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. Kelley Winters, Ph.D.Kelley Winters, Ph.D. GID Reform AdvocatesGID Reform Advocates May 12, 2013May 12, 2013 Wilton Manors, FL USAWilton Manors, FL USA GID Reform in the DSM-5 and ICD-11: a Status Update GID Reform in the DSM-5 and ICD-11: a Status Update
- 2. 1. Social Stigma that equates nonconformity to assigned birth sex as mental defectiveness and sexual deviance. 2. Access vs. barriers to medical transition care, for those who need it. The Issues of Gender Diagnosis
- 3. The History: Gender Diversity nomenclature in the DSM and ICD has historically emphasized enforcement of birth-assigned gender roles
- 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; Sexual Disorders: Transvestic Disorders --Drescher, Cohen-Kettenis, Winter (2012)
- 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 harm and more clinical utility! --Drescher, Cohen-Kettenis, Winter (2012) International Classification of Diseases, published by the WHO, contains both mental and physical diagnostic categories
- 6. “The expression of gender characteristics, including identities, that are not stereotypically associated with one’s assigned sex at birth is a common and culturally-diverse human phenomenon which should not be judged as inherently pathological or negative...” --May, 2010, WPATH Board of Directors Emerging Principles: Depsychopathologization
- 7. Emerging Principles: Medical Necessity of Transition Care “An established body of medical research demonstrates the effectiveness and medical necessity of mental health care, hormone therapy and sex reassignment surgery as forms of therapeutic treatment...” “Health experts in GID, including WPATH, have rejected the myth that such treatments are ‘cosmetic’ or ‘experimental’ and have recognized that these treatments can provide safe and effective treatment for a serious health condition.” American Medical Association Resolution 122 (2008)
- 8. Photo by Kelley Winters Images Photography Stop Trans Pathologization Movement Protest, Barcelona, 2010Stop Trans Pathologization Movement Protest, Barcelona, 2010 Emerging Principles: Human Rights and Self Determination Models of Gender Diversity and Transition
- 9. Gender Identity Disorder is now Gender Dysphoria. Transvestic Fetishism is now Transvestic Disorder The DSM-5 May, 2013
- 10. DSM-5: Gender Dysphoria in Adolescents/Adults N9 The good: Change in title from “disordered” gender identity to Dysphoria (Greek root for distress). Removal from Sexual Disorders chapter to a new Gender Dysphoria chapter. Inclusive non-binary language. Rejected proposal for “autogynephilia” specifier. The bad: The need for medical transition care is still classed as mental disorder. May pathologize difference from birth-assignment. Ambiguous: “desire,” rather than underlying need, for transition care is cast as symptomatic of mental illness. The ugly: False-positive Dx of happy post-transition subjects. May contradict rather than support transition care. Offensive term “Disorder of Sex Development”
- 11. DSM-5: Gender Dysphoria in Children The good: Children must show dissatisfaction with birth-sex assignment and can no longer be diagnosed strictly on the basis of gender role nonconformity. The bad: Children who do not conform to stereotypes of assigned birth-sex are still classed as mentally ill. False-positive Dx of happy socially transitioned children who are too young to need any medical transition/puberty-blocking treatment. The ugly: Nonconformity to anachronistic gender stereotypes is still emphasized as symptomatic of mental disorder.
- 12. DSM-5: Transvestic Disorder Transvestic Disorder, in the Paraphilias section of the DSM, punishes nonconforming gender expression by birth- assigned males and now birth-assigned females with stigma of sexual deviance. Just Ugly: It serves no constructive clinical utility but inflicts great harm.
- 13. The ICD-11 The World Health Organization’s “standard diagnostic tool for epidemiology, health management and clinical purposes.” Revision 11 is scheduled for 2015.
- 14. ICD-11 Proposal: Gender Incongruence of Adolescence and Adulthood The awesome: Moved out of the Mental and behavioural disorders chapter to a new chapter, “Certain conditions related to sexual health.” Incongruence title is distinct from DSM-5 dysphoria title. The bad: Pathologizes incongruence with birth-assignment, not current sex characteristics. Ambiguous: desire for transition care is cast 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. May contradict rather than support transition care.
- 15. ICD-11 Proposal: Gender Incongruence of Childhood The awesome: Moved out of the Mental and behavioural disorders chapter to a new chapter, “Certain conditions related to sexual health.” The bad: Pathologizing coding of happy gender nonconforming or socially transitioned children, too young to need any medical transition/puberty-blocking treatment, is highly controversial. The ugly: Nonconformity to anachronistic gender stereotypes is still emphasized as symptomatic of a pathology.
- 16. ICD-11 Proposal: Eliminate Transvestic Dx The awesome: Eliminate victimless paraphilia categories, including: F65.1: Transvestic fetishism As well as F64.1: Dual-role Transvestism The Ugly: Political pressure for diagnostic creep, which might implicate ego-dystonic cross- dressing.
- 17. Guiding Principle for AA Diagnostic Reform ... Adults and adolescents needing access to medical transition care, or pubescent youth needing puberty blocking medications, require a clear description of the problem to be treated Photo by Kelley Winters Images
- 18. Guiding Principle for Childhood Dx Reform Children do not have medical needs, related to gender diversity, that require a specific diagnosis. Instead, their primary needs are for information, counseling, and support. (Winter 2013). Photo by Dawn Hebert
- 19. Global Action for Trans* Equality (GATE) Civil Society Expert Working Group, Buenos Aires, April, 2013 Global Action for Trans* Equality (GATE) Expert Working Group Meeting, The Hague, November, 2011. http://globaltransaction.files.wordpress.com/2012/05/its-time- for-reform.pdf World Health Organization, ICD11 Beta Draft, June 2013 http://apps.who.int/classifications/icd11/browse/f/en American Psychiatric Association, Gender Dysphoria, 2013, http://www.dsm5.org/Documents/Gender%20Dysphoria %20Fact%20Sheet.pdf Geoffrey Reed, PhD.; Peggy T. Cohen-Kettenis, PhD; Richard Krueger, MD; Dan Karasic, MD; Gail Knudson, MD; Kelley Winters, PhD, “ICD 11,” National Transgender Health Summit, May 2013, Oakland CA.
- 20. Kelley Winters, Ph.D.Kelley Winters, Ph.D. GID Reform AdvocatesGID Reform Advocates May 12, 2013May 12, 2013 Wilton Manors, FL USAWilton Manors, FL USA GID Reform in the DSM-5 and ICD-11: a Status Update GID Reform in the DSM-5 and ICD-11: a Status Update
Editor's Notes
- More than three decades after the American Psychiatric Associationvoted to remove the classification of homosexuality as a mental disorder, people who do not conform to their assigned birth sex, either by inner identity or outer social expression, remain diagnosed as mentally ill in the Fourth Edition, Text Revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). 4 Published by the American Psychiatric Association, the DSM is regarded as the medical and social definition of mental disorder throughout the U.S. and Canada. It strongly influences international psychiatric nomenclature in the International Statistical Classification of Diseases and Related Health Problems (ICD), published by the World Health Organization. But first, who are these people who dare not conform to their birth sex assignment?
- We have been manipulated, we have been bamboozled, into believing a false dichotomy -- when in fact the current diagnostic nomenclature has failed us on both issues of stigma and transition care access. While the existence of a diagnostic coding has helped affirming, supportive care providers to make transition procedures available to some transitioning individuals, the specific diagnostic criteria and supporting text of the current Gender Identity Disorder category support the opposite approach – punitive gender-conversion or gender-reparative therapies intended to change or suppress gender identity or expression which differ from assigned birth sex roles “ I concluded that to provide a surgical alteration to the body of these unfortunate people was to collaborate with a mental disorder rather than to treat it.” --Paul McHugh; Hopkins
- Examples of the consequences of psychosexual stigma: “ This is nothing more than mental illness, and the American Psychiatric Association says so.” “’ Gender Identity Disorder’ is classified as a mental disorder by the American Psychiatric Association. Legal protection against discrimination based on mental illness is not provided for any other disorder, and there is no rational explanation why it should be offered for this one. Those who wish to assume a ‘gender identity’ contrary to their biological sex are in need of mental health treatment to overcome such disturbed thinking, not legislation to affirm it.” Undermining the legitimacy of social and medical transition in the title, diagnostic criteria and supporting text of the current Gender Identity Disorder diagnosis, the American Psychiatric Association has undermined the human dignity and civil justice of gender-variant and especially transitioning people.
- Examples of the consequences of psychosexual stigma: “ This is nothing more than mental illness, and the American Psychiatric Association says so.” “’ Gender Identity Disorder’ is classified as a mental disorder by the American Psychiatric Association. Legal protection against discrimination based on mental illness is not provided for any other disorder, and there is no rational explanation why it should be offered for this one. Those who wish to assume a ‘gender identity’ contrary to their biological sex are in need of mental health treatment to overcome such disturbed thinking, not legislation to affirm it.” Undermining the legitimacy of social and medical transition in the title, diagnostic criteria and supporting text of the current Gender Identity Disorder diagnosis, the American Psychiatric Association has undermined the human dignity and civil justice of gender-variant and especially transitioning people.
- Examples of the consequences of psychosexual stigma: “ This is nothing more than mental illness, and the American Psychiatric Association says so.” “’ Gender Identity Disorder’ is classified as a mental disorder by the American Psychiatric Association. Legal protection against discrimination based on mental illness is not provided for any other disorder, and there is no rational explanation why it should be offered for this one. Those who wish to assume a ‘gender identity’ contrary to their biological sex are in need of mental health treatment to overcome such disturbed thinking, not legislation to affirm it.” Undermining the legitimacy of social and medical transition in the title, diagnostic criteria and supporting text of the current Gender Identity Disorder diagnosis, the American Psychiatric Association has undermined the human dignity and civil justice of gender-variant and especially transitioning people.
- We have been manipulated, we have been bamboozled, into believing a false dichotomy -- when in fact the current diagnostic nomenclature has failed us on both issues of stigma and transition care access. While the existence of a diagnostic coding has helped affirming, supportive care providers to make transition procedures available to some transitioning individuals, the specific diagnostic criteria and supporting text of the current Gender Identity Disorder category support the opposite approach – punitive gender-conversion or gender-reparative therapies intended to change or suppress gender identity or expression which differ from assigned birth sex roles “ I concluded that to provide a surgical alteration to the body of these unfortunate people was to collaborate with a mental disorder rather than to treat it.” --Paul McHugh; Hopkins
- More than three decades after the American Psychiatric Associationvoted to remove the classification of homosexuality as a mental disorder, people who do not conform to their assigned birth sex, either by inner identity or outer social expression, remain diagnosed as mentally ill in the Fourth Edition, Text Revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). 4 Published by the American Psychiatric Association, the DSM is regarded as the medical and social definition of mental disorder throughout the U.S. and Canada. It strongly influences international psychiatric nomenclature in the International Statistical Classification of Diseases and Related Health Problems (ICD), published by the World Health Organization. But first, who are these people who dare not conform to their birth sex assignment?
- Examples of the consequences of psychosexual stigma: “ This is nothing more than mental illness, and the American Psychiatric Association says so.” “’ Gender Identity Disorder’ is classified as a mental disorder by the American Psychiatric Association. Legal protection against discrimination based on mental illness is not provided for any other disorder, and there is no rational explanation why it should be offered for this one. Those who wish to assume a ‘gender identity’ contrary to their biological sex are in need of mental health treatment to overcome such disturbed thinking, not legislation to affirm it.” Undermining the legitimacy of social and medical transition in the title, diagnostic criteria and supporting text of the current Gender Identity Disorder diagnosis, the American Psychiatric Association has undermined the human dignity and civil justice of gender-variant and especially transitioning people.
- Examples of the consequences of psychosexual stigma: “ This is nothing more than mental illness, and the American Psychiatric Association says so.” “’ Gender Identity Disorder’ is classified as a mental disorder by the American Psychiatric Association. Legal protection against discrimination based on mental illness is not provided for any other disorder, and there is no rational explanation why it should be offered for this one. Those who wish to assume a ‘gender identity’ contrary to their biological sex are in need of mental health treatment to overcome such disturbed thinking, not legislation to affirm it.” Undermining the legitimacy of social and medical transition in the title, diagnostic criteria and supporting text of the current Gender Identity Disorder diagnosis, the American Psychiatric Association has undermined the human dignity and civil justice of gender-variant and especially transitioning people.
- Examples of the consequences of psychosexual stigma: “ This is nothing more than mental illness, and the American Psychiatric Association says so.” “’ Gender Identity Disorder’ is classified as a mental disorder by the American Psychiatric Association. Legal protection against discrimination based on mental illness is not provided for any other disorder, and there is no rational explanation why it should be offered for this one. Those who wish to assume a ‘gender identity’ contrary to their biological sex are in need of mental health treatment to overcome such disturbed thinking, not legislation to affirm it.” Undermining the legitimacy of social and medical transition in the title, diagnostic criteria and supporting text of the current Gender Identity Disorder diagnosis, the American Psychiatric Association has undermined the human dignity and civil justice of gender-variant and especially transitioning people.
- More than three decades after the American Psychiatric Associationvoted to remove the classification of homosexuality as a mental disorder, people who do not conform to their assigned birth sex, either by inner identity or outer social expression, remain diagnosed as mentally ill in the Fourth Edition, Text Revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). 4 Published by the American Psychiatric Association, the DSM is regarded as the medical and social definition of mental disorder throughout the U.S. and Canada. It strongly influences international psychiatric nomenclature in the International Statistical Classification of Diseases and Related Health Problems (ICD), published by the World Health Organization. But first, who are these people who dare not conform to their birth sex assignment?