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DSM section 302.85

by Zak Szymanski
Thursday May 29, 2008

As the American Psychiatric Association begins to consider revisions for the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), LGBT advocates say that community members need to have a series of discussions to determine how to unite around the future of Gender Identity Disorder.

GID - recorded as 302.85 according to the DSM-4, and 302.6 as it relates to children - is defined as strong and persistent cross-gender identification (not merely a desire for any perceived cultural advantages of being the other sex). The disorder requires that some degree of suffering be present, and it is not meant to describe gender nonconformity, though therapists and advocates say that the diagnosis can be misused.

The diagnosis is controversial in many camps. Some LGBT advocates say that GID stigmatizes trans people and continues to be a loophole for treating homosexuality as a mental illness. Some trans people, on the other hand, do not favor removing GID from the DSM, because it serves as one of the only ways to access sexual reassignment procedures.

Most people, said transgender activist Jamison Green, fall somewhere in between: recognizing that "we need some kind of mechanism to provide access to transitions," while also wanting to challenge the psychiatric assumptions about a range of gender-nonconforming identities.

Transgender activist Julia Serano concurs.

"A lot of us agree what the best future would be - where transness isn't seen automatically as some kind of mental illness but where those of us who need to transition have access to the means of transition," she said. "The real question is how to get there. There's a lot of disagreement, and we really need to talk among ourselves."

Green's ultimate goal is removing GID from the DSM, though he thinks gender-"related" diagnoses could be useful for people dealing with social issues related to their gender variance.

"Gender identity as a category that can be disordered should be removed," said Green. "But gender variance as social issue ought to be acknowledged. People are going to be in distress and suffer social impairment as a result of being gender-variant and may require assistance of a mental health provider ... but we shouldn't be trying to fix the gender variance."

In the interim, Green's more immediate concerns are with rewriting the GID diagnosis as it stands. Green worries that "there's no way to get out of the diagnosis once you've gotten it." He also doesn't think the diagnosis should hold gender-variant people responsible for the way society reacts to gender.

"I'd like to see the APA put out a statement that gender variance is a normal, human condition, and that stereotypes are not desirable," he said.

Gender therapist Arlene Istar Lev said her ultimate goal is to see GID removed from the DSM.

"It shouldn't be in a psychiatric manual; it should be a medical diagnosis," she said. "That doesn't mean there aren't special needs from therapists, who need to be educated when they're working with any minority person about the specific issues that people face. But a trans client who is depressed can be diagnosed with 'depression' rather than a gender disorder."

Some LGBT advocates think moving GID out of Sexual Disorders and into the Childhood Disorders section of the DSM would help to alleviate some of the stigma, by validating patients' long-term gender identities and distancing GID from patients with sexual fetishes.

Placement in the nomenclature "is an open question and a reasonable question," said the APA's Dr. William Narrow. "I personally would like to see what this workgroup would like to say about sexual and gender identity disorders being together. It certainly is understandable that child molesters and sexual dysfunction don't have anything to do with gender identity disorders."

But other activists point out that such a move could further stigmatize those who did not identify along transgender lines until they were adults, including some trans people who say they are already inaccurately defined as "paraphiliacs."

At least one DSM workgroup member, Ray Blanchard, Ph.D., believes some trans women are "autogynephiliacs" - individuals sexually aroused by themselves as women - which means the LGBT community may need to keep its eye on more than just GID, said Serano.

"Because trans activists are so up in arms about the GID diagnosis, I worry that little attention will be paid to diagnoses such as transvestic fetishism and the possible inclusion of 'autogynephilia' in the paraphilia section, both of which specifically pathologize people on the trans feminine/MTF spectrum," said Serano. "In my experience, many folks on the trans masculine/FTM spectrum are oblivious to these diagnoses, or unconcerned by them, because they are not personally affected by them."

The DSM discussion might therefore require that LGBT organizing be more united and collaborative than ever.

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