DSM-5 Falls Short on gender dysphoria revision, ICD 11 Update

image from GIRESUK (other images added as a visual aids for non experts on transgender issues understanding)

The following are aspects of the a presentation by a leading transgender and Gender Dysphoria Reform advocate, it is a summary by Kelly Winters Ph. D of recent changes to gender related diagnostic categories in the DSM-5, published last month by the American Psychiatric Association, and proposed changes for the ICD-11, scheduled for publication in 2015 by the World Health Organization.  It is based on proposed revisions to the ICD-11 presented by Drs. Geoffrey Reed, Peggy Cohen-Kettenis and Richard Krueger at the National Transgender Health Summit in Oakland last month and on discussions at the Global Action for Trans* Equality (GATE) Civil Society Expert Working Group in Buenos Aires last April.

There are two primary issues in medical diagnostic policy for trans people. The first is harmful stigma and false stereotyping of mental defectiveness and sexual deviance, that was perpetuated by the former categories of Gender Identity Disorder (GID) and Transvestic Fetishism (TF) in the DSM-IV-TR. The second is access to medically necessary hormonal and/or surgical transition care, for those trans and transsexual people who need them. The latter requires some kind of diagnostic coding, but coding that is congruent with medical transition care, not contradictory to it. I have long felt that these two issues must be addressed together –not one at the expense of the other, or to benefit part of the trans community at the expense of harming another.

also see from my sister blogs:  Being Transgender Is No Longer A Mental Disorder ?…………… and Gender Dysphoria Diagnosis to be Moved Out of Sexual Disorders Chapter of DSM-5 ……. The “D” Switcharoo? plus more HERE

The DSM-5 Falls Short, Despite Some Significant Improvements

The new revisions for the Gender Dysphoria diagnosis in the DSM-5 are mostly positive. However they do not go nearly far enough. The change in title from Gender Identity Disorder (intended by its authors to mean “disordered” gender identity) to Gender Dysphoria (from a Greek root for distress) is a significant step forward. It represents a historic shift from  gender identities that differ from birth assignment to distress with gender assignment and associated sex characteristics as the focus of the problem to be treated. This message is reinforced by the August 2012 Public Policy Statement from the American Psychiatric Association, affirming the medical necessity of hormonal and/or surgical transition care. In another positive change, the Gender Dysphoria category has been moved from the Sexual Disorders chapter of the DSM to a new chapter of its own. Non-binary queer-spectrum identities and expression are now acknowledged in the diagnostic criteria, and the APA Working Group has rejected pressure to add an “autogynephilia” specifier to falsely stereotype and sexualize trans women. Children can no longer be falsely diagnosed with this mental disorder label, strictly on the basis of nonconformity to birth assignment.

However, the fundamental problem remains that the need for medical transition treatment is still classed as a mental disorder. In the diagnostic criteria, desire for transition care is itself cast as symptomatic of mental illness, unfortunately reinforcing gender-reparative psychotherapies which suppress expression of this “desire” into the closet. The diagnostic criteria still contradict transition and still describe transition itself as symptomatic of mental illness. The criteria for children retain much of the archaic sexist language of the DSM-IV-TR that psychopathologizes gender nonconformity. Moreover, children who have happily socially transitioned are maligned by misgendering language in the new diagnosis.

More troubling is false-positive diagnosis for those who have happily completed transition. Thus, the GD diagnosis, and its controversial post-transition specifier, continue to contradict the proven efficacy of medical transition treatments.  This contradiction may be used to support gender conversion/reparative psychotherapies– practices described as no longer ethical in the current WPATH Standards of Care.

Finally, the Transvestic Disorder category in the DSM-5 is even more harmful than its predecessor, Transvestic Fetishism. Punitive and scientifically capricious, it only serves to punish nonconformity to assigned birth roles and has no relevance to established definition of mental disorder. The Transvestic Disorder category has been expanded in the DSM-5 to implicate trans men as well as trans women, with a new specifier of “autoandrophilia,” apparently pulled from thin air without supporting research or clinical evidence.

The ICD-11, a Historic New Approach

icd-11-book-cover

The 11th Revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-11) is scheduled for publication in 2015 by the World Health Organization (WHO). It is a global diagnostic manual that contains chapters for both physical medical conditions and mental conditions. In contrast to the DSM-5, the ICD-11 holds promise for unprecedented forward progress on both issues of social stigma and barriers to medical transition care.  At the National Transgender Health Summit in Oakland last month, members of the ICD-11 Working Group for Sexual Disorders and Sexual Health confirmed proposals for  substantive changes in gender and transition related codings.

The Working Group has proposed a historic shift of transition related categories, now labeled “Gender Incongruence,”  out of the Mental and Behavioural Disorders chapter (called F-Codes) entirely. It is to be placed in a new, non-psychiatric chapter, called “Certain conditions related to sexual health.” The Incongruence title is distinct from DSM-5 dysphoria title, to clarify that this is no longer a mental disorder coding.  They have also proposed to eliminate victimless sexual paraphilia categories from the manual, including: F65.1: Transvestic fetishism. A similar category describing dual gender individuals, F64.1: Dual-role Transvestism, would be deleted as well. These changes have the potential for enormous progress in reducing both stigma and barriers to medical transition care, for those who need it.

When implemented, they would effectively obsolete the new psychopathology categories of Gender Dysphoria and Transvestic Disorder in the DSM-5.

There are also questions and shortcomings in the current  ICD-11 proposals.  While the proposed children’s coding of  Gender Incongruence of Childhood is no longer a mental disorder label,  any pathologizing coding of happy gender nonconforming or socially transitioned children, who are too young to need any medical transition or puberty-blocking treatment, is highly controversial among clinicians, families and community members.  The diagnostic criteria for children, like those in the DSM-5, still emphasize nonconformity to anachronistic gender stereotypes as symptomatic of sickness. The adult and adolescent criteria have copied ambiguous language from the DSM-5 that cast desire for transition, in itself, as pathological. Worse yet, false-positive diagnosis of happy post-transition subjects inadvertently contradicts rather than supports medical transition care.

The ICD-11 Working Group for Sexual Disorders and Sexual Health should be commended for advancing these historic reforms. However, it is important that Group members listen to the remaining concerns of community members and supportive care providers.  Adults and adolescents needing access to medical transition care, or pubescent youth needing puberty blocking medications, require a clearer description of the problem to be treated. Young children, who may only need information, monitoring and support, have very different diagnostic needs and diagnostic risks than adults and adolescents.

What needs to be done to help Transsexuals In Jamaica

Coming on the heels of the Miss Jamaica Universe’s group basically disagreeing with the inclusion of a previously booted transgender entrant in Canada albeit she allegedly was not clear on filling out the entry form to say she was born female, a local transgender voice has prepared a post to add her voice to the furore to look at related issues as this time.

I also feel is an opportune moment to help sensitize the public including L, B and G populations about transgenderism and transsexuals as several misconceptions abound and frankly there maybe many persons who identify as GLB but who maybe in fact transgender but do not know it or have sought the necessary consultations to find out.

see a previous post on the Jenna matter from Canada on my sister blog GLBTQ Jamaica on Blogger:

Transphobia: Miss Jamaica Universe Pageant rep says no to transgender entrant in Canada beauty contest

Miss Laura wrote:

Take the buggery law off the books; the buggery law hampers education about this topic. Jamaican’s on a whole consider transgender and transsexuals to be homosexuals. They are not aware that being transgender or transsexual is about a person’s gender Identity their sense of self and not sexual preference. Here in Jamaica people tend to group anything that is not considered normal (gay’s, Lesbians, transvestites, transgender, transsexuals, cross-dressers and the list goes on to be all homosexuals or as it is called (batty man, and sodomites).
Removal of the buggery law would open a door not for just gay men and women but it would also allow transgender people to feel a certain level of security knowing that the law is now on their side and can enjoy equal rights and protection.
I have heard people say that there are no transgender people in Jamaica. That’s just ridiculous and ignorant why would they state this as a fact? Well it is simple most transgender people don’t even know they are transgender or transsexual. They automatically are grouped with the gay community. Many transgender and transsexuals adopt the “GAY Life Style” hoping they would fit into the social landscape where there is friendship and protection and the possibility of feeling less of a freak and more of a normal human being.

Once the buggery law is repealed we can begin to make change in the way how people treat and associate the transgender community with homosexuals and lesbians.


What changes need to be made?
1. The health care system where transgender people can access to counselling, hormone treatments, and Sex Reassignment Surgery. At this time there are no health organisations offering transgender Services Island wide. Many transgender people access hormones mainly on the black market and or through if they are lucky a doctor who is willing to treat them on the QT. Some if they happen to have the financial resources access hormones by purchasing them online.

Many transgender people are often too poor because they cannot get jobs because of their transgender status. Many resort to prostitution due to being ejected from their families and have nowhere to go but the streets. Transgender and transsexuals seek refuge within gay communities as a means to survive.
Those lucky enough to leave the country and make their way to the US or the UK where they can access treatment and live in relative peace. Unlike here in Jamaica where you will most likely be beaten or killed because Jamaican s confuse gender with sexuality.

2. Educating the public about transgender and transsexuals will bring greater enlightenment to the masses, and change the lives of many who are wrestling with a gender identity conflict. Many transgender or transsexuals know they are different from an early age. Little boys seen playing with dolls many not be gay but might be or most likely are transgender or transsexual. Educating people of this will greatly improve the lives of these young children and lead them to a better quality of life and most likely a productive one and far from the thought of suicide.

3. Amendments to Labor laws preventing the discrimination against transgender and transsexual people in the workplace or from being denied job placements in both public and private sector organisations due to their lifestyle or mode of dress e.g. a transsexual living as a woman, dressing as a woman, but may not look feminine . Such a person would be seen as a freak and be automatically turn down for a job placement. Most transsexual’s transition late in life and this tends to be the norm in some cases some transition early in life if they have the support of family.

image from: transgenderzone.com

Late transitioning

A late transition equals less chance of passing unless that person had many expensive surgeries to undo the many years of testosterone exposure. Where early transition starting in the teenage years can have a favourable outcome where the masculine features can be reversed and made feminine under the effects of oestrogen will most of the time produce a passable young woman.

4. Amendments allowing transgender or transsexual men and women to have the same equal right like every other non transgender or transsexual man or woman.This means individuals should have the right to marry like non transgender /transsexual people. Have the right to have their identity papers altered to fit their chosen gender Identity without being judged and told that what you’re doing in the eyes of God is wrong.
Transgender/transsexual people should have the right to equal opportunities like all other peoples that make up our diverse culture.

ENDS

Over the many years of LGBT advocacy in Jamaica transgenderism has been given a back seat for too long and while a few voices speak intermittently on the issues surrounding same it is not enough to properly help the public to understand that there are many identities that abound in the human species and deciphering them is a must for us to co-exist. Major advocates seem not to have time to deal with this matter as decriminalizing buggery is far more important than the other inter and intra community matters that are parallel to men who have sex with men issues. Miss Laura is one of the few voices who have been consistent on the matter from the ground up.

Let us continue to listen to that voice and learn as only she can tell it from her own realities as a transwoman in Jamaica.

Miss Laura can be reached through this email lgbtevent@gmail.com

Peace and tolerance

H