We are mental health and medical professionals, clinicians, researchers and scholars concerned about psychiatric nomenclature and diagnostic criteria for gender-variant, gender-nonconforming, transgender and transsexual people in the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and call ourselves Professionals Concerned About Gender Diagnoses in the DSM. Below are our suggestions for the Transvestic Disorder diagnosis in the DSM V.
The proposed Transvestic Disorder diagnosis (APA 2010), like its predecessor Transvestic Fetishism (APA 1994), punishes gender expression that differs from societal expectations of male birth-assignment and enforces conformity to masculine social stereotypes (Winters 2008). We are concerned that the proposed diagnostic criteria are mysogynistic, sexist, unfairly stigmatizing, over-inclusive, and blame victims of discrimination for their own oppression. We fail to see any positive reasons for including this diagnosis, or how this categorization of people as mentally ill will enhance diagnostic specificity, treatment guidelines, or alleviate stress and discomfort.
Criterion A is inexplicably limited to natal males, holding them to a stricter standard of conformity than natal females. It is sexist and discriminatory, as it takes behavior that is normative and even encouraged in mainstream society as healthy for non-trans women and labels it pathological for others. Since the reverse is not mentioned (i.e., labeling females as mentally ill who wear male clothing), this diagnosis seems to unfairly target natal males who are afforded less freedom of dress within contemporary western culture (Lev, 2004).
Transvestic Disorder remains classified as a “paraphilic” sexual disorder, grouped alongside diagnoses such as pedophilia and exhibitionism, behaviors that expressly harm others. This perpetuates false stereotypes of sexual deviance that are used to deny human dignity and civil justice to gender variant and transgender people. Ambiguous language in Criterion A implicates sexual expression “involving” crossdressing as diagnosable, where there may be no causal relationship between clothing and erotic arousal. As it is currently written, both erotic and nonerotic gender expression or crossdressing may be diagnosed as sexual disorder. It is unclear to us why wearing clothing of any kind would qualify as a psychiatric disorder. Moreover, the clinical significance criterion (B) fails to exclude distress or impairment resulting from societal intolerance, promoting false-positive diagnosis of victims of prejudice. For example, job discrimination may be inferred as symptomatic of mental disorder.
For ego-syntonic crossdressers, this diagnosis pathologizes harmless consensual human expression, which may or may not be sexualized, and does not meet any definition of mental illness. For ego-dystonic crossdressers, Transvestic Disorder pathologizes people who are distressed by internalized shame and societal prejudice, very much as the previous diagnosis of Ego-Dystonic Homosexuality in the DSM-III (APA 1980) pathologized victims of social homophobia (APA, 1987, p.426).
Finally, the Transvestic Disorder category is not limited to crossdressers or male-identified people. It also targets transsexual women with a specifier of “autogynephilia,” a deeply offensive label to many transwomen (Serano 2009), promoting a controversial theory that transsexual women transition for reasons of sexual gratification or fetishism rather than harmony with gender identity (Blanchard 1989).
As Professionals Concerned About Gender Diagnoses in the DSM, we ask the Sexual and Gender Identity Disorders Work Group and the APA DSM-5 Task Force to unequivocally reject the proposed Transvestic Disorder diagnosis and remove “transvestism” nomenclature from the DSM-5.
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Blanchard, R. (1989). “The Classification and Labeling of Nonhomosexual Gender Dysphoria,” Archives of Sexual Behavior, v. 18 n. 4, p. 322-323.
Lev, A.I. (2004). Transgender emergence: Therapeutic guidelines for working with gender-variant people and their families. NY: Routledge.
Serano, J. (2009). “Autogynephilia’ and the psychological sexualization of MtF transgenderism,” International Foundation for Gender Education 2009 Conference, Alexandria VA, March 2009, Available online: http://ai.eecs.umich.edu/people/conway/TS/IFGE2009/Disordered_No_More.html#Julia
Winters, K. (2008). Gender Madness in American Psychiatry: Essays from the Struggle for Dignity. CO: GID Reform Advocates, pp. 33-43.