Professionals Concerned with Gender Diagnoses in the DSM

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Introduction

with 3 comments

We are an interdisciplinary and international group of 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). We call ourselves Professionals Concerned With Gender Diagnoses in the DSM. We collectively represent many years of academic study and research working with topics related to gender variance, as well as many years of clinical experience in working with people who identify and/or have experience and/or history as transgender, transsexual, and/or gender nonconforming. Many of us are trans ourselves and all of us are committed to ending the discrimination faced by trans people worldwide.

The American Psychological Association and the National Association of Social Workers have made clear public statements that discrimination against trans people should be eliminated (APA, 2009; NASW, 2009), and the American Medical Association has affirmed that trans medical treatment should be seen as medically necessary (AMA, 2008). We believe that the current diagnoses in the DSM IV-TR are pathologizing and that this increases the negative treatment towards trans people (Lev, 2004, 2005; Winters, 2005, 2008); we also recognize the hard work of the DSM-5 subworkgroup for gender identity disorders to examine gender-related diagnoses and attempt to develop diagnostic criteria that are less pathologizing and more scientifically accurate.

Our group was formed for the explicit purpose of offering constructive recommendations to the DSM-5 Task Force and its relevant work groups. What we offer to you here is derived from many hours of discussion and review of the existing literature to reach consensus and to offer scientifically sound recommendations.

Our underlying premise is that gender is not an immutable binary system. Instead, we understand gender to be a spectrum rather than a dichotomy and that all human beings, not just the gender nonconforming or transgender child or adult, carry within them the socially constructed attributes of both the “feminine” and the “masculine” along with characteristics that defy any such binary categorization. Gender fluidity can exist within a person at a point in time or over the course of development throughout life. We equate gender nonconformity with health, not pathology, and see the role of the mental health professional as the facilitator of an individual’s unique gender authenticity, which at root can be determined only by that individual alone. We also acknowledge that there is nothing wrong with a gender identity that is firmly male or female, regardless of a person’s assigned sex at birth, and regardless of whether a given individual needs to access medical treatment to actualize her or his gender identity. We call on the field of mental health to predicate their clinical practices on a theory of gender development and functioning that respects variation in human development more than the desire to create a falsely symmetrical metaphysics of gender that deems as pathological any deviations from a socially imposed gender-binary system.

We recognize that the inclusion of Gender diagnoses in the DSM is extremely controversial, and all of us have been engaged personally and professionally in the reform process of these diagnoses. The American Psychiatric Association is unlikely to remove these (or alternative gender-related) diagnoses from the DSM-5. Therefore, we have worked hard to assist in the development of the least noxious criteria that will support trans people throughout the international community in receiving medical and clinical services, should they be needed.

We are addressing a number of areas of recommendations including: suggestions for further reform of the GID/GI diagnosis, specific suggestions for a separate adolescent diagnosis, and reform of the child diagnosis. Additionally, we suggest the removal of Transvestic Disorder from the DSM, and also recommend eliminating the need to specifically mention intersex people in the diagnostic criteria.

We think it is essential that language that pathologizes diverse gender expressions, identity, and consensual or private individual expressions of sexuality be removed from a manual of psychiatric disorders. Alternative diagnostic categories could be used to identify the distress and dysphoria that sometimes accompanies gender diversity within restrictive and oppressive cultures. This includes, adjustment disorders, depression and dysthymia, and anxiety disorders. We would like to point out that there are other medical conditions, ranging from diabetes to cancer, which can result in the need for therapy but which do not have their own separate psychiatric diagnostic labels. The same is true for some emotion-based conditions such as variations of grief.

We would also advise the DSM-5 sexual and gender identity disorders work group to remember that many clinicians using the DSM may not have knowledge or awareness of the many natural cross-cultural variations of gender, the fact that many cultures recognize more than two genders as normative (Blackwood & Wiering, 1999; Mahalingham, 2003; Roscoe, 1993; Whitam & Zent, 1984) or the fact that many people of trans or gender variant experience/identity/history do not conform to gender stereotypes for the gender with which they identify (Bartlett & Vasey, 2006; Ember & Ember, 2004; Halberstam, 1998; Nestle, Wilchins, & Howell, 2002). We also assert the unscientific and inaccurate nature of describing trans people’s gender identities and sexual orientations based on their assigned gender or sex, rather than on their self-identified gender identity. We ask the work group to address these issues in a sensitive and thoughtful manner. While the DSM is not a treatment manual, diagnostic criteria contained in DSM inform treatment and approaches toward trans individuals. We ask that the work group include clear language to address the above concerns in DSM-5.

References

American Medical Association. (2008). Resolution 122, Removing barriers to care for transgender patients. Chicago, IL: Author. Available online: http://www.ama-assn.org/ama1/pub/upload/mm/16/a08_hod_resolutions.pdf

American Psychological Association, Task Force on Gender Identity and Gender Variance. (2009). Report of the task force on gender identity and gender variance. Washington, DC: Author.

Bartlett, N. H., & Vasey, P. L. (2006). A retrospective study of childhood-atypical behavior in Samoan Fa’afafine. Archives of Sexual Behavior, 35(6), 659-666.

Blackwood, E. & Wiering, S.E (Eds.) (1999). Same-sex relations and female desires: Transgender practices across cultures. NY:Columbia University Press.

Cromwell, J. (1999). Transmen and FTMs : Identities, bodies, gender and sexualities. Champaign, IL: University of Illinois.

Ember, C. R, & Ember, M. (2004). Encyclopedia of Sex and Gender: Men and Women in the world’s cultures. New York, NY: Springer.

Halberstam, J. (1998). Female masculinity. Durham NC: Duke Press.

Lev, A. I. (2004). Transgender emergence: Therapeutic guidelines for working with gender-variant people and their families. Binghampton, NY: Haworth.

Lev, A. I. (2005). Disordering gender identity: Gender Identity Disorder in the DSM-IV-TR. Journal of Psychology & Human Sexuality, 17, 35-70.

Mahalingam, R. (2003). Essentialism, culture and beliefs about gender among the Aravanis of Tamil Nadu, India. Sex Roles, 49, 489-496.

National Association of Social Workers. (2009). Social Work Speaks: National Association of Social Workers Policy Statements, 2009-2012 (8th ed.). Washington, DC: NASW Press.

Roscoe, W. (1993). How to become a berdache: Toward a unified analysis of gender diversity. In G. Herdt (Ed.). Third sex third gender: Beyond sexual dimorphism in culture and history (pp. 329-372). New York, NY: Zone Books.

Nestle, J., Wilchins, R., & Howell, C. (2002). GenderQueer: Voices from beyond the sexual binary. LA: Alyson Publications.

Whitam, F. L. & Zent, M. (1984). A cross-cultural assessment of early cross-gender behavior and familial factors in male homosexuality. Archives of Sexual Behavior, 13, 427-439.

Winters, K. (2005). Gender dissonance: Diagnostic reform of Gender Identity Disorder for adults. Journal of Psychology & Human Sexuality, 17, 71-90.

Winters, K. (2008). Gender madness in psychiatry: Essays from the struggle for dignity. Dillon, CO: GID Reform Advocates.

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Written by gidworkgroup

March 29, 2010 at 11:19 am

3 Responses

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  1. Great work.
    On the vexed issue of reforming DSM versus getting rid of any mental disorder diagnosis – Meyer-Bahlburg suggested (see below) that a special section should be created to recognise the unusual situation of “GIV” – but the sub workgroup has not taken that up.
    I think that is a good lever to work on – supporting one of the sub workgroup member’s suggestions.
    riki

    Meyer-Bahlburg, Heino. 2009. From Mental Disorder to Iatrogenic Hypogonadism: Dilemmas in Conceptualizing Gender Identity Variants as Psychiatric Conditions. Archives of Sexual Behavior, http://dx.doi.org/10.1007/s10508-009-9532-4

    The Gender Incongruence
    text would explain the unusual status of the GIV condition
    between psychiatry and non-psychiatric medicine in need of
    specialized mental-health and medical services, but not
    classify it as a psychiatric disorder per se. This formulation
    will probably reduce the stigma potential of the label. On the
    other hand, the retention of a special category for GIV in the
    DSM will make it more likely that health and mental-health
    service providers identify children with GIV early, which
    then provides opportunities for early needs assessment and
    access to care including transpositive, i.e., cross-gender
    supportive approaches (Bockting & Ehrbar, 2005; Cohen-
    Kettenis, 2001), and that anti-discrimination efforts continue
    to be supported. If the overall DSM-IV structure should be
    carried over into DSM-V, ‘‘Gender Incongruence’’ would
    have to be placed under ‘‘Other Conditions that May be a
    Focus of Clinical Attention,’’ but its insurance coverage
    would need to be explicitly backed by respective declarations
    of professional organizations such as the American Medical
    Association and the American Psychiatric Association.

    riki lane

    April 11, 2010 at 10:51 am

  2. Thank you for your work. The NASW National Commitee on LGBT Issues (NCLGBTI)are also preparing a statement. Hoepfully, all the comments with provide for a reconsideration of the DSM5 diagnostic criteria.

    Linda Mockeridge, LCSW

    April 12, 2010 at 8:38 pm

  3. I want to thank all of you for taking on this most important work.
    Also, there is a typographical error in paragraph 2 line 2
    read: discriminate for discrimination

    Amy Hunter

    April 21, 2010 at 2:59 pm


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