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28 June 2022

The DSM - Part III: comments

Part I: history of the APA 
Part III: comments


Homosexuality never was in the DSMs in the way that Transsexuality and Transvestism later were. DSMs I and II had simple lists of Sexual Deviations that included Homosexuality and Transvestitism along with Fetishism, Pedophilia, Exhibitionism, Voyeurism, Sadism and Masochism without giving diagnostic criteria or any other comments. As the campaign to get Homosexuality delisted happened at this time, the delisting was easier.

Transsexualism/Gender Identity Disorder (GID)/Gender Dysphoria (GD) is not mentioned at all in DSM I or DSM II.

The 1973 decision to remove Homosexuality from the DSM was because other ‘sexual deviations’ “regularly caused subjective distress or were associated with generalized impairment in social effectiveness or functioning” but Homosexuality did not. There were always at least some trans persons who likewise did not suffer such distress or impairment. However it was not until DSM V in 2013 Criterion B “clinically significant distress or impairment in social, occupational, or other important areas of functioning” that the definition of GID/GD was restricted to those who actually need therapy.

In the 1960s and 1970s Virginia Prince had advocated that the word ‘transvestite’ be restricted to heterosexual transvestites. This was accepted in DSM III 1980. However to her chagrin, in DSM III-R 1987 Transvestism was renamed as Transvestic Fetishism. Prince had always drawn a clear line between Transvestism and Fetishism but the DSM had removed that line.

The restriction of the term ‘Transvestism’ to heterosexual males as a form of sexual excitement is objectionable as there are many other forms of transvesting. However it was this particular subset who were most likely to seek psychotherapy.

Some reacted to this restriction of the term by referring to gay and female transvestites as cross-dressers. While the Princian groups also later used ‘cross-dresser’ for themselves, the DSM used it for both transvestites and transsexuals. Neither usage has prevailed.

The 302 code was first introduced in DSM II 1968 for ‘Sexual Deviations’. While Gender Identity Disorder/Gender Dysphoria were distinguished from Transvestism/Transvestic Fetishism/Transvestic Disorder – especially in DSM III and DSM V (but not in DSM IV) – when they were separated by hundreds of pages, they continued to share the 302 code.

The word ‘autogynephilic’ appears only in DSM V 2013. Note that it is used only as a variation of Transvestic Disorder. There is no suggestion of there being autogynephilic transsexuals.

Is Gender Dysphoria the same as Gender Identity Disorder? Some regard it as simply a renaming. Others regard GD as no longer a Disorder, but only as a category retained for billing US insurance companies. The claim is that GD is not a Disorder in itself, but distress caused by gender incongruence. The wording is certainly more polite, but remember that the term Gender Dysphoria was coined by psychiatrist Norman Fisk in 1972 because Transsexualism was losing its medical connotations, and he wanted to remedicalize the concept.

In saying that Gender Dysphoria is “a marked incongruence between one’s experienced/expressed gender and assigned gender” the DSM still ignores and denies the lack of acceptance and outright hostility that many trans persons encounter.

Some transitioning trans persons do need therapy and for others a requirement of therapy (especially from therapists who have not themselves transitioned) is at best an irritant. Even DSM V does not admit this, but the B criteria for Gender Dysphoria “the condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning” does actually imply that those trans persons who have been able to arrange a continuation of work, and are receiving hormones, electrolysis etc as required and desired are not Gender Dysphoric and do not need therapy.

As we find in the work of Anne Vitale, early transitioners and alumni from the gay or lesbian scene often do not require therapy (although peer support is good) while late transitioners who have spent decades conforming to their birth gender often suffer from what she calls Gender Deprivation Anxiety Disorder (GEDAD).

Vitale has never been on a DSM work group, and come to that - although there are several noted psychologists, psychiatrists and sexologists who have transitioned - no trans person has been on DSM work groups.

The DSM dropping of ‘transsexual’ for GID and then GD has interacted of course with language political correctness where we are being told that we should not distinguish Transsexual from Transvestite - that we are all Transgender. Transsexual is said to be too clinical. However it remains necessary to designate surgery-track trans persons, and far too often these are being designated as Gender Dysphoric - Fisk’s even more clinical term.

If the retention of Gender Dysphoria is only for US insurance billing, it strenghens the argument that the DSM should not be used in other countries.

The APA has equivocated on whether Intersex persons can be Transsexual/GID/GD. In DSM III “In physical intersex the individual may have a disturbance in gender identity. However, the presence of abnormal sexual structures rules out the diagnosis of Transsexualism.” In DSM IV “The disturbance is not concurrent with a physical intersex condition.” In DSM V the physician is to note if a Gender Dysphoric person has a “disorder of sex development (DSD)”. The usage of the DSD terminology indicates that this was not decided in consultation with Intersex activists as almost all of them reject the term. However this does admit that a person may be both Intersex and GD.

It was a problem in the 1970s and 1980s that cishet psychiatrists and sexologists did not seem to be able to distinguish trans kids from Gender Non-Conforming children. This was openly admitted in Richard Green’s The "Sissy Boy Syndrome" and the Development of Homosexuality. Hopefully that problem is now in the past.

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