Jack Drescher

Queer Diagnoses: Parallels and Contrasts in the History of Homosexuality, Gender Variance, and the Diagnostic and Statistical Manual

The American Psychiatric Association (APA) is in the process of revising its Diagnostic and Statistical Manual (DSM), with the DSM-V having an anticipated publication date of 2012. As part of that ongoing process, in May 2008, APA announced its appointment of the Work Group on Sexual and Gender Identity Disorders (WGSGID). The announcement generated a flurry of concerned and anxious responses in the lesbian, gay, bisexual, and transgender (LGBT) community, mostly focused on the status of the diagnostic categories of Gender Identity Disorder (GID) (for both children and adolescents and adults). Activists argued, as in the case of homosexuality in the 1970s, that it is wrong to label expressions of gender variance as symptoms of a mental disorder and that perpetuating DSM-IV-TR’s GID diagnoses in the DSM-V would further stigmatize and cause harm to transgender individuals. Other advocates in the trans community expressed concern that deleting GID would lead to denying medical and surgical care for transgender adults. This review explores how criticisms of the existing GID diagnoses parallel and contrast with earlier historical events that led APA to remove homosexuality from the DSM in 1973. It begins with a brief introduction to binary formulations that lead not only to linkages of sexual orientation and gender identity, but also to scientific and clinical etiological theories that implicitly moralize about matters of sexuality and gender. Next is a review of the history of how homosexuality came to be removed from the DSM-II in 1973 and how, not long thereafter, the GID diagnoses found their way into DSM-III in 1980. Similarities and differences in the relationships of homosexuality and gender identity to psychiatric and medical thinking are elucidated. Following a discussion of these issues, the author recommends changes in the DSM-V and some internal and public actions that the American Psychiatric Association should take.

Minding the body: Situating gender identity diagnoses in the ICD-11

Abstract The World Health Organization (WHO) is in the process of revising the International Statistical Classification of Diseases and Related Health Problems (ICD) and ICD-11 has an anticipated publication date of 2015. The Working Group on the Classification of Sexual Disorders and Sexual Health (WGSDSH) is charged with evaluating clinical and research data to inform the revision of diagnostic categories related to sexuality and gender identity that are currently included in the mental and behavioural disorders chapter of ICD-10, and making initial recommendations regarding whether and how these categories should be represented in the ICD-11. The diagnostic classification of disorders related to (trans)gender identity is an area long characterized by lack of knowledge, misconceptions and controversy. The placement of these categories has shifted over time within both the ICD and the American Psychiatric Associations Diagnostic and Statistical Manual (DSM), reflecting developing views about what to call these diagnoses, what they mean and where to place them. This article reviews several controversies generated by gender identity diagnoses in recent years. In both the ICD-11 and DSM-5 development processes, one challenge has been to find a balance between concerns related to the stigmatization of mental disorders and the need for diagnostic categories that facilitate access to healthcare. In this connection, this article discusses several human rights issues related to gender identity diagnoses, and explores the question of whether affected populations are best served by placement of these categories within the mental disorders section of the classification. The combined stigmatization of being transgender and of having a mental disorder diagnosis creates a doubly burdensome situation for this group, which may contribute adversely to health status and to the attainment and enjoyment of human rights. The ICD-11 Working Group on the Classification of Sexual Disorders and Sexual Health believes it is now appropriate to abandon a psychopathological model of transgender people based on 1940s conceptualizations of sexual deviance and to move towards a model that is (1) more reflective of current scientific evidence and best practices; (2) more responsive to the needs, experience, and human rights of this vulnerable population; and (3) more supportive of the provision of accessible and high-quality healthcare services.

Gender Dysphoric/Gender Variant (GD/GV) Children and Adolescents: Summarizing What We Know and What We Have Yet to Learn

The optimal approach to treating minors with gender dysphoria/gender variance (GD/GV) is much more controversial than treating these phenomena in adults. This is because children have limited capacity to participate in decision making regarding their own treatment, and even adolescents have no legal ability to provide informed consent. Minors must, therefore, depend on parents or other caregivers to make treatment decisions on their behalf, including those that will influence the course of their lives in the long term. Presently, the highest level of evidence available for selecting among the various approaches to treatment is best characterized as “expert opinion.” Yet, opinions vary widely among experts and are influenced by theoretical orientation and assumptions and beliefs regarding the origins of gender identity, as well as its perceived malleability at particular stages of development. This article outlines some of the more salient points raised by the clinicians who treat GD/GV and their discussants. This article summarizes what the editors believe is known and what has yet to be learned about minors with GD/GV, their families, their treatment, and their surrounding cultures.

Disorders related to sexuality and gender identity in the ICD-11: revising the ICD-10 classification based on current scientific evidence, best clinical practices, and human rights considerations.

In the World Health Organizations forthcoming eleventh revision of the International Classification of Diseases and Related Health Problems (ICD‐11), substantial changes have been proposed to the ICD‐10 classification of mental and behavioural disorders related to sexuality and gender identity. These concern the following ICD‐10 disorder groupings: F52 Sexual dysfunctions, not caused by organic disorder or disease; F64 Gender identity disorders; F65 Disorders of sexual preference; and F66 Psychological and behavioural disorders associated with sexual development and orientation. Changes have been proposed based on advances in research and clinical practice, and major shifts in social attitudes and in relevant policies, laws, and human rights standards. This paper describes the main recommended changes, the rationale and evidence considered, and important differences from the DSM‐5. An integrated classification of sexual dysfunctions has been proposed for a new chapter on Conditions Related to Sexual Health, overcoming the mind/body separation that is inherent in ICD‐10. Gender identity disorders in ICD‐10 have been reconceptualized as Gender incongruence, and also proposed to be moved to the new chapter on sexual health. The proposed classification of Paraphilic disorders distinguishes between conditions that are relevant to public health and clinical psychopathology and those that merely reflect private behaviour. ICD‐10 categories related to sexual orientation have been recommended for deletion from the ICD‐11.

Proposed declassification of disease categories related to sexual orientation in the International Statistical Classification of Diseases and Related Health Problems (ICD-11)

Abstract The World Health Organization is developing the 11th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-11), planned for publication in 2017. The Working Group on the Classification of Sexual Disorders and Sexual Health was charged with reviewing and making recommendations on disease categories related to sexuality in the chapter on mental and behavioural disorders in the 10th revision (ICD-10), published in 1990. This chapter includes categories for diagnoses based primarily on sexual orientation even though ICD-10 states that sexual orientation alone is not a disorder. This article reviews the scientific evidence and clinical rationale for continuing to include these categories in the ICD. A review of the evidence published since 1990 found little scientific interest in these categories. In addition, the Working Group found no evidence that they are clinically useful: they neither contribute to health service delivery or treatment selection nor provide essential information for public health surveillance. Moreover, use of these categories may create unnecessary harm by delaying accurate diagnosis and treatment. The Working Group recommends that these categories be deleted entirely from ICD-11. Health concerns related to sexual orientation can be better addressed using other ICD categories.

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.

Controversies in Gender Diagnoses

This article presents the authors thoughts on gender diagnosis controversies during his tenure at the DSM-5 Workgroup on Sexual and Gender Identity Disorders and the ICD-11 Working Group on the Classification of Sexual Disorders and Sexual Health. The work summarizes some of the published conclusions of the DSM-5 and ICD-11 revision processes regarding three particular controversies: (1) stigma versus access to care; (2) the retention of a child gender diagnosis; and (3) the treatment of prepubescent transgender children. Both the DSM and ICD work groups decided that despite the stigma associated with a diagnosis, retaining an adolescent and adult gender diagnosis is necessary to maintain access to care. As for the child gender diagnosis, given the heterogeneity of this clinical population and that gender dysphoria does not persist in most children, a child diagnosis of Gender Dysphoria (DSM) and Gender Incongruence (ICD) should be retained to facilitate ongoing evaluation and management in childhood while acknowledging the uncertainty of the outcome. The treatment of extremely gender variant prepubescent children remains a controversial subject since some underlying assumptions of the treating clinicians are a matter of opinion rather than of empirical data.

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.

A history of homosexuality and organized psychoanalysis.

Today the Academy of Psychoanalysis and Dynamic Psychiatry welcomes its gay and lesbian members. Yet at the time of its 1956 founding, organized psychoanalytic attitudes toward homosexuality could be reasonably characterized as hostile. First there was a transition from Freuds early views of homosexuality as immature to later neofreudian theories that pathologized same-sex attractions and behavior. Following the 1973 decision of the American Psychiatric Association to remove homosexuality from the DSM, homosexuality is now more commonly regarded as a normal variant of human sexuality. The history of psychoanalytic attitudes toward homosexuality reinforces the impression that psychoanalytic theories cannot be divorced from the political, cultural, and personal contexts in which they are formulated. This history also shows that analysts can take positions that either facilitate or obstruct tolerance and acceptance.

Gender incongruence of childhood in the ICD-11: controversies, proposal, and rationale

As part of the development of the eleventh revision of the International Classification of Diseases (ICD-11), WHO appointed a Working Group on Sexual Disorders and Sexual Health to recommend changes necessary in the classification of mental and behavioural disorders in ICD-10 that are related to sexuality and gender identity. This Personal View focuses on the Working Groups proposals to include the diagnosis gender incongruence of childhood in ICD-11 and to move gender incongruence of childhood out of the mental and behavioural disorders chapter of ICD-11. We outline the history of ICD and DSM child gender diagnoses, expert consensus, knowledge gaps, and controversies related to the diagnosis and treatment of extremely gender-variant children. We argue that retaining the gender incongruence of childhood category is justified as a basis to structure clinical care and to ensure access to appropriate services for this vulnerable population, which provides opportunities for education and informed consent, the development of standards and pathways of care to help guide clinicians and family members, and a basis for future research efforts.