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.
What are the problems with the Gender Identity Disorder diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (DSM)? How are overarching issues of psychiatric stigma and access to medical transition procedures related to specific flaws in the diagnostic criteria and supporting text? The philosopher Jiddu Krishnamurti said,
If we can really understand the problem, the answer will come out of it, because the answer is not separate from the problem.
This is my personal list of the most egregious problems with the current Gender Identity Disorder diagnosis. While far from comprehensive, it is perhaps a starting point for dialogue about how harm reduction of gender nomenclature might be possible in the DSM-V.
- Focus of pathology on nonconformity to assigned birth sex in disregard to the definition of mental disorder, which comprises distress and impairment.
Recent revisions of the DSM increasingly target gender identity and expression that differ from natal or assigned sex as disordered. The current diagnostic criteria for GID in the DSM-IV-TR are preoccupied with social gender role nonconformity, especially for children. Identification with the "other sex," meaning other than assigned birth sex, is described as symptomatic regardless of our satisfaction and happiness with that identification.
- Stigma of mental illness upon emotions and expressions that are ordinary or even exemplary for non-transgender children, adolescents and adults.
Criterion A for Gender Identity Disorder highlights a desire to be treated as, or "frequently passing as," our affirmed gender as pathological. For children, criteria A and B stress ordinary masculine or feminine expression in clothing, play, games, toys, and fantasy as symptoms of mental "disturbance." The supporting text disparages innocent childhood play as disorder, including Barbie dolls, playing house, Batman and "rough-and-tumble" activity, if they violate stereotypes of assigned birth sex. Incredulously, knitting is implicated as a focus of sexual perversion for adult transwomen in the supporting text.
- Lacks clarity on gender dysphoria, defined here as clinically significant distress with physical sex characteristics or ascribed gender role.
The distress of gender dysphoria that necessitates medical intervention is inadequately described in criterion B of the GID diagnosis in the DSM-IV-TR as "discomfort" or "inappropriateness." For children, this often-debilitating pain is obfuscated in the diagnostic criterion, which emphasizes nonconformity to gender stereotypes of assigned birth sex rather than clinically significant distress. Adolescents and adults who believe that we were "born in the wrong sex" meet criterion B on the basis of their belief, even if our gender dysphoria has been relieved by transition or related medical procedures.
- Contradicts transition and access to hormonal and surgical treatments, which are well proven to relieve distress of gender dysphoria.
Social role transition, living and passing in our affirmed gender roles, and desiring congruent anatomic sex characteristics are listed as "manifestation" of mental pathology in criterion A of Gender Identity Disorder. Requests for hormonal or surgical treatment to relieve gender dysphoria are disparaged as "preoccupation" in criterion B and supporting text rather than medical necessity. Evidence of medical transition treatment, such as breast development for transwomen or chest reconstruction for transmen, are described in a negative context as "associated features and disorders" of mental illness in the supporting text.
- Encourages gender-conversion therapies, intended to change or shame one's gender identity or expression.
The DSM is intended as a diagnostic guide without specific treatment recommendations. Nevertheless, the current GID diagnostic criteria are biased to favor punative gender-conversion "therapies." For example, gender variant youth, adolescents or adults who have been shamed into the closet, forced into concealing our inner gender identities, no longer meet the diagnostic criteria of Gender Identity Disorder and are emancipated from a label of mental illness.
- Misleading title of "Gender Identity Disorder," suggesting that gender identity is itself disordered or deficient.
The name, Gender Identity Disorder, implies "disordered" gender identity -- that the inner identities of gender variant individuals are not legitimate but represent perversion, delusion or immature development. In other words, the current GID diagnosis in the DSM-IV-TR implies that transwomen are nothing more than mentally ill or confused "men" and vice versa for transmen.
- Maligning terminology, including "autogynephilia," which disrespects transitioned individuals with inappropriate pronouns and labels.
Maligning language labels gender variant people by our assigned birth sex in disregard of our gender identity. In other words, affirmed or transitioned transwomen are demeaned as "he" and transmen as "she." It appears throughout the diagnostic criteria and supporting text of the GID diagnosis in the current DSM-IV-TR, where affirmed roles are termed "other sex," transsexual women are called "males" and "he" [p. 577], and transsexual men as "females." Such demeaning terms deny our social legitimacy and empower defamatory social stereotypes like "a man in a dress," in the press, the courts, our workplace and our families.
- False positive diagnosis of those who are no longer gender dysphoric after transition and of gender nonconforming children who were never gender dysphoric.
There is no exit clause in the diagnostic criteria for individuals whose gender dysphoria has been relieved by transition, hormones or surgical treatments, regardless of how happy or well adjusted with our affirmed gender roles. The diagnosis is implied "to have a chronic course" for adults [p. 580], despite transition status or absence of distress. Children may be diagnosed with Gender Identity Disorder, solely on the basis of gender role nonconformity, without evidence of gender dysphoria. Criterion A requires only four of five listed attributes, and four of those describe violation of gender stereotypes of assigned birth sex. The fifth, describing unhappiness with birth sex, is not required to meet criterion A. Criterion B may be met by "aversion toward rough-and-tumble play and rejection of male stereotypical toys..." for natal boys and "aversion toward normative feminine clothing" for natal girls.
- Conflation of impairment caused by prejudice with distress intrinsic to gender dysphoria.
Criterion D of the GID diagnosis, the clinical significance criterion, was intended to require clinically significant distress or impairment to meet the accepted definition of mental disorder. Unfortunately, it fails to distinguish intrinsic distress of gender dysphoria from that caused by external societal intolerance. Lacking clarity in criterion D, prejudice and discrimination can be misconstrued as psychological impairment for gender variant individuals who are not distressed by our physical sex characteristics or ascribed gender roles.
- Placement in the class of sexual disorders.
In 1994, Gender Identity Disorders were moved from the class of "Disorders Usually First Evident in Infancy, Childhood or Adolescence," to the section of sexual disorders in the DSM-IV, renamed "Sexual and Gender Identity Disorders." This reinforces stereotypes of sexual deviance for gender variant people.
The DSM-V Task Force has an opportunity to address these shortcomings in the current GID diagnosis. I hope that this list can help provide a way to evaluate proposals for less harmful diagnostic nomenclature in the Fifth Edition of the DSM.
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.