A presentation I prepared for the 2013 Philadelphia Transgender Health Conference, but did not have the opportunity to attend. Summary of recent changes to gender related diagnostic categories in the DSM-5, published last month by the American Psychiatric Association, and proposed changes for the ICD-11, scheduled for publication in 2015 by the World Health Organization.
GID Reform in the DSM-5 and ICD-11: a Status Update
1. Kelley Winters, Ph.D.Kelley Winters, Ph.D.
GID Reform AdvocatesGID Reform Advocates
May 12, 2013May 12, 2013
Wilton Manors, FL USAWilton Manors, FL USA
GID Reform in the DSM-5 and ICD-11:
a Status Update
GID Reform in the DSM-5 and ICD-11:
a Status Update
2. 1. Social Stigma that
equates nonconformity to
assigned birth sex as mental
defectiveness and sexual
deviance.
2. Access vs. barriers to
medical transition care, for
those who need it.
The Issues of
Gender Diagnosis
3. The History: Gender Diversity nomenclature in
the DSM and ICD has historically emphasized
enforcement of birth-assigned gender roles
4. History of Gender Dx in the DSM
➢
DSM-I (1952) none
➢
DSM-II (1968) Sexual Deviations: Transvestitism
➢
DSM-III (1980) Psychosexual Disorders: Transsexualism
➢
Gender identity disorder of childhood
➢
DSM-III-R (1987) Disorders usually first evident in infancy,
childhood or adolescence: Transsexualism, GID of childhood,
GIDAANT
➢
DSM-IV (1994) Sexual and gender identity disorders: GIDAA,
GIDC, Transvestic Fetishism
➢
DSM-IV-TR (2000) same
➢
DSM-5 (2013) Gender dysphoria: GDAA, GDC; Sexual
Disorders: Transvestic Disorders
--Drescher, Cohen-Kettenis, Winter (2012)
5. History of Gender Dx in the ICD
➢
ICD-6 (1948) none
➢
ICD-7 (1955) none
➢
ICD-8 (1965) Sexual deviations: Transvestitism
➢
ICD-9 (1975) Sexual deviations: Trans-sexualism, TV
➢
ICD-10 (1990) Gender identity disorders: TS, Dual Role TV,
GIDC, Other GID, GID Unspecified
➢
ICD-11 (2015) We need codings with less harm
and more clinical utility!
--Drescher, Cohen-Kettenis, Winter (2012)
International Classification of Diseases, published by the WHO,
contains both mental and physical diagnostic categories
6. “The expression of gender characteristics,
including identities, that are not stereotypically
associated with one’s assigned sex at birth is a
common and culturally-diverse human
phenomenon which should not be judged as
inherently pathological or negative...”
--May, 2010, WPATH Board of Directors
Emerging
Principles:
Depsychopathologization
7. Emerging Principles: Medical Necessity of
Transition Care
“An established body of medical research demonstrates
the effectiveness and medical necessity of mental health
care, hormone therapy and sex reassignment surgery as
forms of therapeutic treatment...”
“Health experts in GID, including WPATH, have rejected
the myth that such treatments are ‘cosmetic’ or
‘experimental’ and have recognized that these
treatments can provide safe and effective treatment for a
serious health condition.”
American Medical Association Resolution 122 (2008)
8. Photo by Kelley Winters Images Photography
Stop Trans Pathologization Movement Protest, Barcelona, 2010Stop Trans Pathologization Movement Protest, Barcelona, 2010
Emerging Principles: Human Rights and Self
Determination Models of Gender Diversity and
Transition
9. Gender Identity
Disorder is now
Gender Dysphoria.
Transvestic
Fetishism is now
Transvestic
Disorder
The DSM-5
May, 2013
10. DSM-5: Gender Dysphoria in
Adolescents/Adults
N9
The good: Change in title from “disordered” gender identity to
Dysphoria (Greek root for distress). Removal from Sexual Disorders
chapter to a new Gender Dysphoria chapter. Inclusive non-binary
language. Rejected proposal for “autogynephilia” specifier.
The bad: The need for medical transition care is still classed as
mental disorder. May pathologize difference from birth-assignment.
Ambiguous: “desire,” rather than underlying need, for transition care
is cast as symptomatic of mental illness.
The ugly: False-positive Dx of happy post-transition subjects. May
contradict rather than support transition care. Offensive term
“Disorder of Sex Development”
11. DSM-5: Gender Dysphoria in Children
The good: Children must show dissatisfaction with birth-sex
assignment and can no longer be diagnosed strictly on the basis of
gender role nonconformity.
The bad: Children who do not conform to stereotypes of assigned
birth-sex are still classed as mentally ill. False-positive Dx of happy
socially transitioned children who are too young to need any medical
transition/puberty-blocking treatment.
The ugly: Nonconformity to anachronistic gender stereotypes is still
emphasized as symptomatic of mental disorder.
12. DSM-5: Transvestic
Disorder
Transvestic Disorder, in
the Paraphilias section of
the DSM, punishes
nonconforming gender
expression by birth-
assigned males and now
birth-assigned females
with stigma of sexual
deviance.
Just Ugly: It serves no
constructive clinical utility
but inflicts great harm.
13. The ICD-11
The World Health
Organization’s
“standard diagnostic
tool for epidemiology,
health management
and clinical purposes.”
Revision 11 is
scheduled for 2015.
14. ICD-11 Proposal: Gender Incongruence of
Adolescence and Adulthood
The awesome: Moved out of the Mental and behavioural disorders
chapter to a new chapter, “Certain conditions related to sexual
health.” Incongruence title is distinct from DSM-5 dysphoria title.
The bad: Pathologizes incongruence with birth-assignment, not
current sex characteristics. Ambiguous: desire for transition care is
cast as pathological, though no longer psychopathological. False-
negative Dx of some subjects with need for medical transition care.
The ugly: False-positive Dx of happy post-transition subjects. May
contradict rather than support transition care.
15. ICD-11 Proposal: Gender Incongruence
of Childhood
The awesome: Moved out of the Mental and behavioural disorders
chapter to a new chapter, “Certain conditions related to sexual
health.”
The bad: Pathologizing coding of happy gender nonconforming or
socially transitioned children, too young to need any medical
transition/puberty-blocking treatment, is highly controversial.
The ugly: Nonconformity to anachronistic gender stereotypes is still
emphasized as symptomatic of a pathology.
16. ICD-11 Proposal:
Eliminate Transvestic Dx
The awesome: Eliminate
victimless paraphilia categories,
including:
F65.1: Transvestic fetishism
As well as F64.1: Dual-role
Transvestism
The Ugly: Political pressure for
diagnostic creep, which might
implicate ego-dystonic cross-
dressing.
17. Guiding Principle for AA Diagnostic Reform
...
Adults and adolescents
needing access to
medical transition care,
or pubescent youth
needing puberty
blocking medications,
require a clear
description of the
problem to be treated
Photo by Kelley Winters Images
18. Guiding Principle for Childhood Dx Reform
Children do not have
medical needs, related
to gender diversity, that
require a specific
diagnosis. Instead,
their primary needs are
for information,
counseling, and
support. (Winter 2013).
Photo by Dawn Hebert
19. Global Action for Trans* Equality (GATE) Civil Society Expert
Working Group, Buenos Aires, April, 2013
Global Action for Trans* Equality (GATE) Expert Working Group
Meeting, The Hague, November, 2011.
http://globaltransaction.files.wordpress.com/2012/05/its-time-
for-reform.pdf
World Health Organization, ICD11 Beta Draft, June 2013
http://apps.who.int/classifications/icd11/browse/f/en
American Psychiatric Association, Gender Dysphoria, 2013,
http://www.dsm5.org/Documents/Gender%20Dysphoria
%20Fact%20Sheet.pdf
Geoffrey Reed, PhD.; Peggy T. Cohen-Kettenis, PhD; Richard
Krueger, MD; Dan Karasic, MD; Gail Knudson, MD; Kelley
Winters, PhD, “ICD 11,” National Transgender Health Summit,
May 2013, Oakland CA.
20. Kelley Winters, Ph.D.Kelley Winters, Ph.D.
GID Reform AdvocatesGID Reform Advocates
May 12, 2013May 12, 2013
Wilton Manors, FL USAWilton Manors, FL USA
GID Reform in the DSM-5 and ICD-11:
a Status Update
GID Reform in the DSM-5 and ICD-11:
a Status Update
Notas do Editor
More than three decades after the American Psychiatric Associationvoted to remove the classification of homosexuality as a mental disorder, people who do not conform to their assigned birth sex, either by inner identity or outer social expression, remain diagnosed as mentally ill in the Fourth Edition, Text Revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). 4 Published by the American Psychiatric Association, the DSM is regarded as the medical and social definition of mental disorder throughout the U.S. and Canada. It strongly influences international psychiatric nomenclature in the International Statistical Classification of Diseases and Related Health Problems (ICD), published by the World Health Organization. But first, who are these people who dare not conform to their birth sex assignment?
We have been manipulated, we have been bamboozled, into believing a false dichotomy -- when in fact the current diagnostic nomenclature has failed us on both issues of stigma and transition care access. While the existence of a diagnostic coding has helped affirming, supportive care providers to make transition procedures available to some transitioning individuals, the specific diagnostic criteria and supporting text of the current Gender Identity Disorder category support the opposite approach – punitive gender-conversion or gender-reparative therapies intended to change or suppress gender identity or expression which differ from assigned birth sex roles “ I concluded that to provide a surgical alteration to the body of these unfortunate people was to collaborate with a mental disorder rather than to treat it.” --Paul McHugh; Hopkins
Examples of the consequences of psychosexual stigma: “ This is nothing more than mental illness, and the American Psychiatric Association says so.” “’ Gender Identity Disorder’ is classified as a mental disorder by the American Psychiatric Association. Legal protection against discrimination based on mental illness is not provided for any other disorder, and there is no rational explanation why it should be offered for this one. Those who wish to assume a ‘gender identity’ contrary to their biological sex are in need of mental health treatment to overcome such disturbed thinking, not legislation to affirm it.” Undermining the legitimacy of social and medical transition in the title, diagnostic criteria and supporting text of the current Gender Identity Disorder diagnosis, the American Psychiatric Association has undermined the human dignity and civil justice of gender-variant and especially transitioning people.
Examples of the consequences of psychosexual stigma: “ This is nothing more than mental illness, and the American Psychiatric Association says so.” “’ Gender Identity Disorder’ is classified as a mental disorder by the American Psychiatric Association. Legal protection against discrimination based on mental illness is not provided for any other disorder, and there is no rational explanation why it should be offered for this one. Those who wish to assume a ‘gender identity’ contrary to their biological sex are in need of mental health treatment to overcome such disturbed thinking, not legislation to affirm it.” Undermining the legitimacy of social and medical transition in the title, diagnostic criteria and supporting text of the current Gender Identity Disorder diagnosis, the American Psychiatric Association has undermined the human dignity and civil justice of gender-variant and especially transitioning people.
Examples of the consequences of psychosexual stigma: “ This is nothing more than mental illness, and the American Psychiatric Association says so.” “’ Gender Identity Disorder’ is classified as a mental disorder by the American Psychiatric Association. Legal protection against discrimination based on mental illness is not provided for any other disorder, and there is no rational explanation why it should be offered for this one. Those who wish to assume a ‘gender identity’ contrary to their biological sex are in need of mental health treatment to overcome such disturbed thinking, not legislation to affirm it.” Undermining the legitimacy of social and medical transition in the title, diagnostic criteria and supporting text of the current Gender Identity Disorder diagnosis, the American Psychiatric Association has undermined the human dignity and civil justice of gender-variant and especially transitioning people.
We have been manipulated, we have been bamboozled, into believing a false dichotomy -- when in fact the current diagnostic nomenclature has failed us on both issues of stigma and transition care access. While the existence of a diagnostic coding has helped affirming, supportive care providers to make transition procedures available to some transitioning individuals, the specific diagnostic criteria and supporting text of the current Gender Identity Disorder category support the opposite approach – punitive gender-conversion or gender-reparative therapies intended to change or suppress gender identity or expression which differ from assigned birth sex roles “ I concluded that to provide a surgical alteration to the body of these unfortunate people was to collaborate with a mental disorder rather than to treat it.” --Paul McHugh; Hopkins
More than three decades after the American Psychiatric Associationvoted to remove the classification of homosexuality as a mental disorder, people who do not conform to their assigned birth sex, either by inner identity or outer social expression, remain diagnosed as mentally ill in the Fourth Edition, Text Revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). 4 Published by the American Psychiatric Association, the DSM is regarded as the medical and social definition of mental disorder throughout the U.S. and Canada. It strongly influences international psychiatric nomenclature in the International Statistical Classification of Diseases and Related Health Problems (ICD), published by the World Health Organization. But first, who are these people who dare not conform to their birth sex assignment?
Examples of the consequences of psychosexual stigma: “ This is nothing more than mental illness, and the American Psychiatric Association says so.” “’ Gender Identity Disorder’ is classified as a mental disorder by the American Psychiatric Association. Legal protection against discrimination based on mental illness is not provided for any other disorder, and there is no rational explanation why it should be offered for this one. Those who wish to assume a ‘gender identity’ contrary to their biological sex are in need of mental health treatment to overcome such disturbed thinking, not legislation to affirm it.” Undermining the legitimacy of social and medical transition in the title, diagnostic criteria and supporting text of the current Gender Identity Disorder diagnosis, the American Psychiatric Association has undermined the human dignity and civil justice of gender-variant and especially transitioning people.
Examples of the consequences of psychosexual stigma: “ This is nothing more than mental illness, and the American Psychiatric Association says so.” “’ Gender Identity Disorder’ is classified as a mental disorder by the American Psychiatric Association. Legal protection against discrimination based on mental illness is not provided for any other disorder, and there is no rational explanation why it should be offered for this one. Those who wish to assume a ‘gender identity’ contrary to their biological sex are in need of mental health treatment to overcome such disturbed thinking, not legislation to affirm it.” Undermining the legitimacy of social and medical transition in the title, diagnostic criteria and supporting text of the current Gender Identity Disorder diagnosis, the American Psychiatric Association has undermined the human dignity and civil justice of gender-variant and especially transitioning people.
Examples of the consequences of psychosexual stigma: “ This is nothing more than mental illness, and the American Psychiatric Association says so.” “’ Gender Identity Disorder’ is classified as a mental disorder by the American Psychiatric Association. Legal protection against discrimination based on mental illness is not provided for any other disorder, and there is no rational explanation why it should be offered for this one. Those who wish to assume a ‘gender identity’ contrary to their biological sex are in need of mental health treatment to overcome such disturbed thinking, not legislation to affirm it.” Undermining the legitimacy of social and medical transition in the title, diagnostic criteria and supporting text of the current Gender Identity Disorder diagnosis, the American Psychiatric Association has undermined the human dignity and civil justice of gender-variant and especially transitioning people.
More than three decades after the American Psychiatric Associationvoted to remove the classification of homosexuality as a mental disorder, people who do not conform to their assigned birth sex, either by inner identity or outer social expression, remain diagnosed as mentally ill in the Fourth Edition, Text Revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). 4 Published by the American Psychiatric Association, the DSM is regarded as the medical and social definition of mental disorder throughout the U.S. and Canada. It strongly influences international psychiatric nomenclature in the International Statistical Classification of Diseases and Related Health Problems (ICD), published by the World Health Organization. But first, who are these people who dare not conform to their birth sex assignment?