Lesbian and Gay Parenting Questions & Answers Column With Arlene Istar LevDear Ari

A column by Arlene (Ari) Istar Lev

Trans Alphabet Soup

Posted By on August 16, 2010

Dear Ari:

What is up with the DSM and the APA and GID – there are too many initials to make sense of it all. For the last few months there have been endless emails, and blogs, and website postings about Gender Identity diagnoses, and Ken Zucker and Ray Blanchard, and trying to sort through all this mudslinging is wrecking my make-up. Can you please make sense of this and tell me how it affects me, a part-time cross-dresser?
—Sally in Middle America

Dear Sally:

I can try to sort this out for you, but since no one stands on neutral territory, my sorting will likely reflect my own perspective. I was recently referred to on one trans-activist listserv as “Ken Zucker’s personal press secretary,” for trying to correct some misinformation about that was being said about him, and on another professional listserv as a “grossly misrepresenting the clinical perspectives of pre-eminent psychological researchers,” so I have to assume that if both sides think I am on the other side, then I must actually hold a moderate, middle-of-the-road viewpoint. In truth, I think this is a multi-sided conundrum and an issue I cannot do justice to in a short advice column, but I will try.

APA stands for the American Psychiatric Association, which should not be confused with the other APA, the American Psychological Association. (Why brilliant college-educated professionals in two allied fields couldn’t come up with unique acronyms that distinguish their identities is a bit baffling, but might give some insight into why they get confused about gender identities). The APA (i.e., psychiatric) is responsible for the compilation and distribution of the Diagnostic and Statistical Manual of Mental Disorders or DSM, which is currently in its fourth edition. The DSM is a complex book over 900 pages in length. It weighs nearly three pounds, covers over 300 diagnostic categories and is a significant source of revenue for the APA.

Two of the diagnoses in the DSM are Gender Identity Disorder (GID) and Transvestic Fetishism. Both of these diagnoses are controversial, although the bulk of the attention has been on GID, primarily because GID is the diagnosis used to justify trans-related medical treatments. When people are seeking “the letter” from a therapist, what they are in essence seeking is an official diagnosis of GID, in order to be referred for hormones or surgeries. The APA is in the process of revising the DSM, a long and tedious process. The results of the process, the DSM V, will impact the trans communities for decades to come. Okay, so what is so controversial?

The greatest concern for many trans-activists is that diagnosis infers mental illness. Thirty years ago, homosexuality was also listed as a DSM diagnosis and was removed, in part, because of political pressure from the newly organized gay and lesbian liberation movement. Although many transgender and transsexual people experience emotional discomfort related to their gender, many of us would argue that it is not one’s “gender” that is disordered. For some people the pain is solely related to societal condemnation, and for others the discomfort is anatomical, requiring medical treatments to align their body with their sense of self.

The GID diagnosis is often used for people who are not in any emotional distress at all, for example a person who enjoys cross-dressing. It is also used for those who have completed transition, when the person may well be gender euphoric, not dysphoric. The diagnostic criterion, especially for young children, is based in sexist assumptions about proper boy/girl behavior (i.e., girls who show “little interest in dolls,” or boys who avoid “rough-and-tumble play.”)

Additionally, some of the controversies regarding the diagnoses involve the people who are empowered to lead the APA Work Group on GID. The focus has been on Dr. Ken Zucker, who is a Canadian researcher and clinician who specializes in working with gender-variant children. He has been accused of using “reparative therapy” to treat young children who exhibit cross-gender behaviors. Dr. Zucker has treated about 500 preadolescent gender-variant children with the goal of helping these kids be “more content in their biological gender”; he claims an 80% success rate. Ray Blanchard, another member of the GID Work Group, has developed a theory that identifies MTF transsexuals as either homosexual or fetishistic. Dr. Blanchard theory about autogynephilia has been the focus of strong opposition from many transwoman.

So, in a nutshell, the controversy rests on the concern that the people who are leading the GID Work Group hold outdated ideas about transgenderism, and continue to pathologize trans identities. One of the complications is that the APA is a research-oriented organization, and both Dr.’s Zucker and Blanchard have compiled a sizable amount of documentation for their ideas and when it comes to research, size really does count. The other side of this controversy, however, is that in an effort to discredit their ideas, an enormous amount of disinformation has been flung about the Internet, exaggerating their positions, misrepresenting their ideas, and basically developing a smear campaign (often without even reading the bulk of their work) that sadly muddies the waters.

I do not think hostile and misinformed attacks are the way to influence either the Work Group or the APA, especially when there are plenty of bona fide issues to argue with that Dr.’s Zucker and Blanchard promote, that there is really no need to discredit them with name-calling. It is an emotionally challenging idea to accept that some very intelligent and even well-meaning people, who have in other situations supported transsexual surgeries, can continue to disseminate such dangerous ideas. It is especially disturbing to me, to do it in the name of science.

In my opinion, because I do not stand on neutral territory, is that it would be best to remove GID from the DSM. For those who are concerned about insurance reimbursement (which in the U.S. is rarely covered for gender-related issues) I think there are other ways to diagnosis emotional pain, when necessary. For example, there are many diagnoses in the DSM that look at distress (Depression, PTSD, Adjustment Disorder), without focusing on the “gender” as a problem.

Removing GID from the DSM, does present certain dilemmas, since many countries have national health care systems that currently depend on the GID diagnosis for treatments, as do some legal precedents in the U.S. However, for those seeking medical treatments (i.e., hormones and surgery), physicians can diagnose a physical health problem; there is no need for a mental health diagnosis to receive trans-related medical treatments.  There are other medical problems that are covered by insurance that are not at all “pathological,” for example pregnancy.

It is very unlikely that GID would be removed from the DSM during this current revision process, since the current membership of the APA Work Group represents a conservative perspective on gender identity and transgenderism. However, there is an opportunity now to re-conceptualize the diagnosis so that it does not pathologize transgender people or conflate societal bias with psychological distress. In order to reform the GID diagnosis, the Work Group should be more representative of diverse perspectives.

So how the outcome of this process will impact you, Sally, a cross-dresser, is a good question, but mostly likely you could be labeled as a “fetishist,” if you sought out therapy for marital problems. We are all impacted by this decision whether we identify as transgender or transsexual, whether we are part-time cross-dressers, or young heterosexual parents seeking services for a gender-variant child. I am impacted as a therapist trying to assist clients in receiving necessary services, and all people who cross gender lines are impacted by whether the psychiatric profession reinforces traditional gender norms as the bases for “normal” gender expression. So, Sally dear, fix up your make-up, and remember that some of us professional types are working hard so that all people can wear whatever the hell they want to, whenever they want, without being labeled mentally ill (though personally I think matching outfits look lovely.)