Abstract
The American Psychiatric Association (APA) is in the process of revising its Diagnostic and Statistical Manual (DSM), with the DSM-V having an anticipated publication date of 2012. As part of that ongoing process, in May 2008, APA announced its appointment of the Work Group on Sexual and Gender Identity Disorders (WGSGID). The announcement generated a flurry of concerned and anxious responses in the lesbian, gay, bisexual, and transgender (LGBT) community, mostly focused on the status of the diagnostic categories of Gender Identity Disorder (GID) (for both children and adolescents and adults). Activists argued, as in the case of homosexuality in the 1970s, that it is wrong to label expressions of gender variance as symptoms of a mental disorder and that perpetuating DSM-IV-TR’s GID diagnoses in the DSM-V would further stigmatize and cause harm to transgender individuals. Other advocates in the trans community expressed concern that deleting GID would lead to denying medical and surgical care for transgender adults. This review explores how criticisms of the existing GID diagnoses parallel and contrast with earlier historical events that led APA to remove homosexuality from the DSM in 1973. It begins with a brief introduction to binary formulations that lead not only to linkages of sexual orientation and gender identity, but also to scientific and clinical etiological theories that implicitly moralize about matters of sexuality and gender. Next is a review of the history of how homosexuality came to be removed from the DSM-II in 1973 and how, not long thereafter, the GID diagnoses found their way into DSM-III in 1980. Similarities and differences in the relationships of homosexuality and gender identity to psychiatric and medical thinking are elucidated. Following a discussion of these issues, the author recommends changes in the DSM-V and some internal and public actions that the American Psychiatric Association should take.
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Notes
Cited in Bayer (1981, p. 10).
The 13 WGSGID members are Kenneth J. Zucker, Ph.D. (Chair), Irving M. Binik, Ph.D., Ray Blanchard, Ph.D., Lori Brotto, Ph.D., Peggy T. Cohen-Kettenis, Ph.D., Jack Drescher, M.D., Cynthia Graham, Ph.D., Martin P. Kafka, M.D., Richard B. Krueger, M.D., Niklas Långström, M.D., Ph.D., Heino F. L. Meyer-Bahlburg, Dr. rer. nat., Friedemann Pfäfflin, M.D., and Robert Taylor Segraves, M.D., Ph.D.
In DSM-IV-TR, there is only one diagnosis—GID—with separate criteria sets for children vs. adolescents/adults.
Following Meyer-Bahlburg (2009), “The nomenclature in the area of gender variations continues to be in flux, in regard to both the descriptive terms used by professionals, and, even more so, the identity terms adopted by persons with GIV [Gender-Identity-Variants].” Where possible, this author will use the term “gender variance” to refer to individuals with gender atypical behavior or self presentations.
For example, see http://www.thepetitionsite.com/2/objection-to-dsm-v-committee-members-on-gender-identity-disorders; retrieved February 9, 2009.
For example, see http://professionals.gidreform.org/samples.html; retrieved July 10, 2009.
Retrieved November 9, 2008 from http://www.psych.org/Departments/EDU/Library/APAOfficialDocumentsandRelated/PositionStatements/200502.aspx.
Several years ago, members of the LGBT community protested the content of Northwestern University’s J. Michael Bailey’s (2003) book, The Man Who Would be Queen. While there were activists who primarily criticized the author’s arguments regarding transgenderism, some activists attacked Bailey’s character, reputation, and family members. Dreger (2008) has summarized an account of those events. Critics of Dreger’s account of those events include Bettcher (2008), Gagnon (2008), Lane (2008), Mathy (2008), McCloskey (2008), and Nichols (2008) among others. Also see Archives of Sexual Behavior, Volume 37(3), 2008 for a broad range of discussions of the Dreger article.
See Karasic and Drescher (2005).
In a classic text on the subject, Benjamin’s (1966) The Transsexual Phenomenon takes pains to distinguish transvestitism from transsexualism. The current DSM-IV-TR diagnosis of “transvestic fetishism,” in one form or another, has been found in all editions of the DSM. It is beyond the scope of this paper to go into that history, although, as Benjamin (1966) noted, touching upon transvestitism can be helpful in clarifying one’s understanding of transsexualism.
The use of “transgendered” as an adjective has begun to fall out of favor and has been replaced by “transgender,” as in “transgender people.”
Historically, the term “homosexual” preceded and necessitated the creation of the term “heterosexual”; the latter term emerged as a more specific signifier of what people used to think of as “normal.” Similarly, members of the transgender community have coined the term “cisgender” to describe those whose psychological gender is concordant with their anatomical sex and who usually think of their gender identity as just “normal.” “The word has its origin in the Latin-derived prefix cis, meaning ‘on the same side’ as in the cis–trans distinction in chemistry. In this case, ‘cis’ refers to the unity of a gender identity with a gender role” (http://en.wikipedia.org/wiki/Cisgender). Some trans writers (Serano, 2007) prefer cissexual rather than cisgender.
Ulrichs defined a woman who we would today call a lesbian as urningin, a man’s spirit trapped in the body of a woman.
“But every once in a while…the X and Y chromosomes get jumbled up, and this little strip of DNA from a Y chromosome is ‘mistakenly’ passed to a daughter (or a bit of the X goes to a son). That means boys are getting a tiny bit of ‘female’ chromosome and girls are getting a bit of a ‘male’ chromosome. This raised the intriguing possibility that a genetic crossover between the male and female sex chromosomes is related to the behavioral ‘crossover’ between heterosexuality and homosexuality” (Hamer & Copeland, 1994, p. 128).
Historically referred to as “hermaphroditism” and later as “intersex,” the recent term “disorders of sex development” (DSD), like “gender identity disorder,” has also divided intersex activists between those who see this medical terminology as stigmatizing and those who see it as necessary for providing informed treatment.
The exact “causes” of heterosexuality are also unknown, but as a dominant cultural narrative regarded as “normal,” heterosexuality rarely requires explanation. Yet as Freud (1905) noted, “from the point of view of psycho-analysis the exclusive sexual interest felt by men for women is also a problem that needs elucidating and is not a self-evident fact based upon an attraction that is ultimately of a chemical nature (pp. 145–146n).
Among the key words in the morality tales embedded in etiological theories are “social benefit” and “social harm,” “good and evil,” “health and illness,” “adaptive and maladaptive,” “holy and sinful,” or “mature and childish.”
These theories say that gay people are born different, but their differences are natural and intrinsic to who they are. Today, left-handedness is an apt analogy, as its presence in a minority of people is not defined as illness, although being left-handed may have disadvantages. Yet, in the past, being left-handed did lead to social opprobrium (the word sinister is derived from a Latin root connoting the left side) and historically, analogous to gay men, left-handed children were often treated as if they were abnormal and cured of their antisocial habit by forcing them to write right-handed.
The psychiatrist Edmund Bergler (1956) infamously wrote in a book for general audiences, “I have no bias against homosexuals; for me they are sick people requiring medical help… Still, though I have no bias, I would say: Homosexuals are essentially disagreeable people, regardless of their pleasant or unpleasant outward manner…[their] shell is a mixture of superciliousness, fake aggression, and whimpering. Like all psychic masochists, they are subservient when confronted with a stronger person, merciless when in power, unscrupulous about trampling on a weaker person” (pp. 28–29).
Psychopathia Sexualis also attracted innumerable lay readers who were intrigued, and sometimes felt recognized, to finally read about experiences analogous to their own. Such readers often submitted their own accounts to Krafft-Ebing and, partly for this reason, the volume grew larger in each subsequent edition (J. Kerr, personal communication, July 11, 2009).
Hirschfeld would also help some of his patients obtain early access to sex reassignment surgery (Denny, 2002).
Freud’s earlier diplomatic rebuke of Hirschfeld’s theory can be compared with his more contemptuous assessment several years later: “The mystery of homosexuality is therefore by no means so simple as it is commonly depicted in popular expositions—‘a feminine mind, bound therefore to love a man, but unhappily attached to a masculine body; a masculine mind, irresistibly attracted by women, but, alas! imprisoned in a feminine body.’….If [psychoanalytic] findings are taken into account, then, clearly, the supposition that nature in a freakish mood created a ‘third sex’ falls to the ground” (Freud, 1920, pp. 170–171).
Freud (1905), in The Three Essays, described Krafft-Ebing’s “pathological approach to the study of inversion” as being “displaced by the anthropological. The merit for bringing about this change is due to [Ivan] Bloch, who has also laid stress on the occurrence of inversion among the civilizations of antiquity” (p. 139n).
Freud also signed a 1930 petition calling for decriminalization of homosexuality in Germany and Austria (Abelove, 1993).
Rado was the founder of the Columbia Center for Psychoanalytic Training and Research in New York City.
Responding to Tripp’s challenge of Bieber’s claims of therapeutic success, rather than producing a patient, Bieber filed an ethics complaint with the American Psychological Association for impugning his “scientific honesty and credibility.” The Committee on Scientific and Professional Ethics and Misconduct found no evidence of unethical behavior (Tripp, 1987, p. 287).
In 1903, Hirschfeld surveyed 3,000 students in a technical school and found 1.5% of the students identified as homosexual and 4.5% as bisexuals (Pfäfflin, 1997).
Hooker compared 30 gay men with 30 heterosexual controls using the TAT, the Make-a-Picture-Story test (MAPS test), and the Rorschach inkblot test. Following Hooker, Siegelman (1972) compared 84 homosexual women to 113 heterosexual control and found the former “to be as well adjusted as the latter.” In a more extensive review of the literature, Riess (1980) concluded “there are no psychological test techniques which successfully separate homosexual men and women from heterosexual comparisons” (p. 308).
It should be noted that psychiatrists did not vote, as reported in the popular press, on whether homosexuality should remain in the diagnostic manual. What APA members voted on was to either “favor” or “oppose” the APA Board of Trustees decision and, by extension, the scientific process they had set up to make the determination (Bayer, 1981, p. 148).
The statement was largely based on language formulated by Richard Pillard and Lawrence Hartmann and their pioneering work on this issue within the Northern New England Psychiatric Society (Bayer, 1981).
Retrieved November 9, 2008 from http://www.psych.org/Departments/EDU/Library/APAOfficialDocumentsandRelated/PositionStatements/197310.aspx.
Prior to 1980’s DSM-III, APA published a small number of copies of the DSM. When those were exhausted, another small number was published. After running out of copies of DSM-II printed before the 1973 decision, APA printed up new copies in which “homosexuality” was replaced by “sexual orientation disturbance” (R. L. Spitzer, personal communication).
“As Frank Kameny, a ‘gay activist,’ remarked in 1973, he had no objection to the category of Sexual Orientation Disturbance since any homosexual who was distressed at being homosexual was clearly ‘crazy’ and in need of treatment by a gay counselor to get rid of societally induced homophobia” (quoted in Spitzer, 1981, p. 211).
Also see Leli and Drescher (2004).
Prince’s original term was “transgenderal” and she coined it as an alternative to “transsexual” to describe people who lived in the non-natal gender but did not have transsexual surgery. Prince’s life story and a collection of some of her academic publications can be found in Prince, Ekins, and King (2005). Prince passed away on May 2, 2009 at the age of 96.
It should be noted that there are transgender individuals who desire to live as a member of the other sex and who neither desire nor seek medical or surgical treatment to accomplish that goal.
In 1930, Lily Elbe (born Einar Mogens Wegener), who had been living as a woman for more than a decade, underwent sex reassignment in surgery in Germany under the supervision of Hirschfeld. Ebershoff (2000) has written a novel about Elbe, soon to be released as a film. Also see Hertoft and Sørensen (1978). Hoyer’s (1933) Man Into Woman is also a classic early account.
Blanchard (2003) attributes increased social acceptance of sex reassignment to five factors: (1) high-profile, attractive trans pioneers; (2) positive clinical evidence; (3) the backing of prestigious experts and institutions; (4) sympathetic media; and (5) a favorable social climate.
In line with these cultural changes, in recent years a few states have enacted laws that establish “gender identity” as a protected legislative characteristic, although it remains to be defined as a “suspect category,” a term for groups likely to be subject to discrimination (other suspect classifications include race, ethnicity, age, sex, and, less frequently, sexual orientation). This is a remarkably rapid cultural shift as the modern coinage of “gender identity” only emerged in the mainstream scientific community half a century ago (Stoller, 1964).
“The case history in the questionnaire read as follows: Since early childhood, this 30-year-old biological male has been very effeminate in his mannerisms, interests, and daydreams. His sexual desires have always been directed toward other males. He would like to be able to dress exclusively in woman’s clothes. This person feels inwardly and insists to the world that he is a female trapped in a male body. He is convinced that he can only be happy if he is operated on to make his body look like that of a woman. Specifically, he requests the removal of both testes, his penis, and the creation of an artificial vagina (all of which can, in fact, be done surgically). He also requests that his breasts be made to appear like a woman’s, either surgically or by the use of hormones (this, too, is medically possible)” (Green, 1969, p. 236).
“I trace my initial acquaintance with this new term to communication at the time with Evelyn Hooker, the psychologist now famed for her pioneering studies in Los Angeles that led to the official depathologization of homosexuality. According to a personal communication (1984) with the late Robert Stoller, there was a psychoanalytic gender identity study group at the University of California at Los Angeles (UCLA) Medical Center during this same period, the middle 1960s” (Money, 1994, p. 166). Regular attendees of that study group included Ralph Greenson, Judd Marmor, Robert Stoller, and Richard Green (R. Green, personal communication, July 6, 2009).
Money, as well as his “nurture” theory of gender identity development, was attacked in Colapinto’s (2000) As Nature Made Him. He was accused, among other things, of falsifying published data about a pair of twin boys, one of whom lost his penis at age 8 months in a botched circumcision and was later reassigned to be a girl. Money claimed the child, referred to as “John/Joan” in the case report, successfully accepted gender reassignment. In Colapinto’s book, John/Joan was revealed to be David Reimer who publicly came forward to tell his story of having rejected female assignment.
Hirschfeld (1923) is credited with coining the term transvestism in 1910 and transsexualism in 1923, although he did not define the latter in its current usage (Pfäfflin, 1997). Cauldwell (1949) is often credited with the first usage of the contemporary meaning of transsexualism (Hertoft & Sørensen, 1978; Pfäfflin, 1997).
Founding members include Jack Berger, Richard Green, Donald Laub, Walter Meyer, Jude Patton, Charles Reynolds, Jr., Paul Walker, Alice Webb, and Leo Wollman. Retrieved from A. H. Devor’s web based history, “Reed Erickson and The Erickson Educational Foundation,” at http://web.uvic.ca/~erick123/#HB, July 7, 2009.
In 2006, it was proposed that HBIGDA’s name be changed to the World Professional Association for Transgender Health (WPATH). That name change became official in 2009 after a membership ballot (H. F. L. Meyer-Bahlburg, personal communication, March 2009).
A search of the largest psychoanalytic data base, PEP-WEB (http://www.pep-web.org/), shows that the term “gender identity” only appears in the psychoanalytic literature for the first time in the 1964 Stoller paper.
The other five diagnoses are F64.1, Dual-role transvestism; F65.0, Fetishism; F65.1, Fetishistic transvestism; F65.6, Sadomasochism, and F65.6, Multiple disorders of sexual preference. See “Transvestism ‘no longer a disease’ in Sweden,” published November 17, 2008; retrieved from http://www.thelocal.se/15728/20081117/, February 15, 2009.
Other biblical passages interpreted as prohibitions against homosexuality can be found in Genesis 19, Leviticus 18:7, Judges 19, I Kings 22:46, II Kings 23:7, and I Timothy 1:9–10.
Thanks to Naomi Mark for the Biblical references as well as the information regarding their current interpretations within the orthodox Jewish community.
Boswell (1980, 1994) challenges the historical view of a linear tradition of condemnation, arguing that in different historical eras the western church tolerated same-sex relationships. Boswell (1980) and Gomes (1996) point out the selective use of biblical prohibitions by religious authority figures. Gomes (1996) and Helminiak (1994) offer alternative religious interpretations of traditional religious dogma condemning homosexuality.
The most notable organizations in this movement were the Mattachine Society for men and the Daughters of Bilitis for women. The Mattachine Review and DOB’s The Ladder would publish numerous articles debating normalizing versus pathologizing models.
Donald Webster Cory was the pseudonym of Edward Sagarin.
Stryker (2007) further notes, “Transgender people have their own history of civil rights activism in the United States, one that is in fact older, though smaller and less consequential, than the gay civil rights movement. In 1895, a group of self-described “androgynes” in New York organized a “little club” called the Cercle Hermaphroditos, based on their self-perceived need “to unite for defense against the world’s bitter persecution.” Half a century later, at the same time some gay and lesbian people were forming the Mattachine Society and the Daughters of Bilitis, transgender people were forming the Society for Equality in Dress. When gay and lesbian people were fighting for social justice in the militant heyday of the 1960s, transgender people were conducting sit-in protests at Dewey’s lunch counter in Philadelphia, fighting in the streets with cops from hell outside Compton’s Cafeteria in San Francisco’s Tenderloin, and mixing it up at Stonewall along with lots of other folks.”
Devor made these comments in a paper based on a lecture to members of the Association of Gay and Lesbian Psychiatrists (AGLP). Following a series of discussions leading to publications in its Journal of Gay and Lesbian Psychotherapy, in 2001 AGLP amended its bylaws with gender identity and transgender inclusive language (see Devor, 2002; Denny, 2002; Drescher, 2002b; Seil, 2002).
Devor (2002) cites examples of trans inclusion at the National Gay and Lesbian Task Force (NGLTF) in 1997, Parents, Families and Friends of Gays (PFLAG) in 1998, and the Human Rights Campaign (HRC) in 2001.
A notable exception is the U.S. federal government which to date does not yet offer any protection against discrimination on the basis of either sexual orientation or gender identity. In 1990 the federal government passed the Hate Crimes Statistics Act, the first time a federal statute recognized sexual orientation (Schmalz, 1992).
New York State is a notable exception.
Relationships between the transgender and the rest of the LGB community have not always been harmonious. Wilchins (1997), for example, recounts being excluded, during the 1990s, by lesbians at the Michigan Womyn’s Music Festival, a mostly lesbian organization that to this date apparently continues to exclude trans women from open participation.
The ICD is being revised for an 11th edition (ICD-11) scheduled for a 2014 release.
Retrieved November 9, 2008 from http://www.psych.org/Departments/EDU/Library/APAOfficialDocumentsandRelated/PositionStatements/199013.aspx.
Retrieved November 9, 2008 from http://www.psych.org/Departments/EDU/Library/APAOfficialDocumentsandRelated/PositionStatements/199216.aspx.
Retrieved November 9, 2008 from http://www.psych.org/Departments/EDU/Library/APAOfficialDocumentsandRelated/PositionStatements/199820.aspx.
Retrieved November 9, 2008 from http://www.psych.org/Departments/EDU/Library/APAOfficialDocumentsandRelated/PositionStatements/200001.aspx.
Retrieved November 9, 2008 from http://www.psych.org/Departments/EDU/Library/APAOfficialDocumentsandRelated/PositionStatements/200003.aspx.
Retrieved November 9, 2008 from http://www.psych.org/Departments/EDU/Library/APAOfficialDocumentsandRelated/PositionStatements/200214.aspx.
Lawrence v Texas, retrieved November 9, 2008 from http://www.law.cornell.edu/supct/html/02-102.ZS.html.
Retrieved November 9, 2008 from http://www.psych.org/Departments/EDU/Library/APAOfficialDocumentsandRelated/PositionStatements/200502.aspx.
Subsequent winners of the Fryer award were Lawrence Hartmann, MD (2007), Richard C. Pillard, MD (2008), and San Francisco Mayor Gavin Newsome (2009).
This author chaired the APA Committee on GLB Issues from 2000 to 2006 and fielded numerous questions from journalists and advocacy groups regarding APA positions on gender identity and transsexualism.
APA has issued Practice Guidelines for Acute Stress Disorder and Posttraumatic Stress Disorder, Alzheimer’s Disease and Other Dementias of Late Life, Borderline Personality Disorder, Bipolar Disorder, Delirium, Eating Disorders, HIV/AIDS, Major Depressive Disorder, Panic Disorder, Psychiatric Evaluation of Adults, Schizophrenia, Substance Use Disorders and Suicide. The American Psychological Association has recently issued a report recommending clinical approaches to gender dysphoric and gender variant patients (APA Task Force on Gender Identity and Gender Variance, 2008).
The author served as a member of that American Psychological Association Task Force.
Kelley Winters (personal communication) has recently suggested the term.
Silverstein (2009) makes a similar argument that changing sexual mores propelled by the growth of and exposure to Internet pornography will render obsolete contemporary cultural notions of paraphilias.
APA has also played a significant leadership role in past decades in reducing social stigma associated with public conversations about psychiatric illnesses like depression and anxiety, in normalizing the use of psychotropic medications, and in the growing cultural acceptance of “talk therapies.”
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Acknowledgments
The author is a member of the DSM-V Workgroup on Sexual and Gender Identity Disorders. I wish to acknowledge the valuable input I received from members of my Workgroup: Ray Blanchard, Peggy T. Cohen-Kettenis, Heino F. L. Meyer-Bahlburg, Friedemann Pfäfflin, William Womack, and Kenneth J. Zucker. Feedback from DSM-V Advisors Richard Green and Lawrence Hartmann and William Narrow, Research Director of the DSM-V Task Force, is greatly appreciated. I am also grateful for innumerable conversations with and/or helpful readings of earlier drafts of this article by Stewart Adelson, Kenn Ashley, Mary Barber, Mark Blechner, Phillip Blumberg, William Byne, James Cantor, Susan Coates, Dominic Davies, Ann D’Ercole, Ken Eisold, Todd Essig, Michael First, Sally Herbert, John Kerr, Ubaldo Leli, Vittorio Lingiardi, William Lubart, Mark Maltz, Luisa Mantovani, Naomi Mark, Scot McAfee, Benjamin McCommon, Joe Merlino, Shannon Minter, Robert Mitchell, Robert Spitzer, Cathy Renna, Chris Sekaer, Serena Volpp, Jerome Wakefield, and Kelley Winters. Some of my patients also read earlier drafts of this article and I wish to thank them for their insights as well. Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders V Workgroup Reports (Copyright 2009), American Psychiatric Association.
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Drescher, J. Queer Diagnoses: Parallels and Contrasts in the History of Homosexuality, Gender Variance, and the Diagnostic and Statistical Manual . Arch Sex Behav 39, 427–460 (2010). https://doi.org/10.1007/s10508-009-9531-5
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DOI: https://doi.org/10.1007/s10508-009-9531-5