March 5, 2010

DSM-V: What about autogynephilia?

Some of you have asked me what I think about the proposal for DSM-V, the the fifth edition of the US Diagnostic and Statistical Manual of Mental Disorders (DSM-5) , which is to be published in 2013.

What this manual says about transsexuals and trangendered people matter a lot, both as regards the common understanding of such phenomena and to what extent Americans can get insurance companies to pay for treatments.

The good news is that there is a new gender incongruence category that leaves room for both classical transsexuals as well as other transgendered people. The bad new is that the category for transvestic fetishism remains.

A wide view of gender identity

The description of gender identity disorders has become more tolerant of gender variation. In fact, the proposal no longer talks about a gender identity disorder, but gender incongruence.

The argument is that this is a descriptive term that better reflects the core of the problem: an incongruence between, on the one hand, what identity one experiences and/or expresses and, on the other hand, how one is expected to live based on one’s assigned gender. The term is considered less stigmatizing than gender identity disorder.

This is what it says:

Gender Incongruence (in Adolescents or Adults)

A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested by 2* or more of the following indicators:

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)

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)

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

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)

The transsexual dimension

The revision has been taken as a confirmation of the binary view of sex and gender, meaning that this definition fits "classical transsexuals" (women trapped in men's bodies) only.It does fit the lives of M2f classical transwomen well. Their experience of being born with a body of the wrong sex is accepted, and it seems to me these formulations will help them gain respect as women. That is a good thing.

The transgender dimension

According to the "Rationale", the text also allows for a "transgender" interpretation, opening up for a wide variety of gender identities. Paragraph 5 clearly points to "alternative gender" as well as "the other gender."

This is what the comment says:

"Furthermore, in the DSM-IV, [the present edition] 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. 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)."

There is nothing in the definition of gender incongruence that says that transwomen who have experienced AGP erotic arousal or who have been crossdressing should not be included. But there is a catch.

Transvestic disorder

The manual does keep the additonal transvestic fetishist category, although under a new name. The category is now called "Transvestic Disorder".

This is what the proposal says about crossdressing and autogynephilia:

Transvestic Disorder

A. Over a period of at least six months, in a male, 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)

So crossdressing is no longer a fetish. But don't keep your hopes up. Crossdressers and autogynephiliacs are still perverts.

Committee-member Blanchard argues that the old term (Transvestic Fetishism) stresses erotic interest in the material properties of a woman's clothing. This is too narrow, he believes, as it fails to include the "erotic arousal at the thought or image of one self as a woman" (autogynephilia).

Blanchard believes, as I have noted before, that crossdressing is just one of several subcategories under the top category "autogynephilia". The rest of the text continue to focus on crossdressing, however, and here transvestism is the top category. This leads me to believe that this text is some kind of compromise between Blanchard and other members of the gender identity disorder work group. That is, someone in the committee has insisted that they should stick to "transvestite" as the umbrella term.

Non-crossdressing autogynephiliacs are left out

If autogynephilia is a subcategory under crossdressing, there is no room for autogynephiliacs who do not crossdress. This implicitly means that they do not have a disorder. The crossdressers who want to transition will find themselves marooned in the paraphilia category, however. That means that they have a disorder.

This is, of course, pure nonsense.

All crossdressing is a disorder

As i noted in my previous post on the DSM Blanchard is using his own unscientific prejudices as regards what's normal and what's not as a basis for medical classifications, in effect labeling a lot of people as perverts in the process.

He repeats his extremely narrow definition of normal sex in the accompanying paper (available online).

"Such a name change [Transvestic Disorder] is consistent with my general proposal to distinguish between paraphilias and paraphilic disorders. On this view, a paraphilia is any powerful and persistent sexual interest other than sexual interest in copulatory or precopulatory behavior with phenotypically normal, consenting adult human partners (Cantor, Blanchard, & Barbaree, 2009). "

If you took this definition seriously only heterosexual sex between men and women using a penis and a vagina would pass the muster. And even if Blanchard does accept that homosexuals should not be considered paraphiliacs, the logic underpinning his arguments points in another direction. Note that the definition above has two categories. The A category is a paraphilia. The B category is a paraphilic disorder. The difference is that B - the paraphilic disorder -- causes impairment or distress.

Fine! That would mean that we could leave out the A (the healthy crossdressers), right? And if crossdressing is not a disorder, it should not be included under the headline "transvestic disorder". Moreover, if it is not a disorder, it does not belong in a manual for mental disorders in the first place -- no more than enthusiastic stamp collecting or aggressive mountain climbing.

So you could take out the A category and leave in the B.

The use of language

That is what you would expect. But it does not matter what crossdressers may think, because Blanchard has made up his mind. Read the next paragraph carefully and note the words I have underlined:

"The immediate consequence of re-naming the diagnosis is that the patient does not have to be subjectively distressed or objectively impaired by his transvestism to be identified as a transvestite; he simply has to manifest the syndrome of repeated dressing in women’s apparel with sexual excitement (Criterion A). An ego-syntonic [i.e. in self-denial], well-adjusted transvestite could be classified as a transvestite for research or descriptive purposes without being diagnosed with a disorder.

The crossdresser does not have to be subjectively distressed to be included, because Blanchard believes he has a disorder regardless of what the crossdresser may say. After all, a man who wants to dress up as a woman cannot possible be in his right mind. Getting turned on by imagining himself as a woman having sex as a woman is not a "sexual interest in copulatory or precopulatory behavior with phenotypically normal, consenting adult human partners".

(Or at least, it is not according to him. Most crossdressers actually dream of having normal sex as a woman with normal partners, but who cares about what they say?)


Note that this is the only disorder in the whole manual that is limited to men. A woman who gets aroused by dressing up as a man is not a paraphiliac. Why not? Well, neither the draft nor the Blanchard paper say.

We know that F2M crossdressers and autoandrophiliacs exist. There can only be one explanation: For a man to want to dream about having the body of a woman is considered a disease; for a woman to desire the body of a man is not. What on earth are these people thinking? This is the year 2010, not the misogynistic 19th century!

A convenient excuse

Still, Blanchard clearly sees the problem of classifying healthy people as perverts, so he comes up with an excuse. The "well-adjusted transvestite could be classified as a transvestite for research or descriptive purposes without being diagnosed with a disorder."

So in order to help Blanchard with his autogynephilia research, the American health system is to label a large number of men as mentally ill, even if they are not. And just to make sure that ever doctor in America understand that they are "well-adjusted", the condition is put under the headline "transvestic disorder".

This makes me sick! I know of autogynephiliacs who plan to chemically castrate themselves to get rid of their feelings. Why? Because they are labeled as perverts. Over at Laura's Playground you will find the most tragic tales of transgendered people breaking down under the burden of shame, pain and despair. All caused because their self respect has been obliterated by some people's obsessive need to categorize people as deviants. And yes, there are suicides.

In spite of this Blanchard wants to keep the transvestite disorder category in the manual, so that he can do research.

Smooth operator

In a text that otherwise is both liberal and enlightened, this bigotry makes it through because it is hidden behind a deceivingly smooth phrasing.

Note, for instance, that the word “heterosexual” has been removed "because some transvestites interact sexually with other males, especially when cross-dressed, and may subjectively perceive themselves as bisexual."

OK, so Blanchard and his friends are willing to accept that M2F crossdressers and autogynephiliacs may be attracted to men? Oh no! The phrase "subjectively percieve themselves" means "they may say so, but we don't believe them". Blanchard believes all autogynephilic crossdressers are gynephilic, and that there are no bisexuals.

Where did the gender dysphoria go?

The old DSM-IV specification was the following:

With Gender Dysphoria: if the person has persistent discomfort with gender role or identity

The reason this has been removed is not that Blanchard and his colleagues are not recognizing that crossdressers cannot experience gender dysphoria (or "gender incongruence" as it is called now). They do, but Blanchard argues that you can use the Gender Incongruence category as well if this is the case.

This is actually a good thing. It doesn't matter how much you pull these sentences apart, the manual recognizes that crossdressers can be suffering from "gender incongruence". This also means that autogynephilic fantasies can not in themselves hinder anyone from getting sex reassignment surgery.

But without this specification, the practitioners and specialists do not get the help they need to do this reclassification. The fact that crossdressers can be recognized under the gender incongruence cateogory is hidden. And given that "gender incongruence" is not a disorder, while crossdressing is, this will cause a lot of confusion.

Do we need a "transvestic disorder" category?

I do not accept that crossdressing or autogynephilic fantasies are "paraphilias". I am still open for the possibility that it has a psychological as opposed to a biological origin, although all evidence points in the direction of it having a biological basis. But I do not accept that it is a paraphilia in the way it is defined by Blanchard.

Sexuality is not there for normal procreation only. Sexuality is not that is limited to "copulatory or precopulatory behavior with phenotypically normal, consenting adult human partners". Sexuality is a force that binds us together. Sexuality gives us a room for exploration of our inner identity and of our relationship with others. Sex is creativity. Sex is bonding. And it helps us express love, joy, ecstasy and grief.

For most autogynephiliacs, sexual fantasies are the only way their inner woman can find an expression. And the reason this is the only way, is because there is no room for such feelings in our society. This manual reinforces these prejudices and makes it even harder for these people to find themselves and a life of meaning. This manual negates their identity and makes a mockery of their lives.

I am not saying that there are no mental diseases among autogynephiliacs. There are probably more psychological suffering in this group than in the general population, because of the stigma. There are depressions, obsessions and addictive behavior. But you do not need the "transvestic disorder" category to help them. You can just use the relevant categories for depressions, obsessions and addictive behavior -- as you do for carpenters, hairdressers and lovers of good books.

The transvestic disorder category has to go!


Anonymous said...

Im not 'aroused by the idea of being a woman' im horrified by having a male body and trying to have sex as a man is sickening.
Kay Brown relentlessly attacks 'autogynephiliacs' for diverting attention from the transkids she looks after, as if the two types of mtf transgender are in competition and AGP people are a homogenous group of perverts.
The religious right attacks all transgender people as if we are a homogenous group of perverts.
All it comes down to for me is sex as a guy is horrifying, sex as a (transwoman) is nice. this is true of sex fantasies too.

Jack Molay said...

I agree!

The differences we might see between "early onset" and "late onset" trans women are most likely the effect of different social dynamics, based on sexual orientation or personality (as Jaimie Veale has argued). Indeed, we now see that the "late onset" (understood as trans women who love women) come out at an earlier and earlier age, now that they are met with more tolerance.

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