Hope and Hurt for Trans Americans in the APA's Proposed DSM Revisions

posted by: Steve Williams 1 day ago

On Monday, the National Gay and Lesbian Task Force praised the American Psychiatric Association's (APA) favoring of "gender incongruence" and refutation of "gender identity disorder" (GID) as part of its suggested revisions to the upcoming 5th edition of the Diagnostic Statistical Manual (DSM), a text that is used by clinicians and psychiatrists to diagnose psychiatric illnesses. However, the Task Force notes that there is much work to be done on the problematic diagnostic criteria that still mislabels many trans and gender variant people as having a mental disorder.

From the press release:

WASHINGTON, April 12 — The National Gay and Lesbian Task Force today affirmed the American Psychiatric Association's (APA) refutation of "gender identity disorder" in favor of "gender incongruence," but calls for the removal of "transvestic disorder" and expresses concerns about other proposed revisions to the upcoming 5th edition of the APA's Diagnostic and Statistical Manual (DSM).

"We see this revision as an evolutionary step toward removal of all diagnoses related to gender nonconformity in the DSM," said Jaime Grant, director of the National Gay and Lesbian Task Force's Policy Institute. "Gender variance is not a psychiatric problem; it's a natural human variation that in some cases requires medical attention and support."

The National Gay and Lesbian Task Force released this statement as part of its commentary (linked below) on the latest proposed revisions to the APA's Diagnostic Statistical Manual.

In their feedback, the Task Force praises the aforementioned shift as being more reflective of current understanding of trans identity and as a move towards "affirming a natural variance in human gender identity".

However, the Task Force notes that there is still work to be done. Specifically, the Task Force calls for the removal of the defamatory classification of "transvestic disorder" - used to replace "transvestic fetishism" but given the same diagnostic criteria - which singles out transwomen (those that identify female but were birth-assigned male) as essentially being sexually deviant.

It notes that the "very notion that cross-dressing among female-born individuals is never pathological, while cross-dressing among male-born clients has multiple pathological manifestations reeks of a kind of sexism we find astonishing for psychiatry in the 21st century. It is well past time for the removal of disorders associated with disfavored versions of femininity, which call to mind the infamous 19th century diagnosis of 'hysteria' in women."

As such, the Task Force calls for the removal of “transvestic disorder” and its controversial and heavily challenged specifier “autogynophelia.”

The Task Force makes it clear that while the move toward "distress-based" diagnosis in DSM-V should be applauded, strong concerns remain that the guidelines are still vague and that they fundamentally fail to recognize the difference between what is termed "minority stress" - that is to say, the emotional distress that LGBTs face as a marginalized group that is subject to discrimination - and that of stress brought about by "specific gender expression." The Task Force reiterates a need to make it clear that distress as a result of societal discrimination should not be used as evidence of a mental disorder.

Why are Changes to the DSM Needed?
The blanket categorization of gender variant and trans identity as a disorder creates unnecessary and harmful barriers to surgical and hormonal transition treatments that also reinforces the social stigma that persists surrounding trans issues. The perpetuation of this stigma and the discrimination that many trans patients face in health care is something that the Task Force references in its comments on the proposed DSM-Vchanges:

Data from the National Gay and Lesbian Task Force/National Center for Transgender Equality’s National Transgender Discrimination Survey compiles questionnaires from 6,500 transgender and gender nonconforming people across the United States. Fifty percent (50%) of our respondents report being forced to educate their medical providers to ensure they received adequate and sensitive care. Nearly half of our sample reports postponing some form of medical care because of the pervasive discrimination they faced at the hands of insensitive or bigoted healthcare providers. Thus, the National Gay and Lesbian Task Force advocates for the full declassification of Gender Incongruence, alongside improvements within the International Classification of Diseases and U.S. health care systems to ensure adequate access for all transgender people seeking medical support to fully embody their gender identity.

The label of mental disorder is also particularly harmful to transitioned individuals who may be happy and functional in every respect following their gender reassignment but are still maligned by the current diagnostic criteria which labels them as having a disorder. This can impact many areas of a trans person's life, but in particular can be damaging to their career and employment opportunities.

Though seeking to remedy this, the proposed changes to DSM-V, with its good intentioned move from GID to "gender incongruence," could perpetuate this problem due to ambiguous criterion that also might potentially widen diagnosis to include people that do not even fit thestandard definition of gender disphoria. You can learn more about this by going here to read a concise but thorough analysis of the proposed changes as written by Kelley Winters of GID Reform Advocates.

Overall, the proposed revisions show progress toward recognizing transgender and gender variant identity while removing the label of "disorder" and the stigma that comes with it.

That said, these changes add up to only perfunctory alterations that, for LGBT rights advocates, dance around the heart of the issue - namely that gender identity variance is not a pathology. As such, reform advocates will continue to work strongly to push for less ambiguous, less gender binarycriteria in the DSM to prevent gender variant persons from being unfairly categorized as having a psychiatric problem when no subjective distress or impaired function is evidenced, and for medical assistance to be refocused from a gatekeeper approach to one of facilitating patient care and support that is outcome orientated.

The release of DSM-V is now scheduled for May, 2013.