DSM-V draft

February 10, 2010

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.

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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”.

Additionally:

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.

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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:

  1. 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”.
  2. 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?
  3. Does it mean the legally assigned gender at birth, or at the time of diagnosis?
  4. 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?
  5. What about places (for example, the state of Victoria, Australia) where babies may be assigned a gender of male, female or intersex?
  6. 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:

  1. 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”?
  2. Does it ignore, or not ignore, prior medical gender reassignment?
  3. What about the situation where a second medical opinion results in a different medical gender being assigned?
  4. 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?

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Cross-posted at Questioning Transphobia

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6 Responses to “DSM-V draft”


  1. […] Cross-posted at Bird of Paradox […]

  2. HarpyMarx Says:

    Christ! I loathe the DSM manuals diligently studied by shrinks and anyone with a CSE in mental health who study the ‘bible of disorders’. It just classifies, categorises and labels people…along with suspect criteria etc. The number of times I have seen a shrink thumb through the pages trying to find a category to stick me in, shrink wrap me and working out the criteria and whether I fit (Ooo I only fulfil x of the criteria does that make me borderline?)

    I have always wanted to fling one of those ‘bibles’ at a shrink with the words, ‘analyse this’…

    So Helen I salute your indefatigability for having the patience to scrutinise the latest draft DSM. Solidarity comrade.

    Apols for the rant as well…just seeing ‘DSM’ sets me off (maybe they should develop a label for that…)

  3. Raven Says:

    HarpyMarx: Although I understand your frustration with being “stuck in a category and shrink wrapped”, you need to underdstand how billing works.

    In order for insurance to pay the treatment provider, a diagnosis MUST be made. In order to receive treatment, a diagnosis MUST be made otherwise that treatment can be called into question by the Licensure Board, APA etc. Also it is a matter of paper work. Everything has to be documented and fileld out correctly.

    Sometimes making a diagnosis is difficult when a client comes in, for example, to work out troubles that are here and now such as losing a job and becoming depressed. A clinical diagnosis of Major Depressive Episode (depending on history, extent of symptoms etc.) has to be made for payment to be received. It sucks, but that’s the way it works. This is mainly to safe-guard against someone receiving bogus treatment for a bogus problem and getting PAID to do it.

    Again, I understand your frustrations and you’re certainly entitled to your feelings on the issue.

  4. Raven Says:

    *filled


  5. […] 15, 2010 by Astrid Helen G of Bird of Paradox had a roundup on proposed DSM-V criteria relevent to trans people. Because she has said everything that I could about gender identity but much more eloquently, I am […]

  6. Raven Says:

    I may need to clear something up here:

    “This is mainly to safe-guard against someone receiving bogus treatment for a bogus problem and getting PAID to do it.”

    This was not articulated well. I’m referring to the treatment PROVIDER being paid for possible bogus tx. provided.


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