(In)validating transgender identities: Progress and trouble in the DSM-5

By Kayley Whalen, Task Force board liaison

Last week, the American Psychiatric Association (APA) approved the final text for the fifth version of its manual that provides criteria for mental health disorders. The manual, the Diagnostic and Statistical Manual of Mental Disorders, hereinafter DSM-5, will be released officially in 2013. Earlier this year, the APA also released a position statement affirming their support of transgender rights, and the language of the DSM-5 reflects an increased sensitivity to and respect for the transgender community.

The fifth version of DSM is important for several reasons. The DSM-5 contains two diagnoses relevant to transgender and gender-variant individuals. First, the previous and disliked “Gender Identity Disorder” (GID) will be replaced with the diagnosis “Gender Dysphoria”. The second change will replace “Transvestic Fetishism” with “Transvestic Disorder,” which is a disturbing development because the phrase “Transvestic Disorder” is stigmatizing and problematic for a number of reasons.

The Task Force hails the APA’s revision and renaming of GID to “Gender Dysphoria” as a step in the right direction, and applauds the APA continuing to take a positive stance on transgender civil rights. However, it is our firm stance that both “Gender Dysphoria” and “Transvestic Disorder” should be removed from the DSM entirely. While we support retaining “Gender Dysphoria” for the time being, the “Transvestic Disorder” diagnosis should be removed immediately. (Note: The renaming GID has been confusingly called “removal” by some community members yet our analysis is that it is better understood as a renaming and/or revision.)

Gender variance is not a psychiatric disease; it is a human variation that in some cases requires medical attention. For this edition of the DSM, because there is no other medical diagnosis available for transgender people to seek reimbursement of medical expenses under, we recommended that some version of gender dysphoria appear in DSM-5 as a stop-gap measure. There is a continuing need for the medical and insurance industries to update their procedures for reimbursement so that gender dysphoria can be removed entirely in the future.

Yet, we must understand that as long as transgender identities are understood through a “disease” framework, transgender people will suffer from unnecessary abuse and discrimination from both inside and outside the medical profession. As long as gender variance is characterized by the medical field as a mental condition, transgender people will find their identities invalidated by claims that they are “mentally ill,” and therefore not able to speak objectively about their own identities and lived experiences. This has even been used to justify discrimination against transgender people, such as in child custody cases, discrimination in hiring/workplace practices, or justifying them to be mentally unfit to serve in the military.

Even more alarming is the high rate of children—and adults—who will continue to be forcibly subjected to abusive“reparative” therapies designed to “cure” them of gender variance. While the “Gender Identity Disorder” framework of the DSM-IV did have some usefulness for accessing care, there is significant evidence that it has been gravely abused since its creation as a way to subject gender-variant children and adults to damaging “reparative” treatments against their will.

The National Gay and Lesbian Task Force is also strongly opposed to the inclusion of the diagnosis of “Transvestic Disorder” in the DSM-5 for many reasons. First, many of the paraphillias should not exist as diagnoses overall, given that many are simply diverse expressions of sexuality that harm no one. Second, “Transvestic Disorder” pathologizes and invalidates the identities of individuals who do not conform to stereotypical gender roles. This includes all transgender people who are regularly dismissed as transvestites or fetishists. Third, the definition of “Transvestic Disorder,” unlike its predecessor “Transvestic Fetishism” in the DSM-IV, for the first time includes “autogynephilia,” a supposed condition created by Dr. Ray Blanchard, whose controversial theory has garnered widespread criticism from both the medical community and the transgender community. Blanchard’s theory of autogynephelia falsely argues that someone who is assigned male-at-birth and expresses femininity can only be either a gay male or a “gender dysphoric male…sexually oriented toward the thought or image of themselves as a woman.[1]” Thus, transgender women who identify as heterosexual women are told that they are actually gay men. If they are attracted to women, they are told they have a fetish. This denies the reality that many transgender women live happy, healthy lives as lesbians or other various sexual orientations. Finally, the “Transvestic Disorder” is also blatantly sexist in enforcing binary gender roles because it makes what would otherwise be a non-specified fetish into a special type of fetish (one that gets its own Disorder category) because it involves cross gender behavior when those assigned male-at-birth wear clothes associated with women. (What is a woman who wears men’s clothing called? A woman.)

Presumably to mask the inherent sexism of Transvestic Disorder, the APA, in the second draft of the DSM-5, added the “autoandrophilia” specifier to the “Transvestic Disorder” diagnosis, creating a paraphilia specifier for female-assigned-at-birth individuals who expresses masculinity. There is even less evidence that autoandrophilia exists that there is for autogynephilia. Ultimately, the inclusion of “Transvestic Disorder,” “autogynephelia” and “autoandrophilia” in the DSM-5 demonstrates a kind of sexism that is astonishing for psychiatry in the twenty-first century, and the National Gay and Lesbian Task Force strongly advocates for their removal from the DSM.

The Task Force has long maintained that an identity framework — not a disease framework — is the most ethical and appropriate approach for mental health providers serving transgender and gender nonconforming children and adults. At the Task Force, we are working toward a day when the psychiatric profession, and our larger society, embraces a vibrant spectrum of gender expression among infinite human possibilities. To ensure that transgender people are able to get the care that they need, there should be some type of medical diagnosis, such as an endocrinology-based one, for health insurance purposes. But ultimately, as science and our movement advances, we fully expect both “Gender Dysphoria” and “Transvestic Disorder” to be removed from the DSM-6 and will continue to work for that future.

1. R. Blanchard, “The Classification and Labeling of Nonhomosexual Gender Dysphoria,” Archives of Sexual Behavior, v. 18 n. 4, 1989, p. 322-323.