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GID Reform in the DSM-5 and ICD-11: a Status Update

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A presentation I prepared for the 2013 Philadelphia Transgender Health Conference, but did not have the opportunity to attend. Summary of recent changes to gender related diagnostic categories in the DSM-5, published last month by the American Psychiatric Association, and proposed changes for the ICD-11, scheduled for publication in 2015 by the World Health Organization.

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GID Reform in the DSM-5 and ICD-11: a Status Update

  1. 1. Kelley Winters, Ph.D.Kelley Winters, Ph.D.GID Reform AdvocatesGID Reform AdvocatesMay 12, 2013May 12, 2013Wilton Manors, FL USAWilton Manors, FL USAGID Reform in the DSM-5 and ICD-11:a Status UpdateGID Reform in the DSM-5 and ICD-11:a Status Update
  2. 2. 1. Social Stigma thatequates nonconformity toassigned birth sex as mentaldefectiveness and sexualdeviance.2. Access vs. barriers tomedical transition care, forthose who need it.The Issues ofGender Diagnosis
  3. 3. The History: Gender Diversity nomenclature inthe DSM and ICD has historically emphasizedenforcement of birth-assigned gender roles
  4. 4. History of Gender Dx in the DSM➢DSM-I (1952) none➢DSM-II (1968) Sexual Deviations: Transvestitism➢DSM-III (1980) Psychosexual Disorders: Transsexualism➢Gender identity disorder of childhood➢DSM-III-R (1987) Disorders usually first evident in infancy,childhood or adolescence: Transsexualism, GID of childhood,GIDAANT➢DSM-IV (1994) Sexual and gender identity disorders: GIDAA,GIDC, Transvestic Fetishism➢DSM-IV-TR (2000) same➢DSM-5 (2013) Gender dysphoria: GDAA, GDC; SexualDisorders: Transvestic Disorders--Drescher, Cohen-Kettenis, Winter (2012)
  5. 5. History of Gender Dx in the ICD➢ICD-6 (1948) none➢ICD-7 (1955) none➢ICD-8 (1965) Sexual deviations: Transvestitism➢ICD-9 (1975) Sexual deviations: Trans-sexualism, TV➢ICD-10 (1990) Gender identity disorders: TS, Dual Role TV,GIDC, Other GID, GID Unspecified➢ICD-11 (2015) We need codings with less harmand more clinical utility!--Drescher, Cohen-Kettenis, Winter (2012)International Classification of Diseases, published by the WHO,contains both mental and physical diagnostic categories
  6. 6. “The expression of gender characteristics,including identities, that are not stereotypicallyassociated with one’s assigned sex at birth is acommon and culturally-diverse humanphenomenon which should not be judged asinherently pathological or negative...”--May, 2010, WPATH Board of DirectorsEmergingPrinciples:Depsychopathologization
  7. 7. Emerging Principles: Medical Necessity ofTransition Care“An established body of medical research demonstratesthe effectiveness and medical necessity of mental healthcare, hormone therapy and sex reassignment surgery asforms of therapeutic treatment...”“Health experts in GID, including WPATH, have rejectedthe myth that such treatments are ‘cosmetic’ or‘experimental’ and have recognized that thesetreatments can provide safe and effective treatment for aserious health condition.”American Medical Association Resolution 122 (2008)
  8. 8. Photo by Kelley Winters Images PhotographyStop Trans Pathologization Movement Protest, Barcelona, 2010Stop Trans Pathologization Movement Protest, Barcelona, 2010Emerging Principles: Human Rights and SelfDetermination Models of Gender Diversity andTransition
  9. 9. Gender IdentityDisorder is nowGender Dysphoria.TransvesticFetishism is nowTransvesticDisorderThe DSM-5May, 2013
  10. 10. DSM-5: Gender Dysphoria inAdolescents/AdultsN9The good: Change in title from “disordered” gender identity toDysphoria (Greek root for distress). Removal from Sexual Disorderschapter to a new Gender Dysphoria chapter. Inclusive non-binarylanguage. Rejected proposal for “autogynephilia” specifier.The bad: The need for medical transition care is still classed asmental disorder. May pathologize difference from birth-assignment.Ambiguous: “desire,” rather than underlying need, for transition careis cast as symptomatic of mental illness.The ugly: False-positive Dx of happy post-transition subjects. Maycontradict rather than support transition care. Offensive term“Disorder of Sex Development”
  11. 11. DSM-5: Gender Dysphoria in ChildrenThe good: Children must show dissatisfaction with birth-sexassignment and can no longer be diagnosed strictly on the basis ofgender role nonconformity.The bad: Children who do not conform to stereotypes of assignedbirth-sex are still classed as mentally ill. False-positive Dx of happysocially transitioned children who are too young to need any medicaltransition/puberty-blocking treatment.The ugly: Nonconformity to anachronistic gender stereotypes is stillemphasized as symptomatic of mental disorder.
  12. 12. DSM-5: TransvesticDisorderTransvestic Disorder, inthe Paraphilias section ofthe DSM, punishesnonconforming genderexpression by birth-assigned males and nowbirth-assigned femaleswith stigma of sexualdeviance.Just Ugly: It serves noconstructive clinical utilitybut inflicts great harm.
  13. 13. The ICD-11The World HealthOrganization’s“standard diagnostictool for epidemiology,health managementand clinical purposes.”Revision 11 isscheduled for 2015.
  14. 14. ICD-11 Proposal: Gender Incongruence ofAdolescence and AdulthoodThe awesome: Moved out of the Mental and behavioural disorderschapter to a new chapter, “Certain conditions related to sexualhealth.” Incongruence title is distinct from DSM-5 dysphoria title.The bad: Pathologizes incongruence with birth-assignment, notcurrent sex characteristics. Ambiguous: desire for transition care iscast as pathological, though no longer psychopathological. False-negative Dx of some subjects with need for medical transition care.The ugly: False-positive Dx of happy post-transition subjects. Maycontradict rather than support transition care.
  15. 15. ICD-11 Proposal: Gender Incongruenceof ChildhoodThe awesome: Moved out of the Mental and behavioural disorderschapter to a new chapter, “Certain conditions related to sexualhealth.”The bad: Pathologizing coding of happy gender nonconforming orsocially transitioned children, too young to need any medicaltransition/puberty-blocking treatment, is highly controversial.The ugly: Nonconformity to anachronistic gender stereotypes is stillemphasized as symptomatic of a pathology.
  16. 16. ICD-11 Proposal:Eliminate Transvestic DxThe awesome: Eliminatevictimless paraphilia categories,including:F65.1: Transvestic fetishismAs well as F64.1: Dual-roleTransvestismThe Ugly: Political pressure fordiagnostic creep, which mightimplicate ego-dystonic cross-dressing.
  17. 17. Guiding Principle for AA Diagnostic Reform...Adults and adolescentsneeding access tomedical transition care,or pubescent youthneeding pubertyblocking medications,require a cleardescription of theproblem to be treatedPhoto by Kelley Winters Images
  18. 18. Guiding Principle for Childhood Dx ReformChildren do not havemedical needs, relatedto gender diversity, thatrequire a specificdiagnosis. Instead,their primary needs arefor information,counseling, andsupport. (Winter 2013).Photo by Dawn Hebert
  19. 19. Global Action for Trans* Equality (GATE) Civil Society ExpertWorking Group, Buenos Aires, April, 2013Global Action for Trans* Equality (GATE) Expert Working GroupMeeting, The Hague, November, 2011.http://globaltransaction.files.wordpress.com/2012/05/its-time-for-reform.pdfWorld Health Organization, ICD11 Beta Draft, June 2013http://apps.who.int/classifications/icd11/browse/f/enAmerican Psychiatric Association, Gender Dysphoria, 2013,http://www.dsm5.org/Documents/Gender%20Dysphoria%20Fact%20Sheet.pdfGeoffrey Reed, PhD.; Peggy T. Cohen-Kettenis, PhD; RichardKrueger, MD; Dan Karasic, MD; Gail Knudson, MD; KelleyWinters, PhD, “ICD 11,” National Transgender Health Summit,May 2013, Oakland CA.
  20. 20. Kelley Winters, Ph.D.Kelley Winters, Ph.D.GID Reform AdvocatesGID Reform AdvocatesMay 12, 2013May 12, 2013Wilton Manors, FL USAWilton Manors, FL USAGID Reform in the DSM-5 and ICD-11:a Status UpdateGID Reform in the DSM-5 and ICD-11:a Status Update

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