The diagnostic categories of Transvestic Fetishism and Gender Identity Disorder in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) are examined from a historical and social perspective. The pathologization of transgendered people in the DSM-IV raises substantive questions of consistency, validity, and fairness and serves to enforce notions of essential gender role that denigrate all too many human beings.
Transgendered people have been known by many names in many tongues throughout the course of human history. For instance, near my home there were the Cheyenne he man eh, the Lakota winkte, and the Navajo nadle. In our enlightened Western culture, however, transgendered people are known as "mentally ill."
Over the past year, we have examined the psychiatric classification of gender identity expression as defined in the Fourth Edition of the Diagnostic and Statistical Manual of Mental Disorders, or DSM-IV [APA94]. In the course of our enquiry, a number of questions have emerged, which we would like to pose here:
Regarding the DSM-IV transgender categories Transvestic Fetishism, 302.3, and Gender Identity Disorder, 302.85:
- Are they consistent and clear?
- Are they congruent with the treatment of sexual orientation?
- Do they promote unfair social stereotypes?
- Do they confuse impairment with social prejudice?
- Are they inclusive of socio-cultural research?
302.3 Transvestic Fetishism
Let's begin with Transvestic Fetishism, whose diagnostic criteria [APA94] are as follows:
- A. Over a period of at least 6 months, in a heterosexual male, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving cross-dressing.
- B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
- Specify if: With Gender Dysphoria: if the person has persistent discomfort with gender role or identity.
First, it is peculiar that this disorder is limited to heterosexual males. Apparently, women and gay men are free to wear whatever they chose without a diagnosis of mental illness.
Equally troubling is the grammatical ambiguity of criterion A. The description, "sexually arousing," could be interpreted to apply to only "fantasies" or to all three of "fantasies, sexual urges, or behaviors" with very different meaning. The first interpretation would implicate all recurrent cross-dressing behavior. The second would limit the diagnosis to only sexually motivated cross-dressing and imply the unlikely phrase, "sexually arousing sexual urges." Both interpretations are supported historically in previous DSM editions [APA80,87] and by various conflicting remarks in the text of the DSM-IV. Although labeled a "fetishism," it is not clearly stated whether or not transvestism must be sexual in nature to qualify for diagnosis.
302.85 Gender Identity Disorder
Next, let's examine the second category, Gender Identity Disorder. The diagnostic criteria for adults and adolescents [APA94] are:
- A. A strong and persistent cross-gender identification (not merely a desire for any perceived cultural advantages of being the other sex). In adolescents and adults, the disturbance is manifested by symptoms such as a stated desire to be the other sex, frequent passing as the other sex, desire to live or be treated as the other sex, or the conviction that he or she has the typical feelings and reactions of the other sex.
- B. Persistent discomfort with his or her sex or sense of inappropriateness in the gender role of that sex. In adolescents and adults, the disturbance is manifested by symptoms such as preoccupation with getting rid of primary and secondary sex characteristics (e.g., request for hormones, surgery, or other procedures to physically alter sexual characteristics to simulate the other sex) or belief that he or she was born the wrong sex.
- C. The disturbance is not concurrent with a physical intersex condition.
- D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
- Specify if (for sexually mature individuals) Sexually Attracted to Males, ... Females,... Both, ... Neither.
The clinical significant criterion, D, was added to all conditions in the Sexual and Gender Identity Disorders section. The definition of "distress or impairment" lies at the heart of the issue of pathologization of gender expression.
Dysfunction, Nonconformity, and Mental Disorder
A third interpretation of these categories has been advanced by George Brown of the Veterans' Administration [Brown95] and is widely believed within the gender community [Kirk95]. It holds that the clinical significance criteria for Transvestic Fetishism and Gender Identity Disorder serve to exclude ego systonic or otherwise well adjusted transgendered subjects from medical diagnosis. This view is supported somewhat by the following statement in the DSM-IV introduction:
"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, it is contradicted in the GID section:
"Gender Identity Disorder can be distinguished from simple nonconformity to stereo-typical sex role behavior by the extent and pervasiveness of the cross-gender wishes, interests, and activities."
The second statement implies that you may deviate from social expectation without a diagnostic label, but not too much. Appendix four, the Annotated Listing of changes in DSM-IV, speaks of categories subsumed, not eliminated [APA94]. Nothing in the text of the DSM-IV Sexual and Gender Identity Disorders chapter or the supporting literature conveys an intent to depathologize any transgendered people who were classified in previous editions [Bradley91, APA94b].
Dysfunction, defined as distress or impairment, is the key issue in that all who grow up in a closet, suppressing their identity, experience distress. Therefore, no one is necessarily excluded by the clinical significance criteria. These criteria have proven problematic in other ways. For example, a child molester who is not distressed or socially impaired by the condition would arguably be disqualified for a diagnosis of pedophilia. Kenneth Zucker and Ray Blanchard, members of the DSM-IV Subcommittee on Gender Identity Disorders, have noted that the question of whether distress is inherent to transvestism or imposed by social pressures is not resolved [Zucker95]. It is again not clearly defined who is ill and who is not, the judgement resting upon the personal values of the evaluator.
Gender Identity and Sexual Orientation
Homosexuality was deleted from the seventh printing of the DSM-II in 1973 for the following reasons [APA80, Stoller73]:
- Crucial issue is the consequence, not the etiology of a condition
- Significant portion of subjects
- are satisfied with their sexual orientation
- show no significant psychopathology
- function socially and occupationally
- Condition fails criteria of distress and disability
- Condition fails criterion of inherent disadvantage
This decision is considered a significant milestone in the gay rights movement of the 1970s [Bawer93]. No one has reasonably established why gender orientation is treated so differently in the DSM excepting differences in political organization and influence [Bullough93]. Contrary to the medical stereotype, I have met many people in the transgender community who are satisfied with their gender orientation, show no significant psychopathology, and function very well socially and occupationally.
The Stigma of Psychosexual Disorder
The burden of social stigma suffered by transgendered people is worsened by medical classification [Bolin88]. Transvestic Fetishism, in particular, is organized in the most damaging and demeaning manner possible, classified as a Sexual Paraphilia along with Pedophilia, Exhibitionism, Voyeurism, Frotteurism, Sadism and Masochism.
- DSM-IV Sexual and Gender Identity Disorders: Paraphilias
- 302.4 Exhibitionism
- 302.81 Fetishism
- 302.89 Frotteurism
- 302.2 Pedophilia
- 302.83 Sexual Masochism
- 302.84 Sexual Sadism
- 302.3 Transvestic Fetishism
- 302.82 Voyeurism
This legitimizes stereotypes that unfairly associate cross-gender expression with criminal or harmful conduct.
Myths and Stereotypes
Here are a few examples of transgender myths and stereotypes perpetuated in the DSM and medical literature that are unsubstantiated by research or inaccurately describe many transgendered people:
- The Overbearing Mother
- The Effeminate Childhood
- The Organ of Hate and Disgust
- The Daredeviling Crossdresser
- The Fetishistic Transvestite
- The Masochistic Transvestite
- The Aging Transvestite
- Spontaneous Transsexualism
- The Homosexual Transsexual
The first two "mother-blame" theories [Stoller68] are reminiscent of those unsuccessfully applied to gay men in the past [Stoller73, Zucker95]. Most transsexuals do not necessarily hate their genitals [Bornstein94, Bolin88], and reassignment surgery candidates in fact need the tissues to reconstruct new ones. The "daredeviling crossdresser" [Brown95] represents victim bashing in that crossdressers who suffer discrimination or bigotry are blamed for risking "getting caught." The presumption that non-transsexual crossdressing constitutes sexual deviance is implied by the very name, Transvestic Fetishism. This and the common association of sexual masochism with cross-gender expression [Zucker95] exaggerate the significance of sex in gender and trivialize the role of social expression. Sexual motivation is said to be displaced by gender dysphoria in the Aging Transvestite [Wise80] model, when it is more likely lessened with self-acceptance and increased freedom of expression. Finally, suggestions that favor surgical reassignment candidates with heterosexual outcomes [APA94] deserve scrutiny.
Distress, Impairment, and the Role of Social Intolerance
Micheal Lewis, author of Shame, the Exposed Self, defines shame as a self perceived failure to meet self-imposed standards and a global attribution of failure to the total self [Lewis95]. This occurs at a surprisingly early age, between 18 and 36 months, when children internalize the values of the society around them. While not targeted specifically at socially marginalized groups, Lewis' observations explain much about the experience of a closeted development. Are distress, depression and anxiety, attributed by the medical literature to gender expression, reasonable consequences of undeserved shame? What are the implications of masquerading the spirit?
Conversely, what are the implications of masquerading the body to fit the core identity? Given the harsh stigma associated with cross-gender identity, is it possible that sexual expression serves defensive purposes, representing denial or displacement? Does this explain the commonly reported transience of fetishistic crossdressing [Bradley91, Wise80] more adequately than spontaneous "development" of transsexualism later in life? Again, the DSM fails to distinguish inherent distress from socially imposed distress, presuming the former.
Anthropologist Anne Bolin noted the provincial nature of gender research with socio-cultural findings virtually ignored in medical policy [Bolin87]. There is substantial historical precedent for the enforcement of rigid gender roles by medical practitioners. For example, from the early to mid-1900s, women who exceeded the bounds of gender conformity in demanding civil rights and the right to vote were discredited and often institutionalized with a diagnosis of "hysteria" [Mayor74]. Homosexuality, as noted previously, was classified as mental illness until 1973, representing a violation of "appropriate" gender role.
At the heart of the current medical policy is a presumption of gender essentialism, perpetuating the doctrine of two sexes, immutable, and determined by genitalia. A growing body of literature that considers gender a social construction, not a biological imperative [DeBeauvior52, Kessler78, Butler90, Garber92, Lorber94], has been inexplicably disregarded.
Other social considerations include the power inequity in transsexual psychotherapy and the validation of medical caregivers [Bolin88]. A therapist serving as a gatekeeper to the availability of surgical or hormonal treatment holds absolute power over a transsexual client. This undermines the therapeutic relationship, leaves the client little motivation for honest expression [Blanchard88], and creates a distorted view of transgenderism by psychiatric caregivers reflected in the current medical policy. Finally, medical practitioners and researchers have a self-interest in the present diagnostic categories, which are perceived to lend respectability to gender work [Pauly92], and legitimize association with transgendered subjects [Bolin88].
Cross-Cultural Supernumerary Gender Precedents
Socio-cultural research has elucidated a growing list of supernumerary gender roles among many cultures [Bolin87, Bullough93, Williams86]. A few examples include:
- Native American Two-Spirit Traditions
- The Navajo Nadle
- The Lakota Winkte
- The North Piegan Manly Hearts
- The Tahitian Mahu
- The Madagascar Sekrata
- Hindu Tantric and Hijra Sects
- Islamic Xanith, Khawal, and Sufi Traditions
- The European Castrati
These were accepted, often highly respected, societal roles where gender variation and fluidity were considered a normal variation of human life. Are we to infer now that all of these people were mentally ill?
Our examination of the present classification of Transvestic Fetishism and Gender Identity Disorder has raised substantive questions with disturbing answers. We believe that there is ample evidence to review the policy of gender pathologization with a reasoned dialogue inclusive of the gender community and socio-cultural researchers and open to the possibility that difference is not disease, nonconformity is not pathology, and uniqueness is not illness.
References and Reading List
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