The More Things Change…
…The More They Stay the Same
Recently, the Diagnostic & Statistics Manual, usually called by its initials, the DSM, of the American Psychiatric Association, considered by most physicians and even researchers, to be the single most important document on psychiatric conditions, was updated. The new DSM V has an updated section on transsexual/transgender diagnoses and description. In several ways, it was both an improvement, and a set back, for transfolk.
First, the improvement and a bit of history. Decades ago, during the days that in my history class I called, ‘The Clinic Years”, the days when nearly all North American and European transfolk were dependent upon organized clinics for SRS, often associated with universities such as John Hopkins and Stanford, they typically excluded people that they thought fell outside of the “classic transsexual” diagnoses. If you were a heterosexual MTF, and especially if you admitted to being sexually aroused by cross-dressing, you were not “transsexual” you were simply a “transvestite”, period. But one clinic dispensed with this restriction, led by Norman Fisk, M.D. Dr. Fisk coined a new term and a description of a syndrome that he described as “liberalizing” the allowable indications for HRT and SRS, “Gender Dysphoria”. As Anne Lawrence described it:
“Fisk (1974a, b; Laub & Fisk, 1974) distinguished several types of male patients who sought sex reassignment at the Stanford University gender program. He used the term gender dysphoria syndrome, rather than transsexualism, to refer to these patients’ diagnosis. In Fisk’s typology, the number of recognized typological categories and their exact names varied slightly from one article to another. It appears that persons in only three of Fisk’s typological categories, however, were considered appropriate candidates for SRS in the Stanford program (Laub & Fisk, 1974): classic transsexualism of Benjamin (a reference to Benjamin, 1966), effeminate homosexuality, and transvestism. Only patients in these three categories, for example, were selected for inclusion in a follow-up descriptive study of applicants to the Stanford program (Dixen, Maddever, Van Maasdam, & Edwards, 1984); consequently, only these categories are included in Table 2. Other typological categories described by Fisk included persons with psychosis, extreme sociopathy and psychopathy, and inadequate/schizoid personality (1974b; Laub & Fisk, 1974). Classic MtF transsexualism was characterized by onset in early childhood, life-long feminine behavior, exclusive androphilia, absence of sexual arousal with cross-dressing, and perhaps a disinterest in genital sexuality (Fisk, 1974a; Laub & Fisk, 1974). Effeminate homosexuality progressing to gender dysphoria syndrome was characterized by androphilia, episodic nonerotic cross-dressing, and onset of gender dysphoria in adulthood (Laub & Fisk, 1974). Transvestism progressing to gender dysphoria syndrome was characterized by erotic arousal with cross-dressing, gynephilia, and onset of gender dysphoria in adulthood (Laub & Fisk, 1974).”
Here, I get to share a bit of my personal history, in that I was diagnosed as “transsexual” by Dr. Fisk in early 1975, when I was 17 years old. So I have cherished memories of having had a grand total of six hours talking to him… but in those six hours, I got a glimpse into the mind that cut through the confusion of the differing types of candidates for sex reassignment and sought to offer such liberalized palliative medicine. Yet, I can also tell you from those six hours, two of which were in the company of my parents (one hour each, separately, given that they were in the process of an unhappy divorce) that Fisk was a VERY skeptical man. He dug into my history, sexuality, and aspirations with a vengeance. I’m betting he did so with everyone. In fact, the very first half hour spent with him, I got the very distinct impression that he was ready to believe that every word out of my mouth would be a lie. At the time, I couldn’t understand why that should be, given that at 17, I was very naïve about the state of the on going debate in medical and scientific circles… and especially unknowing of how autogynephilic transwomen were lying to the clinics, including to Dr. Fisk. I think it was meeting my mother, and hearing her very bitter, angry, and even hateful confirmation of my personal history and behavior since early childhood that led him to believe me. I share this to put some color on Fisk’s support of liberalizing the diagnoses with a new inclusive term and syndrome. Dr. Fisk supported HRT and SRS for “older transitioners” not because he believed their narritives, but because he recognized that they were in just as much of a quandary and in pain as the younger androphilic, non-autogynephilic, MTF transkids. He was a hero.
So, back to the DSM. Looking at the history of changes in the DSM over the decades, one can detect an undercurrent of the tides, the ebb and flow, between pragmatic science based medicine and political / social positioning. When trans issues were first described in the DSM, it was “Transsexualism”, from the DSM, as described by Anne Lawrence (personal communication),
“Transsexualism was characterized as a “heterogeneous disorder” (p. 261), and four subtypes were recognized:
“The disorder is subdivided according to the predominant prior sexual history, which is coded in the fifth digit [e.g., 302.53] as 1 = asexual, 2 = homosexual (same anatomic sex), 3 = heterosexual (opposite anatomic sex), and 0 = unspecified.” (p. 262)
This section goes on to explain that “In the third group, ‘heterosexual,’ the individual claims to have had an active heterosexual life.” (p. 262)
In the section “Predisposing Factors (p. 263), the DSM-III recognizes that “Some cases of Transvestism evolve into Transsexualism.” Finally, in the section on “Differential Diagnosis” (p. 263), it is noted that “In both Transvestism and Transsexualism there may be cross-dressing. However, in Transvestism that has not evolved into Transsexualism there is no wish to be rid of one’s own genitals.”
The diagnostic criteria for Transsexualism (pp. 263-264) are admirably brief and uncomplicated:
1. Sense of discomfort and inappropriateness about one’s anatomic sex.
2. Wish to be rid of one’s own genitals and to live as a member of the other sex.
3. The disturbance has been continuous (not limited to periods of stress) for at least two years.
4. Absence of physical intersex or genetic abnormality.
5. Not due to another mental disorder, such as Schizophrenia.”
But later, the DSM changed the name of the disorder to “Gender Identity Disorder” which causes a distortion in therapy for all concerned because it focuses on “identity” on not on the source of their disorder. It is even more of a distortion of the description of the etiological processes. This was somewhat improved in the DSM-IV-TR, in that it used sexual orientation specifiers and an explanation of autogynephilia as a phenomena and an etiological origin of late transitioning transwomen’s late developing “gender identity disorder”.
Now, four decades later, the DSM has finally caught up to Dr. Fisk by using the term Gender Dysphoria Disorder.
This is the good news, in that the diagnoses speaks directly to the actual ‘pain’ of the condition, rather than to the totally inaccurate and misleading concept of a Gender Identity Disorder. It is also good in that the history of the term goes back to Fisk’s papers that specifically describe how it incudes autogynephilic males. However, the bad news is that the DSM no longer adequately describes autogynephilia and how it is etiologically related to gender dysphoria… and worse, still places too much emphasis on the concept of gender identity mismatch as the cause of gender dysphoria in autogynephilic transwomen, rather than the result of autogynephilic gender dysphora, as the science shows. However, this reliance on “gender identity” is now euphemistically cloaked in the term “experienced / expressed gender”.
There are other problems with it, as Lawrence explains,
“…MtF and FtM transsexuals and the clinicians who treat them have traditionally recognized that a profound sense of ‘‘wrong embodiment’’—distress related to biologic sex and sexed body characteristics—is almost always a prominent feature of transsexualism and GD, in part because such wrong embodiment usually makes it difﬁcult or impossible to ‘‘live and be accepted as a member of the opposite sex’’ (World Health Organization, 1992, p. 365). This “trapped in the wrong body’’ metaphor is not mere poetic rhetoric but offers an authentic description of transsexuals’ subjective experience. … This understanding has been largely, if not quite completely, abandoned in the DSM-5. It has been replaced by an emphasis on ‘‘assigned gender,’’ a change that seems to have occurred entirely for political and social reasons, not for scientiﬁc or clinical ones. In the DSM-5, all the clinical indicators of GD—even those that refer to biologic sex characteristics—are now conceptualized as being clinically relevant only by virtue of their evincing an ‘‘incongruence between one’s experienced/expressed gender and assigned gender’’ (APA, 2013, p. 452; the neologism ‘‘experienced/expressed gender’’ is essentially synonymous with ‘‘gender identity’’). In this formulation, the principal thing that feels wrong in transsexualism and GD is not one’s biologic sex but one’s assigned gender. This same perspective is, as we shall see, also reﬂected in the Subwork group members’ implicit position that effective treatment of transsexualism and GD does not require changing sexed body characteristics but only changing nominal gender assignment, as evidenced by their contention that undergoing gender transition—the only absolute criterion for which is ‘‘full-time living in the desired gender’’ (APA, 2013, p. 453)—automatically results in loss of the GD diagnosis.”
I’m not sure that this was their intent… but taken literally, one’s GD diagnoses, and thus any medical necessity justification for performing, and certainly third-party financing of, sex reassignment surgery or much needed ongoing therapeutic support services, is eliminated the moment that one is socially living as, or perceived as being, the opposite sex! This is a bizarre result of the latest rewrite, one that Lawrence contends was done at the behest of “late transitioning” transsexuals themselves, in an effort to rid themselves of the stigma of a psychiatric diagnoses… one that is ended the moment that they transition full time. Hopefully, the next interim revision will correct this mistake.
(Note 9/11/2014: This essay has been edited to correct an error with respect to the history of the DSM III, thanks Anne.)
Fisk, N. (1974a). Gender dysphoria syndrome: The conceptualization that liberalizes indications for total gender reorientation and implies a broadly based multi-dimensional rehabilitative regimen [Editorial comment]. Western Journal of Medicine, 120, 386–391.
Fisk, N. (1974b). Gender dysphoria syndrome (the how, what, and why of a disease). In D. R Laub & P. Gandy (Eds.), Proceedings of the Second Interdisciplinary Symposium on Gender Dysphoria Syndrome (pp. 7–14). Stanford, CA: Stanford University Press.
Laub, D. R., & Fisk, N. M. (1974). A rehabilitation program for gender dysphoria syndrome by surgical sex change. Plastic and Reconstructive Surgery, 53, 388–403.
Lawrence, A. A. (2010). Sexual orientation versus age of onset as bases for typologies (subtypes) of gender identity disorder in adolescents and adults. Archives of Sexual Behavior, 39, 514-545.
Lawrence, A., “Gender Assignment Dysphoria in the DSM-5”, Archives of Sexual Behavior, DOI 10.1007/s10508-013-0249-z