Kelley Winters

Update: Statement on Gender Identity Disorder and Transvestic Fetishism in the DSM-V

Filed By Kelley Winters | November 04, 2009 2:00 PM | comments

Filed in: Living, Transgender & Intersex
Tags: APA, DSM V, gender identity disorder, GID, psychiatry, psychology, Transvestic Fetishism

The Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association is regarded as the medical and social definition of mental disorder throughout North America and strongly influences the The International Statistical Classification of Diseases and Related Health Problems (ICD).

The current psychiatric classifications of Gender Identity Disorder (GID) and Transvestic Fetishism (TF) in the Fourth Edition Text Revision of the DSM (DSM-IV-TR) inflict great harm to gender variant, and especially transsexual, people in three ways:

* Unfair Social Stigma
* Medical Care Access
* Gender-Reparative Therapies

An in-depth look at each after the jump.

Unfair Social Stigma

The GID and TF diagnoses falsely label identities and expressions that differ from assigned birth sex as mental illness and sexual deviance. Behaviors and emotions considered ordinary or even exemplary for other (cisgender) people are mis-characterized as madness for gender variant people.

Transwomen (those who identify as women and were birth-assigned male) are consequently maligned as crazy and sexually suspect "men" by this stereotype and vice versa for transmen.

The defamatory classification of Transvestic Fetishism particularly targets transwomen, including a great many transsexual women (whose gender identities are dramatically incongruent with born physical sex characteristics), as "paraphiliac" or sexually perverse. Across North America, these diagnoses are cited directly when gender variant people are denied human dignity, civil justice, and legal recognition in their affirmed gender roles. Gender variant people lose jobs, homes, families, access to public facilities, and even custody and visitation of children as consequences of these false stereotypes.

Medical Care Access

GID and TF pose barriers to access to medically necessary hormonal and surgical transition treatment for those who need them. The diagnostic criteria, supporting text and categorical placement of GID and TF contradict social and medical transition and mis-characterize transition itself as symptomatic of mental disorder. Transitioned individuals who are highly functional and happy with their lives are forever diagnosable as mentally disordered, according to the current diagnostic criteria.

As a consequence, the medical necessity of hormonal and surgical transition treatments are not commonly recognized by care providers, insurers and government agencies. In the US, only the financially privileged have access to surgical care, with scant few exceptions.

Gender-Reparative Therapies

GID and TF implicitly promote cruel and harmful gender-reparative psychiatric "treatments" intended to enforce conformity to assigned birth sex and suppress gender variant identities and expressions into the closet.

Once diagnosed with GID or TF, the only way a transperson can be released from the current diagnostic criteria is to completely hide his or her gender identity and deny his or her authentic self. Children and adults, already at risk from undeserved guilt and shame, are subjected to more guilt, shame, torturous aversion therapies, drugs and even incarceration with these diagnoses.


I urge reform and redefinition of the Gender Identity Disorder diagnosis to simultaneously address both issues of unfair social stigma and medical necessity of hormonal and surgical transition treatments.

I believe this can best be accomplished in the upcoming Fifth Edition of the DSM (DSM-V) by replacing GID with nomenclature emphasizing painful distress with born physical sex characteristics or ascribed social gender role that are incongruent with gender identity, rather than nonconformity to assigned birth-sex.

I am encouraged by a recent report from Drs. Peggy Cohen-Kettenis and Friedemann Pfafflin, of the Gender Identity Disorders Subworkgroup of the DSM-V Task Force. They acknowledge many of the GID issues described here and recommend a diagnostic focus on distress and exclusion from diagnosis of gender variant people who meet no scientific definition of mental disorder. However, I am concerned about their use of the word, "desire," in their proposed diagnostic criteria, which would ambiguously implicate desire for medical transition treatment in itself as symptomatic of mental illness.

I strongly urge elimination of the scientifically capricious and socially punitive Transvestic Fetishism diagnosis from the DSM-V. I am especially troubled by a September report from Dr. Raymond Blanchard, chairman of the Paraphilias Subworkgroup of the DSM-V Task Force. He proposes to retain the TF diagnosis, renamed "Transvestic Disorder" with its existing diagnostic criteria that ambiguously label all "behaviors involving cross-dressing" by those assigned male at birth as sexually deviant on the basis of their sexual orientation. Moreover, Dr. Blanchard proposes to add the deeply offensive and inflammatory term, "autogynephilia," as a specifier to the diagnosis. I ask the DSM-V Task Force and elected officials of the American Psychiatric Association to reject his proposal.

You can find the complete text and citations at GID Reform Advocates.

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To be brutally honest, I'm following this debate more closely than any marriage initiative. The potential gains for the trans community from a positive rewrite -- especially one that sidesteps TF and simultaneously points to medical necessity of transition -- outweigh any potential gains from political advocacy and ballot initiatives. A proper rewrite could pave the way to basic access to transgender care -- care that doesn't have to come through insurance fraud, medical deception.

I'm a transwoman, and I'm tired of scurrying under the rug like a mouse in the medical system.

battybattybats battybattybats | November 4, 2009 7:30 PM

This is a really important issue. But lets all bear in mind we should not just focus on transsexual issues with this. Absolutely lets keep talking about them as this profoundly effects them.

But crossdressers are also part of Transgender. There are more crossdressers than there are transsexuals but they are often more stigmatised and so the vast majority are closeted and politically inactive and suffering. Some figures have put the number of crossdressers in the population as being comparable to the rest of the GLBT population combined!

And here we have a diagnosis criteria of a mental illness that includes SEXUALITY as one of it's criteria! And SEX as another! From the pdf preview of the report:

"(4) with a heterosexual
orientation. There are, of course, cross-dressers
who fall outside this definition: homosexual men who crossdress without sexual arousal and perhaps rare women who cross-dress with sexual arousal. The existence of these other groups has no necessary bearing on whether the combination of male sex, heterosexual orientation, cross-dressing, and sexual excitement constitutes a distinct syndrome. The consensus of expert clinicians, for almost a century, has been that it does."

Does anyone like the idea of sexual orientation being a criteria for diagnosing a mental illness folks? Think it's good that het male to female crossdressers are seperated from gay ones because of their sexuality in this? Or the female to male ones from the male to female ones because they are assumed to be 'rare'. And strange that being aroused wearing lingerie (something they seem to think only happens with het CDs, not gay ones) is somehow bad but a man being aroused wearing leather chaps or a woman finding wearing a tight corset arousing (which is almost every goth woman i know for the record) is somehow different.

This is an arbitrary definition. Built on policing gender roles from a transphobic gender-binary as well as sexuality double-standards and sexist double-standards. There's something wrong in that affecting everybody! And the knock-on effects through the psychiatric field could effect anyone!

The Transphobic stigma attached to crossdressers is massive, and is then transferred to Transsexuals and the rest of S&GD/Transgender and to a lesser extent to the whole Gay community via Drag. All too often the response has been to try and ditch parts of the community in order to try and sever this chain. The only Ethical and Moral solution however is to fight it at it's source, the Transphobic and Sexist stigmatisation of MtF Crossdressing.

The GLBT community may well need to make efforts to reach out to the closeted crossdressing population and help them become active and involved. With the benefit of possibly doubling the power and size of the GLBT community!

You're so right, Bats, that the TF diagnosis defames a huge population of CD, genderqueer, and other trans folks who have been inexplicably silent on this issue. Moreover, a person does not actually have to be sexually aroused by gender expression to be diagnosed. Criterion A in the current and proposed diagnosis is (conveniently) ambiguously worded to be met by "or behaviors involving cross-dressing." The mere "involvement" of "cross-dressing" is all that is required. Even worse, the second criterion fails to distinguish distress actually caused by gender expression from distress caused by societal prejudice. So a CD individual who is perfectly happy and well adjusted and has been outed and fired can be further bashed by a TF diagnosis, because being a victim of job discrimination can be considered "impairment" in the diagnosis. Dr. Blanchard's TF diagnosis was designed to ensnare as many gender nonconforming people as possible on the basis of male birth-assignment and sexual orientation. It should be removed from the DSM-V.

battybattybats battybattybats | November 4, 2009 8:25 PM

I've been analysing why the main crossdresser community is so silent.

A big part is just closeting and fear of persecution.

But the fear of bringing harm both phisical and social to cis (mainly het) partners and children is a big reason for the closeting of many and their inactivity.

And the often transphobic concerns of cis (mainly het) partners are often weighed by both the CD and cis-partner as more valid than the CDs own needs. Keeping them in the closet, and keeping their gender-expression strictly regulated by the comfort zones of their partners, with many CDs suffering profound levels of distress from the self-repression involved.

And also the partners concerns often keep them distanced from anything gay because of cis het wives fears their MtF partner may turn bi or gay cause they CD.

That leads to exclusion of gay CDs from some CD spaces.

And the internalised transphobia and cisnormative outlook results in lots of other issues.

In fact discussion of politics is banned in many CD forums. I got recently banned from one of the larger ones for 'forceful activism and political innuendo' lol. And that was a site that allegedly still allowed discussion as long as it was non-partisan TG-rights associated. Unless it was same-sex marriage as they started to lock all discussion of that as 'political'. And comparing the dilemma of crossdressers and the impact of them being outspoken on their families to the dilemma of the suffragettes with the impact on their families was apparently such a dangerous topic it had to be deleted entirely in less than 24 hours. And when shortly after that I mentioned that our choices when spending money and voting could effect Jamaica and therfore its policies towards crossdressers there and therefore the fate of crossdressers there.. well apparently that was the 'political innuendo' that went to far and I was banned.

Its a prime example of the way cis concerns are made paramount in the crossdressing community and the way the tough important questions that could lead to increased awareness and activism are silenced.

Is it just me or does "Transvestic Fetishism" sound scary and bad? It's like naming puppies "slobber and poop machines." Who'd want one with that name?

I'm not sure I want friends with "Transvestic Fetishism," since it sounds contagious like a vampire bite. LOL I'll stick to my trans friends instead, thank you very much.

Bad news, Bil.

Some of those trans friends may be classified as transvestic fetishists.

All depends on the nature of their attraction to clothing normatively assigned by cultural standards to the opposite sex.

Whoa! Am I waaaay behind or what. I thought that creep Blanchard had gotten the boot as chair of this committee?

Lisa C. Gilinger | November 5, 2009 12:20 PM

To stigmatize cross-dressing with a broad stroke brush such as Blanchard's TF and to acknowledge such non-science as autogynephilia will do nothing to help relieve distress or achieve greater mental health for anyone. Quite the opposite to be sure.

Dr. Cohen-Kettenis and Mr. Pfafflin have shown some good direction with their paper. However, the use of the word - desire- as a diagnostic marker would be a regrettable support for the sexualization of people trying to resolve a persistent and profound gender incongruity. People engaged in resolving lifelong incongruities as "creatures of Desire", the desire of others, or of their own deisres still smacks strongly of the stigma of transexuals as narcisistic people driven, motivated by sex.

Also Dr. Cohen-Kettenis and Mr. Pfafflin suggest that other potentially relevant specifiers should be investigated and they note - onset date - as one such possibility. This is troublesome, problematic. So many people especially those that matured under the great stigmas of the past (not to suggest that they disappeared in the enlightened society we now enjoy where legislators argue over whether people experiencing gender differently than demanded by stereotype are worthy of protections from violence or job and housing discrimination) so many have spent a lifetime repressing their distress and torturing themselves over the incongruity they experience. After a lifetime of distress at the hands of a violent disproving society they come forward to cross the lines separating the genders. And after a lifetime spent in distress they are seen as experiencing a "late onset" of GID. A regrettable misreading of symptoms and the wrong conclusion.

Kathy Padilla | November 5, 2009 2:39 PM

In a completely unrelated question.

I'm curious Kelley; what type of psychiatric nomenclature would apply to those who continue to force themselves on a class of people who have so strongly requested that they be spared their attentions?

Is there any differential involved if they've built a financial structure around their continued unwelcome attention? Does that raise questions of sociopathy as oppossed to a less conscious condition by the sufferer?

Kathy, exactly what is it youre trying to say here?

Kathy Padilla | November 5, 2009 8:27 PM

It's a purely intellectual interest in what personality factors influence someone to force their attentions on certain groups of people. When that intrusiveness and desire to control certain groups represents a pschopathology and if the affliction might be conceptualized as sociopathic; should some extensive plan realizing personal gain be associated with someone with such an unnatural interest.

Why - what did you think I was asking? I find it an interesting theoretical question. It's not directly germane to this discussion, but as the current discussion touches upon psychiatric nomenclature - I hoped I'd be forgiven if it was a bit off topic.

battybattybats battybattybats | November 5, 2009 9:05 PM

Your suggesting Blanchard may have issues driving him to pester us all?

Could be. However it is quite common for scientists (and pseudo-scientists) to concentrate on a specific area that catches their interest or that they are particularly good at studying etc.

Plenty of people being studied may not like the results of any study. Sometimes the truth (when it is true) can be distressing. However all to often there is a phenomenon I've been observing, and repeatedly subject to in fact.

It's where bad science with poor evidence poor logic poor conclusions and cherry picking of evideence and failing to apply proper scientific method by searching for disproofs of contrary evidence rather than only corroborative evidence get accepted and placed on high because it's consistent with presumptions and unscientific beliefs and what suits the mainstream.

It happens regularly with Chronic Fatigue Syndrome/Myalgic Encephalomyalitus/Fibromyalgia where psychologists are STILL getting pieces published and supported that the illness is psychological in origin and exaccerbated psychologically despite findings of genetic switch activity in blood, despite mitochondrial function evidence, despite evidence in cerebrospinal fuid and evidence of cerebrospinal swelling/inflamation and now the evidence of a retrovirus XMRV previously linked to prostate cancer being found in the majority of CFS sufferers.

In other words in total contrast to empirical evidence which must be ignored and pretended does not exist in order to make these claims the more comfortable stereotype-affirming view gets undue support and acceptance.

If Blanchard GENUINELY wanted to test his theories the very first thing that should be done is to apply all the tests that have found biological corellates in transsexuals upon crossdressers, looking for milder forms or varient forms of the same traits. An obvious thing to rule out surely? But major tenants of Psychiatry are under threat from Neurology, that'd be fraternising with the enemy. And i doubt any genuine test would be applied to his theories by him. He wants to build a theory, not test one. Construct an explanation that fits his preconceptions, not find the truth.

And here is an important question.

Why is it that despite years and years of homophobic and transphobic murder....

There is no sign of homophobia or transphobia listed as mental illnesses? No sign of treatments for them?

Cause there is an unethical notion at the heart of much psychology.. that social norms are right because they are social norms and deviation from social norms and resistance to social conditioning is an aberation. Thats a hilosophical and unethical cancer at the heart of psychology.

Until all Ethical actions and behavior is removed from the DSM and Unethical and Irrational Hate is included then there is Human Rights Abuse at it's heart!

Kathy Padilla | November 5, 2009 10:02 PM

I'm not referring to any person or any particular venue.

But your suggestion about motivations of researchers doesn't cover situations that directly correlate to the questions I'm considering.

Treatment and the rights of people to choose treatment providers and treatment methods among qualified providers might be closer to these concerns; if it's possible to so expand upon a hypothetical.

If there were a situation where people seeking treatment were denied care provided in settings of their choice, by providers perceived as providing the treatments in respectful manners - - and it went so far as one particular provider with one particular treatment approach and use of language that their clients found objectionable were somehow able to use the mechanisms of state power to enforce their treatment on all those needing such care via some mechanism like the state health care system .....well .... I'll grant you might have an argument then.

But, I really can't imagine that happening. No ethical provider would ever seek to prevent people accessing clinically sound treatments options by influencing the government health system to only support one provider of those services. That's crazy talk.


A: Busybodies. Most likely, Excessive Normative Reinforcement Syndrome.

Give me a few days to really dig through lit and I can likely get an even scarier one.

Sociopathy isn't actually used any longer -- now its strictly asocial disorders, and it doesn't fit the criteria required to obtain a diagnosis thereby.

It's a really good question, actually, imo, because it drives to the heart of the nomenclature arguments, and, thusly, to the nature of how psychiatry (and we are, indeed talking abut psychiatry is we are talking abut the DSM) functions.

Since psychiatric diagnostics are dependent on normative standards, and function on the basis of both a negative and a positive variance from the mean to varying degrees, what we would be speaking to in this case is to what degree would such activity be normative in and of itself, and at what point does it become positive (excessive, or too much nosiness) or negative (incessive, or too little nosiness).

Since we are speaking in terms of the general debate therein, the need for a point of nomenclatural identifiers is predicated on establishing the mean -- the principal norm.

In such a case, are the researchers themselves truly justified in establishing what is an isn't normative in this case without falling victim to the issue of cultural bias?

I suspect that the answer there will be no.

As to the unimplicated particulars of a significant body that may or may not have an economic of other fiscal interest in creating a limitation on choice of medical health care service provider and would, or could, use its influence to effect governmental based change to achieve that end -- its not only likely, its certain, as it has happened many times. Indeed, most hospitals, and, in particular, government backed ones run by private interests, do it consistently and constantly, every day.

Nor is there a particular risk for asocial behaviors, as of course these systems are run by well meaning, caring persons who only want to help others.

Now, when it comes to peer reviewed publications, on the other hand, well, all bets are off.

Oh, and for those wondering: yes, that all does make sense.

It might be a bit, um, specific to a particular field, mind you, and so you'd need a bit more than a basic grounding, but I did intentionally avoid using too much lingo, lol

Kathy Padilla | November 7, 2009 9:00 AM

"Nor is there a particular risk for asocial behaviors, as of course these systems are run by well meaning, caring persons who only want to help others."

We're very fortunate that this is the case - and that people from these professions are immune to concerns of either an unexamined internal process effecting their actions or even more concerning - acting solely from a self interest divorced from the needs of those they serve. Their training provides unique insights and their experience in the field acts as a prophylactic panacea to prevent any such mistakes. Willowbrook, Fort Hood, hysteria, homosexuality and suicide rates among psychiatrists being merely exceptions that prove the rule.

Which brings us back to nomenclature, research and their complete lack of relation to the mundane setting we call the real world. They are - of course - completely divorced. As an example - psychologists developing a terminology to describe variations in intelligence and embodiments associated with them developed purely scientific terms like mongoloid, cretin, imbecile and such. These were merely scientific categories reflecting immutable truths. They and the treatment recommendations that flowed from that research had no effect on people, what opportunities they were given in life, what conditions they lived under or how others perceived them. It's simply science divorced from other concerns - pure.

As an example - let's say we use the terms pervert and defective to signify mass and acceleration. They're just placeholders for useful concepts - I don't know why people would be concerned over this. In much the same way I can't imagine why it should be a concern if pervert was used to signify gay and defective were used to signify people with say - erectile dysfunction. It's unimportant in the quest for truth which word is used. These things have no real world effects that need to be considered.

Now – again – if people used a specific nomenclature to reinforce their hold on a state actor that others depended upon for needed services and that resulted in said person’s personal gain - sure – you might have a concern. But outside of the theoretic – ethical service providers would never do so – they know the value of having different modalities tested against one another to insure people are receiving the best possible care. A world of one option wouldn’t allow for patient choice, the ability to have real comparisons of outcomes so one can improve treatment options and the ability to have people provide real feedback on their satisfaction with services. They know that how people are described has real world implications for how others perceive them, the options they have in the world – even what civil rights governments allow them. That’s the vast difference between the realms of treatment and pure science. One has real world implications and the other stands outside – beyond such petty considerations.

We are very fortunate indeed that this dovetailing of scientific nomenclature and treatment isn’t a concern. Can you even imagine someone who would develop a nomenclature that supported their treatment arm to the exclusion of client choice, one that many found stigmatizing and that incorporated a state actor’s power? That’s hardly what we would see in these fields of endeavor. It’s more like what one might see in more extreme political actors – the type of people who would do things like – well - it’s ridiculous to even consider – but like show trials.

I thank my lucky stars we don’t have to worry about such things given the innate nobility of people who work in certain specified fields. Indeed – what was once said with irony I say with conviction.

“What a piece of work is a man, how noble in reason, how infinite in faculties, in form and moving how express and admirable, in action how like an angel, in apprehension how like a god!”

By the way – how’s that young Wormwood doing?

I really need to be more careful in revealing the depths and nature of my sense of humor.

Ya know what I mean, Kathy?

Thank you, Kelley, for all your hard work on this important issue. It is comforting to know that a scholar with your expertise in the discipline is on top of it. I agree with the points you have made, and hope that the APA will come to understand them as well.

Kathy Padilla | November 8, 2009 12:13 PM

I really need to be more careful in revealing the depths and nature of my sense of humor.

Ya know what I mean, Kathy?

dyssonance | November 8, 2009 3:02 AM

Sense of humor?

We at Bilerico do not have a sense of humor that we are aware of.

But - we do look fabu in black.