Professionals Concerned with Gender Diagnoses in the DSM

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Statement on Gender Incongruence in Adults in the DSM-5

with 6 comments

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 Gender Incongruence (in adults) diagnosis in the DSM V.

Our group of scholars struggled with the section of Gender Identity Disorder of Adulthood and new recommendations for Gender Incongruence (in adults). Many of us were concerned about the inclusion of this diagnosis in any form and would prefer to have it removed. All of us agreed that if the diagnosis remains it must reflect a non-pathologizing, trans-positive health approach.

In general, our group supports the change from Gender Identity Disorder to Gender Incongruence, and we are pleased with the range of “alternative genders” acknowledged and the removal of the sexual orientation subtypes. However, we feel that incongruence should be clearly defined to exclude gender role nonconformity. We also think that clarification is needed distinguishing those who should be diagnosed from those who should not, or should no longer, be diagnosed, especially for those who have resolved their gender incongruence through social and/or medical transition.

Our group does not believe that replacing the term “assigned gender” for “sex” provides a clear exit for those whose gender dysphoria has been relieved. Since less than 1% of post-surgical clients report gender dysphoria (Kuiper & Cohen-Kettinis, 1998; Pfafflin, 1992), the focus should remain on actual dysphoria (distress or discomfort), not on conformity or congruence with “assigned gender.” For example, a post-surgical client who no longer feels gender dysphoric may experience/express gender in ways that differ from social stereotypes of the new affirmed gender role. The criteria should clearly exclude diagnosis when gender alignment is achieved. Additionally, actual completion of surgery should not be a requirement for release from a diagnosis of Gender Incongruence. Many FTM men (Cromwell, 1999; Rachlin, 1999) and MTF women are denied access to surgical transition treatments for financial, health and other reasons. Many others achieve gender alignment with social transition alone or with a combination of hormonal and/or surgical transition treatment.

We recommend that a specific statement be made about how to use this diagnosis. The DSM should direct clinicians to use this diagnosis for the purposes of assisting people in achieving legal and social recognition of transgender individuals consistent with their gender identity and expression (APA, 2009). The DSM should include specific instructions to clinicians that when people’s sexual orientations and gender expression do not conform to norms for their gender identity, their experienced/expressed gender identity should still be recognized as valid. The DSM should make clear that gender customs vary widely across cultures, and clinicians must consider the limits of their cultural competence when evaluating people for a diagnosis of Gender Incongruence.

Our group believes that Indicator 3 (a strong desire for the primary and/or secondary sex characteristics of the other gender) reinforces a binary gender model and should be removed. Winters (2008) suggests a change in “maligning terminology” that disrespects the affirmed gender roles of transitioned individuals and reduces them to their assigned birth sex. This refers to a lack of sensitivity often found in the language of transgender research, including misuse of pronouns and terms such as “the other sex.” For example, transwomen, who have transitioned to affirmed social roles, are termed throughout the supporting text of the current DSM-IV-TR GID diagnosis as “men” or “males,” while transmen are wrongly called “women” or “females.” In keeping with the rationale provided by the working group, we believe there should be respect for the spectrum of gender expressions (Vanderburgh, 2007). The word “other” reinforces a male-female dichotomy and should be removed.

We believe that Indicator 6 (a strong conviction that one has the typical feelings and reactions of the other gender) is vague and should be removed. Endorsements of traditional masculine and feminine norms vary considerably among racial and ethnic groups, nationalities, life-stages, genders, and sexual orientations (Kimmel, 2004; Levant & Richmond, 2007), and, within multicultural settings, there are differences in degree of tolerance and acceptance of gender variance. The feminist movement in the United States challenged traditional feminine norms, which has resulted in highly variable role expectations for girls and women. Attempts to satisfy such expectations have become an increasingly difficult process, where role expectations and behaviors vary by social context (Gillespie & Eisler, 1992; O’Neil, Good, & Holmes, 1995). The notion that there are “typical feelings and reactions” associated with a specific gender group is not consistent with research and is entirely too simplistic and stereotypical.

Our group also believes that qualifiers regarding Disorders of Sexual Development should be removed. The Disorder of Sexual Development subtypes send an implicit message that having a developmental variation related to sexual physiology is a subset of being Gender Incongruent. We believe that the supporting text should describe the fact that some people with intersex variations desire medical transition treatments. However, we do not believe that intersex condition subtypes would add anything to the diagnostic framework. Additionally, the subtypes may potentially lack validity/reliability, since most social workers, counselors and psychologists are not trained to diagnose intersex conditions and most people do not know with certainty what sex chromosomes they have.

Again, we feel that the diagnostic criteria should focus on anatomical distress or distress with current ascribed gender role, because it is discomfort, not a particular gender identity or expression, that is the psychological issue. Gender dysphoria may also be manifested by distress or discomfort with deprivation (Vitale 2001) of social role or anatomy that is congruent with experienced gender identity. Experienced gender is not limited to fixed binary roles, but may encompass fluidity, masculinity, femininity, both, or neither.

It is important to note that social role transition, or Real Life Experience (WPATH 2001), and hormonal treatment may have diagnostic value in clarifying gender dysphoria. While transition to an affirmed social role may relieve the distress of gender role dysphoria, individuals may still suffer anatomic dysphoria, or distress with their current physical sex characteristics. It must be carefully stated that the diagnostic threshold is distress related to physical sex characteristics or ascribed current gender role and not gender expression that is nonconforming to social expectations of the ascribed current gender role or natal sex.

Finally, we suggest restoration of a clinical significance criterion, which would clarify that distress, discomfort or impairment must meet a threshold of severity. This would limit false positive diagnosis of gender nonconforming adults who would not benefit from diagnosis. It is crucial, however, that this criterion exclude distress or impairment that is caused by societal prejudice or discrimination. To cast victimization as symptomatic of mental illness would inflict further harm upon victims of prejudice.

Our Suggested Diagnostic Criteria for Gender Incongruence in Adults:

A. A distressing sense of incongruence between persistent experienced or expressed gender and current physical sex characteristics or ascribed gender role in adults, as 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 ascribed gender role or natal sex.

    1. A distress or discomfort with living in the present gender or being perceived by others as the present gender, which is distinct from the experiences of discrimination or the societal expectations associated with that gender.

    2. A distress or discomfort caused by deprivation of gender expression congruent with persistent experienced gender. Experienced gender may include alternative gender identities beyond binary stereotypes.

    3. A distress or discomfort with one’s current primary or secondary sex characteristics that are incongruent with persistent experienced gender.

    4. A distress or discomfort caused by deprivation of primary or secondary sex characteristics that are congruent with persistent experienced gender.

B. Distress or discomfort is clinically significant or causes impairment in social, occupational or other important areas of functioning, and is not due to external prejudice or discrimination.

References

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.

Cohen-Kettenis, P. et al. (2010). “Gender identity disorder in adolescents or adults,” American Psychiatric Association DSM-5 Development. Available online: http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=482#

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

Gillespie, B. L., & Eisler, R. M. (1992). Development of the feminine gender role stress scale: A cognitive-behavioral measure of stress, appraisal, and coping for women. Behavior Modification, 16, 426-438.

Kuiper, A. J., & Cohen-Kettenis, P. T. (1998). Gender role reversal among postoperative transsexuals. International Journal of Transgenderism, 2, 1.

Levant, R. F., & Richmond, K. (2007). A review of research in masculinity ideologies using the Male Role Norms Inventory. Journal of Men’s Studies, 15, 130-146.

O’Neil, J. M., Good, G. E., & Holmes, S. (1995). Fifteen years of theory and research on men’s gender role conflict: New paradigms for empirical research. In R. F. Levant & W. S. Pollack (Eds.). A new psychology of men (pp. 164-206). New York, NY: Basic Books.

Pfäfflin, F. (1992). Regrets after sex reassignment. Journal of Psychology & Human Sexuality, 5, 69-85.

Rachlin, K. (1999). Factors Which Influence Individual’s Decisions When Considering Female-To-Male Genital Reconstructive Surgery. International Journal of Transgenderism, 3, 1.

Vanderburgh, R. (2007). Transition and beyond: Observations on gender identity. Portland, OR: Q Press.

Vitale A. M., (2001). Implications of being gender gysphoric: A developmental review, Gender and Psychoanalysis, An Interdisciplinary Journal, 6(2), 121-141.

Winters, K. (2008). Maligning terminology in the DSM: The language of oppression: GID Reform Advocates essay series on gender diagnoses in the DSM-5. Available on-line: http://www.gidreform.org/blog2008Jun24.html

World Professional Association for Transgender Health (2001). Standards of Care for Gender Identity Disorders Sixth Version, Available online: http://wpath.org/Documents2/socv6.pdf

Written by gidworkgroup

March 30, 2010 at 5:28 am

6 Responses

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  1. This is good work. I have only two comments:
    1) In paragraph #1, the phrase “Gender Incongruence (in children)” appears to be a typographical error.
    2) In paragraph #6 regarding “maligning terminology,” in addition to referencing researchers’ “misuse of pronouns,” it would be helpful to state more plainly that transmen should not be referred to as “transsexual females/women,” and that transwomen should not be referred to as “transsexual males/men.”

    E. Tristan Booth

    April 8, 2010 at 5:03 pm

  2. This looks really well written. One minor point: The second half of the sentence “Additionally, actual completion of surgery should not be a requirement for release from a diagnosis of Gender Incongruence, as FTM men rarely complete lower genital surgery, due to the cost of the procedure and the questionable outcomes (Cromwell, 1999; Rachlin, 1999).” implies that only transmen have valid reasons for not having surgery. There are valid reasons for transwomen to be non-op as well, and this should be stated (or the second half deleted.) In general, surgery should only occur for valid medical or mental health reasons, not for legal reasons or to check off a box.

    Mary Ann Horton

    April 8, 2010 at 7:18 pm

  3. I am glad that there is a dedicated group of professionals taking this issue on. My only comment is in reference to the statement made about FTM bottom surgery resulting in “questionable oucomes” cited by Cromwell and Rachlin, both, in 1999. In the past ten years there has been considerable progress made in surgical procedures, which has manifested in aesthetically and functionally satisfying surgical outcomes for transmen.

    Zander Keig

    April 9, 2010 at 4:03 am

  4. Thanks, Tristan, Mary Ann and Zander. We have clarified the statements that you noted.

    Kelley Winters
    GID Reform Advocates
    kelley@gidreform.org

    gidworkgroup

    April 9, 2010 at 7:15 am

  5. Thank you for this statement. I have one very minor typographical error to point out, otherwise this statement is very clear and hits on the major points that need to be amended in the DSM-5 revision. Paragraph five opens, “We recommend that a specific statement be made about how _to use of_ this diagnosis.” This sentence contains a simple editing error that needs to be corrected. I have set it apart with _underscores_ to highlight it. Thank you again for this excellent work.

    Ruben Hopwood

    April 10, 2010 at 2:16 pm

    • Thanks so much, Ruben, for letting us know. We have made the correction.

      Kelley Winters

      gidworkgroup

      April 10, 2010 at 3:36 pm


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