Psychiatry’s civil war

December 12, 2009

New Scientist magazine has published a lengthy article – Psychiatry’s civil war – about the proposed revision of the Diagnostic and Statistical Manual of Mental Disorders and the “open conflict [which] has broken out among the upper echelons of US psychiatry” regarding the attempt to “extend definitions of mental illnesses so broadly that tens of millions of people will be given unnecessary and risky drugs”.

(Note: Since the article was posted, the American Psychiatric Association has announced that the publication of DSM-V will be delayed until May 2013 to “allow more time for public review, field trials and revisions”.)

The whole article is worth reading, but in particular it has this to say about the redefinition of gender identity:

We are who we say we are

Is history repeating itself? That’s the question facing psychiatrists considering how gender identity should be defined in DSM-V. The APA has a legacy of uneasy relations with the lesbian, gay and transgender community, having included homosexuality in the DSM’s list of psychiatric disorders until 1973. Some transgender activists want issues of gender identity kicked off the list of mental illnesses too.

These activists are up in arms over the membership of DSM-V’s sexual and gender identity disorders work group, in particular the selection of Kenneth Zucker of the University of Toronto, Canada, as its chair. Zucker is reviled by some transgender activists for his work on therapy to reorient children who feel that they were born into the wrong sex. An online petition objecting to the work group’s composition has more than 9500 signatures.

The group is nevertheless likely to recommend changes that could actually ease tensions. One of these is a change in the name of a diagnosis that as currently phrased is inherently offensive to transgender people. “‘Gender identity disorder’ falsely implies that the gender identities of gender variant people are in themselves disordered,” says Kelley Winters, founder of GID Reform Advocates.

The work group has not yet revealed its proposed name, but “disorder” will be dropped. “We’re sensitive to issues of language,” says Zucker. One possibility is “gender dysphoria”, which focuses on the inherent distress of people living in a body that doesn’t match their identity.

That would not satisfy those transgender activists who want issues of gender identity removed from the DSM altogether. But others argue for the retention of a renamed condition to make it easier for those distressed by the mismatch between their identity and their bodies to seek assistance, and also to help those who need sex-change surgery to get it paid for. Even now, many transgender people face problems when insurers refuse to recognise the treatment as a legitimate medical expense.

My opinion on the binary options mentioned in the last paragraph is somewhere between the two viewpoints: I would be more than happy for any mention of gender identity to be dropped provided that trans people are not, as a consequence, denied access to timely, appropriate and free medical treatment. Transitioning needs to be refocused away from a gatekeeping approach to one of facilitation and support.

Additionally, New Scientist has also published an op-ed companion piece – Time’s up for psychiatry’s bible – which suggests that:

With the advent of the internet, there is no longer any compelling need to rewrite the diagnostic criteria for the whole of psychiatry in one go. Yes, diagnoses should be revised as new scientific findings come in. But for this, specialists can be assembled when necessary to address specific areas that have become outmoded. Their suggestions can be posted on the web for comment. More research can be commissioned, if necessary. And when consensus is reached, new diagnostic criteria can be posted online.

Similarly, standing panels could periodically review issues that cut across the whole of psychiatry – such as the inevitable shift away from checklists of symptoms towards a system based on measurements of the underlying biological and psychological determinants of mental health.

Apparently there is resistance to this move towards such a “living document” because such a transition (no pun intended):

[…] would have hurt the APA’s coffers, as a book that becomes a required reference is a big earner; DSM sales since 2000 exceed $40 million.

Which rather leaves me wondering exactly where the APA’s real priorities lie: in providing a framework that would actually help the people who need it, or generating arguably obscene profits at the expense of our health and wellbeing.


(Curtsey to Martha T.G.O. on the TGEU listserv for the heads-up)


Cross-posted at Questioning Transphobia


Previous posts about the DSM on this blog:


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