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Crossdreamer Sidebars is a support blog for Crossdreamers.com, a site devoted to crossdreamer and transgender issues.

Friday, May 2, 2014

The DSM-5 and ICD-11 on Transgender, Gender Dysphoria and Transsexualism

The fact that the DSM-5 text on transgender and transsexual is not available online has become a democratic problem. Transsexual separatist are now misrepresenting the chapter on gender dysphoria for political purposes. I have therefore decided to make parts of the text available to my readers.

In a recent debate on tumblr the DSM-5 chapter on gender dysphoria has been used in support of a new myth created by so-called "truscum" transsexual separatists.

The myth says that the word "transgender" refers to people with gender dysphoria only, and that other gender variant people who use the term transgender are offending "true" transgender men and women.

It seems the main motive for this attempted hijacking of the term is that many of them find the word "transsexual" embarrassing.  I also suspect that many of them would rather not be seen in company with crossdressers, drag queens and other gender-nonconforming people, and that this is another reason for this cleansing of the transgender concept.

I have seen many instances of truscum claiming that the American psychiatric manual, the DSM-5, requires gender dysphoria for a transgender diagnosis. Basically these online activists are trying to mobilize the medical establishment in their support.

The DSM distinguishes between transgender and transsexual

The problem is that none of them have actually read the DSM-5. If they had they would have known that the DSM does not require gender dysphoria for someone to call themselves transgender. Indeed, the word the DSM uses to describe the class of trans people the truscum want to protect is "transsexual".

Transgender is understood as a broad umbrella term encompassing all types of gender variant people. The manual explicitly states that  "Transgender refers to the broad spectrum of individuals who transiently or persistently identify with a gender different from their natal gender." And yes, the word "gender" is meant to include non-binary identities as well.

The only reason the separatists can get away with such untruths is the fact that no one has read the original text. I have therefore decided to share parts of the text with other trans people so that we can get a more open and fact-based debate.

It so happens that this chapter of the DSM gives a very good summary of where the psychiatric communities world wide stand right now as regards gender variance. I do not support everything that is written here, but compared to previous editions the American Psychiatric Association has come a long way towards depathologizing gender variance. The main obstacle now, is not this chapter, but the one on "transvestic disorders".

The DSM subwork group on gender dysphoria

The subwork group responsible for this chapter consisted of Peggy T. Cohen-Kettenis, Ph.D. from the University Medical Center in Amsterdam (Chair): Jack Drescher, M.D. from New York;  Heino F. L. Meyer-Bahlburg, a German born professor of clinical psychology (in psychiatry) at Columbia University, New York; and  Dr. rer. nat., Friedemann Pfäfflin, M.D.,  a German specialist in psychiatry and psychotherapy.

The chapter therefore also reflects international trends in sex and gender research. That makes it harder to argue that it is "obvious" that transgender condition requires gender dysphoria.

The WHO manual on diseases

The DSM is an American manual. Internationally the UN International Classification of Diseases (ICD)  is more widely used (although doctors world wide will look at the DSM as well).

Note that DSM subworking group members Cohen-Kettenis and Drescher are also members of the World Health Organization’s Working Group on the Classification of Sexual Disorders and Sexual Health.

This group will address sex and gender diagnoses in WHO's forthcoming revisions of the International Classification of Diseases (ICD-11).  That manual is expected to be published in 2017. The WHO most often follow changes made in the DSM.

Some countries have already made changes to the current ICD edition, removing the sections on "transvestism" (i.e. crossdressing and crossdreaming).

In a recent paper the ICD-11 Working Group on the Classification of Sexual Disorders and Sexual Health, states that it "believes it is now appropriate to abandon a psychopathological model of transgender people based on 1940s conceptualizations of sexual deviance and to move towards a model that is (1) more reflective of current scientific evidence and best practices; (2) more responsive to the needs, experience, and human rights of this vulnerable population; and (3) more supportive of the provision of accessible and high-quality healthcare services."

In a preliminary consensus meeting on the ICD-11 arranged by WPATH in 2013, there was no mention of reinterpreting the word transgender to mean the same as transsexual. Indeed, the title of the process was "WPATH consensus process regarding transgender and transsexual-related diagnoses in ICD-11" -- a clear indication of the two words being interpreted differently.

Before the meeting the working group had proposed the term "transsexualism" to "gender incongruence", moving gender incongruence out of the chapter on mental and behavioral disorders, and deleting the categories "dual role transvestism" and "fetishistic transvestism".

In other words: Not only is the ICD-11 process moving in the same positive direction as the DSM; it is taking this process further, suggesting that one removes crossdressing and crossdreaming altogether. The term transgender retains its broad meaning.

The DSM-5 chapter on gender dysphoria

You can read an excerpt of the DSM-5 chapter on gender dysphoria here! 

Special thanks to Brenda Lana Smith, who has transcribed significant parts of the text.

Click here for a scanned PDF that also includes the chapter on transvestic disorder.

Click here to buy the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition: DSM-5

See also: "Minding the body: Situating gender identity diagnoses in the ICD-11" by Jack Dreschler, Peggy Cohen-Kettenis and Sam Winter, International Review of Psychiatry, December 2012; 24(6): 568–577

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