Ask Matt: Should Gender Dysphoria Be in the DSM?

A reader writes: “The DSM-V is coming out at the end of the year, and the big question of whether or not gender identity disorder will appear is being decided now, I believe. I heard something about that they gave the revision of this part to the wrong people, and that something terrible could come out of it.

“My main question, though, is: Is it good or bad to remove ourselves from the DSM at this point in time? I know that seeing being trans as a mental disorder is not proper – that I know from living through it. But not everyone else understands.

“I fear that if transsexuality is no longer in the medical books, we will be seen in both the medical and rest of the community as feigning illness. And especially for the former, I see free license to discriminate. I think it shouldn’t be in there, but at this point, when many people still think trans people are just really gay people, what do we gain and lose from taking ourselves off a respected list?”

The debate about whether or not Gender Identity Disorder (GID) (or some other language that represents a similar “condition”) should be in the DSM (Diagnostic and Statistical Manual of Mental Disorders) has been going on for at least as long as I have been in the community. I first learned of the debate when I began transition fifteen years ago.

The DSM-V is scheduled to be released in May of 2013, and at this point, it appears that Gender Identity Disorder will now be called Gender Dysphoria, but I don’t think it’s as simple as a name change. There are various pieces of the diagnosis that have been changed or moved to different categories within the DSM-V, and there have been other changes in language.

Some people feel that these changes are positive, while others want certain categories out of the DSM altogether. However, my understanding is that it will appear as Gender Dysphoria in the DSM-V.

There are people far more knowledgeable on this subject than I am, and I hope that they comment on this post, because I have not studied this issue in depth, and I can only offer the most basic of overviews, along with my opinion.

One source that I recommend for in-depth information is Dr. Kelley Winters of GID Reform Advocates. Her website has a lot of information and analysis on this issue. She has also written a book, Gender Madness in American Psychiatry, that is an important read for those interested in this issue. There are other sources out there as well, offering differing positions. I hope readers will suggest them, so those interested in studying this further can examine all sides of the debate.

But in the limited space of a blog, with the knowledge that I have, we can look at your question: “Is it good or bad to remove ourselves from the DSM at this point in time?”

It turns out to be a moot point, because Gender Dysphoria will be in the DSM-V. However, the arguments at their most basic level are:

> We should be in the DSM, because if we are not, we will not be seen as having a legitimate condition that requires medical intervention. We will be seen as “choosing” transition, and we will not be taken seriously. Any strides that we have made with regard to insurance paying for transition procedures will stall. We need the backing of the medical and psychiatric communities in order to realize full rights and full equality.

> We should not be in the DSM, because we do not have a mental health disorder. If anything, we have a medical condition that was present at birth and is possibly due to hormonal fluctuations during pregnancy or we do not have any kind of “condition” at all, and we are simply one of many ways to be as human. By virtue of our humanity, we are equal to all other humans, and by virtue of a strongly demonstrated need to align our body with our gender identity, we should be able to transition with informed consent and with the understanding from insurance companies and medical professionals that transition is a medical necessity.

Now these arguments as I have worded them here are very basic and simplistic, and they are not the only two. There are many variations within these themes, and many complications and intricacies that are not addressed by the language above. But these very basic components make sense, and I understand both sides of the argument.

When I first started transition, I was pretty anti-therapy, even though I loved my own therapist. I did not, and still don’t, like the “oversight” component of therapy with regard to transition. I think that therapy can be very helpful, and I think that it can be especially beneficial when dealing with the “reality checks” that I think are necessary for transition, as well as offering support and ideas with social-role and adjustment issues that can come with transition.

I’ve always thought that the “gatekeeper” aspect of the therapist’s role with regard to approval for hormones and surgery can interfere with a truly beneficial therapeutic relationship. On the other hand, a good therapist, working with a healthy trans person with realistic expectations, can result in a positive experience.

Unfortunately, a lot of trans people have suffered at the hands of ill-prepared, misinformed, or just plain uncaring therapists who have required a lot of jumping through unnecessary hoops, which does not bode well for a valuable relationship. And there are a lot of therapists out there who still believe that gender issues can be “cured,” particularly in childhood (one of the concerns of the community was that one of the doctors on the DSM-V revision committee was known for “treating” children who exhibited gender issues by forcing them into stereotypical gender roles associated with their birth sex).

My own opinion is that I would like to see Gender Identity Disorder, Gender Dysphoria, or whatever psychiatric label comes about for people whose gender identity does not align with their physical sex (or sex assigned at birth) removed from the DSM. I don’t think that my “condition” is a mental health issue.

Research has demonstrated that transition, a series of medical procedures, can reduce or eliminate the suicidal ideation and other emotional difficulties that many trans people experience. Therefore, I believe that this is a medical issue and should be treated as such. However, there are some trans people who think that even that is too pathologizing, and that transition procedures should be available as on-demand procedures, with the idea that we know our own bodies and minds and should have the right to make our own decisions about care.

I agree with this as well, and this is where I am torn. I believe that I am responsible for my own body, and that I am capable of making decisions about it. I don’t think that I should have to jump through a bunch of someone else’s hoops to do what is best for me. But if gender issues are not part of either a psychiatric or a medical diagnosis, and transition procedures can be issued upon request, then transition becomes a series of “elective” procedures, not considered medically necessary, not covered by insurance or other medical programs, and not recognized as a life-saving intervention.

“Homosexuality” was removed from the DSM in 1973, and the new volume in 1974 reflected that. Since that time, gay and lesbian people have made great strides in rights and acceptance, although, almost forty years later, gay men and lesbians still do not have equal rights. However, the removal of homosexuality from the DSM did not hurt that community in any way that I can see, and probably helped them, because there’s no way that homophobes can turn to the DSM and say, “See? This is a documented mental health issue.”

In that way, it would be quite similar for us, although the difference is that many of us do require medical interventions, whereas gay men and lesbians do not, so while I think that GID/Gender Dysphoria should be removed from the DSM sooner rather than later, there also needs to be provisions in place that will enable those who need to transition to access hormones and surgery in a timely, reasonable, and safe manner.

I would love to hear opinions on this from readers, as well as more detailed information that I don’t have. Thanks in advance for thoughts, comments, and info.

(A quick aside about language: I generally say “we are in the DSM” or “I am in the DSM” simply for ease of communication. The truth is that we are not in the DSM and I am not in the DSM. I am diagnosed with a “condition” that appears in the DSM. I think it’s an important distinction, at least when thinking about yourself as a trans person. We are not our diagnosis.)