Gender as Illness: Issues of Psychiatric Classification |
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6th Annual ICTLEP Transgender Law
and Employment Policy Conference
Houston, Texas, July 1997 |
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Abstract
Twenty-three years after the American Psychiatric Association voted to
delete homosexuality as a mental disorder, the inclusion of the
diagnostic categories transvestic fetishism and gender identity disorder
in the Diagnostic and Statistical Manual of Mental Disorders, or DSM,
continues to raise questions of consistency, validity, and fairness.
Recent revision of the DSM have made these diagnostic categories
increasingly ambiguous and reflect a lack of consensus within the
psychiatric profession. In this paper, issues of gender identity and
expression are examined in light of current definitions of mental illness.
Contents
Mental illness in North America today is defined by the Fourth
Edition of the Diagnostic and Statistical Manual of Mental
Disorders (DSM-IV) published by the American Psychiatric
Association (1994). While homosexuality was removed as a mental
disorder from the second edition of the DSM in 1973, transgender
identity and expression remain in the psychiatric classification
under the diagnostic codes 302.3, transvestic fetishism (TF),
and 302.85, gender identity disorder (GID). Transvestism, from
Latin roots meaning to wear the clothing of the opposite sex,
appears in the psychiatric nomenclature since the term was
coined by Magnus Hirschfeld (1910). Transsexualism, also termed
by Hirschfeld (1923), first appeared in the DSM-III (1980) as a
diagnostic category.
Advances in understanding cross-gender phenomena have brought
changes to the DSM and controversy to the classification of
gender disorders. The issues are complex. There is little
question that the inclusion of gender nonconformity among
psychosexual disorders worsens the burden of stigma that
transgendered individuals face in society (Bolin, 1988). Yet,
psychiatric classification remains the sole justification of
medical necessity that is recognized by surgeons and
endocrinologists who perform sexual reassignment procedures.
Lacking a psychiatric diagnosis of transsexualism, or an
alternative physiological diagnosis, such procedures might be
less available to transsexuals.
At issue is the creeping ambiguity in defining gender disorders
reflected in recent revisions of the DSM. The result is that a
widening segment of gender non-conforming youth and adults are
potentially subject to diagnosis of psychosexual disorder,
severe stigma, and loss of civil liberty. The current diagnostic
categories of transvestic fetishism and gender identity disorder
may be easily interpreted to legitimize intolerance of gender
diversity in the community, workplace, and courts.
In this paper, ambiguous and conflicting language in the DSM-IV
and its supporting literature which serves to endorse harmful
stereotypes of transgendered individuals is examined. This paper
does not attempt to address the broader question of the
appropriateness of classification of any gender role diversity
as mental disorder.
The diagnostic criteria for transvestic fetishism (APA, 1994),
formerly transvestism, are as follows:
- A. Over a period of at least 6 months, in a heterosexual male,
recurrent, intense sexually arousing fantasies, sexual urges, or
behaviors involving cross-dressing.
- B. The fantasies, sexual urges, or behaviors cause clinically
significant distress or impairment in social, occupational, or
other important areas of functioning.
- Specify if: With Gender Dysphoria: if the person has persistent
discomfort with gender role or identity.
The diagnostic criteria for gender identity disorder for adults
and adolescents (APA, 1994), formerly transsexualism, are :
- A. A strong and persistent cross-gender identification (not
merely a desire for any perceived cultural advantages of being
the other sex). In adolescents and adults, the disturbance is
manifested by symptoms such as a stated 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.
- B. Persistent discomfort with his or her sex or sense of
inappropriateness in the gender role of that sex. In
adolescents and adults, the disturbance is manifested by
symptoms such as preoccupation with getting rid of primary and
secondary sex characteristics (e.g., request for hormones,
surgery, or other procedures to physically alter sexual
characteristics to simulate the other sex) or belief that he or
she was born the wrong sex.
- C. The disturbance is not concurrent with a physical intersex
condition.
- D. The disturbance causes clinically significant distress or
impairment in social, occupational, or other important areas of
functioning.
- Specify if (for sexually mature individuals) Sexually Attracted
to Males, ... Females,... Both, ... Neither.
The diagnostic criteria for gender identity disorder for
children (APA, 1994) are :
- A. In children, the disturbance is manifested by four (or more) of the following:
(1) repeatedly stated desire to be, or insistence that he or
she is, the other sex
(2) in boys, preference for cross-dressing or simulating
female attire;
in girls, insistence on wearing only stereotypical
masculine clothing
(3) strong and persistent preferences for cross-sex roles in
make-believe play or persistent fantasies of being the other sex
(4) intense desire to participate in the stereotypical games
and pastimes of the other sex
(5) strong preferences for playmates of the other sex
- B. In children, the disturbance is manifested by any of the
following:
in boys, assertion that his penis or testes are disgusting or
will disappear
or assertion that it would be better not to have a penis,
or aversion toward rough-and-tumble play
and rejection of male stereotypical toys, games and activities;
in girls, rejection of urinating in a sitting position,
assertion that she has or will grow a penis,
or assertion that she does not want to grow breasts or
menstruate,
or marked aversion toward normative feminine clothing.
- C & D. Same as for adults.
Many questions regarding the characterization of cross-gender
identity and expression as mental disorders are unresolved in
the mental health professions. In some instances, a lack of
scientific consensus is reflected in increasingly ambiguous and
conflicting language in recent revisions of the Diagnostic and
Statistical Manual of Mental Disorders. The result is that a
widening segment of gender non-conforming youth and adults are
potentially subject to psychiatric diagnosis, severe stigma,
and loss of civil liberty.
The Ambiguously Sexual Fetish
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. This is consistent with the DSM-IV Casebook (Spitzer,
ed., 1994, pp. 257-259), which recommends a TF diagnosis for a
male whose crossdressing is not necessarily sexually motivated.
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."
Although labeled a "fetishism," it is not clearly stated whether
or not transvestism must be sexual in nature to qualify for
diagnosis. The distinction is left entirely to interpretation.
A Question of Degree
In another example, the Introduction to the DSM-IV (APA, 1994,
p. xxii) states:
Neither deviant behavior ... nor conflicts that are primarily
between the individual and society are mental disorders unless
the deviance or conflict is a symptom of dysfunction...
However, it is contradicted in the gender identity disorder
section (p. 536):
Gender Identity Disorder can be distinguished from simple
nonconformity to stereo-typical sex role behavior by the extent
and pervasiveness of the cross-gender wishes, interests, and
activities.
The second statement implies that one may deviate from social
expectation without a diagnostic label, but not too much.
Conflicting language in the DSM serves the agendas of intolerant
parents, relatives, and employers and their medical expert
witnesses who seek to deny transgendered individuals their
freedom, children and jobs.
The transvestic fetishism and gender identity disorder
categories contain sexist language that appears to presume the
superiority or desirability of one gender role over another.
The Dress Code for Males
Criterion A of the transvestic fetishism disorder limits
diagnosis to heterosexual males. Therefore, women are free to
wear whatever they chose without a diagnosis of mental illness.
This criterion serves to enforce a stricter standard of
conformity for males than females. Its dual standard not only
reflects the disparate positions that men and women hold in
American society, but promotes them. The implication is that men
hold more power and privilege than women, therefore biological
males who emulate women are presumed irrational and mentally
disordered while biological females who emulate males are not.
The Dress Code for Boys and Girls
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 editions. Boys are
once again 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.
The gender disorders of the DSM-IV and its supporting
publications contain wording that is insensitive to the
prejudice that transgendered individuals face and, in one
instance, particularly offensive.
The Label Fetish
The burden of social stigma suffered by transgendered people is
worsened by medical classification (Bolin, 1988). Transvestic
fetishism, in particular, is presented in a most demeaning
manner. Transvestism in the DSM-III was renamed "transvestic
fetishism" in the DSM-III-R (APA, 1987). This misleading label
serves to sexualize a diagnosis that, as described earlier, does
not clearly require a sexual context. Crossdressing by males
very often represents a social expression of an inner sense of
identity. In fact, the clinical literature cites many cases,
considered diagnosable under transvestic fetishism, which
present no sexual motivation for cross-dressing and by no means
represent fetishism (Wise & Meyer, 1980). Moreover, the
transvestic fetishism category is classified as a sexual
paraphilia in the Sexual and Gender Identity Disorders section
of the DSM-IV (APA, 1994, pp. 522-532):
DSM-IV Sexual and Gender Identity Disorders: Paraphilias:
- 302.4 Exhibitionism
- 302.81 Fetishism
- 302.89 Frotteurism
- 302.2 Pedophilia
- 302.83 Sexual Masochism
- 302.84 Sexual Sadism
- 302.3 Transvestic Fetishism
- 302.82 Voyeurism
This classification serves to legitimize stereotypes that
unfairly associate cross-gender expression with criminal or
harmful conduct.
The Fashion Plate
The DSM-IV Casebook (Spitzer, ed., 1994, pp. 257-9) presents the
case of a retired male for whom a diagnosis of transvestic
fetishism is recommended. The title of this section, "the
Fashion Plate," is remarkably offensive and demeaning. It serves
to ridicule an entire class of gender nonconforming males who
have come to rely on the medical professions for understanding
and compassion.
The focus of psychiatric classification in the early 1970s
shifted from cause to consequence. Thomas Sasz's (1961) broad
criticism of psychiatric nosology had a profound influence on
the deletion of homosexuality from the DSM and later changes in
the definition of mental illness (Zucker, 1995; Bayer, 1981).
Consequently, distress and impairment became central to the
definition of mental disorder in the DSM-IV (APA, 1994, p. xxi).
A clinical significance criterion was added to 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 Distressing Lack of Consensus
Distress and impairment are not specifically defined for
transgendered people in the DSM-IV. They are left to the
interpretation of the reader. Tolerant clinicians may infer
that transgender identity or expression is not inherently
impairing, but that societal intolerance and prejudice are to
blame for the distress and internalized shame that transpeople
often suffer (Brown, 1995). Intolerant clinicians may infer the
opposite: that cross-gender identity or expression by
definition constitutes an impairment regardless of the
individual's happiness or well-being.
Both views are unfortunately justified by the current wording of
the DSM-I and were not resolved within the APA when the
criteria were written (Zucker & Blanchard, 1995). As a case in
point, Zucker and others have pointed out that an identical
clinical significance criterion to the pedophilia disorder could
be interpreted to exclude ego syntonic (self-accepting) child
molesters from diagnosis. The APA emphatically denied this,
stating that pedophilia "by definition constitutes impairment"
(APA, 1996). Clearly, the present GID and TF diagnoses may just
as easily be interpreted to constitute impairment by definition
and to implicate all transgendered individuals.
Views of inherent impairment and distress in transvestism and
transsexualism rest on two threads, deviance from presumptions
of biological function and association with other
psychopathology (Wilson, 1997). These same arguments supported
the pathologization of homosexuality before 1973, when they were
rejected by the psychiatric community. They were based on
studies of clinical subjects who did not constitute a
representative gay, lesbian and bisexual population (Hooker,
1957), and failed to explain the existence of healthy
constructive gays, lesbians and bisexuals in society (APA, 1980).
Rebuttals to theories of inherent transgender distress and
impairment closely parallel 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, have failed to consider the
incidence of functional, well adjusted transgendered people and
couples in society (Wilson, 1997).
Nevertheless, proponents of inherent transgender impairment
dismiss the clinical significance criterion as "muddled" and
having little import,
since individuals with [transvestic fetishism] who consult
mental health professionals are presumably, in some respect,
distressed or impaired by their condition (Zucker & Blanchard,
1995).(2)
Blaming the Victim
Transgendered people do suffer distress and impairment from
societal intolerance, discrimination, violence, undeserved
shame, and denial of personal freedoms that ordinary men and
women take for granted. The psychiatric interpretation of
inherent transgender pathology serves to attribute the
consequences of prejudice to its victims, neglecting the true
cause of distress. It promotes treatment paradigms that are
punitive rather than affirmative with the goal of conformity and
not self-acceptance.
In stark contrast, the APA has articulated a growing compassion
and understanding of the issues faced by gays, lesbians and
bisexuals. An amicus brief filed by the American Psychological
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 as it does for transgendered people. Ironically,
the same document acknowledges that gay and transgendered
individuals face much the same discrimination: "Both gay men and
lesbians are often associated with cross-sex characteristics."
A key point in the declassification of sexual orientation as a
mental disorder was the distinction between distress or
impairment caused by society and that believed inherent to
homosexuality itself. It is unfortunate that, over two decades
later, this distinction is left unresolved for the transgender
disorders in the DSM-IV.
As stated previously, the diagnostic criteria for gender
identity disorder of children were significantly broadened the
DSM-IV (APA, 1994, p. 537) to the concern of civil rights
advocates. A child may now 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 in their
choice of clothing and activities. More 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.
The Prehomosexual Agenda
Author Phyllis Burke (1996) describes cases of children as young
as age three institutionalized or treated with a diagnosis of
gender identity disorder 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
psychodynamic etiology which lack evidence in nonclinical
populations (Wilson, 1997). With respect to the third, the
authors 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) :
the San Francisco Human Rights Commission calls on the American
Psychiatric Association and the American Psychological
Association to take immediate steps to stop coercive and
inappropriate treatments of gender atypical children based on
GID.
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.
For sex reassignment procedures (SRS), 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.
This rationale is inconsistent with the APA's decision to merge
the DSM-III-R categories of transsexualism and gender identity
disorder of adolescence or adulthood, nontranssexual type
(GIDAANT) in the DSM-IV:
The desire to uncouple the clinical diagnosis of gender
dysphoria from criteria for approving patients for SRS was one
factor in the subcommittee's recommendation that these
categories be merged under the single heading of Gender Identity
Disorder. The subcommittee was also influenced by the perception
of many clinicians that there are no distinct boundaries between
gender dysphorics who request sex reassignment surgery and those
whose cross-gender wishes are of lesser intensity or constancy.
(Bradley, et al., 1991)
Curiously, the Harry Benjamin standards of care have not been
revised since the publication of the DSM-IV or reconciled with
its broader definition of gender identity disorder. If gender
identity and not sexual orientation is defined as a mental
illness for the purpose of legitimizing surgical and hormonal
procedures, then two questions emerge: Why was GID expressly
uncoupled from SRS approval criteria, and what is the purpose of
diagnosing those who live in a cross-gendered role without
surgery?
The Unmarked Exit
Transsexuals who openly face stigma and discrimination every day
are poorly served by the DSM-IV. The label of psychiatric
disorder burdens them to continually prove their mental
competence. Fraught with murky and ambiguous language, gender
identity disorder has failed to provide a compelling "medical necessity"
for many hospitals and nearly all US insurers, who have dropped SRS
procedures and coverage. Moreover, 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).
American psychiatric perceptions of transgendered people are
remarkably parallel to those for gay and lesbian people before
the declassification of homosexuality as a mental disorder in
1973. The present 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 American
Psychiatric Association. The result is that a widening segment
of gender non-conforming youth and adults are potentially
subject to diagnosis of psychosexual disorder, 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
transsexuals requiring medical sex reassignment, with criteria
that are clearly and appropriately inclusive. It is time for the
transgendered community to engage the psychiatric profession in
a dialogue that promotes medical and public policies which,
above all, do no harm to those they are intended to help.
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(1) Correspondence may be addressed to the author at the Gender
Identity Center of Colorado, P.O. Box 480085, Denver CO,
80248-0085 or by email to kathykw@juno.com.
(2) This reasoning is curiously reminiscent of Alice's experience
in Wonderland:
Said the Cheshire Cat: "We're all mad here. I'm mad. You're mad.
"How do you know I'm mad?" said Alice.
"You must be," said the Cat, "or you wouldn't have come here."
(Charles Dodgson {Lewis Caroll}, Alice's Adventures in
Wonderland, 1865)