       
                       
The Disparate Classification of Gender and Sexual Orientation in American
Psychiatry
Katherine K. Wilson, Gender Identity Center of Colorado, Inc.,
Denver, Colorado, U.S.A.
Abstract
In 1973, the Board of Trustees of the American Psychiatric Association voted
to delete homosexuality as a mental disorder from the seventh printing of the
second edition of the Diagnostic and Statistical Manual of Mental Disorders, or
DSM-II. Twenty-three years later, the inclusion of diagnostic categories for
Gender Identity Disorder and Transvestic Fetishism in the fourth edition of the
DSM continues to raise questions of consistency. In this paper, issues of gender
identity and sexual orientation are compared in light of current definitions of
mental disorder.
Introduction
Although human sexual orientation and gender identification represent
distinct phenomena and are considered largely orthogonal, they are intricately
intertwined in medical theory and social consequence. Since Magnus Hirschfeld
(1910) coined the term " transvestite," studies have revealed that most gays and
lesbians do not crossdress and most crossdressers are heterosexual. Nonetheless,
sexual orientation and gender identity share many common elements pursuant to
the definition of mental illness, including theories of etiology, social stigma,
cross-cultural occurrence, and perceptions of distress, disability, and
disadvantage.
These parallel elements raise questions of consistency in light of the
deletion of homosexuality as a mental disorder from the seventh printing of the
second edition of the Diagnostic and Statistical Manual of Mental Disorders, or
DSM-II, in 1973. If homosexuality and transgender identity or expression were
classified as mental disorders for essentially the same reasons, then it remains
unclear how those reasons uphold the continued inclusion of diagnostic
categories for Gender Identity Disorder and Transvestic Fetishism in the DSM-IV
today.
Prevalent psychodynamic explanations for male-to-female transgender identity
and expression are closely linked to those for male homosexuality (Zucker &
Blanchard, 1995, p. 37). Freud (1905) associated homosexual development with
Oedipal frustration: an intense mother attraction coupled with a distant father
figure. These boys then identify with their denied object of desire and assume
her role in future relationships with men who resemble themselves. This view was
echoed by Bieber and Socarides, who led the opposition to the declassification
of homosexuality in the 1960s and 70s (Stoller, et al., 1973). Socarides (1962)
emphasized a preoedipal failure to complete individuation from the mother. Like
Freud, he made little distinction between sexual orientation and gender
identity:
It is my conviction that it is necessary for all human beings to complete the
separation-individuation of early childhood in order to establish gender
identity. Failure to do so results in a deficit in masculinity for boys, with a
corresponding intensification and continuation of the primary feminine
identification with the mother, thus begins the course toward homosexual
development. (Stoller, et al., 1973, p.1212)
Stoller and Green, of UCLA, applied a similar theory to male-to-female
transsexualism with the axiom, "too much mother made possible by too little
father" (Stoller, 1968, p. 264). Green, a principal analyst for the UCLA
Feminine Boy project of the 1970s (Green, 1987), later equated childhood
cross-gender expression with pre-homosexual orientation in a televised quip:
"Barbies at five. Sleeps with men at twenty-five" (1995). Schott (1995)
similarly correlated males diagnosed with transvestic fetishism with memories of
closer relationships with their mothers than fathers. Person and Ovesey (1974,
1978), echoing Socarides, theorized that male cross-dressing reduces separation
anxiety stemming from a failed preoedipal separation-individuation from the
mother.
Conversely, Freud also postulated that a same-sex orientation could develop
from too much father and too little mother (Freud, 1970). Here, strong paternal
attachment or maternal rejection leads boys to seek father figures as sexual
partners. In a corollary, fear of the father's rage, in retaliation for oedipal
desires, leads a boy to escape castration anxiety by withdrawing from women and
thus competition with the father. Zucker and Blanchard (1995) similarly
associated adolescent transvestic fetishism with mother-son conflict, anger, and
rejection. Zucker and Bradley (1995, p. 323) attributed early crossdressing to
periods of mother absence and unavailability. The principle of Occam's Razor
raises doubt that both theories can be valid, which would imply that ordinary
sex-typed gender development requires a knife-edged balance between maternal and
paternal influence.
Psychodynamic theories of homosexual causation were challenged on several
points. First, they were based on clinical populations of gay and lesbian people
seeking psychiatric help or incarcerated in prisons and hospitals and did not
constitute a representative population (Hooker, 1957). Judd Marmor argued that,
if our judgment about the mental health of heterosexuals were based
only on those whom we see in our clinical practices we would have to conclude
that all heterosexuals are also mentally ill (Stoller, et al., 1973,
p.1208-1209).
He went on to point out that not all gays and lesbians have a background of
"disordered sexual development," not all with such backgrounds become
homosexual, and emphasized that illness cannot be defined by background but must
rest on its merits.
Like Bieber and Socarides, proponents of psychoanalytic theories of
transgender etiologies relied on clinical study populations and anecdotal cases
(Stoller, 1968). Zucker and Bradley (1995, p. 336) acknowledged the "likely bias
in our clinical population," and called for "epdemiological studies of larger
populations." They concluded that "boys who came from father-absent homes were,
if anything, less feminine and/or more masculine" (p. 245). A controlled
anthropological study of non-clinical male youths in a polygamous U.S. community
failed to correlate father absence with cross-sex identity (Parker, et al.
1975). Zucker and Blanchard (1995, p. 40) noted that most men with preoedipal
personality pathology do not exhibit transvestic fetishism and that data
supporting such pathology as the cause of TF is conflicting. They also
criticized a methodological weakness of studies which relied on self-report of
parental relationships without study of the parents themselves.
Freud (1957) himself concluded that homosexuality "cannot be classified as an
illness." It seems ironic that psychoanalytic clinicians, more than any other
mental health faction, opposed the declassification of sexual orientation from
the DSM-II (Bayer 81). Ultimately, the APA concurred with Freud's view that
etiological theory of homosexuality does not imply illness over the objections
of his followers. The theories which failed to justify the pathologization of
sexual orientation and those which support the continued classification of
gender orientation are remarkably similar.
The debate over psychiatric classification of sexual orientation in the early
1970s shifted from cause to consequence. Thomas Szasz's (1961) broad criticism
of psychiatric classification had a profound influence in the sexual orientation
debate and later changes in the definition of mental illness (Zucker, 1995;
Bayer, 1981). His skepticism that antecedent life experiences causally determine
behavioral phenomena was reflected in the APA decision of 1973,
The crucial issue in determining whether or not homosexuality per se
should be regarded as a mental disorder is not the etiology of the condition,
but its consequences and the definition of mental disorder (APA, 1980).
Consequently, distress and impairment became central to the definition of
mental disorder in the DSM-IV (APA, 1994, p. xxi), and a clinical significance
criterion was added to the diagnostic criteria for all Sexual and Gender
Identity disorders, including Transvestic Fetishism and Gender Identity
Disorder:
The fantasies, sexual urges, or behaviors cause clinically significant
distress or impairment in social, occupational, or other important areas of
functioning (APA, 1994, p. 531).
A key point in the classification of sexual orientation was the distinction
between distress or impairment experienced by a person and that believed
inherent to homosexuality itself. It is remarkable that, over two decades later,
this distinction is left unresolved for the transgendered disorders in the
DSM-IV.
By the mid-twentieth century, prevailing psychiatric tradition considered
homosexuality to be inherently pathological regardless of the health, happiness,
or functionality of gay and lesbian individuals. This conclusion followed two
basic threads: that deviance from what was presumed biologically natural
constituted disability, and that homosexuality was inevitably associated with
other pathologies. Rado (1962), following reproductive anatomy, asserted that
male-female pair bonding constituted the sole healthy sexual adaptation. Bieber
(1962) noted that "all psychoanalytic theories assume that homosexuality is
psychopathologic" and referred to the "inherent psychological pain" of
homosexuality (Stoller, et al., 1973, p.1210). As homosexuality was considered a
maladaption to underlying oedipal conflict, it represented a symptom of assumed
pain, even among those happy with their sexual orientation. Socarides (1962)
stated that "heterosexual object choice is determined by two and a half billion
years of human evolution," and linked same-sex practices to schizophrenia,
paranoia, manic-depression, and borderline personality.
Heterosexuality as a biological imperative was disputed by Ford and Beach
(1951), whose studies of non-human primates and supernumerary gender traditions
among non-European societies provided cross-cultural and cross-species
counterexamples. Marmor argued that vegetarians and celibate people also violate
presumed biological norms but are not labeled mentally ill (Stoller, et al.,
1973, p.1208). The concurrence of homosexuality with other psychopathology was
challenged by Evelyn Hooker (1957), who found that a non-clinical gay population
and heterosexual male control group could not be distinguished by Rorschach
results. Marmor's observation of gay and lesbian people who were "happy with
their lives and have made a constructive and realistic adaptation to being of a
minority group in our society" was key to the APA's conclusion that
homosexuality did not represent an inherent disadvantage in all cultures or
subcultures (APA, 1980). Indeed, the emergence of a powerful gay rights
political movement in the early 1970s (Bayer 1981), for all its controversy, was
not congruent with the psychoanalytic portrait of distressed, disabled, and
dependent gays and lesbians.
Views of inherent impairment and distress in transvestism and transsexualism
follow the same threads of deviance from presumed biological function and
association with other psychopathology. Rado (1962), in rejecting Freud's theory
of constitutional bisexuality, stated that "every individual is either male or
female," rejecting the possibility of more than two natural genders. Zucker and
Blanchard (1995) noted in studies of clinical subjects that transvestic
fetishism impairs the ability to form pair bonds, but admitted that "systematic
empirical studies have been scant." Accepting wives of male crossdressers have
been characterized as having poor self-esteem (Feinbloom, 1976) or as angry
toward men (Stoller, 1967), reminiscent of Socarides' (1962) description of
homosexual relationships as "destruction, mutual defeat," and "exploitation."
Gender dysphoria has been clinically associated with borderline personality
disorder (Wise & Meyer, 1980) and crossdressing with various Axis II
disorders (Zucker 1995), as had been homosexuality twenty years earlier.
Rebuttals to theories of inherent transgender distress and impairment closely
paralleled those in the case of sexual orientation. Beginning with Ford and
Beach (1951), anthropological research has revealed a long list of supernumerary
gender roles among many non-European cultures (Bolin, 1987; Bullough, 1993;
Williams, 1986). These were accepted, often highly respected, societal roles
difficult to characterize as pathological. The medical presumption of gender
essentialism, exactly two natural sexes determined by genitalia, has been
challenged by a growing body of socio-cultural literature that considers gender
a social construction, not a biological imperative (DeBeauvior, 1952; Kessler,
1978; Butler, 1990; Garber, 1992; Lorber, 1994). Psychiatric studies of clinical
populations, like those of clinical gay and lesbian subjects in previous
decades, failed to consider the incidence of functional, well adjusted
transgendered people and couples in society. Conversely, a long-term survey of
members of a heterosexual cross-dressers' support organization (Prince &
Bentler, 1972) suggested a high degree of education, vocational success, and
self acceptance.
The deletion of homosexuality from the DSM-II represented a rejection of its
association with inherent distress and impairment by the APA. In contrast, the
issue is left open to interpretation for transvestic fetishism and gender
identity disorder amid controversy (Zucker & Blanchard, 1995). Brown (1995)
concluded that the clinical significant criterion excludes transgendered
subjects from diagnosis in the absence of distress or dysfunction. However, the
APA denies that the same criterion excludes ego-syntonic subjects diagnosed with
pedophilia, "which by definition constitutes impairment" (APA 1996). A similar
interpretation may be inferred for transvestic fetishism and gender identity
disorder. For example, the DSM-IV paradoxically acknowledges non-erotic
motivations for crossdressing in transvestic fetishism: "In such instances, the
cross-dressing becomes an antidote to anxiety or depression and contributes to a
sense of peace and calm" (APA, 1994). Thus, crossdressing that brings about calm
instead of distress may be interpreted as symptomatic of inherent distress, "to
ward off very early anxieties" (Wise & Meyer, 1980). This is reminiscent of
the past characterization of homosexuality as a maladaption to underlying
distress and of success in social functioning as masking pathology (Bayer,
1981).
Proponents of classification of homosexuality as mental illness have long
emphasized its utility in the interests of ego-dystonic gay and lesbian
individuals who suffered distress and concurrent mental disorders. This was an
important motivation for the creation of a new category, Sexual Orientation
Disturbance, in 1973 for those "disturbed by, in conflict with, or wish to
change their sexual orientation" (APA, 1980. p. 380). It was renamed
Ego-dystonic Homosexuality in the DSM-III in 1980. This reasoning was criticized
by Hooker (1956), who characterized disturbed behavior among gays and lesbians
as "ego defensive," attributable to social stigma and victimization. Marmor
(Stoller, et al., 1973, p.1209) concluded that mental disorders and illness
among gays and lesbians are "not intrinsic to their homosexuality but is a
consequence of the prejudice and discrimination that they encounter in our
society." Spitzer, the architect of Sexual Orientation Disturbance, questioned
the role of psychiatric classification in contributing to the distress and
impairment of gays and lesbians:
In the past, homosexuals have been denied civil rights in many areas of life
on the ground that because they suffer from a "mental illness" the burden of
proof is on them to demonstrate their competence, reliability, or mental
stability (Stoller, et al., 1973, p.1216).
Lay activist Ronald Gold, addressing the APA annual convention in 1973,
characterized psychiatric pathologization as "the cornerstone of a system of
oppression that makes gay people sick" (Stoller, et al., 1973, p.1211).
Ego-dystonic Homosexuality was removed entirely from the DSM-III-R (APA, 1987,
p.426) because it associated homosexuality with pathology and because "almost
all people who are homosexual first go through a phase in which their
homosexuality is ego-dystonic."
Gender dysphoria, stated as an aversion toward the physical characteristics
and social roles of one's biological sex (APA, 1994, p. 767), is considered
symptomatic of mental illness by the assumption that masculinity in females and
femininity in males are pathological. Thus, commonly reported midlife gender
dysphoria among male cross dressers is characterized as a "collapse" from
ego-dystonic transvestism to deeper pathology in the face of stress (Wise 1980).
Questioning the premise of cross gender pathology opens another possibility:
that transgendered people commonly go through an ego-dystonic phase in response
to intense stigma similar to that of gays and lesbians. In this paradigm,
midlife incongruity with one's physical sex or expected social role is not
necessarily a "regressive phenomenon" (Person, 1974) but may represent a "coming
out" process as denial gives way to self-acceptance (Wilson & Hammond,
1996).
Whether disability or impairment is considered inherent to cross-dressing or
induced externally by social circumstances remains controversial (Zucker, 1995)
and is not clarified in the DSM-IV. What is more clear is that the societal
prejudice directed toward homosexual and transgendered people is much the same.
Author Leslie Feinberg (1996) observed,
Some people used to say we "looked gay," but unless we were holding
hands with our lovers or walking out of a gay bar, it was not our sexual desire
that made us visible - it was our gender expression.
In contrast to assumptions of inherent impairment, transgendered people hold
a wide variety of responsible occupational positions: psychiatrists,
psychologists, attorneys, artists, scientists and writers, to name a few.
Experienced impairment, in the form of discrimination in employment and
government policy, is much the same for the transgendered as for gays and
lesbians. For example, a recently defeated Washington state ballot initiative
stated:
This act would also prohibit any common school from presenting,
promoting or approving homosexuality, bisexuality, transsexuality, or
transvestism or such practices or relationships, as positive, healthy, or
appropriate behavior or lifestyle. (Washington Committee for Equal
Rights, Not Special Rights, 1994)
Anthropologist Anne Bolin (1988), echoing Spitzer, observed that, "The
problems of stigma and the possible impact of the mental illness label are
overlooked." Distress and impairment among gays and lesbians that result from
stigma, prejudice, and indeed psychiatric classification are not considered
pathological. Lacking a definition of a normal response to shame, stigma and
marginality in the DSM-IV, it is unclear why distress among transgendered people
is treated differently.
Other Differentiating Arguments
Statistical definitions of mental abnormality have been promoted in various
forms for many years. Assumptions of deviation from statistical norms were
central to early concepts of homosexuality as mental illness, before they were
challenged by Alfred Kinsey's (1948) landmark survey of male sexuality. No
formal epidemiological studies of transvestism (Zucker & Blanchard, 1995, p.
29) or of GID children (Zucker and Bradley, 1995, p. 24) have been conducted,
and data on the non-surgical transsexual population is scant. Nevertheless,
Pauly (1992) argued that the infrequent occurrence of transsexualism supports
its classification as mental illness:
First, transsexualism is much rarer than homosexuality, thus it is more
difficult to sustain an argument that these GID [gender identity disordered] are
simply a variation of the human condition.
It seems remarkably inconsistent to classify cross-gender identity as
pathological because it is rarer than homosexuality and not apply the same
argument to homosexuality versus heterosexuality, or left-handedness versus
right-handedness. Moreover, defining deviance as disease has two fundamental
problems (Ullmann, 1975). First, some unusual conditions are very desirable,
such as very high intelligence. Second, a statistical definition equates mental
health with conformity, discounting the historical contributions of
nonconformists and the social dangers of overconformity.
The definition of "mental disorder" included in the DSM-III through DSM-IV is
stated as follows:
In the DSM-IV, each of the mental disorders is conceptualized as a
clinically significant behavioral or psychological syndrome or pattern that
occurs in an individual and that is associated with present distress (e.g., a
painful symptom) or disability (i.e., impairment in one or more important areas
of functioning) or with a significantly increased risk of suffering death, pain,
disability, or an important loss of freedom. (APA, 1994)
This definition does not include statistical deviance as a justification for
psychiatric classification. Just as statistical prevalence does not necessitate
the pathologization of gay and lesbian people, it does not justify the
psychiatric classification of transgendered people.
The psychiatric classification of gender variance has been cited as necessary
to conduct research on gender identity and provide consistent medical care:
Research in the field has been facilitated by having standardized
criteria available for correctly diagnosing individuals with GID.... This has
greatly increased our knowledge and understanding of GID, and has resulted in
improved and more standardized treatment protocols (Pauly 1992).
First, no evidence has surfaced that our understanding of sexual orientation
has diminished in the past 24 years, lacking a label of mental disorder. Gay and
lesbian subjects, presenting a wide variety of disturbances are treated
successfully for those specific conditions without labeling their sexual
orientation as an illness or implying that all gay and lesbian people are
mentally disordered. It is not clear why gender identity or expression differs
in this regard.
Moreover, an intention to standardize the diagnosis and treatment of
transgendered individuals is not evident in the obscure and conflicting language
of the DSM-IV. For example, criterion A of the Transvestic Fetishism disorder is
grammatically ambiguous (Wilson & Hammond, 1996):
Over a period of at least 6 months, in a heterosexual male, recurrent,
intense sexually arousing fantasies, sexual urges, or behaviors involving
cross-dressing. (APA, 1994, p. 531)
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. This is consistent with the DSM-IV Casebook (Spitzer,
ed., 1994, pp. 257-259), which recommends a TF diagnosis for a 65 year old male
whose crossdressing is not necessarily sexually motivated and whose distress is
limited to his spouse's intolerance. The second would limit the diagnosis to
only sexually motivated cross-dressing, as did the DSM-III-R (APA, 1987, p.
289), and imply the unlikely phrase, "sexually arousing sexual urges." Although
labeled a "fetishism," it is not clearly stated whether or not transvestism must
be sexual in nature to qualify for diagnosis. The distinction is left entirely
to the clinician.
The clinical significance criterion for Transvestic Fetishism and Gender
Identity Disorder, described previously, fails to specify what kinds of distress
or impairment indicate a psychiatric diagnosis. A therapist may infer that any
expression of cross-gender identity represents inherent pathology in
ego-syntonic transgendered individuals or the opposite: that only ego-dystonic
subjects qualify for diagnosis. Little guidance is provided by the DSM-IV to
promote consistency.
In the case of gender non-conforming children and adolescents, the GID
criteria are significantly broader in scope in the DSM-IV (APA, 1994, p. 537)
than in earlier revisions, to the concern of many civil libertarians. A child
may be diagnosed with Gender Identity Disorder without ever having stated any
desire to be, or insistence of being, the other sex. Boys are inexplicably held
to a much stricter standard of conformity than girls. A preference for
cross-dressing or simulating female attire meets the diagnostic criterion for
boys but not for girls, who must insist on wearing only male clothing to merit
diagnosis. References to "stereotypical " clothing, toys and activities of the
other sex are imprecise in an American culture where much children's' clothing
is unisex and appropriate sex role is the subject of political debate. Equally
puzzling is a criterion which lists a "strong preference for playmates of the
other sex" as symptomatic, and seems to equate mental health with sexual
discrimination and segregation.
Author Phyllis Burke (1996) describes cases of children as young as age three
institutionalized or treated with a diagnosis of GID for widely varying gender
nonconformity. She presents evidence of increasing use of GID for children
suspected of being "prehomosexual," and not necessarily transsexual. Diagnosis
and treatment is often at the insistence of non-accepting parents with the
intent of changing a perceived homosexual orientation. Burke quotes Kenneth
Zucker, of the GID subcommittee, that parents bring children to gender clinics
for the most part "because they don't want their kid to be gay" (p. 100).
Zucker and Bradley (1995, p. 53) noted that "homosexuality is the most common
postpubertal psychosexual outcome for children [with GID]." They defended the
treatment of gender nonconforming children on three points: reduction of social
ostracism, treatment of underlying psychopathology, and prevention of GID in
adulthood (pp. 266-7). The first appears to shift the blame for the distress of
discrimination from its inflictors to its victims. The second presumes theories
of psychosocial etiology discussed previously. With respect to the third, Zucker
and Bradley conceded that,
there are simply no formal empirical studies demonstrating that
therapeutic intervention in childhood alters the developmental path toward
either transsexualism or homosexuality (p. 270).
This use of Gender Identity Disorder for children and youth was recently
condemned by the National Gay and Lesbian Task Force (originally the National
Gay Task Force, founded in 1973 to lobby against inclusion of homosexuality in
the DSM-II, Lobel, 1996) and the San Francisco Human Rights Commission (1996) :
the San Francisco Human Rights Commission calls on the American
Psychiatric Association and the American Psychological Association to take
immediate steps to stop coercive and inappropriate treatments of gender atypical
children based on GID.
Far from promoting consistency in diagnosis and treatment, ambiguous and
conflicting language in the DSM-IV has created much confusion and controversy.
Interpretation of the Gender Identity Disorder and Transvestic Fetishism
diagnostic criteria may range from a narrow definition of objective distress to
an overinclusive loophole to the American Psychiatric Association decision to
declassify homosexuality as a mental disorder.
Issues involving medical procedures, such as psychotherapy, hormonal therapy
and sexual reassignment surgeries are often cited to support the DSM inclusion
of Gender Identity Disorder in pragmatic terms. Pauly (1992) stated that
necessity of medical intervention justifies the disparate treatment of Gender
Identity Disorder and homosexuality in the DSM:
a homosexual individual need not present to the medical or psychiatric
profession in order to pursue his/her lifestyle.
Psychotherapy or counseling is often helpful to transgendered people dealing
with issues of shame, secrecy, depression, and prejudice. Counseling is
particularly helpful to transsexuals considering lifelong changes in gender role
or sexual reassignment procedures, and these procedures require the specialized
skills of endocrinologists, urologists, and cosmetic surgeons.
However, gay and lesbian individuals suffering social prejudice and stigma
often can benefit from counseling and psychotherapy as well. In a 1993 study of
194 lesbian, gay, and bisexual youth from 14 community centers, 42% reported
prior suicide attempts (D'Augelli, 1993). For those who do seek help, the APA is
very cautious not to worsen their stigma by associating mental illness with
sexual orientation. In fact, the term "homosexuality" is not even listed in the
index of the DSM-IV.
For sex reassignment procedures, the Standards of Care for the Hormonal and
Surgical Sex Reassignment of Gender Dysphoric Persons, from the Harry Benjamin
International Gender Dysphoria Association (1990), specifically require a
diagnosis of transsexualism as listed in the DSM-III-R The rationale is that
cross-gender identity is legitimized by psychiatric classification as a
condition worthy of evaluation and treatment (Pauly, 1992; Bolin, 1988). By
implication, SRS procedures might cease to be offered to transsexuals without a
diagnosis to validate their medical necessity and justify their risks.
This rationale is inconsistent with the APA's decision to merge the DSM-III-R
categories of Transsexualism and Gender Identity Disorder of Adolescence or
Adulthood, Nontranssexual Type (GIDAANT) in the DSM-IV:
The desire to uncouple the clinical diagnosis of gender dysphoria from
criteria for approving patients for SRS was one factor in the subcommittee's
recommendation that these categories be merged under the single heading of
Gender Identity Disorder. The subcommittee was also influenced by the perception
of many clinicians that there are no distinct boundaries between gender
dysphorics who request sex reassignment surgery and those whose cross-gender
wishes are of lesser intensity or constancy. (Bradley, et al., 1991)
Curiously, the Harry Benjamin standards of care have not been revised since
the publication of the DSM-IV or reconciled with its broader definition of
Gender Identity Disorder. If gender identity and not sexual orientation is
defined as a mental illness for the purpose of legitimizing surgical and
hormonal procedures, then two questions emerge: Why was Gender Identity Disorder
expressly uncoupled from SRS approval criteria, and what is the purpose of
diagnosing non-transsexual gender dysphorics?
Finally, the issue of insurance coverage for the substantial costs of
transsexual hormone and surgical procedures has been cited to support the
inclusion of Gender Identity Disorder in the DSM (Pauly, 1992). In fact, GID has
failed to merit coverage by most private North American health insurers.
According to Dr. Stanley Biber (1996), a leading sexual reassignment surgery
specialist, insurance reimbursement for SRS procedures has become extremely rare
in the United States.
Pragmatic reasons alone do not justify the psychiatric classification of an
entire class of people, especially when the distress associated with the
condition results from social stigma that is exacerbated by the classification
itself. On the other hand, deleting Gender Identity Disorder, in the absence of
an accepted medical justification for SRS procedures, would likely reduce access
to those procedures. Perhaps in the future, a physical diagnosis for
transsexualism will be offered that is more consistent with surgical and
hormonal treatments than the current mental disorder model. In the meantime,
there is substantive cause to review the broad and conflicting language of
Gender Identity Disorder and Transvestic Fetishism in the DSM-IV. The benefits
of removing the stigma of psychosexual illness on all transgendered individuals,
while maintaining a clear and specific justification for SRS procedures for
transsexuals, merit investigation.
American psychiatric perceptions of etiology, distress, and treatment goals
for transgendered people are remarkably parallel to those for gay and lesbian
people before the declassification of homosexuality as a mental disorder in
1973. The diagnostic categories of Gender Identity Disorder and Transvestic
Fetishism, like Homosexuality in past decades, may or may not meet current
definitions of psychiatric disorder depending on subjective assumptions
regarding "normal" sex and gender role and the distress of societal prejudice.
Recent revisions of the Diagnostic and Statistical Manual of Mental Disorders
have made these categories increasingly ambiguous and reflect a lack of
consensus within the American Psychiatric Association. The result is that a
widening segment of gender non-conforming youth and adults are potentially
subject to diagnosis of psychosexual disorder, severe stigma, and loss of civil
liberty. Revising these diagnostic categories will not eliminate transgender
stigma but may reduce its legitimacy, just as DSM reform did for homophobia in
the 1970s. It seems possible to define a diagnosis that specifically addresses
the needs of transsexuals requiring medical sex reassignment, with criteria that
are clearly and appropriately inclusive. Until this is accomplished, the
disparate treatment of sexual orientation and gender expression not involving
sex reassignment has little apparent justification.
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