sex characteristics or assigned birth roles that are experienced by trans people who need access to medical transition care.
There is also a second gender classification of Transvestic Fetishism in the DSM, which is a capricious and punitive pathologization of nonconformity to birth-assigned gender roles. I strongly feel that this category should be eliminated altogether from the DSM.
For more thoughts on these issues with the DSM-5 and the WPATH Standards of Care, Version 7, please see my blog at http://gidreform.wordpress.com/
Kelley Winters, Ph.D.
Founder, GID Reform Advocates
Member, International Advisory Panel, WPATH Standards of Care, Version 7
http://www.gidreform.org
I would prefer not to see it in DSM, but in a non-psychiatric section of ICD-10, the World Health Organization’s catalog of health conditions. Barring that, I would prefer it be in the chapter on Disorders First Diagnosed in Infancy, Childhood, and Adolescence (where it was in DSM-III) rather than “Sexual and Gender Identity Disorders” where we are next to Pedophilia. There are also non-disorder categories in DSM which might also be used. I think the current draft of DSM-5 has us in our own individual chapter.
Ultimately, I wish transition could be seen as a normal life event – similar to pregnancy – where there are medical management issues, but it is not considered a “disorder”. There are “well woman” and “well man” medical visits – perhaps they can consider a protocol for a “well trans woman” or “well trans man” visit.
Frankly, I don’t care DSM or no DSM as long as insurance will pay for transition. I guess I see it as something more in the brain, because… There’s nothing wrong with my body. It’s a matter of my brain thinking my body is different than it really is. And bipolar, OCD, depression, anxiety… They’re all also in the brain. And they are no less legitimate than anything else. Admittedly, people still have to advocate for mental illnesses as real illnesses, but… If the problem is the incongruity, then it isn’t really any more stigmatizing, I think. It shows that this is an issue that needs treatment.
Mike, I’m wondering if in that case, there shouldn’t be research for a “brain drug” to change that incongruency in the brain? That would seem more logical than changing the whole body. It would be the same as with body image disorders.
I’m saying this provocatively, as I’m trans myself.
I don’t think that we can get around the question if we define being trans as a disorder or as an identity thing.
You raise a really good point, anon. Gender dysphoria is quite different from a “body image disorder.” Defining painful anatomical or gender-role dysphoria as a mental defect contradicts access to medical transition care, for those of us who need it. This false stereotype, that transitioning people are “confused” and “deluded” about body image is one of the primary reasons that hormonal and surgical transition care are excluded by insurers and employers. This stereotype is the basis for harmful, hateful gender reparative (or gender conversion) psychotherapies, intended to shame trans people into the closets of their assigned birth sex. In my experience, TS people are quite the opposite– extremely grounded in the grim reality of the bodies we are born with and the incongruent roles we were assigned to. Adding to the misunderstanding, the words dysphoria (distress) and dysmorphia (in the context of distorted/delusional self body image) are frequently confused in the press and by some clinicians. Behaviors and feelings of femininity and masculinity that are considered ordinary or even exemplary for cis-privileged people are not pathological for trans people. Difference is not disease.
There have been many studies and many articles, in addition to several declarations by the APA and other medical professionals that transition is a medical necessity. The problem isn’t whether or not it is necessary, it is whether or not insurance wants to pay for it.
There have been some studies done that the brains of trans* people are actually structurally different. No drug can change that. There is no magical brain drug that will rearrange the way that your brain is formed.
http://amydentata.com/2012/03/06/the-difference-between-dysphoria-and-negative-body-image/
“There’s nothing wrong with my body. It’s a matter of my brain thinking my body is different than it really is.”
It’s the other way around for me, Mike – there’s nothing wrong with my brain, but my body doesn’t match it. I guess these individual differences should also be taken into account when determining what should be included in the new DSM.
When I say nothing wrong with my body, I mean that it functions. It works well, as a body. The big problem is the gap between what my brain thinks is true and what my body actually is. Sorry for the confusion.
Mike writes: Frankly, I don’t care DSM or no DSM as long as insurance will pay for transition.
That is a view widely held and Mike is far from alone, so nothing personal. However, it is shocking that people fail to realize that it is dishonest to act in the way implied. Feigning a mental disorder in order to justify treatment is, put simply, fraud. That is to say consciously and knowingly perpetuating a falsehood in order to gain financial advantage. Criminal fraud if a professional medic knowingly goes along with the sham, they should do prison time.
Why do people not realize that this is unethical??
It is no different ethically from pretending to have a headache when the purpose of getting aspirin in response would be to treat known high blood pressure.
I respect your opinion, Henry Hall, I really do. However, I disagree about what’s unethical in this case. I say whenever the law (rule, policy, etc.) is clearly wrong, we should challenge it – in any way necessary. If we can’t make changes via legislation, then why not defy it outright? We can’t always play by the rules, and sometimes it works out better that way. Defiance sometimes brings the necessary changes that “playing nice” doesn’t get us.
But what else can I say, I’m a pirate.
CaptLex writes: But what else can I say, I’m a pirate.
Since presumably you are not a physician(?) then your opinion as to your putative mental illness carries no weight and is not fraud. It is the psychiatrist who being an unethical fraudster if he diagnoses GID. Put simply, she is lying in order to get you money for treatment.
No, not a doc, but if I knowingly go along with the shrink or doc wording things in such a way as to get me access to what I need, I am as much responsible for any supposed unethical or fraudulent action done on my behalf. However, that wasn’t my point – I don’t see it as necessarily unethical, is what I meant. But that’s okay dude – we can agree to disagree.
CaptLex: I don’t see it as necessarily unethical, is what I meant.
Sure, people have different ethical codes. But it does make one wonder that if lying and feigning mental illness to get other people to spend their money on you is not unethical – then is anything unethical?
You write: ” … because we do not have a mental health disorder. …”
If that is true then including it in the DSM as a disorder is both fraudulent and unethical. If your statement (we do not have a mental health disorder) is true then the American Psychiatric Association has no problem with being dishonest and unethical.
Regardless of whether K.Zucker succeeds in getting it into DSM-5 (and he probably will), it will not appear in ICD-11. See
http://www.europarl.europa.eu/sides/getDoc.do?pubRef=-//EP//TEXT+TA+P7-TA-2011-0427+0+DOC+XML+V0//EN&language=EN
Because the European Parliament is on the record as saying that Transsexualism is not a mental disorder.
Thanks for all the great perspectives here, and thanks, Kelley Winters, for coming over to comment.
The “brain drug” idea is interesting (and futuristic). I don’t know whether or not such a thing could actually be created, but it then brings up the controversy of “cure.” If there was a “brain drug” that could adjust a person’s gender identity to match his or her physical body, would people take it? I know many people who would, and I also know many who would not. And if such a drug existed, would taking it be voluntary or mandatory for those who exhibit gender dysphoria?
So far, we have not been able to change the gender identity to match the physical body, so changing the body to match the gender identity (transition) has been the accepted treatment for those who require it. But it certainly does bring up an interesting point (and a future blog post) about the positive and negative consequences of such a drug.
For the record I have always resented being classified as mentally ill although I suppose most mentally ill (or defective) people would voice the same resentment.
Speaking of topics for new posts Matt I recently ran across this ….> http://www.post-gazette.com/stories/local/region/transgender-man-claims-discrimination-631663/
What is disturbing to me about that news article is that Johnston is receiving Social Security Disability. Yet if the DSM continues to include transsexuals perhaps it makes sense and the Social Security system should be obligated to pay disability. I’ll bet that would get howls from the righteous right.
Also for the record thanks Kelley for your extensive efforts to bring at least some level of sanity and acceptance to the transsexual experience.
That’s really interesting – that he’s receiving Social Security Disability “for a variety of emotional liabilities that included gender identity disorder.” I have not known anyone who has been determined by the Social Security Administration to be disabled based on a diagnosis of GID, although in this case, it appears that there are multiple issues for this man. But if GID was actually one of the “emotional liabilities” that the SSA considered in their determination, then that opens up a whole other can of worms or takes the debate off in a whole other direction.
The Americans with Disabilities Act (ADA) of 1990, as amended contains the following text –
§512(b) Certain Conditions. Under this Act, the term “disability” shall not include
§512(b)(1) transvestism, transsexualism, pedophilia, exhibitionism, voyeurism, gender identity disorders not resulting from physical impairments, or other sexual behavior disorders;
§512(b)(2) compulsive gambling, kleptomania, or pyromania; or …
So the issue for a person diagnosed with the psychosis called gender identity disorder becomes – “Does this condition result from a physical impairment or not?”
A smart attorney would interpret the words literally and say that if the petitioner has made a showing of GID then the burden falls on Social Security to prove that the GID was NOT a result of a physical impairment. If they cannot prove that (because the cause is unknown) then the GID is covered under ADA. A diagnosis of “GID of unknown etiology not excluding a possibility of a cause of physical impairment because intersex cannot be ruled out as a possibility” would clinch the issue.
I doubt anyone has had the guts to advance that argument but that is how the law reads.
Interesting, Henry Hall about the ADA. What is interesting is that various people have used the ADA for getting special accommodation for being fat – something that most times can be cured by proper diet and exercise. Another thing that apparently the ADA allows as a disability is alcoholism or drug abuse. Granted, these things can stem from a propensity for addiction that can be hereditary. And all these people need treatment. These people can get SSI from Social Security Administration for these things. I have seen these people use their SSI to buy drugs and booze and I resent that. I, as a blind person, get painted with the same brush as a drug addict when I get SSI. I didn’t ask for my disability and I didn’t cause it so I won’t get into that can of worms.
As for the DSM and GID, I think there should be something somewhere to indicate that we Trans people have a condition that we did not create or cause – it came to us – so we can get the medical treatment we may need to help us to feel normal and to function in the world free of discrimination. Wonder what James Green thinks about this. He’s with the WAPATH that is dealing with this issue of the DSM.
Lyn: > As for the DSM and GID, I think there should be something somewhere to indicate that we Trans people have a condition that we did not create or cause
DSM is silent as to etiologies. Statements on causation could not be included.
As to the question of loosing payment for treatment- in some EU countries, for example Germany, transition is fully covered despite the fact that it it is not seen as a disorder.
It is covered because of the distress (depression, anxiety and so on) that can be caused by the discongruence between body and identity. E.g. it’s the same thing as surgeries that are not neccesary for physical health but for social functioning, like when someone is born with a visible deformation, and gets sugery paid because people stare, which then causes intolerable stress.
This way it is always the decision of the individual which treatments they need without diminishing the treatment for another person (some would want to live with the visible difference, other can’t cope with the stress, both is accepted)
It’s quite simple really.
As a therapist who works with trans clients, I found your post to be spot on Matt!
Go to ICATH.org for a place that is trying to take Transgender Health issues out of the provence of the Psychs and into the reality of a true medical condition treated by Informed Consent, as it should be
Leigh Smythe:- Go to ICATH.org for a place that is …
Ah, here is an outfit with a bit more political clout than ICATH that is taking a similar line on depathologisation:
http://www.lgbt-ep.eu/press-releases/lgbt-rights-in-the-annual-report-on-human-rights-in-the-world/
April 18th, 2012, on this day the European Parliament adopted its annual report on human rights in the world, paying close attention to EU action for the human rights of LGBT people. …
Regarding gender identity, the European Parliament repeats its earlier call to the Commission to work with the World Health Organization to withdraw ‘gender identity disorder’ from the International Classification of Diseases, and seek a non-pathologising reclassification.
The European Parliament represents 500 million people, being the population of the 27 member European Economic Community. It likely has a some pull as to the ICD-11 being written in Europe.
I’ve seen quite in a few TS in my 22 years contact with the a vast swat of the community and though most are very intelligent, I wouldn’t call them levelheaded when they initially contact people that can help them.
From experience, only about 40% of these actually transition. Yet, at least 90% initially wanted paper for hormones and surgery almost immediately. Why the big gap if there is no need for a therapist? Because many with gender disphoria find out they don’t need to transition (either non-op or post-op) to ease their pain. That’s an important to know don’t you think?
So, even though being a TS is not a disease or body or mind, the tremendous confusion and distress this produces has an impact (that’s where disphoria comes in). While transitioning very early can limit to almost zero, its almost always present. That’s what should be in the DSM in my opinion.
Jean-Yves:- That’s what should be in the DSM in my opinion.
All very well for North America (DSM).
Thank goodness the rest of the world is moving in the opposite direction (ICD-11).
I talked to someone from the Phillipeans, who remarked that America is so up-tight and condescending to trans people, its not like that in the rest of Asia. Yep, it sucks to be us.
Many years ago I met 2 people from the Philippians. Both were in the twenties and physically very attractive. One was getting bottom surgery and the other was there for support. The one who was more feminine IMHO was not the one getting surgery. She was not about inclined to give up her penis because that was in her view the source of income. We had some very interesting conversations and I learned quite a bit. I think that I agree with you about how uptight our society is versus the rest of the world.
Thanks this article and discourse has helped me a great deal. I have to write a Psych paper on this topic and it answered a LOT of questions…again thanks for all that you do!