Reflections on the Proposed DSM5 Revisions and the Role of Community Consultation
The proposed revisions for the Diagnostic and Statistical Manual edition 5 (DSM-5) -- which governs mental health diagnoses -- have been released. The DSM-5 includes diagnoses relevant to the trans community and potentially relevant to other sex and gender minorities as well. Where The Wild Things Are First, dispensing with non-trans categorizations. The "Sexual and Gender Identity Disorders" categorization is divided into three sub-groups: Sexual Dysfunctions, Paraphilias, and Gender Identity Disorders. Earlier indications from a presentation by Dr. Ray Blanchard (who oversees the Paraphilias work group) and another by the Sexual Dysfunctions work group were that there was consideration being given to dropping "distress" as a requirement for diagnosis. A number of people raised this concern with me, as it would result in a number of communities being faced with the potential for enforced diagnosis and aversion therapy in people whose identities are experienced without distress, without adverse effects on others, and practiced responsibly and consensually -- such as asexuality, consensual BDSM and more. The first thing I've noticed is that distress does indeed remain as an important requirement. It's still not clearly defined, but it's still a requirement.
"We are proposing that the DSM-V 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, havinga paraphilia would be a necessary but not a sufficient condition for having a paraphilic disorder."
However, in the rationale, the Paraphilias subgroup clarifies that without distress, their categories are still considered paraphilias -- but with distress, they become paraphilic disorders. They feel the distinction is important, because to them, only the latter needs psychiatric treatment... but the former still need to remain categorized, even though they're referring to them as normative behaviour. Clear as mud? I'll bet people will be recognizing this distinction when talking about whether or not all crossdressers and / or consensual BDSMers are mentally ill. The second major change to this sub-group is that distress is widened to reflect the distress of others, but the lack of definition of "distress" becomes a bigger concern here. Certainly, if someone goes flashing their undies at people or engaging in non-consensual actions that affect participants or onlookers, this should be addressed, and would be a reasonable cause to recommend treatment. But for everything outside pedophilia, without a qualifier based on the explicit or understood mature / informed consent of those involved, it makes the usage far too wide. A crossdresser's very existence causes distress for many people in society who may never actually encounter them. And is it just me, or is placing the role of defining the whole of normative sexual behaviour in our society in the hands of a workgroup that only references three sources (all written by the work group head) a problem? What's In A Name? Regarding the trans-related concerns, yes, the current classifications remain in the DSM list of classifications, with some changes. "Gender Identity Disorder" is being rebranded as "Gender Incongruence." It was clear from the controversies surrounding continued inclusion of trans identities in a catalogue of mental health issues that disordered terminology was not welcome. This will not satisfy those calling for GID's outright removal, and will not disarm anti-trans sentiment that uses the existence of a classification as evidence that trans identities are "disordered" but I suppose it does address some peoples' comfort level with the terminology. Name aside, a few other things have changed. There is less emphasis on gender behaviour, although the adult classification rebrands this as "desire to be" categories (whereas the childhood classification focuses on an insistence that one *is,* in a tightening of the qualifiers, in order to address the controversy of trans youth by making diagnosis more restrictive). Semantically speaking, that still makes transsexual identity seem illusory or a misguided wish. I know for myself, it was less of a "desire to be" and more of a sense of being which my body had somewhere along the way failed to notice. It also continues to restrict the discussion to two strict genders, which remains problematic for those who experience a sense of being dual-gendered in some way or whose model of self doesn't include full GRS. What's distinctly different this time around is that you are now considered fully cured after surgery. This was largely the assumed case previously, but never stated in the DSM-IV, leaving the door open for law, record and policy to declare / enforce the label long after it became irrelevant. It also removes the "perceived cultural advantages" terminology, which was often used to undermine transmale identities. Intersex was previously listed as a disqualifier, although that criterion hasn't really been used in quite some time. Now, they divide the categories between where there is and isn't a known "Disorder of Sex Development" (why eliminate disordered terminology on one hand and entrench it on the other?), the implication being that if you're intersex and experience some gender incongruence, you're now considered mentally ill (it at least does not encompass all intersex people). The probably-unintended inference is that if you're surgically assigned to a gender that doesn't fit you, then it's you who's got the problem. Not good, and certainly not helpful. The inclusion of intersex as a subtypal characteristic also sets the stage so that even if much of transsexuality is eventually demonstrated to have a biological origin and a medical model is developed, psychiatry retains province over the diagnosis and treatment. Personally, I'm not in the remove-GID-from-the-DSM-now crowd, and see value in keeping a therapist part of the equation, but I do look toward some change when there is a medical model developed... and see this as a problem that could jump out of the bushes when that time comes. That may not have been the intention, but it does open the possibility. There is no acknowledgment of the biological studies to date showing a likelihood of biological origin of transsexuality. Is this reflected in other conditions (i.e. autism)? Will have to look further. While I don't see biological origin as something to stake our legitimacy on, it does currently help others accept and understand trans identities as something more than a whim or sex fantasy -- and it would certainly help address the inaccurate grouping with sexual disorders. Not changed: being transsexual is still the reason for categorization in the DSM at all. Suggested: the anxiety and accompanying stresses brought about by societal attitudes towards transsexuals ought to be pointed instead. It would go some way to explain why a mental health issue can be alleviated by surgery and would probably do a lot more to address stigma than a name change. New Transvestitic Fetishism: Now With 50% More Disorder! As a part of the Paraphilias sub-cat, TF has the distress guideline mentioned above: does not need treatment if no distress, but still catalogued as a paraphilia. The only positive is that gender incongruity is removed as a subtype -- however, there is still an attempt to assert linkage. TF retains the distinction as being the only paraphilia ascribed to only one gender. This carries with it several implications that -- I think -- single it out as a particularly flawed diagnosis. Dr. Kelley Winters makes the case for the removal of TF from classification. But the biggest concern is that "Autogynephilia" gets slipped in, and (in the rationale, anyway) reaches beyond Paraphilias to assert a link to Gender Dysphoria / Incongruity, implying a causal distinction.
Other transvestites, whom Blanchard (1989) has called autogynephiles, are most aroused by the thought or image of themselves as women. As a practical matter, the autogynephilic type seems to have a higher risk of developing gender dysphoria. This was confirmed in a secondary data analysis reported by Blanchard (2009c). The results of that analysis clearly suggested that the addition of the proposed specifiers to the diagnosis of Transvestic Disorder could provide clinically meaningful information as well as data useful for research.
Andrea James provides a thorough dissection of Autogynephilia as proposed by Blanchard. More will follow, as it should. A Place At The Table I have a confession to make. For some reason, this tends to shock people, and in quite a number of exchanges since my participation in the discussion of DSM classifications began, it has happened time and time again that I can have lengthy, significant conversations with professionals yet the moment I mention this, I never hear from them again, save for perhaps a patronizing lament that "it's a shame, you could have added so much to this conversation." The same people who describe what I have to say as "insightful, well-reasoned and valuable" instantly decide I have no valid input the moment this comes out. So I'm coming out of the closet for the sake of transparency, but maintaining that despite this, I -- and people like me -- still deserve a place at the table. My education ended after high school. I never had the money to be able to continue into post-secondary studies. For those of professional backgrounds that are looking at that statement as reason to walk away from everything I have to say, that is a mistake, and here is why: History has demonstrated the removal of homosexuality from the DSM as an accurate and appropriate move to make. This removal happened because of the realization that beyond the distressed people who struggled with their sexual orientation that psychiatrists saw, there existed a larger population of people living healthy, adjusted, responsible -- non-disordered -- lives. Those non-clinical and detailed experiences far broadened the scope of sexual orientation study and provided context that was often not available in a clinical setting. Simply, well-adjusted people usually did not seek out or act in such a way that would mandate psychiatric care, so the therapists in question never took them into account. Transsexuality is a little different in that transwomen and transmen are required by the current medical system to submit to a psychiatric process in order to achieve certain landmarks that they feel they need (i.e. hormones, surgery), although this can be circumvented by those with enough money. However, transsexual patients don't always have enough time in regularly-scheduled visits to fully communicate trans experiences (which can be quite complex)... and if they believe that certain statements are required in order to achieve what they're hoping for, they might not always be completely truthful. Additionally, beyond transsexual identities, other trans identities are much like gay and lesbian populations, where only the distressed and socially-troublesome people are commonly seen. I'm not saying that community advocates like myself can provide a full-scope understanding of every identity. I'm also not saying that it needs to be me specifically. There are many experienced, well-spoken advocates within the trans community who can engage the discussion, some more than I. However, it is absolutely crucial that people with insight into trans identities have a place at the table. And the greater the sampling, the less chance that someone will misrepresent parts of what is clearly a vast community when speaking to identities not present in the discussion. Advocates of HBS, "classic transsexualism" and the like can speak to their experiences better than I can. Genderqueer people can represent their identities better than I can. Crossdressers can give a better assessment of their lives than I. And I can speak to my own experiences in the middle far better than they. And in the absence of people to speak to other trans identities, advocates with a positive / constructive approach can acknowledge them to the extent that they have learned about them (which can still be more than what is typically available to clinical therapists), deferring when those people can be found or step forward to speak for themselves. And from the community perspective, we have a responsibility to respond to the proposals in an informed, balanced and diplomatic way that is cognizant of scientific method and the situation in which these work groups find themselves. Psychiatry works best when there is an intuitive understanding of the individual, but science does not like intuition, and stresses repeatability (while no two individuals are exactly the same). Classification can never be perfect, so we must respect the difficulty of the job. Making demands or attacking personalities does nothing to help us at this stage, but well-researched arguments do. I say this because the release of the proposals is accompanied by an opportunity to provide feedback, and because I know that when we feel our identities are at stake, that feedback can get very emotional. Trans identities are not by their nature disordered -- let's make sure that our response is careful and reasoned enough to reflect that. (Crossposted to DentedBlueMercedes and offered to Pam's House Blend)