Transvestic Disorder and Policy Dysfunction in the DSM-V

April 22, 2009

Kelley Winters, Ph.D. GID Reform Advocates www.gidreform.org

At the Annual Meeting of the Society for Sex Therapy and Research this month, a “Provisional Report by the DSM-V Workgroup on Sexual and Gender Identity Disorders,” was presented by Chairman Kenneth Zucker and a panel of workgroup members.1 Ray Blanchard, who chairs the Paraphilias Subcommittee, summarized proposals for “Pedohebehpilic Disorder” and “Transvestic Disorder” in the DSM-V.2 While Charles Moser, Ph.D., M.D., and others have long raised concern about all paraphilia diagnoses in the DSM,3 the current diagnostic category of Transvestic Fetishism is particularly stigmatizing and defamatory for male-to-female (MTF) cross-dressers as well as many transsexual women.4 Unfortunately, Dr. Blanchard’s proposal of Transve6stic Disorder offers little to allay these concerns.

First, Dr. Blanchard broadly expanded the definition of paraphilia to include,

“any intense and persistent sexual interest other than sexual interest in genital stimulation or preparatory fondling with phenotypically normal, consenting adult human partners.”

This would appear to implicate masturbation and erotic stimulation without a partner as paraphilia and sexual deviance: a proscription rooted in religious dogma rather than science. Moreover, no clarification is given for “phenotypically normal” Although Blanchard notes that he would exclude same-sex adult partners from his paraphilia definition, it is not clear whether anyone attracted to a trans or intersex partner with atypical physiology or social role would be labeled as paraphilic under this definition.

Blanchard did however make a distinction between paraphilia as sexual phenomena and paraphilic disorder in diagnostic nomenclature. The latter, he noted, “causes distress or impairment to the individual or harm to others,” If applied to the DSM-V, this would narrow the scope of paraphilic diagnostic nomenclature to a degree by tying it to the definition of mental disorder.

Second, Dr. Blanchard proposed that the diagnosis of Transvestic Fetishism in the DSM-IV-TR be renamed Transvestic Disorder. While somewhat less pejorative than the current title, Transvestic Disorder would still imply that all cross-dressing represents mental disorder. It would continue to perpetuate this defamatory stereotype.

Unfortunately, Dr. Blanchard proposed to retain the current diagnostic criteria5 for Transvestic Fetishism:

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.

Criterion A is grammatically ambiguous6. The phrase, “or behaviors involving cross-dressing,” implies that all cross-dressing, whether or not it is erotically motivated, represents paraphilia and mental disorder. Criterion B fails to make any distinction between distress or impairment directly caused by cross-dressing from those caused by social intolerance and prejudice. Thus, all transwomen, including transsexual women, who are birth-assigned male, attracted to women, wear clothing that is typical or ordinary for other women, and are distressed by social or familial prejudice would perpetually meet both diagnostic criteria. Under Blanchard’s proposal they would be subject to diagnosis with Transvestic Disorder for the rest of their lives, regardless of how happy and well adjusted they might be with their lives and gender expression.

Furthermore, these diagnostic criteria define the proposed Transvestic Disorder as a gender-reparative therapy diagnosis, engineered to facilitate psychological “treatment” to suppress gender expression that differs from assigned birth sex. Only by hiding gender nonconforming expression deep into the closet, may a gender variant individual be emancipated from these criteria and paraphilic diagnosis.

Finally, Dr. Blanchard proposes to change the Specifier Options to the diagnosis. The current Transvestic Fetishism diagnosis has a single specifier, “With Gender Dysphoria: if the person has persistent discomfort with gender role or identity.”7 Blanchard’s proposal would replace this with a specifier of “Autogynephilia (Sexually Aroused by Thought or Image of Self as Female).”

The term, autogynephilia was coined by Blanchard in 19898, not merely to describe a phenomenon of human sexuality, but rather to promote his derogatory theory that all lesbian, bisexual and asexual transsexual women were motivated to transition by a narcissistic sexual obsession.9 This word was subsequently associated by author J. Michael Bailey with profoundly defamatory remarks and stereotypes in his 2003 book, The Man Who Would be Queen: The Science of Gender-Bending and Transsexualism.”10

It is difficult to imagine how a term that has become so offensive and so damaging to the dignity of transwomen11 could serve any constructive clinical purpose in the DSM-V.12

To summarize, Dr. Blanchard’s proposal for Transvestic Disorder in the DSM-V fails to address serious issues of unfair social stigma and stereotyping that surround the current Transvestic Fetishism diagnostic category. Moreover, it would worsen these concerns by adding the pejorative term “autogynephilia” as a specifier to the diagnosis.

I ask the elected leadership and Board of Trustees of the American Psychiatric Association to affirm in a public statement that gender identity and expression which differ from assigned birth sex do not, in themselves, constitute mental disorder and imply no impairment in judgment or competence. I ask the DSM-V Task Force to honor this principle in the DSM-V by removing the current category of Transvestic Fetishism and rejecting Dr. Blanchard’s proposal to replace it with Transvestic Disorder. Finally, I invite members, allies and affirming care providers of the transcommunity to voice their concerns by publishing comments to this essay at gidreform.wordpress.com. I will forward these postings to the APA and DSM-V Task Force at the APA Annual Meeting in May.

1 Society for Sex Therapy and Research, “Program Schedule: SSTAR 2009,” April 2009, http://www.sstarnet.org/download/20090402ProgramSchedule.pdf

2 R. Blanchard, “DSM-IV Paraphilias Options: General Diagnostic Issues, Pedohebephilic Disorder, and Transvestic Disorder,” Annual Meeting of the Society for Sex Therapy and Research, Alexandria VA, April 2009, http://individual.utoronto.ca/ray_blanchard/index_files/SSTAR.html

3 C. Moser and P. Kleinplatz, “DSM-IV-TR and the paraphilias: An argument for removal.” Journal of Psychology and Human Sexuality 17(3/4), also published in Sexual and Gender Diagnoses of the Diagnostic and Statistical Manual (DSM), Eds. D. Karasic, and J. Drescher, Haworth Press, 2005, p. 106.

4 K. Winters, “Disordered Identities: The Ambiguously Sexual Fetish,” GID Reform Advocates, November 2008, http://www.gidreform.org/blog2008Nov02.html, https://gidreform.wordpress.com/2008/11/02/disordered-identities-the-ambiguously-sexual-fetish/

5 American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, Washington, D.C., 2000, p. 575.

6 K. Winters (published under pen-name Katherine Wilson) and B. Hammond, “Myth, Stereotype, and Cross-Gender Identity in the DSM-IV,” Association for Women in Psychology 21st Annual Feminist Psychology Conference, Portland OR, 1996, http://www.gidreform.org/kwawp96.html.

7 DSM-IV-TR, 2000, p. 574.

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

9 K. Winters, “Autogynephilia: The Infallible Derogatory Hypothesis, Part 1,” GID Reform Advocates, November 2008, http://www.gidreform.org/blog2008Nov10.html

10 J. Bailey, The Man Who Would Be Queen: The Science of Gender-Bending and Transsexualism, Joseph Henry Press, 2003, pp. xii, 172, 178, 183-185, 206.

11 J. Serano, “Autogynephilia’ and the psychological sexualization of MtF transgenderism,” International Foundation for Gender Education 2009 Conference, Alexandria VA, March 2009, http://ai.eecs.umich.edu/people/conway/TS/IFGE2009/Disordered_No_More.html#Julia

12 K. Winters, “Autogynephilia: The Infallible Derogatory Hypothesis, Part 2,” GID Reform Advocates, November 2008, http://www.gidreform.org/blog2008Nov19.html