Sexual and Gender Diagnoses of the Diagnostic and Statistical Manual (DSM)

A Reevaluation

Dan Karasic, Jack Drescher

• Publisher: Routledge
• Year: 2014
• eBook ISBN: 9781317954569
• Topic: Social Sciences
• Subtopic: Gender Studies
• Index: Social Sciences

Get the latest on the controversies of the sexual and gender diagnoses contained in the current DSM

The revision of the Diagnostic and Statistical Manual (DSM) is an ongoing process, and changes in criteria or terminology can have significant implications for diagnosis and treatment. Sexual and Gender Diagnoses of the Diagnostic and Statistical Manual (DSM): A Reevaluation provides a range of viewpoints from noted authorities on gender and sexuality issues presently included in the DSM. Arguments for or against revisions of various gender and sexual diagnoses are presented-some may have repercussions regarding insurance reimbursement and patient access to care. This book is certain to raise questions for mental health professionals interested in how cultural influences affect psychiatric diagnoses.

Sexual and Gender Diagnoses of the Diagnostic and Statistical Manual (DSM) reviews those controversial gender issues previously seen as being a disorder. The book critically evaluates the medical, psychotherapeutic, and civil rights issues in the diagnosis, assessment, and treatment of GID in children, adolescents, and adults, and presents evidence and debates for its exclusion from the next DSM. Arguments for and against removal of paraphilias from the DSM are explored in detail. Finally, sexual pain criteria for diagnoses are examined, reviewing the latest studies that support or criticize the view that dyspareunia and vaginismus may be better classified as a pain disorder.

Sexual and Gender Diagnoses of the Diagnostic and Statistical Manual (DSM) presents controversial debate from experts such as:

• Robert Spitzer, MD
  
• Charles Moser, MD, and Peggy J. Kleinplatz, PhD
  
• Walter O. Bockting, PhD, and Randall Ehrbar, PsyD
  
• Kelley Winters, PhD
  
• Arlene Istar Lev, CSW-R, CASAC
  
• Paul Jay Fink, MD
  
• and other respected authorities!
  
  

Sexual and Gender Diagnoses of the Diagnostic and Statistical Manual (DSM) is thought-provoking, enlightening reading for psychiatrists, psychologists, mental health workers, epidemiologists, researchers, educators, and students.

Disordering Gender Identity: Gender Identity Disorder in the DSM-IV-TR

Arlene Istar Lev, LCSW, CASAC

SUMMARY. The inclusion of Gender Identity Disorder and Transvestic Fetishism in a psychiatric diagnostic nosology is a complex topic that is best understood within the larger context of the history and politics of diagnostic classification systems. The diagnostic labeling of gender-variant individuals with a mental illness is a topic of growing controversy–within the medical and psychotherapeutic professions and among many civil rights advocates. An overview of both sides of this controversy is outlined, highlighting questions about the potential damage caused by using psychiatric diagnoses to label sexual behaviors and gender expressions that differ from the norm, and the ethical dilemmas of needing a psychiatric diagnosis to provide legitimacy for transsexuals’ right to attain necessary medical treatments. The author reviews the use of diagnostic systems as a tool of social control; the conflation of complex issues of gender identity, emotional distress, sexual desire, and social nonconformity; the reification of sexist ideologies in the DSM; the clinical and treatment implications of diagnosing gender for “gatekeepers”; and some recommendations for GID reform.

KEYWORDS. Diagnosis, Diagnostic and Statistical Manual, DSM, GID, gender, gender identity, Gender Identity Disorder, psychiatry, stigma, transgender, transsexual

The inclusion of Gender Identity Disorder within the official diagnostic nosology of mental disorders is a controversial topic that invokes many questions about the role of the psychiatric establishment in the labeling of those who violate societal norms, particularly norms involving sex and gender issues. These questions are not unique to Gender Identity Disorders but involve a larger contextual analysis of the historical role of politics in the construction of diagnostic classification systems, and the medico-psychiatric (mis)treatment of those labeled with unusual sexual behaviors or gender expressions.

The Diagnostic and Statistical Manual of Mental Disorders (DSM) delineates the authoritative nomenclature of psychiatric nosology within the western world. The DSM is not a static document, but continues to evolve through text revisions and advanced scientific knowledge (Bartlett & Vasey, 2001; Bower, 2001; Zucker, 2005). The current publication is the fourth text revision (APA, 2000) and includes both the diagnoses for Gender Identity Disorder (GID), the official diagnosis for transsexualism, and Transvestic Fetishism (TF), the official diagnosis for erotic transvestism, within the section on Sexual and Gender Identity Disorders. The diagnosis of GID, following a thorough psychosocial assessment and evaluation, is essential in order to receive a referral to a physician who can prescribe hormones, a necessary step to begin a medical sex reassignment process.

The DSM, undoubtedly the clinical “bible” of the psychiatric, psychological, and social work fields, is not, however, without its critics. Numerous academics, theoreticians, clinicians, researchers, and social commentators have levied accusation at the DSM for being over-inclusive, arbitrary, imprecise, lacking reliability and validity, being a tool for managed care and insurance companies, and for contributing to a pathologization of normal human diversity (Brown, 1994; Caplan, 1995; Kirk & Kutchins, 1997; Szasz, 1970; Wakefield, 1997). The inclusion of GID and TF in the DSM has become the focus of a complex controversy regarding the purpose and use of the diagnostic systems in labeling people who express sexual and diversity. On one hand, the diagnosis invokes challenging questions about the use of psychiatric diagnoses to label as mentally ill those with sexual behaviors and gender expressions that differ from the norm, and on the other hand, raises equally compelling questions about the ethics of using a psychiatric diagnoses within a manual of mental illness to provide legitimacy for transsexuals’ right to attain necessary medical treatments.

The DSM stresses that a mental disorder must “ ...beconsidered a manifestation of a behavioral, psychological, or biological dysfunction in the individual. Neither deviant behavior (e.g., political, religious, or sexual) nor conflicts between the individual and society are mental disorders unless the deviance or conflict is a symptom of a dysfunction in the individual” (APA, 2000, p. xxxi). The DSM does not offer clear guidance, however, in distinguishing deviant behavior that is caused by a psychiatric disturbance from socially non-conforming, but mental sound, deviant behavior (Kirk & Kutchins, 1997; Wakefield, 1997). The DSM also does not offer a definition of mental health, or functionality, although the authors of the DSM acknowledge the limitations of their definition of mental illness and the difficulties of developing a consistent operational language for defining behavior that is “disordered,” “abnormal” or “dysfunctional.” However, the consequence and impact of this ambiguity on individuals who express “deviant” political, religious, and especially sexual lifestyles has been under-examined.

Diagnosis as a Tool of Social Control

Diagnostic classification systems are presumed to rely on scientific study and positivistic research; diagnostic manuals are supposed to represent an expert and unbiased methodological perspective. The history of diagnosis in western cultures reveals bias and prejudicial assumptions that belie these expectations, and exposes an underlying psycho-medical gaze that has intentional sought out human deviance with the intention of establishing institutionalized social control (Foucault, 1965, 1978, 2003). The psychiatric field has a long history of using diagnostic classifications to pathologize ordinary human diversity in the realms of race, ethnicity, sex, gender, class, disability, and sexual orientation, and being labeled psychologically deviant has inevitable consequences for the civil rights and social status of minority peoples (Brown, 1994; D’Emilio, 1983; Kutchins & Kirk, 1997; Somerville, 2000). In the mid 1880s there was an explosion of anthropological, sociological, psycho-medical, and judicial explorations into abnormal sexual behavior, with a specific focus on libidinous desire, particularly in women and children, and sexual deviations, like inversion (cross- gendered homosexuality) and hermaphroditism (intersexuality) (Dreger, 1998; Foucault, 1965, 1978, 2003; Herdt, 1994). Many of the diagnoses in the current DSM are the legacy of these early explorations into human sexual deviations from what was presumed common and “normal,” despite Kinsey’s subsequent research showing enormous human diversity in sexual expression and behavior, raising questions about “normalcy” and actual human sexuality (Kinsey, 1948, 1953). The examples outlined below will reveal an aspect of societal regulation and attempts at political control inherent in classification systems, and how this impacted the development of a psychiatric hegemony over acceptable subjectivities, i.e., the defining of mentally disordered sexual and gender expressions that were therefore socially and legally unsanctioned.

According to scientific and medical experts of the 1800s, immigrants to the US–particularly the Irish–were thought to be more prone to mental illness, criminality, and other forms of social deviance. Italians, Slavs, and Jews were believed to suffer from serious mental illnesses based on a biological heredity that was said to “degenerate” with each successive generation (Bell, 1980). Benjamin Rush, known as the father of American psychiatry, believed dark African skin was caused by a medical illness related to leprosy; he also believed that people who had a fervent commitment to mass participation in democracy suffered from a mental illness called anarchia (Bell, 1980; Kutchins & Kirk, 1997). Two common mental disorders of the 1800s were drapetomania, a mental illness among African slaves whose primary symptom was trying to escape slavery, and dysathesia ethiopica, used to describe slaves who destroyed plantation property, who were disobedient, who fought with their masters, or who refused to work (Kutchins & Kirk, 1997).

These diagnoses could be viewed merely as odd historical footnotes, but in fact they have impacted law and public policy in profound ways. These diagnoses were used to support the need for slavery and racial segregation as well as setting strict quotas on the immigration of various European and Asian groups (Bell, 1980; Kirk & Kutchins, 1997). Additionally, they provided the political support for anti-miscegenation laws which prohibiting marriages between races and sterilization laws to allegedly stop the spread of insanity, directed exclusively at minority peoples (ibid). In contemporary Western cultures, books are still marketed to “prove” the inferiority of black people’s intellectual functioning (Herrnstein & Murray, 1994), and research has shown that clinicians tend to ascribe more violence, suspiciousness, dangerousness, and psychological impairment to black clients than they do to white clients (Jones, 1982; Loring & Powell, 1988); Blacks and Hispanics continue to be diagnosed with schizophrenia more frequently then whites (Wade, 1993). Racist underpinnings remain active in scientific study, in clinical assessment, and in the use of nosologies (consciously or unconsciously) to label minorities with mental health disturbances.

Just as medical diagnoses reinforced racist policies, they were similarly used to label women with mental health disturbances. From the mid 1800s through the twentieth century, women were diagnosed with neurasthenia, nervous prostration, dyspepsia, and hysteria, which were believed to be due to the “wandering” of the uterus within women’s bodies (Ehrenreich & English, 1978, 1973). Women were subjected to institutionalization in mental asylums, clitoridectomies, hysterectomies, removal of their ovaries, leeches applied to their labia, and forced rest cures based on these diagnoses (Geller & Harris, 1994). When women began advocating for increasing social and political rights, medical experts evoked frightening pronouncements about the impact this might have on society. Women were accused of having a disorder called andromania, “a passionate aping” of “everything mannish.” It was feared that if women won the right to vote, it would “make them change physically and psychically and pass along pathologies to their children” (as cited by Katz, 1995, p. 89).

A more contemporary example of sexism was the invisibility of the impact of childhood sexual abuse, adult sexual assault, domestic violence, and other trauma on the lives to women before the rise of second wave of women’s liberation, and how their symptoms of abuse and trauma were misdiagnosed as masochistic behavior and Borderline Personality Disorder (Brownmiller, 1975; Herman, 1992; Miller, 1994; Schechter, 1982). Early feminist research showed how traits that were considered specific to women were believe to be less healthy than male traits, and but when women presented with more traditional male traits they were also thought to be mentally substandard (Broverman, Broverman, Clarkson, Rosenkrantz, & Vogel, 1970). Contemporary feminist researchers and clinicians continue to expose the overuse of psychotropic medications in treating women, and the mislabeling of women’s propensity for affiliation and connection to others as signs of codependency (see Mowbray, Lanir & Hulce, 1985 Brown, 1994).

Caplan (1995) describes the debate over the addition of Premenstrual Dysphoric Disorder in the DSM-IV despite controversies over the lack empirical basis for the category, and the social and political consequences it may infer for women. Self-Defeating Personality Disorder (formerly called Masochistic Personality Disorder) was removed from the DSM following political pressure from prominent feminist researchers (Caplan, 1995). Criticisms continue to be levied at the diagnoses of Borderline Personality Disorder and Dissociative Identity Disorder, which are disproportionately seen in women who are victims of trauma; these diagnoses downplay the etiology of the disorders, placing the cause on dysfunction with the personality of the trauma survivor (Caplan, 1995; Herman, 1992; Kutchins & Kirk, 1997; Miller, 1994).

The relationship between social mores and diagnostic processes is exemplified in the inclusion and subsequent removal of Homosexuality from the DSM (Bayer, 1981). Homosexuality initially appeared in the DSM-I under the label of sociopathic personality disturbance (APA, 1952), and was listed in the DSM-II as a Perversion (APA, 1968). Etiological theories of homosexuality prevalent before the 1970s were based on non-representative clinical or incarcerated populations (D’Emilio, 1983) and assumed that all homosexuals suffered from psychopathology (Smith, 1988). Evelyn Hooker’s 1957 report of a non-clinical sample of homosexual men suggested that a significant portion of homosexual men showed no significant psychopathology, functioned well, and were satisfied with their sexual orientation (D’Emilio, 1983). In 1973, Homosexuality was removed from the DSM II (7th printing) because it failed to meet the criteria for distress, disability, and inherent disadvantage (APA, 1980; Bayer, 1981; Stoller et al., 1973). According to Bartlett and Vasey (2001), it was this controversy over removing Homosexuality from the DSM that compelled the writers of the DSM to develop a definition of mental disorders.

It is important to note that Homosexuality was not technically removed, but rather modified, and a...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Contents
• Foreword
• Introduction: Sexual and Gender Diagnoses of the Diagnostic and Statistical Manual (DSM): A Reevaluation
• Gender Identity Disorders in Childhood and Adolescence: A Critical Inquiry
• Disordering Gender Identity: Gender Identity Disorder in the DSM-IV-TR
• Gender Dissonance: Diagnostic Reform of Gender Identity Disorder for Adults
• DSM-IV-TR and the Paraphilias: An Argument for Removal
• Sexual and Gender Identity Disorders: Discussion of Questions for DSM-V
• Sexual and Gender Identity Disorders: Discussion of Questions for DSM-V
• Commentary: Gender Variance, Dissonance, or Identity Disorder?
• Politics versus Science: An Addendum and Response to Drs. Spitzer and Fink
• What Is Sexual Pain? A Critique of DSM's Classification of Dyspareunia and Vaginismus
• Index