On the Proposed Sexual and Gender Identity Diagnoses for DSM-5: History and Controversies

Abstract

In February, 2010, the American Psychiatric Association unveiled its proposed revisions to the Sexual and Gender Identity Disorders for the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The proposals have reinvigorated historical controversies about whether sexual and gender diagnoses may stigmatize and medicalize behaviors that are now considered nonpathological. This article traces the recent past of these controversies, beginning with early discourse about the future DSM-5. It addresses the content of the DSM-5's proposed changes to Gender Identity Disorder (GID) and the paraphilias, outlining responses to them in mental health and activist communities. Points of contention surrounding the recent proposals are assessed within the context of historical concerns. Additionally, my opinion regarding the potential of the DSM-5 proposals to assuage versus exacerbate longstanding controversies is presented.

Acknowledgments

This article exists because of the invaluable feedback and encouragement provided by my graduate advisor, Frederick Wertz. I am also grateful for the generosity and editorial efforts of Jill Roche, Ariana Reines, Emily Maynard, and Brian Pilecki.

Notes

¹Wilson (2003), for example, compared GID to retired diagnoses such as anarchia (a passionate commitment to democracy), drapetomania (a slave's desire for freedom), and hysteria (once used to pathologize women).

²In the DSM-IV-TR (APA, 2000), the three categories are presented in the following order: sexual dysfunctions, paraphilias, and GID. I have here listed GID and the paraphilias first because of their prominence in recent debates.

³The DSM-III (APA, 1980) featured Gender Identity Disorder of Childhood. The 1987 text revision of the manual added Gender Identity Disorder of Adolescence and Adulthood, nontransexual type. The DSM-IV (1994, 2000) introduced the overarching category GID, with subcategories for children versus adolescents and adults (Zucker & Spitzer, 2005).

⁴Insofar as symptoms of Sexual and Gender Identity Disorders are phenomenologically similar and often comorbid with those of other diagnoses (e.g., mood changes, anxiety, interpersonal difficulties), the notion that these symptoms result from gender dysphoria or sexual behaviors is an etiological presupposition.

⁵The last major revision was the DSM-IV, published in 1994; a text revision (the DSM-IV-TR) was published in 2000.

⁶The APA's Resolution on Reparative Therapy is made available by Herek (1997) at http://psychology.ucdavis.edu/rainbow/html/resolution97.html

⁷Zucker (2006) has questioned the APA's resolution on reparative therapy, arguing that the resolution raises questions about the ethicality of patient autonomy in general. In doing so, Zucker cited Szasz's (1965) book, The ethics of psychoanalysis: The theory and method of autonomous psychotherapy, implicitly aligning critiques of reparative therapy with both psychoanalysis and criticisms of psychiatry as a whole (Szasz is a well-known critic of psychiatric practice).

⁸The petition can be found at http://www.thepetitionsite.com/peti

⁹The report is located at http://www.apa.org/pi/lgbt/resources/policy/gender-identity-report.pdf

¹⁰Notably, some bold forum commentators posted criticisms that prefigured the controversies-to-come (e.g., Carolynn, 2010).

¹¹One common argument against diagnosing gender variance in children is that parents play a deciding role in the designation of normal versus abnormal behavior. This phenomenon is evidenced in the severity ratings for GI in children as proposed for DSM-5. Four examples are presented here (the response options for each item are: a. none, b. mild, c. moderate, d. strong, and e. very strong):

	Over the past 6 months, how intense was your daughter's resistance to the wearing of typical feminine clothing?
	Over the past 6 months, how intense was your daughter's preference for the toys, games, and activities typical of the other gender?
	Over the past 6 months, how intense was your son's avoidance of rough-and-tumble play?
	Over the past 6 months, how intense was your son's preference for female roles in fantasy or pretend play?

¹²In the rationale for Transvestic Disorder on DSM-5.org, the only three references cited are articles by Blanchard, head of the Paraphilias Subworkgroup (APA, 2010e).

¹³The Oxford Dictionary of English Etymology explains that the verb ascertain comes from the Old French acertain, which meant to “make certain,” and later, to “learn, find out” (Onions, 1966, p. 53).

¹⁴The Subworkgroup later added the specifiers in remission and in a controlled environment to the paraphilic disorders (see APA, 2010f). Thus, there may also be future efforts to differentiate between the new in remission and in a controlled environment specifiers (added to the DSM-5 proposals after the Task Force collected feedback), and the act of ascertaining criterion A alone (see APA, 2010 g; Asexualexplorations, 2010).

¹⁵The DSM-5 proposals' rating scales for the severity of the paraphilic disorders (APA, 2010e) appeared to assess the frequency and nature of the paraphilic behaviors rather than the distress and impairment they may cause. Some examples are:

(Transvestic Disorder) During the past two weeks, how often did you feel a sexual urge to dress as a member of the opposite sex, style your hair as a member of the opposite sex, or otherwise groom yourself as a member of the opposite sex?

1. Never

2. Once

3. About once a week

4. Several times a week

5. About every day

(Sexual Masochism) During the past two weeks, how sexually exciting was the idea of experiencing physical pain or injury, suffocation, fear for your well-being, or severe humiliation?

1. Not at all exciting

2. Slightly exciting

3. Moderately exciting

4. Strongly exciting

5. Extremely exciting

(Voyeurism) During the past two weeks, how many different people did you secretly watch, while they did something private?

1. 0

2. 1

3. 2

4. 3

5. 4 or more

¹⁶The Task Force accepted comments from February 10, 2010 to April 20, 2010.

¹⁷Though Zucker (2010a) published his commentary on March 31, he responded to Frances's February 11 piece and not his March 14 article, dedicated exclusively to a the SGI diagnoses (“DSM-5 sexual disorders make no sense: DSM-5 and sexual disorders—Just say no”; Frances, 2010a, 2010b).

¹⁸At a meeting of the American Association of Psychiatry and Law in October 2010 (Franklin, 2010), a group of forensic psychiatrists who work regularly with sex offenders voted against these disorder categories (with a vote of 31–2 for Paraphilic Coercive Disorder and 29–2 for Hypersexual Disorder). (The psychiatrists also voted against Pedohebephilia with a vote of 31–2).

¹⁹In the Greek myth, Pandora is the first woman; overcome by curiosity, she ignores the prohibitions of the gods and opens the box, unleashing all of the world's evils.

²⁰One attempt for reducing stigma in the DSM-IV was a change in terminological policy such that individuals were not identified with a disorder class, but rather as existing with a particular disorder. For example, DSM-IV did not refer to schizophrenics, but rather to individuals with schizophrenia. Presumably, the designator individual with a paraphilia is preferable to paraphilac.

²¹Frances responded to Zucker as follows:

I thank Dr Zucker for accurately stating my position and then illustrating it with a particularly vivid and well-chosen example. I continue to find no reason to label as mental disorder sexual urges, fantasies, or behaviors that are harmless to others and cause no distress or impairment to the individual. As psychiatrists, we have our hands full taking care of the suffering and distress caused by real mental disorders. (Zucker, 2010a, para. 1).

²²In one of the references cited by the Paraphilias Subcommittee, Blanchard (2009c) explicitly aligned ascertaining with ontology and diagnosing with epistemology: “One would ascertain a paraphilia (determine whether it is present or absent according to common signs or symptoms) but diagnose a paraphilic disorder (determine whether the paraphilia is distressing the patient or impairing his psychosocial functioning)” (p. 5).

²³Notably, the term paraphilia, coined by Stekel (1925/1971) in his book Sexual Aberrations, has never been used to designate nonpathological behaviors; it is a medical term that was invented to describe pathologies, and it has historically been employed for this purpose.

Additional information

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Sarah R. Kamens

Sarah R. Kamens is a doctoral student in clinical psychology at Fordham University in New York. She holds an M.A. in Media & Communications from the European Graduate School. Her current research uses qualitative methods to investigate discourse about psychiatric diagnosis.