Monday, December 3, 2012

Trans people still “disordered” according to latest DSM

This morning, I woke up and found my Twitter feed full of article links celebrating that transgender people are no longer “disordered” according to the DSM (that is, the Diagnostic and Statistical Manual of Mental Disorders - often referred to as the "psychiatric Bible" because it contains all of the official psychiatric diagnoses). The DSM gets revised every 10-20 years or so, and diagnoses sometimes get modified, expanded, or completely removed. The change that people are now celebrating is the fact that the previous diagnosis of Gender Identity Disorder (GID) has now been changed to Gender Dysphoria.

Admittedly, the new Gender Dysphoria diagnosis is an improvement over GID for a number of reasons - Kelly Winter of GIDreform.org describes some of these improvements, as well as many of the lingering problems with the new diagnosis. Despite the remaining drawbacks (for instance, that gender variance is still formally pathologized in the DSM), many people seem excited that transgender people are no longer described as being "disordered" in the DSM. But the problem is that this is patently untrue.

When the new DSM committee was chosen back in 2008, all the focus was on what the new committee (chaired by the notorious Ken Zucker) would do with GID. This is understandable, given that this is the diagnosis that trans people are required to submit to if they with to access the means to legally and/or physically transition. It has also been used to justify horrible reparative therapies against gender-non-conforming children. But the greater trans community gave short shrift to the other existing DSM diagnosis that affected transgender people: Transvestic Fetishism.

I was especially horrified when Ray Blanchard was named to head the DSM "Paraphilia" section, which historically contains several sexual crimes (e.g., pedophilia, frotteurism and exhibitionism) and a handful of other generally consensual but unnecessarily stigmatized sexual acts (such as fetishism and BDSM) that are considered “atypical” by sex researchers - including Transvestic Fetishism.

I sometimes joke that Ray Blanchard is my arch nemesis (after all, every trans narrative needs a good arch nemesis!). Much of his career has been spent psychiatrically sexualizing trans female/feminine-spectrum people, most notably via his theory of "autogynephilia." I won't go into all the details here, as I have written about Ray Blanchard's theories extensively elsewhere.

Being familiar with his work, I was worried that Blanchard might try to expand the Transvestic Fetishism diagnosis. He did not disappoint. As I outlined in my 2009 article "Why feminists should be concerned with the impending revision of the DSM," Blanchard sought to both expand the DSM definition of "Paraphilia," as well as expand the previous Transvestic Fetishism diagnosis, which he renamed "Transvestic Disorder." As I pointed out in my keynote for the Philly Trans Health Conference that year:

Ray Blanchard has been named to chair the Paraphilia subworkgroup for the DSM-V, and he has proposed changing the Transvestic Fetishism diagnosis to Transvestic Disorder with one of two modifiers: with Fetishism, or with Autogynephilia. While the diagnosis supposedly targets “heterosexual males” who crossdress, the psychological literature regarding autogynephilia (the bulk of it written by Blanchard) repeatedly claims that lesbian, bisexual and asexual trans women are really just heterosexual men with a fantasy problem. Therefore, according to Blanchard’s proposal, a queer-identified trans woman (such as myself) could theoretically be diagnosed as having "Transvestic Disorder" any time that I have any kind of sexual urge while wearing women's clothing. Since I wear women's clothing pretty much every day of my life these days, my sexuality would presumably be considered perpetually transvestically disordered according to this diagnosis.

I tried at great length to raise awareness of the Transvestic Disorder diagnosis when it was first proposed. So did a few other trans activists and advocates, most notably Kelly Winters. But for the most part, the trans community ignored the proposed diagnosis, probably because (in its original form) it was not applicable to trans male/masculine folks nor heterosexual-identified trans women. Personally, I stopped writing about it because I felt like the community was simply not concerned.

And then, when no one was looking, in mid-2010, Blanchard and the DSM committee expanded it even further, so that it now includes trans people of all identities, trajectories and sexual orientations. As it is written now, Transvestic Disorder can be applied to any person who is sexually active while wearing clothing incongruent with their birth-assigned sex. It also canonizes the term "autoandrophilia" as a sexualizing diagnosis that can be applied to trans male/masculine folks. And while GID/Gender Dysphoria are pathologizing, Transvestic Disorder is both pathologizing and sexualizing. And when you sexualize someone, you invalidate them!

So please don't say that transgender people are no longer considered "disordered" according to the latest DSM. It is simply not true.

post-note: here is a speech I wrote for the trans protest of the 2009 American Psychiatric Association (who write the DSM) called "Stop Sexualizing Us"




49 comments:

  1. btw, sorry that I went a bit link happy with this post - I just wanted to get all of this info about Transvestic Disorder out there...

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    1. As a female-bodied lesbian, it worries me that the fact that I generally wear my boxer briefs over my strap-on (to keep it in place)automatically pushes me under the Transvestic Disorder diagnosis...Oh well :P

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  2. Absolutely disgusting. As a transwoman I feel like the DSM made one little itsy bitsy step forward but two giant steps backs in regards to progress. One has to ask how someone like Blanchard became head of a DSM section...I suppose the complete lack of transparency and exclusiveness during the revision reeks of intellectual dishonestly and lack of objectivity in general.

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    1. Because it's still an "Old Boys Club" in any elite grouping These are "elites". Elites are allowed to have their head up their ass, but because they're seen as God-like, no one disagrees. Think Guru.
      Then grant them Enlightenment at the end of a spear...

      BTW, I'm transgender or transsexual, MTF, want breasts, beauty, and grace - and I think my (GG) partner is about at her end of acceptance (which for her really is a BIG step - She brings new meaning to Vanilla.)

      (Since she may come by to read this - I'm explaining DSM to her re: Counselling - I'm going to stay Anon on this one.)

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  3. Despite being a trans man, I always hated the "autogynephilia" diagnosis as I saw how pathologising and invalidating it was for trans women who were suffering purely from gender dysphoria, not a sexual fetish. However, there's no way I ever imagined that an equivalent diagnosis would be fashioned for people on the FTM spectrum (yes, I realise that's due to male privilege). Urgh, now I really am frustrated!

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  4. I guess I kept hoping they'd never get DSM-V out the door, and would simply start working on DSM-VI. Thanks for the heads-up!

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  5. Blanchard's theory set me back a decade, and that lost decade meant that I ended up dragging a wife and three children through transition. The damage that man has done goes far beyond just the trans people who hate themselves and live in denial because of his "theory".

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  6. As long as there is any mention of people born with transsexualism, or who are transgender, within any version of the DSM, then they are saying "disorder" since the very purpose of the DSM is to list various "mental" illnesses.

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  7. I concur with Brynn. Blanchard screwed me big time. It was far too late when I finally learned that the guy knows _nothing_ of value related to trans people.

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    1. I lost what might have been the best 20 years of my life largely to Blanchard's BS. Now I am transitioned and happy, but so much needless pain on the way. I do believe he is a sociopathic monster with blood on his hands.

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    2. I would like to nominate Zucker and Blanchard as well as the receptionist witch at CAMH GIC as co winners of the Douche bags of the year award. And also thank "Mr" ( a term that should only be used out of respect and he has none from me) Smitherman, oh privileged white gay male so full of himself he had to run for the mayor's office which gave us Rob Ford, after Smitherman had to run out of the Ministry of Health office in Ontario for all the scams he ran. He can pick and chose his baby from anywhere in the world with his partner or husband and yet, I had no choice in surgeon. I had to have a butcher who has no desire to learn how to to do top surgery properly which left me disfigured. Instead of Ontario tax payer dollars going to an Ontario doctor (that makes too mcuh sense for government after all) I had to go out of province and choose a docctor who has no interest in treating top surgeery or improving their technique...they are al baout inverting the penis to give a fully sensate vagina, but if your a trans man who want to keep his nipples, your SOL. Thanks for butchering me. I'm sure there's some kickbacks going on there, if everyone who wants funded surgery has to go to Montreal. And btw, I have no male privilege. I am poor , disabled, in chronic pain and NO CHOICE in surgeons. Show me the privilege. That's a constructed theory meant for natal males. Porve to me I have privlege....yeah, from your ivory towers of academia. Try living my life and telling me I have privilege. You wouldn't want my "privilege". Most of you who claim trans guys have privilege haven't walked a second in my shoes. Cause they couldnt' tolerate it, if they tried. How about this? Some trans guys have privilege. Not all.

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    3. I'm not sure if you've been to CAMH recently, but they seemed to have changed DRAMATICALLY. I went in October and found them to be very professional and knowledgeable.

      They've also been made aware of some of your concerns above and have provided more options for trans guys at least in regards to top surgery. It's possible to get surgery in Ontario now and the Montreal clinic has a new surgeon (Dr. Maud Belanger) who has apparently had great reviews.

      I agree with not being able to see much male privilege. I think the majority of that is reserved for society's "ideals" of how a male should be, which I'm not a part of. It's incredibly hard to be validated as a male without a "legitimate" penis.

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    4. My top surgery is also a hack job. In receiving a bi-lateral mastecomy the surgeon merely cut off half of my breasts, leaving me with lumpy misshapen c cups.

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    5. Sounds like you have male privilege, but not cis privilege, able-bodied privilege or class privilege. Poor cis men also tend to claim that male privilege does not apply to them. The truth is that being disprivileged in any number of respects does not negate the privileges that one does have. Basically, if you were a poor disabled trans woman, you would be even worse off.

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  8. I think you're exactly right, Julia. Trans and especially TS women and men are still labeled as mentally disordered in the DSM-5, just as we were in previous versions. The change in title shifted the diagnostic focus further from the Clarkean stereotype of "disordered" gender identity and closer to the distress of anatomies and social assignments that are painfully incongruent for the individual. That part is positive. However, the diagnostic criteria for the revised Gender Dysphoria category still contradict social and medical transition and continue to describe transition itself as symptomatic of mental illness. As you point out, Blanchard's Transvestic Fetishism/Disorder has gone from bad to worse. It is punitive and scientifically capricious--- designed to stigmatize and punish nonconformity to assigned birth roles.

    On December 1, the APA Board of Trustees approved the proposed changes in the DSM-5, unfortunately retaining the unconscionable Transvestic Disorder category. The APA has also disregarded public and professional criticism of its lack of transparency in the revision process by blocking the text of the proposed DSM-5 revisions from public view on the dsm5.org web site. I think history will remember the treatment of trans and gender variant people in the DSM-5 as a missed opportunity to move beyond false stereotypes and bad science.

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  9. Thanks for this enlightening article. Everything about the DSM sends me into a seething rage. These experts self-perpetuate their own BS, and sadly everyone else gets very badly hurt.

    It's almost like they kept waving the "but, it's now Gender Dysphoria and therefore not a disorder anymore" flag to distract us from what was really going on...

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  10. @Julia Serano great analysis! As a queer trans woman I'm also concerned about this revised category (also I loathe Blanchard...) which I hoped so much to be erased from DSM. I run a transfeminist blog in my country and I want to ask permission to translate some of you texts... This one, the one that talks about bissexuality not reinforcing the gender binary and the "Why feminists should be concerned with the impending revision of the DSM,". Thanks Serano!

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  11. I must admit I have always gone against the grain with the view of GID in the DSM. I don't know what stigma is attached to it outside of the Netherlands, but here there is none. In fact no one outside of my therapists even know about it!

    What is does give though is full coverage under the Dutch compulsory base health insurance.

    It also means that you have discrimination coverage by law as well.

    If you remove it as a health issue then the legal and health coverage is also removed. As far as I see it there is a problem in that my head and body don't match. I have no idea how else I would describe it.

    Mind you, the new changes do sound rather disturbing!

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    1. If only these people saw others as brains who happen to be in bodies, rather than bodies which happen to have brains in them, maybe being transgender could be removed entirely from the DSM and added to a list of physical, not mental, health conditions.

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    2. Now that I agree with completely!

      But whatever happens I think it's important to ensure that it remains on *a* health condition list. Otherwise I do think it would be all too easy to fall through cracks when trying to get help.

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    3. Stace I feel very much the same way! I realize that the term "mental disorder" has some negative connotations, however I think it's somewhat necessary in order to receive health coverage.

      I follow certain studies on transsexualism and some hypotheses seem to suggest that brain development and genital development in the womb didn't follow the same trajectories. This may be just part of human variation, but it can be justified as a disorder because (for many of us at least) it can disrupt our functioning in day to day activities and may even provide a health risk if treatment isn't sought.

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    4. I agree completely with ZoëB, and think that that's where we'll end up. Hopefully in the ICD-11,but probably later, alas.

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  12. Two things:

    One, I didn't know you had a blog, and will insta-follow you here. :D

    Two: this is really disheartening news. I'll admit that I hadn't paid much attention to Blanchard heading the paraphilia section of the DSM-V; my ax was mostly ground against Zucker. I regret that now; this diagnosis sounds pretty horrible, and could be a huge roadblock for trans people seeking treatment.

    However, the optimist in me wonders if this matters as much as it did just a few years ago. The trans community has matured by leaps and bounds and has built a pretty good community of support, networking, and best practices. Sure, some doctors will diagnose transvestic disorder to avoid acknowledging trans identity. However, won't those folks wash out of the trans community's recommendations quickly? I know when I transitioned in Indiana we always knew who the "good docs" were, and the list was constantly updated by the community there.

    (Again, not exactly a fix. I'm just trying to see some silver lining in all this.)

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  13. Well if they put in “autogynephila” and “autoandrophilia” it will make It easier to have the whole field declared a religion. Nobody can call the “research” that was done as scientific.

    For a scientific study you would need:
    A large enough sample to be statistically meaningful
    The sample should be random
    You should have a control group
    You would have to maintain “scientific detachment”
    It would need to be independently confirmed before general acceptance.

    For a religion, all you need is a “Prophet” to have a revelation. This seems to be a better description of how these “conditions” came about.

    Now all we need is someone to sue the US Govt for helping to fund a “Religion” (money was given to APA to fund the new version of the DSM) This is of course against the First Amendment.

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  14. Thank you for your analyse, worth reading.

    French psychiatrics used to be too aligned to the DSM.

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  15. Thanks for writing this excellent article... and LOVE the links! -- much appreciated.

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  16. The idea that men can take any object in this world to contribute, own, and contaminate the sacred essence of being born a woman feels me with anger.

    The idea that men want to barge into our identify to find acceptance and somewhat make their own vision of I'd unacceptable. This is a mental disorder of greed and confusion and should be kept as the same.

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    1. If you think that's what being trans* is...wow. I'm sad for you.

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    2. Oh yeah, 'cos this isn't a show of raging cis privilege or anything - with the idea that only you and your kind are ever allowed to identify and live your life as you wish. As for a "mental disorder of greed and confusion", I suggest you actually educate yourself by reading Dr. Serano's 'Whipping Girl' instead of simply assuming you know better.

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    3. Ah, another radical, second-wave feminist whose entire belief system is founded on sexism and an irrational hatred of men.

      Sorry, but transgender women take absolutely nothing away from cisgender women. You still have your own identity, which is in no way diluted or contaminated by the fact that other people sometimes are born with birth defects. So take your "sacred essence" nonsense and kindly go away. You aren't contributing anything worthwhile, and you're only making yourself and other feminists look bad.

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    4. so for the record, I do not allow blatant cissexism on my blog. I have outlined my comments policy previously: http://juliaserano.blogspot.com/2011/09/on-returning-to-blogging.html

      this comment slipped through the cracks & I will leave it up because I don't wanna delete the other folks comments.

      for the record, I completely understand the many reasons why people might want to remain anonymous on the internet. but when someone who goes by "anonymous" spews uninformed cissexist bullshit (rather than engaging in thoughtful dialogue), I can only assume that they are a coward...

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  17. Wow! Thank you for writing this!!

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  18. Hi Julia .I too want to thank you for all you do for the community.
    I am in the first 6 months of my transition and was struggling for a moment with figuring how I fit into my own personal social situations ...(personal privilege) and how much of it would or would not affect me . I was in the process of dealing with it ... When another person suggested your book whipping girl ...
    It has been a great read so far and has addressed the issue I was working on....
    Thank you for the insight.
    Juli Richmond .

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  19. I hope the trans community will learn from this and unite in a demand for removal from DSM by the next revision. They tell us this is about insurance coverage, while in fact it is about control. They are even about to publish guidelines "to make more psychiatrists help" transgender people. There are plenty of ways to cover transition care in ICD10 already we did not need DSM.

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  20. Damn Skippy. Swapping one D word for another doesn't stop us from being pathologized by the APA. There were calls for us to be included in a V section which would have been a improvement by recognizing the main problem of being trans, social stigmatization, but that didn't happen.

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  21. I'm sorry, but anyone who needs the words of psychiatrists to feel validated, or determine who they are, has a mental disorder called "stupid".

    The problem isn't one lonely definition in their DSM. It's the whole concept. The DSM is big and inclusive enough that every single human being on the planet can be determined to have at least a few "mental illnesses". Except for the psychiatrists, of course, who must maintain the illusion that they are qualified to judge the behavior and motivations of others.

    They aren't. Some of the most screwed-up basket cases I know are children of psychiatrists, who apparently felt obliged to analyze and manipulate their offspring.

    Don't even bother trying to change these quacks and their DSM. Just stop paying attention to them. Don't give them power over you. They deserve only derisive laughter, not reasoned argument. (Of course, this too is a DSM-defined "mental disorder" called anti-authoritarian-complex or something. Ridiculous.)

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    1. That attitude is fine for some people, but when someone needs access to prescription medication and surgery that can only be (legally) provided by doctors who follow those psychiatric guidelines, then they can't just ignore it.

      The issue is less "hooray psychiatrists said I'm not as crazy, so I feel good about myself now" and more "how do these changes affect how healthcare providers and lawmakers will treat me?"

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    2. Well, there is that. However...

      Transexuals (as in full SRS etc) are never going to win this one. There's the fundamental catch-22 in a)insurance isn't going to pay for something that isn't wrong with you, thus b)they must find some way to declare what's wrong with you. This leads to the cognitive dissonance of "I have a birth defect/born in wrong body/gender dysphoria -- BUT THERE'S NOTHING WRONG WITH ME!!!"

      That said, the thing sane people do when confronted with legality vs. necessity is to err on the side of necessity. You can spend all your time and money fighting the government regulations and the medical establishment (both of which are NOT getting any easier), or save up a few grand and take a holiday in Thailand. I find it odd that a class of people (TS), whom this society has not treated very well, are so damnably eager to follow every dictate of that society. I should think it easier to defy rules than to defy biology.

      I am not TS and so don't have a dog in the fight, but I am an intersexed (genetically outside the M/F binary) individual whose gender 'presentation' or lack thereof varies by the day -- though typically leaning more to the female end of the spectrum, away from what my ID says. So I do understand these issues, having spent my whole life with them.

      It just seems to me that too many people are trying to rely on government and professional establishments for their personal happiness. The notion is absurd on its face. Government exists to expand government. Professional establishments exist to further the aims of the professionals in them, not their customers. It's really quite foolish to expect anything different.

      We could also point out the nanny-state element that vainly attempts to protect everyone from everything. I know, for instance, that I could pop down to Mexico and buy myself 500 kilos of estrogen pills, and their government will make no attempt to stop me from using them in any amount I choose. It's entirely my problem if I kill myself. Guidance can be had without mandating it -- but we no longer seem to be a country that values freedom, nor understands the concept of personal responsibility.

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    3. I must admit, I do like the idea of personal freedom and individual responsibility. If the healthcare system in the U.S. would just stop worrying about trying to prevent people from supposedly making a "terrible mistake," things would be much better off. People should have a right to do whatever they want with their own bodies.

      Though on the other hand, there is still the issue of whether or not insurance will cover the cost of the surgeries. Part of me wonders whether many of these legal hoops we have to jump through are created not to protect us, but rather to protect the insurance companies...

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    4. This comment has been removed by a blog administrator.

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  22. What gives anyone the right to say what we are thinking or feeling inside much less to give a label on it..

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  23. for the record, I just deleted another comment (from someone posting as "Anonymous, surprise surprise). Basically it was a trans health = frivolous cosmetic surgery rant that (de)evolved into a "Obamacare sucks" manifesto. It defied my commentary guidelines: http://juliaserano.blogspot.com/2011/09/on-returning-to-blogging.html

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  24. Reminds me of when the Navy decided that sit-ups were bad for us. So they started calling them "Crunches", the problem was that they required us to do the exact same motion as the sit-up. BUT we were now doing 'crunches' so everything was alright. My hopes for DSM-V went out the window when Blanchard got involved.

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  25. While I agree whole hardheartedly with the spirit of this entry, the discrediting of Blanchard, and the long term harm caused by the autogynephilia hypothesis , I feel like this blog entry doesn't give a complete picture of how the diagnostic criteria is designed to be applied.

    From the Changes section of the Rationale:
    A Paraphilic Disorder is a paraphilia that is currently causing distress or impairment to the individual or a paraphilia whose satisfaction has entailed personal harm, or risk of harm, to others in the past. A paraphilia is a necessary but not a sufficient condition for having a Paraphilic Disorder, and a paraphilia by itself does not automatically justify or require clinical intervention. ( source: http://www.dsm5.org/Lists/ProposedRevision/DispForm.aspx?ID=189 )

    It is difficult for me to imagine someone having such a good time that it "justifies or require clinical intervention," but I suppose it is possible. I do wish the counter indication of gender dysphoria was more explicit but I only wish that because I do not trust the judgment of most therapists to come to the same logical conclusion. If someone with gender dysphoria is misled by this, the ultimate blame should be with the therapist. If it is possible that someone who does not have gender dysphoria to simply haave an enjoyable hobby, sexual fantasy, or kink, but is then coerced into finding harm where there is none, the blame should also be with the therapist.

    It is the therapist who should also help determine whether this paraphilia, harmful or not, is masking a denial about gender identity. My greater concern of course is for those who stumble upon this without the context of a qualified therapist or by those who would cause us harm or seek to deny anyone treatment, including a child. We are today still locked in court battles fighting Blanchard and Bailey's other brainchild, conversion therapy--something to which even Exodus no longer subscribes. We are winning and this will follow in time. Their place in history will ultimately be in infamy.

    Gender Identity is no longer a disorder and this is a good thing. It is not the most ideal victory but it is still victory. The core of our identity may now be acknowledged as real. If gender identity causes a conflict or negative impairing feelings, gender dysphoria can be used to bill related therapy. When there ceases to be negative impairing feelings, the dysphoria diagnosis should no longer apply. As the pathology for gender identity is removed from society, we must remain assume vigilance to replace it with education and community.
    -kelly

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    1. Hi Kelly, I appreciate your remarks, but I respectfully have to disagree with you about the application of paraphilias (including Transvestic Disorder). Charles Moser has talked at great length in the sexology literature about how words like "distress" and "impairment" are often subjectively used (e.g., if my partner and I are having relationship issues, and my sexuality or clothing choice is one of the issues we fight about, and if I feel distress about our fighting, some therapists may blame the situation on my desires and view my distress as stemming directly from that).

      You also said "My greater concern of course is for those who stumble upon this without the context of a qualified therapist " - yes yes yes! I don't have any statistics, but I always come across trans people who say their first therapist didn't know anything about trans health or issues, and who turn to the DSM or other psych literature for guidance. Having Transvestic Disorder in the DSM means that therapists may read their clients through that lens, whether warranted or not.

      Finally, the DSM has ramifications outside of therapist-client relationships. Conservative groups opposed to trans rights have already latched onto "autogynephilia" as a way to dismiss trans people, and the DSM will give them more ammunition sadly...

      best wishes, -j.

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  26. I'm going to sound out a different thought here and see what everyone thinks.

    I still find the changes in the DSM-V encouraging. The main diagnosis of GID has been removed, hence the stigma of "mental" disorder" has been removed, at least from that point of view. That has been replaced with Gender Dysphoria, which recognizes being TG exists without stigmatizing it, and that it can carry serious issues that can be diagnosed and treated. To me, this all spells out, that being trans is not a mental disorder but it clears the way for a person with it to be treated by insurance and proper health care (i.e., hormones and surgery).

    But now, then, there is this other thing, the fetishism part. First, I don't understand why they seem to basically have two categories for trans folk in the DSM. There's the above Dysphoria diagnosis, and a second Travestic Disorder diagnosis too? This does seem to undermine the Dysphoria diagnosis, however, it doesn't seem to remove the legal and medical protections.

    At the end of the day, the most important thing is, is there a diagnosis that makes it hard for insurance companies to ignore their trans customers, and it seems to me that the answer is yes. So that's good. The whole Travestic Disorder issue seems more like an annoying slap in the face to the TG community from Blanchard, but that's really nothing new.

    I would like to know how others feel about this though. The insurance company I am currently under has within this past year stepped up its own TG services, including covering HRT (which they have been covering for some years now) and SRS. I would be concerned if changes in the DSM could subvert those advances.

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    1. Oops, apologies too, the post right above mine seems pretty much the same thought, I had missed that one.

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