By Julia Serano
The Diagnostic and Statistical Manual of Mental Disorders (DSM) has been called the "bible of mental illness" because it lists and defines all of the "official" psychiatric diagnoses according to the American Psychiatric Association. The DSM is in the early stages of undergoing its 5th major revision; each previous revision has seen the total number of mental disorders recognized (some might say invented) by the APA greatly increase. Last year, trans activists were particularly concerned to learn that Ken Zucker and Ray Blanchard had been named to play critical lead roles in determining the language of the DSM sections focusing on gender and sexuality, especially given that these researchers are well known for forwarding theories and therapies that are especially pathologizing and stigmatizing to gender-variant people.
Blanchard has recently presented some of his suggestions to revise the "Paraphilia" section of the DSM. In the past, this section has generally received little attention from feminists, as it has been primarily limited to several sexual crimes (e.g., pedophilia, frotteurism and exhibitionism) and a handful of other generally consensual but unnecessarily stigmatized sexual acts (such as fetishism and BDSM) that are considered "atypical" by sex researchers. However, there are two aspects of the proposed Paraphilia section revision that should be of great concern to feminists, as well as anyone else who is interested in gender and sexual equality.
Expanding "Paraphilia"
First, Blanchard is proposing a significant expansion of the DSM's definition of "paraphilia" to include:
"any intense and persistent sexual interest other than sexual interest in genital stimulation or preparatory fondling with phenotypically normal, consenting adult human partners."
The first concern here is the term "phenotypically normal" (meaning "normal" with regards to observable anatomical or behavioral traits). Thus, according to this definition, attraction to any person deemed by sex researchers to be "abnormal" or "atypical" could conceivably be diagnosed as paraphilic. So, do you happen to be attracted to, or in a relationship with, someone who is differently-abled or differently-sized? Or someone who is gender-variant in some way? Well congratulations, you may now be diagnosed with a paraphilia!
Seriously.
Blanchard and other like-minded sex researchers have coined words like Gynandromorphophilia (attraction to trans women), Andromimetophilia (attraction to trans men), Abasiophilia (attraction to people who are physically disabled), Acrotomophilia (attraction to amputees), Gerontophilia (attraction to elderly people), Fat Fetishism (attraction to fat people), etc., and have forwarded them in the medical literature to denote the presumed "paraphilic" nature of such attractions. This tendency reinforces the cultural belief that young, thin, able-bodied cisgender women and men are the only legitimate objects of sexual desire, and that you must be mentally disordered in some way if you are attracted to someone who falls outside of this ideal. It's bad enough that such cultural norms exist in the first place, but to codify them in the DSM is a truly terrifying prospect.
Another frightening aspect of Blanchard's proposal is that any sexual interest other than "genital stimulation or preparatory fondling" is now, by definition, a paraphilia. In his presentation, he claimed that paraphilias should include all "erotic interests that are not focused on copulatory or precopulatory behaviors, or the equivalent behaviors in same-sex adult partners." Copulatory is defined as related to coitus or sexual intercourse (i.e., penetration sex). So, essentially, all forms of sexual arousal and expression that are not centered around penetration sex may now be considered paraphilias.
So, do you and your partner occasionally role-play or talk dirty to one another over the phone? Or engage in arousing play that is not intended to necessarily lead to "doing the deed"? Do you masturbate? Do you get a sexual charge from wearing a particularly sexy outfit or performing any act that falls outside of "genital stimulation or preparatory fondling"? Well, then congratulations, you can be diagnosed with a paraphilia!
"Transvestic Disorder," Gender Inequality and the Sexualization of Feminine Gender Expression
Blanchard also wants to retain (with minor tweaking) the "Transvestic Fetishism" diagnosis from the previous DSM Paraphilia section; the new diagnosis is to be called "Transvestic Disorder." Like it's predecessor, it applies to "heterosexual males" who experience "recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving cross-dressing." As Kelly Winters of GID Reform Advocates points out:
"Curiously, women and gay men are free to wear whatever clothing they chose without a label of mental illness. This criterion serves to enforce a stricter standard of conformity for straight males than women or gay men. Its dual standard not only reflects the social privilege of heterosexual males in American culture, but promotes it. One implication is that biological males who emulate women, with their lower social status, are presumed irrational and mentally disordered, while biological females who emulate males are not. A second implication stereotypically associates femininity and cross-dressing with male homosexuality and serves to punish straight males who transgress this stereotype."
The "heterosexual male" nomenclature should also be of concern to many trans women, as Blanchard (and like-minded psychologists) routinely mis-describe lesbian-identified trans women as "heterosexual male transsexuals" in the medical literature. Since the Transvestic Disorder diagnosis does not explicitly exempt transsexuals, then a queer-identified trans woman (such as myself) could theoretically be diagnosed as having "Transvestic Disorder" any time that I have *any kind* of sexual urge while wearing women's clothing. Since I wear women's clothing pretty much every day of my life these days, my sexuality would presumably be considered perpetually transvestically disordered according to this diagnosis.
Kelley Winters has also written at length about how the vagueness of Transvestic Fetishism/Disorder wording enables the diagnosis of individuals who do not experience any sexual arousal in association with wearing women's clothing. She argues:
"It serves to sexualize a diagnosis that does not clearly require a sexual context. Crossdressing by males very often represents a social expression of an inner sense of identity. In fact, the clinical literature cites many cases, considered diagnosable under transvestic fetishism, which present no sexual motivation for cross-dressing and by no means represent fetishism."
We live in a heterosexual-male-centric culture, where femaleness and feminine gender expression are routinely sexualized, and where sexual symbolism is projected onto women's clothing. For this reason, people (including psychologists such as Blanchard) regularly sexualize trans women, male crossdressers, and others on the trans feminine spectrum, and attribute sexual motives to us, even when no such motives exist. Thus, the Transvestic Disorder diagnosis both sexualizes people on the trans feminine spectrum, while simultaneously reinforcing the societal sexualization of women and feminine gender expression more generally.
Sexism and the DSM Paraphilia Section
Proponents of the DSM Paraphilia section would argue that paraphilia diagnoses are only applicable when the individual in question exhibits "significant distress or impairment" over their sexual urges. This ignores the fact that many happy and healthy individuals are sometimes diagnosed with paraphilias. Further, the mere fact that Transvestic Fetishism, Masochism and Sadism have been listed in the DSM (under the same category as several nonconsensual sexual crimes, no less) is regularly cited by those who wish to delegitimize or legally discriminate against male crossdressers and people who practice consensual BDSM. Labeling any form of gender or sexual expression as a "mental disorder" is necessarily stigmatizing and ignores the vast amount of gender and sexual variation that exists in the world.
It was not that long ago that Homosexuality and Nymphomania were listed in the "Sexual Deviation" (which was later renamed "Paraphilia") section of the DSM. They were removed, in part, due to public pressure, as both diagnoses only served to reinforce cultural double standards (i.e., the idea that same-sex attraction is less legitimate that heterosexual attraction, and that women should exhibit less sexual interest than men, respectively). We have a word to describe double standards that exist with regards to sex, gender or sexuality--it's called sexism.
The proposed revision of the DSM Paraphilia section is sexist in numerous ways. We, as feminists, should fight to have *all* forms of sexual expression that occur between consenting adults removed from the DSM entirely. And we should especially fight for the removal of "Transvestic Disorder" on the grounds that it sexualizes feminine gender expression and reinforces rigid cis-hetero-male-centric gender norms.
What you can do to help:
1) raise awareness about this issue in feminist circles.
2) contact the American Psychiatric Association and share your concern with them.
3) if you live in the San Francisco Bay Area, please come out to the protest of the upcoming American Psychiatric Association conference on Monday, May 18th between 6:00pm to 7:30pm in front of the Moscone Center. This protest will focus primarily on the removal of the trans-focused DSM diagnoses Gender Identity Disorder (GID) and Transvestic Disorder. While the GID diagnosis is of great concern to trans activists (including me), I did not discuss it here because it is not listed as a Paraphilia, and because (to the best of my knowledge) no information has been released regarding proposed revisions to GID in the next DSM.
For more information about the Paraphilia section of the DSM, I encourage you to read DSM-IV-TR and the Paraphilias: An Argument for Removal by Charles Moser and Peggy J. Kleinplatz.
For more info about "Transvestic Disorder," check out Transvestic Disorder and Policy Dysfunction in the DSM-V by Kelly Winters. (Also, her blog and book provide excellent critiques of both the Transvestic Disorder and GID diagnoses).
Julia Serano is an Oakland, California-based writer, spoken word performer, trans activist, biologist, and author of Whipping Girl: A Transsexual Woman on Sexism and the Scapegoating of Femininity.
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They shouldn't identify a behavior as a psychiatric disorder unless it is a disorder. How can there be a problem if the person involved doesn't believe it is a problem, doesn't report it as a problem, and has no negative repercussions from the behavior that don't arise from societal intolerance?
By the way, is there diagnostic criteria for intolerance in the DSM?
I think it would be hard to label what is causing distress. Are the paraphilias distressed because of how they feel about their identity, or does the distress stem from how they are treated by our society?
I would lean toward the latter, in which case, as you state, people in our society should be diagnosed with intolerance and hate, and the paraphilas shouldn't be diagnosed at all.
What about Antisocial Personality Disorder, Schizophrenia, or Sexual Sadism? Many, probably most, people with these disorders have absolutely no problem with their behaviors. Are you saying that people with these disorders should not be diagnosed and given medical treatment?
I think that the "has no negative repercussions from the behavior that don't arise from societal intolerance" qualifier would cover these sorts of disorders, since there are obvious negative repercussions (even if the person experiencing the disorder doesn't necessarily see them or view them as problematic).
i think what needs to be emphasized is that informed consent between adults should never be stigmatized, no matter how "unnatural" their actions may seem to mainstream.
[ sarcasm ] I think the term they use for that is "professionalism" [ / sarcasm]
From their perspective, expanding the DSM is all about the utilitarian need to help people get treatment. If it's in the DSM, you get insurance coverage. If not, well, you're SOL. If the paraphilia is causing "significant distress," to the point where the person wants treatment so that they can date "normal" (ugh, "normal") people, they're in luck! The magician, I mean, shrink, can wave his magic Freudstick, use some DBT and MAYBE some EMDR (in the case of trauma) and the patient can go on to lead a perfectly happy (?) and boring lovelife.
Or, you know, he could just accept his love of transmen who also happen to be Little People. It's a small dating circle, I know, and many of them find him a little weird and objectifying, but really? Is it so wrong?
On the other hand, if he feels perfectly fine with himself and his sexuality, a competent doctor would not treat him for a psychological disorder. Suffering, to most shrinks, is the key implication of disorder. Why fix a psyche that isn't in pain? That's akin to putting a patient through chemo even though you found the tumor benign.
It makes me wonder how many gay people sought treatment for their gayness after they found out it was a disease. I wonder if it prolonged suffering, whereas these individuals would have come to acceptance sooner.
See, this is why I find abnormal psychology to be nothing more than an amusing form of pseudoscience. Pathologize Asian fetishes. Now THOSE guys are creepy. They need help, if not incarceration.
On the plus side, I believe they're making some positive changes for eating disorder criteria. This means, of course, that if you suffer from (as of now) "subclinical" anorexia or bulimia and have had trouble receiving treatment, that may be soon to change.
I've been thinking about it, and what I've just written could be true of child molesters and rapists as well. I'd like to add that it shouldn't be identified as an issue if it doesn't result in negative repercussions to any person directly involved.
I can see how this diagnosing thing is complicated, which is why I would hope they would err in favor of not stigmatizing behavior unless it was absolutely necessary.
for the disorders that generally involve nonconsenting individuals, the criteria is set up that either the individual have distress/impairment because of their urges, OR have acted on it. now obvi there are still problems with the paraphilia "diagnoses". for example, pedophilia must be "recurrent" (!!!!) in the current DSM-IV-TR criteria.
i strongly recommend anyone concerned over the paraphilias, GID, etc. in the DSM to go read it. don't be intimidated by its huge size, the section is pretty miniscule. heck, take a few minutes to read it in a bookstore or something. but def. read the WHOLE section, not just skim over the criteria listings.
i def. have problems with some things in the DSM, and i am a clinical psychology grad student. so to everyone out there, please don't put all psychologists/therapists/counselors in the same "intolerance" bag.
Ok. Never mind my comment then.
As a gender-variant person, the new DSM has me literally scared shitless. I am terrified of being denied care because I am bisexual, or because I do not fit a strict definition of the female gender. Or because I DO wear a dress before starting hormones. Or because someone looks down on me and dismisses my needs based on their disturbing views on human psychology.
The current DSM-IV is tough enough on transwomen (forget transmen, they don't exist according to many licensed doctors and therapists) and puts a rigorous, terrifying maze between them and the care they need.
I am almost ashamed to admit but, but these problems, and more importantly the intolerance & ignorance I see in the medical and psychological community has kept me from seeking the care I need for a few years now. How can I trust someone who might dismiss the very person I am as a mere "paraphilia?" Blanchard et. al. are dangerous and scare me.
There are, thank goodness, some therapists and doctors and other professionals that look at the current GID diagnosis and treatment as downright stupid and dangerous, and some have spoken out against the proposed changes for DSM-V. But alas this sort of marginalization by the APA just add fuel to the intolerance fire. No insurance company will pay to treat you for a sexual fetish, after all!
I asked one of my professors, who is a psychologist, if a therapist would diagnose Gender Identity Disorder to a transgender client who sought therapy for something else (e.g., depression, anxiety, sleep problems). She said that therapists most likely wouldn't diagnose the GID to someone who already identifies as transgender. That makes sense, since there's no gender identity disorder in anyone who has already formed a gender identity, whether they're trans or cis. Psychologists and counselors are also ethically bound to choose the least stigmatizing diagnosis.
If you really need therapy, you're going to have to try harder than most people to find a competent therapist. It sucks, but most counselors don't have experience with trans clients. If you can't find a competent therapist in your area, it's possible to do counseling over the Internet or phone. There are some security issues with this, of course, so you have to make sure precautions are taken so that your confidentiality is ensured.
Thank you for the information. I have spoken with two therapist who were very experience with LGBT clients, especially transgender youth like myself (at the time... I'm and adult now). But sadly the other therapists and doctors I spoke with were, frankly, dangerously bad. Two said such damaging things... well I began to self-harm again. One of these professionals was worse than Blanchard. He literally diagnosed me out of the DSM-IV, checking off from the list of GID symptoms. It was humiliating and dehumanizing... and he decided since I didn't act female enough, I wasn't transgender.
Oops, sorry. Hit submit by accident.
Anyways, my insurance wouldn't cover hormones or anything like that at the time, and I have no insurance now, partially because I am trans... no family to support me and help pay the medical bills you see.
This is not true, at least in all cases. In many instances, it is necessary to have a diagnosis of GID to begin hormone therapy. Many doctors require a letter from a therapist with this diagnosis before they will allow you to progress with transition. It doesn't matter if your gender ID is causing you distress or not, nor does the diagnosis grant you insurance coverage. So in many cases, it is only a pathologizing step that must be taken to move forward with transition.
"How can I trust someone who might dismiss the very person I am as a mere "paraphilia?"
A competent practitioner won't do that; she'll recognize that your gender variance is a positive, essential part of your identity and she'll support you through your transition and beyond. But, like an accountant or plumber or anything else, not all shrinks are competent, or use the problematic-but-important DSM in a responsible manner. Like you, although for a different reason, I have experienced sadists in psychiatrists' clothing. But it's truly worth the search for a good one.
Like many other people have suggested, the DSM is an expression of psychological normality. While the normal is culturally constructed (so is the empirical methodology used to ascertain it), the book is still a valuable tool, and so is the paraphilia classification. Politically correct or not, paraphilias often point to underlying issues. There are people who express preferences for disabled or fat people because they are predators and find the former groups easy to victimize, or because they have poor self-esteem and see those people as less-than-human and therefor more accessible. A would-be trans person may be auto-oppressed and come in with severe depression related to being born the wrong sex; without a "Transvestitic Disorder" co-morbidity, he or she may never get properly diagnosed and may never be able to live as the right sex, which may lead to suicide.
I haven't read much of the DSM so I can't comment on whether or not the text presupposes disorder with paraphilias. Since it seems from the OP that they do, Borea, and everybody, do you think there is another way to class paraphilias so that they're still useful?
As it's been said elsewhere, one problem with the DSM is it's created by a community of people trying to make money. Our health system needs to NOT be a for-profit system, for starters.
As for making parahpila diagnoses useful tools... well, perhaps if it is seen as a more general symptom for deeper problems? Which seems to be what you're suggesting.
Thanks for writing this and bringing the issues to light. I agree that desire is only a problem if it results in harm to anyone directly involved. And, I think the DSM-V should bulk up on its pathologization of issues related to intolerance and needs to enforce social controls.
Yikes, so now trans women are "woman-man transformers" and trans men are "man fakers?" WTF?
The contents of the DSM should concern all human beings. It was scary and unscientific enough before. It sounds like they've found a way to make it even more disturbing, irrational, socially irresponsible, and needlessly pathologizing.
Damn, as someone who already counts as hopelessly disordered under the DSM-IV, I don't know how I'm going to sleep tonight.
This is a fantastic piece, thank you!
[This comment has been deleted]
Ahhh, I was wondering when the transphobia would show up in this thread.
this is a tremendous piece! thank you for writing it!
and while i have a whole host of thoughts (mostly very angry ones) running through my head in response to the proposed revisions, i just wanted to point out that all deliberations regarding revisions to the DSM are happening behind closed doors. for the first time in history contributors were required to sign a nondisclosure agreement. the NYT did a piece about it late last year (see link below).
imagine: a group of overwhelmingly white, heterosexual, older males are currently getting together to figure out what precisely is wrong with the rest of us.
http://www.nytimes.com/2008/12/18/health/18psych.html?pagewanted=2&_r=1&partner;=permalink&exprod;=permalink
A "Freud-stick" joke here would be facetiously appropriate here... I'll refrain... =)
(@Tsunade)
The biggest problem with the DSM is right on the cover: American Psychiatric Association. The manual is written by a group of people who have the least interaction with clients. There are very few psychologists, licensed professional counselors, and clinical social workers who put their two cents in, and these are the professionals who have the most contact with counseling, assessing, and diagnosing people with mental disorders.
The Paraphilia section has to be revised, but not in a way that classifies more people as sexual deviants. As for Gender Identity Disorder, it's difficult for me to say whether or not it should be taken out. For insurance purposes, it's good that it's in there, since it's the only way that an identity problem can be covered by insurance. But the stigmatization sucks. I don't like the idea of transgender people being labelled as deviant for the rest of their lives.
I'm just...I could say stunned silent, but I don't know if that's quite right.
I guess part of me has always thought persons who are supposed to be analytical about the behavior and thought processes of humans might take into consideration what promotes "norms" in our culture and consider things accordingly...
At any rate, thanks for bringing this to attention. I'll be looking into it and contacting the APA.
I thought it would be useful for you guys to hear from the perspective of a graduate psychology student who worrys about this very topic; considering the fact that I am seeking a sub-speciality in sex therapy. Throughout my graduate years I, along with my fellow students, have been torn with regards to the DSM. Even though it organizes disorders and diagnosis in an easy manner it does have its limitations including the above topic of "paraphilias".
To provide some self disclosure I, myself, has a paraphilia that would not doubt throw the A.P.A. and Freud for a loop (I'm a devotee - meaning I am attracted to individuals with physical disabilities). Does this label mean that my sexual interests differ from the norm? Yes. Does this label automatically mean that I have a disorder? No.
Thankfully, I can assure many of you on here that from my experience at the school that I attend that with each year us psych students are being exposed to and learning more and more about all the variants of human sexuality including differences in sexual orientation and gender identity. This is not to say that there will not be therapists out there that will be quick to diagnose one of us with a disorder just because the DSM tells them to but I like to think positive on this subject from what I have observed with my peers in stating that sexual diversity is becoming more understood with each generation of psychology students.
I appreciate your reassurances and your mature, enlightened attitude. But the troubling thing is most of the people deciding the medical future of people like me are older, more close-minded (and sometimes downright dangerous) individuals. I'm sorry to say waiting until a new generation in charge isn't satisfactory for me or many other gender-variant people.
Out of curiosity though, what happens when a student expresses disagreement with an "elder" on such a subject as GID or the DSM in general?
People who are opposing the proposal to expand the definition of paraphilia in the upcoming revision of the DSM over the idea that it's going to marginalize/label those people with attractions or desires having to do with transvestism, cross dressing, etc., have no idea what it is like to live with someone who is truly sick, who sees trans individuals, amputees, and disabled people as only sex objects with no humanity under the surface, who spends hours and hours a day looking at pornography of these people, who take it to work on hand held computers, and let it destroy their own, real life relationships. That is the kind of thing the APA is talking about in revision, not about diagnosing the average transgender individual, the average cross-dresser, or people who are more attracted to them, or even the people who happen to find people with disabilities attractive because of the underlying strength it takes to get through the world with disabilities on top of everything else.
There is a huge difference between people who aren't of the societal norm, yet are living full and happy lives, and those who are living with a mind that is obsessed 24/7 with seeing certain human beings as nothing but sex objects, and engaging in dangerous activities with total strangers of that type to fulfill their need, while never once talking to or seeing any TG, CD, or amputee as anyone human with a personality of their own.
What the APA is proposing is not as sinister as it sounds- perhaps the wording could be better. But when you've known and been friends with TG, CD, and others outside the so-called norm, and then you deal with someone who's sickness sees those communities as less than human, maybe you will understand where these criteria come from, and why this revision is actually necessary.
This isn't about squashing sexual and gender diversity. It's about illness.
I think the thing that makes it difficult to give the APA the benefit of the doubt is the fact that Blanchard and Zucker were selected to lead the work. They are not particularly open-minded to the trans community and tend to diagnose any trans-related behavior as a paraphilia.
Yep. Zucker practices reparative therapy for transgender kids, which should be more than enough reason to keep him far, far away from any major decision-making involving the welfare of trans people.
I honestly do hope you are indeed correct, krc. But obviously people like have major doubts. The wording isn't just poor, it's downright worrisome. Looking at how Blanchard, et. al. talk about transmen is a good example. They talk about these people with terribly dehumanizing language. As far as my understanding goes, Blanchard is part of the camp that thinks many trans-peoples' desires for gender reassignment surgery stems for a sexual desire, a fetish. This dehumanizes transpeople, allows people to treat them as deviants. I really, REALLY hope this understanding of mine is wrong. But currently Blanchard & Co. want to put some very dangerous language into the DSM-V.
For example, the current wording for GID is used by "ex-gay" therapists to torture "the gay" out of their patients... force them back into traditional gender roles, thus curing their lgbt patients of their "gender identity disorder."
This is what we are worried of. People using and abusing bad wording in a document like the DSM to justify their mistreatment of lgbt people.
OK, but define "societal norm." To many, many people, anyone who doesn't perform gender properly and adhere to the binary is abnormal. And a lot of psych professionals feel this way too.
And if this is only concerned with those who have such an extreme obsession that they can't function properly (i.e. hold down a job and pay their own bills, this is capitalism after all) then why is the wording so vague that it includes anyone who varies from the "norm"? Where's the wording about "obsession" and "can't leave the house" and "can't maintain real-life relationships" etc?
hi krc, i replied to your comment in the main comments section (see below), but i thought i'd reiterate it here:
First off, I disagree with the last part of your statement. If you read Blanchard’s research papers (which sadly, I have), you’ll see that he does view crossdressing and people attracted to transgender people as paraphilic.
Second, the habits that you described for the supposedly “truly sick” people (watching porn, seeing people only sex objects, having their sexual obsession interfere with their relationships) also apply to many cis heterosexual men who view cis women that way! The only reason that one is listed as a paraphilia while the other is not is because “phenotypically abnormal” people are viewed as sick and undesirable in the first place.
-julia
Wouldn't addiction to porn be listed as a paraphilia anyway? If not then I guess it should for consistency, no matter whether the type of porn a person might be addicted to fits some "norms" or averages or not.
If paraphilias are defined as any sort of desires deviating from the norm, then everyone is going could be diagnosed with a paraphilia. I don't know anyone that falls in the "normal" category in every single aspect of sexual desire or behavior.
I'm curious if anyone here has read Julia Serano's comments about medical diagnosis to get hormones/surgery to transition. Borea has most indicated experience here, but never said specifically trans. But, if you need a diagnosis to get insurance to try and cover your medicine/therapy(I don't know how well that ever works out in practice) how do you balance that with not stigmatizing?
I am trans and identify as such, but beyond speaking with various therapists (of various schools of thought and indeed some were psychiatrists, some were therapists, others psychologists, etc.) I have not had any experience with the medical community and its treatment of trans-people, mostly because I don't have any health insurance. I do know a few trans people, both with and without insurance, who have gotten hormones, GRS, etc. As far as I know, getting a diagnosis, even from a psychiatrist is NO guarantee of your insurance company covering anything. They tend to go with whatever can save them the most money, after all. And so they act/believe transitioning because you are transgender is very much an optional choice.
As to how they can "treat" us without dehumanizing us... I'm not sure. I personally support GID staying in the DSM. It would be impossible for anyone anywhere in the States to get treatment for GID unless they could pay for it out of pocket. (Some companies have health plans that cover it, and apparently once in a while an insurance company would cover it.) There are some specific ways the APA can change the language regarding GID, but it'd take a long while to get into specifics. Suffice to say it'd be hard to make it "intolerant-proof" and "idiot-proof" if you will... but possible.
The issue of the DSM highlights a problem with coming up with a consistent definition of what transgender means. If identifying as trans is, as I believe it should be, considered a natural condition, one possibility in a wide spectrum of gender idenities, one which does not need to be "fixed," then simultaneously identifying it as a disorder is deeply problematic. As an adult, I should be allowed to express my gender identity any way I wish. However, if I wish to change my physical sexual characteristics (particularly to have SRS, or to legally take hormone replacement therapy), I have no choice but to go through a doctor of some sort (be it therapist, endocrinologist, surgeon), and these require a medical diagnosis, which suggests that there is something physiologically "wrong" with me. Now, I could take the view that perhaps sex-change medicine should be considered in a manner consistent with cosmetic surgery--that is, it would be entirely elective, requiring no diagnosis of a medical problem, only a voluntary desire to change something. Problem with this is, I would be hard pressed to argue that most examples of elective cosmetic surgery should be covered by insurance. However, if somebody feels that they are suffering due to an incongruity between their physical body and their gender identity (what I think at least used to be called gender dysphoria), then I could see the existence of a medical condition. So, at what point do we define trans people as physiologically ill and when is it a natural, acceptable-as-is condition? And should it not be possible for trans people without a dysphoric diagnosis still to choose to change their physical body? Maybe the DSM sorts out these distinctions and I'm not aware of it? Any thoughts?
Insurance coverage for SRS? How elitist is that? Seriously, only those who come out later in life and who have attained ranks of status tend to have health insurance.
I recently saw some seriously appalling statistics on transgender/transsexual unemployment and under employment in San Francisco that suggested a close to 50% unemployment.
I got SRS nearly 40 years ago and I am finally looking forward to getting health insurance from the government when I reach 65. Other than a half dozen or so years of my adult life I have been either denied health insurance, offered it at more than I could afford or not given it by employers.
The DSM Diagnosis and mandated therapy/guidance should more appropriately be called the Psych. Profession Personal Income Enhancement DSM entry.
Few of us need their services. We could be better served if they were to function only as screeners and not with mandatory counseling.
What they do is indoctrinate in their pet theories of our having a mental illness instead of an innate physical condition.
Suzy Q is sadly exactly right. I'm seriously thinking of moving to Canada. Because the decade or so it would take me to get what limited health coverage they have for transitioning (they cover hormones or SRS, but no both... I think. I can't remember off the top of my head.) because that is FASTER than it would take me here in the States.
You have to remember: you CAN discriminate against a trans-person in the USA. Insurance companies and companies hiring use this to their advantage all the time. Even if they get sued, how likely is a lgbt-friendly judge going to rule on the case?
So, in other words the DSM-IV sucks as far as GID goes, but the DSM-V could be a lot worse if Blanchard & Co. have their way.
(Didn't want to get too off topic there, hence the last comment.)
Hi everyone, Julia here, thanks for all the really great comments! I wanted to address a couple of them here:
1) Some of the comments have touched on the fact that pedophilia is in the Paraphilia section. To be honest, I think that the fact that most people feel that the pedophilia diagnosis is legitimate opens the door to them accepting the less egregious diagnoses (e.g., “Transvestic Disorder” or “Fetishism”). This is the exact same slippery slope argument that people like Rick Warren make when they try to compare same-sex marriage to pedophilia in order to delegitimize the former. Also, it is important to mention that rape used to be a Sexual Deviation (i.e., Paraphilia) in the DSM, but was removed mostly because of feminists, who thought that people who rape should be punished for the crime they commit and not be able to fall back on a mental illness defense. Theoretically, one could make a similar case with pedophilia.
2) krc made the following comment:
“People who are opposing the proposal to expand the definition of paraphilia in the upcoming revision of the DSM ... have no idea what it is like to live with someone who is truly sick, who sees trans individuals, amputees, and disabled people as only sex objects with no humanity under the surface, who spends hours and hours a day looking at pornography of these people, who take it to work on hand held computers, and let it destroy their own, real life relationships. That is the kind of thing the APA is talking about in revision, not about diagnosing the average transgender individual, the average cross-dresser, or people who are more attracted to them...”
First off, I disagree with the last part of your statement. If you read Blanchard’s research papers (which sadly, I have), you’ll see that he does view crossdressing and people attracted to transgender people as paraphilic. Second, the habits that you described for the supposedly “truly sick” people (watching porn, seeing people only sex objects, having their sexual obsession interfere with their relationships) also apply to many cis heterosexual men who view cis women that way! The only reason that one is listed as a paraphilia while the other is not is because “phenotypically abnormal” people are viewed as sick and undesirable in the first place.
3) several posts inquired about the likelihood that a crossdresser or someone attracted to a trans person might actually be diagnosed as paraphilic. I know that at least the case of crossdressers and individuals who engage in consensual BDSM, it does occasionally happen. But what is even more frequent and damaging than an actual diagnosis is the fact that in legal settings (e.g., employment discrimination cases, child custody cases) lawyers will point to the fact that these behaviors are listed in the DSM in order to make the case that the parent is unfit a priori, or that the employer is justified in firing the person for something they do at home in private. Thus, these diagnoses do regularly cause damage to people regardless of whether they have been formally diagnosed or not.
Thnaks again for all your thoughts! -julia
I used to view the DSM as a giant clusterfuck that accidentally gets some things right. But I've revised my view. The true function of the DSM is not to help therapists and patients "get it right" and find treatments that work for them. Instead, it's about making money, in which case it's a smashing success. The primary goal of the entire medical industry is to maximize profits, and I see no reason why this would be an exception. And the trend in all areas of medicine is toward an increasingly pharmaceutical-driven process. So obviously the goal is to increase the number of behaviors that are pathologized, because that fuels the number of prescriptions that are written every year. Just look at the whole PMDD debacle.
I would suspect that what actually happens is the people who are working on the DSM sieze upon behaviors that are widely viewed as abnormal among the general population and pathologize them. Once social awareness on that issue builds to critical mass and people aren't OK with pathologizing that behavior anymore (like homosexuality) then you remove it in order to prevent a PR crisis. But you need to replace it with other disorders to keep the money flowing.
This is obviously a deeply cynical view, and contains a bit of hyperbole. But we shouldn't forget that the people who produce the DSM work in the field which stands to gain by pathologizing a wider range of behaviors.
Finally, to those who defend it by claiming that only those who are disturbed by their lack of gender binary conformity will be seeking help... Two things: Many people who are trans or otherwise not-properly-gendered will feel distress due to the fucked up culture we live in. To quote Jiddu Krishnamurti "It is no measure of health to be well adjusted to a profoundly sick society." And second, many people who receive "treatment" for these things are minors whose parents are forcing them into it. The pathologization of homosexuality was used to justify the Jesus Camps that kids used to be (and sometimes still are) sent to, and if you think for one minute that social conservatives won't use the DSM to justify compulory "retraining" of trans and genderqueer teens then you've got your head in some thick and deep sand.
On a brighter note, at least we can envision our great-grandkids reading this stuff with the same mix of horror and amusement and disbelief as we feel when we read Victorian medical texts.
this, (to paraphrase another comment from another thread_ is why health care should not be a 'for profit' industry.
So much in here I could comment on, but to keep from getting too angry, I'm just going to say....
Phenotypically normal human? So all those 13-year-old girls out there getting worked up over "Twilight" are so obviously sexual deviants! Whatever would the Mormon church say? I mean, seriously... the very existence of such phenomena as sexy vampires proves that the range of our sexualities is far broader by default than "phenotypically normal human", even in the most ordinary, have-only-just-started-thinking-about-this middle-school girls.
Ha! And on a related note, the "phenotypically normal" clause pathologizes everyone who's partnered with any individual who was intersex at birth. This is pretty ironic given the lengths to which the medical industry goes in order to make intersex individuals "normal" and ensure that they can have "normal" sexual relationships, assuming that's possible once all your nerve-endings that correlate to sexual pleasure have been butchered in a surgery you didn't consent too...
Indeed, indeed. It disincludes a whole swathe of people from ever being "normal enough" for it to be "right" to have a relationship with. And that is pretty damn sickening, IMHO.
It might be useful to actually explain what "phenotypically normal" means.
I have tried googling, but it isn't clear to me. I don't think it includes 'short' people, gays, redheads, etc. I cannot believe it menas "atypical".
So biologists (like myself) never use the term "phenotypically normal," because normal is very value laden, implying that there is one "right" or "natural" way to be. In reality, biology is about variation amongst populations and over time, so there can be no "normal." Biologists will describe individuals of a species as "phenotypically wild type" - which means they appear similar to most members of that species that appear in the wild. But it's a given that there is not necessarily anything "wrong" with individuals that don't appear wild type. Such individuals would be said to be phenotypically variant.
Blanchard is not a biologist, but a psychopathologist. He has spent his career studying people who are variant with regards to gender and sexuality. He categorizes and subcategorizes these groups based upon the assumption that something must have "gone wrong" with an individual who is atypical or uncommon in their gender and sexual expression.
Having read his research papers, I would say that he probably doesn't view redheads as phenotypically abnormal. And someone who's on the short side of the spectrum probably wouldn't be considered abnormal either. But I'd bet money that he would consider people who are commonly called "midgets" or "dwarves" abnormal.
Also, I know for a fact that he views homosexuality to be abnormal; he’s written a lot about the subject, and he clearly believes something "goes wrong" with a person to make them gay. But he's not an idiot, and he knows the backlash would be fierce if he tried to put homosexuality back into the DSM.
Damn. And to think I was looking forward to the DSM-V - there's been some talk of them revamping the autistic spectrum disorders and possibly putting Asperger's in with HFA, which would be very very good, and it looks as though Hyposexual Desire Disorder may be changed to be more asexual-friendly, which would be *amazing*. But... *damn*. I had no idea this was going on, it's terrible. I can only hope the APA comes to their senses.
holy. shit. thank you for posting this. re-blogging, emailing, and phone calls are on my agenda for tonight.
so, wait.
i am disabled. and because of this disability, i am about 30lbs overweight.
so my boyfriend is "paraphiliac" because he thinks i am hot and sexy?
what the fuck does that say about *me*, the disabled overweight person who still wants to get laid?
and being attracted to a transperson is "paraphiliac"? (i know transpeople who don't look like their genetic sex. i know a transwoman who i *never* would have believed used to be male if i hadn't seen her birth cert! by the guys who follow her around - in droves - are paraphiliac?). people are attracted to other people because they are attracted. i know very cis-men who have seen very femme men, and those cis men have been attracted to what they perceived as female (until they realize that the guy is *not* female, normally. i am lucky that the guys that i know don't get mad when they realize they were attracted to another man)
pedophilia is a mental illness. its fucked up.
being attracted to a(n adult) person is *NOT* an illness.
i have also never understood why being trans, or wanting to be trans, is still considered a mental illness - and i am very worried by the implications of broadening the perceived pathology. we should be getting better at understanding that some people just ARE, not making it harder for them. not othering them more! if (generic) you is not hurting anyone, and everything is done in an open and consenting way - whether thats BDSM, roleplaying, cross-dressing, being with a transperson, *WHATEVER* - if everyone involved is happy and consenting and wanting to be there, how the *HELL* is that wrong?!?!
but as much as the implications for non-cis-people are frightening, i think i am more frightened about the implications for people like me, who are disabled. there are a *lot* of disabled people, and a large percentage of us *do* have sexual relationships. but how long is it going to last, how long until children are taught that people with disabilites are not lovable, if this comes out in the DSM-V?
how long until we are treated as social, romantic and sexual pariahs, because it is an "illness" to be attracted to somone who is disabled?
(i am not trying to dismiss LGBTQI people; its just that *I* am disabled, so that hits home. i have been pissed for months over the implications of Blanchard being selected, how that will affect LGBTQI people. now i am not pissed and frightened at one removed, worried about my friends - now it is *me*, too. does that make sense?)
Yes it does make sense, and no, you're not de-railing the topic through cis privilege.
I had no idea that you'd be caught in the crossfire too. That's my ablist privilege showing. Thanks for bringing this to my attention.
It makes the issue even more important. You know sometimes, I really, really, really hate this Patriarchal BS. Blanchard and Zucker aren't bad, just appallingly arrogant. They oppress and don't even realise it.
I'd like to add that the persistent labeling of only het males as transvestic fetishists is based on the old presumption that women don't have / can't desire the same way men do.
hi Helen,
Yes, you are exactly right. I didn't discuss that in this piece but I do talk about it in my book. "Paraphilias" are typically defined as occurring primarily or exclusively in males (with MTF spectrum folks being considered "male"). This notion is rooted in the ancient yet stupid assumption that males have sexual appetites and agency, while females do not. So paraphilias more generally, and transvesticism more specifically, are sexist in that way too.
When I give presentations that debunk autogynephilia or transvestic fetishism, the biggest laugh I get by far is when I read Blanchard and Stoller quotes that argue that there are virtually no cases of women (or FTM spectrum folks) who get an erotic charge out of wearing men's clothing. After everyone laughs, I usually follow by suggesting that they should get out more...
(btw, if you're interested, you can hear a version of that presentation that I gave at the recent IFGE conference: http://www.juliaserano.com/av/2_6_09-IFGE09.mp3
A word in defence of Blanchard; he wrote:
So you would not be diagnosed with a paraphilia for being sexually attracted to say, me - someone not phenotypically normal. You would be ascertained to be paraphiliac instead.
Good luck getting a Judge or Jury to understand the difference in a custody case.
You would only be diagnosed with a paraphiliac disorder if it would cause distress or impairment to you or others. For example, if your boss disapproved of intersexed people and fired you for being attracted to one.
Oh yes, and it doesn't just pathologise masturbation, but......
It gives a backdoor for rapists to claim an insanity defence. They have a "paraphiliac disorder".
Adding additional paraphilia categories to the DSM-V is a red herring. The DSM-IV was actually a huge step forward for sensibility towards a rational, modern approach to fetishism because it changes the definition to indicate that the condition only applies if "...the disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning" (which will undoubtedly carry over into the DSM-V.)
I.e., if it doesn't cause distress, then it's not a mental health issue. This is a perfect way to approach atypical non-harmful behavior. If a person's behavior is causing them "clinically significant distress," then it would certainly be helpful for mental health professionals to be able to refer to something in the literature which relates to the specific behavior of the patient.
Being diagnosed with a paraphilia is not necessarily an indication that "there's something wrong with the patient that needs to be fixed," it can, instead, tell the professional that the patient needs help with self-acceptance issues or help with relating to other members of society, given the context of their unique behavior.
When is a paraphilia not a paraphilia? If two people decide to try a little bondage, are they on the verge of mental illness? What about those of us in the BDSM community who regularly practice kink and function in society?
And why isn't there a "missionary-position" fetish, or a "lights-off-and-blinds-drawn" paraphilia? It seems that all of these labels are being applied to activities which contradict Victorian sensibilities. Even if a person's particular sexual behavior is obviously harmful or inappropriate, shouldn't we be asking the question of whether that behavior is a "disease" in itself, or a symptom of another problem (such as sociopathy or obsessive-compulsive disorder)?
Charles Moser, Peggy Kleinplatz and other have argued for removing paraphilias from the DSM altogether. As radical as that sounds, feminists and other progressives should seriously examine and debate such a proposal. When the line between diagnosis and moral condemnation is that fuzzy, then we have to question the motivations and research behind those labels.
DSM? Isn't that the same guide that actually has a listing for a disorder that involves a person loving math problems?
Or being stoned? http://www.youtube.com/watch?v=Nbx4m5b7KLU&feature;=related