Friedemann Pfäfflin

The DSM Diagnostic Criteria for Gender Identity Disorder in Adolescents and Adults

Apart from some general issues related to the Gender Identity Disorder (GID) diagnosis, such as whether it should stay in the DSM-V or not, a number of problems specifically relate to the current criteria of the GID diagnosis for adolescents and adults. These problems concern the confusion caused by similarities and differences of the terms transsexualism and GID, the inability of the current criteria to capture the whole spectrum of gender variance phenomena, the potential risk of unnecessary physically invasive examinations to rule out intersex conditions (disorders of sex development), the necessity of the D criterion (distress and impairment), and the fact that the diagnosis still applies to those who already had hormonal and surgical treatment. If the diagnosis should not be deleted from the DSM, most of the criticism could be addressed in the DSM-V if the diagnosis would be renamed, the criteria would be adjusted in wording, and made more stringent. However, this would imply that the diagnosis would still be dichotomous and similar to earlier DSM versions. Another option is to follow a more dimensional approach, allowing for different degrees of gender dysphoria depending on the number of indicators. Considering the strong resistance against sexuality related specifiers, and the relative difficulty assessing sexual orientation in individuals pursuing hormonal and surgical interventions to change physical sex characteristics, it should be investigated whether other potentially relevant specifiers (e.g., onset age) are more appropriate.

Opinions About the DSM Gender Identity Disorder Diagnosis: Results from an International Survey Administered to Organizations Concerned with the Welfare of Transgender People

ABSTRACT A survey on various issues related to the DSM-IV-TR gender identity disorder diagnosis was conducted among 201 organizations concerned with the welfare of transgender people from North America, Europe, Africa, Asia, Oceania, and Latin America. Forty-three organizations from all continents completed the survey. A majority of 55.8% believed the diagnosis should be excluded from the 2013 edition. The major reason for wanting to keep the diagnosis in the DSM was health care reimbursement. Regardless of whether groups were for or against the removal of the diagnosis, the survey revealed a broad consensus that if the diagnosis remains in the DSM, there needs to be an overhaul of the name, criteria, and language to minimize stigmatization of transgender individuals.

Memo Outlining Evidence for Change for Gender Identity Disorder in the DSM-5

IntroductionIn 2008, when the diagnostic Work Groups for the DSM-5 wereestablishedandformallyannouncedbytheAmericanPsychiatricAssociation,oneofthefirsttasks wastoreviewtheexistingdiag-nostic categories and to conduct literature reviews. The GenderIdentity Disorders (GID) subwor kgroup was one of three sub-workgroups of the Sexual and Ge nder Identity Disorders WorkGroup.Likeotherworkinggroups,itschargewastoevaluatewhatwas,ifanything,‘‘good’’abouttheexistingdiagnosisofGIDintheDSM-IV-TR and what, if anything, required changes. The sub-workgrouppublishedfourliteraturereviewsinwhichsomeinitialproposals and recommendations were made (Cohen-Kettenis PDrescher,2010; Meyer-Bahlburg, 2010; Zucker,2010). The subworkgroup had feedback from its advisors, fromother professionals, and from the public, including three periodsof APA-sponsored feedback on the DSM-5 website.Around mid-way during the DSM-5 preparation period,which ended on 1 December 2012, the Task Force added to thereview phase two additional committees. One was a ScientificReview Committee (SRC) and the second was a Clinical andPublic Health Committee (CPHC).The SRC was charged with providing feedback on all pro-posed changes to the diagnos tic criteria that were based onempirical evidence. The CPHC was charged with providingfeedback with regard to additional parameters, such as clinicalutility and public health concerns.EachWorkGrouporsubworkgroupoftheDSM-5TaskForcejustifiedtheproposedchangesofdiagnosticcategoriesinareportentitled Memo Outlining Evidence for Change (MOEC). Withthe permission of the American Psychiatric Association, wereproduce here the final version of the MOEC prepared by theGIDsubworkgroup(‘‘inpress’’referenceshavebeenupdatedandtypographical errors corrected). Publication of the MOEC thusmakestransparenttheargumen tationadvancedbythesubwork-group for interested readers. Comments on the proposal arewelcomeintheformofaLettertotheEditorofthisJournal.

What happens in therapy with sexual offenders? A model of process research

This paper presents two studies (one single case and one comparative study) examining change processes within individual therapy sessions as well as during the course of treatment. The Therapeutic Cycle Model (TCM), developed for general psychotherapy to objectify change events in the course of psychotherapies, is applied to transcribed tape recordings of therapy sessions with sexual offenders. The TCM focuses on emotional experience and cognitive mastery and uses computer assisted text analysis. In addition to the TCM approach clinical ratings are used as independent criteria. The predicted relationship between the phases of the TCM and scores on the respective scales of the clinical ratings were supported.

Changes in personality scores among couples subsequent to sex therapy

Changes in personality scores and self-perception of 92 couples through sex therapy are reported. The sample included 52 couples with female symptoms (orgasmic dysfunction and vaginismus) and 40 couples with male symptoms (erectile dysfunction and premature ejaculation), who all completed therapy. One-year follow-up showed significant changes indicating a general increase of emotional stability and a reduction of neurotic tendencies in both partners.

Attachment and interpersonal problems in a prison environment

Abstract This study investigated the relationship between attachment styles, interpersonal problem areas, and violent behaviour in German offenders compared with two non-violent comparison groups living in the community. To measure attachment, a semi-structured interview designed to identify and classify prototypes of attachment was applied. Interpersonal problems were assessed with a self-report measure. Offenders showed less secure attachment styles, more instability in relationships, less emotional attachment to others, and a strong wish for personal autonomy, but most interpersonal problem areas did not differ across the groups. Violent offenders are by no means all insecurely attached. Their results match with those of any socially disadvantaged, non-clinical group. The implications of these findings are discussed.

Transsexualism: Treatment Outcome of Compliant and Noncompliant Patients

ABSTRACT The objective of the study was a follow-up of the treatment outcome of Finnish transsexuals who sought sex reassignment during the period 1970–2002 and a comparison of the results and duration of treatment of compliant and noncompliant patients. Fifteen male-to-female transsexuals and 17 female-to-male transsexuals who had undergone hormone and surgical treatment and legal sex reassignment in Finland completed a questionnaire on psychosocial data and on their experience with the different phases of clinical assessment and treatment. The changes in their vocational functioning and social and psychic adjustment were used as outcome indicators. The results and duration of the treatment of compliant and noncompliant patients were compared. The patients benefited significantly from treatment. The noncompliant patients achieved equally good results as the compliant ones, and did so in a shorter time. A good treatment outcome could be achieved even when the patient had told the assessing psychiatrist a falsified story of his life and sought hormone therapy, genital surgery, or legal sex reassignment on his own initiative without a recommendation from the psychiatrist. Based on these findings, it is recommended that the doctor-patient relationship be reconsidered and founded on frank cooperation.

Selecting and Monitoring Living Skills in Forensic Mental Health Care: Cross-Border Validation of the BEST-Index

Background: Assessment of living skills and violence risk in forensic psychiatric patients is a priority for clinicians. Suitably fine-grained instruments are rare.Aim: We cross-validate a norm-based psychometric assessment battery (the Behavioral Status Index [BEST-Index]) against known valid instruments. Method: Parallel cohort studies were undertaken in five European countries. Inpatients (N = 231) from 24 forensic psychiatric clinics were assessed three times, using five instruments measuring living skills, psychological symptoms, aggression, and violence risk. Results: Positive clinical changes were noted in communication and living skills, with little change in violence risk, which was low to medium for 90 percent of patients. Clinical congruence was observed between logically cognate items of cross-validators and the BEST-Index. Discussion: Evidence for the scientific and clinical utility of the BEST-Index as an effective guideline for treatment priorities and outcomes is discussed.

Issues, Incidence, and Treatment of Sexual Offenders in Germany

This article will touch on the following topics: the law and law reforms, incidence of sexual offenses, national survey studies, treatment, and a recently started research project on psychotherapy process research at the Department of Psychotherapy at Ulm University.

Remarks on the History of the Terms Identity and Gender Identity

ABSTRACT Presently, there is an ongoing international debate about deleting gender identity disorders from the Diagnostic and Statistical Manual of the American Psychiatric Association and about removing transsexualism from the International Classification of Diseases, Mental and Behavioral Disorders of the World Health Organization. The effort is based on the argument that such a psychiatric diagnosis automatically contributes to discrimination of gender-variant people. Parallel to this discussion, are petitions of three factions of the German parliament to include sexual identities into Art. 3, para. 3, of the German Constitution (Grundgesetz), a paragraph that lists factors such as sex, race, origin, belief, and native language for protection against discrimination. From both philosophical and practical points of view, it is important to know whether identity is something stable and unchangeable or something subject to permanent change. This article reflects on the history of the term identity in general and especially on sexual/gender identity and concludes that an amendment of the German Constitution is not needed.