The Diagnostic and Statistical Manual of Mental Disorders (DSM) is a document published by the American Psychiatric Association (APA). It has been one of the most influential documents in the pathologization of sex and gender minorities.
The fight over the fifth revision (DSM-V) came at a major turning point in transgender activism. After the APA announced non-psychiatrists Kenneth Zucker and Ray Blanchard would be involved in writing the sections that affected our community, we staged protests and campaigns to minimize their involvement and the promotion of their ideology in the revision.
Every trans person fighting the academic exploitation of our community got involved. Kelley Winters had a leading role through her GID Reform project, books, and presentations.
James (2010)
Below is what I submitted to the American Psychiatric Association regarding the highly problematic proposed revisions for the Diagnostic and Statistical Manual of Mental Disorders (DSM-V). Comments are due April 20.
I’m grateful to those diplomatically working on damage control regarding this ill-fated DSM-V revision. Its negative effects will harm sex and gender minorities well into the 2020s. It will particularly harm an entire generation of transgender youth and intersex people.
My comments below are not diplomatic. I am noting for the record that those responsible missed their historic opportunity. They rejected the depathologization of sex and gender minorities in 2013. The DSM-V is on track to be remembered for how the responsible parties reinforced and even expanded the pathologization of sex and gender minorities, rather than taking the courageous and historically inevitable step of depathologization.
DSM-IV editor Allen Frances observed that this group has proposed two of the most troubling DSM-V revisions. Since the actual number of problems makes an exhaustive yet brief commentary impossible, I will focus on the worst of the worst:
“Paraphilia”
The worst decision in this fiasco will be to continue treating “paraphilia” as a mental disorder rather than as a sexual orientation. It is clear that the listed sexual interests cannot be “cured” any more than those orientations currently deemed non-disordered by the APA. What should be diagnosed for treatment is not the underlying interest, but the thoughts and actions related to the interest. These are no different than any other forms of impulse control issues. Any behavior can be taken to a level that could become problematic.
Most “paraphilias” involve consensual behaviors and should not be considered disorders. Characterizing these as “erotic target location errors” or diseases echoes now-outmoded “clinical wisdom” on homosexuality. We are about to see a broad expansion of “disordered” sexualities, a doubling of the types. This is being promulgated by those who think creating new “paraphilias” through iatrogenic artifact is their bid for immortality (Blanchard), or who don’t think peddling “cures” to self-hating crossdressers and what-not (Kafka) is a direct conflict of interest with the aims of this revision.
As for nonconsensual sexual interests, they are not mental disorders, either. Consent is a legal concept, not a medical one. Arousal studies suggest that many people with interests deemed illegal never act on those interests, and in fact they may face a lifetime of silent struggle not to act on these interests because of the medico-juridical climate surrounding these interests. Diagnoses support criminal statutes and vice versa: in most jurisdictions where homosexuality is illegal, it is also considered a disease.
“Experts” leverage the moral panic about intergenerational sexuality and age of consent to get funding and job security, in the same way the moral panic about homosexuality created a cottage industry. What politician wants to say they voted against funding to “cure” pedophilia? Anyone who questions any aspect of current protocols is immediately considered sexually suspect themselves, akin to earlier moral panics about communism, terrorism, and again, homosexuality. It’s clear that doctors have an important role in preventing non-consensual sexual behavior. What they are treating is not the underlying interest, but the ability to control the impulses to act on those interests.
Unconventional sexual behavior that is consensual can reach a level where impulse control needs to be managed, but that should not be thought of as “curing” the interest itself. There’s no need to diagnose or “cure” harmless sexual interests. It’s sad to see that we are well into the 21st century, yet some experts still cling to the idea that “transvestic fetishism” or other forms of consensual kink are disorders.
“Disorders of sex development”
It was inevitable that DSD would make its way into these revisions, since the term is such a huge step backwards for sex minorities. That this disorder is intermingled with gender minorities in these proposed revisions was also inevitable. From the moment I heard the term “disorders of sex development” being bandied about by self-styled ethicists, I know this is where we would end up. Their short-sighted advocacy will now result in a generation of people with natural human variations in sex anatomy to be de facto mentally disordered as well as physically disordered. This term implies that these people have a form of retardation (developmental disorder), and we will see an uptick in “cures” for both fetuses and neonates thanks to the term DSD.
The pathologization of sex diversity through the term “disorders of sex development,” which was railroaded through in a sham “consensus,” should not be codified in the DSM. To use one of Zucker’s favorite analogies (racism), policing racial distinctions is the same thing as policing sex and gender distinctions. The DSM-V should avoid engaging in this sort of policing activity: it’s politics, not science.
“Gender identity disorder”
“Gender identity disorder” and “disorders of sex development” have at their hearts the same problem: diversity is not disorder. I have lobbied long and hard against both concepts because both DSD and GID emerged from the same mindset that sees the world through a medical lens of sickness. It has troubling overlap with heterosexist reproductive ideologies as well, where those who can’t procreate are less able or even less human.
There are some trans people, especially older trans people, who argue that disease models validate their identities and allow treatment. They want GID to stay because they fear trans health services will become less available. Some also wish GID to remain because they consider themselves disabled because of GID and collect government benefits based on this alleged disability. Their self-interests should not affect the scientific debate at hand.
Most transgender people do not seek out transition-related medical services. Of those who do, most people are doing things the way we did before the rise of the “gender clinics.” Gender clinics function as gatekeepers and thus want to keep “gender identity disorder” in place. Ritual documents like the DSM encourage regressive protocols that few trans people have the patience to endure. These regressive gender clinics like CAMH in Toronto have turned down as many as 90% of patients in the past, leaving them to seek higher-risk options like medical tourism at their own expense. They then get drugs and surgery from exotic locales and/or unqualified providers unless they have the money to seek less risky treatment. Gender clinics that engage in regressive gatekeeping result in the opposite of harm reduction by forcing patients to find care outside the established system.
My position is simple but unpopular among some: Subsidized healthcare is not a fair trade for human dignity. If the psychopathology model of gender diversity promulgated in Toronto by American ex-pats is imported to the US via the DSM-V, it will have disastrous long-term consequences. The UK has made it clear that trans people are able to have access to trans health services without the stigma of a mental illness diagnosis. Other countries have followed. It’s time to remove gender identity disorder and look at options that do not situate a disorder within trans peoples’ minds.
Inflicting trauma and shame on gender-variant children through “GIDC”
In the years I have been raising awareness about the atrocities committed against gender-variant children at CAMH in Toronto, I have come to see in Zucker what can only be called anti-intellectualism regarding philosophy of science, history of science, the sociology of theory, and other relevant academic disciplines critical to understanding how pathological science and systemic bias seep into scientific methodology. We are expected to rely on Zucker’s “clinical wisdom” rather than objective outcome data. We are not supposed to question why 5 to 30 times as many children assigned as males have historically been targeted for “curing.” We are not supposed to ask if we can talk to any of the children Zucker “cured,” just as John Money wouldn’t divulge the status of a patient against whom he committed atrocities then lied about “curing.”
Clinicians have called Zucker and his colleague Susan Bradley’s therapeutic intervention for children “something disturbingly close to reparative therapy for homosexuals” and have noted that the goal is preventing transsexualism: “Reparative therapy is believed to reduce the chances of adult GID (i.e., transsexualism) which Zucker and Bradley characterize as undesirable.” Author Phyllis Burke wrote, “The diagnosis of GID in children, as supported by Zucker and Bradley, is simply child abuse.”
Conclusion
When Zucker was in charge of a similar ritual document for the American Psychological Association, he and his team cheerfully ignored a wide range of suggested changes. Between that farce and this process, I have lost faith in these empty gestures toward public commentary. So I’ll end here for now, since I am not confident in this process or its outcome.
We see these people ignoring legitimate scientific objections and continuing to use unscientific and inaccurate terminology like “shemales” (Blanchard) and “homosexual transsexual” (Cohen-Kettenis), both of which are considered outrageous slurs outside of the bubble in which these alleged experts live. Science and its terminology evolve with understanding, and if these experts are unable to evolve their terminology and thinking as well, they should not be placed in positions of authority.
Let’s hope we don’t have to resort to stunts like Dr. H. Anonymous to make our points. I doubt even someone of his fortitude could overcome all the problems with this proposed revision.
Andrea James
April 2010Note: These views are mine only and do not necessarily reflect the views of any other organizations or individuals. If you require footnotes, I am happy to provide them after the fact, but I don’t really feel like taking the time after similar efforts were cheerfully ignored by Zucker and company on the 2007 American Psychological Association Task Force.
DSM-V site
http://www.dsm5.org/Pages/Default.aspx
Sexual and Gender Identity Disorders
http://www.dsm5.org/ProposedRevisions/Pages/SexualandGenderIdentityDisorders.aspx
Original URL:
http://www.tsroadmap.com/notes/index.php/site/my_comment_on_the_dsm_v_proposals/
My reading list (2009)
critical of DSM and the bio-psych merge
As Nancy Ordover points out in American Eugenics: Race, Queer Anatomy, and the Science of Nationalism, attempts to graft the hard science of biology to the social science of psychology has been a major American obsession for over a century. It’s had a number of names, including eugenics, sociobiology, and evolutionary psychology. This “bio-psych merge” has profound implications for sex and gender minorities. For those interested in the topic, Ordover’s book linked above is a good place to start. The books below represent a range of views on this burgeoning problem.
Paula J. Caplan. They Say You’re Crazy: How The World’s Most Powerful Psychiatrists Decide Who’s Normal. Da Capo Press, 1996 ISBN 978-0201488326
Ethan Watters & Richard Ofshe. Therapy’s Delusions: The Myth of the Unconscious and the Exploitation of Today’s Walking Worried. Scribner, New York, 1999
Louise Armstrong. And They Call It Help: The Psychiatric Policing of America’s Children. Addison-Wesley Pub. Co., Reading, Mass., 1993
Lee Coleman, MD, The Reign of Error: Psychiatry, Authority, and Law. Beacon Press, Boston, 1984
Colin A. Ross, MD, & Alvin Pam, PhD, et al. Pseudoscience in Biological Psychiatry: Blaming the Body (Wiley Series in General and Clinical Psychiatry). John Wiley & Sons, Inc., New York, 1995
Ehrbar et al (2009)
Paper: Revision Suggestions for Gender Related Diagnoses in the DSM and ICD
At the 2009 WPATH conference in Oslo, a reformed disease model was presented based on work by Randall Ehrbar, Psy.D., Kelley Winters, Ph.D. and Nick Gorton, M.D. It reconfigures gender dysphoria as an acute form of distress that can go into “remission.”
Summary of Proposed Diagnosis:
Dx Criteria – Both A and B
• A: Strong and persistent distress with physical sex characteristics, or ascribed social gender role, that is incongruent with persistent gender identity.
• B: Distress is clinically significant or causes impairment in social, occupational, or other important areas of functioning, when this distress or impairment is not solely due to external prejudice or discrimination.GD in remission
• No longer meets criteria, needs treatment to maintain remission‘Exit clause’
• No longer meets criteria, doesn’t need treatment to maintain remission
Full article:
http://www.gidreform.org/wpath2009/
Protest and rally (2009)
Please spread the word about the upcoming protest and rally at the American Psychiatric Association meeting in San Francisco.
Monday, May 18, 2009
Time: 6:00pm – 7:30pm
Location: Moscone Center 747 Howard St, San Francisco, CA 94103
Phone: 701-885-1125
Email: protestgenderdx at gmail dot com
The APA appointed Kenneth Zucker and Ray Blanchard to determine how trans people will be categorized in the next version of the Diagnostic and Statistical Manual of Metal Disorder (DSM-V). On the 18th, trans community leaders will be speaking on a panel:
“In or Out?”: A Discussion About Gender Identity Diagnoses and the DSM
1. The DSM-V Revision Process: Principles and Progress William E. Narrow, M.D.
2. Beyond Conundrum: Strategies for Diagnostic Harm Reduction Kelley Winters, Ph.D.
3. Aligning Bodies With Minds: The Case for Medical and Surgical Treatment of Gender Dysphoria Rebecca Allison, M.D.
4. The Role of Medical and Psychological Discourse in Legal and Policy Advocacy for Transgender Persons in the U.S. Shannon P. Minter, J.D.
We need to stand up and be heard! This DSM-V revision will affect an entire generation of trans people and will be a historically significant factor in how our legal status is determined during the next 15 to 20 years.
Please join this Facebook event to help us plan the event. Questions? Contact Lore M. Dickey at the contact information above.
http://www.facebook.com/profile.php?id=519725212#/event.php?eid=187297865362&ref=mf
Winters (2009)
Transvestic Disorder and Policy Dysfunction in the DSM-V
Kelley Winters notes:
At the Annual Meeting of the Society for Sex Therapy and Research this month, a “Provisional Report by the DSM-V Workgroup on Sexual and Gender Identity Disorders,” was presented by Chairman Kenneth Zucker and a panel of workgroup members. Ray Blanchard, who chairs the Paraphilias Subcommittee, summarized proposals for “Pedohebephilic Disorder” and “Transvestic Disorder” in the DSM-V. While Charles Moser, Ph.D., M.D., and others have long raised concern about all paraphilia diagnoses in the DSM, the current diagnostic category of Transvestic Fetishism is particularly stigmatizing and defamatory for male-to-female (MTF) cross-dressers as well as many transsexual women.
Dr. Winters then proceeds to dismantle these new spurious categories.
We are starting to see how the next edition of the DSM is being shaped, and how it will affect trans people until the mid-2020s.
Full article.
She adds:
“I ask the elected leadership and Board of Trustees of the American Psychiatric Association to affirm in a public statement that gender identity and expression which differ from assigned birth sex do not, in themselves, constitute mental disorder and imply no impairment in judgment or competence. I ask the DSM-V Task Force to honor this principle in the DSM-V by removing the current category of Transvestic Fetishism and rejecting Dr. Blanchard’s proposal to replace it with Transvestic Disorder. Finally, I invite members, allies and affirming care providers of the transcommunity to voice their concerns by publishing comments to this essay at gidreform.wordpress.com. I will forward these postings to the APA and DSM-V Task Force at the APA Annual Meeting in May.”
| Trans group: reflect all views in DSM-V revision committee |
Winters (2008)
Kelley Winters at GID Reform has announced a drive to add more diversity of opinion to the American Psychiatric Association Task Force that will determine the fate of trans people in the fifth Diagnostic and Statistical Manual of Mental Disorders (DSM-V). Headed by Arlene Istar Lev, they are calling on all professionals to write in support of expanding the group. Trans people have protested the heavy representation of people and views associated with Toronto’s Centre for Addiction and Mental Health (CAMH). The CAMH has promoted reparative therapy on trans children they felt could be cured of gender identity disorder, and they advocate a taxonomy that asserts all trans women are either homosexuals or paraphilics.
More info:
http://www.professionals.gidreform.org
Dr. Winters’ blog post:
Balancing Views on Gender Diversity in the DSM-V Process
A new group of concerned mental health and medical professionals and scholars is calling upon clinicians and researchers supportive of gender transcendent people to press for reform of gender diagnoses in the Diagnostic and Statistical Manual of Mental Disorders. Organized by author and Clinical Social Worker Arlene Istar Lev, they are urging colleagues to write the American Psychiatric Association with recommendations that new members be added to committees responsible for gender nomenclature in the upcoming fifth edition (DSM-V).
Professionals Concerned with Gender Diagnoses in the DSM urges all trans-supportive medical and mental health practitioners and researchers to write the APA DSM-V Task Force and request that the Sexual and GID Work Group be expanded to include more affirming views of gender diversity and transition care. A web resource at http://www.professionals.gidreform.org provides specific recommendations for nomination with biographical information and sample letters. For more information, contact GIDreform@gmail.com.
Kelley Winters, Ph.D.
GID Reform Advocates
http://www.gidreform.org
kelley@gidreform.org
Original URL: http://www.tsroadmap.com/notes/index.php/site/2008/09/P10/
| Maligning Terminology in the DSM: The Language of Oppression |
Kelly Winters of GIDreform has a good post on “maligning language” and how it effaces the identities of trans people.
Maligning language contradicts the social legitimacy of transitioned individuals. It denies our humanity and contributes to an environment of intolerance, discrimination and even physical violence. Tragically, such disrespectful conduct is encouraged with the authority of the American Psychiatric Association (APA) in the diagnosis of “Gender Identity Disorder” (GID) in the Diagnostic and Statistical Manual of Mental Disorders (DSM)
* Maligning Terminology in the DSM: The Language of Oppression
https://web.archive.org/web/20121204100702/http://www.tsroadmap.com/notes/index.php/site/maligning_terminology_in_the_dsm_the_language_of_oppression/
Miskimen (2008)
| Dr. Linda Miskimen: oppose Ken Zucker and Ray Blanchard on DSM committee |
Reverend Linda Miskimen has written a position statement opposing involvement in Ken Zucker and Ray Blanchard in the Sexual and Gender Identity Disorders work group for the DSM-V revision.
Full article (PDF)
zucker_APA.pdf
Reverend Linda Miskimen, Doctor of Philosophy in Religion, Circle Ministries, Bloomington MN.
http://www.circleministries.org
Forstein (2008)
| Update on the DSM-V Issue from Dr. Marshall Forstein |
Via quench zine, Dr. Marshall Forstein notes:
Before people get overly hysterical about the Gender Identity Work group for the DSM, some things need to be made clear.
The letter you are asking us to sign onto is inaccurate in many ways and does not help our cause. Let me clarify what I know as someone who has worked with the American Psychiatric Association for many years.
1- there are TWO professional associations: Both unfortunately go by A P A
a) one is the American Psychiatric Association [this is a MEDICAL society of physicians who specialize in psychiatry]
b) the other is the American Psychological Association [this is a non- medical society of psychologists who are not medical doctors but have a PhD or PsyD or EdD in psychology, either clinical or research or academic or all.]
The American PSYCHIATRIC Association is the organization that publishes the DSM. This is a guide to diagnosis and NOT to Treatment.
Dr. Zucker, although not my preferred choice to head the work group on Gender and Sexuality, does not decide himself what the American Psychiatric Association publishes in the next DSM. In fact, there is a lengthy, and complicated process of peer review based on PUBLISHED scientific literature- in fact, the way we got homosexuality OUT of the DSM [1973] was to force the scientific program committee to produce evidence that homosexuality was an illness, and then in 1989 we removed ego-dystonic homosexuality because there was no evidence to support it and we suggested that there was also ego-dystonic heterosexuality that was a phase of people coming to understand their inner nature.
Sexual orientation is NOT even an issue for the DSM committee to consider. Transgender Identity is a bit more complicated, especially in childhood. The DSM work group will struggle with these issues in coming up with criteria for what to diagnose as a true gender identity disorder. I WANT TO EMPHASIZE THAT TREATMENT RECOMMENDATIONS ARE NOT A PART OF THIS ENDEAVOR.
Any treatment recommendations that the American Psychiatric Association makes are the result of significant process of creating EVIDENCED based research.
I am currently the Chair of the Work group on Practices Guidelines on HIV Psychiatry for the American Psychiatric Association, and so am intimately aware of the process. Guidelines go through rigorous research review for controlled studies in order to make recommendations. Hundreds of people review these guidelines before publication, and the same will be true of the criteria set forth by the work group on the DSM gender identity subcommittee.
EVEN if there is literature out there that disturbs those of us who are comfortable with the concepts of transgender identity, unless it meets peer review by legitimate journals ( i.e. non religious based periodicals) it will not be considered in the development of criteria for diagnosis or treatment.
I hope that what I have written makes us pause a bit before we do something to alienate even our supporters and friends in the American Psychiatric and the American Psychological Association who have been very pro-gay and pro-trans in their deliberations so far. There will always be a vocal minority that claim otherwise, but the process is vetted by many people committed to scientific integrity and evidence.
I have alerted the Association of Gay and Lesbian Psychiatrists to the announcement of Dr Zucker’s appointment and we will be addressing the implications of this within the psychiatric and psychological professional groups. I will also be talking with the Medical Director of the American Psychiatric Association and the Director of the Research group that oversees the DSM to convey the concerns that people have about the “transphobia” that may emerge.
In good conscience, however, I cannot sign a petition that is inaccurate and misleading – it may do far more harm than good. Clarity of the scientific evidence, asking the right questions of the committee, and addressing the criteria that will be put forth for review before it is ever considered ready for publication is the only way we will be taken seriously.
Please let me know how I can help to keep the issues clear.
Marshall Forstein, M.D.
Associate Professor of Psychiatry
Harvard Medical School Director, Adult Psychiatry Residency Training
The Cambridge Hospital
The Cambridge Health Alliance
Thanks to quench zine for publishing this.