WPATH responds to the APA’s proposed DSM 5 Criteria for Gender Incongruence

May 26, 2010

WPATH (the World Professional Association for Transgender Health) has posted its formal response to the APA’s proposed DSM 5 Criteria – here’s the direct link to the 9-page PDF.

The document points out the following aspects it considers to be “improvements” in the proposed revisions:

  1. The change in name from Gender Identity Disorder to Gender Incongruence is an improvement. It is less pathologizing as it no longer implies that one’s identity is disordered.
  2. The proposed criteria are better able to account for the diversity in gender and transgender identities encountered in clinical practice, reflecting the paradigm shift away from a binary understanding and treatment approach toward affirmation of a spectrum of transgender identities.
  3. Criterion 1, “a strong desire to be of the other gender or an insistence that he or she is of the other gender,” is proposed as required in order to qualify for a diagnosis of Gender Incongruence in Children. This will appropriately prevent children with a gender variant expression without an incongruence between gender identity and sex assigned at birth to receive the diagnosis, which was a common point of critique for DSM IV. […]
  4. Adding a specifier of “with or without a Disorder of Sex Development” is an improvement over the need to use the “Not Otherwise Specified” diagnosis because individuals with intersex conditions may have a similar experience regarding their gender identity and desire corresponding treatment interventions. In DSM IV-TR, individuals with intersex conditions are specifically excluded from the unqualified diagnosis.
  5. The removal of the specifier of sexual orientation is a welcome change, acknowledging that gender identity and sexual orientation are two separate components of identity that are often conflated […]
  6. The proposed diagnosis includes an “exit clause” so that individuals who have successfully resolved their incongruence no longer are considered to have a mental disorder.

WPATH’s criticisms include:

  1. Inclusion or Removal of the Diagnosis: The discussion whether a diagnosis of Gender Identity Disorder or Gender Incongruence should be included in the DSM or not is not addressed on the APA web site with the proposed revision and its rationale. One of the major arguments put forth by consumer groups for removal of the diagnosis, is that it is not a mental disease or disorder, and that classifying gender variance as such perpetuates stigma attached to gender nonconformity. […]
  2. Diagnostic Criteria: We generally agree with the accuracy of the wording of the six criteria proposed for adolescents or adults. However, we have a concern about the very broad reach of the criteria. Although an explanation is offered for why only two of the six criteria are needed to fulfil the diagnosis of Gender Incongruence, the need for such a broad definition without a clear link to treatment is questionable. […] Instead of broadening the diagnosis, the WPATH Consensus Group recommends a narrowing of the diagnosis to those who experience distress associated with gender incongruence (Knudson, De Cuypere, & Bockting, in press). […]
  3. Separate or Combined Diagnoses for Adolescents and Adults: Because, from a clinical perspective, the challenges faced by adolescents are sufficiently different from either children or adults, the WPATH Consensus Group recommended separate diagnostic categories for adolescents and adults rather than combining them, which is currently the case in DSM IV-TR with no change proposed for DSM 5. If these diagnoses will indeed remain combined, we strongly recommend that at least the text draws special attention to the issues faced by adolescents and how these differ from those faced by adults.
  4. Name of the Diagnosis: Given the above discussion and WPATH’s recommendation for diagnoses based on distress instead of identity, it should come as no surprise that we favor changing the name of the diagnoses from Gender Identity Disorders to Gender Dysphoria. While we think the proposed new name of Gender Incongruence is an improvement, we prefer the term Gender Dysphoria to reflect that a diagnosis is only needed for those transgender individuals who at some point in their lives experience clinically significant distress associated with their gender variance. Moreover, the term incongruence implies that congruence is the norm and that incongruence is per definition problematic, which is not necessarily the case. […]
  5. Location of the Diagnoses within DSM: The place of the proposed diagnoses in the nomenclature is still unknown and under consideration. Placing Gender Incongruence under “Other Conditions that May be a Focus of Clinical Attention,” as Meyer-Bahlburg (2010) suggested, as long as this does not endanger health insurance coverage of transgender-specific health care, would go a long way in alleviating the criticism of professionals and consumers who advocate depathologization of gender variance and gender variant identities. The WPATH Consensus Group recommends that the diagnosis not be placed with the sexual disorders. We suggest two alternatives: Placement in a chapter of Psychiatric Disorders Related to a Medical Condition (which might ensure better health insurance coverage of transgender-specific medical interventions) or placement in a chapter on childhood-onset disorders (Knudson, DeCuypere, & Bockting, in press).

I read the conclusion of the WPATH Consensus Group for revision of the DSM diagnoses of Gender Identity Disorders as being quite critical; it seems to be saying that the proposals are more stylistic than substantive, and that “the proposed diagnostic criteria are now so broad that almost any transgender person could meet criteria for a mental disorder regardless of whether or not they experience clinically significant distress and desire or need intervention“. The WPATH report views this as a bad thing because it’s likely to pathologise more rather than fewer transgender people.

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Cross-posted at Questioning Transphobia

6 Responses to “WPATH responds to the APA’s proposed DSM 5 Criteria for Gender Incongruence”

  1. earwicga Says:

    Criterion 1, “a strong desire to be of the other gender or an insistence that he or she is of the other gender,” is proposed as required in order to qualify for a diagnosis of Gender Incongruence in Children.

    How about an absolute knowledge? Would be much more appropriate.

    individuals who have successfully resolved their incongruence no longer are considered to have a mental disorder.

    what does the ‘successfully resolved’ here actually mean? If a trans girl knows she is a girl and has always known it, then there has never been a ‘mental disorder’.

    The way I see it is that a trans child need not experience any ‘distress’. It is others that cause this distress to the child.

  2. Helen G Says:

    I completely agree.

  3. Jessica Says:

    I wonder at the greatly increased reach of the diagnostic criteria; it will now not only include transsexuality (and presumably sex identity) from DSM III, the addition of transgenderism and gender identity from DSM IV, and now intersex and “disorders of sex development.”

    I really don’t understand how this actually facilitates the divergent needs of these three very different, “consumer groups;” it always seemed to me the ‘convenience’ of “gender incongruence” is more for others than those of us who actually need help in our lives–and is another social construct which we will now, dutifully reify.

    I don’t see how the suggested “spectrum” can include everyone from transgender people, to transsexual people and intersex people.

    I’m unconvinced transgender people need medical interventions, or intersex people want medical intervention. As I understand it, from my own experience, only transsexual people need/want intervention.

    Rather than make clear the differences between identities, conditions and experience, these proposals continue the hegemony of Blanchard and Zucker, who, in any other context, most transsexual, transgender and intersex people would be fighting tooth and nail.

    For some peculiar reason, when it is placed in this bible, virtually all T and I people fight tooth and nail FOR Blanchard and Zucker.

    And WPATH thinks, even in a limited way, this is a good thing?!?

  4. Helen G Says:

    Jessica: While I understand what you’re saying, it should be remembered that this is the WPATH’s response to the proposals for the DSM and not a document issued by the APA itself. The final DSM revisions seem likely to happen in a way that suits the APA’s “Task Force”, over which Drs Zucker and Blanchard exert a huge amount of influence, as we know. And given their support for “reparative therapy” techniques, it seems likely that the new DSM will reflect that, regardless of what you, I or WPATH may think.

    That said, you make a couple of generalisations which I’m uncomfortable with:

    I’m unconvinced transgender people need medical interventions, or intersex people want medical intervention.

    I think that’s actually quite a contentious statement – some do, some don’t and I don’t think it’s safe to assume that all transgender and intersex people would agree with you – assuming you could ask them all individually. And my understanding of intersex support groups such as OII is that surgery is about enforced normalisation and is therefore primarily a human rights issue. (And let’s not forget that the range of intersex variations isn’t limited solely to people with ambiguous genitalia)

    As I understand it, from my own experience, only transsexual people need/want intervention.

    Again, I don’t agree with this generalisation. You might need/want medical intervention – and I definitely did – but I don’t believe you can just apply that metric to an entire class of people.

    For some peculiar reason, when it is placed in this bible, virtually all T and I people fight tooth and nail FOR Blanchard and Zucker.

    Do we? Do we really? Where’s the evidence of this? I’m sorry to carp, Jessica, but I think you’re in danger of undermining your own arguments (which I’m actually in broad agreement with) if you can’t substantiate these assertions.

  5. Jessica Says:

    I believe your discomfort, Helen, and mine, turns on the definitions and the acceptance of which you have challenged me to substantiate.

    Gender Identity. And in the future, Gender Incongruity.

    The next time you review a trans news list or website, I encourage you to notice how gender identity has, in the life times of younger transgender and transsexual people, reified into being not just a diagnostic “convenience,” but also a fixed, practically physical entity that has, anachronistically, existed for all time.

    I cannot, of course, do an empirical study on the incidence of the term, though I would argue any sort of critical dialogue analysis would indicate my contention.

    You are quite correct in pointing out the document at the base of my comments, here, is a WPATH commentary on the DSM proposals.

    We both agree DSM 5 will reflect the proposals as published because of the dominance of Blanchard and Zucker and their ideology; it is this ideology I am holding up for scrutiny. One which, as their terminology has reified, takes on the appearance of something other than ideology.

    But is there any indication WPATH thinks much differently?

    The World Professional Association on **Transgender** Health.

    I have not read everything WPATH has ever published, though for the future I just might have to.

    However, my experience with WPATH and Canadian Professional Association on Transgender Health (CPATH) members (which has, I understand, more members than the World Association) though a life saver personally, merely points out that gender identity, until the bible changes, is reified into the form of universal history.

  6. Angela Says:

    WPATH disorders intersex while depathologizing transgender

    http://oiiaustralia.com/wpath-disorders-intersex-depathologizing-transgender/

    “Get out of intersex, WPATH, and stick to your brief as the World Professional Association for Transgender Health.

    The blatant hypocrisy you have towards intersex demonstrates your antipathy to our struggle to be accepted as norman human beings with slightly different anatomies.

    You moan and groan about pathologizing gender variance and differences but are more than happy to see differences of sex anatomies pathologized as a mental disorder as well as a physical disorder.”


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