The DRAFT (emphasis added) DSM-V

Wednesday, 10 February 2010

The DRAFT (emphasis added) DSM-V

Is available at http://www.dsm5.org/Pages/Default.aspx :

DSM-5: The Future of Psychiatric Diagnosis
Publication of the fifth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in May 2013 will mark one the most anticipated events in the mental health field. As part of the development process, the preliminary draft revisions to the current diagnostic criteria for psychiatric diagnoses are now available for public review and comment. We thank you for your interest in DSM-5 and hope that you use this opportunity not only to learn more about the proposed changes in DSM-5, but also about its history, its impact, and its developers. Please continue to check this site for updates to criteria and for more information about the development process.

Areas of particular interest are:

Gender Identity Disorders
302.6 Gender Identity Disorder in Children
302.85 Gender Identity Disorder in Adolescents or Adults
302.6 Gender Identity Disorder Not Otherwise Specified

Paraphillias
302.3 Transvestic Fetishism

Taking it from the top…..
302.6 Gender Identity Disorder in Children

The Good:

A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested by at least 6* of the following indicators (including A1): [2, 3, 4]

1. a strong desire to be of the other gender or an insistence that he or she is the other gender [5]

At last! The requirement that a child be deemed TS only if they think they’re of a different sex from the one they have been assigned! Mere cross-gendered behaviour is not enough. I’m not sure of the duration being reduced to only 6 months though. The rationale is this:

However, there is no clear empirical literature supporting this particular period (e.g., 3 months vs. 6 months or 6 months vs. 12 months). There was, however, consensus among the group that a lower-bound duration of 6 months would be unlikely to yield false positives.

I would have put the bar higher – out of sheer conservatism. In this case, I must grudgingly bow to the consensus. I’d like some empirical evidence though, especially from the Dutch group that have a 100.00 batting average on diagnosis.

The Bad:

Subtypes
With a disorder of sex development
Without a disorder of sex development

Being Intersexed is no longer a “defence” against the charge of being “mentally ill”. Exactly what various IS groups have been afraid of with the classification of Transsexuality as being effectively an Intersex condition.

So now children who were surgically mutilated surgically assigned a sex of convenience are now not merely “disordered” (rather than “different”) due to their biology, but suffer a “psychiatric illness” should they dare to object to an incorrect assignation.

It’s as .. perverse… as reacting to a situation where, because broken arms are mis-classified as a “mental illness”, and research shows that broken legs have a similar etiology (ie a physical fracture of the skeleton), that broken legs should now be classed as a mental rather than a physical condition too.

Whisky Tango Foxtrot Interrogative.

The Ugly:

The references – nothing, absolutely nothing, by Swaab, or Gooren, or Diamond, or… anyone at all writing anything on neuro-anatomy.

Harry Benjamin, back in 1966, wrote:

Many psychologists, particularly analysts, have little biological background and training. Some seem actually contemptuous of biological facts and persistently overstate psychological data, so much so that a distorted, one-sided picture of the problem under consideration results.
Psychiatrists with biological orientation strongly disagree and even decry the exclusive psychoanalytic interpretations. But their voice is heard too rarely.”

Never has this been more obviously illustrated than here. Anything which might contradict Money’s debunked theories of psychosexual neutrality at birth has been… ignored. Just plain not referenced, either to confirm of refute.

Moreover, in the references, amidst a number of journals with one, sometimes two citations, there’s reference after reference to the “Archives of Sexual Behaviour”, of which many on the panel are editors, and where the editors contribute much of the content. Calling it a “Vanity Press” publication would be most unjust and very inaccurate. It is however… monocultural. Incestuous. That can happen in any specialised area and is often inevitable. But it’s not inevitable here, it appears to be the consequence of many of the people on the DSM-V revision panel (in this area) being part of this clique. Calling it a clique is harsh, but I’m afraid to say no other word fits. And the chair of the section revision committee, Ken Zucker, is an editor of this publication.

Moving right along…

302.85 Gender Identity Disorder in Adolescents or Adults

The Good

Not so much what has been included, as what hasn’t been. Nothing about paraphilias, nothing about mis-directed sexual drives. The renaming to “Gender Incongruence” is also good. The “Exit Clause” better.

The change also makes it possible for individuals who have successfully transitioned to “lose” the diagnosis after satisfactory treatment. This resolves the problem that, in the DSM-IV-TR, there was a lack of an “exit clause,” meaning that individuals once diagnosed with GID will always be considered to have the diagnosis, regardless of whether they have transitioned and are psychosocially adjusted in the identified gender role (Winters, 2008). The diagnosis will also be applicable to transitioned individuals who have regrets, because they did not feel like the other gender after all. For instance, a natal male living in the female role and having regrets experiences an incongruence between the “newly assigned” female gender and the experienced/expressed (still or again male) gender.

This recognises that Gender Incongruence is something experienced by some no matter what situation they’re in. The Gender Binary fits most people well, as does the Sex Binary. But it fits some not at all. Just as some are Bi-Gendered, able to function with adequate (if not good) facility in either Gender role, some unfortunates can’t fit in either.

I don’t like to think about them. I should, but I find their situation too distressing. I also wonder if this can be called a psychiatric condition, or one induced by a sick and overly-rigid society, composed of people like me. People who fit in, and don’t understand people who don’t.

The Bad

The criteria have been considerably relaxed. Now no distinction is made between the Transsexual – those for whom physical change of the body, the sex, is a matter of life-and-death (literally), and those who are merely gender variant. Sex and gender are completely conflated, biology and social construct inextricably mixed.

Now while some of what we normally think of as “cross-gendered” behaviour is actually cross-sexed, a matter if neurology…. most isn’t. It’s a matter of convention, a social construction if you will. I’ve had to “fight the good fight” to point out that it’s not 100% social construction, that male and female brains differ in significant ways. But there’s a practical issue here: merely Transgendered people do not require bodily correction. Transsexuals do.

Now while it may be that more Transgendered behaviour than we think has a physiological causation – I think it probably does – I’d be flabbergasted if it all did. Worse though, the conflation of the two might encourage Transgendered people into seeking body modification when it’s highly undesirable, inducing a medical condition where none existed. Even worse, causing Transsexual people to be denied life-saving treatment as “Gender is just a social construct”. That’s a very popular notion with many “Gender Studies” Departments, but is contradicted by the facts – unless you believe in psycho-sexual neutrality at birth, and ignore neuro-anatomy. Which is what they’ve done.

The Ugly

Many of the Ugly bits are the same as for the previous diagnosis. But there’s this, which I think shows some insight. These are smart people.

Although the DSM-IV diagnosis of GID encompasses more than transsexualism, it is still often used as an equivalent to transsexualism (Sohn & Bosinski, 2007). For instance, a man can meet the two core criteria if he only believes he has the typical feelings of a woman and does not feel at ease with the male gender role. The same holds for a woman who just frequently passes as a man (e.g., in terms of first name, clothing, and/or haircut) and does not feel comfortable living as a conventional woman. Someone having a GID diagnosis based on these subcriteria clearly differs from a person who identifies completely with the other gender, can only relax when permanently living in the other gender role, has a strong aversion against the sex characteristics of his/her body, and wants to adjust his/her body as much as technically possible in the direction of the desired sex. Those who are distressed by having problems with just one of the two criteria (e.g., feeling uncomfortable living as a conventional man or woman) will have a GIDNOS diagnosis. This is highly confusing for clinicians. It perpetuates the search for the “true transsexual” only, in order to identify the right candidates for hormone and surgical treatment instead of facilitating clinicians to assess the type and severity of any type of GI and offer appropriate treatment. Furthermore, in the DSM-IV, gender identity and gender role were described as a dichotomy (either male or female) rather than a multi-category concept or spectrum (Bockting, 2008; Bornstein, 1994; Ekins & King, 2006; Lev, 2007; Røn, 2002). The current formulation makes more explicit that a conceptualization of GI acknowledging the wide variation of conditions will make it less likely that only one type of treatment is connected to the diagnosis.

So far so good. I think that identifying the “true transsexual” is no bad thing though, as long as you have good criteria, and you define “true transsexual” as someone requiring hormonal and surgical intervention. I hate the phrase, as it inevitably leads to all sorts of elitist cliquishness, who are the “cool kids”, the “real McCoys” vs the “wannabes”.

At the moment we have an unholy conflation of sex and gender, illustrated by the confusion in the diagnostic criteria:

1. a marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or, in young adolescents, the anticipated secondary sex characteristics) [13, 16]

2. a strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or, in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics) [17]

3. a strong desire for the primary and/or secondary sex characteristics of the other gender

It’s got nothing to do with gender. Now it may be, as in my own case, that after transition I found that I was far, far more feminine in many ways than I’d thought. But I’m still a Geek Girl, a Tomboy, and while I fit in exactly with these gals, they’re not exactly gender-typical in some ways.

It’s about sex. Not sexual orientation. Not about who you want to go to bed with, but who you want to go to bed as.

You know, on various blogs I’ve been accused (at the best) of “sitting on the fence”. Of being a “TG Activist”, of engaging in Gender Politics to the detriment of the “cool kids”. I haven’t blogged about that as I don’t consider it important. I’m not actually interested in the least in “gender politics” and certainly not activism purveying some obscure technical doctrine. Human Rights, now those I’m interested in. But that’s separate from the Science of Sex and Gender, my main interest. Just the facts ma’am. So it’s ironic that here I am, criticising a group for doing what I’ve been (inaccurately) accused of myself. But I digress.

I’d re-write that as follows:

1. a marked incongruence between one’s neurological sex (as measured by tests of smell, hearing, MRI patterns) and somatic primary and/or secondary sex characteristics (or, in young adolescents, the anticipated secondary sex characteristics) [13, 16]

2. a strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s somatic sex (or, in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics) [17]

3. a strong desire for the primary and/or secondary sex characteristics of the other sex

Neither Gender nor sexual orientation come into it – but one or the other will often be involved as well, depending on how much of the brain is cross-sexed, and which parts.

If we don’t simplify and clarify like that, we have this kind of thing

Taking the above regarding the avoidance of male-female dichotomies into account, in the new formulation, the focus is on the discrepancy between experienced/expressed gender (which can be either male, female, in-between or otherwise) and assigned gender (in most societies male or female) rather than cross-gender identification and same-gender aversion (Cohen-Kettenis & Pfäfflin, 2009).

Assigned gender???? Bafflegab.

Some “gendered behaviour”, that which is a constant across all societies through time and space, is sexed behaviour, and while there’s overlap, and few if anyone wholly stereotypical, it’s as physically defined as height or genital shape. Both of which have overlap, and many who don’t fit in either male or female stereotype, not completely. But most of “gendered behaviour” has at best a tenuous connection with biology, and often none whatsoever.

Let’s look at the rest of the diagnostic criteria:

4. a strong desire to be of the other gender (or some alternative gender different from one’s assigned gender)

5. a strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender)

6. a strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender)

I’d not qualify for anything other than 1) and 6) when pre-op. I didn’t want to be a woman – I just was one. Now that the body’s been fixed…. I rather like it, and rather like a lot of the stereotypical gender stuff too. Not all though: some doesn’t fit. I’m arrogant enough to say that it doesn’t have to.

302.6 Gender Identity Disorder Not Otherwise Specified

Not Finished yet. But now that Intersexed people are included in the other diagnoses, it will have to be changed. The DSM-IV-TR version has:

This category is included for coding disorders in gender identity that are not classifiable as a specific Gender Identity Disorder. Examples include

1. Intersex conditions (e.g., partial androgen insensitivity syndrome or congenital adrenal hyperplasia) and accompanying gender dysphoria

2. Transient, stress-related cross-dressing behavior

3. Persistent preoccupation with castration or penectomy without a desire to acquire the sex characteristics of the other sex

Basically, nothing to do with any of the rest, a grab-bag of bizarre behaviour associated with other conditions.

302.3 Transvestic Fetishism

Here’s the total list of all of the references used in this section.

Blanchard, R. (1989). The classification and labeling of nonhomosexual gender dysphorias. Archives of Sexual Behavior, 18, 315-334.

Blanchard, R. (2009b). The DSM diagnostic criteria for Pedophilia. Archives of Sexual Behavior. Sept 16 [Epub ahead of print]. DOI 10.1007/s10508-009-9536-0

Blanchard, R. (2009c). The DSM diagnostic criteria for Transvestic Fetishism. Archives of Sexual Behavior.Sept 16 [Epub ahead of print]. DOI 10.1007/s10508-009-9541-3.

See previous remarks about monoculture and intellectual incest. Did I mention that Dr (PhD not MD or of Psychiatry) Blanchard is on the working-group in charge of writing this section of the DSM? IIRC he actually heads it…

I know it’s a “work in progress”, but still…

This approach leaves intact the distinction between normative and non-normative sexual behavior, which could be important to researchers, but without automatically labeling non-normative sexual behavior as psychopathological. It also eliminates certain logical absurdities in the DSM-IV-TR. In that version, for example, a man cannot be classified as a transvestite-however much he cross-dresses and however sexually exciting that is to him-unless he is unhappy about this activity or impaired by it.

Now while I’ll never understand male sexuality…. I thought that we were trying to make a diagnostic manual for mental illnesses here. So while I can understand having a definition of non-normative behaviours that may be signs of a mental illness – such as an aversion to eating rotted chicken embryos in the shell in the Phillipines, or a desire on the part of a woman to vote in Saudi – I don’t think any of them qualify as a mental illness, any more than “sluggish schizophrenia” with “democratic idealism” qualified in the late and unlamented Soviet Union. Whether they cause distress or not.

OK, I think transvestites are weird. But some would say that I’m weird too. Not so much for being Intersexed (many don’t know that, I don’t tell everyone), but for being a Rocket Scientist and sometime Naval Combat System Architect who’s doing a PhD in Genetic Algorithms and Evolutionary Computation. THAT some men find weird in a chick – weird and threatening.

at 02/10/2010

http://aebrain.blogspot.com/2010/02/draft-emphasis-added-dsm-v.html