The Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) is slated for publication in May of 2013. This much-anticipated event has been surrounded by heated controversy since its early planning stages more than a decade ago. One of the more scathing critiques of the DSM revisions comes from Dr. Allen Frances, former chair of the psychiatry department at Duke University School of Medicine – and former chair of the DSM-IV task force. “DSM-V promises to be a disaster,” he recently wrote in a New York Times op-ed piece. And transpeople and trans activist groups are among those who believe that the DSM changes will indeed be disastrous.
For those of you who are unfamiliar with the current and proposed DSM categories, I’ll give a brief overview. Currently, the DSM includes two diagnoses that could potentially apply to transpeople, one of which I’ll talk about in this post. (I’ll address the other one at a later date.) Gender Identity Disorder (GID) is used to describe people who feel a discontent with the sex they were assigned at birth and the gender roles associated with that sex. In children, this can involve “strong and persistent preferences for cross-sex roles in make-believe play or persistent fantasies of being the other sex,” or it can involve an “intense desire to participate in the stereotypical games and pastimes of the other sex.” In other words, a GID diagnosis could be applied to young boys who want to play with dolls and get their toenails painted, and to young girls who want to run around and play with trucks. The most common form of treatment for children diagnosed with GID is gender-reparative therapy – getting them to conform to societally prescribed gendered behaviors.
In adults, GID involves a “preoccupation with getting rid of primary and secondary sex characteristics (e.g., request for hormones, surgery, or other procedures to physically alter sexual characteristics to simulate the other sex) or belief that he or she was born the wrong sex.” Because medical intervention is typically part of the gender transition process, transpeople seeking hormones or surgery have, until recently, needed to get permission from a team of gatekeepers before moving forward. And the first step in one’s gender transition involved being labeled with a psychiatric diagnosis.
Sometimes receiving a diagnosis is comforting, validating, and ultimately helpful. Anyone who’s experienced a mysterious and disturbing collection of symptoms will likely feel a sense of relief once a doctor says, “Oh, you have ________ – and this is what we can do to help you.” When a diagnostic label is applied, it means (1) you’re not the only one that’s experienced this (which can be comforting), and (2) knowing what you have likely gives the doctor an idea about what to do about it (assuming something needs to be done about it).
Unfortunately, being labeled with a psychiatric disorder is, for many people, deeply pathologizing and potentially harmful. For example, a recent wire news article describes the case of a transwoman who was at risk of losing custody of the children she fathered before her transition, because she is diagnosed with a “serious, chronic mental illness.” For many people, receiving a diagnostic label carries an intense level of social stigma. David Rosenhan’s classic article titled, “On Being Sane in Insane Places” documented the results of his study of eight healthy individuals (including himself) who faked a mental illness, got themselves admitted to a psychatric hospital, and behaved normally in an attempt to see whether or not the staff would catch on to the ruse. One of the most powerful findings that emerged from that study was the concept of the “stickiness of the diagnostic label.” If a person receives a diagnosis, it sticks to them forever – and that label clouds the lens through which others perceive them. A person is no longer an individual with dignity – they’re a schizophrenic, or they’re bipolar, or they’re ADHD, and they’re treated like a leper. Being diagnosed with GID, trans activist groups say, strips the individual of dignity and creates yet another target of oppression.
Trans activist groups find themselves between a rock and a hard place. On the one hand, many would like to see the GID diagnosis eliminated altogether, just as homosexuality was depathologized in 1973. Along those lines, last year the World Professional Association for Transgender Health (WPATH), which has developed the Standards of Care for the Health fo Transsexual, Transgender, and Gender Nonconforming People, took a depathologizing stance by eliminating the requirement that a transperson undergo psychotherapy – and receive a psychiatric diagnosis – before undergoing gender transition. However, some are concerned that, because insurance companies require a diagnosis before authorizing reimbursement, eliminating the GID diagnosis altogether will result in people having to pay out of pocket.
Instead of eliminating the GID diagnosis, the DSM-V working groups are proposing a name change and a distinction between children and adults. The two newly proposed categories are “Gender Dysphoria in Children” and “Gender Dysphoria in Adolescents or Adults.” The criteria for these diagnoses remain similar to the verbiage in DSM-IV. What’s interesting is that, in both diagnostic categories, two subtypes are being proposed: “with a disorder of sex development” and “without a disorder of sex development.” A disorder of sex development (DSD), essentially, is an intersex condition – a term used for a variety of conditions in which a person is born with a reproductive or sexual anatomy that doesn’t seem to fit the typical definitions of female or male. So now intersex people are at risk for being labeled with a psychiatric diagnosis, whereas DSM-IV excludes people with intersex conditions from consideration for the diagnosis. Essentially, we’ve ended up with more diagnostic categories, instead of fewer. From my vantage point, that looks like a step backward, rather than a progressive move forward.
So much has been written about ethics, empowerment, and psychiatric diagnosis – particularly from the feminist community – and I wish the DSM-V Task Force would pay attention to it. Laura Brown’s book Subversive Dialogues: Theories in Feminist Therapy contains a chapter titled, “Diagnosis and Distress,” which I think should be required reading for anyone involved in the enterprise of psychiatric diagnosis. From her perspective, diagnoses in and of themselves aren’t inherently bad – but the motivations behind them and the ways they are used can be incredibly harmful. There’s a vast difference between using diagnoses as a tool of conformity and a form of control, and using diagnoses to empower people and improve their quality of life.