Follow up on DSM-still-considers-trans-folks-"disordered" post

First, thanks to everyone re-tweeted, re-posted, shared links, and commented on my Trans people still “disordered” according to latest DSM blogpost yesterday. The response has been overwhelming, and I'm sorry that I haven't been able to respond to people's comments and questions...

As I alluded to in that post, I was disappointed that the DSM's Transvestic Disorder diagnosis received so little attention at the time. But this latest interest/outrage encourages me that we may be able to work toward completely removing this diagnosis from the next revision of the DSM (DSM-VI?).

There are a few things that I want to add here as a postscript:

1) several people asked me what the official language of Transvestic Disorder is. So I went to the dsm5.org (the official DSM-V site), where all the proposed language once resided, but it is no longer there. Here's the explanation they give:

Because the draft diagnostic criteria posted most recently on www.dsm5.org are undergoing revisions and are no longer current, the specific criteria text has been removed from the website to avoid confusion or use of outdated categories and definitions.

How convenient...

So I went through my past notes and found the following update from May-17-2010. Note: it could have been subsequently updated, so I am not 100% sure this is the final language. In any case, here it is:

Transvestic Disorder

A.    Over a period of at least six months, recurrent and intense sexual fantasies, 
        sexual urges, or sexual 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.

Specify if:

With Fetishism (Sexually Aroused by Fabrics, Materials, or Garments)

With Autogynephilia (Sexually Aroused by Thought or Image of Self as Female)

With Autoandrophilia (Sexually Aroused by Thought or Image of Self as Male)

2) Fascinating shenanigans: This was not the initial language. As I mentioned in my last post, the initial language was specific to "heterosexual males" (cissexist psychiatry jargon for assigned-male-at-birth individuals who are sexually oriented toward women).

Those of us who fought against the initial Transvestic Disorder diagnosis did so on the grounds that it did not serve the trans community (e.g., unlike GID/Gender Dysphoria, it does not provide access to the means to legally and/or medically transition), that it pathologizes gender variance, that it sexualizes trans female/feminine spectrum people's gender identities and expressions, and that it was sexist (in that it singled out trans folks of a specific identity, trajectory and orientation).

In what seemed to be an unprecedented move (although I am not a DSM scholar), the DSM quietly expanded the language in May 2010 (after the period for comments had passed) to include trans people of all identities, orientations & trajectories. Presumably, this was done to avoid accusations that the diagnosis was sexist. So in other words, they used trans activist & advocate criticisms as an excuse to *expand* the diagnosis rather than remove or reform it.

3) Upon reading the above diagnoses, some might cite the requirement that such behaviors must "cause clinically significant distress or impairment in social, occupational, or other important areas of functioning" in order to argue that a trans person is not considered Transvestically Disordered if they do not experience such issues. However, this is not necessarily the case. The "distress or impairment" language is quite vague and open to the psychiatrist/therapists's interpretation. If I am fired from my job because of my manner of dress, and if this causes me distress, I could potentially be diagnosed with Transvestic Disorder. This has historically been a problem with diagnoses targeting gender and sexual minorities (as well as other populations that have been DSM'd), namely, that they do not distinguish between personal distress, and distress that arises secondarily due to social stigma and marginalization.

4) I am curious as to why all these news articles about transgender people supposedly no longer being considered "disordered" in the DSM suddenly appeared in the last few days. As I scoured the internet for such articles, I noticed that most of them were quite short, offered no critical analysis, nor did they seek comments from any trans activist and advocates who have been immersed in challenging the DSM.

This has led me to believe that the DSM must have sent out some kind of press release touting their supposed "trans-friendliness," and that several gay, queer and LGbt outlets that are largely oblivious to the nuances of trans politics simply engaged in copywriting based on the DSM press release. Granted, this is speculation on my part, but I'd love to hear what went down behind the scenes to cause this bizarre flurry of inaccurate news stories...

-julia

++++++++++++++


further postscript added 1:15pm 12-4-12:

via a friend of a friend, I was able to access what I think may be the final Transvestic Disorder language, described as being "Updated April-28-2012":

Transvestic Disorder

A. Over a period of at least 6 months, recurrent and intense sexual arousal from cross‑dressing, as manifested by fantasies, urges, or behaviors.

B. The fantasies, sexual urges, or behaviors cause marked distress or impairment in social, occupational, or other important areas of functioning. 

Specify if:

With Fetishism (Sexually Aroused by Fabrics, Materials, or Garments)

With Autogynephilia (Sexually Aroused by Thought or Image of Self as Female)

With Autoandrophilia (Sexually Aroused by Thought or Image of Self as Male)

Specify if:

In a Controlled Environment

In Remission (No Distress, Impairment, or Recurring Behavior for Five Years and in an Uncontrolled Environment) 

So this is mostly the same except for some word rearrangement in part A, and in the addition "Controlled Environment" and "In Remission" as specifications. This latter language is new to me, so I haven't had a chance to digest it yet. But the thing that immediately jumps out at me is the "In Remission" clause. This seems to expand the diagnosis even further. After all, regardless of one's current sexuality and/or manner of dress, one could still be considered as being Transvestically Disordered, albeit in remission...

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"