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Printable White Paper on GID of Adults

the very name, Gender Identity Disorder, suggests that cross-gender identity is itself disordered or deficient

failing to distinguish gender diversity from gender distress, the APA has undermined the medical necessity of sex reassignment procedures

that the DSM-IV-TR prevalence numbers are off by almost two orders of magnitude presents a direct challenge to the psychiatric profession's credibility

the DSM does not acknowledge the existence of well-adjusted transsexual or gender variant people or differentiate them from those who could benefit from treatment

Issues of GID Diagnosis for Transsexual Women and Men -- Kelley Winters, Ph.D.

Under the premise of disordered gender identity, self-identified trans-women and trans-men lose any rightful claim to acceptance as women and men, but are reduced to mentally ill men and women respectively. This is underscored throughout the supporting text, where subjects are offensively referred to by their born sex and not their experienced preferred gender.

Medically Necessary Treatment of Gender Dysphoria. Gender Dysphoria is defined in the DSM-IV-TR as:

A persistent aversion toward some or all of those physical characteristics or social roles that connote one's own biological sex (p. 823).

In failing to distinguish gender diversity from gender distress, the APA has undermined the medical necessity of sex reassignment procedures for transsexuals who need them. It is little wonder that the province of Ontario and virtually all insurers and HMOs in the U.S. and have denied or dropped coverage for sex reassignment surgery (SRS) procedures. Since gender dysphoria is not explicitly classified as a treatable medical conditon, surgeries that relieve its distress are easily dismissed as "cosmetic" by insurers, governments and employers.

The transgender community and civil rights advocates have long been polarized by fear that access to SRS procedures would be lost if the GID classification were revised. In truth, however, transsexuals are poorly served by a diagnosis that stigmatizes them unconditionally as mentally deficient and at the same time fails to establish the medical necessity of procedures proven to relieve their distress.

Overinclusive Diagnosis. Distress and impairment became central to the definition of mental disorder in the DSM-IV (1994, p. xxi), where a generic clinical significance criterion was added to most diagnostic categories, including criterion D of Gender Identity Disorder. Ironically, while the scope of mental disorder was narrowed in the DSM-IV, Gender Identity Disorder was broadened from the classification of Transsexualism in prior DSM revisions and combined with Gender Identity Disorder of Adolescence or Adulthood, Nontranssexual Type (GIDAANT) from the DSM-III-R (1987, pp. 74-77).

Unfortunately, no specific definition of distress and impairment is given in the GID diagnosis. The supporting text in the DSM-IV-TR lists relationship difficulties and impaired function at work or school as examples of distress and disability (2000, p. 577) with no reference to the role of societal prejudice as the cause. Prostitution, HIV risk, suicide attempts and substance abuse are described as associated features of GID, when they are in truth consequences of discrimination and undeserved shame. The DSM does not acknowledge the existence of many healthy, well-adjusted transsexual or gender variant people or differentiate them from those who could benefit from medical treatment. These are left to the interpretation of the reader. Tolerant clinicians may infer that transgender identity or expression is not inherently impairing, but that societal intolerance and prejudice are to blame for the distress and internalized shame that transpeople often suffer (Brown, 1995). Intolerant clinicians are free to infer the opposite: that cross-gender identity or expression by definition constitutes impairment, regardless of the individual's happiness or well-being. Therefore, the GID diagnosis is not limited to ego-dystonic subjects; it makes no distinction between the distress of gender dysphoria and that caused by prejudice and discrimination. Moreover, the current DSM has no clear exit clause for post-operative transsexuals, however well adjusted. It lists postsurgical complications as "associated physical examination findings" of GID (2000, p. 579).

Pathologization of Ordinary Behaviors. Conflicting and ambiguous language in the DSM serves to confuse cultural nonconformity with mental illness and pathologize ordinary behaviors as symptomatic. The Introduction to the DSM-IV-TR (2000, p. xxxi) 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...

Gender Identity Disorder can be distinguished from simple nonconformity to stereo-typical sex role behavior by the extent and pervasiveness of the cross-gender wishes, interests, and activities.

In the supporting text of the Gender Identity Disorder diagnosis, behaviors that would be ordinary or even exemplary for ordinary women and men are presented as symptomatic of mental disorder on a presumption of incongruence with born genitalia. These include passing, living and a desire to be treated as ordinary members of the preferred gender. For example, shaving legs for adolescent biological males is described as symptomatic, even though it is common among males involved in certain athletics. Adopting ordinary behaviors, dress and mannerisms of the preferred gender is described as a manifestation of preoccupation for adults. It is not clear how these behaviors can be pathological for one group of people and not for another.

Maligning Terminology. Of the disrespectful language faced by gender variant people in North America, none is more damaging or hurtful than that which disregards their experienced gender identities, denies the affirmed gender roles of those who have transitioned full time and relegates them to their assigned birth sex. Throughout the diagnostic criteria and supporting text, the affirmed gender identities and social role for transsexual individuals is termed “other sex.” In the supporting text, subjects are offensively labeled by birth sex and not their experienced affirmed gender. Transsexual women are repeatedly termed “males,” and “he.” For example,

For some males …, the individual’s sexual activity with a woman is accompanied by the fantasy of being lesbian lovers or that his partner is a man and he is a woman. (APA, 2000, p. 577, emphasis noted by underline)

Adult males who are sexually attracted to females, … usually report a history of erotic arousal associated with the thought or image of oneself as a woman (termed autogynephilia). (p. 578, emphasis noted by underline)

The Numbers Don't Add; Transsexual Prevalence -- Prof. Lynn Conway, Full Text (Conway, 2001) The DSM-IV-TR cites the prevalence of Gender Identity Disorder with the following statement:

There are no recent epidemiological studies to provide data on prevalence of Gender Identity Disorder. Data from smaller countries in Europe with access to total population statistics and referrals suggest that roughly 1 per 30,000 adult males and 1 per 100,000 adult females seek sex-reassignment surgery (p. 579)

One way to triangulate on the prevalence of MtF transsexualism in the U.S. is to first estimate the number of people who have actually undergone SRS and divide that number by the population of adult males up to about age 60. The prevalence of transsexualism would then have to be many times that SRS number. When I underwent SRS in 1968, I learned from Dr. Harry Benjamin that I was about the 600th to 700th in the U.S. to do so. U. S. numbers took a jump in the 1970's because of university gender-identity programs, and many surgeons in the U. S. began performing "The Operation." In a meeting with Dr. Benjamin in 1973, I learned that there had already been 2500 SRS's on U. S. males. The top three U. S. surgeons (Eugene Schrang, Toby Meltzer and Stanley Biber) together now perform a total of 400 to 500 SRS's each year. Stanley Biber alone has done over 4,500 SRS's since1969. At least 800-1000 MtF surgeries are now performed in the U. S. each year, and at least half that many or more are performed on U. S. citizens abroad. The table below shows my estimates of SRS operations on U. S. citizens by well-known primary SRS surgeons here and abroad, extrapolated to include those done by many, many secondary surgeons. A range of values is given from conservative to likely numbers.

Adding these numbers , there are now at least 32,000 to 40,000 post-op transsexual women in the U. S. (the large majority of those undergoing SRS over the years are still living). The total number of males in the U. S. in the 18-60 age range is about 80,000,000. Dividing 32,000 by 80,000,000, more than one out of every 2500 males born in the U. S. has undergone SRS. This makes the 1:30,000 estimate in the DSM-IV-TR wrong by at least a factor of 12. However, I estimate that at least 5 to 10 times as many people in the U.S. suffer from intense gender dysphoria as have undergone SRS. This makes the DSM-IV-TR prevalence numbers off by almost two orders of magnitude. Such a truly egregious error presents a direct challenge to the psychiatric profession's credibility in the entire area of transsexualism.