Antonia D'orsay

Compromise: Analysis Of The DSM-V Revisions, Part 1

Filed By Antonia D'orsay | February 12, 2010 3:00 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

A multi-part series on the finer points of the DSM-V proposed revisions to certain disorders and the clinical structure behind them.

It is a mixed bag, this proposal for revision. Make no mistake, it is not fixed in stone (although at this point it's going to be damn close). Some out there are aware I tread a fine line between the separatists and the whole hog trans community, that I seek to focus on what is defined and definable, and to listen to both sides even when I don't agree with them.

It's been said compromise is reached when no one is completely happy.  Well, this is one hell of a compromise.

If you look at the DSM-V site, they have a specific proposal for the criteria for diagnosis on the first part. This is under a tab called "Proposed Revision". Next to that are a couple additional tabs. The first is Rationale, and this is a pretty important one as it explains the thinking of the committee (that is, the entire team, typically in a super majority, 66%) in making the changes and supports those with peer reviewed and established scientific studies that have passed the team's smell test. Given the team is not entirely composed of people who get along, this fact is significant.

The next tab is Severity.  This is a pretty big deal, and something that I hope others don't overlook as it's of critical importance in the practical application end.

After that, comes a tab marked DSM-IV.  It's technically referring to the DSM-IV-TR, by the way, which is the current standards for the same thing and the stuff they are changing.  It's provided for reference.

So, without further ado, away we go...


The first change is the name itself.  This isn't all that unusual.  Since 1980 when transsexualism first entered the DSM (mostly because it was already in the ICD), it has undergone changes both before and after that point.  Prior to 1980, it was focused primarily on children and on what were thought at the time to be homosexuals (though in truth, a mix of LGB and trans folk).

The new name for Gender Identity Disorder is proposed as Gender Incongruence. The reasoning for the change is to more accurately reflect a couple of things that are rather important: stigma, scientific findings, and new methodologies.

The stigma part comes from actually talking to trans people.  Yes, they listened, and yes they paid attention.  Rather cool, actually. One of the citations for this is the work done through the All Gender Health seminars and studies, and online version of which is currently in the early stages.  I've done some work with this, and will say that the data compiled is some of the most incredible.  I'll also note that it's been heavily funded by HIV/AIDS education and research monies (partially through the NIH).

Some of the findings also come from that - if you are someone who seeks to work on behalf of trans folk, I strongly encourage you to seek out a seminar on it.

Among the new methodologies involved is the greater understanding of what is called Sex Identity and the way it differs from what is called Gender Identity. I discussed them in my writings about Sex and Gender previously. By taking this approach, they've been able to get more accurate and better probing questions to understand the meanings and actualities behind the all too often spoken but terrible at explaining it statement of "I was born in the wrong body".

This is reflected in a tool that is proposed for use, developed primarily under the supervision of Dr. Peggy Cohen-Kettenis.  The tool is still being developed, but a portion of it is given in the tab marked Severity.  This is important because there is a scale and a degree of Incongruence that must be determined.  This harkens back to the days of the Harry Benjamin SOS (still in use today), but is far more detailed and involved, and is designed to measure the degree of incongruence (severity) of anyone from a cis person to a part time one weekend a month cross dresser to a full fledged "Type 6" transsexual who's about ready to perform their surgery themselves.

It's also worthwhile to note that this is important for a factor that people in general are kinda overlooking and that's the overarching concepts that are guiding the revision as a whole in terms of the kind of structural work that is being sought out. That factor is that part of the goal of this revision as a whole is to make the task of diagnosing something more germane to the ideas of what is distress and what is impairment, since they want to make that more uniform.

There is some concern there for many on the basis of what if the distress or impairment of an individual isn't significant enough to warrant the diagnosis. And that's a pretty fundamental concern, but not one that transsexuals in general will need to worry about. Since the new criteria make it clear that pretty much the entire Trans spectrum as I've described it previously are included, it's entirely possible that a genderqueer person or causal crossdresser would not be considered significantly distressed or impaired enough to warrant any treatment.  I'm inclined to say that while there will inevitably be some people who do that (and/or use the fact that they are such to justify some form of reparative treatment for trans people), for the most part, the professionals working in the trans community at present are educated enough to do a decent job (and they get most of their business from referrals by other trans people, so it ultimately stays all in the family and reduces the impact of those "bad eggs").

The use of the term Incongruence also reflects this deeply, as it indicates that the actual diagnosis is not only not a disorder in the sense as it was introduced previously (a neurosis), but also that the goal of treatment is to achieve congruence.

This term, Congruence, has a particular meaning here that's important, best described as rapport within oneself, or internal and external consistency, perceived by others as sincerity or certainty.  For some, this can also be described as balance between self, other and context, although there are some foundational issues with the source of that particular description.

That's a significant change in overall approach towards the whole issue - in many ways, it's almost a tidal shift in terms of differences between the last change to the DSM early last decade (-TR) and the current one.  And an enormous change from the way it was approached in the late 70's and early 1980's.

The authors of the PR (Proposed Revision) explain this shift in a brief point in Rationale 2.a.:

(a)    we have proposed a change in conceptualization of the defining features by emphasizing the phenomenon of "gender incongruence" in contrast to cross-gender identification per se (Meyer-Bahlburg, 2009a);

The study cited there is From mental disorder to iatrogenic hypogonadism: Dilemmas in conceptualizing gender identity variants as psychiatric conditions. Archives of Sexual Behavior, doi: 10.1007/s10508-009-9532-4.

From the Abstract of that study:

... [things considered include] GIV as psychopathology versus natural variation; definition of ''impairment'' and ''distress'' for GID; associated psychopathology and its relation to stigma; the stigma impact of the mental disorder label itself; the unusual character of ''sex reassignment surgery'' as a psychiatric treatment; and the consequences for health and mental-health services if the disorder label is removed. Finally, several categorization options are examined: Retaining the GID category, but possibly modifying its grouping with other syndromes; narrowing the definition to dysphoria and taking ''disorder'' out of the label; categorizing GID as a neurological or medical rather than a psychiatric disorder; removing GID from both the DSM and the International Classification of Diseases (ICD); and creating a special category for GIV in the DSM. I conclude that--as also evident in other DSM categories--the decision on the categorization of GIVs cannot be achieved on a purely scientific basis, and that a consensus for a pragmatic compromise needs to be arrived at that accommodates both scientific considerations and the service needs of persons with GIVs.

The author of this paper is Heino F. L. Meyer-Bahlburg, a member of the psychology body at Columbia University in New York. He works in a few field areas, including HIV issues, but his major focus is gender variant children. He has written  (over 10 years ago, before a huge body of work came along) that gender identity depends largely on postnatal environmental influences, while sex-dimorphic behavior and temperamental sex differences appear to be modified by prenatal sex hormones (Osborne, Duncan (October 28, 1997). An Attack On Our Most Vulnerable: The Use and Abuse of Gender Identity Disorder. Lesbian and Gay New York). He's also on the committee for Intersexuality of the WPATH.

The paper can actually be read as a PDF from the link given above (scroll down the page). Most important is his conclusions as described in the abstract above, as this paper, and, therefore, his conclusions, are being cited as support for this.  It's published in a very important publication (despite the issues that I have with it), and therefore peer reviewed, etc.

The next time someone tells you that they aren't listening to us, or that they are just trying to wander off and do their own thing, remember this particular team cited the above - which explicitly says they need to listen to us and get our input . Not only did they get our input, but they acknowledge, in this action, the effect of stigma on trans lives, and that leads one to note a shift in their understanding to one more closely fitting with the way they see cisLGB folks - that the biggest problem is not us, but the world we live in.

And they have been doing that.  Keep in mind these are large institutions involved here, and they move slowly, and there is still a massive vote by the board of trustees and the assembly ahead. Two years is a long time, and much can happen. But the most likely scenario I see is still a ways off, as its dependent on the ICD-11 team when that forms.

However, it's fairly clear that they are looking to move it into a new category (out of Sexual and Gender Identity Disorders and into a new one or a different one entirely) or out of the DSM entirely (something they still may have a challenge on and not for the usually cited reasons but because of the social effect that can have - in other words, it's absolutely got to be medical before it's taken out, and that means getting it moved in the ICD).

So my take is to not expect it to be removed from the DSM this go around, but *maybe* next time, if the ICD team (United Nations World Health Organization) does it. It's entirely possible it will be placed into its own category - like pregnancy is in the ICD - but I suspect that's a bit more challenging for reasons I'll get into later surrounding a different diagnosis.

All of that combines together to show a conceptual understanding on the part of the working group that is more closely aligned with the broader trans community understanding of what it means to be trans, as well as adoption of our particular lingo and neologisms (cisgender is used in a lot of the writings, as is cissexual).

They generally agree that we don't belong in the DSM, then, they generally agree that we still need treatment, and they are aware that the primary cycle for that treatment comes through the efforts of a therapist, social worker, psychologist, or psychiatrist. They are aware that many policies and procedures for what we go through are based on and developed through the diagnosis and the attendant Standards of Care associated with it.

So what's in a name?  A hell of a lot.  And that's just the start of it all.

More analysis to come.

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I wonder if they know what it is like sitting here with a pile of bills on my dining room in a half finished renovation project full of suspicion as to what will be written next about me after spending a lifetime trying to reconcile myself with the fact I am who I am. I have two years of college and I have become obsessed with what Meyer-Bahlburg has to say about Sharon Preves and pre-natal exposure to DES, etc., pub med, med line articles, court decisions, queer theory, feminist theory, linguistics, philosophy, sociology, psychology, history, personal narratives, etc. trying to keep one step ahead of what's coming next; all the while being condemned by other people born transsexual for trying to understand myself while being made nauseous listening to those who think they understand more than they do who would insist I am mentally ill for deciding the kind of surgery I eventually opted for is much better than what a doctor was proposing for me forty-six years ago.

What seems obvious to me is that there is pre-natal development dependent on how one is exposed to hormones, post natal development dependent on exposure to hormones and also the environment someone has to live in and interact with whether you are "gay straight or 'lying'". There are not very many either/or's in my world. Concepts like gay and straight do not make any sense to me, while terms like male and female are relative terms.

If someone wants to go looking for "etiologies", let them conduct a biopsychosocial study of the whole human race and see what they come up with, if they were to expose everyone to the kind of scrutiny transsexual and intersex people have had to endure at the hands of some of these clinicians.

Current song on the WERS playlist - "She's a Rainbow" by the Rolling Stones

Hi Edith.

Same here. A bit more complex due to the biological anomalies in my peculiar metabolism, but essentially I'm in the same position.

pre-natal exposure to DES, etc., pub med, med line articles, court decisions, queer theory, feminist theory, linguistics, philosophy, sociology, psychology, history, personal narratives, etc.
Yes, it seems I need several years of legal training and research just to know what restroom it's legal for me to use in what jurisdiction. It varies. Though for the vast majority of places it's a non-issue, for some I would quite literally be breaking the law if I got it wrong. Used the F instead of the M, or M instead of the F. Could be tricky in a restroom straddling state or even county lines.

As for marriage - in the UK, I could only marry another woman: in Australia, only marry a man. In the US, it would not only depend on what state or county I was in, but whether my UK passport or UK birth certificate was deemed the cardinal document - and if neither, on medical opinion.

Hi Zoe,

It sure does get complicated, doesn't it? I am not one for labels. I had transsexual treatments that work pretty well. Others will put labels on people and put them into categories. Under the current societal scheme of things, the "F" category suits me best. There is not much to refute that except a bunch of conflicting rationales. Meyer-Bahlburg and those he works in concert with, seem reluctant to acknowledge the overwhelming complexity of biological diversity. Sex is a diverse phenomenon. Denying someone their sex identity makes it horribly difficult for someone to fit into a social schema and develop a gender identity.

zoe and dyss,

as the dsm 'project' is asking for input,
and many people are unhappy re/
"disorders of sex developement", (re/ "IS")
what about suggesting changing it to a more neutral phrase, like:

"differentials of sex developement"
or "differances of sex developement" ?
just a thought....

How nice. It sounds like we have improved in our mental health in the view of those who write this DSM of being "I'm OK, you're not OK but keep coming and we might almost make you OK if your checks do not bounce" to being "I'm OK, and you're OK, but you still need to keep coming back to see me so I can pay for my new BMW". I suppose that is an improvement but you might have to excuse me from the jumping up and down with joy party planned. Much like many things it seems too slow in coming to cause me to get all giddy inside.

Renee Thomas | April 14, 2010 4:20 PM

Or we could just cut to the chase and at last conclude:

Human beings are complex and, as a natural outgrowth of that innate complexity, will from time to time need to alter their social circumstances or their bodies . . . or both.

Is it in the medical profession's (and thus the larger society's) best interest to lend a hand? Well, yeah sure, happy, well-adjusted and self-actualizing individuals are arguably a good thing. Besides, their help in delivering babies is much appreciated too.

Is there a societal virtue to accepting in the social milieu what is an established fact in nature – that a significant percentage of human beings, absent the influence of false dichotomies reinforced by ancient superstition, are fluid as to both gender expression and/or sexuality?

Now tell me again, just whose ox is being gored?