Editors' note: Kelley Winters, Ph.D. is a writer on issues of transgender medical policy, founder of GID Reform Advocates and an Advisory Board Member for the Matthew Shepard Foundation and TransYouth Family Advocates. She has presented papers on the psychiatric classification of gender diversity at the annual conventions of the American Psychiatric Association, the American Counseling Association and the Association of Women in Psychology.
On May 9th and 23rd, the American Psychiatric Association (APA) issued statements on "GID and the DSM," repeating that,
It is important to recognize that the DSM is a diagnostic manual and does not provide treatment recommendations or guidelines."
This was in response to concern from the transgender community and allies that the current "gender identity disorder" (GID) diagnosis is biased to facilitate gender-conversion therapies.
These are punitive psychotherapies attempting to change the gender identities of gender variant youth and adults, exemplified in a May 7 National Public Radio interview of Dr. Kenneth Zucker (chairman of the DSM-V Sexual and Gender Identity Disorders work group) which described his therapy regimen for a gender-nonconforming child he diagnosed with gender identity disorder:
Bradley would no longer be allowed to spend time with girls. He would no longer be allowed to play with girlish toys or pretend that he was a female character. Zucker said that all of these activities were dangerous to a kid with gender identity disorder.
Such harsh shame and punishment, for behaviors which would be ordinary or exemplary for other children assigned female at birth, drew outrage from many transitioned individuals who themselves were forced to grow up in painfully incongruent gender roles.
A joint statement from the National Center for Trangender Equality and other leading advocacy organizations echoed broad concern about gender-conversion and sexual-orientation-conversion therapies:
It is inconceivable that in the 21st century any credible scientist or medical professional would recommend any discredited treatment that would attempt to change a person's core gender identity or sexual orientation. Such treatments have no empirical basis and are harmful.
However, the APA's denial of any treatment guidance in the Diagnostic and Statistical Manual of Mental Disorders, (DSM) has been repeated often and is stated bluntly on the APA DSM FAQ page,
No information about treatment is included.
But does repeating a thing often enough make it true? In fact, diagnostic nomenclature and treatment are inseparably intertwined. This is because the efficacy of all drug and psychotherapy treatments are judged according to specific diagnostic criteria listed in the DSM and ICD.
For example, it stands to reason that the efficacy and marketability of a psychopharmacological product could be expediently improved by tweaking DSM diagnostic criteria to favor its strengths. In response to concerns of influence by drug manufacturers on diagnostic nomenclature, the APA requires disclosure of financial ties to pharmaceutical corporations by members of the DSM-V Task Force.
What does the the current DSM-IV-TR imply about gender-conversion treatment? Kids and adults driven deep in the closet by gender-conversion therapies no longer meet the four diagnostic criteria for GID and are emancipated from diagnosis of mental disorder. On the other hand, affirmed youth and adults who are happy and well-adjusted after transition remain diagnosable with GID and suffer stigma of mental illness and sexual deviance for the rest of their lives.
Children may be diagnosed with GID strictly on the basis of gender nonconformity, without evidence of gender dysphoria or distress with assigned birth sex (criteria A,B). Adults and adolescents are implicated with "disordered" gender identity so long as they identify with or pass as other than their assigned birth sex or believe that they were "born the wrong sex" (criteria A,B). Furthermore, current GID criteria fail to clarify that clinically significant distress or impairment, the basis for defining mental illness in the DSM, should exclude societal or family prejudice or intolerance (criterion D). Therefore, discrimination itself can be used as a basis to label transitioned or gender nonconforming victims as mentally ill.
The APA statement also mentioned the appointment of a new task force, separate from the DSM effort, to "review the scientific and clinical literature on GID treatment." At this date* it is not known who is on this treatment task force or what kinds of treatment it will favor. In any case, the problem of treatment bias within the GID diagnostic criteria remains unaffected by the efforts of a separate APA treatment task force.
While the current GID diagnostic criteria do not explicitly recommend gender-conversion therapy, they are certainly biased to favor that harmful treatment approach and to contradict the legitimacy of transition. This is a major reason the DSM-V is of great importance to the transgender community and supportive mental health care providers. I hope that the DSM-V Task Force will move beyond denial and beyond archaic gender stereotypes in drafting new diagnostic nomenclature that does not harm those it is intended to help.
For full citations, please check out the original version of this blog post at Kelley's site. For more information about her project, visit GID Reform Advocates.
*This article on the relationship between GID diagnosis and treatment was originally posted June 16, 2008.