Trans People Are Still “Disordered” in the DSM-5

“Trans People Are Still ‘Disordered’ in the DSM-5” by Julia Serano this is Chapter 34 from Julia’s third book: OUTSPOKEN a decade of transgender activism & trans feminism citation for this essay: Julia Serano, Outspoken: A Decade of Transgender Activism and Trans Feminism (Oakland, CA: Switch Hitter Press, 2016), pp. 156-161. 34 Trans People Are Still “Disordered” in the DSM-5 This chapter is a revised and updated version of two pieces that were originally posted on my blog in December 2012, after the diagnoses in the new DSM-5 had been inalized.1 An alternative revamping of these blog posts was published in the online journal Social Text in 2013.2 On the morning of December 3, 2012, I woke up to ind my Twitter feed full of article links celebrating the supposed fact that transgender people are no longer considered “disordered” according to the newly inalized DSM-5.3 The DSM gets revised every ten to twenty years or so, and diagnoses sometimes get modiied, expanded, or completely removed. The change that people on Twitter were celebrating was the fact that the previous diagnosis of Gender Identity Disorder (GID) would be formally changed to Gender Dysphoria in the DSM-5. Admittedly, the new Gender Dysphoria diagnosis is an improvement over GID for a number of reasons—Kelley Winters of GID Reform describes some of these improvements, as well as many of the lingering problems with the new diagnosis (for instance, that the biased wording of the diagnosis seems to encourage gender-reparative psychotherapies over transitioning, and renders happy and healthy post-transition trans people as “forever diagnosable” with Gender Dysphoria).4 Despite some of these drawbacks, many in the trans community seemed excited that the change in name means that transgender people are no longer literally described as “disordered” in the DSM. But the problem is that this is patently untrue. When the new DSM-5 workgroup on Sexual and Gender Identity Disorders was chosen back in 2008, virtually all of the focus was on what that committee would do with GID. This was understandable given that this was Trans People Are Still “Disordered” in the DSM-5 157 the diagnosis that trans people were generally required to obtain if they wished to access the means to physical and/or legal transition. In addition, the related diagnosis GID in Children had long been used to justify reparative therapies for gender-non-conforming children.5 While concern over GID was certainly warranted, the greater trans community gave short shrift to the other DSM diagnosis that targeted transgender people, namely, Transvestic Fetishism. And the revised version of that diagnosis remains in the DSM-5 under the new name Transvestic Disorder. Unlike GID, Transvestic Fetishism (and now its successor Transvestic Disorder) resides in the Paraphilia section, which contains several sexual crimes (e.g., pedophilia, frotteurism, exhibitionism) and a handful of other generally consensual but unnecessarily stigmatized sexual acts (such as fetishism and BDSM) that are considered to be pathologies by some psychiatrists. While the existence of a trans-speciic diagnosis in this particular section of the DSM should horrify trans people, many I have spoken with seemed either unaware of, or relatively unconcerned by, the existence of this diagnosis, perhaps because (at the time) it could not be applied to trans male/masculine folks, nor to trans female/feminine-spectrum people who are sexually oriented toward men. While I had been concerned about this diagnosis for quite some time, I became even more alarmed when I learned that Ray Blanchard had been named Chair of the DSM-5 Paraphilia subworkgroup that would revise it and the other diagnoses in that section. I sometimes joke that Ray Blanchard is my arch-nemesis (after all, every trans narrative needs an arch-nemesis!). I say this because we so drastically differ in our views on sexuality and trans people. Where I see valid gender identities, Blanchard sees psychopathologies. Where I see autonomous and consensual sexual activities, he sees “erotic target location errors” and “abnormalities.” While I have spent a decade challenging trans-misogyny, Blanchard has spent several decades psychiatrically sexualizing trans female/feminine-spectrum people, most notably via his theory of “autogynephilia.” So I was extremely concerned about what potential revisions to the Paraphilia section he might concoct. An early ominous sign came in 2009, during a presentation Blanchard gave in which he proposed signiicantly broadening the category of “paraphilia” to include: “any intense and persistent sexual interest other than sexual interest in genital stimulation or preparatory fondling with phenotypically normal, physically mature, consenting human partners”—this deinition has since been 158 Outspoken incorporated (almost verbatim) into the DSM-5.6 The term “phenotypically normal” implies that feeling sexual attraction toward anyone who is anatomically or behaviorally atypical—such as people who are diferently-sized, disabled, or gender variant, to name a few possibilities—constitutes a paraphilia (and Blanchard’s other writings support this interpretation).7 This language reinforces the cultural belief that able-bodied cisgender women and men are the only legitimate objects of sexual desire. In addition, Blanchard’s proposal asserted that paraphilias include all “erotic interests that are not focused on copulatory or precopulatory behaviors, or the equivalent behaviors in same-sex adult partners.”8 So essentially, all forms of sexual arousal and expression that are not centered on genital penetration sex may now be considered paraphilic. The DSM-5 speciically lists relatively mundane acts (by today’s standards) such as spanking, binding, and phone sex as paraphilias, and one cannot help but wonder whether masturbation in the absence of a partner might also be considered paraphilic according to this deinition.9 And in a subsequent interview, Blanchard insinuated that, if he were to “start from scratch,” he would be inclined to reclassify homosexuality as a paraphilia on the basis that it is a non-reproductive sexual activity.10 Blanchard and his supporters would likely point out that the new DSM-5 language states that a paraphilia only becomes a “paraphilic disorder” (i.e., a diagnosable mental illness) when it is associated with “distress, impairment, or harm to others”11 But as many authors have pointed out, this is basically a distinction without a diference.12 After all, one can feel distress about being unemployed or being short, but neither “unemployment” nor “small stature” are listed in the DSM. Therefore, the new DSM-5 paraphilia deinition implies that atypical and non-reproductive sexualities are disordered a priori, otherwise there would be no reason to mention them in the DSM. In addition, “distress” and “impairment” will always remain somewhat open to individual mental health professionals’ interpretations.13 For instance, if a male crossdresser is comfortable with that aspect of his person, but is distressed about his relationship (which has been in turmoil since he came out to his partner as a crossdresser), some therapists (particularly those who harbor negative views of crossdressing) might decide that the client’s distress is “the immediate or ultimate result of the paraphilia.”14 Furthermore, outside of mental health settings (and even when not accompanied by distress or impairment), the mere labeling or listing of consensual, noncriminal behaviors as “paraphilias” (e.g., in the DSM) can lead to consider- Trans People Are Still “Disordered” in the DSM-5 159 able discrimination against individuals who express them (e.g., in the judicial system, healthcare settings, the media).15 When Blanchard was recently asked about such a possibility for discrimination with regards to Gender Dysphoria or Transvestic Disorder, he lippantly responded, “how many people who make a joke about trannies consult the DSM irst?”— this ignores the countless examples of people who have cited the DSM in their attempts to invalidate trans people.16 While the expanded paraphilia deinition implies that a plethora of “paraphilic disorders” potentially exist, only eight are explicitly categorized and detailed in the DSM-5. One of these is Transvestic Disorder, and it seems to have been personally spearheaded by Blanchard, as he was the author of the original proposed revision that was announced in 2009 (and which I previously critiqued in Chapter 30).17 That initial revision was rather similar to the Transvestic Fetishism diagnosis in the previous DSM, but with the addition of “autogynephilia” (along with “fetishism”) as a speciier (meaning that one can be diagnosed as having “Transvestic Fetishism with Autogynephilia”). While the World Professional Association for Transgender Health (WPATH) repeatedly argued that there is “not enough solid empirical evidence to include these speciiers,” they nevertheless remain in the inal Transvestic Disorder diagnosis.18 But then in 2010, after the formal period for submitting input and comments to the DSM-5 committees had passed, the diagnosis was quietly revised several more times, and signiicantly broadened in the process.19 The irst of these changes was the removal of the phrase “heterosexual male” from the diagnosis, which means that it can now potentially be applied to both trans female/feminine- and trans male/masculine-spectrum people, and regardless of their sexual orientation.20 While many trans women and trans men may presume that they are somehow exempt from this diagnosis (on the basis that they do not consider themselves to be “cross-dressed”), as I explained in Chapter 30 this is not necessarily the case. The DSM-5 does not state whether “cross-dressing” is deined in relation to birth-assigned sex or self-identiied gender—presumably this is left up to individual mental health professionals to decide for themselves (and much of the previous psychiatric literature favors the former interpretation). Furthermore, the fact that the DSM-5 clearly states that an individual can be diagnosed with both Transvestic Disorder and Gender Dysphoria simultaneously (according to both diagnoses), and that Gender Dysphoria does not have an “exit clause” (meaning that post-transition trans- 160 Outspoken sexuals are still considered to have the condition), together seem to imply that trans women and trans men can be considered to be in a perpetual state of being “cross-dressed” and therefore diagnosable with Transvestic Disorder if they meet the other criteria (which are discussed below). Along with this broadening of language, many of us were surprised to ind that Blanchard also added “autoandrophilia” (i.e., “sexually aroused by thought or image of self as male”) as a new speciier to this proposed diagnosis, even though at the time, no empirical research whatsoever existed on the phenomenon.21 In a 2013 interview, Blanchard admitted that he did not believe that “autoandrophilia” even existed, and that he only proposed it in order to avoid accusations of sexism—this struck many people as an extremely cavalier way to go about crafting a psychiatric diagnosis.22 The speciier of “autoandrophilia” was ultimately not included in the inal DSM-5 diagnosis, although its broadening to potentially include “cross-dressed” people of any gender or sexual orientation still remains. Two other changes were made to Transvestic Disorder during the course of the revision process. The phrase “recurrent and intense sexual fantasies, sexual urges, or sexual behaviors involving cross-dressing” was changed to “recurrent and intense sexual arousal from cross-dressing, as manifested by fantasies, urges, or behaviors” (emphasis mine). This is a small yet positive change, as it somewhat narrows the scope of the diagnosis, making it less likely that a trans person could be diagnosed with Transvestic Disorder for simply having sexual thoughts or being a sexual person while wearing clothing consistent with their identiied gender. However, this potential improvement was completely undermined by the addition of the speciier “in remission.”23 So for instance, a well-adjusted trans woman who does not experience sexual arousal from wearing items of clothing can nevertheless receive a “Transvestic Disorder in remission” diagnosis if she reveals to her therapist that, long ago as a teenager or young adult, she passed through a phase where she was distressed about her desire to crossdress and the associated sexual arousal that she experienced. In other words, there is no “exit clause”: Once one experiences “Transvestic Disorder,” they are forever diagnosable with the condition. While one might argue that (despite its many laws) the Gender Dysphoria diagnosis does at least provide some beneit for trans people (in that it allows those of us who have adequate health insurance or inancial means to access trans-related health care), Transvestic Disorder is completely unnecessary and has absolutely no potential beneit to anyone. All it does is stigmatize Trans People Are Still “Disordered” in the DSM-5 161 gender-non-conforming behavior and sexualize transgender-spectrum people. And in a world where anti-trans forces have increasingly turned to using the specter of “sexual deviancy” to undermine our identities and call our motives into question,24 this newly expanded Transvestic Disorder diagnosis merely reinforces those eforts. Notes What follows is the Notes section for the entire “Part 3: Pathological Science Revisited” section of Outspoken: A Decade of Transgender Activism and Trans Feminism. Notes speciically for Chapter 30, “Psychology, Sexualization, and Trans-Invalidations,” begin on page 302. Notes speciically for Chapter 33, “Reconceptualizing ‘Autogynephilia’ as Female/Feminine Embodiment Fantasies,” begin on page 308. Notes speciically for Chapter 34, “Trans People Are Still ‘Disordered’ in the DSM-5,” begin on page 310. Full citations for some references may be found in the Notes for previous chapters (which is why I have included all the endnotes for Part 3). 302 Outspoken Part 3: Pathological Science Revisited 1. Serano, Whipping Girl, 115–160. 2. Serano, Whipping Girl, 253–271 and 283–306. 3. Julia Serano, “A Matter of Perspective: A Transsexual Woman-Centric Critique of Dreger’s ‘Scholarly History’ of the Bailey Controversy,” Archives of Sexual Behavior 37, no. 3 (2008), 491– 494. Dreger’s article and numerous peer commentaries are cited in Chapter 30, Notes 1, 4, and 6. 4. These critiques are compiled in Julia Serano, “Alice Dreger’s disingenuous campaign against transgender activism” (http://juliaserano.blogspot.com/2015/04/alice-dreger-and-makingevidence-it.html). 5. Julia Serano, “Debunking Psychological Diagnoses and Theories about Transsexual and Transgender People” (http://juliaserano.com/TSetiology.html). 6. Sheryl Ubelacker, “CAMH to ‘wind down’ controversial gender identity clinic services,” The Globe and Mail, December 15, 2015 (http://www.theglobeandmail.com/news/ toronto/camh-to-wind-down-controversial-gender-identity-clinic-services/article27766580/); “Support Airmative Care for Trans and Gender Diverse Kids!,” (http://www.ipetitions.com/ petition/support-airmative-care-for-trans-kids). The backlash is described (and critiqued) in Casey Plett, “Zucker’s ‘Therapy’ Mourned Almost Exclusively By Cis People,” Harlot, April 11, 2016 (http://harlot.media/articles/2582/zuckers-therapy-mourned-almost-exclusively-by-cispeople). 7. Julia Serano, “Placing Ken Zucker’s clinic in historical context,” February 9, 2016 (http:// juliaserano.blogspot.com/2016/02/placing-ken-zuckers-clinic-in.html). 30 – Psychology, Sexualization and Trans-Invalidations 1. For instance, Ray Blanchard—who has carried out research on trans people at Centre for Addiction and Mental Health (formerly the Clarke Institute of Psychiatry) for decades—when asked “Do you think that classifying transgender people as having a disorder does contribute to stigma against the trans community?” callously replied “No. I mean how many people who make a joke about trannies consult the DSM irst?”; see Laura Cameron, “How the Psychiatrist Who CoWrote the Manual on Sex Talks About Sex,” Motherboard, April 11, 2013 (http://motherboard. vice.com/blog/heres-how-the-guy-who-wrote-the-manual-on-sex-talks-about-sex). In J. Michael Bailey. The Man Who Would Be Queen: The Science of Gender-Bending and Transsexualism (Washington D.C.: Joseph Henry Press, 2003), 158, Bailey seemingly admires his colleague’s contemptuous attitude when he says, “Blanchard is irreverent, cynical, and politically incorrect . . . He has little patience for arguments about whether research is good for people (such as ‘Are homosexual people hurt or harmed by research on the genetics of sexual orientation?’).” But the example that was fresh in my mind when writing this speech was Alice Dreger, “The Controversy Surrounding The Man Who Would Be Queen: A Case History of the Politics of Science, Identity, and Sex in the Internet Age,” Archives of Sexual Behavior, 37, no. 3 (2008), 366–421, in which she repeatedly played down and dismissed trans people’s legitimate concerns about Bailey’s book and its potential ramiications (as noted in most of the peer commentaries cited in Note 4). 2. The word “transgenderism” has a long history of being used as a neutral term to describe the phenomenon of transgender people and experiences, much like “transsexuality” or “transsexualism” is the phenomenon of transsexual people and experiences. However, some contemporary Notes 303 trans activists have tried to claim that the term is derogatory, mostly due to how it has been misappropriated in recent years by trans-exclusive radical feminists (e.g., Sheila Jefreys in her book Gender Hurts; see Chapter 35) to give the impression that it refers to an aberrant political ideology rather than the phenomenon of gender variance. This is but one of many examples of the Activist Language Merry-Go-Round phenomenon that I describe in the second half of Chapter 45. I discuss the history of the word “transgenderism,” and why I feel that we should not abandon it, in Julia Serano, “Regarding Trans* and Transgenderism” (http://juliaserano.blogspot. com/2015/08/regarding-trans-and-transgenderism.html). 3. Throughout this piece, I use the term “mainstream psychology” as an umbrella term to refer to those psychological, psychiatric, and sexological discourses on gender variance, transgenderism, and transsexuality that have dominated the medical/mental health literature or have been institutionalized in our society (e.g., via the gatekeeper system and the DSM) over the last half century. I chose the word “psychology” (rather than “psychiatry”) primarily because most of the theories and diagnoses that I critique here have been invented and/or forwarded by psychologists. 4. A few examples include: Walter O. Bockting, “Biological reductionism meets gender diversity in human sexuality,” The Journal of Sex Research, 42 (2005), 267–270; Madeline H. Wyndzen, “The world according to J. Michael Bailey inside ‘The Man who would be Queen: The Science of Gender Bending and Transsexualism’,” All mixed up: A transgendered psychology professor’s perspective on life, the psychology of gender, & “gender identity disorder” (http://GenderPsychology. org/autogynpehilia/j_michael_bailey); and peer commentaries from John Bancroft (426–428), Ben A. Barres (429), Talia Mae Bettcher (430–433), John H. Gagnon (444–447), Riki Lane (453–456), Charles Moser (472–475), Margaret Nichols (476–480), Julia Serano (491–494), and Elroi J. Windsor (495–497) in Archives of Sexual Behavior 37, no. 3 (2008). 5. Zak Szymanski, “DSM controversy could overshadow opportunities,” Bay Area Reporter, May 29, 2008 (http://ebar.com/news/article.php?sec=news&article=3018). 6. The quote is a reference to Anne Lawrence, “Shame and Narcissistic Rage in Autogynephilic Transsexualism,” Archives of Sexual Behavior 37, no. 3 (2008), 457–461, which is her peer commentary on Dreger’s article (cited in Note 1). Both Lawrence and Dreger depict trans people as engaging in an irrational, mass overreaction to mainstream psychology, although Lawrence’s article is admittedly signiicantly more psychopathologizing than Dreger’s. 7. The World Professional Association for Transgender Health (WPATH) Standards of Care (SOC) is a set of guidelines for trans health providers. While early versions of the SOC were rather horriic (see Serano, Whipping Girl, 116–126), recent revisions have incorporated changes suggested by the trans community—see Eli Coleman et al., “Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7,” International Journal of Transgenderism 13 (2011), 165–232. 8. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) (Washington D.C.: American Psychiatric Association, 2000). 9. Alix Spiegel, “Two Families Grapple with Sons’ Gender Identity,” National Public Radio (NPR), May 7, 2008 (http://npr.org/2008/05/07/90247842/two-families-grapple-with-sonsgender-preferences). Throughout this chapter, I will use the phrase “cross-gender-identiied” in reference to people who identify as the gender other than the one they were assigned at birth. 304 Outspoken 10. Deinition according to Dictionary.com (http://dictionary.reference.com/browse/invalidate). 11. Reviewed in Viviane K. Namaste, Invisible lives: The erasure of transsexual and transgendered people (Chicago: University of Chicago Press, 2000); Currah, P., Juang, R. M. and Minter, S. P. (eds.) Transgender Rights (Minneapolis: University of Minnesota Press, 2006); Serano, Whipping Girl. 12. Talia May Bettcher, “Appearance, Reality, and Gender Deception: Relections on Transphobic Violence and the Politics of Pretence,” in Felix Ó. Murchadha (ed.), Violence, Victims, and Justiications (Oxford: Peter Lang Press, 2006); Talia May Bettcher, “Understanding Transphobia: Authenticity and Sexual Abuse,” in Krista Scott-Dixon (ed.), Trans/Forming Feminisms: Transfeminist Voices Speak Out (Toronto, Canada: Sumach Press, 2006); Talia May Bettcher, “Trans Identities and First Person Authority,” in Laurie J. Shrage (ed.), You’ve Changed: Sex Reassignment and Personal Identity (Oxford: Oxford University Press, 2009). 13. Further discussion of the depiction of trans people as mentally incompetent can be found in Kelley Winters, Gender Madness in American Psychiatry: Essays from the Struggle for Dignity (Dillon, CO: GID Reform Advocates, 2008). Bettcher, “Trans Identities and First Person Authority” (see previous Note) ofers an in depth philosophical analysis to explain why trans people are not typically viewed as having legitimate “irst person authority” regarding gender identity. Serano, Whipping Girl, 161–193, provides a framework to challenge many of the foundational assumptions that enable such trans-invalidations. 14. Elizabeth Ewen and Stuart Ewen, Typecasting: On the Arts and Sciences of Human Inequality (New York: Seven Stories Press, 2006); Stephan Jay Gould, The Mismeasure of Man (New York: W.W. Norton and Company, 1996). 15. Mara Mayor, “Fears and Fantasies of Anti-Sufragists,” The Connecticut Review 7 (1974), 64–74. 16. Winters, Gender Madness in American Psychiatry, 45–49. See also Madeline H. Wyndzen, “The banality of insensitivity: portrayals of transgenderism in psychopathology,” All mixed up: A transgendered psychology professor’s perspective on life, the psychology of gender, & “gender identity disorder” (http://GenderPsychology.org/psychology/mental_illness_model.html). 17. Winters, Gender Madness in American Psychiatry, 19–43. 18. Winters, Gender Madness in American Psychiatry, 71–78. 19. Winters, Gender Madness in American Psychiatry, 161–167. 20. Critiques of the gatekeeper system can be found in Anne Bolin, In Search of Eve: Transsexual Rites of Passage (South Hadley, MA: Bergin and Harvey, 1988), 48–68; Namaste, Invisible Lives, 157–234; Arlene Istar Lev, Transgender Emergence: Therapeutic Guidelines for Working With Gender-Variant People and Their Families (Binghamton: The Haworth Clinical Practice Press, 2004), 25–54; Jacob C. Hale, “Ethical Problems with the Mental Health Evaluation Standards of Care for Adult Gender Variant Prospective Patients,” Perspectives in Biology and Medicine 50 (2007), 491–505; Serano, Whipping Girl, 115–160. 21. This is a reference to George W. Bush, who while president, once said: “But I’m the decider, Notes 305 and I decide what is best.” 22. For other examples of trans women not being taken seriously by gatekeepers because they did not dress especially feminine, see Bolin, In Search of Eve, 107–108; Namaste, Invisible Lives, 163–164. 23. Paul McHugh is a psychiatrist who does not believe in sex-reassignment and who has become the “go to” authority and interviewee for those wishing to invalidate trans people—the speciic quotes cited here are from Bailey, The Man Who Would Be Queen, 206; FoxNews.com, “Critics Slam Boston Doctor Who Ofers Sex Change Treatment to Kids,” May 19, 2008 (http://foxnews.com/story/0,2933,356592,00.html). Dr. Phil is a psychologist and television host whose eponymous show ran an episode called “Gender-Confused Kids” on October 29, 2008 (http:// drphil.com/shows/show/1138). 24. Spiegel, “Two Families Grapple with Sons’ Gender Identity.” 25. For a comprehensive list of references supporting this fact, see Serano, Excluded, 308, Note 4. 26. American Psychological Association Task Force on the Sexualization of Girls, Report of the APA Task Force on the Sexualization of Girls (Washington, DC: American Psychological Association, 2007), 2 (www.apa.org/pi/wpo/sexualization.html). Note: the American Psychological Association is diferent from the American Psychiatric Association (who publishes the DSM). 27. American Psychological Association Task Force on the Sexualization of Girls, Report of the APA Task Force on the Sexualization of Girls, 27–35. 28. American Psychological Association Task Force on the Sexualization of Girls, Report of the APA Task Force on the Sexualization of Girls, 31–32. 29. Serano, Whipping Girl, 134–138 and 253–271. 30. Meyerowitz, How Sex Changed, 168–170 and 196–207. 31. Meyerowitz, How Sex Changed, 197–198. 32. Meyerowitz, How Sex Changed, 168, 202. 33. Gore Vidal, Myra Breckinridge (Boston: Little, Brown & Company, 1968). For a description of the impact that Myra Breckinridge had on popular culture (and thus, popular assumptions about trans female/feminine people) see Meyerowitz, How Sex Changed, 203–206. 34. Vidal, Myra Breckinridge, 166–197. 35. Serano, Whipping Girl, 16, 134, 261–262. 36. This case is made in more detail in Serano, Whipping Girl, 35–52 and 253–271. 37. Meyerowitz, How Sex Changed, 206. 38. I describe my own personal experiences of this in Serano, Whipping Girl, 255–259. While 306 Outspoken such experiences (which many other trans women have shared with me) are admittedly anecdotal, they are indirectly documented in the sexual harassment and abuse statistics cited in Note 39. 39. Recent reports have chronicled that up to 64 percent of transgender people have been the victims of sexual assault, and that 76 percent of transgender students had experienced sexual harassment, including unwanted sexual remarks or being touched inappropriately—see Grant et al., Injustice at Every Turn; Emily A. Greytak, Joseph G. Kosciw, and Elizabeth M. Diaz, Harsh Realities: The Experiences of Transgender Youth in Our Nation’s Schools (New York: GLSEN, 2009). The phenomenon of “walking while transgender” (discussed in Chapter 24, Note 2) is also an example of the sexualization of trans women being linked with discrimination and harassment. The interconnectedness of sexualization, discrimination, and violence is further explored in Bettcher, “Understanding Transphobia: Authenticity and Sexual Abuse”; Talia Mae Bettcher, “Evil Deceivers and Make-Believers: On Transphobic Violence and the Politics of Illusion,” Hypatia: A Journal of Feminist Philosophy 22, no.3 (2007), 43–65. 40. Serano, Whipping Girl, 126–139 and 253–271; Lev, Transgender Emergence, 132–143. 41. Reviewed in Serano, Whipping Girl, 126–139. See also Bolin, In Search of Eve, 106–120; Namaste, Invisible Lives, 163–164 and 202–205. 42. American Psychiatric Association, DSM-IV-TR, 535. As I describe in the more recently written Chapter 34, this statement is no longer accurate for the DSM-5. For critiques of the DSM’s Paraphilia section, see Charles Moser, “Paraphilia: A Critique of a Confused Concept,” in Peggy J. Kleinplatz (ed.), New Directions in Sex Therapy: Innovations and Alternatives (Philadelphia: Brunner-Routledge, 2001), 91–108; Charles Moser and Peggy J. Kleinplatz, “DSM-IVTR and the Paraphilias: An argument for removal,” Journal of Psychology and Human Sexuality 17, no. 3/4 (2005), 91–109. 43. American Psychiatric Association, DSM-IV-TR, 574–575. For critiques of the Transvestic Fetishism diagnosis, see Charles Moser and Peggy J. Kleinplatz, “Transvestic fetishism: Psychopathology or iatrogenic artifact?” New Jersey Psychologist 52, no. 2 (2002), 16–17; Serano, Whipping Girl, 127–129 and 263–265; Winters, Gender Madness in American Psychiatry, 33–43. 44. Kelley Winters, “Issues of Psychiatric Diagnosis of Cross-Dressers,” GID Reform Advocates (http://web.archive.org/web/20090510090634/http://www.gidreform.org/tf3023.html). 45. Gordene Olga MacKenzie, Transgender Nation (Bowling Green: Bowling Green State University Popular Press, 1994), 52–53, 88–89; Lev, Transgender Emergence, 141; Niklas Långström and Kenneth J. Zucker, “Transvestic fetishism in the general population: prevalence and correlates,” Journal of Sex and Marital Therapy 31 (2005), 87–95. See also Chapter 33, Note 11. 46. Robert J. Stoller, Sex and Gender: On the Development of Masculinity and Femininity (New York: Science House, 1968), 195. On the numerous occasions that I have shared this Stoller quote while giving talks on trans, queer, and/or feminist issues, it consistently evokes uproarious audience laughter. I point this out to show the huge disparity between what is taken for granted within mainstream psychology (e.g., that men’s clothing has no erotic value, or that female-assigned people cannot possibly experience any bona ide arousal via crossdressing) and what real people outside of the psychological establishment actually experience in real life. 47. Serano, Whipping Girl, 283–306. Notes 307 48. Ray Blanchard, “The Classiication and Labeling of Nonhomosexual Gender Dysphorias,” Archives of Sexual Behavior 18, no. 4 (1989), 315–334; Ray Blanchard, “The Concept of Autogynephilia and the Typology of Male Gender Dysphoria,” The Journal of Nervous and Mental Disease 177, no. 10 (1989), 616–623; 49. For example, Bailey, The Man Who Would Be Queen, 146. 50. These and many other facts and indings that together disprove Blanchard’s autogynephilia theory are reviewed in Julia Serano, “The Case Against Autogynephilia,” International Journal of Transgenderism 12, no. 3 (2010), 176–187; Charles Moser, “Blanchard’s Autogynephilia Theory: A Critique,” Journal of Homosexuality 57, no. 6 (2010), 790–809; Julia Serano, “The real ‘autogynephilia deniers’,” July 13, 2015 (http://juliaserano.blogspot.com/2015/07/the-realautogynephilia-deniers.html). 51. American Psychological Association Task Force on the Sexualization of Girls, Report of the APA Task Force on the Sexualization of Girls, 27–35. 52. Lynda Lytle Holmstrom and Ann Wolbert Burgess, The Victim of Rape: Institutional Reactions (New Brunswick: Transaction Books, 1983), 171–188. While somewhat tangential, it is worth noting that Bettcher (in “Trans Identities and First Person Authority”) points out that the denial of irst person authority plays a central role in both rape and in trans-invalidations. In the irst case, a rapist will dismiss the fact that the woman explicitly said “no” to his sexual advances, and instead privilege his own interpretation of her (e.g., arguing that she must have really meant “yes” because of what she was wearing, or supposedly communicating with her body language). Similarly, a trans-invalidator will ignore what a trans woman (or man) says about her own gender identity and experiences in favor of their own interpretation of her gender. 53. “Forced” or “rape” fantasies are fairly common in women. Anywhere between 31 to 57 percent of women report having them—reviewed in Joseph W. Critelli and Jenny M. Bivona, “Women’s erotic rape fantasies: an evaluation of theory and research,” The Journal of Sex Research 45 (2008), 57–70. The term “autoraptophilia” does not exist in the psychological or sexological literature—I invented it for the sole purpose of demonstrating how invalidating and potentially damaging it can be to deine people based upon their sexual fantasies, especially if the population in question is already routinely sexualized in the culture at large. 54. Ray Blanchard, “DSM-V Paraphilia Options: General Diagnostic Issues, Pedohebephilic Disorder, and Transvestic Disorder,” a paper presented at the Annual Meeting of the Society for Sex Therapy and Research on April 3, 2009, at Arlington, Virginia (http://individual.utoronto. ca/ray_blanchard/index_iles/SSTAR_2009_Talk_on_DSM.html). Unbeknownst to me at the time, this proposed diagnosis would undergo numerous subsequent revisions—see Chapter 34 for speciics. 55. Blanchard, “DSM-V Paraphilia Options.” I discuss this deinition (and the many problems with it) in more depth in Chapter 34. 56. Paraphilize (transitive verb): to deem a person’s autonomous or consensual sexual desires, urges, and/or orientations to be abnormal, unhealthy, or psychopathological. 57. For example, see Ray Blanchard, “Typology of male-to-female transsexualism,” Archives of Sexual Behavior 14 (1985), 247–261. 308 Outspoken 58. Bailey, The Man Who Would Be Queen. Bailey’s hypersexualization of trans women is mostly found on pp. 141–212. The “especially well-suited to prostitution” quote can be found on p. 185. Most of the trans-women-as-pathological-liars depictions can be found on pp. 157–176. 59. Discussed more in depth in Winters, Gender Madness in American Psychiatry, 107–116. 31 – Stop Sexualizing Us! 1. Jerry Springer and There’s Something About Miriam were television series that portrayed trans women in a sensationalistic and sexualizing manner (described in Serano, Whipping Girl, 37– 38), and Myra Breckinridge was discussed in the previous chapter. 2. This quote is found in Moser and Kleinplatz, “Transvestic fetishism: Psychopathology or iatrogenic artifact?” 3. He does this in Ray Blanchard and Peter I. Collins, “Men with sexual interest in transvestites, transsexuals, and she-males,” Journal of Nervous and Mental Disease 181 (1993), 570–575, wherein he coined the term “gynandromorphophilia” to describe the supposed paraphilia of being sexual attracted to trans female/feminine-spectrum people. It is also implied in Blanchard’s broadening of deinition for “paraphilia” for the DSM-5 (mentioned in the last chapter and discussed in more depth in Chapter 34), as it is clear that he does not consider trans people as “phenotypically normal.” 33 – Reconceptualizing “Autogynephilia” as Female/Feminine Embodiment Fantasies 1. Serano, Whipping Girl, 126–139 and 253–271; Winters, Gender Madness in American Psychiatry, 117–140. 2. Serano, “The Case Against Autogynephilia”—full citation in Chapter 30, Note 50; available for download at http://juliaserano.com/av/Serano-CaseAgainstAutogynephilia.pdf. 3. Moser, “Blanchard’s Autogynephilia Theory: A Critique”—full citation in Chapter 30, Note 50 (available for download at www.tandfonline.com/doi/pdf/10.1080/00918369.2010.486241). 4. American Psychiatric Association, DSM-IV-TR, 568. While the accuracy of this claim is debatable, the crucial point here is that this notion (that paraphilias are male-speciic) is what allowed Blanchard to portray “autogynephilia” as a paraphilia in the irst place: In his 1989 paper in which he irst introduces the concept (Blanchard, “The Classiication and Labeling of Nonhomosexual Gender Dysphorias”), Blanchard considers the presence of “autogynephilia” in many trans women, and the supposed lack of its counterpart in trans men, to be evidence that it must be a paraphilic impulse (under his presumption that trans women are “men” and trans men are “women”). In stark contrast, recent indings (see Note 5) indicate that what Blanchard calls “autogynephilia” is likely to be a more general sexual phenomenon associated with female/ feminine-identiied people (both cis and trans), rather than being a trans-speciic paraphilia. 5. Charles Moser, “Autogynephilia in Women,” Journal of Homosexuality 56, no. 5 (2009), 539– 547. See also Jaimie F. Veale, Dave E. Clarke, and Terri C. Lomax, “Sexuality of male-to-female transsexuals,” Archives of Sexual Behavior 37 (2008), 586–597; Noah Berlatsky, “Why Are Trans Women Penalized For Body Fantasies Everyone Has?,” The Establishment, May 16, 2016 (http:// www.theestablishment.co/2016/05/16/why-are-trans-women-penalized-for-body-fantasies- Notes 309 we-all-have). 6. Numerous examples of this are compiled in Julia Serano, “The real ‘autogynephilia deniers’.” 7. Serano, “The Case Against Autogynephilia.” 8. Harold Leitenberg and Kris Henning, “Sexual fantasy,” Psychological Bulletin 117 (1995), 469– 496; Emily Dubberley, Garden of Desires: The Evolution of Women’s Sexual Fantasies (London, UK: Black Lace, 2013). See also Berlatsky, “Why Are Trans Women Penalized For Body Fantasies Everyone Has?” 9. Blanchard’s taxonomic view of trans female/feminine people (centered on the presence or absence of “autogynephilia”) is reviewed and debunked in Serano, “The Case Against Autogynephilia”; Moser, “Blanchard’s Autogynephilia Theory: A Critique”; Jaimie F. Veale, “Evidence Against a Typology: A Taxometric Analysis of the Sexuality of Male-to-Female Transsexuals,” Archives of Sexual Behavior 43, no. 6 (2014), 1177–1186. 10. Serano, Whipping Girl, 268–269; Talia Bettcher, “When Selves Have Sex: What the Phenomenology of Trans Sexuality Can Teach About Sexual Orientation,” Journal of Homosexuality 61, no. 5 (2014), 605–620 (https://learningtrans.iles.wordpress.com/2013/12/whenselves.pdf ). 11. “Autoandrophilia” seems to have irst appeared in the sexological literature in a singular case study of a cisgender gay man; see Anne A. Lawrence, “Anatomic autoandrophilia in an adult male,” Archives of Sexual Behavior 38, no. 6 (2009), 1050–1056. For less pathologizing examples, see Tracie O’Keefe, “Autogynephilia and Autoandrophilia in Non-Sex and Gender Dysphoric Persons,” Paper presented at the World Association for Sexual Health conference, Sydney, April, 2007 (http://tracieokeefe.com/autogynephilia-and-autoandrophilia-in-non-sex-andgender-dysphoric-persons); Jack Molay, “Autoandrophilia, on women who fantasise about having a man’s body,” Crossdreamers, February 13, 2010 (http://crossdreamers.com/2010/02/ autoandrophilia-on-women-who-fantasise.html). 12. See Serano, “The Case Against Autogynephilia,” and references therein. 13. For evidence of MEFs in gay trans men, see the Discussion section of Matthias K. Auer, Johannes Fuss, Nina Höhne, Günter K. Stalla, Caroline Sievers, “Transgender Transitioning and Change of Self-Reported Sexual Orientation,” PLOS ONE 9, no. 10 (2014), e110016. “Girlfag” is a term (mostly used in online communities) to describe androphilic (i.e., attracted to men) female-assigned individuals who identify with gay men, gay male culture, and/or fantasize about being gay men having sex with other men—e.g., see Ili, “‘I am something that does not exist!’ (On queer schwulwomen, girlfags and guydykes),” Crossdreamers, September 1, 2014 (http:// crossdreamers.com/2014/09/i-am-something-that-does-not-exist-on.html), and other posts listed in Jack Molay, “A Reader’s Guide to the Crossdreaming and Autogynephilia Blog,” January 1, 2008 (http://crossdreamers.com/2008/01/readers-guide-to-confessions-of.html). 14. The “repression-mystiication” hypothesis I describe here was irst forwarded (in much greater detail) in Serano, Whipping Girl, 283-306. The “identity-defense” model is described in Jaimie F. Veale, Terri C. Lomax, and Dave E. Clarke, “Identity-defense model of gender-variant development,” International Journal of Transgenderism 12, no. 3 (2010), 125-138. While these models vary in certain respects, they both posit that the two “types” or “classes” of trans female/ feminine-spectrum people frequently cited in the psychiatric/sexological literature represent dif- 310 Outspoken ferent reactions or defense mechanisms in response to societal transphobia/trans-misogyny. The “current trend” I mention here is a personal observation based on informal conversations that I’ve shared with numerous young (typically college-aged) queer-identiied trans women. The claim (and supporting data) that FEFs (more speciically, in the form of transvestic fetishism) “may be a historically fading phenomenon” is from Larry Nuttbrock, Walter Bockting, Mona Mason, Sel Hwahng, Andrew Rosenblum, Monica Macri, and Jefrey Becker, “A further assessment of Blanchard’s typology of homosexual versus non-homosexual or autogynephilic gender dysphoria,” Archives of Sexual Behavior 40, no. 2 (2011), 247-257. 34 – Trans People Are Still “Disordered” in the DSM-5 1. The original 2012 blog posts are Julia Serano, “Trans people still ‘disordered’ according to latest DSM” (http://juliaserano.blogspot.com/2012/12/trans-people-still-disordered-according.html) and Julia Serano, “Follow up on DSM-still-considers-trans-folks-‘disordered’ post” (http://juliaserano.blogspot.com/2012/12/follow-up-on-dsm-still-considers-trans.html). This piece also draws from my 2009 piece: Julia Serano, “Why feminists should be concerned with the impending revision of the DSM,” (http://juliaserano.com/TSetiology.html#FeministingParaphilias). 2. Julia Serano, “Trans People Still Disordered in DSM,” Social Text, DSM-CRIP issue (http:// socialtextjournal.org/periscope_article/trans-people-still-disordered-in-dsm). 3. Twitter is a social media platform that allows people to share short messages (which are referred to as “tweets”). As I searched the Internet for such articles, I found that most of them were quite short, used similar language, ofered no critical analysis, nor included comments from any trans activists or advocates who had been critical of the DSM-5 revision process. It seems to me that the most likely scenario is that the American Psychiatric Association (who publishes the DSM) probably sent out some kind of press release touting their supposed “trans-friendliness,” and that several news outlets simply passed the misinformation along as “news” to their readers. 4. Kelley Winters, “Third Swing: My Comments to the APA for a Less Harmful Gender Dysphoria Category in the DSM-5” (http://gidreform.wordpress.com/2012/06/19/third-swingmy-comments-to-the-apa-for-a-less-harmful-gender-dysphoria-category-in-the-dsm-5). The diagnosis itself can be found in the “Gender Dysphoria” section of American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) (Washington D.C.: American Psychiatric Association, 2013). 5. Serano, “Placing Ken Zucker’s clinic in historical context” (and references therein); Winters, Gender Madness in American Psychiatry. 6. The deinition that appears in the text is from the “Paraphilic Disorders” section of American Psychiatric Association, DSM-5. It is identical to the one Blanchard proposed in 2009 (see Blanchard, “DSM-V Paraphilia Options”; full citation in Chapter 30, Note 54) with the exception that the phrase “physically mature” has replaced the word “adult.” The vast array of problems with this deinition are dissected in Andrew C. Hinderliter, “Deining Paraphilia in DSM-5: Do Not Disregard Grammar,” Journal of Sex and Marital Therapy 37, no. 1 (2011), 17–31; see also Charles Moser, “Yet another paraphilia deinition fails,” Archives of Sexual Behavior 40 (2011), 483–485. 7. In Blanchard, “DSM-V Paraphilia Options,” he explicitly describes sexual attraction to “amputees, paralyzed persons, physical deformities” as paraphilic, and in Blanchard and Collins, “Men with sexual interest in transvestites, transsexuals, and she-males,” he described attraction to trans Notes 311 female/feminine individuals as a paraphilia that he named “gynandromorphophilia.” Blanchard is also a co-author on a paper that argues that people who have a sexual interest in individuals outside of the age range of seventeen to forty-ive are paraphilic (see Hinderliter, “Deining paraphilia in DSM-5: do not disregard grammar”). See Chapters 42 and 43 for my argument against conceptualizing such forms of attraction as “paraphilias.” 8. Blanchard, “DSM-V Paraphilia Options.” While this speciic language does not appear in the inal DSM-5, the sentiment clearly remains—see Note 9. 9. The DSM-5 explicitly lists “interests in spanking, whipping, cutting, binding,” and “telephone scatologia (obscene phone calls)” as examples of paraphilias, and the Fetishistic Disorder diagnosis additionally includes “recurrent and intense sexual arousal” in response to various articles of clothing or footwear, or “a highly speciic focus on nongenital body part(s)” (see “Paraphilic Disorders” section of American Psychiatric Association, DSM-5). Hinderliter, “Deining paraphilia in DSM-5: do not disregard grammar,” discusses how the DSM-5 paraphilia deinition could be interpreted to deem masturbation, orgasming without genital stimulation, watching pornography, reading erotica, and sexual role play as paraphilic as well. 10. Cameron, “How the Psychiatrist Who Co-Wrote the Manual on Sex Talks About Sex” (full citation in Chapter 30, Note 1). 11. “Paraphilic Disorders” section of American Psychiatric Association, DSM-5. 12. Charles Moser, “Problems with Ascertainment,” Archives of Sexual Behavior 39 (2010), 1225– 1227; Patrick Singy, “What’s Wrong With Sex?” Archives of Sexual Behavior 40 (2011), 483–485. Both these authors point out that this sort of false distinction is precisely why the diagnosis “Ego-dystonic Homosexuality” was removed from previous DSM revisions. Hinderliter, “Deining paraphilia in DSM-5: do not disregard grammar,” additionally points out that the term “paraphilia” has a several-decade-long history in the psychiatric literature (including previous DSM revisions) to refer to a set of diagnosable mental disorders, and thus is entirely unsuitable as a label to describe nonpathological behaviors. 13. Charles Moser and Peggy J. Kleinplatz, “DSM-IV-TR and the Paraphilias: An argument for removal,” Journal of Psychology and Human Sexuality 17, no. 3/4 (2005), 91–109. 14. Charles Moser and Peggy J. Kleinplatz, “Transvestic fetishism: Psychopathology or iatrogenic artifact?” New Jersey Psychologist 52, no. 2 (2002). “The immediate or ultimate result of the paraphilia” is language that appears in the “Paraphilic Disorders” section of American Psychiatric Association, DSM-5. 15. Marty Klein and Charles Moser, “SM (Sadomasochistic) Interests as an Issue in a Child Custody Proceeding,” Journal of Homosexuality 50 (2006), 233–242; Peggy J. Kleinplatz and Charles Moser, “Towards clinical guidelines for working with BDSM clients,” Contemporary Sexuality 38, no. 6 (2004), 1, 4; Keely Kolmes Wendy Stock, and Charles Moser, “Investigating Bias in Psychotherapy with BDSM Clients,” Journal of Homosexuality 50 (2006), 301–324; Charles Moser, “A Diferent Perspective,” Archives of Sexual Behavior 37 (2008), 366–421; Serano, “The real ‘autogynephilia deniers’.” 16. The Blanchard quote is from Cameron, “How the Psychiatrist Who Co-Wrote the Manual on Sex Talks About Sex,” and numerous examples of people citing DSM diagnoses (e.g., GID) 312 Outspoken as justiication for discriminating against trans people can be found in Winters, Gender Madness in American Psychiatry, 71–78. 17. Ray Blanchard, “The DSM Diagnostic Criteria for Transvestic Fetishism,” Archives of Sexual Behavior 39 (2010), 363–372. 18. Luk Gijs and Richard A. Carroll, “Should Transvestic Fetishism be classiied in DSM 5? Recommendations from the WPATH Consensus Process for Revision of the Diagnosis of Transvestic Fetishism,” International Journal of Transgenderism 12 (2010), 189–195. 19. Between April 2010 and June 2011, there were at least three diferent proposed versions of “Transvestic Disorder”—these are all listed in Gail Knudson, Griet De Cuypere, and Walter Bockting, “Second Response of the World Professional Association for Transgender Health to the Proposed Revision of the Diagnosis of Transvestic Disorder for DSM 5,” International Journal of Transgenderism 13, no. 1 (2011), 9–12. The inal diagnosis difers somewhat from all of these, and can be found in the “Paraphilic Disorders” section of American Psychiatric Association, DSM-5. 20. Many trans activists and advocates working to eliminate this diagnosis from the DSM (including myself—see Serano, Whipping Girl, 127–128) often pointed out that the diagnosis was sexist in that it singled out “heterosexual men” (whereas people of other genders and sexual orientations were presumably free to crossdress without the stigma of pathology). Our purpose in doing so was to point out the ludicrousness inherent in the diagnosis, in the hopes that it would ultimately be removed. Frankly, it never occurred to me (although perhaps it should have) that Blanchard might use these accusations of sexism as an excuse to expand it to include even more people (he essentially admits to this in the article cited in Note 22). 21. For more on “autoandrophilia,” see Chapter 33, Note 11. 22. Cameron, “How the Psychiatrist Who Co-Wrote the Manual on Sex Talks About Sex.” 23. WPATH also opposed both the speciiers “in remission” and “in a controlled environment” (not discussed here) on the grounds that they “exclude the possibility of an ‘exit clause.’”—see Knudson, De Cuypere, and Bockting, “Second Response of the World Professional Association for Transgender Health to the Proposed Revision of the Diagnosis of Transvestic Disorder for DSM 5.” In the inal DSM-5, the speciier is listed as “In full remission” and requires one to experience “no distress or impairment in social, occupational, or other areas of functioning for at least 5 years,” which seems to imply that someone who has not experienced those issues for four years still qualiies for the full diagnosis sans speciier. 24. See for example Luke Brinker and Carlos Maza, “15 Experts Debunk Right-Wing Transgender Bathroom Myth,” Media Matters for America, March 20, 2014 (http://mediamatters. org/research/2014/03/20/15-experts-debunk-right-wing-transgender-bathro/198533); Serano, “The real ‘autogynephilia deniers’.” 35 – An Open Letter to The New Yorker 1. Julia Serano, “Op-ed: An Open Letter to The New Yorker,” Advocate.com, August 5, 2014 (http://advocate.com/commentary/2014/08/05/op-ed-open-letter-new-yorker). 2. Michelle Goldberg, “What Is a Woman? The dispute between radical feminism and trans-