Issues of Psychiatric Classification
Of Gender Expression

Transgendered people have been known by many names in many tongues throughout the course of human history. For instance, here in Colorado there were the Cheyenne he man eh, the Lakota winkte and the Navajo nadle. In our "enlightened" Western culture, however, transgendered people are known as "mentally disordered."

The psychiatric classification of gender identity expression as defined in the Fourth Edition of the Diagnostic and Statistical Manual of Mental Disorders, or DSM-IV, is a complex issue that has divided the transgender community in recent months.

Many questions have emerged around the diagnostic categories known as Transvestic Fetishism, 302.3, and Gender Identity Disorder, 302.85. Here are some of those questions and some answers:

1. Are the diagnostic criteria consistent and clear?

No. 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, severe stigma, and loss of civil liberty.

For example, criterion A of the Transvestic Fetishism disorder is grammatically ambiguous:

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

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. The second would limit the diagnosis to only sexually motivated cross-dressing, as did the DSM-III-R, 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 the clinician.

In another example, the Introduction to the DSM-IV 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 a dysfunction in the individual." This squarely conflicts with the following in the GID section: "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." It implies that you may deviate only so far from social expectations without a diagnostic label.

Conflicting language in the DSM serves as ammunition for psychologists and MDs who may be employed as expert witnesses by intolerant parents, relatives, and employers who seek to deny transpeople their freedom, children, and jobs.

This is not what the DSM-IV says; it is what many wish it to say. It refers to the "clinical significance criterion" added to most diagnostic categories in the DSM-IV. It requires a "clinically significant distress or impairment in social, occupational, or other important areas of functioning," for a diagnosis of mental disorder. The problem is that distress and impairment are not defined for transgendered people in the DSM-IV. They are left to the interpretation of the practitioners. Tolerant MDs and therapists believe that TG identity or expression is not inherently impairing, but that societal intolerance and prejudice are to blame for the distress and internalized shame that the transgendered often suffer. Intolerant MDs and therapists presume 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-IV. Kenneth Zucker, of the GID subcommittee, acknowledged that these conflicting views were not resolved when the GID criteria were written. As a case in point, Zucker and others have pointed out that the same 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." Clearly, the present GID and TF diagnoses may just as easily be interpreted to constitute impairment by definition.

No. In 1973, the American Psychiatric Association deleted homosexuality as a mental disorder from the DSM-II. No one has reasonably established why gender orientation is treated so differently in the DSM excepting differences in political organization and influence.

Much psychiatric literature about transgendered people is shockingly similar to that published about homosexuality before it was depathologized. It is based on a presumption that cross-gender identity/expression is by definition pathological, is focused on unsubstantiated theories of psychodynamic (mother-blame) cause and anecdotal case studies of institutionalized subjects, denies the existence of healthy productive TG people in society, and ignores anthropological evidence of accepted cross-cultural TG roles. These tired old myths were debunked for sexual orientation 25 years ago and have been recycled to target transgendered individuals.

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

In Gender Shock, Exploding the Myths of Male and Female, Phyllis Burke (1996) describes cases of children as young as age three institutionalized or treated with a diagnosis of GID for widely varying gender nonconformity. She presents evidence of increasing use of GID for children suspected of being "prehomosexual," and not necessarily transsexual. Diagnosis and treatment is often at the insistence of unaccepting parents with the intent of changing a perceived homosexual orientation. This use of Gender Identity Disorder for children and youth was recently condemned by the San Francisco Human Rights Commission and the National Gay and Lesbian Task Force.

Yes. The transgender diagnostic categories are open to interpretation that promotes invalid stereotypes; sexualizes self-expression that is often social; and fails to reflect the diversity of the transgendered community. Moreover, Transvestic Fetishism is classified as a paraphilia, legitimizing stereotypes that associate cross-gender role with criminal or harmful conduct. TSs who are out of the closet must bear the greatest brunt of stereotypes that presume mental illness or incompetence in the home, workplace, and community.

No. A growing body of sociological and anthropological literature that regards gender as a social construction, not a biological imperative, is inexplicably ignored. There are many examples of "supernumerary gender" precedents in non-western cultures. These were accepted, often highly respected, societal roles where gender variation and fluidity were considered a normal part of human life. Are we to infer now that all of these people were mentally ill?

Yes. For sex reassignment procedures, the Standards of Care for the Hormonal and Surgical Sex Reassignment of Gender Dysphoric Persons, from the Harry Benjamin International Gender Dysphoria Association, 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. 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, however, 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). They were replaced by a nebulous category, Gender Identity Disorder, which could be interpreted to implicate a very broad slice of gender non-conforming children, adolescents, and adults who are not necessarily TS.

Transsexuals who openly face stigma and discrimination every day are poorly served by the DSM-IV. The label of mental 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. Furthermore, the current wording has no clear exit clause for post-operative TSs. It lists postsurgical complications as "associated physical examination findings" of individuals with GID.

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 Gender Identity Disorder expressly "uncoupled" from SRS approval criteria, and what is the purpose of diagnosing non-transsexual gender dysphorics?

Perhaps in the future, a physical diagnosis for transsexualism will be offered that is more consistent with surgical and hormonal treatments than the current mental disorder model. In the meantime, the benefits of reducing the stigma of psychosexual illness, while maintaining a clear and specific justification for SRS procedures for transsexuals, merit consideration by the APA.

Psychiatric perceptions of causality, distress, and treatment goals for transgendered people are remarkably parallel to those for gay and lesbian people before the declassification of homosexuality as a mental disorder in 1973. The diagnostic categories of Gender Identity Disorder and Transvestic Fetishism, like Homosexuality in past decades, may or may not meet current definitions of psychiatric disorder depending on subjective assumptions regarding "normal" sex and gender role and the distress of societal prejudice. Ambiguous and conflicting language in recent revisions of the Diagnostic and Statistical Manual of Mental Disorders serve to subject more gender non-conforming youth and adults with the stigma of psychosexual disorder.

The transgender community is deeply divided on this issue, but needlessly so. It is possible to retain a diagnosis that specifically addresses the needs of pre-operative transsexuals, requiring medical sex reassignment, with criteria that clearly and unambiguously exclude others for whom diagnosis serves no constructive purpose. This would address the misuse of GID for suspected "prehomosexual" children. It would also free non-operative and post-op transsexuals from the stigma of psychiatric diagnosis. At the same time, the diagnosis of Transvestic Fetishism should be limited to those for whom cross-dressing represents a legitimate sexual fetish that truly interferes with their life, or perhaps deleted altogether. Currently, TF may broadly implicate many transgendered people regardless of sexual motivation or self-acceptance.

These reforms would acknowledge the existence of transgendered people who are capable, happy, and healthy despite severe societal prejudice. Instead of legitimizing unfair stereotypes upon all TG people, a revised DSM would acknowledge the fact that many many TG people are not mentally disordered, distressed, or impaired and do not deserve to be treated as such.

It is crucial that the transgender community reach a consensus on this important issue and with a united voice communicate our needs to other civil rights groups and the medical professions. Medical policy in our society should be open to the possibility that difference is not disease, nonconformity is not pathology, and uniqueness is not illness.

The most recent text representing the psychiatric view is Gender Identity Disorder and Psychosexual Problems in Children and Adults, by Kenneth Zucker and Susan Bradley, Guilford Press, 1995. They are with the Clarke Institute in Toronto and were on the DSM-IV subcommittee that authored the GID section.

The opposing view is presented by Phyllis Burke, Gender Shock, Anchor, 1996. This a must-read for anyone concerned with transgendered, gay or lesbian children and adolescents. She documents cases of young boys and girls incarcerated and subjected to cruel treatment for the crime of gender nonconformity. She also illustrates the disturbing practice of using childhood GID as a justification for 'fixing' the sexual orientation of suspected gay children. One of her subjects was featured in an ABC "20/20" episode last year.

Les Feinberg's Transgender Warriors, Beacon, 1996 is a fascinating tour of historical and current gender diversity from a social activist viewpoint.

Perhaps the best insights into why gender identity is not a mental illness lie in the history of the pathologization of sexual orientation. See R. Bayer, Homosexuality and American Psychiatry, Princeton, 1981.

In Search of Eve,, by Anne Bolin, Bergin&Garvey, 1988, is a classic reference from an anthropological view of TS people and their caregivers.

An excellent overview of the crossdressing phenomenon is given in Cross Dressing, Sex, and Gender, by Vern and Bonnie Bollough, University of Pennsylvania, 1993.

The Spirit and the Flesh: Sexual Diversity in American Indian Culture, W. Williams, Beacon Press, 1986, is the best known reference for Native American transgender traditions.

See K. Wilson and B. Hammond, "Myth, Stereotype, and Cross-Gender Identity in the DSM-IV," 21st Annual Feminist Psychology Conference, Association for Women in Psychology, Portland OR, March 1996, for more details and references on the pathologization of gender diversity.