Wednesday, 10 February 2010

The DRAFT (emphasis added) DSM-V

Is available at :

DSM-5: The Future of Psychiatric Diagnosis
Publication of the fifth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in May 2013 will mark one the most anticipated events in the mental health field. As part of the development process, the preliminary draft revisions to the current diagnostic criteria for psychiatric diagnoses are now available for public review and comment. We thank you for your interest in DSM-5 and hope that you use this opportunity not only to learn more about the proposed changes in DSM-5, but also about its history, its impact, and its developers. Please continue to check this site for updates to criteria and for more information about the development process.
Areas of particular interest are:

Gender Identity Disorders
302.6 Gender Identity Disorder in Children
302.85 Gender Identity Disorder in Adolescents or Adults
302.6 Gender Identity Disorder Not Otherwise Specified

302.3 Transvestic Fetishism

Taking it from the top.....
302.6 Gender Identity Disorder in Children

The Good:
A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested by at least 6* of the following indicators (including A1): [2, 3, 4]

1. a strong desire to be of the other gender or an insistence that he or she is the other gender [5]
At last! The requirement that a child be deemed TS only if they think they're of a different sex from the one they have been assigned! Mere cross-gendered behaviour is not enough. I'm not sure of the duration being reduced to only 6 months though. The rationale is this:
However, there is no clear empirical literature supporting this particular period (e.g., 3 months vs. 6 months or 6 months vs. 12 months). There was, however, consensus among the group that a lower-bound duration of 6 months would be unlikely to yield false positives.
I would have put the bar higher - out of sheer conservatism. In this case, I must grudgingly bow to the consensus. I'd like some empirical evidence though, especially from the Dutch group that have a 100.00 batting average on diagnosis.

The Bad:
With a disorder of sex development
Without a disorder of sex development
Being Intersexed is no longer a "defence" against the charge of being "mentally ill". Exactly what various IS groups have been afraid of with the classification of Transsexuality as being effectively an Intersex condition.

So now children who were surgically mutilated surgically assigned a sex of convenience are now not merely "disordered" (rather than "different") due to their biology, but suffer a "psychiatric illness" should they dare to object to an incorrect assignation.

It's as .. perverse... as reacting to a situation where, because broken arms are mis-classified as a "mental illness", and research shows that broken legs have a similar etiology (ie a physical fracture of the skeleton), that broken legs should now be classed as a mental rather than a physical condition too.

Whisky Tango Foxtrot Interrogative.

The Ugly:

The references - nothing, absolutely nothing, by Swaab, or Gooren, or Diamond, or... anyone at all writing anything on neuro-anatomy.

Harry Benjamin, back in 1966, wrote:
Many psychologists, particularly analysts, have little biological background and training. Some seem actually contemptuous of biological facts and persistently overstate psychological data, so much so that a distorted, one-sided picture of the problem under consideration results.
Psychiatrists with biological orientation strongly disagree and even decry the exclusive psychoanalytic interpretations. But their voice is heard too rarely."
Never has this been more obviously illustrated than here. Anything which might contradict Money's debunked theories of psychosexual neutrality at birth has been... ignored. Just plain not referenced, either to confirm of refute.

Moreover, in the references, amidst a number of journals with one, sometimes two citations, there's reference after reference to the "Archives of Sexual Behaviour", of which many on the panel are editors, and where the editors contribute much of the content. Calling it a "Vanity Press" publication would be most unjust and very inaccurate. It is however... monocultural. Incestuous. That can happen in any specialised area and is often inevitable. But it's not inevitable here, it appears to be the consequence of many of the people on the DSM-V revision panel (in this area) being part of this clique. Calling it a clique is harsh, but I'm afraid to say no other word fits. And the chair of the section revision committee, Ken Zucker, is an editor of this publication.

Moving right along...

302.85 Gender Identity Disorder in Adolescents or Adults

The Good

Not so much what has been included, as what hasn't been. Nothing about paraphilias, nothing about mis-directed sexual drives. The renaming to "Gender Incongruence" is also good. The "Exit Clause" better.
The change also makes it possible for individuals who have successfully transitioned to “lose” the diagnosis after satisfactory treatment. This resolves the problem that, in the DSM-IV-TR, there was a lack of an “exit clause,” meaning that individuals once diagnosed with GID will always be considered to have the diagnosis, regardless of whether they have transitioned and are psychosocially adjusted in the identified gender role (Winters, 2008). The diagnosis will also be applicable to transitioned individuals who have regrets, because they did not feel like the other gender after all. For instance, a natal male living in the female role and having regrets experiences an incongruence between the “newly assigned” female gender and the experienced/expressed (still or again male) gender.
This recognises that Gender Incongruence is something experienced by some no matter what situation they're in. The Gender Binary fits most people well, as does the Sex Binary. But it fits some not at all. Just as some are Bi-Gendered, able to function with adequate (if not good) facility in either Gender role, some unfortunates can't fit in either.

I don't like to think about them. I should, but I find their situation too distressing. I also wonder if this can be called a psychiatric condition, or one induced by a sick and overly-rigid society, composed of people like me. People who fit in, and don't understand people who don't.

The Bad

The criteria have been considerably relaxed. Now no distinction is made between the Transsexual - those for whom physical change of the body, the sex, is a matter of life-and-death (literally), and those who are merely gender variant. Sex and gender are completely conflated, biology and social construct inextricably mixed.

Now while some of what we normally think of as "cross-gendered" behaviour is actually cross-sexed, a matter if neurology.... most isn't. It's a matter of convention, a social construction if you will. I've had to "fight the good fight" to point out that it's not 100% social construction, that male and female brains differ in significant ways. But there's a practical issue here: merely Transgendered people do not require bodily correction. Transsexuals do.

Now while it may be that more Transgendered behaviour than we think has a physiological causation - I think it probably does - I'd be flabbergasted if it all did. Worse though, the conflation of the two might encourage Transgendered people into seeking body modification when it's highly undesirable, inducing a medical condition where none existed. Even worse, causing Transsexual people to be denied life-saving treatment as "Gender is just a social construct". That's a very popular notion with many "Gender Studies" Departments, but is contradicted by the facts - unless you believe in psycho-sexual neutrality at birth, and ignore neuro-anatomy. Which is what they've done.

The Ugly

Many of the Ugly bits are the same as for the previous diagnosis. But there's this, which I think shows some insight. These are smart people.
Although the DSM-IV diagnosis of GID encompasses more than transsexualism, it is still often used as an equivalent to transsexualism (Sohn & Bosinski, 2007). For instance, a man can meet the two core criteria if he only believes he has the typical feelings of a woman and does not feel at ease with the male gender role. The same holds for a woman who just frequently passes as a man (e.g., in terms of first name, clothing, and/or haircut) and does not feel comfortable living as a conventional woman. Someone having a GID diagnosis based on these subcriteria clearly differs from a person who identifies completely with the other gender, can only relax when permanently living in the other gender role, has a strong aversion against the sex characteristics of his/her body, and wants to adjust his/her body as much as technically possible in the direction of the desired sex. Those who are distressed by having problems with just one of the two criteria (e.g., feeling uncomfortable living as a conventional man or woman) will have a GIDNOS diagnosis. This is highly confusing for clinicians. It perpetuates the search for the “true transsexual” only, in order to identify the right candidates for hormone and surgical treatment instead of facilitating clinicians to assess the type and severity of any type of GI and offer appropriate treatment. Furthermore, in the DSM-IV, gender identity and gender role were described as a dichotomy (either male or female) rather than a multi-category concept or spectrum (Bockting, 2008; Bornstein, 1994; Ekins & King, 2006; Lev, 2007; Røn, 2002). The current formulation makes more explicit that a conceptualization of GI acknowledging the wide variation of conditions will make it less likely that only one type of treatment is connected to the diagnosis.
So far so good. I think that identifying the "true transsexual" is no bad thing though, as long as you have good criteria, and you define "true transsexual" as someone requiring hormonal and surgical intervention. I hate the phrase, as it inevitably leads to all sorts of elitist cliquishness, who are the "cool kids", the "real McCoys" vs the "wannabes".

At the moment we have an unholy conflation of sex and gender, illustrated by the confusion in the diagnostic criteria:
1. a marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or, in young adolescents, the anticipated secondary sex characteristics) [13, 16]

2. a strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or, in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics) [17]

3. a strong desire for the primary and/or secondary sex characteristics of the other gender
It's got nothing to do with gender. Now it may be, as in my own case, that after transition I found that I was far, far more feminine in many ways than I'd thought. But I'm still a Geek Girl, a Tomboy, and while I fit in exactly with these gals, they're not exactly gender-typical in some ways.

It's about sex. Not sexual orientation. Not about who you want to go to bed with, but who you want to go to bed as.

You know, on various blogs I've been accused (at the best) of "sitting on the fence". Of being a "TG Activist", of engaging in Gender Politics to the detriment of the "cool kids". I haven't blogged about that as I don't consider it important. I'm not actually interested in the least in "gender politics" and certainly not activism purveying some obscure technical doctrine. Human Rights, now those I'm interested in. But that's separate from the Science of Sex and Gender, my main interest. Just the facts ma'am. So it's ironic that here I am, criticising a group for doing what I've been (inaccurately) accused of myself. But I digress.

I'd re-write that as follows:
1. a marked incongruence between one’s neurological sex (as measured by tests of smell, hearing, MRI patterns) and somatic primary and/or secondary sex characteristics (or, in young adolescents, the anticipated secondary sex characteristics) [13, 16]

2. a strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s somatic sex (or, in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics) [17]

3. a strong desire for the primary and/or secondary sex characteristics of the other sex
Neither Gender nor sexual orientation come into it - but one or the other will often be involved as well, depending on how much of the brain is cross-sexed, and which parts.

If we don't simplify and clarify like that, we have this kind of thing
Taking the above regarding the avoidance of male-female dichotomies into account, in the new formulation, the focus is on the discrepancy between experienced/expressed gender (which can be either male, female, in-between or otherwise) and assigned gender (in most societies male or female) rather than cross-gender identification and same-gender aversion (Cohen-Kettenis & Pfäfflin, 2009).
Assigned gender???? Bafflegab.

Some "gendered behaviour", that which is a constant across all societies through time and space, is sexed behaviour, and while there's overlap, and few if anyone wholly stereotypical, it's as physically defined as height or genital shape. Both of which have overlap, and many who don't fit in either male or female stereotype, not completely. But most of "gendered behaviour" has at best a tenuous connection with biology, and often none whatsoever.

Let's look at the rest of the diagnostic criteria:
4. a strong desire to be of the other gender (or some alternative gender different from one’s assigned gender)

5. a strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender)

6. a strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender)
I'd not qualify for anything other than 1) and 6) when pre-op. I didn't want to be a woman - I just was one. Now that the body's been fixed.... I rather like it, and rather like a lot of the stereotypical gender stuff too. Not all though: some doesn't fit. I'm arrogant enough to say that it doesn't have to.

302.6 Gender Identity Disorder Not Otherwise Specified

Not Finished yet. But now that Intersexed people are included in the other diagnoses, it will have to be changed. The DSM-IV-TR version has:
This category is included for coding disorders in gender identity that are not classifiable as a specific Gender Identity Disorder. Examples include

1. Intersex conditions (e.g., partial androgen insensitivity syndrome or congenital adrenal hyperplasia) and accompanying gender dysphoria

2. Transient, stress-related cross-dressing behavior

3. Persistent preoccupation with castration or penectomy without a desire to acquire the sex characteristics of the other sex
Basically, nothing to do with any of the rest, a grab-bag of bizarre behaviour associated with other conditions.

302.3 Transvestic Fetishism

Here's the total list of all of the references used in this section.
Blanchard, R. (1989). The classification and labeling of nonhomosexual gender dysphorias. Archives of Sexual Behavior, 18, 315–334.

Blanchard, R. (2009b). The DSM diagnostic criteria for Pedophilia. Archives of Sexual Behavior. Sept 16 [Epub ahead of print]. DOI 10.1007/s10508-009-9536-0

Blanchard, R. (2009c). The DSM diagnostic criteria for Transvestic Fetishism. Archives of Sexual Behavior.Sept 16 [Epub ahead of print]. DOI 10.1007/s10508-009-9541-3.
See previous remarks about monoculture and intellectual incest. Did I mention that Dr (PhD not MD or of Psychiatry) Blanchard is on the working-group in charge of writing this section of the DSM? IIRC he actually heads it...

I know it's a "work in progress", but still...
This approach leaves intact the distinction between normative and non-normative sexual behavior, which could be important to researchers, but without automatically labeling non-normative sexual behavior as psychopathological. It also eliminates certain logical absurdities in the DSM-IV-TR. In that version, for example, a man cannot be classified as a transvestite—however much he cross-dresses and however sexually exciting that is to him—unless he is unhappy about this activity or impaired by it.
Now while I'll never understand male sexuality.... I thought that we were trying to make a diagnostic manual for mental illnesses here. So while I can understand having a definition of non-normative behaviours that may be signs of a mental illness - such as an aversion to eating rotted chicken embryos in the shell in the Phillipines, or a desire on the part of a woman to vote in Saudi - I don't think any of them qualify as a mental illness, any more than "sluggish schizophrenia" with "democratic idealism" qualified in the late and unlamented Soviet Union. Whether they cause distress or not.

OK, I think transvestites are weird. But some would say that I'm weird too. Not so much for being Intersexed (many don't know that, I don't tell everyone), but for being a Rocket Scientist and sometime Naval Combat System Architect who's doing a PhD in Genetic Algorithms and Evolutionary Computation. THAT some men find weird in a chick - weird and threatening.


Dyssonance said...

One note, and that's all, lol. I promise. My critique will hit in the next couple of days while I look into some data I didn't have before the release.

Blanchard does not head the working group for Gender Identity. Peggy does. Which is why so much of the overall work and in particular the loosened structure reflects her so-called "Test for Transsexualism".

Blanchard does oversee the entirety of the group that the GI section falls in, and which includes paraphilias. However, that position is, essentially, pretty much an honorary one in this case, since what we have are two very antagonistic models coming to bear on each other between Cohen-Kettenis/Goren (GID) and Blanchard/Zucker (paraphilias).

This is academic warfare, Zoe. ;)

Anonymous said...

Yah, you ever notice that when someone comes in from some far off place they always say “we didn’t do it that way back home”? That’s mono-culturalizm in a nut shell.
The fact that they’ve used just one author for citation or one publishing house with maybe one or two editors…. If it was a college paper I’d reject it as too insular. If one author, or the publishing house is found flawed at any point in time in the future then the whole work is flawed.

And this work? Yeah, its flawed in several ways. (hell, its authorial masturbation… or a circle jerk)

I do have to agree with Zoe on this matter, including someone Intersexed… well. That’s conflating a physical condition with a psychological one.
Seriously, do you think someone born blind needs to see a therapist for it? And telling that person “you have a mental issue, you really need therapy” would really piss them off. Here’s a hint, I’m pissed off.

They do need to remove that language referring directly to IS people for GII, but should add a foot note that using therapies addressing gender identify issues could be used to support gender questioning IS people. That’s what I’m dealing with and how I’m dealing with it.


Zoe Brain said...

Dys - Blanchard heads the working group for paraphilias. That was what I meant by "this section", not Gender/Sex Disorders in general.

Apart from that, yes, I agree.

See what I wrote nearly a year ago on the subject.

And I predict that IS groups will go ape when the consequences of this draft are realised. We may be able to lance this particular boil as the result.

Ana said...

I'm not sure that it is an altogether bad thing to relax the criteria for gender incongruence. From what I've understood (from reading, among other things, this blog :) ), it is not an on/off thing, but rather there are degrees in various directions. In that way, it makes sense to include all of it under one broad diagnosis.

However, and this is a big however, there needs to be a way to show the difference between someone who needs HRT and SRS, and another who does not. It must be written down visibly enough that not all gender incongruous need full-blown medical treatment, or even social transition from one binary gender to the other. The diagnostic criteria should at least hint at this, but it's not clear to me that two (or more) entirely separate diagnoses are needed.

This is related to the decision to blur the line between gender and sex. If two diagnostic categories are needed, it would seem most natural to separate gender incongruence from sex incongruence, regardless of the severity of those conditions. The current draft has not decided to do this, and your criticism of the result is spot on (although with the possible caveat that instead of 'neurological sex' one might talk about 'internal/experienced/something-along-those-lines sex', since proper neurological diagnosis isn't really feasible yet). But again, it's not completely clear to me that there have to be separate diagnostic categories, as long as it's clear to everyone that different people need widely different treatments.

Similarly, in some ways it would be better to just mention somewhere that several of the treatment options for gender incongruence are also useful for certain intersex conditions, like Gina already wrote in her comment. On the other hand, GI resulting from the mutilation of an intersexed baby is not really different from GI resulting from an unwarranted SRS, and including both here is in a way a logical result from the decision to have an exit clause. Either way has its good and bad points, and while the current draft will result in heated discussions it's not entirely clear that the choices made here were wrong.

As for transvestic fetishism, after reading the new criteria (and especially the questions for assessing the severity of the condition) it seems that a suitably oriented psychiatrist could and likely would use this diagnosis for just about any trans woman who isn't completely asexual. If one has a healthy female sexuality (fantasies and masturbation count) while having a male-looking body, one is likely to qualify. Similarly, the criteria are so vague that over his lifetime, a healthily sexual cis man is likely to collect enough matches to qualify, especially if suitable pornographic material is available.

It looks to me as if the criteria for transvestic fetishism have been written to allow for as many false positives as the authors feel they can get away with. But what do I know – my academic credentials involve linguistics and computation, not psychiatry.

Dyssonance said...


The purpose of the DSM is not to determine treatment options, but to classify (at least, that's the idea, lol).

The means and ways of determining how to separate things will fall to the development of the Standards of Care, which means WPATH.

And that's a whole different enchilada that will have some surprises in store.

Julie Moriarty said...

Forgive me if I go on a rant but reading all this psychobabble these so called experts (many of whom have never lived a day as a transgender person) spew out in an attempt to establish criteria to help them label as “mentally disordered persons” those who have a mind-body gender conflict, rubs me the wrong way.

The goal always seems to be determining what is normal, and too often that means sameness. And in the case of gender variance, that’s exactly the goal mental health professionals have strived to achieve. We are all unique, even identical twins, who usually differ the most in their personalities – the mind. So I find it laughable when mental health “experts” focus on normal as it relates to sameness. That’s not sound thinking.

I can function well in society. I’m reasonably intelligent, skilled in my profession and have very good people skills. I can do quite well as long as people with phobias about transgender people don’t discriminate against me. I don’t need therapy to understand myself, I need therapy to learn how to deal with people who are phobic and impair my ability to have a decent life. And before I honor their requests to go into therapy for being transgender, I will ask them first to enter into therapy to deal with their phobias. After all, phobia is a mental disorder and it too is in the DSM.

While I’m happy to see the “exit clause” I find it interesting that treating the physical self, not the mind, is the “cure”. I will now be able to say, “I used to be mentally disordered then I had vaginoplasty and now I’m not.” What’s wrong with this picture? I can see it, why can’t these so called experts?

This draft for DSM-V still hangs onto the idea there is a mental disorder diagnosis for someone who is unhappy society has pressured them to live a life they aren’t happy living, rather than the one they want (and will harm no one). The intent seems to be on addressing societal phobias and not upsetting the masses who are phobic. The message sent: “I’m really not happy with the way you are living your life, even though it harms no one, so you’ll just have to change.” That’s not a reasonable request (demand). And if they think it is, I’d suggest they enter into therapy because they are the ones suffering from a mental disorder.

Zoe Brain said...

I will now be able to say, “I used to be mentally disordered then I had vaginoplasty and now I’m not.

Excellent way of putting it. And if we put it that way, so clearly, maybe, just maybe, this crazy situation will be reformed.

Anonymous said...
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MgS said...

Actually, I think that the subcategorization that includes DSD conditions has some interesting implications - and they aren't all bad.

First of all, it recognizes that some percentage of people who undertake gender transition are also people with intersex conditions.

The good news about this is that it implicitly recognizes that someone who is assigned to live in the wrong gender role faces many of the same struggles to resolve the conflict - whether or not they have an Intersex condition. (as an aside, this isn't necessarily a large change that has happened here - the GIDNOS category in the DSM IV-TR pretty much covered the same ground.

I will take some exception to your proposed rewording, Zoe. As much as I admire the depth of the research that you have publicized (and I hope will continue to do so!) that points towards biological roots to transsexualism, I don't think the evidence is sufficiently conclusive to be used in the manner you suggest.

Similarly, the wording you suggest implies that some kinds of clinical tests to identify transsexuals would have to exist in order to meaningfully apply those definitions. As far as I know, such tests do not yet exist, which would render a neurologically-based definition less than useful in the clinical world.

There are also interesting dimensions to the proposed changes that drive it in the direction of gender as describing a spectrum of human experience - a concept that more correctly describes the overall picture.

Anonymous said...

Unfortunately, the new text still seems to confuse at least three distinct, but sometimes overlapping, conditions.

First of all, there is the brain/body mismatch. For the foreseeable future, self-reporting will remain more appropriate than brain function tests.

Second, there is the gender role mismatch which some transsexual people and some cissexual people experience.

Third, there are culturally-rooted feelings of shame about one's body or certain parts of it. Among western cis womyn, eating disorders seem to be the most common result, but hatred of one's sex characteristics is not an unknown result.

- Marja E

Abbi said...

Hi Zoe,
Just gotta point out that your analysis seems a little inconsistent with your history of activism. For a long time, you've promoted a concept of congenital neurological intersexuality (CNI), which seems a little at odds with your critique and analysis of the proposed DSM5 standards. Doesn't the subtyping of 302.85 according to disorders of sex development support your own activisim regarding CNI? It seems to me tht the new standards indirectly reflect what you've been advocating for years.

Just a thought. And I'd also love to exchange contact info with you sometime, as I've done alot of programming with GAs and EPs, adn would love to chat shop talk. Are you studying/familiar with Michalewicz?

Abby (Philadelphia, USA)

Yamin said...
This comment has been removed by a blog administrator.
Battybattybats said...

As i mention on Bilerico the removal of the need to be heterosexual to be considered to have transvestic fetishism is good but the notes they give make some bizarre comments about bisexuality that suggests they don't believe in it.

Of course the entire notion of transvestic fetishism is plagued with problems.

The 'stress relief' transvestism is a seperate section and listed only as transient when its very common (relief of the stress of mild/partial gender dysphoria perhaps? Guess they don't look into that).

No attempt is made to seperate sexual arousal from dressing alone and sexual arousal while dressed because thats how you feel comfortable/attractive (and how others find you attractive). No mention is made of self-acceptance as a factor related to these 'symptoms' even though those who do profess sexual arousal on dressing often report his changes with time to stress-relief/normal part of life, with any sexual aspect incidental as they gain self-acceptance.

Again it focuses on males even though females also crossdress (like my partner!).

Absolutley no attempt is made to seperate whether the happiness/discomfort is free of societal pressure and discrimination or fear thereof.

If a male-bodied crossdresser is happy and is accepted by others but is EVER sexual while dressed or turned on wearing something 'sexy' they would by this be labelled a transvestite fetishist but not with the disorder.

If they are never sexual they are not. If its a female-bodied crossdresser who finds wearing a suit is a turn-on as they feel sexy in it (like several lesbians i know) thats not a fetish? And if a woman likes wearing somehing sexy thats made for women again not a fetish?

They have removed one sexuality double-standard but retain a series of serious problems.. there's incongruities in this, logic incongruities!

Why there'd be any reason at all to have transvestism in their at all has not been explained.

Anonymous said...

All psychology is inherently political. The only difference between the Soviet Union and here is that in the Soviet Union nobody believed what the officials said (including the officials).

Disclaimer: hubby spent the first eighteen years of his life there.

Crissy S said...

This is just so totally messed up:

1. I am not mentally ill. (People who are mentally ill don't get engineering degrees. Not while they're sick!)

2. It's my body that was messed up, not my gender role. The fact that I slid so readily into the (sterotypical) female gender role is irrelevant.

The DSM is just a total mess.

That isn't to say that there aren't some really messed up people out there. But most of what is being addressed here isn't mental illness, it's mostly natural variation the falls outside the stereotypical binary. When you think about it, that really covers a lot ground.

So why does it have to be in the DSM at all?

riki said...

As others have noted there is no reliable neurological test.
so "a marked incongruence between one’s neurological sex (as measured by tests of smell, hearing, MRI patterns)" would be a nightmare - all these things exist on a wide spectrum in which you can make out 'male-typical' and 'female-typical' groupings if you start with that in mind, but they are certainly not dichotomous. Lots of people who have no desire to change their sex or gender would fall on the other side on these tests, and lots who need GRS would not.
Leaving out all references to a biological aetiology does seem really odd - I know that at least Meyer-Bahlburg and Cohen-kettenis have an open mind, and lean in that direction, at least as a contributing factor.
Also - Zoe - have you actually read much stuff that happens in the "Gender studies" departemtns you slag off? You might find that there is a little more complexity than seeing gender as "just a social construct". It is important to understand all our knowledge about this stuff (including 'just the facts' of biology) is actually a social product of human investigation. Social and biological construction of our identities are eqully real and true.
Your dichotomous distinction beteween transsexual and transgendered is a problem too - a lot of people want some hormonal adn surgical treatment, but not the whole GRS package. So these reccomendations allow for authorisation of such partial treatments - that is a good thing.

Anonymous said...

IMO there is no such thing as "psychological." We do what we do because of what we are. Everything is physiological in the end. The concept of "mind" separate from body is dualistic bullshit.

Mercedes said...

Nobody's going to see these points elsewhere, so if you think they're worth it, you might want to write a bit about them (sorry it's part copy/paste):

- The inclusion of intersex as a subtypal characteristic also sets the stage so that even if much of transsexuality is eventually demonstrated to have a biological origin and a medical model is developed, psychiatry retains province over the diagnosis and treatment. That may not have been the intention, but it does open the possibility.

- Acknowledging the biological studies to date showing a likelihood of biological origin of transsexuality would certainly help justify moving to a different category from sexual disorders.

- The anxiety and accompanying stresses brought about by societal attitudes towards transsexuals need to be pointed to as what is disordered, a kind of PTSD -- not transsexuality itself. That's still not accomplished.