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transcript of the talk as it was given at the 2009 WPATH conference in Oslo, Norway, June 19, 2009
Diagnosis should center on gender dysphoria, which is distress associated with sexed characteristics of the body and/or social gender role
should be large enough to encompass all of those who need it
should be narrowly defined to only include those who are experiencing gender dysphoria, not to those who are merely gender non-conforming
Gender Madness in American Psychiatry Gender Madness in American Psychiatry: Essays from the Struggle for Dignity,
by Kelley Winters (2008)
www.gendermadness.com
Sexual and Gender Diagnoses of the Diagnostic and Statistical Manual (DSM), A Reevaluation , Karasic and Drescher, Eds. (2005)
Order from IFGE

Presentation to the 2009 WPATH Symposium, Oslo, Norway

Revision Suggestions for Gender Related Diagnoses in the DSM and ICD

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


Ehrbar, Randall D., Psy.D.
Winters, Kelley, Ph.D.
Gorton, R. Nicholas, M.D

a presentation to

The World Professional Association for Transgender Health (WPATH)
2009 XXI Biennial Symposium
June 19, 2009
Oslo, Norway


Abstract:


Starting with different beliefs and assumptions about appropriate diagnoses for transgender and gender variant individuals suffering from gender dysphoria, the members of this panel have reached similar conclusions about desirable changes to diagnostic categories in the next version of the DSM and ICD. Important points of agreement are that revised versions of diagnoses such as GID, Transsexualism, and GID in children 1) should center on gender dysphoria, which is distress associated with sexed characteristics of the body and/or social gender role, 2) should be large enough to encompass all of those who need it including those with non-binary gender identities, and those who do not wish to fully medically or socially transition to the “opposite” gender, 3) should be narrowly defined to only include those who are experiencing gender dysphoria (and are therefore presumably in need of treatment), not to those who are merely gender non-conforming. We will discuss the different premises and constructs on which the three authors base their conclusions and explore how despite these significant epistemological differences, the same conclusions become apparent. We will also discuss placement of diagnostic categories, nomenclature, “exit clauses” for trans-people who no longer experience gender dysphoria, cultural and sociopolitical significance of diagnostic categories and discourses around such categories, and appropriate diagnosis of distress primarily due to discrimination and oppression rather than gender dysphoria.


Note: This is largely a transcript of the talk as it was given at the 2009 WPATH conference in Oslo, Norway. At the end of the document we also present some of the audience comments and responses during our discussion at the end. Randall's part of the presentation is in green, Kelley's in red and Nick's in blue.


Introduction:


We come at this issue from a variety of different backgrounds and viewpoints differing on whether there should be a diagnosis at all or what kind of diagnosis it should be. When I first approached Dr. Nick Gorton and Dr. Kelley Winters they both were a bit skeptical, in fact, because they perceived that the other had very different viewpoints. Yet we agree about fundamental principles of treatment and rights for trans people. We may just differ in the ways that we think these things can best be accomplished. In the process of working on this talk we discovered that not only do we share common basic principles, but even had some common ground about utility of having a diagnosis and what such a diagnosis should look like if there is a diagnosis. . We were also able to generate compromises that could accommodate those areas where we do have fundamental differences. One of the first things we did in preparing for our talk was to write in 30 words or less our fundamental beliefs about diagnosing transgender people with an illness and what that does for the community.


Exercise: In 40 words summarise your thoughts about:


  • Do transgender people experience illness? Mental illness?

  • Regardless of whether it is a (mental) illness, should it be kept in the DSM or in the ICD?

  • Does understanding transgenderism as illness help or hinder the civil and medical rights movement for the community

On the next slide we are going to present our summaries, and while I present that and before the end of the talk, I want you to write your own summary... try to keep it under 40 words, but it can be as simple as just a few. At the end we're going to look at some or all of them... you don't have to write your name.


What We Think:


  • Winters - Individuals whose gender identity or expression differ from assigned birth-sex are labeled mentally disordered in the DSM-IV-TR, inflicting harmful social stigma and barriers to transition care.

  • Ehrbar - Practically, diagnosis is needed for access. Conceptually, it makes sense to categorize gender dysphoria as a mental health disorder.

  • Gorton - GID (by any name) belongs in DSM-V. Revisions can foster acceptance among consumers without compromising scientific accuracy. Diagnosis facilitates insurance coverage and disability protections.

We also explicitly identified our common ground is with regard to access to care, non-discrimination, social justice, and civil rights. We have a good deal of common ground about how we think the world should be. In fact, we suspect that most if not all of the folks here at WPATH share these fundamental beliefs. , I It's worth reminding ourselves that we do agree that trans and gender variant people shouldn't be subject to discrimination, should have access to health care and should have civil rights and protections.


The Authors' Shared Vision:


  • End discrimination on the basis of gender identity and expression

  • Gender identity and expression that differ from assigned birth sex do not, in themselves, constitute a mental disorder or an impairment in competence

  • Hormonal and/or surgical transition treatments to relieve gender dysphoria are medically necessary

  • Insurance and health care coverage for medically prescribed transition treatment

  • Legal recognition/documentation for all people that is consistent with their gender identity and expression.

  • Reform must fit everyone's needs, but as a social justice movement we must weigh more heavily the needs of those least enfranchised.


What is Your Vision?


The second exercise we invite you you to do is to identify any fundamental principles on which you think people on all sides of this issue can agree that we've missed. Briefly, exercise 1 is what you think. whereas exercise 2 is the common ground on which we all agree.


The Purpose of Diagnostic Nosology:


The use of a formal diagnosis is often important in offering relief, providing health insurance coverage, and guiding research to provide more effective future treatments” WPATH Standards of Care, 2001


So we come to the question of why do we diagnose things in the first place? The primary reasons are that we want to be able to offer treatments to people and to do so effectively. We also need to describe and understand what we are treating. Since people tend to have the same sorts of illnesses, it can be useful to know what treatments are effective for people with a given illness as a group instead of starting fresh with every individual. We also, in our society believe that people should have access to health care. However in one form or another payment for care is restricted to care that is necessary and that treats an illness or significantly promotes health. Thus we also use diagnoses as a standardized way to describe what are real health problems. An example of this is the ICD – the international classification of diseases, which helps us know what is a disease and helps insurance payers know what they should cover. In addition we want to be able to improve the care we provide through medical research, so diagnostic categories can be useful to help us define populations. This is the reason that the DSM is the diagnostic and statistical manual of mental disorders.


The Conundrum:


The transcommunity and care providers have long been polarized by fear that we must chose between stigma of mental illness and sexual deviance or lose access to hormonal and surgical procedures as well as disability protections.


One of the problems with this question historically is that the trans community has been divided about whether we should be classified as a having a disease. This is one of the major points where there is a lack of consensus on this panel. On one side people believe that having a diagnosis is necessary to gain access to health care services. They feel that it is important to ensure that we have a diagnostic nomenclature so insurers will judge us as having a condition for which there is necessary care and so that disabilities protections will include us. On the other side, many feel that there is an inherent harm in accepting the illness label and that this label is used against trans people in both legal situations and within the health care arena to deny access rather than gain it.


Discourse around removing or modifying the diagnosis, should be mindful of issues concerning the broader disability rights movement.

When discussing the stigma of mental illness we should refrain from language that itself stigmatizes people with mental illness


Though whichever side of this discourse one espouses, its very important for us to remember that when talking about the stigma and negative consequences for people with medical or mental health disabilities we must refrain from using language that perpetuates the stigma. We shouldn't do to others what we do not wish to be done to our community.


I come from a people who gave the Ten Commandments to the world. Time has come to strengthen them by three additional ones, which we ought to adopt and commit ourselves to: thou shall not be a perpetrator; thou shall not be a victim; and thou shall never, but never, be a bystander”

-Yehuda Bauer, Professor of Holocaust Studies Hebrew University of Jerusalem


That quote is important to consider. Even if we believe that transgender people have no mental illness or any illness whatsoever, its important that our community not be a bystander while others are subject to the very discrimination that we think no one should endure.


The GID/TF Diagnoses Pose Barriers on Both Civil Liberties and Medical Care Access:


The current diagnostic nomenclature of disordered gender identity and Fetishistic Transvestism has failed us on both issues of stigma and transition care access. It is not a question of either/or; not of one versus the other; it is a failure on both issues.

The current diagnostic criteria for Gender Identity Disorder for Adults, and Adolescents and for Children, lack clarity on who should be diagnosed and who should not. Ambiguous language, preoccupation with antiquated sex stereotypes, and incongruence with the definition of mental disorder have confused care providers, medical policymakers, and insurers, posing barriers to access to transition care.


Worse yet, the specific diagnostic criteria and supporting text of the current GID category contradict transition care and are more congruent with the opposite approach – punitive gender-conversion or gender-reparative treatments intended to shame or suppress gender identity and expression which differ from assigned birth sex roles.


...but a better diagnosis can be used to advance both civil liberties and medical care access


Supportive care providers need better diagnostic coding to make transition procedures available to individuals who require them. We believe it is possible to replace GID with nomenclature in the DSM-V that addresses both issues of social stigma and access to transition care: reducing unfair stigma of mental illness and sexual deviance while at the same time supporting rather than contradicting social and/or medical transition.



Social Stigma of Sexual Deviance:


A full-page ad campaign last year was sponsored by Focus on the Family in opposition to trans-inclusive civil rights legislation in Colorado. It depicted transwomen as sexual predators in restrooms. This is how transwomen are portrayed, this is the obstacle we face each day in our communities, as a consequence of this unfair stigma that is perpetuated and legitimized by the current GID and TF nomenclature.

Political extremists increasingly cite the American Psyhiatric Association directly in defaming gender variant people. For example, a New Hampshire group stated in 2008:

“Is New Hampshire ready to give civil rights to a behavior that is classified as mental disorder by the ... APA?”

In 2007, a Maryland extremist group dedicated an entire web page to denouncing transgender civil rights based on the DSM. It stated,

“’Gender Identity Disorder’ is classified as a mental disorder by the American Psychiatric Association. Legal protection against discrimination based on mental illness is not provided for any other disorder, and there is no rational explanation why it should be offered for this one. Those who wish to assume a ‘gender identity’ contrary to their biological sex are in need of mental health treatment to overcome such disturbed thinking, not legislation to affirm it.”


Transition Medical Care Access:


Many health insurance plans categorically exclude coverage of mental health, medical, and surgical treatments for GID, even though many of these same treatments, ... are often covered for other medical conditions”

American Medical Association Resolution 122


Last year, the American Medical Association acknowledged that “Many health insurance plans categorically exclude coverage of mental health, medical, and surgical treatments for GID, even though many of these same treatments, ... are often covered for other medical conditions”

The role of the current GID and TF categories in these barriers is illustrated by Dr. Paul McHugh, former psychiatrist-in-chief at Johns Hopkins Hospital, who used psychiatric classification to justify terminating gender confirming surgeries there. He said,

“I concluded that to provide a surgical alteration to the body of these unfortunate people was to collaborate with a mental disorder rather than to treat it.”[7]


Dr. Paul Fedoroff of the Toronto CAMH center (formerly the Clarke Institute of Psychiatry) cited the GID diagnosis to urge elimination of gender confirming surgeries in Ontario in 2000. He stated,

“TS [transsexualism, in reference to the GID diagnosis] is also unique for being the only psychiatric disorder in which the defining symptom is facilitated, rather than ameliorated, by the ‘treatment.’ … It is the only psychiatric disorder in which no attempt is made to alter the presenting core symptom.”


RESOLVED, That the AMA support public and private health insurance coverage for treatment of gender identity disorder; and be it further

RESOLVED, That the AMA oppose categorical exclusions of coverage for treatment of gender identity disorder when prescribed by a physician”

American Medical Association Resolution 122



In contrast, the American Medical Association, the American Psychological Association, and I'm very proud to say, WPATH have issued public statements clarifying the medical necessity of hormonal and/or surgical transition treatments for those who suffer distress caused by deprivation of physical characteristics congruent with their gender identity. Moreover, they have opposed healthcare exclusion of trans and transitioning individuals. This is the model, the new standard, that the we hope the American Psychiatric Association will follow in the DSM-V and in their own public position statements.


Recommendations for Harm Reduction of the GID Diagnosis in the DSM-V:


The DSM-V will likely impact public acceptance, civil rights, social justice and medical care of gender variant people through the end of the 2020s.


We know that there will almost definitely be a diagnosis in the DSM V and the ICD-11 which will affect the medical access and civil rights of transgender people for many years; therefore, the immediate issue is to improve the diagnosis so that it better reflects the experience of trans people and is more useful in supporting access to care and civil rights of trans people rather than undermining them.


Exercise 3, Three Boxes:


Exercise 3, Three Boxes

  • 3 boxes: 5 votes

  • What should govern whether gender dysphoria is included in the DSM/ICD?


The next exercise we invite you to do is to describe which considerations you think are the most import in making decisions about whether a diagnosis should exist in the DSM and ICD and what that diagnosis should look like. Please draw three boxes on your third card... label the first one Scientific and Clinical validity, the second Civil Rights and Social Consequences. And since we don't want to force anyone into binary categories, there is a third box for other considerations.

Then after you have your boxes drawn, you get 5 votes to put in those boxes and you can divide your 5 votes among the factors you find most important. If for example, you think Civil Rights and Social Consequences are the only thing that should be considered, you can put all 5 marks in that box and so forth.


Exercise 4, Three Humps:

Exercise 4, Three Humps

As the result of a discussion in the WPATH Consensus Statement Workgroup during this conference we added a fourth exercise to our talk. This exercise is the result of a discussion where we tried to gain consensus by trying to classify attitudes within a binary system of belief (which is quite interesting coming from a group of people who are transgressing boundaries or helping our patients transgress boundaries.)

However we came up with a model where while there are ends of the spectrum that few people inhabit, there are three large humps that we can identify on the spectrum where people tend to gather. The far left end of the spectrum is that transgender people have no recognizable diagnosis and that there should be no diagnostic classification identifying transgender people in any scheme – no diagnosis in the DSM-V, but also no diagnosis in the ICD-11. The far right end of the spectrum is the belief that the current DSM criteria are appropriate and should be kept as they are without revision in DSM V. The first hump going left to right is the group who feel it definitely isn't a mental illness and should not at all be in the DSM but it should be included in the ICD as a non-psychiatric diagnosis. The middle hump takes a pragmatic attitude that it is in the DSM and our focus should be on reforming the criteria to work better to help transgender people access health care and acceptance in society. People in this group may believe it is not a mental illness, or they may not be sure whether it is, or simply not care whether it is, simply focusing on pragmatic use. The most right-ward hump is those people who believe that gender dysphoria makes sense as a mental health condition, and thus is best classed in the DSM. However this group also believes that the diagnosis should be changed in ways similar to the middle hump so that it better serves transgender people.


The main difference between the middle and the right most hump is the belief that it is actually a mental illness. The difference between the middle and left most hump is the belief that gender dysphoria should be kept in the DSM.


Focus of Pathology on Gender Dysphoria:


  • Clarify diagnostic criteria to reemphasize gender dysphoria:

  • Gender identity per se is not a symptom

  • Remove actions taken to resolve dysphoria from criteria (i.e. presenting in desired gender role)‏

  • Remove nonconformity to assigned birth sex from diagnostic criteria

The conceptual center of the diagnosis is gender dysphoria, and the criteria for GID in the DSM as well as Transsexualism in the ICD should be modified to reflect this. It is clear from the experience of trans people that their gender identity is not “the problem,” nor is degree of gender conformity “the problem.” Unfortunately, the current diagnostic criteria are overly broad and also treat gender identity different from that assigned at birth and gender non-conforming behavior as if they were pathological, and actions taken to resolve gender dysphoria as if they were symptoms


Gender Dysphoria Is...

  • Distress with current

    • physical sex characteristics, (including anticipated pubertal changes for youth)
      AND/OR
    • ascribed gender role that is incongruent with persistent gender identity

There are two separate but related aspects of gender dysphoria—distress with sexed aspects of the body, that is primary or secondary sex characteristics and distress related to social gender role. Distress with physical sex characteristics also includes anticipated development of secondary sex characteristics, for example in puberty. This is especially important for natal males who may undergo distressing masculinization if testosterone is not suppressed.


This distress should be conceptualized as relative to the current situation—the current state of the body and social gender role, not the gender role assigned at birth or the body prior to modification. People who have been able to access physical interventions and are now happy with their body—great! They no longer have anatomic gender dysphoria. Similarly, people who have successfully been able to shift to a social gender role congruent with their gender identity they no longer have social gender dysphoria.


Clinical Significance Criterion


  • Clarify impairment in the clinical significance criterion to exclude sequelae of societal intolerance, prejudice and discrimination.

  • Distinguish distress of gender dysphoria, with physical sex characteristics or ascribed social gender role, from distress caused externally by societal or family intolerance.

The DSM should never imply that to be a victim of prejudice is to be mentally disordered.


While it can be difficult to distinguish between internal distress and distress which is influenced by stigma or minority stress, if a person is happy with his/her/hir social gender role and physical body, that person should not be diagnosed with this diagnosis. . (Although they may be in remission—more on that later.) Someone who is facing anti-trans discrimination may not need any diagnosis—certainly being in a group which is subject to discrimination is not diagnosable per se. If they are experiencing a significant level of distress which qualifies a diagnosis in another diagnositic category may be appropriate. Examples include adjustment disorder, depression, anxiety, or even PTSD in cases of extreme mistreatment. This is similar to how we would handle diagnosis of someone who is being subject to discrimination for any other reason such as homophobia, classism, racism, sizism, etc.


Diagnosis:


  • Diagnosis isn’t the same as etiology

  • Diagnosis isn’t the same as treatment

  • A clarification in the conceptual center of the diagnosis does not necessarily change HOW treatment is done, but does change WHY treatment is done

  • Measure of successful treatment is remission of gender dysphoria:


Not gender conformity, gender identity, or sexual orientation


Diagnoses often capture diverse groups of clients who share a conceptually central presenting concern. It is clear that there are a variety of meaningful categories into which trans-people can be divided. At a basic level, transmen and transwomen are different from one another. However, it is not necessary to have separate diagnostic categories for each identifiable subgroup of people with different identities or gender expressions as the ICD currently attempts to do with different diagnostic categories of Transsexualism and Dual Role Transvestism. We only need to ask: does this person experience gender dysphoria?


Diagnosis is also distinct from treatment. One of the problems with the current GID diagnosis is that it is worded in such a way as to imply that treatment which facilitates transition is inferior to treatment which encourages conforming with gender assignment at birth. The conceptual why of treatment should hinge upon the central concept of the diagnosis—in this case gender dysphoria. If treatment helps to resolve gender dysphoria, that treatment is successful. If it does not, it is not. For example in the case of children, because the current diagnostic criteria include a lot of criteria which reflect gender role conformity, a provider working with a child to behave in gender role conforming ways can say “this treatment was successful—the child no longer meets the diagnostic criteria.” Under a gender dysphoria based diagnosis a clinician who believes that working with a child to be more successful in behaving in a gender appropriate way will resolve the gender dysphoria the child experiences could still use that treatment. So the how doesn’t necessarily change. But the measure of whether the treatment is successful changes: the question become not is the child gender conforming, but does the child experience gender dysphoria?


Gender Dysphoria in Children:


  • Reduce stigma of psychosexual pathology for gender expression differing from assigned birth-sex role.

  • Reduce false positive diagnosis of gender nonconforming children who were never gender dysphoric.

  • Remove all reference to gender nonconforming expression in diagnostic criteria and supporting text.

  • Remove archaic “aversion” clauses in diagnostic criteria regarding “rough and tumble play” and “normative feminine clothing”

Speficically exploring the diagnosis of children, the criteria should also center upon gender dysphoria rather than gender nonconformity. A boy can enjoy activities which are stereotypically feminine and still feel confident that he is a boy and be happy with his body. He should not receive this diagnosis as he does not have gender dysphoria. If he is happy with himself and functioning well he does not have a mental illness at all. If he is suffering due to relationship problems with family or peers another diagnostic category would be more appropriate just as would be used for a boy who is suffering because he is ridiculed on some other grounds, such as weight or religion. It can be useful in diagnoses describing children to provide behavior examples as children may not be able to verbalize their inner states as well as adolescents or adults. However those examples should be centered upon gender dysphoria rather than behavior that adults label as 'male typical' or 'female typical.' Examples should include a natal female who is distressed by lack of a penis or a natal male who is distressed by the presence of one. The current criteria seem to equate the dislike of rough and tumble play in a natal male to distress because a natal male wishes his penis would disappear, and this equation is not conceptually sound. While it may be common for natal males who experience gender dysphoria to dislike rough and tumble play, this is not per se an expression of gender dysphoria in and of itself.


Appropriate Diagnostic Inclusion:


The Goldilocks Test: Gender Dysphoria Dx should be

not too big,
not too small,
but just right.

In the Story of Goldilocks and the Three Bears, a young antagonist seeks that which is “just right” in her journey of burglary and criminal trespass: not too hard, not too soft, not too hot or cold, but just right. Psychiatric diagnosis should similarly fit the needs of the patients and society: not inappropriately overinclusive, not exclusive of those who need care, but just right.


Inclusion of Those Who Need Care :


Clarify anatomical dysphoria to include:

  • Distress with current incongruent characteristics

  • Deprivation of congruent characteristics

Include full spectrum of human diversity as legitimate gender identities and expressions.

  • Remove binary language of 'other' and 'opposite' sex from criteria and supporting text

An InRemission specifier to provide care to those no longer dysphoric


Diagnostic nomenclature should be inclusive enough to meet the needs of those who need care. We recommend that criteria clarify the anatomical component of gender dysphoria to include clinically significant distress with current sex characteristics that are incongruent with gender identity, including distress caused by deprivation of characteristics that are congruent with inner identity. These should encompass anticipated sex characteristics for gender dysphoric youth approaching puberty as well.

Diagnostic criteria and supporting text should respect a diverse spectrum of gender identities and expression that are beyond stereotypical binary sex stereotypes. We suggest that dichotomous language such as “cross-gender,” “other sex” and “opposite sex” be removed.

Finally, we suggest that an InRemission specifier may be necessary for individuals who previously met the diagnostic criteria, whose dysphoria has been successfully ameliorated, and who require ongoing access to medical or mental health care to maintain relief from dysphoria. The supporting text should clarify when the diagnosis and specifier would no longer apply to an individual.


Reduction of False-Positive Diagnosis:

Limit Dx to those experiencing dysphoria

Exclude those who are merely gender non-conforming

  • Remove gender expression stereotypes from Dx

  • Exclude gender non-conforming children who are not distressed by anatomy or birth assignment


Another concern with the current GID category is false-positive diagnosis of people who meet no definition of mental disorder and suffer no distress or impairment with their bodies or ascribed roles. For example, children may be diagnosed with GID strictly on the basis of gender role nonconformity with no evidence of distress with their born bodies or assigned role. We recommend that all references to attypical or nonconforming gender expression be removed from the diagnostic criteria. They are not relevant to the definition of mental disorder and equate difference in itself to disease.


Exit Path for those who are no longer dysphoric

  • Remove 'cross-gender' and 'other sex' language

  • Remove pathological description of transition

  • Remove 'conviction' and 'belief' language

Moreover, there is no exit clause to the GID diagnosis for those who have transitioned and gained relief from gender dysphoria, regardless of how happy and well adjusted they are. For example, post-transition individuals are permanently trapped in criteria A and B by language of nonconformity to assigned birth sex. For example, Criterion A includes the clauses,

“desire to be the other sex, frequent passing as the other sex, desire to live or be treated as the other sex, or the conviction that he or she has the typical feelings and reactions of the other sex,”

as symptomatic of mental illness, where “other sex” means, other than assigned birth-sex. These assertions would remain true for all happy, ego-syntonic individuals who have transitioned, who for the rest of their lives would meet Criterion A.

Criterion B historically was the gender dysphoria criterion before the DSM-IV. However, gender dysphoria is rendered moot by the clause,

“belief that he or she was born the wrong sex.”

Again, virtually all happy, well adjusted, transitioned people will always believe that they were born or assigned the wrong sex and will therefore always meet Criterion B. Like the Hotel California, there is no escape from a GID diagnosis.

“You can check out any time you like, but you can never leave.”

We recommend removal of “cross-gender” and “other sex” language, pathological descriptions of transition, as well as clauses describing beliefs and convictions as pathological.


Issue: Should diagnosis be limited to anatomic gender dysphoria, or should social role dysphoria be included?

An issue for discussion is the scope of gender dysphoria for diagnostic purposes. Should it be limited to anatomical dysphoria as just described, or should it also include social gender dysphoria, that is distress with ascribed or assigned gender role? While no clinical assessment is necessary for social gender role transition for many individuals, access to medical transition procedures, such as hormones or FTM chest reconstruction, is prerequisite to social transition for others. For this reason, we include both anatomic and social gender dysphoria in our recommendation for diagnostic criteria.


Transvestic Fetishism:


Recommendation: Remove the diagnostic category of Transvestic Fetishism (TF), in the Paraphilias section.

It equates crossdressing and expression of femininity by born males with sexual deviance.

Located in the Paraphilias section with pedophilia, exhibitionism, and voyeurism, Transvestic Fetishism equates crossdressing and expression of femininity by birth-assigned males with sexual deviance. Ambiguous language in Criteria A and B may implicate all transwomen, including transsexual women, who are birth-assigned male, attracted to women, wear clothing that is typical or ordinary for other women, and are distressed by social prejudice as perpetually diagnosable. In fact, the DSM-IV Casebook, edited by Robert Spitzer, recommends a diagnosis of Transvestic Fetishism for a male whose cross-dressing is not necessarily sexually motivated and whose only impairment is an intolerant spouse.

Dr. Ray Blanchard, chair of the Paraphilias Subcommittee of the DSM-V Workgroup for Sexual and Gender Identity Disorders, has proposed to retain these flawed diagnostic criteria and add the pejorative label of “autogynephilia” to the diagnosis, as a specifier for transsexual women.

The Transvestic Fetishism diagnosis benefits no one and yet inflicts harm on all who do not conform to a male birth-assignment. We urge that it be removed entirely from the DSM-V.


Location in the DSM:


GID Dx in Sexual & Gender Identity Disorders is neither clinically accurate nor palatable to many transpeople


Alternate Location in the DSM?

  • Separate section within Axis I

  • Disorders generally first diagnosed in infancy, childhood, or adolescence

  • Anxiety disorders


We all agree that gender dysphoria in the Sexual and Gender Identity disorders section is neither clinically accurate nor palatable to most people in the transgender community. We also agree that there are three possible places that GD could go and that any of these would be an improvement on the current placement. However we disagree on which could be the best location. Possible classification is 1) in a separate category including the diagnosis in adults, children, and adolescence as well as other possible conditions relating to ones gender identity, 2) Disorders usually first diagnosed in infancy, childhood, or adolescence, and 3) Anxiety disorders.


A separate category would eliminate concerns about drawing connections to other diagnoses in that group (much as transgender people now object to being in the group containing pedophilia). However a separate class under Axis 1 might appear awkward and might eliminate scientific and research accuracy by failing to draw valid connections to other disorders in a class. For example the vast majority of transgender people report awareness of their gender identity was present in childhood or adolescence. In addition transgender people often experience significant trauma making PTSD and anxiety disorders in some ways related.)


Classification in disorders first diagnosed in infancy, childhood or adolescence could be helpful given that most transgender people understood their gender identity before adulthood and this location would be less objectionable than classing it with paraphilias. However similar objections could be raised by people who object to describing transgender people as a form of developmental delay or aberration.


Classification within anxiety disorders could facilitate understanding that many of the adverse mental health symptoms transgender people experience stem from the trauma that patients experience due to either sublimating their gender identity or due to the discrimination to which they are subject by being gender non-conforming. However this might also suggest a connection with OCD which might misplace a focus on patients seeking transition related care as being obsessed. This may suggest that proper treatment might be to end the obsession-compulsion cycle with medication or therapy aimed at changing a patient's core gender identity.


Nomenclature Affects Individuals:


  • Diagnostic Label

    • GID vs ?

  • Respectful (& understandable) terms

    • Sexual orientation r/t birth assigned gender

    • Pronouns and sex listed as birth gender

    • Academic traditions.... change


There are two primary problems in nomenclature and terminology: the name of the diagnosis as well as the pronouns and description of the sexual orientation of transgender people. Even someone like me who agree that GID is a reasonable (albeit improvable) term still objects vehemently to referring to me with female pronouns or describing my sexual orientation as heterosexual because my affectional preference is for men. The academic tradition of using pronouns and describing sexual orientation in reference to gender as assigned at birth is not only hurtful to individuals and increases the conflict between the medical and transgender communities but its also inaccurate and confusing to people not well versed in the transgender literature. If you described me as heterosexual, most people would be very surprised to find out that my partner is a man. If you described me as a heterosexual female transsexual, most people would be very confused and might in fact think that I was an MTF person who was pre-transition. Moreover even in the academic community there is no longer a common standard adding to the confusion in the literature. The supporting information in any revision should set the academic nomenclature so that its consistent and respectful of transgender identities. And academic traditions do evolve with our understanding. Its really time to get rid of inches and all use the metric system.


Affirming Language:


  • Transitioned individuals should be described with pronouns and terms of their affirmed gender.

  • Gender neutral terms should be used to describe people where transition status is not known.

  • Autogynephilia” has multiple ambiguous meanings, many of which are maligning and offensive to many transsexual women. Usage not constructive in the DSM.

We should use the system that is most logical and understandable by everyone who accesses the literature whether they are scientists, clinicians, or laymen from within or outside of the transgender community. This system would mean that transgender people should be referred to by the pronoun and terms of their affirmed gender. In cases where we don't know, using gender neutral terms should be appropriate. Finally, Autogynephilia as it has been used is such a diffuse term encompassing definitions including discreet experiences, etiological theory about transgender women, or a formal diagnosis such as Dr. Ray Blanchard's proposed modification for transvestic fetishim that it has really lost much of its utility. Given that it has such limited utility along with the fact that it is the proverbial red rag to the bull in the transgender community, we might be best off if we let it die off. This is not actually something unusual in medicine or science. The medical term 'mongolism' became Downs' Syndrome, and recently since people have realized that Dr Downs was actually a racist who espoused eugenicist principles many in the medical community are avoiding this eponym and simply calling it trisomy 21.


Proposed Diagnostic Label:


  • Name

    • (Incongruent) Gender Dysphoria

    • (Incongruent) Gender Dissonance

  • Location

    • Separate category (W, E, G)‏

    • Disorders commonly dx'd in infancy through adolescence (E, G)

    • (Anything’s better than 302)‏

So we propose a diagnosis that looks like this: Changing the name to reflect the fact that it focuses on the dysphoria rather than identity as the defining characteristic of a disorder. Two proposed names that we could agree on are Gender Dysporia or Gender Dissonance with or without the 'incongruent' modifier. Gender dysphoria is particularly useful because it is a term already used in the art and diagnostic language. It is also quite descriptive if we are focusing on the dysphoria itself.


With regard to location, we would all accept it being in a separate Axis 1 category. Randall and I (Nick) would also accept it being in disorders commonly diagnosed in childhood and infancy. However we can all agree that anywhere is better than 302 (sexual and gender identity disorders.)


Proposed DX Criteria: Both A & B:


So we are getting close to finishing the didactic portion of this session... I am going to summarize what we've come up with as a diagnostic scheme that we could all live with. It is not that far off what many people seem to be talking about, but it includes some things that will make it more broadly acceptable to people across the spectrum of beliefs about pathology and utility of the diagnosis.

We have two proposed criteria for adult and adolescent gender dysphoria, both of which must be met:


A: Strong and persistent distress with physical sex characteristics, or ascribed social gender role, that is incongruent with persistent gender identity.


B: The 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 Specifier:


  • What is the difference between remission and cure?

  • Why do we need 'In Remission'?

  • Pragmatic

    • Continued access to care

    • Disability protections

  • Scientific validity

    • Would symptoms return without treatment?

We also feel that a specifier for GD in remission should be included. But in order to include that we should define what we mean. When any disease is 'in remission' that implies that it no longer causes symptoms or problems but it would likely re-manifest if treatment was stopped. A cured disease is one that one does not expect to return even without continued treatment.


The utility of an in remission specifier is two fold. First it has pragmatic utility. A trans person might no longer manifest or experience any clinically significant dysphoria but even so, that doesn't mean that treatments can be safely stopped. We do not want to give insurers or health care systems the opportunity to justify such a cessation because this could set transgender people up on a cycle where they resolve their dysphoria, be deprived of treatments, then become dysphoric again and thus re-qualify for treatment. Additionally, an ongoing diagnosis, even if in remission could allow transgender people to continued access to certain disability protections and accommodations.


Moreover an 'in remission' specifier is more diagnostically accurate. For example a transgender man who has successfully transitioned physically and socially to the full extent that is appropriate for him who is for some reason deprived of ongoing hormonal treatment may or may not experience a return of gender dysphoria. For example if he has not had hysterectomy and oophorectomy, cessation of hormones could result in resumption of menstrual cycles. This may cause a return of symptoms, whereas if he had undergone a hysterectomy/oophorectomy he might have menopausal symptoms but not a return of dysphoria.

So the in remission specifier would state:

  • Patient previously met the diagnostic criteria for GD (whether or not he or she received a formal dx), AND

  • Patient no longer has symptoms sufficient to merit a mental health diagnosis, AND

  • Patient has ongoing need for GD specific health care in order to maintain remission

GD in Remission: Supporting Text:


That 3rd qualifier – that ongoing treatment be necessary to maintain remission actually makes room for the 'exit clause' that many people in the transgender community advocate for. With this specifier it would be the case that lack of distress and or real risk for the return of distress without treatment would mean no diagnosis is applicable. In order to make this explicit the supporting text could specify that:

Individuals felt by both themselves and a mental health provider to not likely have a recurrence of GD qualifying symptoms if deprived of future medical, surgical, or mental health care would not meet the criteria for either GD or GD in Remission and would no longer be considered to have a mental health condition.


Summary:


  • It's about Dysphoria

  • Respectful Language

  • Not too Big; Not too Little; but Just Right

  • Accurate Classification Placement

  • Remove Tranvestism/Fetishism Categories

Our main points are: 1) gender dysphoria is the conceptual center of the diagnosis, 2) use respectful language in nomenclature and description of individuals, 3) include those who are in need of inclusion, do not include those who should not be, 4) move the diagnosis out of the sexual and gender identity disorders chapter, 5) and remove transvestic fetishim.


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

Regardless of our viewpoint on such fundamental issues as whether there should be a diagnosis, there are principles of what diagnostic categories should look like such as centering upon gender dysphoria rather than gender identity or conformity, including all people who experience gender dysphoria but not people who do not. We also hope that you will find not only our proposals for nomenclature, categorization and criteria but also this discussion helpful. Please take a look at our nifty website for a recap and further information.


Further Reading:


www.gidreform.org/wpath2009/


About the Authors:

Randall Ehrbar is a clinical psychologist with extensive training and experience working with transgender clients. He has also been actively involved in the American Psychological Association’s efforts to address transgender concerns.

Kelley Winters is a writer and consultant on gender diversity issues in medical, employment and public policy.

Nicholas Gorton is a medical doctor who provides primary care to many transgender clients at Lyon Martin Health Services

Copyright © 2009 Randall Ehrbar, Kelley Winters, Nicholas Gorton

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