Latest version of Diagnostic and Statistical Manual still includes gender variance as a disorder,recommends ‘reparative’ therapy
Mental illness can carry a heavy stigma. It can destroy families, end careers, cause health care to be turned down and even the most basic of human rights to be denied.
Just look at homosexuality as an example: It was once labeled a mental disorder, and the liberation of LGB people today continues to depend upon them having a clean bill of mental health.
But that same clean bill is routinely denied to freely expressing gender-variant people — from toddlers to adults — regardless of transgender identity. And though the liberating road ahead is anything but clear, many voices are speaking out amidst a firestorm of controversy, and they’re speaking to the American Psychiatric Association.
The 38,000-member APA, formed in 1892, has the mission to "ensure humane care and effective treatment for all persons with mental disorders." The organization defines and publishes criteria for mental disorders in its Diagnostic and Statistical Manual, originally published in 1952 and now in its fourth edition.
The upcoming DSM-V, with draft revisions released just last month, and its appointed revising committee for disorders related to sexuality and gender are at the center of the controversy, enough so that the National Gay and Lesbian Task Force issued a statement on the subject in May of last year.
Those revisions show the DSM continues to include the GID entry, a fact that has transgender advocates up in arms.
The Task Force declared the appointments of Drs. Kenneth Zucker and Ray Blanchard to be "clearly out of step with the occurring shift in how doctors and other health professionals think about transgender people and gender variance. It is extremely disappointing and disturbing that the APA appears to be failing in keeping up with the times when it comes to serving the needs of transgender adults and gender-variant children."
Zucker is the psychologist-in-chief at the Centre for Addiction and Mental Health in Toronto and is the head of the Gender Identity Service in the Child, Youth, and Family Program at CAMH. He is a proponent of treating gender-variant children to adjust to their birth sex, which some have criticized as a form of "reparative therapy."
Zucker chairs the DSM-V Sexuality and Gender Identity Disorders Work Group (Work Group).
Blanchard is also with CAMH as senior scientist in the Clinical Research Department and head of Clinical Sexology Services. He is known for his research in gender dysphoria and for coining the term autogynephilia meaning "[an erotic] love of oneself as a woman."
His belief that all male-to-female transsexuals desire gender reassignment either for autoerotic reasons or as an attraction to men has not been well received by the transgender community.
Indeed, the International Foundation for Gender Education has issued a resolution last year calling on the APA to ameliorate harm against transgender individuals by issuing a statement stating that "gender variance, and gender non-conforming behavior, do not constitute a psychological disorder."
The APA issued a statement declaring the organization stands by Zucker and Blanchard, and has not issued any statements at this time in regard to gender variance as not being pathological in and of itself. Zucker and Blanchard declined comment to the Dallas Voice.
Transgender woman Deidre McCloskey, an economics professor at the University of Illinois and well-known transgender activist, was committed twice to mental hospitals for her gender-variant behavior in the mid-1990s. She feels strongly that the appointment of the CAMH researchers is unjust.
"I regard the new DSM’s committee and its recommendations as a coup by a radical wing of the sexology community against reason. It is a throwback to the era before 1973 in which homosexuality … was considered a sickness by the APA," McCloskey said.
She said she is "astonished that in the face of a more than a 1,000-person petition against the new [Work Group] and its slanted composition, the APA chose to go along with the reactionaries."
Dr. Jack Drescher, a distinguished member of the APA and member of the Work Group, said he believes he is the only gay man on the Gender Identify Disorder (GID) subcommittee and that there is no transgender representation in the group.
But Beth Casteel, spokeswoman for the APA, said that Jamison Green, "a respected transgender person," is advising the Work Group.
Drescher said he feels that Zucker and Blanchard don’t always get a fair shake. "I don’t think demonization of individuals has been helpful toward arriving at a more trans-positive DSM," he said.
But Dr. Kelley Winters, founder of Gender Identity Disorder Reform Advocates, said the bottom line is that the current DSM contains diagnoses for GID and Transvestic Fetishism, and that anyone that exhibits significant cross-gender behavior is classified as mentally ill in one of these categories — though women are excluded from TF.
Winters said there should be a "call to arms" from the transgender commnity for DSM reform because "anyone who is caught as a crossdresser can lose their rights."
Following in the footsteps of one of her heroes, Frank Kameny, Winters staged the "Reform GID Now" protest on Howard Street outside the Annual APA Meeting last May in San Francisco.
Winters, who is transgender, stood with bullhorn in hand, declaring, "My identity is not disordered."
Winters spoke with about a dozen other speakers at the meeting, including Masen Davis, executive director of the Transgender Law Center; Mara Keisling, executive director of the National Center for Transgender Equality; and Andrea James, director of Trans Youth Family Allies.
Madeline Deutsch, M.D., won applause from the transgender activist for exposing the presumptuousness of the APA in requiring that transgender people should have to prove they are psychologically sound.
"It is time to change society and change the system, rather than placing the social, financial and psychological burden on transgender people," Deutsch said.
One symposium at the Annual APA Meeting was held to discuss whether or not Gender Identity Diagnoses should be "In or Out" of the DSM. Members of both the DSM-V community and leaders from the transgender community, including Kiesling and Winters, were present.
According to Casteel, Dr. Peggy Cohen-Kettenis, the chair of the GID subcommittee, attended the symposium and has been described by some as a "trans ally."
It is not entirely clear why gender reform of the system is coming at a slower pace than for homosexuality, but Dr. Susan Stryker, an associate professor at the Gender Studies Department of Indiana University suggested that while it may not be useful to rank oppressions, she does "think that gender is a more fundamental category than sexual orientation."
"The gut reaction some people have against same-sex attractions can be understood as a reaction against gender-norm transgression … so I see trans, gay and lesbian issues as all being related to one another, in that they all need to contest limiting notions of conventional personhood," Stryker said.
Homosexuality was removed from the DSM in 1973, but it took until 1987 to have its consecutive replacements, Sexual Orientation Disturbance and Ego Dystonic Homosexuality, removed. With the appointments of Zucker and Blanchard to the Work Group, rumors that homosexuality would be re-added to DSM have surfaced.
Drescher, in a report he has preliminarily released to the Dallas Voice, stated that "there is no factual basis to the rumors that the APA … might reinstate homosexuality to the DSM."
In regard to change forthcoming in the DSM-V, he said, "The needs and desires of the trans community decades ago are much different than those today. Thus the DSM evolves, perhaps not as quickly as some would like, with changing times."
Arlene Istar Lev, a social worker and transgender advocate who writes on GID reform, does not believe that the GID entry will be removed from the next DSM issue, and she does "firmly believe there will be slow reform on this."
The APA DSM-V draft released last month does indeed maintain the GID entry.
Lev, who said she "cares deeply" about the transgender community, says her hope is to help the Work Group develop "the least noxious diagnosis" and she is "pushing for the language that is least pathological."
Lev said she believes change is slow in the APA due to research. She said the APA is a group of researchers and academicians of the highest educational levels and their world is a "clinical research perspective."
"The only truth that matters to them are the numbers … what the research says," Lev said. "However, the nature of research is if you ask certain questions though, you will be assured of certain answers."
And when the APA asks who has the gender disorder numbers, she said Blanchard and Zucker are the only ones able to say "I do."
Lev said she believes Blanchard and Zucker have been unfairly maligned, but she said she strongly disagrees "with their gender research methods and their values and goals" and believes new research will show that transgender individuals transition to self-actualize.
Lev compares the research needed today on transgenderism to the 1950s research done by Evelyn Hooker, a psychologist who was convinced gay men were as socially adjusted as their non-gay counterparts. Her scientific "numerical" research was instrumental in convincing the APA to remove homosexuality from the DSM in 1973.Â
The difficulty in proving the analogous social adjustment for transgender people, Lev said, is that "in today’s economy, there is not $100,000 to do the work."
According to Dr. William Narrow, DSM-V research director, "The fate of gender identity disorders in the DSM-V has been one of the most emotionally charged issues we have faced in the DSM revision."
He said, "The listing of this disorder in the DSM, the content of the diagnostic criteria and the accompanying text all are being closely examined. Each member of the work group recognizes that there are not just clinical ramifications to their decisions, but also unique personal and social issues that affect each person who receives a diagnosis of GID."
Both Winters and James said that GID reform may be made harder due to a conflict of interest. Winters said that CAMH has a "lucrative business model that is based upon gender identity conversion."
James, who was cast in the Oscar-nominated film "Transamerica," added, "Dr. Zucker’s job depends on maintaining the status quo. He’s the main hindrance to ending ‘gender identity disorder’ and reparative therapy of gender-variant youth, because he helped create both. He’s just delaying the historically inevitable paradigm shift that’s underway."
Two mental health organizations outside the APA, the American Psychological Association and the National Association for Social Workers, released statements in 2008 supporting the civil rights of gender variant individuals and encouraging an end discriminatory practices.
The American Medical Association also released a statement in 2008 stating that its members "oppose discrimination on the basis of gender identity."
The APA recognizes that DSM GID reform is needed, but without transgender representation on the GID reform committee, the urgency of reform and the discrimination against gender variant individuals can hardly be felt, according to Winters.
Another concern, Winters said, is that focusing on GID reform, while necessary, may overshadow the need for having Transvestic Fetish as a mental disorder removed. She said this may be hard because, "my personal view is that [the classification of] Transvestic Fetishism is not based upon science, but based upon religious prohibitions of feminine expression by birth assigned males."
Winters also said that Blanchard proposed last April to retain TF, but rename it Transvestic Disorder, and proposed to add Autogynephilia as new third entry.
"The transgender community should be jumping up and down over this," Winters said.
The APA DSM-V draft revision currently does not add a third entry, but adds autogynephilia as part of the TF diagnosis.
Drescher believes that the APA committee will make some advances forward.
"Hopefully the DSM-V will be more reflective (although probably not entirely) of today’s trans community’s wishes, desires and sensibilities than previous volumes have been,"Drescher said.
The DSV-V is now expected out in May of 2013 and the public is encouraged to review the draft (until April 20, 2010) online at DSMfive.org.
For more information on GID reform, go online to GIDReform.com.
Renee Baker is a transgender diversity consultant and can be found online at GenderPower.com.
This article appeared in the Dallas Voice print edition March 12, 2010.