Tuesday, 10 May 2011

Three Medical References

None of the flawless, but all of them useful.

A Transgender Therapy Primer - The Body
The basics of Hormone Replacement Therapy. Especially useful is the partial drug interaction chart.

Hormone Replacement Therapy for Dummies Transgenders: Do's and Don'ts
This is a Powerpoint Presentation on "what is a hormone?". I disagree in some minor ways with some of the details, but close enough.

There's also a handy list of references for use in educating your GP and Endo. This includes not just articles, but lists of useful websites on the subject. Highly recommended.

(Draft) DSM-5
The latest version of the (draft) Diagnostics and Statistical Manual from the American Psychiatric Association. Compared to the previous draft, there have been quite a few changes in the area to do with Transsexuality.

Gender Dysphoria, as it is now called, rather than "Gender Identity Disorder", has its own section now. This emphasises its peculiar nature as the mental illness you have when you're not mentally ill.
Please find below a list of disorders that are currently proposed for the diagnostic category, Gender Dysphoria. This category contains diagnoses that were listed in DSM-IV under the chapter of Sexual and Gender Identity Disorders.
In response to criticisms that the term was stigmatizing, we originally proposed to replace the term “Gender Identity Disorder” with Gender Incongruence. This was accompanied by a re-definition of the condition, revised criteria, eliminating the previous subtype pertaining to sexual attraction, and introducing a new subtype categorization that does not exclude such individuals with a somatic disorder of sex development (DSD). We chose the new term, Gender Incongruence, as descriptive and to avoid a presupposition of the presence of a clinically significant acute distress in all cases as a requirement for the diagnosis. In part, this was based on more general discussions in the DSM-5 Task Force on separating out the distress/impairment criterion and evaluating these parameters as a separate dimensions.

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).
Unusual? Try "Unique". Try "Sticks out like dog's..." um, you know. Try "obviously doesn't belong but if we don't put it here the consequences would be Bad News(tm) for the patients". Now Intersexed people with the wrong assignment of their sex by others at birth are included as not-mentally-ill-but-in-the-diagnostic-manual anyway too. Well, at least they're consistent...

With a disorder of sex development [14]

Without a disorder of sex development

14. There is considerable evidence individuals with a DSD experience GI and may wish to change from their assigned gender; the percentage of such individuals who experience GI is syndrome-dependent (Cohen-Kettenis, 2005; Dessens, Slijper, & Drop, 2005; Mazur, 2005; Meyer-Bahlburg, 1994, 2005, 2009a, 2009b). From a phenomenologic perspective, DSD individuals with GI have both similarities and differences to individuals with GI with no known DSD. Developmental trajectories also have similarities and differences. The presence of a DSD is suggestive of a specific causal mechanism that may not be present in individuals without a diagnosable DSD.
Maybe, just Maybe, hypothetically speaking of course, being castrated as a baby might just make one a tadge upset, so yes, there would be issues there. This is in addition to the problems of Gender Dysphoria (not Gender Incongruence now I think). I've seen no real difference in those with diagnosable Intersex conditions who transition, and those without. Often, and I'm starting to think it's the majority, the latter have sub-clinical IS conditions anyway, it's getting beyond a joke the number who do.

A work in progress. Or perhaps regress in some ways. Whatever, this document will have very real effects on tens of thousands of people's lives. Child custody arrangements for example - for who would place children in the care of a "nutcase"? Human Rights - again, it's easy to say that claims by the insane can be safely ignored. Especially since in the current DSM-IV-TR manual they - we - are classed in the same group as paedophiles, sadists etc.

At least there's an attempt at finding an evidential basis now. I wish they'd get off the fence and accept that the preponderance of evidence for biological causation is now beyond reasonable doubt.


Ana W.-L. said...

And of course transvestic disorder is still there, complete with the option of autogynephilia (and autoandrophilia, which seems to have been invented to give this the appearance of being balanced). Looking at the questions for determining severity, it's apparent that any less than completely asexual trans person could be given this diagnosis instead of gender dysphoria if the psychiatrist happened to want to do so. I'd be very surprised to hear I was the only one who pointed this out to the DSM-5 group back when the first draft was out for comments.

Then again, it isn't exactly surprising that the label of autogynephilia can be attached to just about any of us. After all, it's already known (at least to people who read scientific articles, in this case Charles Moser's Autogynephilia in Women, 2009) that that up to 93% of cis women fit the criteria.

dentedbluemercedes said...

TF has been raised as an issue by at least a few folks that I'm aware of, myself included. It hasn't seemed to make much difference at this stage, though, and it's clear that not enough people are recognizing the danger.

Absolutely, TF is poised to be the alternate diagnosis of choice for anyone not wanting to acknowledge the reality of transsexuality (Gender Dysphoria diagnosis or no).


Chris Phoenix said...

dentedbluemercedes, interesting article; thanks for the link.

I got the feeling, reading it, that the psychological theorists were indulging in too much "splitting" - making up too many many different labels (which leads to, among other things, the problem of overlapping diagnosis that you mentioned).

In the end, I have to wonder: If not for society's arbitrary beliefs about gender roles and society's neurosis about most things sexual, how many of these labels would be completely unnecessary?

Is there any inherent reason why a man who likes to wear dresses is any stranger or more in need of treatment than a man who likes to wear bow ties?

If a person who's mentally a woman happens to have a penis they don't want, is there any reason why that should be treated differently than other plastic surgery?

Of course, care should be taken with any irreversible body modification, but that applies, in varying degrees, all the way down to tattoos.

And I guess, because of the way medical care is funded, someone wearing a body that seriously impairs their mental well-being may need a psychological diagnosis to get financial help with the treatment. So that's a reason for keeping some of this stuff in the DSM.

But, really - given the wide variety of things that turn people on, why should medical *or* psychological specialists care about a man who happens to be turned on by imagining himself as a woman? Why do they even think it matters? On what basis would they expect it to be even correlated with gender dysphoria?

I suspect them of thought processes like this: "Well, they're both sexual weirdnesses..." (wrong, and wrong) "...so they must be related." Duh, no.

Ana W.-L. said...

Chris, it's more a matter of competing theories. The criteria for transvestic disorder are based on an old sexological view that sees anything trans-related in terms of sexuality, while those for gender dysphoria are more in line with recent research.

Coincidentally, Finland has just joined the slowly but steadily growing group of countries that have removed transvestism (both dual-role and fetishistic) from the national version of ICD-10. Fetishism and sadomasochism are gone as well.

HHB said...

>> … I wish they'd get off the fence and accept that the preponderance of evidence for biological causation is now beyond reasonable doubt.

Probably true. But it misses the point inasmuch as it is a scientific response to a non-scientific problem.

Medicine is the ART of healing, and art sometimes collides with science. The problem is that medicine has lost its way.

Instead of posing the scientific question "What is wrong with these people and how can we fix it?" the approach should be "What remedies work and how can we justify them?"

The answer is shockingly simply. For transmen the remedy that works is testosterone and mastectomy and it can be justified with a diagnosis of gynaecomastia. The same diagnosis as is used for non-trans men in need of the same remedies.

"All" that is needed is to change medically assigned sex at the start of assistance instead of at the end, for no more reason that is promotes health to do that (if only medicine could remember that it is supposed to be the art of healing).

Where mental sequellae exist pursuant to conflicts between gender and external entities they can (and should) be diagnosed without reference to gender. In the same way that sequellae to bullying are diagnosed without a "bullied" qualifier.

WPATH could and should take the lead. WPATH is missing inaction (pun intentional).
WPATH says that gender variance should not be psychopathologised and then sets up committees to do exactly that.

-- Henry Hall

bonzeblayk said...

I checked out the updated section on "Gender Dysphoria", and in the "Severity" section recently, and they still can't get the distinction between "sex" and "gender" straight... no, I do not want to change to the "other" gender! I like being gendered female! I want to get my body fixed so that my sex is consonant with it!

"A3. Over the past 6 months, how intense was your desire for the primary and/or secondary sex characteristics of the other gender?

- None
- Mild
- Moderate
- Strong
- Very Strong"


But of course, they're looking for "Very Strong" to indicate that you may require surgery... an answer which, to me, would indicate that you're not in fact psychologically transgendered!


I preferred the Old "New Label", Gender Incongruence: I love being gendered female: perhaps it should be called "Sexual Embodiment Dysphoria" or somesuch, if they want to use a label indicating Dysphoria...

Failing to keep the distinction straight results in making a hash of everything... such a mess!