Petitions to end labelling transgender people as mentally ill

[Tippe]

Hello everybody,

it doesn't seem to have received much attention but the American Psychiatric Association is currently in the process of revising the DSM, which classifies transgender people as suffering from a mental disorder.

LGBT Denmark initiated an in-depth paper dealing with the consequences of such a diagnosis relating to treatment access and living conditions of transgender people. We kindly ask you to review it and consider joining the statement as co-signatories. Organizations as well as individuals are welcome.
The paper is available in English http://www.grevsen.dk/TS/SPGV.pdf and in Danish http://www.grevsen.dk/TS/SST.pdf
If you want to join email me at vibe@lgbt.dk

There is also an online petition against GID in Adolescents and Adults, which you might want to sign
http://www.change.org/petitions/remove-transgender-from-the-dsm-5

For further reading see
http://www.tsroadmap.com/notes/index.php/site/comments/more_european_rights_groups_oppose_gender_identity_disorder_in_dsm_v/#When:23:00:00Z

http://www.tsroadmap.com/notes/index.php/site/comments/british_psychological_society_joins_critics_of_proposed_dsm_v_revisions/#When:00:27:01Z

http://www.tsroadmap.com/notes/index.php/site/comments/my_comment_on_the_dsm_v_proposals/

[Muffins]

[Just Kate]

I have responded to the paper point by point.  I am not convinced by its contents that the diagnosis should be removed from the DSM nor have its classification as a mental disorder revoked.  It does it present sufficient pragmatic evidence that removal of such will dramatically increase quality of life of the people it identifies.  I will not sign the petition nor encourage others to do so.

The psychiatric diagnosis and the evaluation, related to it, leads to stigmatization. It has been documented, that stigma negatively affects human prosperity mentally as well as socially (9). It increases the sense of shame and guilt relating to transgender identity and probably results in delayed treatment request. The assessment procedure seems to prevent people from requesting
documentation changes too, meaning that only a minor part of those who would benefit from them actually obtain them. For this reason we urge the removal of diagnoses relating to gender identity.

Mental illness has a negative stigma, but that applies to all mental illness, not just GID.  Based on this argument, should we remove all currently categorized mental illnesses from the diagnostic criteria due to its potential negative stigma?

Difficulty obtaining documentation changes can be alleviated by lessening their restrictions and can be done regardless of psychiatric changes to the labeling of GID.

Unlike other psychiatric conditions, the essential criterion is not, whether a child's behavior is in itself abnormal, but whether it is abnormal, compared to the expected behavior of children with said genital sex. ... The F64.2 diagnosis
thereby expresses direct discrimination based on the physical characteristics of the body.

Expectations of behavior is how mental illnesses are defined – this again is not exclusive to GID.  Mental illness is a psychological or behavioral pattern generally associated with subjective distress or disability that occurs in an individual, and which is not a part of normal development or culture  This is just one of the criteria for mental illness, not all of it.  The fact that these professionals note behavioral differences from the norm in a person with GID is no more discriminatory than noting differences in other behaviors from the norm.

When a transgender person chooses to undergo social, hormonal and/or surgical treatment, it is thus not an expression of maladapted behavior, but rather an expression of well adjusted behavior. Therefore it is inconsistent to characterize the transsexual's wish for body-changes as a symptom of
a psychiatric disorder and we urge the removal of diagnoses related to gender identity.

Individuals with social anxiety disorder choose not to interact publicly as much as possible because it relieves the stress of the social anxiety - however this is considered maladjusted behavior.  Reacting to stimuli, even in self preserving, and non-harmful ways, can still be symptomatic of a disorder.  Should the fact that a person avoids the public be removed from the Social Phobia Inventory used to diagnose those with social anxiety disorder because this is an understandable reaction to their social discomfort? 

The term "gender identity disorder" explicitly states, that the transgender persons own sense of gender is disordered and that the person does in fact belong to a different gender

There is no research that has provided a smoking gun showing that the body is what is disordered and not the brain.  Attempts to state otherwise are at best wishful thinking and at worst deception.

As previously noted, we do not believe, that a short glance of a small child's genitals, or other body characteristics, should allow anyone the right to force lifelong expectations of a certain behavior or self-image upon the child. It is considered a human right to be able to define and to be acknowledged by your gender identity (13). We must strongly distance ourselves from classifications, that legitimize lack of respect towards gender identity, and urge the removal of the diagnoses relating to gender identity.

While I stand with them that no one should be allowed the right to force lifelong expectations of certain behavior because of one's sex or gender, expectations based on sex are not a result of GID being listed as a disorder – it happens anyway. 

The psychiatric diagnoses, related to transgender people, creates confusion about how to relate to them. LGBT Denmark knows of people who were recommended to seek psychiatric treatment in order to change their identity. This is a problem, because there is no evidence that this is possible

The lack of the ability to treat an ailment listed as a mental disorder with psychiatric treatment is not evidence that is it not a mental disorder.  The DSM and other diagnostic criteria only list the symptoms, not the treatments.  In fact many mental disorders are currently treated almost exclusively through medicines and not psychiatry.  This paper seems to be more and more of an attack on the existence and characterization of mental disorders and not on the inclusion of GID as one.

The diagnoses related to transgender people are a branding that leads to marginalization of the particular group. It is in fact possible to offer exactly the same kind of treatments using single diagnoses, without a diagnosis relating to gender identity. It also appears that a diagnosis is not a necessity for research within the field. In fact the growth in research has been faster in other areas such as homosexuality than it has in the area of transsexualism. Diagnoses related to ->-bleeped-<- therefore constitutes a redundant registration of a persons gender identity which should rightfully come to an end according to The Ministers Committee and we must urge the removal of the diagnoses related to gender identity.

Because treatment and research can occur independent of a psychological diagnosis, does not indicate there is no value for a psychological diagnosis.  To use an analogy, I can, without a doctor's diagnosis or intervention, treat a serious cut on my foot.  However, self treating won't necessarily reveal the potentially more lethal blood clot that formed.

Since a number of negative consequences are connected with the use of diagnoses related to gender identity, and since there is solid evidence of the effect of gender correction as health preserving and health promoting care, we must urge the removal of diagnoses related to gender identity and recommend the necessary treatments to be offered within the frame of relevant single diagnoses.

If the doors are opened to anyone desiring gender correction without psychiatric diagnosis this does not merit the removal of psychiatric diagnosis.  In the end psychiatric diagnosis exists because gender identity problems fit the established criteria for a mental disorder.  When those desiring gender correction stop fitting those criteria or if the criteria for identifying a mental disorder changes, then it will stop being listed as such.  Being identified as a mental disorder is completely independent of treatment or stigma and the fact that either exists does not disqualify psychiatric diagnosis.

[Muffins]

it's amazing how plastic surgery can cure a mental illness.

[Just Kate]

it's amazing how plastic surgery can cure a mental illness.

I agree!  Equally amazing are those who don't need surgery, merely hormones, and/or non-op transition.

[Tippe]

Hi Interalia,

thank you for taking the time to comment.

You comment on a document listing several Class A-evidence. Do you care to produce references to back your statements or should they be considered evidence Class E, private opinions? Will it be okay for APA to consider transgender people as mental illness without producing evidence, that it is it?

Expectations of behavior is how mental illnesses are defined – this again is not exclusive to GID.

No, impair and distress is. Variation from sociocultural norms is explicitly excluded.

Take a disease such as scizophrenia for instance. Positive and negative symptoms would affect the suffering person no matter which social context the person was placed within.

On the contrary the DSM5 proposal itself notes that impair and distress within transgender people is dependent on their social context and that children and adolescents who grow up in supportive environments and receive puberty delaying hormones may never actually experience impair and distress.

There is no research that has provided a smoking gun showing that the body is what is disordered and not the brain.  Attempts to state otherwise are at best wishful thinking and at worst deception.

For an overview of the literature on transsexuality order a copy of
Gullstrand A. The Ethiology of Transsexuality - Mental Illness, Physical Abnormality or Natural Phenomenon. University of Copenhagen, 2008.

There is a growing evidence base suggesting a biological etiology, whereas the debated  ->-bleeped-<- theory is the only psychological model of explanation, which has any noteworthy following in the literature.

The DSM and other diagnostic criteria only list the symptoms, not the treatments.  In fact many mental disorders are currently treated almost exclusively through medicines and not psychiatry.

Wow, hold on now. Psychoactive drugs ARE part of psychiatric treatment and certainly is effective in affective disorders (mania, depression, bipolar disease) and psychotic disorders among others. Even electroconvulsive therapy is beneficial in severe depressions, which may in some cases be life threatening.

The problem with GID as a psychiatric classification is that none of the treatments offered by psychiatry have been able to change the gender of a transgender person. It seems that both etiology and cure is medico-surgical.

In the end psychiatric diagnosis exists because gender identity problems fit the established criteria for a mental disorder.  When those desiring gender correction stop fitting those criteria or if the criteria for identifying a mental disorder changes, then it will stop being listed as such.

I understand you haven't followed the revision process at the APA site?

In the previous revision the "impair and distress" criterion was omitted with this explanation:

15. It is our recommendation that the GI diagnosis be given on the basis of the A criterion alone and that distress and/or impairment (the D criterion in DSM-IV) be evaluated separately and independently. This definitional issue remains under discussion in the DSM-V Task Force for all psychiatric disorders and may have to be revisited pending the outcome of that discussion. Although there are studies showing that adolescents and adults with the DSM-IV diagnosis of GID function poorly, this type of impairment is by no means a universal finding. In some studies, for example, adolescents or adults with GID were found to generally function psychologically in the non-clinical range (Cohen-Kettenis & Pfäfflin, 2009; Meyer-Bahlburg, 2009a). Moreover, increased psychiatric problems in transsexuals appear to be preceded by increased experiences of stigma (Nuttbrock et al., 2009). Postulating "inherent distress" in case one desires to be rid of body parts that do not fit one's identity is, in the absence of data, also questionable (Meyer-Bahlburg, 2009a).

in the recent it was reintroduced with this:

Furthermore, as the definition of "mental disorder" in the Introduction of DSM-IV-TR (American Psychiatric Association, 2000, p. xxxi), in addition to "present distress...or disability," includes "a significantly increased risk of suffering death, pain, disability, or an important loss of freedom," we added a correspondingly modified B criterion. As this is in line with the empirical evidence, this change permitted us to adopt the "gender dysphoria" term without presupposing the existence of acute or inherent distress at the time of diagnosis.

Two things are interesting here

1. The reason for adding the B criterion was to make the diagnosis fit the criteria of mental disorder!!!

2. In the previous revision they did not find evidence supporting inherent impair or distress - and they quoted three references - while in the second they found evidence of inherent distress without even quoting any.

So to return to your statement

In the end psychiatric diagnosis exists because gender identity problems fit the established criteria for a mental disorder.

it rather appears that gender diagnoses exist in the DSM for other reasons.



Best regards

[Just Kate]

You comment on a document listing several Class A-evidence. Do you care to produce references to back your statements or should they be considered evidence Class E, private opinions?

I'm a commenter, on a post, on a thread, somewhere on the internet.  I'm honored you hold me in such high regard that I should be able to refute "class-a" evidence, but in the end, I believe the burder of proof isn't on me; I agree with the existing psychiatric consesus.  If it changes based on new evidence, I will agree with its new findings.

If that makes my post not worth reading nor worth consideration, then please, skip over it like much of the innane, opinionated drivel that appears on the internet daily.


The current definiton of a mental disorder is as follows:

A.  A clinically significant behavioral or psychological syndrome or pattern that occurs in an individual

B.  Is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom

C.  Must not be merely an expectable and culturally sanctioned response to a particular event, for example, the death of a loved one

D.  A manifestation of a behavioral, psychological, or biological dysfunction in the individual

E.  Neither deviant behavior (e.g., political, religious, or sexual) nor conflicts that are primarily between the individual and society are mental disorders unless the deviance or conflict is a symptom of a dysfunction in the individual

The DSM-IV-TR considers GID to match that criteria.  If they change the criteria so that GI no longer fits in the DSM-V, then it should no longer be considered a mental disorder.

[kate durcal]

The emerging research data (last ten years) clearly indicates that GID is due to genetic malformation of the stria terminalis on or before the 8th week of embryonic formation, and thus a birth defect, not a psychiatric illness but a medical condition.

The idea of removing GID from the DSM was initiated by the new generation of mental and health providers. This idea has been opposed by the old providers with no rational whatsoever, other than the usual "because I believe so."

I agree that GID can be treated with hormones alone, but that is mostly so because of the physical changes hormone produce in the body.

Just because GID is removed from the DSM does not mean that its standard therapies would not be covered by health insurances or change or not be offered. Removing GID from the DSM would not mean that a mental health provider will not be involved in the evaluation of people seeking HRT or SRS.

I have two doctorates and over 30 years of experience in biomedical research. I strongly urge the sister and brothers in this forum to support the Danish initiative to have GID remove from the DSM.

Kate D

[RhinoP]

@ Interalia, both C. and E. that you listed seems to mean that GID is not a mental condition. Society as a whole would mourn if they woke up with a body part (face or genitalia) that doesn't belong to the sex that they've perceived themselves as being. And with E., transsexualism is indeed a fight between us and society; society is what is stopping us from getting cures half of the time. GID is also a deviant behavior, it is religious, political, and sexual depending on the person, which seems to make it not a mental disorder according to E.

Personally, I just look for contradictions in all the "official definitions" and if a contradiction is there, it means the source needs to be revised.

Now, with A., B., and D., I'm sure those three can apply to some forms of transsexualism, but I often find that strong transsexualism is a response to a society's treatment of a male appearance or genitalia, rather than something that naturally occurred in the person's brain. I believe in most cases, the want of hormones and surgery is a response to the negativity that naturally bestows a man who dresses like a woman; many naturally androgynous and female looking men who already pass beautifully never opt for hormones or surgery. It's a reaction to the specific way that an individual's body has grown; let's face it, the more manly a guy looks, the more he's going to want corrections.

So that qualifies as a response to danger, which I'm not sure the DSM qualifies as a mental disorder. I wouldn't think the DSM qualifies looking both ways before you cross the street to be a disorder. So if they consider transsexualism to be a disorder under contradictory terms, they truly need to change it!

For instance, a very masculine man who dresses like a female may and often receives violent threats or opinions, while a man who looks extremely passable by genetics or hormones or surgery often goes unnoticed. Again, this is a response to danger. The overproduction of male hormones, which causes an extremely masculine appearance, is also a medical condition in itself, and many straight men are even stressed about this condition; when hormones are kept calm and in line (not routinely done in the States), the body and face grows to androgynous, soft proportions, no matter if the person is male or female. It is not a mental condition to respond negatively to what may be a medical overproduction of certain hormones.

[Annah]

Food for thought: If they remove Transsexualism from the DSM then the companies that offer SRS as part of their health care packages (which are quite a large number and expanding greatly every year) will cease to exist. As I mentioned in a prior thread, Companies offer these changes because they recognize SRS being greatly tied into a person's GID of well being. If this is no longer part of the DSM, then SRS would simply be classified as an elective procedure such as FFS and BA, and thus not covered.

It would be more prudent to keep it in the DSM until transsexualism can be proven through physical means versus mental means.....at this point in time, there are a LOT of conjectures, findings, and research to transcend TS the physical microscope but at this point in time there is no concrete proof to prove TS through genetics, brain functions, etc (concrete proof).

Keeping it in the DSM until at which time, it can be proven physically, would be a better transition.

Taking it out of the DSM right now will cause many companies to forcibly close the option of SRS in their health benefits as it would be seen as a cosmetic surgery.

Now, those who work in a company that doesn't offer srs to their employees will probably not care but to a TS who has their srs covered would certainly see this as a tragic move.

Something to think about.

[Tippe]

Taking it out of the DSM right now will cause many companies to forcibly close the option of SRS in their health benefits as it would be seen as a cosmetic surgery.

I don't necessarily think so. Pre SRS, post legal gender change you could well be considered a female with congenital absence of vagina. Whether that absence is due to a syndrome such as MRKH or another condition should not make a difference. What does make a difference is that the doctor agrees that you are/should truly be female. Nothing would forbid you to seek a gender specialist and have her confirm your inner sense of self to support this.

Even in spite of legal recognition, which is not possible pre-op in Denmark, I still have a letter from the head of gynecology at the National Danish Hospital describing me as a woman in lack of her natural hormone production and one from the psychologist describing me as biologically male, phenotypical female.

Alternatives exist already.

[gennee]

Psychiatry has done much damage labeling groups because they aren't part of the dominant culture. Transgender is no different. I never understood why being who we are is a mental illness. 

[tekla]

As the majority of people in the TG umbrella are not TS, there is no need to keep it there to pay for anything, as most of us don't need those treatments - and you don't have to read too many threads in here to find that the TS persons would deprive us of the special treatment they seek.  For those who do, they can divest themselves of some of the material possessions in their life and pay for it, or perhaps a fund could be set up to provide loans that could be paid back, but there is no sense in labeling an entire group as having a mental illness just so a few people can don't have to cover their own financial burden. 

[Steph]

As the majority of people in the TG umbrella are not TS, there is no need to keep it there to pay for anything, as most of us don't need those treatments - and you don't have to read too many threads in here to find that the TS persons would deprive us of the special treatment they seek.  For those who do, they can divest themselves of some of the material possessions in their life and pay for it, or perhaps a fund could be set up to provide loans that could be paid back, but there is no sense in labeling an entire group as having a mental illness just so a few people can don't have to cover their own financial burden.

Very subtle...

...to find that the TS persons would deprive us of the special treatment they seek

...divest themselves of some of the material possessions in their life and pay for it

...just so a few people can don't have to cover their own financial burden

Can't wait to see how this ends.  It's lucky that I'm cured, I did have to fund my therapy and the surgery though.  On the other hand I did work several jobs to help ease the burden, held onto most of my stuff as well, did it all on my own, well with some profession help.

I agree that generally those under the TG umbrella who are not diagnosed as TS should not be listed for as you said they don't need the treatment we need. 

[tekla]

Who pays for what is never a subtle argument.  Money is a zero-sum game.

[justmeinoz]

Medical treatments are covered by our Medicare system, so it's only a problem for some of us. Which is a pity.

Karen.

[Tippe]

For your reference we submitted the following letter to American Psychiatric Association in July together with the communal statement.


Dear American Psychiatric Association,

Thank you for accepting comments regarding the revision of DSM.

Communal statement against psychopathologizing transgender people

In elaboration of our previous comments we are happy to announce that the communal statement on removal of transgender people from the psychiatric nosologies and alternatives for providing treatment, which can be found at

http://www.grevsen.dk/TS/SPGV.pdf

have currently obtained support from 33 associations world wide including organizations such as the Danish Association of Sexologists, the International Medical Cooperation Committee (Copenhagen department) and their nation wide education network SexEkspressen.

The statement concerns the proposed categories Gender Dysporia as well as the proposed category Transvestic Disorder.

Other initiatives against psychiatric classifications of transgender people

LGBT Denmark note several other international initiatives have been launched aiming to end psychopathologizing transgender people.



Survey
In a world wide survey on the opinions about Gender Identity Disorders carried out last year 55.8% of the replying organizations wanted the diagnoses to be removed, which is 2.7 times the number of organizations who wanted to keep it in the DSM.
Even considering only the replies from organizations who believed depathologization would affect access to physical care they were split roughly equal in the question.
[Vance Jr., Stanley R. , Cohen-Kettenis, Peggy T. , Drescher, Jack , Meyer-Bahlburg, Heino F. L. ,
Pfäfflin, Friedemann and Zucker, Kenneth J.(2010) 'Opinions About the DSM Gender Identity Disorder Diagnosis: Results from an International Survey Administered to Organizations Concerned with the Welfare of Transgender People', International Journal of ->-bleeped-<-, 12: 1, 1 - 14]



STP2012 initiative
The worldwide initiative STP2012 has currently obtained support from more than 270 organizations in their fight for depathologization of transgender and intersex people. The main demand of the initiative is:

"The removal of GID from the international diagnosis manuals (their next versions DSM-V and ICD-11)."
[STP2012 website http://www.stp2012.info/old/en/objectives]



WPATH statement
The World Professional Association for Transgender Health issued a statement on May, 26 2010 wherein they note:

"The WPATH Board of Directors strongly urges the de-psychopathologisation of gender variance worldwide. The expression of gender characteristics, including identities, that are not stereotypically associated with one's assigned sex at birth is a common and culturally-diverse human phenomenon which should not be judged as inherently pathological or negative."
[http://www.wpath.org/announcements_detail.cfm?pk_announcement=17]



British Psychological Society
The British Psychological Society expressed criticism about the Gender Dysphoria diagnoses as well as the Transvestic Disorder diagnosis in their comments on the DSM revision including the following objections:

Gender Dysphoria:
"We believe that classifying these problems as 'illnesses' misses the relational context of problems and the undeniable social causation of many such problems.
...
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."

Transvestic Disorder:
"We believe that classifying these problems as 'illnesses' misses the relational context of problems and the undeniable social causation of many such problems.
...
of particular concern are the subjectiveand socially normative aspects of sexual behaviour.  It is a matter of record that homosexuality used to be considered a symptom of illness.  The Society would not be able to support considering sexual differences as symptoms of illness."

[http://apps.bps.org.uk/_publicationfiles/consultation-responses/DSM-5%202011%20-%20BPS%20response.pdf]



German Human Rights Group
The German Human Rights Group Menschenrecht und Transsexualität in Germany declares:

"The United Nations should, in particular, demand that the APA, the American Psychiatric Association, delete the term "gender identity disorder" from the DSM without replacement and discontinue their practice of human rights violations against transsexual people."
[http://atme-ev.de/index.php?option=com_rubberdoc&view=doc&id=209&format=raw&Itemid=53 p. 36]


ILGA-Europe campaign
The International Lesbian & Gay Alliance have joined the STP2012 initiative and recommended other organizations to do the same. They have also launched their own campaign, making posters with the title "Transgender people are not mentally ill" available worldwide.

The poster can be seen here:
http://www.ilga-europe.org/home/publications/reports_and_other_materials/two_posters_on_the_rights_of_trans_people_december_2009/transgender_people_are_not_mentally_ill

In the Trans Rights Declaration adopted at Malta they declare among other demands:
"We observe with great concern that trans identities are still pathologized and considered a mental health condition. Given its strong implications on the living of trans people in Europe we therefore demand the removal of gender identity disorder from the International Classification of Diseases (ICD) and the Diagnostic and Statistical Manual of Mental Disorders (DSM)."
[http://ilga.org/ilga/en/article/m8rJEPY1eN]



TGEU statement
Transgender Europe have joined the STP2012 campaign and issued a call for action asking other organizations to do the same. Among other things they note:

"We join the main demand of the campaign: 

The removal of Gender Identity Disorder from the international diagnosis manuals."
[http://tgeu.org/node/73]



IFGE-petition
The International Foundation for Gender Education collected 10.000 signatures in a petition to remove Transvestic Disorder from the DSM. The site has been taken down now, but the contact information of the organization is still present.
[http://dsm.ifge.org/petition/]



Kelli Busey-petition
Kelli Busey have currently collected 1.918 signatures on her petition with this goal:

"American Psychiatric Association, please remove "302.85 Gender Identity Disorder in Adolescents or Adults" from the DSM-5"
[http://www.change.org/petitions/remove-transgender-from-the-dsm-5]



Calling together to END TRANS AND INTERSEX PATHOLOGIZATION
Lynda Sheridan et al launched a Facebook groups against pathologizing transgender people, which currently hosts 1076 members.
[http://www.facebook.com/group.php?gid=120317420674]



Professionals Concerned With Gender Diagnoses in The DSM
Although the group Professionals Concerned With Gender Diagnoses in The DSM have chosen to advocate for reform rather than removal of the diagnoses they did express in their statement that many of them would prefer to see the diagnoses removed:

"Our group of scholars struggled with the section of Gender Identity Disorder of Adulthood and new recommendations for Gender Incongruence (in adults). Many of us were concerned about the inclusion of this diagnosis in any form and would prefer to have it removed."
[http://gidconcern.wordpress.com/statement-on-gender-incongruence-in-adults-and-adolescents-in-the-dsm-5/]



IDAHOT campaign
The International Day Against Homophobia & Transphobia is currently running a campaign under the name Cures that Kill, in which they state:

"Homosexuality and transsexualism are naturally occurring expressions of human diversity and are protected by the principles of liberty, equality and human dignity enshrined in the Universal Declaration of Human Rights and other international instruments.
...
Those who support the campaign "CURES THAT KILL" oppose the so called "therapies" which aim to "repair," or "correct," or "cure" homosexuality and ->-bleeped-<-."
[http://www.dayagainsthomophobia.org/Sign-the-Petition,513]



Science behind the revisions

From a scientific perspective the circumstances surrounding the removal and later reintroduction of the impair and distress-criterion appears questionable.

In the first proposed revision the work group quoted three studies, which found that many transgender people do not suffer impair and/or distress and on that basis they omitted the B criterion.

"Although there are studies showing that adolescents and adults with the DSM-IV diagnosis of GID function poorly, this type of impairment is by no means a universal finding. In some studies, for example, adolescents or adults with GID were found to generally function psychologically in the non-clinical range (Cohen-Kettenis & Pfäfflin, 2009; Meyer-Bahlburg, 2009a). Moreover, increased psychiatric problems in transsexuals appear to be preceded by increased experiences of stigma (Nuttbrock et al., 2009). Postulating "inherent distress" in case one desires to be rid of body parts that do not fit one's identity is, in the absence of data, also questionable (Meyer-Bahlburg, 2009a)."

It is therefore very interesting how the work group later reintroduced the B criterion in the second proposed revision without quoting any new research!
The rationale seems to imply that a major reason for the reintroduction was that the proposed criteria did no longer fit the general criteria for a mental disorder:

"as the definition of "mental disorder" in the Introduction of DSM-IV-TR (American Psychiatric Association, 2000, p. xxxi), in addition to "present distress...or disability," includes "a significantly increased risk of suffering death, pain, disability, or an important loss of freedom," we added a correspondingly modified B criterion."

LGBT Denmark note that WPATH asked for a reintroduction of the B criterion, but their rationale for doing so was to narrow down the number of diagnosable people to those who might benefit from a diagnosis.
[http://www.wpath.org/documents/WPATH%20Reaction%20to%20the%20proposed%20DSM%20-%20Final.pdf]

The current reformulation of the criterion does in no way narrow the diagnosis and is as such clinically irrelevant. It therefore seems plausible that the reason for the reintroduction was in fact to satisfy the general criteria for mental disorders, thus the reason to classify transgender people as mentally disordered is not that they are disordered per definition!



Treatment access and human rights

We understand from the rationale that the work group are themselves aware of the concerns regarding classifying transgender people as mentally ill:

"We also debated and discussed the merit of placing this condition in a special category apart from (formerly Axis-I) psychiatric diagnoses to reflect its unusual status as a mental condition treated with cross-sex hormones, gender reassignment surgery, and social and legal transition to the desired gender (particularly with regard to adolescents and adults). We chose not to make any decision between its categorization as a psychiatric or a medical condition and wished to avoid jeopardizing either insurance coverage or treatment access (Drescher, 2010)."

LGBT Denmark agree access to transition care is very important when dealing with transgender individuals.

In the issue paper Human Rights and Gender Identity, the European Commissioner for Human Rights proclaimed however:

"The first aspect in discussing health care for transgender persons is the existence of
international and national medical classifications defining transsexuality as a mental
disorder... Such classifications may become an obstacle to the full enjoyment of human rights by transgender people, especially when they are applied in a way to restrict the legal capacity or choice for medical treatment... Alternative classifications should be explored in close consultation with transgender persons and their organisations. From a human rights and health care perspective no mental disorder needs to be diagnosed in order to give access to treatment for a condition in need of medical care."
[https://wcd.coe.int/ViewDoc.jsp?id=1476365]

Psychiatrist have often treated people who, due to their illness, were not able to act in their own interest and they may as such have a predisposition for acting paternalistic towards their clients. We understand that this attitude may also be present in the way psychiatrists respond to wishes from transgender people including the wish for a removal from the psychiatric nosology. Some psychiatrists may feel that transgender people are themselves not able to understand the implications of the removal from the psychiatric nosology.
Transgender people are however not cognitively impaired in any way by their ->-bleeped-<- so there is no reason to believe they are unable to understand the consequences of their wish and psychiatrist should not consider themselves in a position where they can neglect the wish of transgender people regarding for instance retaining or removing the psychiatric diagnoses concerning transgender people.

In light of the massively expressed wish for removal of Transvestic Disorder as well as the categories formerly known as Gender Identity Disorder within the transgender community as well as the fact that the phenomena don't satisfy the criteria for being mental disorders according to the research quoted by the work group we believe those categories should be removed from the Diagnostic and Statistical Manual of Mental Disorders.

Instead, in accordance with the recommendations from the Commissioner on Human Rights, alternatives should be sought in collaboration with the transgender organizations.



Existing alternatives
One such alternative, which is readily available, is to use the already existing somatic codes within ICD-10 for providing care. To clarify here are a few examples:

R49.0   Dysphonia

E34.9   Endocrine disorder, unspecified

Q97      Other sex chromosome abnormalities, female phenotype, not elsewhere classified
L68.0   Hirsutism
N64.9    Disorder of breast, unspecified
Q50.0   Congenital absence of ovary
Q52.0   Congenital absence of vagina

Q98      Other sex chromosome abnormalities, male phenotype, not elsewhere classified
N62       Hypertrophy of breast (Gynaecomastia)
Q55.0   Absence and aplasia of testis
Q55.5   Congenital absence and aplasia of penis

When the medical community considers a transgender man to be a man nothing should prevent the diagnosis of for instance gynaecomastia with the aim of top surgery and the diagnosis of absent testis and penis with the aim of bottom surgery.
In fact rejecting to treat a man for those conditions, because he is transgender might well be considered an act of discrimination.

Much clinical research suggests a biological etiology underlying ->-bleeped-<-. When one considers a transgender man to be a man one might consider him to be a man, who was so unfortunate to be born with XX-chromosomes instead of XY-chromosomes. According to this framework a transgender man with a male gender presentation i.e. a male phenotype, could be considered to have a chromosomal variation whereby he ended up with XX-chromosomes instead of the XY-chromosomes he was supposed to.

With a little creativity numerous possibilities arise for treatment within the somatic classifications, and we can attest that some practitioners actually use them already.

LGBT Denmark understands that the insurance coverage for transition care has grown since WPATH and AMA issued their statements in support of transgender care. We feel that the American Psychiatric Association could secure care even with a transition to using somatic codes by issuing a similar statement, in which it declares that there is solid documentation supporting the benefit and medical indication for transition care, but that transition care should no longer be understood as relating to a mental disorder, but rather as relating to a somatic problem, and that treatment should therefore be coded within the somatic classification.

LGBT Denmark also want to point out that there is a lapse between the revision of DSM in 2013 and the revision of ICD in 2015, which means that the ICD-10 classification Transsexualism will still exist for two years after the DSM revision allowing a smooth transition for the insurance policies.



Invitation to dialogue
By 2013 it will be 40 years since homosexuality was removed from the DSM. We believe it is time that the APA listens to the huge majority of organizations and drops transgender related diagnoses from the DSM as well.

LGBT Denmark would be happy to join a dialogue regarding alternative classifications for transition care and the implementation hereof.

[mimpi]

Psychiatry has done much damage labeling groups because they aren't part of the dominant culture. Transgender is no different. I never understood why being who we are is a mental illness.

With you all the way on that, sister.

Here in the UK there are horrific statistics regarding the sectioning (locking up) of Black Males under the Mental Health Act with schizophrenia diagnosis's. I forget the percentage discrepancy compared to White males but IIRC it is at least 500%. Dominant culture indeed.

[xxUltraModLadyxx]

i found it's much better to just be matter of fact about it. i've been told before by some people "you're a guy, get over it." this is what i would say now "yeah, i did get over it, that's why i'm a girl." the only people who are mentally ill are the ones resisting our transitions. genitalia is not a membership card.

[Tippe]

reminds me of an It Gets Better video:

"If I could tell my teenage self two things it would be: Dude, you're a girl, deal with it and enjoy - and get those wisdom teeth out real quick"