Today, February 10, the American Psychiatric Association (APA) has published a draft of the fifth version of its Diagnostic and Statistical Manual of Mental Disorders (DSM-V). It must be stressed that this is only a draft, posted for review and comment – the full publication remains slated for May 2013. Needless to say, it still seems as problematic as expected, even (especially?) with the introduction of so-called dimensional ratings.
From The Economist:
The APA’s DSM-V task force, however, has suggested it would like to introduce a “new paradigm” into the manual. It wants to recognise that many conditions, such as anxiety and depression, tend to overlap, so that a diagnosis of only one or the other does not always make sense. The new version of the DSM is also expected to include a “dimensional” component, one that considers the severity as well as the nature of symptoms.
It’s going to take a while to read through the review documents – there are a lot of them – but it seems clear there will be much heated debate. How could there not be with proposals to add, for example, Hypersexual Disorder and Paraphilic Coercive Disorder to the DSM-V?
Autogynephilia, as expected, looks set to be given the fancy new title of Transvestic Fetishism – and if the Sexual and Gender Identity Disorders Work Group thought they could bury it in the depths of the Paraphilias section (along with such things as pedophilia) where nobody would notice, well, guess what Dr Zucker? We’ve got news for you…
The main index page for the Sexual and Gender Identity Disorders consultation documents is at http://www.dsm5.org/ProposedRevisions/Pages/SexualandGenderIdentityDisorders.aspx
Read it and weep.
ETA: Digging a little deeper, I see that in section 302.3 Transvestic Fetishism, under the Rationale tab, a distinction is made between “paraphilias” – which don’t cause distress or impairment, and thus don’t require psychiatric intervention – and “paraphilic disorders” – which do cause distress or impairment, and thus do require psychiatric intervention.
The Paraphilias Subworkgroup states: “This approach leaves intact the distinction between normative and non-normative sexual behavior, which could be important to researchers, but without automatically labeling non-normative sexual behavior as psychopathological.”
Another change worth noting appears in the end notes under sections 302.6 Gender Identity Disorder in Children and 302.85 Gender Identity Disorder in Adolescents or Adults – “Gender Identity Disorder” will be renamed “Gender Incongruence”:
In a recent survey that we conducted among consumer organizations for transgendered people (Vance et al., in press), many very clearly indicated their rejection of the GID term because, in their view, it contributes to the stigmatization of their condition.
So what was previously described as “a strong and persistent cross-gender identification” is now referred to as “a marked incongruence between one’s experienced/expressed gender and assigned gender”.
The term “sex” has been replaced by assigned “gender” in order to make the criteria applicable to individuals with a DSD (Meyer-Bahlburg, 2009a, 2009b). During the course of physical sex differentiation, some aspects of biological sex (e.g., 46,XY genes) may be incongruent with other aspects (e.g., the external genitalia); thus, using the term “sex” would be confusing. The change also makes it possible for individuals who have successfully transitioned to “lose” the diagnosis after satisfactory treatment. This resolves the problem that, in the DSM-IV-TR, there was a lack of an “exit clause,” meaning that individuals once diagnosed with GID will always be considered to have the diagnosis, regardless of whether they have transitioned and are psychosocially adjusted in the identified gender role (Winters, 2008).
Which seems to suggest two things:
- First, it enables the diagnosis of intersex people with GI. The use of the highly contentious acronym DSD – “disorders of sex development” – doesn’t go unnoticed. The Organisation Intersex International (OII) has been protesting the use of the term since it was first coined in 2008 – more details here.
- Second, it will enable people who have transitioned to be free of the diagnosis. I’m unclear what effect this may have on people who have transitioned and who live in countries where there is state-funded prescription of, for example, hormones. Presumably if it’s decided that you no longer experience GI, then there will be no requirement for the state to contribute to the cost of your meds. I don’t know if that’s what will happen, but it certainly seems like it could be a possibility.
ETA, February 12: The concept of “Assigned Gender” is a new introduction in the DSM 5 – but it doesn’t seem to be clearly defined anywhere in the documentation. It appears in sections 302.6 Gender Identity Disorder in Children and 302.85 Gender Identity Disorder in Adolescents or Adults, under the description of Gender Incongruence – “A marked incongruence between one’s experienced/expressed gender and assigned gender […]”.
“Experienced/expressed gender” seems fairly self-explanatory – but “assigned gender”? The cynic in me wonders if the omission of a definition might be deliberate, to give practitioners plenty of ‘wiggle room’ in their interpretations.
Does it mean “legally assigned gender” or “medically assigned gender”?
If “legally assigned gender” is intended then:
- In the end notes, where it says “[…] one’s assigned gender (usually at birth) […]”, does that mean “most people are not transsexual and for non-transsexual people the concept is simple” or does it mean “legally reassigned gender is usually to be ignored for diagnostic purposes”.
- Does it mean the legally assigned gender where the patient resides, or the legally assigned gender where the patient is being diagnosed, as these may be different if a transsexual person travels?
- Does it mean the legally assigned gender at birth, or at the time of diagnosis?
- For people who live in federated republics (such as the U.S.) does it mean legal gender in Federal law or legal gender in State law?
- What about places (for example, the state of Victoria, Australia) where babies may be assigned a gender of male, female or intersex?
- What about people who have multiple citizenships and passports (and other documents) in different sexes? (See my recent post about Jenny T. Ramsey for an example of the kinds of problems already existing)
But if the DSM 5 means “medically assigned gender” then:
- What about people who have multiple medical providers (and/or non-government insurers), some of whom treat the patient as being “medically male” and others regard the patient as “medically female”?
- Does it ignore, or not ignore, prior medical gender reassignment?
- What about the situation where a second medical opinion results in a different medical gender being assigned?
- Some countries (for example, Cuba) regard transsexualism as not being a mental disorder at all. Is the medically reassigned gender of people in those countries considered for mental health diagnostic purposes?
Cross-posted at Questioning Transphobia
Previous related posts:
- Psychiatry’s civil war (December 12, 2009)
- London trans activists call for boycott of sham demo on October 17th (October 11, 2009)
- TGEU call for action/support – “Stop Trans Pathologization 2012″ (August 29, 2009)
- IFGE calls for action from APA (May 18, 2009)
- Transsexuality will no longer be classified in France as a mental illness (May 17, 2009)
- APA protest – San Francisco, May 18 (May 16, 2009)
- Looking back, pushing forward (April 30, 2009)
- APA Task Force reviews possible Gender Identity Disorder treatment guidelines (April 29, 2009)
- Close the CAMH Gender Identity Clinic – Facebook group (April 28, 2009)
- OII receives a letter from Dr Zucker’s legal representatives (March 21, 2009)
- Lynn Conway targeted by Kenneth Zucker for speaking out against his appointment to the APA Task Force (March 5, 2009)
- TGEU Policy Statement on DSM Reform (November 3, 2008)
- Developing DSM-V in Secret (October 17, 2008)
- Reminder: Demo against Zucker at RSM tomorrow (1st October 2008) (September 30, 2008)
- Demonstration against Kenneth Zucker at RSM, 1st October 2008 (September 22, 2008)
- Zucker *still* to speak at RSM conference (September 9, 2009)
- Zucker to Speak At Royal Society of Medicine Conference (August 15, 2008)
- WPATH Clarification (July 19, 2008)
- With God on Our Side (July 7, 2008)
- Crazy love (June 1, 2008)
- Still mad: more on DSM-V/Zucker/Blanchard (May 18, 2008)
- Mad as hell (May 6, 2008)