Although Gender Identity Disorder (GID) and homosexuality has been in the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM) for many years, I was personally unaware of the controversy that surrounded it. I realized that I needed to educate myself in the issues and changes that have occurred in the DSM regarding GID and homosexuality over the years. The APA is in the process of revising its DSM and part of that process has been to create a Work Group on Sexual and Gender Identity Disorders (WGSGSID).
The Work Group is one of 13 groups participating in the DSM-V revision process (Drescher, 2010). There has been a high level of concern from the lesbian, gay, bisexual, and transgender (LGBT) community in regards to the status of the category of GID in the DSM (Drescher, 2010). Activists argued that it is wrong to label expressions of gender variances as symptoms of a mental disorder. Advocates for the removal of the GID compare it to the removal of homosexuality in 1973 (Drescher, 2010).
According to the World Professional Association for Transgender Health, people experiencing “strong cross-gender identification and a persistent discomfort with their sex or a sense of inappropriateness in the gender role of that sex” were diagnosed with transexualism in the DSM-III. In 1994, the DSM IV changed that diagnosis to GID. (Drescher, 2010). Removing GID from the DSM would be a major step in destigmatizing the lives of transgendered people, however it would come at a price and this will be reviewed in this paper.
Individuals that identify as gay, lesbian, bi-sexual or transgendered do not believe that they have a disorder and are mentally ill. The inclusion of gender nonconformity among disorders creates stigma for transgendered individuals in society. In 1973, homosexuality was declassified in the DSM (second edition), however, transgender identity and expression still remains. In this paper I will discuss issues of gender identity, how they are defined in the DSM, and the controversy that surrounds them. History of Gender Identity Disorder (Transgender)
I’ve always learned that to understand the issues of today we must look at history. And so we don’t repeat the misfortunes of yesterday we must learn from them. So, for this section I have researched a brief history of Gender Identity Disorder and how it became a psychiatric classification. Under diagnostic codes in the DSM, transvestic fetishism, formerly transvestism, (TF) means to wear the clothing of the opposite sex. This term was created and used by Magnus Hirshfeld in 1910. Transsexualism, also termed by Hirchfeld in 1923, first appeared in the DSM-III (1980) as a diagnostic category.
Currently in the DSM, heterosexual men can be diagnosed with TF if they meet only two criteria: they have sexual fantasies about cross-dressing and those fantasies cause “impairment in social, occupational, or other important areas. ” DSM Manual The DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th edition) development timeline began almost ten years ago with a series of meetings and conferences that summarized the findings that had accumulated in the scientific literature since the publication of DSM-IV and then developed research agendas for DSM-5 (Narrow & Cohen-Kettenis, 2010).
There are no restraints on the amount of change that can occur in formulating the DSM-5, provided that the changes are based on sound research findings and will enhance its clinical usefulness (Narrow & Cohen-Kettenis, 2010). The DSM-5 Task Force is composed of workgroup chairs and professionals from other stakeholder groups including APA governance representatives. There is a consumer representative on the task force and the members of the task force are diverse in ethnic and racial groups and gender.
There are 13 workgroups, and the workgroups focus on specific diagnostic areas (Narrow & Cohen-Kettenis, 2010). The taskforce and workgroups are composed of 163 members, 39 of whom are from outside the United States. Thirty percent of the members are female, 18% are non-Caucasian, and there is a diversity of disciplines represented. There is a DSM-5 Web site, www. dsm5. org, which contains Task Force meeting summaries, workgroup progress summaries, the names of the members of the taskforces and workgroups and their disclosure information (Narrow & Cohen-Kettenis, 2010) .
There has been a subworkgroup formed to work on the Gender Identity Disorder. Four topics were nominated by the group to discuss: general issues, the differences and similarities between homosexuality and GID with regard to the DSM; and specific research literature of the criteria for GID in adolescents and adults (Narrow & Cohen-Kettenis, 2010) . One of the first things that the subgroup did was distribute a short survey amongst transgender organizations.
The survey was designed to help the group learn what transgender organizations, not only in the United States and Europe but also worldwide, were thinking about various hot topics in gender identity. They were interested in suggestions for possible reconstruction of the diagnosis if it were to remain a diagnosis in the DSM-5 (Narrow & Cohen-Kettenis, 2010) . More than 50% of respondents believed that GID should not stay in the DSM. Political and educational transgender organizations were very much in favor of removing GID from the DSM.
The political groups had the highest percentages (75%) favoring removal of the diagnosis, followed by the educational groups (70%) (Narrow & Cohen-Kettenis, 2010) . The DSM is a political document—a social construction—shaped more by sociocultural influences than the demands of practicing professionals in the field of mental health (Conner-Greene, 2006). The DSM has become a profoundly powerful book in terms of the health insurance industry, the pharmaceutical industry, and even the courts (Conner-Greene, 2006). Problems with the Current Diagnostic Criteria for GID
Some reasons given for deleting GID from the DSM included: (1) concerns that the diagnosis inappropriately pathologized an aspect of one’s identity; (2) the conviction that the diagnosis is stigmatizing and that this is a major cause of distress; (3) the potential use of the diagnosis as a discriminatory tool, resulting in, for example, exclusion from military service or healthcare services; and finally (4) the belief that GID is a neurological or brain phenomenon, not a mental disorder (Narrow & Cohen-Kettenis, 2010). Support of Keeping the GID Diagnosis in the DSM
The most important reason cited for allowing the diagnosis to persist was insurance reimbursement and legal advocacy. Some members and advocates of the trans community expressed concern that deleting GID from the DSM-V would lead third party payers to deny access to care for those transgender adults already having issues with inadequate private and public sources of healthcare (Drescher, 2010). Some argued that keeping the diagnosis of GID in the DSM would make it harder to misdiagnose transgender individuals with other mental illnesses.
Others suggested that it would be easier for family and friends to accept a transgender person’s identity if this identity had an official place somewhere (Narrow & Cohen-Kettenis, 2010). Retention of the GID diagnoses would eventually lead to putting the diagnosis of “homosexuality” back into the manual (Drescher, 2010). I personally do not see this ocurring, however, it is not inconceivable. Clinical efforts with gender variant children aimed at getting them to reject their felt gender identity and to accept their natal sex were unscientific, unethical, and misguided.
Activists labeled such efforts as a form of reparative therapy (Drescher, 2010). Definitions of Conditions in the DSM Transsexualism The second half of the twentieth century saw the development within the psychological and medical communities of a transsexual model and procedures for identifying, describing, and treating individuals who sought sex reassignment. This model viewed transsexualism as a form of mental illness characterized by a pervasive and ongoing wish to be a member of the other sex (Denny, 2004).
The 1990s, however, brought an increasing awareness among researchers and clinicians that genital sex reassignment surgery (SRS) is not uniformly desired or sought by all persons who dress and behave as members of the other sex on a full-time basis (Denny, 2004). Therapists Role in Transgendered Issues There is a world of difference when both the therapist and the patient believe the patient to be mentally ill and in crisis, and when both the therapist and the client believe the client to be healthy and self-actualized and contemplating a life-altering decision (Denny, 2004).
There is evidence that is reasonably strong that psychotherapeutic interventions are not particularly successful with transgendered individuals (Zucker, 2008). The empirical evidence from adulthood suggests that gender dysphoria is best treated through hormonal and surgical interventions, particularly in carefully evaluated patients (Zucker, 2008). Today’s client is likely to be educated about transgender issues, to know his or her options, and to have a broad-based support system.
The therapist can and should provide factual information, help the client understand the available options, and make necessary referrals. This can prove difficult to a therapist unfamiliar with the transgender model, hence it is important to be educated in this area (Denny, 2004). Psychiatrists and other caregivers should be careful not to confuse their personal beliefs about gender with the clinical needs of the patients they are treating. Therapists should know that despite nonsurgical lifestyle options now open to transgendered people, transsexuals tend to view SRS as the treatment of choice (Denny, 2004).
In most communities, there are not enough such specialists available to allow for two different roles needed of specialists: one who is the therapist and one (or two, in the case of surgery recommendations) who is the evaluator. Thus, clinicians often find themselves in dual roles of therapist and evaluator. This frustrates many clinicians who worry that clients will withhold information that would aid in the therapeutic process for fear that it will jeopardize their chances of acquiring letters of recommendation (Griffin, 2011).
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