The classification of gender diversity and nonconformity to birth-assigned gender roles as mental illness by the American Psychiatric Association (APA) has drawn growing protest and outrage from transpeople and and allies worldwide. The Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the APA, is regarded as the medical and social definition of mental disorder throughout North America and strongly influences international diagnostic nomenclature. The fifth edition of the manual, the DSM-5, is in development and scheduled for publication in 2013. While the diagnostic category of Gender Identity Disorder (GID) has garnered most of the controversy, a second category of so-called Transvestic Fetishism (TF) has harmed transwomen, including transsexual women, as well as male-to-female crossdressers, dual gender and gender nonconforming people since the earliest days of the DSM. Trans and LGB advocates have been inexplicably quiet about the TF category, even after the APA proposed to expand the category in the DSM-5, renamed Transvestic Disorder, to implicate gender nonconforming people of all sexes and all sexual orientations.
The proposed DSM-5 diagnosis of Transvestic Disorder, even worse than its predecessor Transvestic Fetishism, labels gender expression not stereotypically associated with assigned birth sex as inherently pathological and sexually deviant. The diagnosis is punitive and scientifically capricious, serving to punish social and sexual gender nonconformity and enforce binary stereotypes of assigned birth sex. Here are ten reasons why the Transvestic Disorder diagnosis should be eliminated entirely from the DSM-5.
1. Diagnosis of Diversity
The World Professional Association for Transgender Health (WPATH), formerly the Harry Benjamin International Gender Dysphoria Association, (HBIGDA), publishes recognized standards of medical transition care for those who need it. In May, 2010, WPATH issued the following pivotal statement on de-psychopathologisation of gender variance,
The WPATH Board of Directors strongly urges the de-psychopathologisation of gender variance worldwide. The expression of gender characteristics, including identities, that are not stereotypically associated with one’s assigned sex at birth is a common and culturally-diverse human phenomenon which should not be judged as inherently pathological or negative. The [psychopathologisation] of gender characteristics and identities reinforces or can prompt stigma, making prejudice and discrimination more likely, rendering transgender and transsexual people more vulnerable to social and legal marginalisation and exclusion, and increasing risks to mental and physical well-being. WPATH urges governmental and medical professional organizations to review their policies and practices to eliminate stigma toward gender-variant people.
Gender expression that differs from social expectations of assigned birth sex does not meet any medical or scientific definition of mental pathology. Difference is not disease.
2. Stigma of Sexual Deviance
Transvestic Disorder is classified as a “paraphilic” sexual disorder, grouped with diagnoses of such harmful behaviors as pedophilia and exhibitionism. The resulting stereotypes of sexual deviance deny human dignity and civil justice to transgender and gender variant people, including transsexual individuals, who consequently lose their jobs, homes, families, children, freedoms and access to public accommodation.
In the United States, these false stereotypes were exemplified in a full-page newspaper ad campaign in 2008 by Focus on the Family, a political extremist group opposed to civil rights for transpeople in the state of Colorado. A transwoman was depicted in a photo as a disheveled suspicious male in dirty work boots, lurking in a women’s restroom as a little girl stepped out of a stall. The ad contained the headline, “Colorado Just Opened Its Bathrooms to Either Sex!” with the phrase, “sexual predator.” The association of transwomen with sexual predation and threat to children was in reference to the association of transwomen with “paraphilia” in the DSM.
3. Denial of Civil Justice
In the DSM-III, the APA stated, “The crucial issue in determining whether or not homosexuality per se should be regarded as a mental disorder is not the etiology of the condition, but its consequences and the definition of mental disorder.” Tragically, the APA has neglected to apply this same logic to the consequences of psychopathologization of gender variance and nonconformity.
For example, Andrea Lafferty, of the extremist Traditional Values Coalition, exploited the TF and GID diagnostic categories to oppose national employment nondiscrimination legislation for GLBTQ Americans in a CBS News interview this year. Lafferty cited the APA while repeating that transpeople have “a serious mental disorder” and represent a threat to children. In fact, the current TF and GID nomenclature have played a pivotal role in the ongoing defeat of the Employment Nondiscrimination Act (ENDA) in the U.S. Congress, as opponents have focused on sensational false stereotypes of mental illness and sexual deviance rather than direct attack against gay and lesbian people.
4. Pathologization of Ordinary Behaviors.
The supporting text of the Transvestic Fetishism diagnosis describes behaviors that would be ordinary or even exemplary for cisgender women as symptomatic of mental disorder for transgender women and gender nonconforming males. These include wearing female clothing, dressing entirely as females, wearing makeup, expressing feminine mannerisms and appearing publicly in a feminine role. The text goes so far as to list “involvement in a transvestic subculture” among pathological “transvestic phenomena.” It is not clear how the very same behaviors and social/political affiliations can be pathological for one group of people and not for others.
5. Harm to Transsexual Women
The proposed Transvestic Disorder category is not limited to crossdressers or male-identified people. It also targets transsexual women with a specifier of “autogynephilia,” a deeply offensive label that sexualizes ordinary and customary social gender expression and promotes a poorly supported and socially defamatory theory that transsexual women transition to satisfy a sexual fetish rather than attain harmony with their experienced gender identity. The label of Transvestic Fetishism has also been used to deny medical transition treatment for transsexual indivicuals who need it. For example, the diagnosis was cited by Federal attorneys against Ms. Rhiannon O’Donnabhainn in her recent landmark case in U.S. Tax Court. They used the TF category to promote a false stereotype of fetishism to argue that corrective transition surgeries for transsexual women are not medically necessary.
6. Harm to Transmen
In June of this year, the phrase “in a male,” in reference to birth-assigned sex, was removed from criterion A for the proposed Transvestic Disorder without explanation. As a result, transmen and masculine or butch women may now be implicated with Transvestic Disorder because of the clothes they wear. A new specifier of “with autoandrophilia” was added to the diagnostic criteria to target transsexual men, much as the specifier of “autogynephilia” would target and defame transsexual women.
7. Harm to Non-erotically Motivated Crossdressers
Ambiguous language in Criterion A of the APA Transvestic Disorder proposal implicates sexual expression “involving” crossdressing, without evidence of causation. Thus, virtually any gender expression among bigender, dual-gender or genderqueer people that is coincident with any kind of a sex life may be inferred as diagnosable, whether erotically motivated or not.
It is apparent that DSM authors have long intended for the TF diagnosis to implicate non-erotic or ambiguously erotic crossdressing as a fetishistic psychopathology. For example, the DSM-IV Casebook recommended a Transvestic Fetishism diagnosis for a male-identified subject whose crossdressing was not necessarily sexually motivated.
8. Harm to Erotically Motivated Crossdressers
Crossdressing that is erotically motivated is a benign consensual sexual expression that does not rise to the definition of mental illness. There is no scientific justification for labeling this behavior as mentally or sexually pathological. The DSM-IV-TR states, “Neither deviant behavior … nor conflicts that are primarily between the individual and society are mental disorders unless the deviance or conflict is a symptom of dysfunction…”
9. Harm to Ego-Dystonic (self-unaccepting) Crossdressers
The APA proposal for Transvestic Disorder, pathologizes ego-dystonic crossdressers, who are distressed by internalized shame and societal transphobia, very much as the previous diagnosis of Ego-Dystonic Homosexuality in the DSM-III pathologized victims of social homophobia. Ego-Dystonic Homosexuality was removed entirely from the DSM-III-R in 1987, because it inexorably associated all same sex orientation with pathology and because “almost all people who are homosexual first go through a phase in which their homosexuality is ego-dystonic.” The very same logic should apply to the Transvestic Disorder diagnosis in the DSM-5. It would be tragic for the APA to perpetuate a diagnosis so analogous to Ego-Dystonic Homosexuality of the last century.
10. Implicit Endorsement of Gender-Reparative Therapies
In 2008, the American Psychiatric Association (APA) released public statements that, “…the DSM is a diagnostic manual and does not provide treatment recommendations or guidelines.” In fact, however, diagnostic nomenclature and treatment are inseparably related. The efficacy of all drug and psychotherapy treatments are judged according to specific diagnostic criteria listed in the DSM and ICD. The diagnostic criteria for the proposed Transvestic Disorder in the DSM-5 favor gender-reparative therapies that serve to repress gender nonconforming fantasies, urges and behaviors, described in criterion A. Bigender, dual gender or gender variant individuals who are not shamed into repression but are distressed by external societal intolerance, would perpetually meet the criteria regardless of how happy and functional they might otherwise be.
It is time to call upon the APA leadership to reject the proposed diagnostic category of Transvestic Disorder and remove nomenclature from the DSM that casts crossdressing and gender role nonconformity in themselves as mental disorder.
Appendix A: DSM-IV-TR Diagnostic Criteria for Transvestic Fetishism
- A. Over a period of at least 6 months, in a heterosexual male, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving cross-dressing.
- B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
- Specify if: With Gender Dysphoria: if the person has persistent discomfort with gender role or identity
Appendix B: Proposed DSM-5 Diagnostic Criteria for Transvestic Disorder
- A. Over a period of at least six months, recurrent and intense sexual fantasies, sexual urges, or sexual behaviors involving cross-dressing.
- B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.:
- Specify if:
- With Fetishism (Sexually Aroused by Fabrics, Materials, or Garments)
- With Autogynephilia (Sexually Aroused by Thought or Image of Self as Female)
- With Autoandrophilia (Sexually Aroused by Thought or Image of Self as Male)
- Specify if:
- In Remission (During the Past Six Months, No Signs or Symptoms of the Disorder Were Present)
- In a Controlled Environment
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Focus on the Family Action (2008). Colorado Springs, CO, http://www.citizenlink.com. Photo available online athttp://www.gidreform.org/2008FOFsb2006.jpg
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