Tag: DSM

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Transvestic Disorder? Really?!

Yes, really. The proposed idea is for DSM V, the same book that wants to change Gender Identity Disorder to Gender Incongruence is also planning on changing Transvestic Fetishism to Transvestic Disorder. (You can see all the relevant proposed changes in a previous post.)

The entry in the current DSM on Transvestic Disorder, like the former entry on Transvestic Fetishism, is authored by Dr. Ray Blanchard of the Toronto Centre for Addiction and Mental Health (formerly known as the Clarke Institute). Blanchard has drawn outrage from the transcommunity for his defamatory theory of autogynephilia, asserting that all transsexual women who are not exclusively attracted to males are motivated to transition by self-obsessed sexual fetishism. He is canonizing this harmful stereotype of transsexual women in the DSM-5 by adding an autogynephilia specifier to the Transvestic Disorder diagnosis.

Worse yet, Blanchard has broadly expanded the diagnosis to implicate gender-nonconforming people of all sexes and all sexual orientations, even inventing an autoandrophilia specifier to smear transsexual men.

For those who don’t see why this is a problem: let me posit the idea that there is no such thing as cross-dressing. That is, you can’t wear/get turned on by clothes of the opposite sex is the sexes aren’t oppositional. That is, a guy can wear a skirt and then it’s a guy’s skirt, just as a woman’s jeans are just jeans.

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WPATH’S Recs

WPATH, the World Professsional Association for Transgender Health – the organization formerly known as HBIGDA, or the Harry Benjamin Internaltional Gender Dysphoria Association – has issued a statement/report on their recommendations for the “gender incongruence” (formerly known as GID, & previously as gender dysphoria) for the upcoming DSM V.


You can read the whole of the 9 page .pdf here.

Here are excerpts:

The WPATH Consensus Group believes that gender variance is not in and of itself pathological and that having a cross- or transgender identity does not constitute a psychiatric disorder (Knudson, DeCuypere, & Bockting, in press). However, the WPATH Consensus Group did not reach consensus on whether or not the diagnosis should be retained or removed. Instead, participants chose to present a continuum of positions ranging from removal to reform with the majority advocating for reform (Knudson, DeCuypere, & Bockting, in press; Ehrbar, in press, for a discussion of the pros and cons for removal or reform).

Instead of broadening the diagnosis, the WPATH Consensus Group recommends a narrowing of the diagnosis to those who experience distress associated with gender incongruence (Knudson, De Cuypere, & Bockting, in press). Therefore, we disagree with the absence of a distress component in the proposed criteria. It appears that in an honourable attempt to be inclusive of the wide spectrum of gender variance and gender variant identities, and to account for healthy, well adjusted individuals who might seek hormonal or surgical interventions, the workgroup decided to remove any component of distress or suffering which lead many transgender and transsexual individuals to seek treatment (see also Meyer-Bahlburg, 2010). Above all, it is treatment for the latter group, those who are experiencing distress or suffer, which justifies and might necessitate a diagnosis. If there is no distress or suffering and no treatment is desired, why is a diagnosis needed?

The WPATH Consensus Group recognizes that although some children present with gender dysphoria, it persists in few into adolescence or adulthood (American Psychological Association, 2009). Many of the behaviours captured in the proposed criteria are seen by many as variation in normal development, although sometimes heavily stigmatized, which a diagnostic label might reinforce (Pleak, Herbert and Shapiro, 2009). The WPATH workgroup charged with reviewing and making recommendations for revision considered to recommend removal of the childhood diagnosis, yet consensus on this issue was not achieved. What we did reach consensus on is that, if a childhood diagnosis would be retained, it should only apply to those with a desire to be of the other gender or an insistence that he or she is of the other gender, reflective of persistent and severe internal dysphoria associated with incongruence between sex assigned at birth and gender identity (Knudson, DeCuypere, & Bockting, in press).

(thanks to Courtney)

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Co-Signers of the Letter to the APA about GID

Here is the final list of the co-signing organizations & individuals of the Callen-Lorde/Gay Center letter to the APA about the DSM V revision of GID:

Co-signing Institutions:

  1. CenterLink: The Community of LGBT Centers, New York, NY
  2. Agnodice Foundation, Lausanne, Switzerland
  3. Brainpower Research and Development Services Inc
  4. Brooklyn Community Pride Center, Brooklyn, NY
  5. Capital District Gay and Lesbian Community Council, Albany, NY
  6. Center on Halsted, Chicago, IL
  7. The DC Center for the LGBT Community
  8. Equality Ohio, Columbus, OH
  9. The Gay Alliance in Rochester NY
  10. Gay, Lesbian, Bisexual and Transgender Community Center of Colorado, Denver, CO
  11. L.A. Gay & Lesbian Center, Los Angeles, CA
  12. Legacy Community Health Services, Houston, TX
  13. LGBT Community Center Coalition of Central Pennsylvania, Harrisburg, PA
  14. The LOFT LGBT Community Services Center, White Plains, NY
  15. Malecare, New York, NY
  16. Mazzoni Center, Philadelphia, PA
  17. Milwaukee LGBT Community Center, Milwaukee, WI
  18. National Coalition of Anti-Violence Programs (NCAVP), New York, NY
  19. National LGBT Cancer Network, New York, NY
  20. New Mexico GLBTQ Centers, Las Cruces, NM
  21. New York City Anti-Violence Project, New York, NY
  22. New York Trans Rights Organization (NYTRO), White Plains, New York
  23. Out With Cancer – The LGBT Cancer Project, New York, NY
  24. Pride in Practice, Silver School of Social Work, New York University, New York, NY
  25. Rainbow Heights Club, Brooklyn, NY
  26. Sacramento Gay & Lesbian Center, Sacramento, CA
  27. San Francisco LGBT Community Center, San Francisco, CA
  28. Services and Advocacy for GLBT Elders (SAGE), New York, NY
  29. Spectrum LGBT Center, San Rafael, CA
  30. Third Root Community Health Center, Brooklyn, NY
  31. YouthPride, Inc., Atlanta, GA

The following individuals have requested their names be added to this letter in show of support:

  1. Alison Aldrich, LCSW, Clinical Assistant Professor, NYU Silver School of Social Work, New York, NY
  2. Alison Alpert, New York, NY
  3. Angie Canelli, MA MHP LMHC NCC, Gender and Sexual Minority, Specialist, Seattle Counseling Service, Seattle, WA
  4. Brenda Solomon, Ph.D., M.S.W., Graduate Program Coordinator and Associate Professor, Social Work at The University of Vermont, Burlington, VT
  5. Craig Sloane, LCSW, New York, NY
  6. David J. Brennan, MSW, PhD, Assistant Professor, Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, ON
  7. David Steinberg, San Francisco, CA
  8. Deanna Croce, LMSW, New York, NY
  9. Dennis Holly
  10. Devon Claridge, Brooklyn, NY
  11. Dr. Karra Bikson, Assistant Professor, NYU Silver School of Social Work, New York, NY
  12. E Maxwell Davis, Ph.D., LISW, Assistant Professor, Human Development & Women’s Studies, California State University, East Bay, CA
  13. Elizabeth Mullaugh, Board Secretary, LGBT Community Center of Central Pennsylvania, Harrisburg, PA
  14. Fareen Ramji, LMSW, Brooklyn, NY
  15. Foresta Castañeda, MSW, Middlebury, VT
  16. Franklin Brooks, Ph.D., LCSW, Chairperson, Committee on Lesbian, Gay, Bisexual and Transgender Issues, National Association of Social Workers, Maine Chapter, Portland, ME
  17. Helen Boyd, author and lecturer in Gender Studies, Lawrence University, Appleton, WI
  18. Holly Rider-Milkovich, Director, Student Wellness Center. New York City College of Technology, New York, NY
  19. Jane Mildred, MSW, MA, PhD, Amherst, MA
  20. Jean Sienkewicz, MSW–Offender Re-Entry Housing Specialist, Burlington Housing Authority, Burlington VT
  21. Jase Schwartz, BA Psychology, MSW Candidate, Hunter College School of Social Work, New York, NY
  22. Jeff Brody, LMHC, ATR-BC, Licensed Mental Health Counselor, Board-Certified Art Therapist, Licensed School Adjustment Counselor, Braintree, MA
  23. Jeremy D. Schwartz, MSW Candidate, Student Senator, NYU Silver School of Social Work, New York, NY
  24. Jessie Jacobson, Los Angeles, CA
  25. Joyce E. Garee, LMSW, Albany, NY
  26. Justus Eisfeld, co-director, GATE – Global Advocates for Trans Equality, New York, NY
  27. Karalyn Shimmyo, LMSW, Brooklyn, NY
  28. Kayleen White, Thornbury, Victoria, Australia, former co-convenor of Victoria’s TransGender Victoria
  29. Laura Booker, LCSW, New York, NY
  30. Lex Moran, New York, NY
  31. Mauro Cabral, co-director, GATE – Global Advocates for Trans Equality, Córdoba, Argentina
  32. Melissa Sklarz, New York, NY
  33. Michael Miller, MSW Candidate, 2011, Silver School Of Social Work, New York University, New York, NY
  34. Michelle Kay, MS, FNP, New York, NY
  35. Misty L. Wall, PhD, MSSW, LCSW, Assistant Professor, School of Social Work, Boise State University, Boise, ID
  36. Nerissa Belcher RN, Decatur, GA
  37. Nickerson Hill, LMSW, Masters of Public Health Candidate, Center for the History and Ethics of Public Health, Columbia University Mailman School of Public Health, New York, NY
  38. Nicole Paige, New York, NY
  39. P. Swan, MSW, Seattle, WA
  40. Paisley Currah, Professor, Brooklyn College-CUNY, Brooklyn, NY
  41. Pamela Bianco, Staten Island, NY
  42. Pega Ren, Ed.D., Registered Clinical Counsellor, Board Certified Sexologist, Vancouver, British Columbia, Canada
  43. Rebecca Capri-Durkee Transgender Health Advocate, Boston, MA
  44. Robin Mangini, New York, NY
  45. Romy Reading, MA, New School for Social Research, New York, NY
  46. Rosalyne Blumenstein LCSW ACHP-SW, Therapy2Go, Los Angeles, CA
  47. Samuel Lurie, Director, Transgender Training and Advocacy
  48. Sand Chang, PhD, San Francisco, CA
  49. Sari Surkis, MBA, MSW Candidate, New York, NY
  50. Sean M. Endress, MA, LCSW, Albany, NY
  51. Sebastian Colon-Otero, LMSW, Brooklyn, NY
  52. Shelley Schwartz, Chappaqua NY
  53. Sherry Tripepi, MSW, EqualityToledo, Toledo, OH
  54. Stacey Peyer, MSW, LCSW, CalSWEC Field Consultant, CSULB Department of Social Work, Long Beach, CA
  55. Steve Prentice, LMSW New York, NY
  56. Steven Lipsky, LCSW, CASAC, New York, NY
  57. Sue Langer, LCSW, New York, NY
  58. Susan E. Roche, Ph.D., M.S.S.W., University of Vermont Department of Social Work, Burlington, VT
  59. Tim Pierce, President, Community Alliance and Action Network, Joliet, IL
  60. Toby C. Siegel, Astoria NY
  61. Trey Polesky, MSW, Bloomington, IL
  62. Tyler Blake Kim, New York, NY
  63. Yosenio V. Lewis, Transgender Health Advocate, San Francisco, CA
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Response to the APA’s New GID

Callen-Lorde and the Lesbian, Gay, Bisexual, and Transgender Community Center, both of New York, have written a response to the APA’s revised DSM diagnosis for Gender Identity Disorder — which is now being re-named Gender Incongruence. They make a few important and valid points in a statement which is tidy, well-written, and well-argued. I’m impressed & will be added as a signatory.

Re: Comment on the proposed “Gender Incongruence” in the draft revision of the of the Diagnostic and Statistical Manual of Mental Disorders, version 5
(DSM-5)

American Psychiatric Association:

The undersigned providers of and advocates for medical and mental health services to transgender and gender non-conforming communities welcome this opportunity to offer feedback and comment on the American Psychiatric Association’s draft revision diagnosis for Gender Identity Disorders (GID), “Gender Incongruence” (GI).

The lead organizations facilitating this response are Callen-Lorde Community Health Center and the Lesbian, Gay, Bisexual, and Transgender Community Center of New York City. Each of these organizations started providing community services in 1983 and together serve over 2,000 people of transgender experience with primary health care and hormone care as well as substance abuse, mental health, and community building services. Our organizations, as well as the other signatories to this letter, represent the largest settings providing health and social services to transgender and gender non-conforming people and their families in the United States.

We appreciate the APA’s proposed “Gender Incongruence”(GI) diagnosis is an effort intended to de-stigmatize gender non-conformity and improve transgender-identified people’s access to mental health care. We agree with the intention behind this effort; however, we endorse an alternative viewpoint, based on our years of collective practice knowledge. We believe GI will continue to inappropriately pathologize gender non-conformity, maintain barriers to medically necessary health care, and lend justification to gender based stigmatization and discrimination.

Prior to addressing the reasons behind our recommendation, we would like to respectfully address the process by which the APA undertook this effort.
From the vantage point of LGBT health and community centers, the conceptualization of “Gender Incongruence” occurred without valuable and necessary input from community providers who serve and are accountable to significant numbers of people affected by this diagnosis. The November 2008 Report of the DSM-V Sexual and Gender Identity Disorders Work Group indicates that the “sub-work group has addressed feedback from interested advocacy groups and other stakeholders. Surveys were sent to more than 60 organizations.” While other agencies have provided feedback in this process, we are concerned that the institutions that provide the bulk of medical and mental health services to transgender people nationwide were not asked for input. We have reached out to LGBT community health centers and LGBT community centers; none of these key, high-volume, client-centered, community-driven stakeholders seem to have been included in the research or vetting process. Without input from a representative sample of such organizations and their clients, the conclusions of the sub-work group regarding GI cannot be considered generalizable.

Our specific concerns regarding the validity and utility of the proposed inclusion of GI are as follows:
– Gender non-conformity is not a mental disorder: The proposed definition of a mental disorder in the DSM-V expressly prohibits the inclusion of diagnoses that are “primarily the result of social deviance or conflicts with society” (APA, 2010). The “Gender Incongruence” diagnosis inherently contradicts this tenet. Whereas the criteria for other psychiatric diagnoses are lists of symptoms that impair functioning, the proposed criteria for GI are a list of characteristics of gender non-conformity. There is no evidence or need for treatment that decreases gender non-conformity or crossdressing, as noted in “Transvestic Fetishism.” The GI diagnosis obfuscates the root cause of the distress many transgender people experience – pervasive discrimination. It is commonly acknowledged among mental health providers that being gay, bisexual or lesbian is not a disorder, but that the social impact of stigma, discrimination and homophobia can cause the individual great distress. GI falsely assigns dysfunction to the gender non-conforming person, rather than within the social environment.

– An inappropriate pathway to transgender-specific medical care: There is legitimate community concern that removal of a mental health diagnosis would limit access to transgender-specific medical care. While a minority has succeeded in using the legal system or in fulfilling their insurer’s requirements for coverage to access care, the majority of people needing transgender-specific medical care are denied coverage. GI maintains these barriers to care. Medical interventions are better substantiated by the use of medical diagnoses, not psychiatric diagnoses. Access to transgender-specific, medically necessary care can be directly and more effectively addressed by utilization of a revised medical diagnosis in the International Classification of Diseases (ICD). The psychiatric needs of transgender people are better addressed by existing psychiatric diagnoses.

– GI lays the groundwork for unethical and harmful reparative therapy: A GID diagnosis has historically been misused to justify treatment of “pre-homosexual” children in the hope of preventing or delaying the development of a positive and healthy gay or lesbian identity. With adults, transgender-specific medical intervention is often offered only if reparative therapy fails to relieve distress and improve social functioning.
The GI diagnosis will continue to lend false credence to interventions that foster shame, encourage children and adults to betray their true selves, and delay healthy identity development. This practice is harmful and unethical.

In summary, we propose all diagnoses addressing gender non-conformity and identity be eliminated from the DSM-5. The mental health needs – when present – of gender non-conforming people are addressed by existing diagnoses. We ask the APA to formally renounce reparative therapy addressing gender non-conformity in children, adolescents and adults. We acknowledge that a diagnosis must exist for those who require medically necessary transgender-specific care, and ask the APA to advocate for a viable transgender-specific medical diagnosis in the ICD. Finally, we respectfully request that the APA include lesbian, gay, bisexual and transgender healthcare institutions and community centers in these processes.

Sincerely,

Callen-Lorde Community Health Center
The Lesbian, Gay, Bisexual & Transgender Community Center of New York City Continue reading “Response to the APA’s New GID”

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DSM V Preview

For those of you who are following the DSM revision controversy as it unfolds, here is a recently launched website by the Association for Women in Psychology Committee on Bias in Psychiatric Diagnosis, spearheaded by Paula Caplan. It takes on the problems with a number of categories, including Gender Identity Disorder, Parental Alienation Syndrome, and Female Sexual Dysfunction.

Some highlights of the upcoming DSM V:

[1] The Paraphilias Subworkgroup is proposing two broad changes that affect all or several of the paraphilia diagnoses, in addition to various amendments to specific diagnoses. The first broad change follows from our consensus that paraphilias are not ipso facto psychiatric disorders. We are proposing that the DSM-5 make a distinction between paraphilias and paraphilic disorders. A paraphilia by itself would not automatically justify or require psychiatric intervention. A paraphilic disorder is a paraphilia that causes distress or impairment to the individual or harm to others. One would ascertain a paraphilia (according to the nature of the urges, fantasies, or behaviors) but diagnose a paraphilic disorder (on the basis of distress and impairment). In this conception, having a paraphilia would be a necessary but not a sufficient condition for having a paraphilic disorder.

This approach leaves intact the distinction between normative and non-normative sexual behavior, which could be important to researchers, but without automatically labeling non-normative sexual behavior as psychopathological. It also eliminates certain logical absurdities in the DSM-IV-TR. In that version, for example, a man cannot be classified as a transvestite—however much he cross-dresses and however sexually exciting that is to him—unless he is unhappy about this activity or impaired by it. This change in viewpoint would be reflected in the diagnostic criteria sets by the addition of the word “Disorder” to all the paraphilias. Thus, Sexual Sadism would become Sexual Sadism Disorder; Sexual Masochism would become Sexual Masochism Disorder, and so on.

and

Transvestic Disorder
A. Over a period of at least six months, in a male, recurrent and intense sexual fantasies, sexual urges, or sexual behaviors involving cross?dressing. [11]
B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specify if: [12]
With Fetishism (Sexually Aroused by Fabrics, Materials, or Garments)
With Autogynephilia (Sexually Aroused by Thought or Image of Self as Female)

and

302.85 Gender Identity Disorder in Adolescents or Adults
Gender Incongruence (in Adolescents or Adults) [1]
A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested by 2* or more of the following indicators: [2, 3, 4]
1. a marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or, in young adolescents, the anticipated secondary sex characteristics) [13, 16]

2. a strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or, in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics) [17]

3. a strong desire for the primary and/or secondary sex characteristics of the other gender

4. a strong desire to be of the other gender (or some alternative gender different from one’s assigned gender)

5. a strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender)

6. a strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender)

Subtypes
With a disorder of sex development
Without a disorder of sex development
[14, 15, 16, 19]

and

For the adult criteria, we propose, on a preliminary basis, the requirement of only 2 indicators. This is based on a preliminary secondary data analysis of 154 adolescent and adults patients with GID compared to 684 controls (Deogracias et al., 2007; Singh et al., 2010). From a 27-item dimensional measure of gender dysphoria, the Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults (GIDYQ), we extracted five items that correspond to the proposed A2-A6 indicators (we could not extract a corresponding item for A1). Each item was rated on a 5-point response scale, ranging from Never to Always, with the past 12 months as the time frame. For the current analysis, we coded a symptom as present if the participant endorsed one of the two most extreme response options (frequently or always) and as absent if the participant endorsed one of the three other options (never, rarely, sometimes). This yielded a true positive rate of 94.2% and a false positive rate of 0.7%. Because the wording of the items on the GIDYQ is not identical to the wording of the proposed indicators, further validational work will be required during field trials.

Continue reading “DSM V Preview”