Recently I have found myself in some heated discussions online about DSM5′s proposed splitting of Gender Identity Disorder(GID) + GID Not Otherwise Specified (GID.NOS) into two new types, Gender Dysphoria (GD) with Disorder of Sex Development (DSD) & without DSD. My main objection to this was that it reinforces the use of disorder to describe intersex people’s medical conditions.
However, I have been made aware that unlike the UK, from where I draw my experience, a GID diagnosis draws no funding from public health providers or insurers. In the UK intersex people’s access to treatment to deal with issues they might have about gender assignment is currently made more complicated if their health authority insists they have to access treatment via a Gender Identity Clinic (GIC). But, having intersex specified would make things easier if access has to be via a GIC (said with a caveat: UK GIC’s tend to use ICD-10 rather than DSM-IV at present). But in countries like the USA & Australia (where DSM is followed), such treatment is more easily accessible to intersex people than transsexual people, because having a recognised intersex condition means funding can be available, while GID is not funded out of public or insurance healths schemes. In that situation, inclusion of DSD within DSM5 may be harmful to intersex people, because if they are forced to go via a GIC and are there required to have a GD diagnosis, they may not be able to access funds for some interventions they need to address issues arising from their original assignment in a way they can now.
This situation would be even more problematic where an intersex individual’s experiences lead them to feel unable to identify as either male or female. The status of such individuals is not made clear in the proposed revisions for DSM5, although it does suggest they will fall within one of the two new GD diagnoses. There are fears that this will perpetuate a system that coerces non-binary identified people to reassign and identify with one of two distinct available genders, with no space for identifying between or outside the binary gender system. The consequences of this for intersex people who reject their original assignment, but who are not comfortable with a clear presentation or identification with either of the two (compulsory) binary genders could be catastrophic.
Of course, we just don’t know how these changes would work out in practice, and because problems like these are not even touched on, it gives more room for concern than confidence that what on the face of it will benefit people with or without DSD. Potential benefit is easier access to GIC services for intersex people who reject their original assignment.
The BPS response to the draught seems to nail the problem of the diagnosis itself:
on p.21 of the BPS response to the APA draught DSM5 on Gender Dysphoria.
… we are concerned that clients and the general public are negatively affected by the continued and continuous medicalisation of their natural and normal responses to their experiences; responses which undoubtedly have distressing consequences which demand helping responses, but which do not reflect illnesses so much as normal individual variation.
We believe that classifying these problems as ‘illnesses’ misses the relational context of problems and the undeniable social causation of many such problems. For psychologists, our well-being and mental health stem from our frameworks of understanding of the world, frameworks which are themselves the product of the experiences and learning through our lives.
Of particular concern are the subjective and socially normative aspects of sexual behaviour. We are very concerned at the inclusion of children and adolescents in this area. There is controversy in this particular area – the concept of a ‘diagnosis’ of a ‘psychiatric disorder’ disputed.
Labelling people who need help as ‘ill’ may make supportive and therapeutic responses more difficult.
…
This resonates with me far more than any other argument I have heard against the revision. It does not go into how an alternative approach would work, what it would involve, how people would access support, what that might consist of, and how it would attract funding.
As I reflect on this, I am becoming increasingly open to the BPS position; in the UK there has been a shift in perspective for over a decade now away from a model of mental illness towards mental health. The association of GID/GD with the term ‘mental illness’ I find problematic, because ‘mental illness’ is considered derogatory in the UK, having been replaced with ‘mental health’ for at least a decade, so it is pretty redundant; transsexual reassignment is now recognised legally, and through equalities legislation in UK Law it is not regarded as a form of ‘mental illness’, but in a similar way to lesbian or gay identities.
I have never had an issue with the stipulation of RLE before treatment, as part of a clear diagnostic test before commencing treatment, for people who are transsexual. My view on depathologising the process of reassignment left me concerned about how people would access treatment without a GID diagnosis (coming from the UK, where this was not a barrier to funding, but a route). At the same time, I dislike the stigmatising effect of having a disorder listed in DSM5. So I applaud the attempt to replace GID with GD as an attempt to reduce the stigma by losing the concept of disorder in relation to gender dysphoria. But, now I am shifting in this, and think it really should be out of DSM completely, along with paraphilias or sexual choice. All these should be removed.
Where I get to including paraphilias arises from this criticism:
p.25 of the BPS response to the APA draught DSM5 on Paraphilia:
We, finally, have severe misgivings about the inclusion of “Paraphilic Coercive Disorder” in the appendix. Rape is a crime, not a disorder. Such behaviours can, of course, be understood, but we disagree that such a pattern of behaviour could be considered a disorder, and we would have grave concerns that such views may offer a spurious and unscientific defence to a rapist in a criminal trial.
…
And this really could apply to any paraphilia. If what is listed as a paraphilia is a crime, it is not a disorder, and should be treated as such – if it is not a crime, then it is down to an individual’s choice and preference. So, I am becoming supportive of the elimination of Paraphilia as well as Gender Dysphoria from DSM5, regardless of whether GD is for people with a DSD or not.
The issue of funding becomes redundant, as surgical treatment becomes situated like any other form of cosmetic surgery, and eligibility for funding would be considered on that basis – in much the same way as funding is considered for people who feel their nose is to big, or who have to have reconstructive or plastic surgery following an accident or cancer, and intersex people appear able to access because that is either an ongoing part treatment they are receiving, or addressing problems arising from treatment they received previously. Hormonal steroids are prescribed on the basis of what is established as being necessary by an endocrinologist, rather than with the permission of a psychiatrist. Everybody wins, and it does away with stupidity like people having to dress up as women or men (or pretend to) for a year before they can be prescribed sex steroids & have Sex Reassignment Surgery (SRS) or Gender Reassignment Surgery (GRS).
British Psychological Society response to APA DSM5 development, June 2011
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 3.0 Unported License.
This week, the submission on the proposed changes to DSM-V that Morgan of OII Australia and I co-authored has been sent to the American Psychiatric Association, to the WPATH Standards of Care Committee, the WPATH intersex (DSD) committee, and ANZPATH, as it is directly relevant to their inclusion of intersex children and adults with ‘gender dysphoria’.
