This year, the American Psychiatric Association unveiled proposed changes to the Diagnostic and Statistical Manual (commonly known as the DSM), which provides information to clinicians diagnosing and treating mental health conditions. The DSM is revised periodically and reflects changes in attitudes and treatments among practitioners; this will be the fifth edition. NCTE applauds the inclusion of transgender people and the clinicians who serve our community in the current revision process; their input has clearly impacted the emphasis on reducing stigma and providing appropriate and supportive care.
The proposals include significant revisions to the sections on gender identity, including replacing Gender Identity Disorder with the term Gender Incongruence (GI). The stated rationale points out that this more closely reflects the condition experienced by transgender people and is less stigmatizing. By focusing on incongruence, the new diagnosis will also mean that once congruence is achieved through whatever treatments are deemed appropriate by the patient and the professionals involved in his/her care, the person will cease to have a diagnosable condition. The previous guidelines did not provide a means to resolution in this way.
NCTE provided official comments to the American Psychiatric Association as part of the revision process:
NCTE sees substantial positive changes in the proposed draft on Gender Incongruence, and commends the careful work of the gender identity disorders subworkgroup in preparing this draft. There is nothing pathological whatsoever about having and expressing a gender identity that is different from one’s assigned gender. NCTE believes the proposed draft, including proposed name, appropriately focuses on the experience of gender incongruence, rather than on an individual’s gender identity or expression, as the focus of clinical attention.
We are heartened that the proposed draft seeks to make the diagnosis inapplicable to individuals who have successfully transitioned and require continued treatment, if at all, only for maintenance of a healthy condition. NCTE also believes that a diagnosis of GI is inappropriate in the case of non-transgender children who simply fail to conform to stereotypical assumptions about their behavior or preferences, and recognizes that the proposed draft goes far toward preventing such inappropriate diagnoses. Clinicians should not be in the position of evaluating children based on their conformity or lack of conformity to gender stereotypes.
We commend the draft’s recognition that adults and adolescents may have identities other than male or female, and that adolescents may experience distress based on the anticipated development of sex characteristics at puberty. NCTE also supports the suggestion of moving GI to a more appropriate chapter in the DSM, which would facilitate a more accurate public understanding of transgender people.
However, NCTE also has concerns about the proposed draft. The use of the phrase “strong desire” in the a diagnostic indicators, together with the absence of a clinical distress or impairment criterion, could send the message to families, policymakers and insurers that GI is not a serious condition potentially requiring medical intervention. This language also creates a lack of clarity regarding the intended diagnostic “exit clause.” Another concern relates to the proposed severity question regarding sexual attraction and “age of onset,” which appear unrelated to the diagnostic criteria and have no articulated clinical basis. NCTE is concerned that the inclusion of these questions could reinforce unfounded assumptions and stereotypes about transgender people rather than facilitate appropriate assessment and treatment.
NCTE urges that the supporting text for these diagnoses in the DSM 5 reflect a more accurate and respectful understanding of transgender people, by avoiding flawed and outdated prevalence estimates, language that disrespects individuals’ gender identities, or a focus on gender stereotypes or sexual orientation. Consistent with decades of clinical experiences and research, the DSM should focus on the incongruence individuals experience between their innate gender identity and their assigned social, legal and documented gender and/or physical sex characteristics as the proper subject of diagnosis and treatment.
Finally, NCTE believes there is no place in the twenty-first century for a diagnosis of Transvestic Fetishism/Tranvestic Disorder. While there are certainly some individuals who experience psychological distress in relation to their desire to cross-dress – often due to the pervasive social stigma and discrimination against transgender people – this experience no more justifies a psychiatric diagnosis than does “ego-dystonic homosexuality.” We urge the APA to eliminate this unnecessary and harmful diagnosis in the DSM 5.
You can access information about the revisions related to transgender people here: http://www.dsm5.org/ProposedRevisions/Pages/SexualandGenderIdentityDisorders.aspx