I normally lurk far more than I post on these forums, but this thread caught my interest - at least in part because I recently had quite a long conversation with my therapist about almost exactly the topic.

Amy Sez:

QuoteI am militant about it because I realize the DSM as currently written is more political and based on stereotypes, then an effective diagnostic tool.  I want it changed because I know how insurance companies have used it to justify exclusions.  It needs to be changed.

I have a few thoughts regarding the current DSM-IV TR edition, and how it is interpreted by many (especially and including insurance companies).

First off, the actual diagnostic criteria are not particularly based on stereotyping.  In fact, the language is extremely broad, and legitimately can, and does, include transfolk who do not fit into traditional social gender stereotypes. 

However, where people often get hung up is the 'narrative' that is wrapped around the diagnostic criteria - which in fact is the language that Amy seems to take real (and legitimate) exception to.  I agree that if interpreted in a literal fashion, the narrative description can be seen as not only offensive in the stereotypes it projects, but downright wrong.  The most offensive language is that used to describe young transfolk (when I say young, I mean children younger than adolescence), which clearly reflects a series of gender stereotypes from the 1960s.

The narrative around adults is much more subtle in its wording, and tends to speak in terms of persistence, focus and a few other attributes that are legitimately descriptive of a fairly broad swath of transfolk.  (Not necessarily all, but a reasonable cross-section)

When I discussed this with my own therapist a few months ago (yes, we occasionally explore topics such as the language of diagnosis and philosophy - but that's a different conversation), he pointed out a few key aspects of interpreting the DSM that he uses as guiding principles:

• The DSM is intended to descriptive, not prescriptive
• It is primarily a lexicon for communication between professionals  (This is particularly significant - like medical or technical jargon, the DSM is aimed primarily at specialists, and as such is easily misinterpreted by others outside of the domain)
• The narrative aspects are supposed to give a non-specialist practitioner a starting point for further research into a specific topic.  The DSM is not encyclopedic in nature - it's more akin to those "dictionary-encyclopedia" crosses you can find in bookstores - further, and real, research is needed to comprehend any given topic in detail

My advocacy around the DSM (and it applies to the SOC as well) is along these lines:

1.  The DSM is misinterpreted too easily.  There needs to be a much clearer distinction between the narrative and diagnostic sections for a given condition.  {This applies across the board in the DSM}
2.  The cautionary notes around interpreting the DSM need to be much more prominent.  (I think the most interesting is on pg.  xxxvii of the preface right now - easily breezed over)
3.  I believe that GID needs to be present in the DSM for descriptive reasons - primarily to give the practitioners that we are approaching for assistance (medical and psychological) a common language to understand each other.  {Again, I have had the privilege of having a therapist who is very open with me about what he communicates with my doctor(s), and the precise language used}
4.  The DSM has to be clear about the fact the 'narratives' are meant to provide some basic, but very limited, insight into the kinds of patient narrative that are often typical for someone with a given condition.  (It is not right now)
5.  The DSM should make it clear that although it is a decent lexicon, it is not a substitute for ongoing research and literature study on the part of practitioners.

Taking GID out of the lexicon puts both transfolk (us) and the medical practitioners we are asking to assist us in our journeys into a very awkward spot indeed.  As much as we like to insist that we know what we are asking for (and most of us do), we do have to respect the fact that we are asking for treatments that many practitioners could see as contrary to their view of the various oaths and professional codes they are bound to. 

That said, similarly, there is a necessity to agitate for remedy either legislative or otherwise where organizations such as insurance companies are concerned (especially in the United States, and to some degree in Canada as well).  They are arguably mis-applying the DSM by being unduly rigid and literalist in their interpretation of it.  (One can raise the same criticism of the way the religious right wing treats the DSM - and transsexuals in general - but that's a different rant altogether)

....anyhow ... just a few thoughts on the topic du jour.

- Michelle

I say drop the narrative altogether.  The SoC did and it was all the better for it.

Again, I stress, the sexuality portion as it is currently written, is extremely flawed as well. 

The DSM-IV regarding GID is extremely flawed.  This is something that can be clear, simple, concise and descriptive.   I think the 6th edition of the SoC does a very good job.  It is not perfect, but it is as close as it is going to get to being an effective diagnostic manual.   I would prefer it if the DSM just had in big words: Refer to current edition of The World Professional Association for Transgender Health Standards of Care. 

I have read so many instances of the DSM-IV being used as the lone diagnostic criteria and as a result the therapist using it against their transgender patient.  These were often therapist who were unaware of the SoC, with very little expereince with gender identity issues.  It is part of my core arguement against the DSM, most trans folk DO NOT fit clearly into the narrative and that the sexuality aspects of the DSM is problematic. 

I could go on deconstructing the issues with the DSM-IV.  Like I stated earlier, most competant gender therapist have long since tossed it aside in favor of the SoC.         

I picked Gender Identity Disorder.  After I shared TG issues with my wife she has referred to me as having mental illness.

This Labor Day weekend my youngest daughter asked me if TG was a genetic disorder.  I was not sure what answer to give her.  However that term sounds better than mental illness.

why do we even bother with this discussion?  fact is, they're all stupid labels.  if a person is considering blowing their brains out because of this dysphoria, disorder or whatever, i really don't give a damn how you call it.  what difference does it make?

Quote from: Katia on May 30, 2007, 06:46:40 PM
if a person is considering blowing their brains out because of this dysphoria, disorder or whatever, i really don't give a damn how you call it. 

I call that painful... very painful.  Sorry Katia.

Quote from: Katia on May 30, 2007, 06:46:40 PM
why do we even bother with this discussion?  fact is, they're all stupid labels.  if a person is considering blowing their brains out because of this dysphoria, disorder or whatever, i really don't give a damn how you call it.  what difference does it make?

It had to be you, you, you, and only you....Ditto! (subject closed by me at least )


tink

Quote from: Ell on May 30, 2007, 11:19:36 PM
where would we be without the standards of care? if they hadnt been there, i personally would have been reaching for something without a diagnosis. rather than transitioning, id probably be in a hole somewhere. yes, the established medical community is going to be able to make some money from our suffering. well? they dont work for free. and in return, we get standards of care, ongoing research, medical legitimacy as viable patients in need, rather than weirdos, and most importantly, we get a chance, at least, to become ourselves. i say thats a pretty fair deal.

I agree.  Some of us, like myself, come from countries like Argentina where the DSM and the Standards of care are the only guidelines gender specialists rely upon.  Without these guidelines we couldnt get into treatment, receive hormone therapy and genital surgery.  It would result in the suicide of many trans girls.  I chose gender idenity disorder too.

Quote from: Pia on May 31, 2007, 12:28:00 AM

Quote from: Ell on May 30, 2007, 11:19:36 PM
where would we be without the standards of care? if they hadnt been there, i personally would have been reaching for something without a diagnosis. rather than transitioning, id probably be in a hole somewhere. yes, the established medical community is going to be able to make some money from our suffering. well? they dont work for free. and in return, we get standards of care, ongoing research, medical legitimacy as viable patients in need, rather than weirdos, and most importantly, we get a chance, at least, to become ourselves. i say thats a pretty fair deal.

I agree.  Some of us, like myself, come from countries like Argentina where the DSM and the Standards of care are the only guidelines gender specialists rely upon.  Without these guidelines we couldnt get into treatment, receive hormone therapy and genital surgery.  It would result in the suicide of many trans girls.  I chose gender idenity disorder too.

I do agree there needs to be guidelines for medical treatment, but that does not mean it has to be classified as a mental illness (as it is now).
I personally have very few issues with the SoC, but even the SoC are moving away from the "Gender Identity Disorder" and mental illness concept. 
It is a medical condition, but it is NOT a mental illness.  I am not mentally ill, and neither are you.  Having guidelines for treatment is important regarding the ability to access care.  But treating it as a mental disorder, well that lends its hand toward further stigmitization and is a big reason why insurance companies in the US do not cover this.

I could go on, but I think very few people voting for Gender Identity Disorder have a grasp on the problem of it being called Gender Identity Disorder or it being considered a mental illness.  It certianly is a medical condition that needs treatment guidelines, but it being  considered a mental illness is more harmful then helpful.   

Gender Identity Disorder

Trust me I know how it is to be closeted.  Being closeted about who we are is what causes many of the issues with regards to depression.  The thought that to become who we are it would be devastating.  The thought that it could not be done.  But above all else the shame, the guilt, the fear, over who we are and how society views us.  Ultimately who we are wins out.  We are men and women with the wrong bodies.

By the way here is the 2003 APA roundtable on gender variance and transsexuality.  It suggests that the DSM-V will likely be the biggest leap forward for trans people with regards the medical establishment.

http://www.tsroadmap.com/info/div-44-roundtable.html

This is easily my favorite section, and represents a huge leap forward in thinking:

The very name, Gender Identity Disorder, suggests that cross-gender identity is itself disordered or deficient. It implies that gender identities held by diagnosable people are not legitimate in the sense that more ordinary gender identities are, but represent perversion, confusion or defective development. This message is reinforced in the diagnostic criteria and supporting text that emphasize difference from cultural norms over distress, and Daryl talked about many of those a minute ago. Under the premise of "disordered" gender identity, self-identified transgender women and transgender men are reduced to mentally ill "men" and "women" respectively. This intent is underscored throughout the supporting text in the GID section, where the subjects are offensively referred to by their natal sex and not by their own experienced gender.
Distress and impairment became central to the definition of mental disorder in the DSM-IV, when a generic clinical significance criterion was added to most categories, including criterion D of Gender Identity Disorder.
Unfortunately, no specific definition of distress and impairment is given in the GID diagnosis. The supporting text in the DSM-IV-TR lists relationship difficulties and impaired function at work or school as examples of distress and disability with no reference to the role of societal prejudice as the root cause. Prostitution, HIV risk, suicide attempt, and substance abuse are described as associated features of GID, rather than consequences of discrimination and shame. The DSM does not acknowledge the existence of healthy, well-adjusted transsexual or gender variant people or differentiate them from those who could benefit from medical treatment. GID currently makes no distinction between the distress of gender dysphoria and that caused externally by prejudice and discrimination.
Conflicting language in the DSM serves to conflate cultural nonconformity with mental illness and pathologize ordinary behaviors as symptomatic. The Introduction to the DSM-IV-TR states: "Neither deviant behavior .... nor conflicts that are primarily between the individual and society are mental disorders unless the deviance or conflict is a symptom of dysfunction."
However, in the supporting text of the GID diagnosis, behaviors that would be ordinary or even exemplary for natal women and men are presented in Criterion A as symptomatic of mental disorder. These include passing, living and a desire to be treated as ordinary members of the preferred gender. And I'll stress the word "ordinary". Adopting ordinary behaviors, dress and mannerisms of one's own experienced gender is termed "preoccupation" for diagnosable adults and adolescents. It is not clear how these same behaviors can be pathological for one group of people and not for another.

and this:

Consequently, medical coverage for sex reassignment surgery procedures are extremely rare in the U.S. today. Since gender dysphoria is not unambiguously defined as a condition to be treated, procedures that relieve its distress are all too easily dismissed as cosmetic and elective by insurers, employers, HMO's, and governments. In order to receive medical and surgical treatments, gender dysphoric people must first receive a referral from a mental health specialist who has completed a psychosocial evaluation. Referral for medical services require a diagnosis of GID. Consequently, GID has become a desired "admission ticket" for transgender and transsexual people seeking medical treatment.
It is quite difficult to develop an authentic therapeutic relationship with a client when the initial diagnostic evaluation casts the clinician in the role of gatekeeper who controls access to medical treatments. In response to this, they're are emerging treatment philosophies based on a model of educated self-determination, where gender variance is respected and clinicians serve as advocates and educators as well as evaluators of mental health. For example, in the early 1990's the Tom Waddell Health Center here in San Francisco, developed a new culturally competent approach to the treatment of gender dysphoria for homeless individuals. It incorporated the following principles, which were adopted by the Denver based Colorado Coalition for the Homeless Stout Street Clinic in 1999. And they are:
· Assuming that most TG people are sane and responsible
· Recognizing cultural/social factors that affect care
· Promoting a respectful, non-pathologizing approach
· Rejecting a label of TG Identity as sexual perversion
· Adopting a model of informed consent and harm reduction for treatment
In conclusion, we would like to propose that GID be replaced in the nosology of mental disorders with a diagnosis based on distress, and having the following characteristics:
· Defined unambiguously by distress with one's physical sex characteristics or their associated social roles.
· Excludes social gender nonconformity and ordinary, normal behaviors and expressions as symptomatic of mental illness.
· Excludes consequences of societal prejudice or intolerance as symptomatic
· And excludes reference to sexual orientation as symptomatic
· It should clearly differentiate those who are diagnosable and may benefit from treatment from those who are not
Just as DSM reform reduced stigma and fear surrounding same sex orientation thirty years ago, reform of the Gender Identity Disorder diagnosis holds similar promise today. It is possible to define a diagnosis that both reduces the stigma of gender difference while legitimizing the medical necessity of sex reassignment treatment for gender dysphoria with criteria that are clearly and appropriately inclusive. Thank you so very much.



In 2011 we will realize how this 2003 APA roundtable was historic.  The year the DSM-V appears, we will be seen not as mentally diseased individuals, but individuals who need medical care, but are sane functioning human beings.  While there is psychological EFFECTS from transsexuality as a result of incongruety, we are not mentally ill and it is clear from this roundtable the DSM-V will not treat us as mentally ill, and there will be clear medical guidelines that state the medical necessity of HRT and SRS. 


So basically if you read this Gender Identity Disorder will become Gender Identity Distress.
Distress is not a mental disease, but rather a psychological side effect from a physical condition. 

Who are we trying to fool?  We're mental, insane, crazy, out of it, off the wall, disordered, whacked out ~laugh~  does it matter what I think?  I'm sure the gender specialists don't.  At least I'm where I want to be now even if they call me "mental".  Gender identity disordered gal here.  ~laugh~

I'm with you Butterfly.
So i'm crazy, metal, insane I don't care. >
Let the sane people be afaird, I plan to be happy.
Jillieann

ROFL!     I have to agree with Butterfly and Jillieanne.  Be aware, there's nothing more twisted than a mentally ill fairy!  LOL    >

tink

Oh my I'm glad your on myside ........ I'm on yourside.
Jillieann

I like GEDAD,

Deprevation of gender expression - though I feel dysphoric when i can't express myself any which way.

QuoteDistress is not a mental disease, but rather a psychological side effect from a physical condition.

Very nice!  I concur completely.

The more I think about this thread, I'd add that calling it syndrome is slightly better than disorder, however it is only a step. I don't wish to have my life defined as merely a medical condition. Who I am is also a conscious choice, a political understanding and a spiritual awakening to the complexity of gender. It is demeaning to have that reduced to a disorder or syndrome.

zythyra 

Quote from: zythyra on June 03, 2007, 09:06:52 PM
The more I think about this thread, I'd add that calling it syndrome is slightly better than disorder, however it is only a step. I don't wish to have my life defined as merely a medical condition. Who I am is also a conscious choice, a political understanding and a spiritual awakening to the complexity of gender. It is demeaning to have that reduced to a disorder or syndrome.

zythyra 

Do we consider it a disorder or syndrome based upon the emotional stigmas that go along with being TG/TS? If this is the case, then could it be possible that the syndromes or disorders aren't from being TG/TS but from shame, guilt, and embarrassment that we go through due to societal expectations? If that is possible then wouldn't being TG/TS just a part of the human condition just as being gay or lesbian is? If this were determined then we would lose some support for our prescriptions and procedures as they are currently dealt with. So that brings the question of do we hang on to old ideals and stereotypes in order to work the system or do we recognize being TG/TS simply as who we are and nothing more?

QuoteDo we consider it a disorder or syndrome based upon the emotional stigmas that go along with being TG/TS? If this is the case, then could it be possible that the syndromes or disorders aren't from being TG/TS but from shame, guilt, and embarrassment that we go through due to societal expectations?

Renae, you've brought up an important point. I believe it's very difficult to separate the pain of being transgendered from the traumas we experience by societal and external pressures. Imagine if from early childhood our gender differences were celebrated, and we were encouraged to openly express our gender without fear of negative repercussions!

Of course, I don't wish to see things classified in a such a way to deny a person the medical treatment they need and desire, but as the system is now, most insurance policies don't cover medical treatments for TS and TG people.

zythyra