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an accurate nosology of gender disorders must distinguish enforcement of social conformity from legitimate issues of distress, impairment and effective medical care
theories which failed to justify the pathologization of sexual orientation are remarkably similar to those which underlie the present TF and GID categories
deletion of homosexuality from the DSM-II represented a rejection of its association with inherent distress and impairment
the issue is left open to interpretation for transvestic fetishism and gender identity disorder in the DSM-IV
an intention to standardize the diagnosis and treatment of transgendered individuals is not evident in the obscure and conflicting language of the DSM-IV
the current wording has no clear exit clause for post-operative transsexuals
the disparate treatment of sexual orientation and gender expression represents medical policy harmful to those it is intended to help

The Disparate Classification of Gender and Sexual Orientation in American Psychiatry

The Disparate Classification of Gender and Sexual Orientation in American Psychiatry

Katherine K. Wilson

Gender Identity Center of Colorado, Inc.,

1455 Ammons St., Suite 100

Lakewood, CO, U.S.A. 80215-4993

http://gicofcolo.org

 

1998 Annual Meeting of the American Psychiatric Association

Workshop IW57, Transgender Issues

Toronto, Ontario Canada

June 2, 1998

 

Abstract

In 1973, the Board of Trustees of the American Psychiatric Association voted to delete homosexuality as a mental disorder from the seventh printing of the second edition of the Diagnostic and Statistical Manual of Mental Disorders, or DSM-II. Twenty-five years later, the inclusion of diagnostic categories for Gender Identity Disorder and Transvestic Fetishism in the fourth edition of the DSM continues to raise questions of efficacy, consistency and stigma. In this paper, issues of gender identity and sexual orientation are compared in light of current definitions of mental disorder.

Introduction

Although human sexual orientation and gender identification represent distinct phenomena and are considered largely orthogonal, they are intricately intertwined in medical theory and social consequence. Since Magnus Hirschfeld (1910) coined the term "transvestite," studies have revealed that most gays and lesbians do not crossdress and most crossdressers are heterosexual. Nonetheless, sexual orientation and gender identity share many common elements pursuant to the definition of mental illness, including theories of etiology, social stigma, cross-cultural occurrence, and perceptions of distress, disability and disadvantage.

These parallel elements raise questions of consistency in light of the deletion of homosexuality as a mental disorder from the seventh printing of the second edition of the Diagnostic and Statistical Manual of Mental Disorders, or DSM-II, in 1973. If homosexuality and transgender identity or expression were classified as mental disorders for essentially the same reasons, then a reexamination of the DSM-IV categories of Gender Identity Disorder and Transvestic Fetishism is called for. On the other hand, direct comparisons of transgender and homosexual classification are complicated by the necessity of sex reassignment procedures for many transsexuals. Therefore, an accurate nosology of gender disorders must distinguish historical artifacts that serve to enforce social conformity from legitimate issues of distress, impairment and effective medical care.

 

Common Theories of Etiology

Prevalent psychodynamic explanations for male-to-female transgender identity and expression are closely linked to those for male homosexuality (Zucker & Blanchard, 1997). Freud (1905) associated homosexual development with oedipal frustration: an intense mother attraction coupled with a distant father figure. These boys then identify with their denied object of desire and assume her role in future relationships with men who resemble themselves. This view was echoed by Bieber and Socarides, who led the opposition to the declassification of homosexuality in the 1960s and 70s (Stoller, et al., 1973). Socarides (1962) emphasized a preoedipal failure to complete individuation from the mother. Like Freud, he made little distinction between sexual orientation and gender identity:

It is my conviction that it is necessary for all human beings to complete the separation-individuation of early childhood in order to establish gender identity. Failure to do so results in a deficit in masculinity for boys, with a corresponding intensification and continuation of the primary feminine identification with the mother, thus begins the course toward homosexual development. (Stoller, et al., 1973, p.1212)

Stoller and Green, of UCLA, applied a similar theory to male-to-female transsexualism with the axiom, "too much mother made possible by too little father" (Stoller, 1968, p. 264). Green, a principal analyst for the UCLA Feminine Boy project of the 1970s (Green, 1987), later equated childhood cross-gender expression with pre-homosexual orientation in a televised quip: "Barbies at five. Sleeps with men at twenty-five" (1995). Schott (1995) similarly correlated males diagnosed with transvestic fetishism with memories of closer relationships with their mothers than fathers. Person and Ovesey (1974, 1978), echoing Socarides, theorized that male cross-dressing reduces separation anxiety stemming from a failed preoedipal separation-individuation from the mother.

Conversely, Freud also postulated that a same-sex orientation could develop from too much father and too little mother (Freud, 1970). Here, strong paternal attachment or maternal rejection leads boys to seek father figures as sexual partners. In a corollary, fear of the father's rage, in retaliation for oedipal desires, leads a boy to escape castration anxiety by withdrawing from women and thus competition with the father. Zucker and Blanchard (1997) similarly associated adolescent transvestic fetishism with mother-son conflict, anger, and rejection. Zucker and Bradley (1995, p. 323) attributed early crossdressing to periods of mother absence and unavailability. The principle of Occam's Razor raises doubt that both theories can be valid, which would imply that ordinary sex-typed gender development requires a knife-edged balance between maternal and paternal influence.

Psychodynamic theories of homosexual causation were challenged on several points. First, they were based on clinical populations of gay and lesbian people seeking psychiatric help or incarcerated in prisons and hospitals and did not constitute a representative population (Hooker, 1957). Judd Marmor argued that,

if our judgment about the mental health of heterosexuals were based only on those whom we see in our clinical practices we would have to conclude that all heterosexuals are also mentally ill (Stoller, et al., 1973, p.1208-1209).

He went on to point out that not all gays and lesbians have a background of "disordered sexual development," not all with such backgrounds become homosexual, and emphasized that illness cannot be defined by background but must rest on its merits.

Like Bieber and Socarides, proponents of psychoanalytic theories of transgender etiologies relied on clinical study populations and anecdotal cases (Stoller, 1968). Zucker and Bradley (1995, p. 336) acknowledged the "likely bias in our clinical population," and called for "epidemiological studies of larger populations." They concluded that "boys who came from father-absent homes were, if anything, less feminine and/or more masculine" (p. 245). A controlled anthropological study of non-clinical male youths in a polygamous U.S. community failed to correlate father absence with cross-sex identity (Parker, et al. 1975). Zucker and Blanchard (1997) noted that most men with preoedipal personality pathology do not exhibit transvestic fetishism and that data supporting such pathology as the cause of TF is conflicting. They also criticized a methodological weakness of studies which relied on self-report of parental relationships without study of the parents themselves.

Freud (1957) himself concluded that homosexuality "cannot be classified as an illness." It seems ironic that psychoanalytic clinicians, more than any other mental health faction, opposed the declassification of sexual orientation from the DSM-II (Bayer 81). Ultimately, the APA concurred with Freud's view that an etiologic theory of homosexuality does not imply illness over the objections of his followers. The theories which failed to justify the pathologization of sexual orientation are remarkably similar to those which underlie the present TF and GID categories.

 

Distress and Impairment

The debate over psychiatric classification of sexual orientation in the early 1970s shifted from cause to consequence. Thomas Sasz's (1961) broad criticism of psychiatric classification had a profound influence in the sexual orientation debate and later changes in the definition of mental illness (Zucker & Bradley, 1995; Bayer, 1981). His skepticism that antecedent life experiences causally determine behavioral phenomena was reflected in the APA decision of 1973,

The crucial issue in determining whether or not homosexuality per se should be regarded as a mental disorder is not the etiology of the condition, but its consequences and the definition of mental disorder (APA, 1980).

Consequently, distress and impairment became central to the definition of mental disorder in the DSM-IV (APA, 1994, p. xxi), and a clinical significance criterion was added to the diagnostic criteria for all Sexual and Gender Identity disorders, including Transvestic Fetishism and Gender Identity Disorder:

The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (APA, 1994, p. 531).

A key point in the classification of sexual orientation was the distinction between distress or impairment experienced by a person and that believed inherent to homosexuality itself. It is remarkable that, over two decades later, this distinction is left unresolved for the transgendered disorders in the DSM-IV.

Inherent Distress and Impairment in Sexual Orientation

By the mid-twentieth century, prevailing psychiatric tradition considered homosexuality to be inherently pathological regardless of the health, happiness, or functionality of gay and lesbian individuals. This conclusion followed two basic threads: that deviance from what was presumed biologically natural constituted disability, and that homosexuality was inevitably associated with other pathologies. Rado (1962), following reproductive anatomy, asserted that male-female pair bonding constituted the sole healthy sexual adaptation. Bieber (1962) noted that "all psychoanalytic theories assume that homosexuality is psychopathologic" and referred to the "inherent psychological pain" of homosexuality (Stoller, et al., 1973, p.1210). As homosexuality was considered a maladaption to underlying oedipal conflict, it represented a symptom of assumed pain, even among those happy with their sexual orientation. Socarides (1962) stated that "heterosexual object choice is determined by two and a half billion years of human evolution," and linked same-sex practices to schizophrenia, paranoia, manic-depression, and borderline personality.

Heterosexuality as a biological imperative was disputed by Ford and Beach (1951), whose studies of non-human primates and supernumerary gender traditions among non-European societies provided cross-cultural and cross-species counterexamples. Marmor argued that vegetarians and celibate people also violate presumed biological norms but are not labeled mentally ill (Stoller, et al., 1973, p.1208). The concurrence of homosexuality with other psychopathology was challenged by Evelyn Hooker (1957), who found that a non-clinical gay population and heterosexual male control group could not be distinguished by Rorschach results. Marmor's observation of gay and lesbian people who were "happy with their lives and have made a constructive and realistic adaptation to being of a minority group in our society" was key to the APA's conclusion that homosexuality did not represent an inherent disadvantage in all cultures or subcultures (APA, 1980). Indeed, the emergence of a powerful gay rights political movement in the early 1970s (Bayer 1981), for all its controversy, was not congruent with the psychoanalytic portrait of distressed, disabled, and dependent gays and lesbians.

Inherent Distress and Impairment in Gender Orientation

Views of inherent impairment and distress in transvestism and transsexualism follow the same threads of deviance from presumed biological function and association with other psychopathology. Rado (1962), in rejecting Freud's theory of constitutional bisexuality, stated that "every individual is either male or female," rejecting the possibility of more than two natural genders. Zucker and Blanchard (1997) noted in studies of clinical subjects that transvestic fetishism impairs the ability to form pair bonds, but admitted that "systematic empirical studies have been scant." Accepting wives of male crossdressers have been characterized as having poor self-esteem (Feinbloom, 1976) or as angry toward men (Stoller, 1967), reminiscent of Socarides' (1962) description of homosexual relationships as "destruction, mutual defeat," and "exploitation." Gender dysphoria has been clinically associated with borderline personality disorder (Wise & Meyer, 1980) and crossdressing with various Axis II disorders (Zucker & Blanchard, 1997), as had been homosexuality twenty years earlier.

Rebuttals to theories of inherent transgender distress and impairment closely paralleled those in the case of sexual orientation. Beginning with Ford and Beach (1951), anthropological research has revealed a long list of supernumerary gender roles among many non-European cultures (Bolin, 1987; Bullough, 1993; Williams, 1986). These were accepted, often highly respected, societal roles difficult to characterize as pathological. The medical presumption of gender essentialism, exactly two natural sexes determined by genitalia, has been challenged by a growing body of socio-cultural literature that considers gender a social construction, not a biological imperative (DeBeauvior, 1952; Kessler, 1978; Butler, 1990; Garber, 1992; Lorber, 1994). Psychiatric studies of clinical populations, like those of clinical gay and lesbian subjects in previous decades, failed to consider the incidence of functional, well adjusted transgendered people and couples in society. Conversely, a long-term survey of members of a heterosexual cross-dressers' support organization (Prince & Bentler, 1972) suggested a high degree of education, vocational success, and self acceptance. A recent study (Cole, et al., 1997) of 435 gender dysphoric individuals found no significant Axis I or Axis II comorbidity on the basis of clinical interview and the Minnesota Multiphasic Personality Inventory (MMPI). This is remarkable given that the study was limited to a clinical population, two-thirds of which were undergoing hormonal treatments and committed to a real-life transition subject to considerable discrimination.

The deletion of homosexuality from the DSM-II represented a rejection of its association with inherent distress and impairment by the APA. In contrast, the issue is left open to interpretation for transvestic fetishism and gender identity disorder amid controversy (Zucker & Blanchard, 1997). Brown (1995) concluded that the clinical significant criterion excludes transgendered subjects from diagnosis in the absence of distress or dysfunction. However, the APA has stated that the same criterion includes ego-syntonic subjects diagnosed with pedophilia, "which by definition constitutes impairment" (APA 1996). A similar interpretation may be inferred for transvestic fetishism and gender identity disorder. For example, the DSM-IV paradoxically acknowledges non-erotic motivations for crossdressing in transvestic fetishism: "In such instances, the cross-dressing becomes an antidote to anxiety or depression and contributes to a sense of peace and calm" (APA, 1994). Thus, crossdressing that brings about calm instead of distress may be interpreted as symptomatic of inherent distress, "to ward off very early anxieties" (Wise & Meyer, 1980). This is reminiscent of the past characterization of homosexuality as a maladaption to underlying distress and of success in social functioning as masking pathology (Bayer, 1981).

Experienced Distress and Impairment

Proponents of classification of homosexuality as mental illness have long emphasized its utility in the interests of ego-dystonic gay and lesbian individuals who suffered distress and concurrent mental disorders. This was an important motivation for the creation of a new category, Sexual Orientation Disturbance, in 1973 for those "disturbed by, in conflict with, or wish to change their sexual orientation" (APA, 1980. p. 380). It was renamed Ego-dystonic Homosexuality in the DSM-III in 1980. This reasoning was criticized by Hooker (1956), who characterized disturbed behavior among gays and lesbians as "ego defensive," attributable to social stigma and victimization. Marmor (Stoller, et al., 1973, p.1209) concluded that mental disorders and illness among gays and lesbians are "not intrinsic to their homosexuality but is a consequence of the prejudice and discrimination that they encounter in our society." Spitzer, the architect of Sexual Orientation Disturbance, questioned the role of psychiatric classification in contributing to the distress and impairment of gays and lesbians:

In the past, homosexuals have been denied civil rights in many areas of life on the ground that because they suffer from a "mental illness" the burden of proof is on them to demonstrate their competence, reliability, or mental stability (Stoller, et al., 1973, p.1216).

Lay activist Ronald Gold, addressing the APA annual convention in 1973, characterized psychiatric pathologization as "the cornerstone of a system of oppression that makes gay people sick" (Stoller, et al., 1973, p.1211). Ego-dystonic Homosexuality was removed entirely from the DSM-III-R (APA, 1987, p.426), because it associated homosexuality with pathology and because "almost all people who are homosexual first go through a phase in which their homosexuality is ego-dystonic."

The medical professions have articulated a growing compassion and understanding of the issues faced by gays, lesbians and bisexuals. An amicus brief filed by the American Psychiatric Association, the American Psychological Association, the National Association of Social Workers and the Colorado Psychological Association in the case of Romer vs. Evans (APA, et al., 1994) states the following:

The harmful effects of prejudice, discrimination, and violence, however, are not limited to such bodily or pecuniary consequences... The effects can include depression, a persistent sense of vulnerability, and efforts to rationalize the experience by viewing one's victimization as just punishment. Gay people, like members of other groups that are subject to social prejudice, also frequently come to internalize society's negative stereotypes.

Clearly, the American Psychiatric Association does not consider such distress symptomatic of mental disorder for gay and lesbian people. Language that equates victimization with mental disorder trivializes the suffering caused by societal intolerance and draws attention away from legitimate sources of pain, such as gender dysphoria.

Gender dysphoria, stated as an aversion toward the physical characteristics and social roles of one's biological sex (APA, 1994, p. 767), is often described as a symptom of presumed underlying pathology rather than as a distress in itself. Thus, commonly reported mid-life gender dysphoria among male cross dressers is characterized as a "collapse" from ego-dystonic transvestism to deeper pathology in the face of stress (Wise 1980). Questioning the premise of cross gender pathology opens another possibility: that transgendered people commonly go through an ego-dystonic phase in response to intense stigma similar to that of gays and lesbians. In this paradigm, mid-life incongruity with one's physical sex or expected social role is not necessarily a "regressive phenomenon" (Person, 1974) but may represent a "coming out" process as denial gives way to self-acceptance (Wilson & Hammond, 1996). In evidence, Cole, et al., (1997) observed that their subjects "perceived themselves as happier, increasingly competent, and more productive... once they finally acknowledged their gender dysphoria."

Whether disability or impairment is considered inherent to cross-dressing or induced externally by social circumstances remains controversial (Zucker & Bradley, 1995) and is not clarified in the DSM-IV. What is more clear is that the societal prejudice directed toward homosexual and transgendered people is much the same. For example, a defeated 1994 Washington state ballot initiative stated:

 

This act would also prohibit any common school from presenting, promoting or approving homosexuality, bisexuality, transsexuality, or transvestism or such practices or relationships, as positive, healthy, or appropriate behavior or lifestyle. (Washington Committee for Equal Rights, Not Special Rights, 1994)

Transgendered people hold a wide variety of responsible occupational positions: psychiatrists, psychologists, attorneys, artists, scientists and writers, to name a few. Wording in the DSM-IV and supporting literature that implies inherent impairment for all transgendered people is inconsistent with the present understanding of distress among gay and lesbian people.

Other Differentiating Arguments

Statistical Prevalence

Statistical definitions of mental abnormality have been promoted in various forms for many years. Assumptions of deviation from statistical norms were central to early concepts of homosexuality as mental illness, before they were challenged by Alfred Kinsey's (1948) landmark survey of male sexuality. No formal epidemiological studies of transvestism (Zucker & Blanchard, 1997) or of GID children (Zucker and Bradley, 1995, p. 24) have been conducted, and data on the non-surgical transsexual population is scant. Nevertheless, Pauly (1992) argued that the infrequent occurrence of transsexualism supports its classification as mental illness:

First, transsexualism is much rarer than homosexuality, thus it is more difficult to sustain an argument that these GID [gender identity disordered] are simply a variation of the human condition.

It seems remarkably inconsistent to classify cross-gender identity as pathological because it is rarer than homosexuality and not apply the same argument to homosexuality versus heterosexuality, or left-handedness versus right-handedness. Moreover, defining deviance as disease has two fundamental problems (Ullmann, 1975). First, some unusual conditions are very desirable, such as very high intelligence. Second, a statistical definition equates mental health with conformity, discounting the historical contributions of nonconformists and the social dangers of overconformity.

The definition of "mental disorder" included in the DSM-III through DSM-IV is stated as follows:

In the DSM-IV, each of the mental disorders is conceptualized as a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom. (APA, 1994)

This definition does not include statistical deviance as a justification for psychiatric classification. Just as statistical prevalence does not necessitate the pathologization of gay and lesbian people, it does not justify the psychiatric classification of all transgendered people.

Diagnostic and Treatment Standards

The psychiatric classification of gender variance has been cited as necessary to conduct research on gender identity and provide consistent medical care:

Research in the field has been facilitated by having standardized criteria available for correctly diagnosing individuals with GID.... This has greatly increased our knowledge and understanding of GID, and has resulted in improved and more standardized treatment protocols (Pauly 1992).

First, no evidence has surfaced that our understanding of sexual orientation has diminished in the past 24 years, lacking a label of mental disorder. Gay and lesbian subjects, presenting a wide variety of disturbances are treated successfully for those specific conditions without labeling their sexual orientation as an illness or implying that all gay and lesbian people are mentally disordered. It is not clear why gender identity or expression differs in this regard.

Moreover, an intention to standardize the diagnosis and treatment of transgendered individuals is not evident in the obscure and conflicting language of the DSM-IV. For example, criterion A of the Transvestic Fetishism disorder is grammatically ambiguous (Wilson & Hammond, 1996):

Over a period of at least 6 months, in a heterosexual male, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving cross-dressing. (APA, 1994, p. 531)

The description, "sexually arousing," could be interpreted to apply to only "fantasies" or to all three of "fantasies, sexual urges, or behaviors" with very different meaning. The first interpretation would implicate all recurrent cross-dressing behavior and is very broadly inclusive. This is consistent with the DSM-IV Casebook (Spitzer, ed., 1994, pp. 257-259), and is endorsed by the present DSM Project Manager (McQueen, 1997). The second would limit the diagnosis to only sexually motivated cross-dressing, as did the DSM-III-R (APA, 1987, p. 289), and imply the unlikely phrase, "sexually arousing sexual urges." This confusion has sparked colorful controversy in the literature (Zucker & Blanchard, 1997, p. 273), but at the expense of transgendered individuals stigmatized by the overinclusive interpretation. Although labeled a "fetishism," it is not at all clear whether or not crossdressing must be sexual in nature to qualify for diagnosis.

The clinical significance criterion for Transvestic Fetishism and Gender Identity Disorder, described previously, fails to specify what kinds of distress or impairment indicate a psychiatric diagnosis. A clinician may infer that any expression of cross-gender identity represents inherent pathology in ego-syntonic transgendered individuals or the opposite: that only ego-dystonic subjects qualify for diagnosis. Little guidance is provided by the DSM-IV to promote consistency.

In the case of gender non-conforming children and adolescents, the GID criteria are significantly broader in scope in the DSM-IV (APA, 1994, p. 537) than in earlier revisions, to the concern of many civil libertarians. A child may be diagnosed with Gender Identity Disorder without ever having stated any desire to be, or insistence of being, the other sex. Boys are inexplicably held to a much stricter standard of conformity than girls. A preference for cross-dressing or simulating female attire meets the diagnostic criterion for boys but not for girls, who must insist on wearing only male clothing to merit diagnosis. References to "stereotypical " clothing, toys and activities of the other sex are imprecise in an American culture where much children's' clothing is unisex and appropriate sex role is the subject of political debate. Equally puzzling is a criterion which lists a "strong preference for playmates of the other sex" as symptomatic, and seems to equate mental health with sexual discrimination and segregation.

Author Phyllis Burke (1996) describes cases of children as young as age three institutionalized or treated with a diagnosis of GID for widely varying gender nonconformity. She presents evidence of increasing use of GID for children suspected of being "prehomosexual," and not necessarily transsexual. Diagnosis and treatment is often at the insistence of non-accepting parents with the intent of changing a perceived homosexual orientation. Burke quotes Kenneth Zucker, of the GID subcommittee, that parents bring children to gender clinics for the most part "because they don't want their kid to be gay" (p. 100).

Zucker and Bradley (1995, p. 53) noted that "homosexuality is the most common postpubertal psychosexual outcome for children [with GID]." They defended the treatment of gender nonconforming children on three points: reduction of social ostracism, treatment of underlying psychopathology, and prevention of GID in adulthood (pp. 266-7). The first appears to shift the blame for the distress of discrimination from its inflictors to its victims. The second presumes theories of psychosocial etiology discussed previously. With respect to the third, Zucker and Bradley conceded that,

there are simply no formal empirical studies demonstrating that therapeutic intervention in childhood alters the developmental path toward either transsexualism or homosexuality (p. 270).

This use of Gender Identity Disorder for children and youth was recently condemned by the National Gay and Lesbian Task Force (originally the National Gay Task Force, founded in 1973 to lobby against inclusion of homosexuality in the DSM-II, Lobel, 1996) and the San Francisco Human Rights Commission (1996).

Far from promoting consistency in diagnosis and treatment, ambiguous and conflicting language in the DSM-IV has created much confusion and controversy. Interpretation of the Gender Identity Disorder and Transvestic Fetishism diagnostic criteria may range from a narrow definition of objective distress to an overinclusive loophole to the American Psychiatric Association decision to declassify homosexuality as a mental disorder.

The Necessity of Medical Intervention.

Issues involving medical procedures, such as psychotherapy, hormonal therapy and sexual reassignment surgeries are often cited to support the DSM inclusion of Gender Identity Disorder in pragmatic terms. Pauly (1992) stated that necessity of medical intervention justifies the disparate treatment of Gender Identity Disorder and homosexuality in the DSM:

...a homosexual individual need not present to the medical or psychiatric profession in order to pursue his/her lifestyle.

Psychotherapy or counseling is indeed helpful to transgendered people dealing with issues of shame, secrecy, depression, and prejudice. Counseling is often crucial for those anguished by their genitalia, and corrective procedures require the specialized skills of endocrinologists, urologists, and cosmetic surgeons. Moreover, dysphoria of one's born gender role can be extremely painful, even for transgendered individuals not pursuing SRS procedures.

The central issue of medical necessity is one of treatment focus. Is the distress of genitalia and assigned roles that are incongruent with inner gender identity the focus of treatment, or is gender identity itself the disorder when incongruent with genitalia and assigned role?

For example, gay and lesbian individuals suffering social prejudice and stigma often can benefit from counseling and psychotherapy. In a 1993 study of 194 lesbian, gay, and bisexual youth from 14 community centers, 42% reported prior suicide attempts (D'Augelli, 1993). For those who do seek help, the APA is very cautious not to worsen their stigma by associating mental illness with sexual orientation. In fact, the term "homosexuality" is not even listed in the index of the DSM-IV.

For sex reassignment procedures, the Standards of Care for the Hormonal and Surgical Sex Reassignment of Gender Dysphoric Persons, from the Harry Benjamin International Gender Dysphoria Association (1990), specifically require a diagnosis of transsexualism as listed in the DSM-III-R The rationale is that cross-gender identity is legitimized by psychiatric classification as a condition worthy of evaluation and treatment (Pauly, 1992; Bolin, 1988). By implication, SRS procedures might cease to be offered to transsexuals without a diagnosis to validate their medical necessity and justify their risks.

However, the current wording has no clear exit clause for post-operative transsexuals. It lists postsurgical complications as "associated physical examination findings" of individuals with GID (APA, 1994, p. 535). Transsexuals who openly face discrimination every day are poorly served by a stigma of psychiatric disorder that burdens them to continually prove their mental competence.

An overinclusive psychiatric classification of an entire class of people is problematic, especially when the distress associated with the condition results from social stigma that is exacerbated by the classification itself. On the other hand, deleting Gender Identity Disorder, in the absence of an accepted medical justification for SRS procedures, would likely reduce access to those procedures. Perhaps in the future, a physical diagnosis for transsexualism will be offered that is more consistent with surgical and hormonal solutions than the current mental disorder model. In the meantime, there is substantive cause to review the broad and conflicting language of Gender Identity Disorder and Transvestic Fetishism in the DSM-IV. The benefits of reducing the stigma of psychosexual illness on all transgendered individuals, while maintaining a clear and specific justification for treating the pain of gender dysphorias, merit investigation.

 

Summary

American psychiatric perceptions of etiology, distress, and treatment goals for transgendered people are remarkably parallel to those for gay and lesbian people before the declassification of homosexuality as a mental disorder in 1973. The diagnostic categories of Gender Identity Disorder and Transvestic Fetishism, like Homosexuality in past decades, may or may not meet current definitions of psychiatric disorder depending on subjective assumptions regarding "normal" sex and gender role and the distress of societal prejudice. Recent revisions of the Diagnostic and Statistical Manual of Mental Disorders have made these categories increasingly ambiguous and reflect a lack of consensus within the medical professions. The result is that a widening segment of gender non-conforming youth and adults are subject to diagnosis of psychosexual disorder, severe stigma, and loss of civil liberty. Revising these diagnostic categories will not eliminate transgender stigma but may reduce its legitimacy, just as DSM reform did for homophobia in the 1970s. It is possible to define a diagnosis that specifically addresses the needs of those requiring medical treatment with criteria that are clearly and appropriately inclusive. Until this is accomplished, the disparate treatment of sexual orientation and gender expression represents medical policy harmful to those it is intended to help.

 

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This paper is a revised and expanded version of a previous article of the same title, published in Psychiatry On-Line, The International Forum for Psychiatry, Priory Lodge Education, Ltd., April, 1997, www.priory.co.uk/psych.htm. The original article is available on-line at www.priory.com/psych/disparat.htm.

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