The Diagnostic and Statistical Manual of Mental Disorders (DSM) from the American Psychiatric Association has been the bible of its treatment for six decades, with the most recent edition to be released in May 2013. DSM-V has made a number of changes in definition, including the loss of Asperger’s syndrome when it was shifted to a form of autism and the addition of hoarding and binge eating as psychiatric disorders.
Within the LGBT community, however, the biggest buzz has been the change of “Gender Identity Disorder,” referring to transgender people, to “Gender Dysphoria,” described as “a persistent discomfort with gender role or identity.” In addition, GD is supposed to be placed in a chapter of its own, no longer linked with sexual dysfunctions and paraphilias (non-normative causes of sexual arousal), which will also have chapters of their own.
Earlier this year, the APA also released new health guidelines for transgender patients and a position statement affirming transgender care and civil rights. Both documents align with a new standard for respecting trans people in the medical community.
Since the DSM-III first used the term “disorder” for trans people in 1980, many in the trans community have pointed out that the term doesn’t fit them because it is associated with symptoms that impede people from living their lives fully and which encroach on their overall well-being. Although gender appearance and identity mismatch may cause trans people depression and anxiety, gender realignment intervention can change that.
The GID diagnosis has been used to discriminate against trans people because the word “disorder” is seen as a descriptor for someone who is mentally ill. In one legal case, according to San Francisco psychiatrist Dan Karasic, a trans woman from Utah benefits from the change to GD. Because she is trans, a lawyer has argued that her GID is a “severe, chronic mental illness that might be harmful to the child” who she fathered before her transition. The change from GID to GD may help her, but the fact that gender identification appears at all in the DSM-V continues the stigma for this community.
A problem with the change from GID to GD arises in preserving and increasing access to medical treatment; insurance companies are more willing to cover expenses if they view treatment as medically necessary rather than what they consider cosmetic. For transgender prisoners, the shift from a GID diagnosis may cause them to lose access to hormones, surgery, and other trans health care. Benefits don’t necessarily come from only a GID diagnosis, but it can be important when combined with other issues.
While the DSM-V may have moved forward on the issue of transgender, it moved backwards by changing “Transvestic Fetishism” to “Transvestic Disorder.” This makes the unscientific assumption that any social irregularity from occasional cross-dressing to transitioning into another gender is “motivated by a sexual obsession to see themselves as the opposite sex … used to justify shame-based ex-trans therapy and stigmatize all forms of gender variation among all sexes and all sexual orientations.” according to
Because Transvestic Disorder has been placed in the sexual disorders chapter, it is grouped with paraphilic diagnoses such as pedophilia and exhibitionism. Authored by Dr. Raymond Blanchard of the Toronto Centre for Addiction and Mental Health (formerly called the Clarke Institute of Psychiatry), “this punitive and scientifically capricious category maligns many gender variant people, including transsexual women and men, as mentally ill and sexually deviant, purely on the basis of nonconforming gender expression,” according to trans activist Kelley Winters. She also wrote, “It is written to promote Blanchard’s unfounded theories of ‘autogynephilia’ and ‘autoandrophilia’ that conflate social and medical gender transition with fetishism.” Sponsored by the International Foundation for Gender Education (IFGE), an online petition calling for the removal of this harmful diagnosis from the DSM has garnered thousands of signatures.
It appears that DSM-V giveth and it taketh away. On one hand, gender dysphoria may align DSM-V with current moves to affirm trans identity, but on the other, concerns over Tranvestic Disorder’s broad and damaging nature may undercut the good found in the first change.
Experts in the field of psychiatry are concerned about the influence of this volume. Ron Rosenbaum wrote about the DSM in “The Gonzo Neurologist,” an article about Oliver Sacks in the December 2012 edition of The Smithsonian: “[The DSM’s] supposedly objective quantifiable ‘criteria’ for mental illness … [reshapes] the way we think about what is ‘normal’ and what is ‘malfunctioning’ … because the health insurance industry demands a certifiable DMS diagnosis from a psychiatrist before it will agree to subsidize payment for medication and treatment.”
Sacks compares the use of the DMS in diagnosis to using “a sledgehammer rather than a scapel, obliterating questions such as what is the difference between ‘justified’ sadness and clinical depression.”
The British Psychological Society in the United Kingdom has an equally harsh response, stating that it has “more concerns than plaudits”. Like Sacks, the Society criticized proposed diagnoses as “clearly based largely on social norms, with ‘symptoms’ that all rely on subjective judgements … not value-free, but rather reflect[ing] current normative social expectations.” Other doubts about the reliability, validity, and value of existing criteria are that personality disorders were not normed on the general population. In addition, “not otherwise specified” categories covered a “huge” 30% of all personality disorders.
The Society also expressed concerns that “clients and the general public are negatively affected by the continued and continuous medicalization of their natural and normal responses to their experiences … which demand helping responses, but which do not reflect illnesses so much as normal individual variation.” It suggested a change from using “diagnostic frameworks” to a description based on an individual’s specific experienced problems, exploring mental disorders as part of a spectrum shared with normality.
Another criticism came from Robert Spitzer, the head of the DSM-III task force, concerned because the APA mandated that DSM-V task force members sign a nondisclosure agreement, effectively conducting the whole process in secret. Later the APA instituted a disclosure, but many people believe the process is not transparent enough and doesn’t protect against industry influence.
In a Point/Counterpoint article, Lisa Cosgrove, PhD and Harold J. Bursztajn, MD noted that “the fact that 70% of the task force members have reported direct industry ties—an increase of almost 14% over the percentage of DSM-IV task force members who had industry ties—shows that disclosure policies alone, especially those that rely on an honor system, are not enough and that more specific safeguards are needed.”
Those who don’t need to worry about employment, housing, insurance, benefits in prison, etc. are safe from the decisions of codification in the DSM-V. But those who lack this freedom, including young people, will need an understanding psychiatrist to survive its ramifications.
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