May 2, 2014

What the DSM-5 says about terms like transgender, transsexual and gender dysphoria

The recent edition of the American psychiatric manual, the DSM-5 distinguishes clearly between the broader umbrella term transgender and the much narrower term transsexual. The text gives, in fact, a pretty good summary of the dominant model of gender variance. It is time transgender people get a chance to read it.

In the transgender debate words like "transgender", "transsexual" and "gender dysphoria" are used often without there being any clear, common understanding of what the terms really mean.
Photo: Janka Dharmasena

Unfortunately sex and gender is one of the most controversial topics around. We need love to thrive and be happy, and any real or perceived threat against the possibility of finding real love and affirmation as a sexual being can therefore be life threatening.

Because of this people seem to be willing to do anything to be included in the category of "normal", to the point of excluding other  people from the transgender community, often by attempting to  take full control over the meaning of essential words.

The purification of the term transgender

This especially applies to so-called transsexual separatists. Some of them redefine the word "transgender" to mean any gender variant person who is not like them ("classic transsexuals" and the HBS tribe). Transgender people can therefore not be "real transsexual women", as they see it.

Lately we have also seen separatists who want to appropriate the word "transgender", in effect redefining it to mean the same as the word "transsexual" (the truscum tribe). The end result is the same: The expulsion of all transgender people who do not adhere to their idea of what it means to be a real woman or a real man.

This is a vicious circle. Since significant sections of society, including parts of the medical, political and religious communities, insist on stigmatizing those who are different, the separatist believe that they must separate themselves from the crossdreamers, crossdressers, genderqueer and "non-binaries", not realizing that many of these "perverts" are actually gender dysphoric like themselves.

They also fail to see that in the eyes of the bigots, being a "pure" transsexual makes no difference. We are all perverts to them, and by supporting the exclusion of other gender variant people, they are in fact helping those who want to exclude all transgender.

The separatists often embrace established medicine to strengthen their claim to real womanhood or manhood, arguing that their transsexual conditions is nothing but a misalignment mind and body that can be corrected with hormones and surgery. It is this that makes them completely different from "non-binaries" like crossdreamers, they argue.

I do not question their claim of being the men and women they say they are. Being gender dysphoric myself, I believe there is a biological component to the cause of our misery. But there is no clear and absolute barrier between the gender dysphoric on the one hand and other types of transgender on the other.

A more open minded and tolerant psychiatry

The latest developments in both psychiatry and psychology reflect a greater awareness and respect for sex and gender diversity, and also a willingness to understand gender diversity not as a mental illness, but partly as expressions of natural gender variance and partly as instances of "gender incongruence" (i.e. a mismatch between mind and body).

The recent edition of the psychiatric manual of the American Psychiatric Association, the DSM-5, reflects this in a much better way than previous editions. This especially applies to the section on gender dysphoria, which was written by a subworkgroup headed by Dr. Peggy T Cohen-Kettenis. (1)

Giving you a chance to read the DSM chapter

Since separatists often make use of medical terms to prove that they do not belong to the larger transgender family, I have decided to make parts of the gender dysphoria  chapter of the 2013 edition of the DSM available to my readers. With a price tag of 110 US$, most crossdreamers and transgender will never be able to read it.

The text sums up the dominant thinking about gender variance in the American psychiatric community in a good way. There is still much that is problematic with a text like this one, but Cohen-Kettenis and her colleagues have managed to capture some of the complexity of gender identity and gender expressions. In any case the text debunks all of the major truscum myths about what is required to be considered transgender.

DSM-5 on transgender, some important points

Please make note of the following:

1. The DSM-5 defines "transgender" as a wider umbrella term that encompasses a wide variety of gender variance. Gender dysphoria is not needed to be classified as transgender. Transsexual is a sub-category of transgender. The terms are not synonymous.

2. The diagnosis "gender dysphoria" does not require a complete identification with one of the two genders as traditionally defined. Non-binary identities are accepted.

3. "A strong conviction that one has the typical feelings and reactions of the other gender" is only one of many possible criteria. It is not a required criteria. In fact, you need to fulfill only two of the six criteria for gender dysphoria listed to be diagnosed as having gender dysphoria.

4. The manual stresses that "In adults with gender dysphoria, the discrepancy between experienced gender and physical sex characteristics is often, but not always, accompanied by a desire to be rid of primary and/or secondary sex characteristics and/or a strong desire to acquire some primary and/or secondary sex characteristics of the other gender." (My emphasis) This is important as it is often argued that an anatomic dysphoria is needed for someone to be classified as gender dysphoric.

5. Crossdressers and crossdreamers can be diagnosed with having gender dysphoria. The chapter underlines that "An individual with transvestic disorder who also has clinically significant gender dysphoria can be given both diagnoses. In many cases of late-onset gender dysphoria in gynephilic natal males, transvestic behavior with sexual excitement is a precursor."

In other words: The DSM-5 clearly states that there is no absolute distinction between the groups of crossdreamers and crossdressers on the one hand and other transgender people on the other. Some (but not all) crossdreamers are truly gender dysphoric. In fact, the manual argues that crossdreaming can be an early sign of gender dysphoria and therefore transsexualism.

6. One of the reasons the DSM-5 distinguishes between gender dysphoria and transsexualism, is that people with gender dysphoria do not always end up transitioning. In the DSM the word transsexual is limited to those who plan to transition to their target sex, or who have done so.

7. The DSM-5 does not require "bottom surgery" for someone to be considered transsexual.

You can read an excerpt of the DSM-5 chapter on gender dysphoria in this blog post over at Crossdreamers 2.

Special thanks to Brenda Lana Smith, who transcribed large parts of the text!

Click here to buy the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition: DSM-5

See also:
This is what the word transgender actually means
Why we need a broad interpretation of transgender
On Truscummery and access to information
Truscum and the transgender war of words
"You are not one of us!" said the separatist transsexual

1) The DSM-section on "transvestic disorder", unfortunately, remains stigmatizing, which should come as no surprise, as that subworkgroup was led by the notorious Ray Blanchard, the father of the autogynephilia concept. But the fact that the category of transvestic fetishism or transvestic disorder is being removed from the manuals used in an increasing number of countries leads me to believe that it is only a matter of time before it is left out of the American manual as well. The World Health Organization’s Working Group on the Classification of Sexual Disorders and Sexual Health has proposed that crossdressing and crossdreaming should be removed from the next edition of the international ICD-11 manual. The era of the Ray Blanchards of the world is coming to an end.


Ashley W. said...

One of the reasons the separatists will never be able to control the definitions is that there are a lot of people out there who perfectly fit the "true transsexual narrative" but reject the word transsexual (usually because of its pathologizing history) and prefer transgender. Even Christine Jorgensen was an example of that.

Jack Molay said...


You are right about that. But this is what the new generation truscum separatists understand. They want to use the word transgender. In fact: They want to keep the word for themselves and stop other transgender people from using it.

In the end that might be a much more effective approached than the failed CT/HBS narrative.

joannaS said...

All of the separatist chatter comes NOT from any experts working on this subject but from frightened radicals who want to wash their hands from the toxin known as gender dysphoria.

The WPATH standards if care talks very much the same language as this version of the DSM and I was surprised when I read it. It even discusses alternate methods to treating.dysphoria other than transition.

Everywhere there is acknowledgement of dysphoria as a scaled phenonmenon (including in Harry Benjamin's work ) but for some radicals to think that they suffer from a unique condition due to the fact that their severity was so overwhelming and the call to transition so great.

Benjamin would have simply termed them a type V or VI.

What radicals think is not relevant however and I am gladened by the way dysphoria is being treated in professional circles.

joannaS said...

I would not be too concerned about tranvestic fetishism as there is a caveat in the definition in that the person must find this condition disabling or distressing. Therefore whether you are a young pre transition transsexual or a mild dysphoric experimenting with crossdressing and you are happy and comfortable then you suffer no such condition.

The other aspect is that your dressing be motivated by sexual reasons only which in both aforementioned cases this is clearly not the case.

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