Antonia D'orsay

Compromise 2 - Analysis of the DSM-5 PRs

Filed By Antonia D'orsay | February 13, 2010 3:30 PM | comments

Filed in: The Movement, Transgender & Intersex
Tags: Cohen-Kettenis, Columbia, DSM V, Gender Incongruence, ICD-10, ICD-11, psychiatry, Psychology, trans, trans awareness, trans kids, trans portrayals, trans youth, transgender, transgender counseling, UN, United Nations, WHO, World Health Organization

This is part two of a series of columns analyzing the impacts of the DSM-V revisions on LGBT people.

The proposed revisions to the DSM-V are out, and they are a startling compromise. If compromise is the art of given two sides what they want to a point where no one is happy, then this one succeeds admirably.

Last time we looked at Nomenclature, this time we will look at Criteria - or, as some might say, what makes someone gender incongruent. And what we see is that the criteria are extremely broad. So broad that you may even be gender incongruent (and there's nothing wrong with that).

The Criteria put forth in the Diagnostics are, of course, of great import. Not so much to those who have already been diagnosed under various versions in the past and even in the near future, but absolutely for those diagnosed in the years to come.

When looking at criteria, one of the tasks given to the team is to fit the proposed reasons for the revisions in the first place. This is not, as some might think, about revising the category in which Gender Incongruence falls, but rather about the classifications and structure and purpose of the manual as a whole. Recent discussion with a similar tone to the trans community's complaints about the DSM have come from those working in fields such as Autism, Alzheimer's, and Social Disorders. All of them - and more - are affected by these changes, and they are very overarching.

One of the things that it was felt important to return to was:

No information about treatment is included in DSM.  While determining an accurate diagnosis is a first step for the clinician in defining a treatment plan for a patient, DSM contains no recommendations on what that course of treatment should be. That said, DSM is certainly important to those who provide treatment to patients with mental illness, because accurate diagnosis leads to appropriate treatment.

So it is important to note that the DSM does not deal in "how" something is dealt with, only in identifying the particular aspects of a specific diagnosis.

This is critical, because a great many of the fears often spoken about regarding the DSM deal in "well, how does this affect the way I will be treated?". Trans folk are concerned about the impact of things like hormone prescriptions, surgeries, and so forth.  There are also those who are claiming that the DSM says that surgery cures one - this is incorrect.  It does not, and, indeed, is explicitly not able to do so.  It can, however, say that after treatment - whatever that treatment may be - they are cured.

What determines the treatment is subject to a lot of other factors, and the organization that most heavily impacts the lives of trans folk in the United States is the World Professional Association for Transgender Health, or WPATH.  WPATH is the organization that is charged with developing the Standards of Care. It just so happens that many members of the team that developed the Revisions here are members of the WPATH. Several of the researchers and people mentioned in previous articles are even past presidents of the organization (the current president is Walter O. Bockting). The members of WPATH work with trans folk on a fairly continuous basis, and in general are responsible for the changes we see presented now in the proposed revisions.

So they will most likely be the same people writing the treatment guidelines, and in light of that, there can be some idea of what it is that will ultimately change within the standards of care currently in place, but given the dramatic shift involved, making any guesses at this point is a crapshoot, in part because the stuff noted here, in the proposed revisions' overall guidelines:

The current process for revising DSM has been guided by four principles.  First, the highest priority is clinical utility - that is, making sure the manual is useful to those who diagnose and treat patients with mental illness, and to the patients being treated.  Second, all recommendations should be guided by research evidence. Third, whenever possible, DSM-5 should maintain continuity with previous editions. And fourth, no a priori restraints should be placed on the level of change permitted between DSM-IV and DSM-5.  The third and fourth principles may seem contradictory, but both principles are necessary - those charged with revising the manual must carefully consider the impact that any changes would have on clinical practice, disorder prevalence and other important factors, while at the same time, considering the diagnostic advances that would be made through implementation of new scientific knowledge and clinical understanding.

In revising DSM, work groups (made up of global experts in various areas of diagnosis) have looked at what elements of the current edition (DSM-IV) are working well, what elements do not meet the needs of clinicians and how best to correct those concerns.  For example, the work groups are determining how to better assess the severity of symptoms and how to handle psychiatric disorders that often occur together in the same patient (called co-occurring disorders), such as anxiety and depression. They are focusing on reducing diagnoses currently called "Not Otherwise Specified" in DSM-IV and on improving diagnostic criteria that are not precise.  The work groups are also aiming to better specify "treatment targets" for clinicians - helping them identify those symptoms that should be addressed in treatment and for which improvement may be possible.

Additionally, the DSM-5 Task Force has focused on how to include assessment of common symptoms that are not addressed within the diagnostic criteria for a specific illness (for example, symptoms of insomnia that may be experienced by a patient with schizophrenia). One way of addressing these issues is through cross-cutting dimensional assessments.

Given the aspect of looking at what works and what doesn't, and the degree of change involved - especially in light of the tasks of using dimensional assessments and reduction of NOS as well as severity assessment - demonstrates that the current system is considered by the authors to be broken, and quite lacking in the aspects being sought (something I agree with).

The criteria now offered are 6 points, and any 2 of them can used to diagnose gender incongruence, and one significant change made is that there is no longer a requirement that there be any kind of distress or impairment involved.

An example of stress or impairment is the oft heard statement that "I just *had* to have surgery or I'd kill myself". However, there are multiple other forms of persons with Gender Incongruence for whom that surgical aspect is not critical, and for whom functioning in their lives is not a problem.  These people lack a clinically significant degree of impairment or stress about themselves, and so have historically been subject to a lack of treatment.

An example here would be the rare but still present person assigned male and masculine at birth, who enjoys and excels in their life as a male, but still possesses an extreme sense of bodily discomfort or dysphoria (what some have called a somatic transsexual as opposed to a social transsexual or the combined somatic and social transsexuals such as myself). So for them, surgical options are needed, but they do not need to "transition" from one social gender role and expression to another.  You have men who were born men and identify as men, but have modified their bodies to that of a female. Under the current criteria, these people have had to resort to ways and methods outside the mainstream systems for treatment, placing themselves at risk in doing so, since they cannot get treatment through "regular" channels.

This is reflected in two parts:

2. (e) we have proposed that the "distress/impairment" criterion not be a prerequisite for the diagnosis of GI (see Endnote 15);


15. It is our recommendation that the GI diagnosis be given on the basis of the A criterion alone and that distress and/or impairment (the D criterion in DSM-IV) be evaluated separately and independently. This definitional issue remains under discussion in the DSM-V Task Force for all psychiatric disorders and may have to be revisited pending the outcome of that discussion. Although there are studies showing that adolescents and adults with the DSM-IV diagnosis of GID function poorly, this type of impairment is by no means a universal finding. In some studies, for example, adolescents or adults with GID were found to generally function psychologically in the non-clinical range (Cohen-Kettenis & Pfäfflin, 2009; Meyer-Bahlburg, 2009a). Moreover, increased psychiatric problems in transsexuals appear to be preceded by increased experiences of stigma (Nuttbrock et al., 2009). Postulating "inherent distress" in case one desires to be rid of body parts that do not fit one's identity is, in the absence of data, also questionable (Meyer-Bahlburg, 2009a).

Some things to note here that are important.  The authors are not saying that transsexuals are everyone affected herein.  Indeed the specifically call out transsexuals separately from other trans folks for "increased psychiatric problems" as the direct result of stigma.  Concepts of privilege play into this stigma as well. In short, it is not too far off from the truth to say that cis folk drive us crazy (if I can be forgiven the ableism inherent there). Literally.

They are also saying that issues other than GI that impact a person in terms of impairment or stress be looked at without any regard to the GI as the primary cause, meaning that they are not technically co-morbidities, or something that is off about them due to the GI.

That said, the new criteria are:

1. a marked incongruence between one's experienced/expressed gender and primary and/or secondary sex characteristics (or, in young adolescents, the anticipated secondary sex characteristics) [13, 16]

The rationales for this one are described thusly:

13. In the DSM-IV, there are two sets of clinical indicators (Criteria A and B). This distinction is not supported by factor analytic studies. The existing studies suggest that the concept of GI is best captured by one underlying dimension (Cohen-Kettenis & van Goozen, 1997; Deogracias et al., 2007; Green, 1987; Johnson et al., 2004; Singh et al., 2010).

Meaning that in the current system, there's simply no basis scientifically to support the basis that a person with gender incongruence has both a strong and persistent cross-gender identification (not merely a desire for any perceived cultural advantages of being the other sex) and a Persistent discomfort with his or her sex or sense of inappropriateness in the gender role of that sex. Or, from a trans woman's perspective, the DSM-IV authors were making it up as they went along.


16. Although the DSM-IV diagnosis of GID encompasses more than transsexualism, it is still often used as an equivalent to transsexualism (Sohn & Bosinski, 2007). For instance, a man can meet the two core criteria if he only believes he has the typical feelings of a woman and does not feel at ease with the male gender role. The same holds for a woman who just frequently passes as a man (e.g., in terms of first name, clothing, and/or haircut) and does not feel comfortable living as a conventional woman. Someone having a GID diagnosis based on these subcriteria clearly differs from a person who identifies completely with the other gender, can only relax when permanently living in the other gender role, has a strong aversion against the sex characteristics of his/her body, and wants to adjust his/her body as much as technically possible in the direction of the desired sex. Those who are distressed by having problems with just one of the two criteria (e.g., feeling uncomfortable living as a conventional man or woman) will have a GIDNOS diagnosis. This is highly confusing for clinicians. It perpetuates the search for the "true transsexual" only, in order to identify the right candidates for hormone and surgical treatment instead of facilitating clinicians to assess the type and severity of any type of GI and offer appropriate treatment. Furthermore, in the DSM-IV, gender identity and gender role were described as a dichotomy (either male or female) rather than a multi-category concept or spectrum (Bockting, 2008; Bornstein, 1994; Ekins & King, 2006; Lev, 2007; Røn, 2002). The current formulation makes more explicit that a conceptualization of GI acknowledging the wide variation of conditions will make it less likely that only one type of treatment is connected to the diagnosis. Taking the above regarding the avoidance of male-female dichotomies into account, in the new formulation, the focus is on the discrepancy between experienced/expressed gender (which can be either male, female, in-between or otherwise) and assigned gender (in most societies male or female) rather than cross-gender identification and same-gender aversion (Cohen-Kettenis & Pfäfflin, 2009).

What they are saying here is that the current system more or less requires a person to be a transsexual to get a diagnosis of 302.85 (so, if you have that, you are a transsexual, under the current system). On the other hand, so is a butch woman.

This conflicts with the fact that a transsexual person is obviously different from a butch woman, and also the other types of trans folk that are supposed to be included in the diagnosis, but only have part of the whole (one half or the other in the current).

This makes the job of a therapist more difficult and affects their ability to properly aid and treat those with less severe degrees of the same problem that afflicts transsexuals.

Lastly, they point out directly that in the current system, there are only men and women, and nothing in between, when, in reality,  people are all over the map (as I explained previously), since gender is a multiple category or spectrum based thing, without an either/or basis. With this in mind, they changed the way that this entire section deals with that, and allow for a greater understanding on the part of therapists.

2. a strong desire to be rid of one's primary and/or secondary sex characteristics because of a marked incongruence with one's experienced/expressed gender (or, in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics) [17]

This one deals with Gender Identity as I've described it before - that is, the internal awareness of how you wish to be perceived by others. For cis folk, this particular aspect is even more difficult to self know than, say, sex identity is, and it can be reflected in the statement "I want to be a girl" as opposed to the statement "I am a girl".  The first one usually describes one's gender identity (meaning, they want to be seen by others as a girl), while the second one describes one's sex identity (meaning they see themselves as a girl). Both Sex identity and Gender Identity are physiologically inherent in the individual by most consensus.

In this case, the person is expressing that they want to be seen as such by others, and have an awareness that part of the reason they are not seen as such is due to the damnable growths of the wrong sex on their body.

This is increasingly more common in children, which is the focus of most of the researchers involved in this work (since it is considered to start at an early age in all persons, even if they only present it in later life (come out or escape denial, the classic late transsexual).

This is supported by the rationale:

17. In referring to secondary sex characteristics, anticipation of the development of secondary sex characteristics has been added for young adolescents. Adolescents increasingly show up at gender identity clinics requesting gender reassignment, before the first signs of puberty are visible (Delemarre-van de Waal & Cohen-Kettenis, 2006; Zucker & Cohen-Kettenis, 2008).

As a kid, perhaps the absolute worst thing I ever experienced in my life -- worse than the testosterone injections and "bodybuilding powders" before it -- was the process of going through puberty. Just thinking about it makes me cry, as it was as if not only had the world decided to make my life hell, but now they were twisting my body.  It's like being in a car accident and not being able to stop it, and it goes on for years.  Seven of them, on average. In slow motion, like some horrible action movie.

3. a strong desire for the primary and/or secondary sex characteristics of the other gender

This one is pretty direct, and is obviously the sex identity aspect - I'm a girl, so I should have girl parts. As some would say, this is essential to the concept of a "classic transsexual".

4. a strong desire to be of the other gender (or some alternative gender different from one's assigned gender)

Here they step out of the bounds of what has been known in the past, and move into areas that speak to the issues of non transsexual people, which share the same basic underlying issue but to a different degree of severity. They are, of course, speaking to bigendered, agenders, gender queer and similar folk. Most of which have not been able to gain medical treatment that might aid them as a result of the inordinate amount of focus that practitioners (therapists) have as a rule on treating transsexuals.

5. a strong desire to be treated as the other gender (or some alternative gender different from one's assigned gender)

And again, back to the concept of gender identity, with the same reflections as previous.

6. a strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one's assigned gender)

Fairly self explanatory, but very problematic for many in the trans community as a whole. Fortunately, the criteria still requires two aspects to be present.

As the criteria require any two of the 6 to be present, a gender incongruent person could be someone who is assigned masculine but thinks like a girl and wants to be treated like one. And that this person is separated fro a transsexual, but only by the degree of severity of their gender incongruence, as transsexuals are generally postulated to suffer to the greatest severity.

The treatments, again, are still unknown, so what that person might be treated with and how they might be treated, is variable.  It could be that they might simply begin living their lives full time, or even part time, or possibly that they won't have any treatment at all, and essentially be a guy we all call she and her. Until such time as there are new standards of care, we won't know.

For the record, I fall into all six of the above criteria.

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The head of the revision team has made it clear to at least one professional in the Psychiatric field in the past 24 hours that the "exit" clause is to be applied to the "clearly different" (classic transsexual) and no congruence outside the binary is implied.

Official Certificates of Gender Congruency will be available upon proof of completion of transition in mind and body. These can be signed by a practicing Psychiatrist making them completely "official" regarding your exit from the DSM and transgenders.....non ops not eligible, sorry.

Suggested retail value: Priceless! (the first two have already been issued)

Rather interesting that someone's issued certificates based on a new criteria that hasn't been put into place and won't be for two years.

Angela Brightfeather | February 14, 2010 2:50 PM

I think that the gleeful exuberance of Radical Bitch points out a big problem in the proposed criteria.

While I am overjoyed for many who will have an "exit plan" that they can now use to declare themselves one of two genders, one has to wonder what this does to our community in the future.

I want to make myself crystal clear on this. I have sat through literally hundreds of support group meetings in my many years of activism for Transgender Rights. I have heard every story imaginable and variations of many common themes.
The happiness I feel in my heart for many friends who will benefit from supportive changes reflected in these early words coming from the DSM committees means so much to them and a lot to me personally. But as a person who does not believe in two finite gender types or expressions, I have to also wonder what this means to our community in general and especially in the future.

Perhaps an analogy might be made by saying, if GLB people were to be confirmed by scientists next week, to have a chromosome that confirms they were destined to be GLB, then would GL
B people who do not have that chromosome then be less than GLB?

I see the DSM revisons as setting up the same scenario in the Transgender Community, and of course that is compounded by many within the Trans community who have for years been seeking separation from the term gender diverse and sprinting to the social construct of only two genders being acceptable. This new framework of being made more "real" than the next person sharing the same inequalities, at least up to the point of being declared that way by the medical profession, may be giving to some people the rights that they need at the expense of the vast majority of the total Transgender Community. Or perhaps, the "new" Transsexual Community, comprised of perhaps 10% of the previous whole, will be the only one that is considered as being able to now prove that they deserve the rights in ENDA and Hate Crimes legislation, while the "old" Transgender Community comprised of 90% of the previous community, is now made "less than real" or forced to take steps that they may not have wanted to in the past, such as seeking medical help and/or surgical or hormone intervention to become considered more real.

Perhaps many of my friends who have been living in the opposite gender for years and years or those who are non-op due to things like heart disease or being prone to blood clotting, will never be considered anything more than fetishistic crossdresser's and therefore not deserving of the same non-discrimination of the women and men made more real by DSM-V. But to think that belies the realities of their lives and the situations they live and have lived in for years.

Much like ENDA four years ago which threw all Trans people under the bus, I would be interested in understanding how these new DSM changes aren't throwing 90% of the Trans community under the bus in a few years and what can be done about it. I think that one thing is for sure. Once these changes take affect, it will cause a restructuring of the Trans community, over time, that will leave many fighting for equality in that community more lonely than usual in that fight, due to the DSM graduation in becoming declared as more real and deserving.

I think that feeling unbounded joy for the 10%, we need to remember the overall affect to 90% of the community that might be left behind and what will be in their future.

I have to ask: What good is an "Official Certificate of Gender Congruency?" What would it be used for? As a club to beat on all other gender variant people? As a validation of Genuine Womanhood™ to be used to gain access to "The Land?" Do we really think this thing would count with the RadFems that exclude us now? Would it help us gain employment, housing and public accommodation rights protections?

I like the ideas behind the Gender Incongruence designation. I doubt, however, that any cissexual person will recognize the "exit clause" for a very very long time.

I would like to speak to misunderstandings about the exit clause issue, as the GID subcommittee cites my book in raising the issue and quotes me for the phrase "exit clause." Actually, I first raised the issue and used the phrase at the 1997 ICTLEP Trans Law Conference in Houston.

"Exit clause" is not a literal phrase added to the GIN diagnosis (I hate using the GI acronym -- yuk); it is my metaphor for DSM-IV criteria that were written so that once diagnosed, a TS person remained diagnosed forever, no matter how happy and well adjusted he or she might be post-transition. "Roach Motel" and "Hotel California" are equally valid metaphors that I've used. There is no specific wording for exiting diagnosis and no sign-off. When a person no longer meets the diagnostic criteria, then the diagnosis of mental disorder should simply no longer apply. And the diagnostic criteria should clarify who should and should not be diagnosed, consistent with the stated definition of mental disorder.

Again, the DSM4 GID failed to do this. Thus, these diagnostic criteria made GID a gender-reparative diagnosis that contradicted rather than supported transition. This is important, because the efficacy of any medical treatment is judged against the symptoms described in the diagnostic nomenclature. The DSM4 GID criteria were cleverly worded to describe "symptoms" that would be mitigated by gender-reparative therapy and the closet and would be worsened by transition, hormonal/surgical treatments and affirmed life. This posed a huge barrier to medical transition care access that was constantly exploited and publicized by transphobic political extremists.

An exit from psychiatric diagnosis, once the distress of gender dysphoria has been relieved by social and/or medical transition, should never imply conformity to binary gender stereotypes. It should mean that the person has moved, socially and/or physically, to a place of congruence with his or her unique affirmed gender identity-- be it masculine, feminine, both or neither. The subcommittee has not yet clarified this and I hope they do.

Finally, I am gratified that the subcommittee acknowledged the exit clause/roach motel problem that effectively endorsed gender reparative therapies in past DSMs. However, they did not completely fix the problem. Ambiguous language in subcriteria 5 and 6 can still entrap post-transition and even post-operative individuals to remain permanently diagnosed as mentally disordered. See for more on this.

Angela Brightfeather | February 15, 2010 8:37 AM

Dear Kelley,

Thank you for elaborating on those points. I appreciate the fact that now non-ops and those Trans people who opt out of surgical genital operations for various and very valid reasons will not have to run the gamut of post ops who will claim that they are officially "more complete" or "more real." However, I still do not see an equilization factor in these future standards that will go one iota farther in relieving the "ick" factor that people have about Transgender people who do not opt for surgeries to assert their gender expression, or who prefer to live a more fluid life in one or more, of many various gender presentations.

I find the inclusion of "fetishistic crossdressing" and continuing to label it as a compulsion, adding to the separatist arguments within the Trans community and I also find it a very harsh judgement leveled at a group of people who essentially do littel or no harm to others, many of which can walk away from the "compulsion" for years at a time if necessary, perhaps be less than happy about those circumstances, and return to expressing themselves when the circumstances in their lives allow it. In reality, does the act of expressing one's prefered gender need to be forced on a person all of the time in order for them to be considered mentally healthy by the DSM?

I also think that the peoplew ho fall between the lines, such as pre ops or non ops, are unfairly catagorized inthe DSM and it lookw to me as though that isn't going to change one bit. Perhaps I am just reading this all wrong, but I would really like a common sense and understandable explanation, in lay terms, on how these future steps in DSM-V will not continue the fracturing of the Transgender Community, the in fighting and the marginalization of gender diverse people, and how they will do the right thing for everyone and not for only 10%.

Or am I simply hoping for to much out of the committees?

>I also think that the people who fall between the lines, such as pre ops or non ops, are unfairly catagorized in the DSM

Angela, as I read the proposed diagnostic criteria, I think you are correct and raise a very valid concern. Thank you for raising the issue. Without further clarification, I agree that people who transition socially but not medically could be explicitly, permanently diagnosed with Gender Incongruence under subcriteria 4, 5 and 6:

4. a strong desire to be of the other gender (or some alternative gender different from one's assigned gender)

5. a strong desire to be treated as the other gender (or some alternative gender different from one's assigned gender)

6. a strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one's assigned gender)

I feel that these subcriteria should be rewritten so that nonconformity to birth-assigned gender roles is not cast as symptomatic of mental illness.

Worse yet is the expanded defamatory category of Transvestic Disorder that sexualizes and punishes nonconformity to a birth-assigned male role. This category should be deleted entirely from the DSM.

In my view, transpeople who are happy with their bodies and have no need for access to hormones or surgeries should never be subjected to a gender diagnosis.

IMHO it is and always shall be that the psychiatric establishment needs repair. Someone should do a study on why sex and gender diversity so profoundly destabilizes this group of 'professionals".

Why not let the transgender be treated anyway they deem appropriate and let the post-op TS's alone, to go their own merry way?

FurryCatHerder | February 16, 2010 4:35 AM

Because those of us who are post-SRS folks are often the justification used for everyone else. If "the community" didn't have a way to hold us hostage, they'd be in big trouble.

Interestingly enough, once the new SoC comes out, they will be.

Of course, then they'll be colonizing trans spaces, which is a bit problematic...

Dapper Ninja | February 16, 2010 2:56 AM

...the current system more or less requires a person to be a transsexual to get a diagnosis of 302.85 (so, if you have that, you are a transsexual, under the current system). On the other hand, so is a butch woman.

This conflicts with the fact that a transsexual person is obviously different from a butch woman...

I think what you meant to say was "butch cissexed women."

My fellow MtF butch and our brothers, the FtM flamers, really screw with the diagnostic criteria.

yes, and I should have made that clear but was distracted by claims regarding that statement made by others.

My apologies.

I will, however, point out that in a lot of the supporting lit, one of the groups that is totally screwing with their heads are the "tranny boys" (as they term them, not I), who seek to remove breasts but otherwise avoid Testosterone and other treatments and maintain a feminine gender identity, while engaging in a masculine gender expression and role.

Its rather humorous to me, personally.

If this is about insurance, then we are all screwed anyway. But here's two flippant cents for da pre-op from da elder post-op .

Defeat the psycho-medical establishment,

Go to Thailand, and be a Preecha girl like me.

Tracheal shave, lipo, and surgery for $6000.00

Plane ticket 700.00

Bangkok Mickey D....CHEAP.
In and out for under $7000.00 [2001]

Do you really need a 'Sexpert' to confirm what you've always known about yourself?