My comment on the DSM-V proposals


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:


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.”


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.

DSM-V site

Sexual and Gender Identity Disorders

This is talk, not advice. See Terms of Use for details.
Posted by Andrea James on 04/20 at 04:21 AM

Brava Andrea! Thank you yet again for casting the issue with such succinct clarity and forthrightness.

Posted by  on  04/20  at  11:39 AM

Well said , very very well said Andrea. Thank you Andrea. If they ignore all the feed back this go round it won’t have been because people have not given it their all , that bubble they live in is hard to pierce, for the reasons you point to, its clear.  What is also clear is that until they become more concerned with harm reduction they break their oaths and ought to loose their licenses. ( do i smell a class action suit somewhere ? i dunno ) Mal Practice it surely is - we will not rest until this country catches up with most of the civilized world.

Word for word , once again your consumer advocacy pov shines a very bright light on what is going down and the atrocities committed upon the gender variant by this particular bunch of insulated so called scientists
- Never has the science of psychology been as soft as it is, with this bunch of self serving so called clinicians.  - thank you from the bottom of my heart. They had better read it - you boiled it down to a short memo it ought not strain their brains too too much. The opinion i am express is my own.

Posted by  on  04/21  at  07:09 AM

Well said Andrea, I hope that there may be a reconsideration by the DSM, but Money seems to be the deciding authority, not science.

Posted by  on  04/21  at  09:36 AM

I take a few issues with these comments.

Fristly, while I have mixed feelings on the inclusion of Gender Identity Disorder as a paraphilia in the first place, I take issue wiht your statement that it is being “added.” It isn’’s always being lumped in with homosexuality in previous additions. I see it being separated as a step forward in recognizing that it is a separate, diverse condition and not a variation on a theme. It’s not being “added,” it’s being revised.
Secondly, you talk about outmoded treatments, stigmatizing, and attempting to “cure” these sexual orientation variations. The abuses you mention are all experimental, highly discredited in the field, and are not among the recommended treatments or standards of care for homosexuality, gender identity disorder, or any other “harmless” sexual variance in the manual. In fact, standard treatment includes therapy to accept the self, and treatment for any accompanying depression or anxiety. No serious professional compares homosexuality to pedophilia nor does standard treatment include supressing the urge.
Thirdly, you state that non-inclusion of GID as a mental disorder would not result in medical catastrophe and lack of care; you argue that the current system rejecting a majority of patients drives people to attempt meidcal tourism and to try to acquire unsafe drugs and hormones from unlicenced dealers. You als stated that if the sexual orientations in question were not classified as “disroders,” patients could simply resort to older, more traditional means of self-treatment, and you imply this is a good thing. A simple question: how can you have it both ways? How can self-treatment without medical guidance be a good thing if this is not classified as a disorder, and a bad thing if it is? The result is still medical tourism and unsafe street drugs. Or are you proposing that a m2f individual should be happy with the old-fashioned Kleenexin-the-bra and avoid hormones altogether?
You say the U.K. does not treat these conditions as disorders and it has resulted in a happy transgender population that is adequately treating itself. I’d like to see data.
I think that activists are framing this issue poorly: they are improperly implying that things are being added to the DSM-V, when they aren’t; they are implying this is a new attack by a moral few. They are misunderstanding statistical judgements as value judgements, and hearing name-calling in it when there is none. And they are lying to their constituents in order to rally support. No matter how righteous your cause, this action is a wrong-doing.
I think the removal of the word paraphilia from the classification may be appropriate, but I think removing these particular conditions from the manual as treatable psychological conditions would be a monumental mistake. It would be a step forward in rights nad public face, but in terms of treatment, I think it is dangerous.
I have a trans spouse. She spent years trying to dress. She needed hormone therapy, not just to physically change, but to help her emotional state as well. If gender identity disorder was not classified as a mental illness, our insurance would never have even covered her clinic visit to be diagnosed, let alone her check-ups, her prescriptions, her annual liver screening. In point of fact, insurance aside, no doctor, psychological or physical, would have ever seen her in the first place, because it would not have been a clinical condition. She would have continued stuffing her bras and having suicidal thoughts; she is now happy and healthy.
What “traditional treatment” short of street drugs, or alternative medicine used in the U.K. would you propose instead?

Posted by  on  04/23  at  06:59 AM

For many years before and during my transition I was flummoxed by the inconsistent explanations surrounding transsexuality so I understand how difficult it can be to wrap one’s head around this business. But Andrea has laid it out so clearly. I’m puzzled why Alicia doesn’t get it, because clearly she and so many others do not. None of the conclusions she reaches or positions she ascribes to Andrea follow from what Andrea wrote.

It’s not something to dismiss lightly, because reaching the people who suffer most from DSM stigmatism must be as important as getting us out from under it, or at least getting it changed.

Posted by  on  04/23  at  03:14 PM

I am not “flummoxed” or “failing to wrap my head around these issues.” You seem to assume that the only reason I could possibly disagree with Andrea’s, and therefore your, point of view is a lack of intelligence, understanding, or education. That’s deeply insulting.
I understand Andrea’s letter. I understand it completely. I may not be transgendered myself, but I am married to a trans woman. This means I share a great deal in any stigmas she faces, and I also face the stigma of being labelled a lesbian, which is another of the “paraphilias” in question in the DSM-V.
I also understand that if this condition were removed from the DSM-V entirely, my spouse would have walked into a psychologist’s office six years ago and said, “I think I was born the wrong sex,” and the therapist would have said something akin to, “That’s not an illness and I can’t help you. Here, have some antidepressants.” I have no doubt I would be a widow by now.
In contrast, my spouse walked into the office, the therapist referred her to a medical practitioner, who put her on HRT, and she is now a healthy and well-adjusted individual.
I merely pointed out a few logical inconsistancies in Andrea’s argument; this implies that I neither ignored her points nor misunderstood them, merely disagreed. She states that, “most people are doing things the way we did before the rise of the ‘gender clinics.’” She also states that, “They then get drugs and surgery from exotic locales and/or unqualified providers unless they have the money to seek less risky treatment.” You can’t have it both ways. Non-medically-supervised treatment cannot be both ideal and harmful, and you cannot remove the condition from the diagnostic manual entirely and still expect for medically-supervised treatment to be the norm.
She also states that “gender clinics...have turned down as many as 90% of patients in the past....” Well, frankly, I’d like to see where she got that statistic, since statistics on people with G.I.D. (or newly-termed G.M.D.) are notoriously difficult to collect, since patients prefer to remain uncounted before, during, and after treatment, as they do not wish to be known as anything besides their identified gender. This statement additionally stands for her claim that, “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.” Again, what study? The U.K. also has one of the highest suicide rates in the world. Random statements do not a conclusion make.
Andrea states that most of the paraphilias in the manual regard sexual orientation; she further states that none of those paraphilias should really exist. Her reasoning is that sexual orientation is a genetic issue, and the remaining paraphilias involve consent, which is a legal issue and not a psychological one.
Again, I disagree, and strongly. Sexual orientation has been shown to have genetic factors, as have a number of other conditions, such as addiction. But in genetic studies, it has been shown that as few as 40% - 60% of people who exhibit the behavior in question actually possess the gene in question; the remainder don’t. This means that plenty of people exhibit these behaviors for reasons other than biology, and plenty of people possess the gene in question and never manifest the behavior. Genetics play a statistically significant role, but they are hardly the whole picture, and any psychiatrist worth even half his salt will tell you that neither nature nor nurture is entirely at work, but a union. And you can check any textbook on either general psych or abnormal psych to confirm my statements; it’s a common exercise for a psych student.
As for the other paraphilias, consent is NOT merely a legal concept. Not rapist nor pedophile, nor their victims, will agree that consent and the ability thereunto did not play an enormous role in what happened to them. The aggressor in question has a psychological complex that makes consentual sex undesirable or even impossible. This is a deep-rooted mental problem, not a legal loophole.
Where I do agree with Andrea is on the issue that orientation of sexuality or gender identity should not be a major psychosis, and should probably be re-classified away from paraphilias. Perhaps likening them to complexes associated with depression would be more accurate. But to remove them entirely would be to remove all possibility of any medically necessary, supervised treatment of any kind. A political victory, perhaps, but a medical setback.

Posted by  on  04/24  at  07:44 AM

Züker should be seeing a psychologist, not be one.

Posted by  on  04/24  at  10:54 AM

It’s too bad if Alicia feels insulted, but as they say, if the shoe fits, wear it. There is no contradiction in anything Andrea wrote. Alicia simply can’t or won’t acknowledge that she doesn’t understand the debate, and her repeated statements evidence that she really doesn’t understand the debate.

It begs the imagination that six years ago Alicia and her spouse could not have found a single psychologist who would have recognized that her spouse’s transsexuality was not a mental illness but rather a birth trait. Lots of us did, and much earlier than six years ago. They’re out there. Sometimes you have to search them out. Sometimes you have to educate them, because like most of the populace these “experts” are largely clueless. So Alicia’s broad-brush statement is flat-out wrong.

Alicia and her ilk remind me of the minority of biblical Israelites who preferred to remain slaves in Egypt rather than brave the unknown associated with freedom. She and people like her cling to a diagnosis that if not outright false is unsupported by any kind of factual data, but also dangerously stigmatizing to the entire population of transfolk. But Alicia doesn’t care about others – just herself. Such people are short-sighted and selfish. They demand the meager crumbs doled-out parsimoniously by the gatekeepers, caring little or not at all for the far greater harm suffered by the larger trans population who pay the exorbitant price that comes inextricable linked with the mental illness model. Alicia rejects out-of-hand Andrea’s suggestion for a medical model, one that is supported by an increasingly (and now, I believe) overwhelming body of scientific and clinical evidence. No, Alicia defends a psychiatric model that beyond being factually wrong actually harms transpeople. It has to go. It can be done. Unfortunately, some people will be inconvenienced as we shift to the better paradigm, but you can’t make an omelet without breaking a few eggs.

Alicia doesn’t know that last year the French Psychological Association formally rejected the mental illness model. So have the Swedes, and the Brits. Alicia, who feels herself insulted by me, doesn’t consider her demand that Andrea spoon-feed her whatever it is Alicia can’t be bothered to look-up for herself to be insulting. I do. She wants a source? Check out Press For Change and do the reading.

Posted by  on  04/24  at  03:22 PM

Debra, *you* are the one who clearly doesn’t understand *my* comments. In fact I don’t even think you’re *reading* them.

I am not saying we didn’t find help. I am saying if the world were the way Andrea (and you) would make it, we *would not* have, and that future generations might not, either. It’s a simple logical question, not a demand to be “spoon-fed.”

And I’m sure if Andrea, and you, are the intellectuals you claim to be, a little logical question should pose neither threat nor problem. Ideas worth having are also worth defending...with ideas, not with rudeness. Surely she has a simple answer that doesn’t just involve calling people names and invoking fake, self-righteous pity, a.k.a. condescension. It’s a lazy intellect that simply dismisses an opponent by saying, “Well, you’re just stupid.” And it’s an activist who will LOSE a fight if they do not realize that their opposition may have a genuine concern that also deserves address. After all, you can’t demand that your opposition take you seriously and consider you logically and as a whole person if you are not willing to extend the same courtesy.

Further evidence you’re not paying attention to anything other than your own keep spelling my name wrong.

I have done the reading. Studies from all over the world disagree. If you only do your research from websites presented by ACTIVISTS, you get cherry-picked facts and half-truths.

I’m not saying status quo is OK, or that oppression is OK; I’m saying that all options, and their consequences could be weighed.

And I think you’re too busy thinking about political gains to consider that your politics may have negative consequences.

Debra, my dear, your passion is admirable and understandable, but other people have well-thought-out opinions that they also have a right to, and a right to express, and they don’t have to agree with you to be just as right as you.

Funny thing about free speech....

Posted by  on  04/26  at  06:22 AM

Oh, and on a more positive note, I do agree with you about Zucker and those like him, Amber.

Posted by  on  04/26  at  07:07 AM
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