Below is what I submitted to the American Psychiatric Association regarding the highly problematic proposed revisions for the Diagnostic and Statistical Manual of Mental Disorders (DSM-V). Comments are due April 20.
I’m grateful to those diplomatically working on damage control regarding this ill-fated DSM-V revision. Its negative effects will harm sex and gender minorities well into the 2020s. It will particularly harm an entire generation of transgender youth and intersex people.
My comments below are not diplomatic. I am noting for the record that those responsible missed their historic opportunity. They rejected the depathologization of sex and gender minorities in 2013. The DSM-V is on track to be remembered for how the responsible parties reinforced and even expanded the pathologization of sex and gender minorities, rather than taking the courageous and historically inevitable step of depathologization.
DSM-IV editor Allen Frances observed that this group has proposed two of the most troubling DSM-V revisions. Since the actual number of problems makes an exhaustive yet brief commentary impossible, I will focus on the worst of the worst:
“Paraphilia”
The worst decision in this fiasco will be to continue treating “paraphilia” as a mental disorder rather than as a sexual orientation. It is clear that the listed sexual interests cannot be “cured” any more than those orientations currently deemed non-disordered by the APA. What should be diagnosed for treatment is not the underlying interest, but the thoughts and actions related to the interest. These are no different than any other forms of impulse control issues. Any behavior can be taken to a level that could become problematic.
Most “paraphilias” involve consensual behaviors and should not be considered disorders. Characterizing these as “erotic target location errors” or diseases echoes now-outmoded “clinical wisdom” on homosexuality. We are about to see a broad expansion of “disordered” sexualities, a doubling of the types. This is being promulgated by those who think creating new “paraphilias” through iatrogenic artifact is their bid for immortality (Blanchard), or who don’t think peddling “cures” to self-hating crossdressers and what-not (Kafka) is a direct conflict of interest with the aims of this revision.
As for nonconsensual sexual interests, they are not mental disorders, either. Consent is a legal concept, not a medical one. Arousal studies suggest that many people with interests deemed illegal never act on those interests, and in fact they may face a lifetime of silent struggle not to act on these interests because of the medico-juridical climate surrounding these interests. Diagnoses support criminal statutes and vice versa: in most jurisdictions where homosexuality is illegal, it is also considered a disease.
“Experts” leverage the moral panic about intergenerational sexuality and age of consent to get funding and job security, in the same way the moral panic about homosexuality created a cottage industry. What politician wants to say they voted against funding to “cure” pedophilia? Anyone who questions any aspect of current protocols is immediately considered sexually suspect themselves, akin to earlier moral panics about communism, terrorism, and again, homosexuality. It’s clear that doctors have an important role in preventing non-consensual sexual behavior. What they are treating is not the underlying interest, but the ability to control the impulses to act on those interests.
Unconventional sexual behavior that is consensual can reach a level where impulse control needs to be managed, but that should not be thought of as “curing” the interest itself. There’s no need to diagnose or “cure” harmless sexual interests. It’s sad to see that we are well into the 21st century, yet some experts still cling to the idea that “transvestic fetishism” or other forms of consensual kink are disorders.
“Disorders of sex development”
It was inevitable that DSD would make its way into these revisions, since the term is such a huge step backwards for sex minorities. That this disorder is intermingled with gender minorities in these proposed revisions was also inevitable. From the moment I heard the term “disorders of sex development” being bandied about by self-styled ethicists, I know this is where we would end up. Their short-sighted advocacy will now result in a generation of people with natural human variations in sex anatomy to be de facto mentally disordered as well as physically disordered. This term implies that these people have a form of retardation (developmental disorder), and we will see an uptick in “cures” for both fetuses and neonates thanks to the term DSD.
The pathologization of sex diversity through the term “disorders of sex development,” which was railroaded through in a sham “consensus,” should not be codified in the DSM. To use one of Zucker’s favorite analogies (racism), policing racial distinctions is the same thing as policing sex and gender distinctions. The DSM-V should avoid engaging in this sort of policing activity: it’s politics, not science.
“Gender identity disorder”
“Gender identity disorder” and “disorders of sex development” have at their hearts the same problem: diversity is not disorder. I have lobbied long and hard against both concepts because both DSD and GID emerged from the same mindset that sees the world through a medical lens of sickness. It has troubling overlap with heterosexist reproductive ideologies as well, where those who can’t procreate are less able or even less human.
There are some trans people, especially older trans people, who argue that disease models validate their identities and allow treatment. They want GID to stay because they fear trans health services will become less available. Some also wish GID to remain because they consider themselves disabled because of GID and collect government benefits based on this alleged disability. Their self-interests should not affect the scientific debate at hand.
Most transgender people do not seek out transition-related medical services. Of those who do, most people are doing things the way we did before the rise of the “gender clinics.” Gender clinics function as gatekeepers and thus want to keep “gender identity disorder” in place. Ritual documents like the DSM encourage regressive protocols that few trans people have the patience to endure. These regressive gender clinics like CAMH in Toronto have turned down as many as 90% of patients in the past, leaving them to seek higher-risk options like medical tourism at their own expense. They then get drugs and surgery from exotic locales and/or unqualified providers unless they have the money to seek less risky treatment. Gender clinics that engage in regressive gatekeeping result in the opposite of harm reduction by forcing patients to find care outside the established system.
My position is simple but unpopular among some: Subsidized healthcare is not a fair trade for human dignity. If the psychopathology model of gender diversity promulgated in Toronto by American ex-pats is imported to the US via the DSM-V, it will have disastrous long-term consequences. The UK has made it clear that trans people are able to have access to trans health services without the stigma of a mental illness diagnosis. Other countries have followed. It’s time to remove gender identity disorder and look at options that do not situate a disorder within trans peoples’ minds.
Inflicting trauma and shame on gender-variant children through “GIDC”
In the years I have been raising awareness about the atrocities committed against gender-variant children at CAMH in Toronto, I have come to see in Zucker what can only be called anti-intellectualism regarding philosophy of science, history of science, the sociology of theory, and other relevant academic disciplines critical to understanding how pathological science and systemic bias seep into scientific methodology. We are expected to rely on Zucker’s “clinical wisdom” rather than objective outcome data. We are not supposed to question why 5 to 30 times as many children assigned as males have historically been targeted for “curing.” We are not supposed to ask if we can talk to any of the children Zucker “cured,” just as John Money wouldn’t divulge the status of a patient against whom he committed atrocities then lied about “curing.”
Clinicians have called Zucker and his colleague Susan Bradley’s therapeutic intervention for children “something disturbingly close to reparative therapy for homosexuals” and have noted that the goal is preventing transsexualism: “Reparative therapy is believed to reduce the chances of adult GID (i.e., transsexualism) which Zucker and Bradley characterize as undesirable.” Author Phyllis Burke wrote, “The diagnosis of GID in children, as supported by Zucker and Bradley, is simply child abuse.”
Conclusion
When Zucker was in charge of a similar ritual document for the American Psychological Association, he and his team cheerfully ignored a wide range of suggested changes. Between that farce and this process, I have lost faith in these empty gestures toward public commentary. So I’ll end here for now, since I am not confident in this process or its outcome.
We see these people ignoring legitimate scientific objections and continuing to use unscientific and inaccurate terminology like “shemales” (Blanchard) and “homosexual transsexual” (Cohen-Kettenis), both of which are considered outrageous slurs outside of the bubble in which these alleged experts live. Science and its terminology evolve with understanding, and if these experts are unable to evolve their terminology and thinking as well, they should not be placed in positions of authority.
Let’s hope we don’t have to resort to stunts like Dr. H. Anonymous to make our points. I doubt even someone of his fortitude could overcome all the problems with this proposed revision.
Andrea James
April 2010
Note: These views are mine only and do not necessarily reflect the views of any other organizations or individuals. If you require footnotes, I am happy to provide them after the fact, but I don’t really feel like taking the time after similar efforts were cheerfully ignored by Zucker and company on the 2007 American Psychological Association Task Force.
