July 25, 2012

Campaign against pathologization of transgender in medical manuals

The Coordination Team of STP 2012, the International Stop Trans Pathologization Campaign, has published a document called  “Reflections on the ICD Revision Process from a Depathologization and Human Rights Perspective”.

The document includes a good discussion on the way the American manual for mental diseases (DSM-5) and the UN/WHO International Classification of Diseases (ICD) cover transgender issues.

The team argues that both the gender identity disorders and the transvestic fetishism categories ought to be removed from the manuals.

The group is also initiating an International Day of Action for Trans Depathologization, which  will take place on Saturday, October 20th, 2012.


  1. And thus the circle is completed... Transsexual, tha stolen narrative that is trotted out everytime some old man in a frock is confronted with his fetish is finally thrown under the bus. "Trans" is an issue of lifestyle and sexual preference? Surger? Strictly cosmetic and only for those who are so deeply ashamed of their genitals they might be considered... You know, what's the word? Oh yes! Crazy!

    And yet I and my sisters are suppose to welcome as family the TG same TG that used me like a whore!

    Sorry, but fuck you very much!

  2. @Miz Know-It-All

    I am not going to answer for the people behind this campaign, but your view of what this blog stands for is definitely wrong.

    So let me sum up my position for you:

    Being a transsexual is not a fetish or a life style choice.

    Being transsexual is not the same as belonging to a third sex, or being androgynous or gender queer.

    As far as I am concerned, transsexual men and women have a mismatch between their inner sex identity and their bodies, a mismatch that may be rectified by way of hormones and surgery.

    So in my eyes, you are a woman, plain and simple. You are not a fetishist or something in between genders.

    In other words: I am not really your enemy.

    Where we part, I guess, is in our view of other transgender people.

    Even if I believe that there are many clear cut cases where people are either transsexual or non-transsexual, others fall in between.

    Indeed, many transwomen have lived as men in denial for years, trying to adapt to the role society requires of them. That does not make them fetishists.

    Then there are others who actually have no clear sex identity. But that does not make them less human.

    There are also those who experience strong gender dysphoria, but who -- for many legitimate reasons -- chose to stay in their roles as men. That does not mean that they treat you like a whore.

    None of these people have chosen to become like this. Crossdreaming or crossdressing are not life choices.

    But yes, there are those for whom crossdreaming and crossdressing seem an innocent games or types of role playing. Some of them even argue that this is all a fetish, and that you too are a fetishist.

    But that is not me.

    I am sure putting up a kind of oversimplified enemy image of the evil imperialistic TG makes your life easier, but I am afraid that does not make it true.

    By repeating this narrative you are not only hurting non-transsexual transgender, but also genuine transwomen in search of a genuine life.

    You see, many of them take part in this community, and the reason for this is that they see that crossdreamers, crossdressers and transwomen may help each other, even if we are not all the same.

  3. Jack,

    I agree with your reply to Miz Know-It-All 100%.

    Wow, it's hard to tell where she is coming from. Is she saying that the only ones who can use the prefix "trans" are transexuals? She seems to think that the transgendered are trying to ride on the transsexuals coattails or maybe that transsexuals own the term transgendered. Or maybe she has different definitions for transgendered and transsexual. Maybe if we aligned our definitions she would loose her rancor.

    If some transsexuals don't want to be included in the transgendered umbrella thats fine. No one is forcing them. But they shouldn't try to prevent us from making our voices heard.

    But the non-transsexual transgendered are just looking for answers. They want to know if they might be transsexual, crossdresser, crossdreamer, etc... We want to know if we're crazy or not, or are we just part of the normal spectrum of human sexuality.

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  5. I don't think that there is any question, that transsexualism and gender varaince are distinct. For those that are transsexual recognition that their condition as a physical medical condition (i.e. pathologic) is of great importance. What exists if you will is a gender/sex conflict. It carries very distinct health care demands. Transsexualism is not a lifestyle choice but rather a failure for whatever reason to develop a physiology that is congruent with innate gender experience of self. The gender is fixed and the sex is wrong. Any psychological aspects are usually collateral and will vanish after surgical correction unless Axis 1 or 2 issues exist separate and apart.

    Gender Variance usually can be described as a gender/gender conflict. It has it's own health care demands which are usually psychological and are rooted in social acceptance of variation. This condition is often considered by those suffering from it as a lifestyle choice. The freedom to express as you want.

    De-pathologicalization (not really a word) of the transsexual condition will close the door on the health care needs of transsexuals. That would be a devastating move.

    Transsexuals have been fighting a desperate fight not to be drowned in the great transgender soup, because it will literally kill them unless their condition is recognized as a physical medical condition.

    Transsexuals lives are so often used as a justification for transgender politics. In a sense the transgender community tends to point to us and says: "we are like them" when on closer examination and reflection that is not at all the case.

    Without discriminating between these two conditions and their very distinct health care demands there can be no "help for each other".

    Consider the recently approved amendments of DSM 5. I commented somewhere else recently this: "The DSM V wording is very suspect because it perpetuates gender/gender conflict instead of the gender/sex conflict and is essentially designed to keep matters in psychiatry and psychology land for purposes of diagnosis; the industry approach to continued client streams.

    It is important that in the "indicators" sex characteristics are used to support a gender/gender conflict scenario. "

    It is so easy to wave off a increasingly radical view of transsexuals of their co-option into the TG ranks. If there was unequivocal understanding and clarity about the differentiation of the conditions in the public mind and especially among gender variant persons, the debate would be moot. What will the gender variant community do to promote this?

  6. @Kathryn Dumke

    Thanks for the very clear and concise explanation. I think it meshes quite closely with what Jack said but in a more clinical manor. I agree with everything you said.

    But, what are the transgendered to do? Are they just to crawl under a rock and disappear? Are their issues to be ignored so the the transsexual's can advance their cause? Are their psychological issues less important than transsexuals pathological issues?

    It may be that being transgender is psychological and transsexual is pathological. But neither one belongs in the DSM V. It seems to me that both groups could work together on this. Especially since the general public doesn't know the difference between them. Don't we all just want to be accepted?

    My opinion is that this is social issue and not a medical/psychological issue. We have to get the general public to accept us as legitimate. If we're all seen as normal the transgendered's psychological issues go away and the transsexuals medical treatment is accepted.

  7. @Kathryn

    "I don't think that there is any question, that transsexualism and gender varaince are distinct. "

    I agree with much of what you say, but this statement -- I believe -- is misleading.

    There are both crossdreamers/crossdressers and transwomen out there that want to uphold this belief.

    The crossdreamers and crossdreamers want to avoid to be labelled transsexual as it threatens their gender identity, and the transsexual women wants to avoid association with the crossdressers/crossdreamers as it threatens their sex identity.

    That is: Both consider the other side toxic, as they threaten their social acceptance as being male or female.

    This is also why you will find both crossdreamers/crossdressers and transwomen who call crossdressers "fetishists", as this presumably makes it clear that crossdreaming is about culture and psychology, and not about biology. Crossdressers are simply men with a fascinating kink.

    I simply do not buy it.

    Yes, if you compare the a post-op transwoman with a crossdresser who completely identifies with his male role, they have little in common. The first is a woman, the other is a man, socially, culturally and psychologically defined.

    But if you look at the grey area in between, it becomes harder to make an absolute distinction between the two categories.

    Many crossdressers and crossdreamers experience severe gender dysphoria, me included.

    The crossdreamers and crossdressers who do transition must be accepted as transsexual, because they truly are women.

    Kelley Winters puts it this way when criticizing the related distinction between "autogynephiles" and "homosexual transsexuals" (i.e. androphilic transwomen, cp. Ray Blanchard):

    "is it credible that the same effect, gender dysphoria, comes from not one but two unrelated causes depending on the sexual orientation of the person? is this science, or do these proliferating theories represent a defensive response -- a denial of contradicting evidence that challenges the status-quo? Perhaps Occam's Razor would be good medicine for the behavioral sciences as well."

    I believe it was Viriginia Prince who established the meme that crossdressers and crossdreamers are men with a broad cultural gender expression. It suited her and her friends, because it made crossdressing less threatening for spouses and friends.

    I think she was wrong. i believe all gender dysphoria has a biological core, but that many crossdressers and crossdreamers avoid this conclusion, as they fear it will threaten their lives as men. They will often be right about that.

  8. Jack,
    Since I posted Kathyrn has done a bang up job of elaborating on my intent... But,the problem is and the part I think you and most others still do not get is the line betwixt the two is not blurry, it is razor sharp! Transsexual is something you are born with end of story! Transsexual is an unresolvable conflict between your physical self and your freudian id. It is that conflict which drives us and nothing more... The conflict between the physical self and the mental must be resolved and honestly? Either way would be just peachy! But it seems the id is immutable, and the body not, so it is the body which must in the end be changed! Ergo if that is NOT your narrative 100%, bada boom bada bing, you're not transsexual!

    Now as to what happens to the TG for whom that is not their narrative? Oh I could easily be flip and say I don't give a damn! Particularly after the way they have colonized us. But, to be honest? I do care. I care because the answer to their dilemma is something that affects us all. The answer is not to opt out and continue to take the path of least resistance created Arnold Loman. Instead the real answer. The answer he should have taken was to stand up and be a man. Albeit a man with a need to be other than what the narrow limits of man say you can be! Likewise for the women! Stand up and be women! Women who are not going to take being a second class human! Women who are not going to accept that male is better! The answer to all of this lies in ending the misogyny! The misogny which is so deeply ingrained into our world that men still routinely use the term "ladies" amongst themselves as a motivational insult and the why that it is an insult never even crosses their minds! Really? Is being female THAT derogatory and you never ask WHY?

    So stop the hedging, toss the umbrella on the garbage pile where it belongs, and with it much of this issue will simply vanish!

  9. Jack,

    I would like to say a few words about the Kelly Winters quote.

    "is it credible that the same effect, gender dysphoria, comes from not one but two unrelated causes depending on the sexual orientation of the person? is this science, or do these proliferating theories represent a defensive response -- a denial of contradicting evidence that challenges the status-quo? Perhaps Occam's Razor would be good medicine for the behavioral sciences as well."

    I disagree with the notion and statement that transsexuals suffer from gender dysphoria. Stripping it down, dysphoria is simply a facy word for depression. Because we experience our gender immutable the actual cause of depression is the conflict between how we experience ourselves and how our bodies developed. The result is increasing depression as we become self aware. Psychiatrists and psychologist call this gender depression when in fact it is depression caused by lack of congruence. It is as said above a gender/sex conflict. Gender dysphoria is a complete misnomer.

    Depression in gender variant persons has quite a different root, that is it is caused by the mutability of the gender experience that these persons have. Their inner experience is not bound into a gender binary, like most people on this planet. This gender fluidity causes very serious depression when no social integration can be achieved for any other position but male or female. Most gender variant never get help for their innate gender condition. They are, from a health care perspective left to their own devices and in the rare cases where they are diagnosed they are diagnosed with gender depression which in my view is quite a correct diagnosis. Where Wpath and other Standards of Care and DSM 5 fail is that they conflate the two conditions by not distinguishing the nature of distress gender variant persons experience and the nature of distress that transsexuals experience. In addition, they require that the person desires to change at least one primary or secondary sex characteristic. This is the worst that could have happened. Instead of making the call we are left with a hash of everything they could think of, in my view a sloppy joe of diagnostic indicators.
    Transsexuals need to change all of their primary and secondary sex characteristics. Not one, not two, all of them.

    Comparing these forms of depression is like saying situational and constitutional depression are the same thing. It is in essence like comparing depression by a person who has lost a limb and needs to relearn working with a prosthesis to be whole to depression because of a severe mood disorder. It is simply not the same thing. And saying that those two groups should be under one umbrella and should support each other no matter what, helps neither. Recognizing what the conditions are and having the correct therapeutic approach does.

    No gender variant person is actually helped by surgery. In fact most have absolutely no interest in switching sex because the does not heal the underlying condition.

    All actual transsexuals need and must have surgery because it does heal the underlying condition.

  10. @Kathry

    I don't think that Kelley Winters reduces transsexuality to gender dysphoria (or body dysphoria, which is probably a better term, as this is primarily about the body and not culture). Indeed, i think she would agree with you, as will I.

    Gender dysphoria is a term that can be used to describe the effect of the transsexual condition, but nothing more. This is proven by the fact that most post-op transwomen and transmen report no such dysphoria.

    The problem with your argument is, I fear, that it will be used to put all crossdreamers, crossdressers and non-op transsexuals into the gender variant category, burying the fact that many of them are truly gender dysphoric, using your definition of the term.

    Certainly, there are gender variant people out there who suffer from not being allowed to express a wider spectrum of feelings and personality traits, because their culture won't allow it. There might even be some crossdressers and crossdreamers among them.

    Still, I seriously doubt that this is what drives many other (if not most) crossdreamers and crossdressers. When you scratch the surface, the real pain appears, and that pain is uncannily like gender dysphoria. I know that for many it is truly depression of the transsexual kind.

    The problem is that your clean and orderly distinction between the two groups requires that all non-op transwomen must be completely aware of the true nature of what ails them.

    In the real world this is not the case. For many this is a journey that takes years. This is especially true for the gynephilic transgender, who's sexual orientation lures them into longer periods of denial, for the simple reason that they want to find a woman to love.

    Believe me, most crossdreamers and crossdressers are securely anchored in the gender binary. Very few of them identify as gender queer. Their crossdreaming and crossdressing are simply way for their psyche to try to resolve the unresolvable.

    By sorting all crossdreamers and crossdressers into the gender variant box, you therefore risk mislabeling many transwomen.

    I do not think that our disagreement is of the fundamental kind. There are gender variant people of the kind you describe, and it may well be that the DSM is making a mess of this as well.

    But the main problem with the DSM 5 is that is forces ALL gynephilic transwomen who have ever crossdressed or dreamed of having sex as a woman into the transvestic disorder category, and I am afraid that your line of reasoning can lead to the same mistake.

  11. The problem is that your clean and orderly distinction between the two groups requires that all non-op transwomen must be completely aware of the true nature of what ails them.
    By sorting all crossdreamers and crossdressers into the gender variant box, you therefore risk mislabeling many transwomen.
    But the main problem with the DSM 5 is that is forces ALL gynephilic transwomen who have ever crossdressed or dreamed of having sex as a woman into the transvestic disorder category, and I am afraid that your line of reasoning can lead to the same mistake.


    A fundamental problem of diagnosing persons with a transsexual condition is that the vastness of individual experiences presented clouds a clear view of the true underlying but very observable phenomena. Psychology and psychiatry are, as scientific disciplines, the great groping in the dark and this continues in the DSM 5 because no one has enough fortitude to actually take a principled approach for fear of being found unaccommodating to those being diagnosed.

    My concern with this is that unless you can establish the rules you cannot possibly observe variances from it. And of course perception is always drawn to the irrelevant rather than to the relevant. I cannot count the number of times I have heard stories of a crossdresser who “discovered” their nature under some tutelage of a therapist. Exploration begins, he/she is sent to “support groups” to further explore and find others who feel likewise and with them and before you know it an external dynamic controls the entire situation, until one day they will say “I am a woman”. Being at the receiving end of this kind of treatment, how can you not be utterly confused. This approach also obscures matters for those who, if properly diagnosed under objective criteria, would be transsexual. When you really dig deep into this whole approach (and please note that I avoided the word circus) it suffers from exactly the kind of discipline that would avoid the risk of mislabelling either transsexual or gender variant persons.

    Transsexuals often are not aware of their true nature. The fact of incongruence with which you were born makes it impossible to have such an awareness. Once an experience of incongruence rises from becoming self aware, the fight begins. This can sometimes take a very long time to resolve. That does not make the diagnostic approach subjective. It makes the diagnosis increasingly difficult but no less clean and orderly. It is a huge disservice to gender variant persons and transsexuals if they are mis-diagnosed.

  12. Let me see if I understand the distinction being made here.

    A transsexual is a person who, upon receiving surgery has their depression resolved. A transgender person is one who, upon receiving surgery does not have their depression resolved, theoretically because they still wish to be acknowledged in a way as the sex of origin.

    From a practical point of view, these people will appear virtually identical through much of their lives. Self identification is a key element in diagnosis, denial is a reality and high social costs cause both gender variant and transsexual people to try similar things to self diagnose themselves, or even cure themselves.

    Given that, why would these supposedly distinct groups not have more in common politically than not in common? Other than self reporting after medical intervention, how can we tell who is who? How do we tell a transsexual in denial living a military life from a gender variant individual who is living full time as the opposite gender saving and dreaming of being able to afford the big op?

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  14. Edit to expand:

    Dear Anonymous:

    Let me see, where do I start. I have yet to find a gender variant person who needs surgery or considers surgery a viable treatment option once properly diagnosed. When you consider the system set up to emphasize an external dynamic through psycho-therapy and the so called support groups there is a significant number of persons who get drawn into considering surgery.

    In my experience those that are transsexual will have surgery and those that are gender variant will not. The great failure of our current health care approaches is that it allows such a dynamic to be determinative of diagnosis and then after the fact claims they were right.

    If you go back to Benjamin's approach, he determined one of the characteristics of the transsexual was the requirement to have surgery and hormonal therapy.

    In his chapter "three different types of transsexuals" he characterizes all three as transsexuals. The last two were characterized as true transsexuals, while the first lives often as a gender variant person (he calls them transvestites) but desires surgery but is prevented from obtaining the surgery be real or imagined external factors.

    While science has progressed since the 1960s I am not sure that anyone has developed a comprehensive approach but rather for fear of being politically incorrect science has made a hash of things.

    I think I leave it that.


  15. @Anpnymous

    "A transsexual is a person who, upon receiving surgery has their depression resolved. A transgender person is one who, upon receiving surgery does not have their depression resolved, theoretically because they still wish to be acknowledged in a way as the sex of origin."

    There are no clear, completely unambigious, definitions of these terms.

    Transgender is normally an umbrella term. It encompasses a variety of individuals, behaviors, and groups involving tendencies to diverge from the normative gender roles connected to their original biological sex, including transsexuals.

    A transsexual man or woman is an individual who identifies with a physical sex that is different from his or her biological one.

    The problem is since we have no way of finding out what REALLY goes on in the head of a human being, the field is wide open for those that want to define what constitutes a REAL transsexual, as opposed to a "fake" one.

    Sexist stereotypes has led to all kinds of sorting mechanisms:

    Some argue that a MTF transsexual must display feminine looks and mannerisms, others than he and she must desire and require surgery, others that he or she must never have felt arousal from imagining himself or herself having the body of the target sex; others again sees crossdressing as proof of perversion.

    If you think about it none of these demands makes much sense (Why shouldn't a transman get aroused by the idea of having sex as a man?), which leads me to believe that we are facing strict disciplinary tactics here aimed at avoiding cross-contamination between those that manage to live up to traditional gender stereotypes and those that society consider perverts.

    Since some older gynephilic "transtitioners" do not live up to the heterosexual paradigm, they are considered fake.

    My point is not that the extremes of the transgender group are identical. A transwoman is a woman who normally identifies completely as a woman, and not some vague androgynous third sex.

    The problem is that given the enormous social pressure towards adhering to the sexist stereotypes, there is a large group of people who are truly transsexual, but who deny it or -- because of lack of relevant socialization -- misses the mark when it comes to socially defined gender behavior.

    These are the one who are unfairly stigmatized, by the professionals and by some other transgender people, both transsexuals and non-transsexuals.

    There are transwomen who want to avoid association with such "perverts", as they believe their own female identity may be questioned. There are also crossdreamers and crossdressers who fear this group, as they forces them to question their own sex identity.

    The "depression test" you suggest won't work, for several reasons. (1) Post op transwomen can be depressed for various reasons. A late transitioner will, for instance, face a different kind of social reaction than a younger one. (2) In general research shows that post-op transwomen are doing well, and given that so many of them are late trasitioners, that tells me that they are as likely to be "cured" of their dysphoria as others.

  16. @Jack,

    I think that another reason so many late transitioners don't show any depression after transitioning is that society is more accepting of transsexuals now than 30 or 40 years ago. If these individuals were in their 20's now the "classic" transsexuals would welcome them with open arms.

    I still don't understand why there is a criteria that TS's have to look totally feminine. A woman trapped in a mans body is still a woman no matter what she looks like. All TS's should be supporting her at all costs.

  17. @Lindsay,

    I have to totally agree with you that society is more accepting today then years ago. I myself am a Post-op MTF and have no regrets. I'm not a totally feminine girl, but i don't really care. Your right that a woman trapped in a man's body is a woman no matter what she looks like and i accepted the fact that i was a woman.


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