Transgender Advocates’ Statements on APA DSM Workgroups

Jim Burroway

May 30th, 2008

The American Psychiatric Association has convened several panels to discuss revisions to the Diagnostics and Statistical Manual (DSM), which is currently in its fourth edition (DSM-IV). It’s a standard practice for the APA to revise the manual every decade or so in order to incorporate knowledge generated by more current research.

The APA has begun the work of compiling the data for DSM-V, and that process has sparked several strange rumors around the Internet that really didn’t ring true with me. According to a few of these rumors, the American Psychiatric Association (APA) is poised to either reinstate homosexuality in the Diagnostics and Statistical Manual (DSM), or that the APA was going to decide to approve of sexual reorientation therapy. There is nothing however to suggest that anything like that will be happening.

But most of these rumors surround the diagnosis of Gender Identity Disorder (GID), which is of particular interest to the transgender community. These rumors are centered around two researchers who have been appointed to some of the working groups: Kenneth Zucker, who chairs the Sexual and Gender Identity Disorders work group, and Ray Blanchard, who chairs the Paraphilias subworkgroup under Zucker.

To understand transgender people’s concern about these two appointments, some background is in order. Kenneth Zucker and Ray Blanchard are associated with the Centre for Addiction and Mental Health in Toronto, Canada. This center resulted from the merger of four mental health centers, one of which was the Clarke Institute of Psychiatry. The Clarke Institute was the referral agency for transgender clients who wanted to surgically transition.

Many transgender clients found their treatment in the hands of the Clarke Institute degrading and offensive, feelings which were greatly magnified by the Institute’s main mission of treating sex offenders. Transgender clients often describe inappropriate and degrading tests and experiences at the institute. In fact, feelings run so deeply about the Clarke Institute that some transgender advocates have dubbed it “Jurassic Clarke.”, while others append the adjective “notorious” in front of the Institute’s name so routinely that one might be tempted to think that its official name was “The Notorious Clarke Institute.”

Because of the Clarke Institute’s history, virtually anything emanating from the Centre for Addiction and Mental Health is suspect among the transgender community, and those suspicions often radiate to the rest of the LGBT community.

Associations with the Clarke Institute however isn’t the only source of transgender advocates’ concerns. Also controversial are some of Blanchard’s theories on MtF transgender etiology that he calls “autogynephilia,”which many people find deeply offensive and off the mark. (Blanchard, on the other hand, is a leading researcher into what he believes to be the biological causes of male homosexuality.) Also controversial is Zucker’s approach to treating transgender clients, which involves counseling the client to take on behaviors and attitudes which are considered to be more socially appropriate to that person’s biological sex. This is an approach which raises alarm bells among gays and lesbians who recognize the parallels to sexual reorientation therapies, which may be the source of the rumors concerning homosexuality and sexual reorientation therapy that I mentioned earlier.

Today, we have a statement from four Transgender advocacy groups, which will hopefully provide some clarification on Zucker’s and Blanchard’s role in the DSM-V revision.

Statement from:

National Center for Transgender Equality (NCTE)
Transgender Law and Policy Institute (TLPI)
Transgender Law Center (TLC)
Transgender Youth Family Allies (TYFA)

On May 1, 2008, the American Psychiatric Association (APA) announced the composition of work groups to review scientific advances and research-based information to develop the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V). The composition and scope of the work group on Sexual and Gender Identity Disorders and two subgroups are of great interest to transgender people and therefore to our organizations.

Though no consensus exists among transgender people about whether and how a GID diagnosis should be in the DSM-V, there is certainly agreement that decisions made by the APA about transgender and gender non-conforming people will deeply affect the lives of millions of transgender adults, adolescents and children.

We have met with and strongly encouraged the APA to closely adhere to its stated commitment to scientific process regarding diagnosis of transgender people. We are confident that a fair, unbiased review of current knowledge can result in a DSM-V that can move society toward a more rational and humane understanding of transgender people.

We encourage our transgender brothers and sisters to approach this issue with thoughtful consideration of all available information. To that end, we encourage transgender people and allies to remember that:

The naming of this working group on May 1 was not the commencement of advocacy around rethinking or revision of the GID diagnosis. Thoughtful advocates, within and without the APA, have been working on this issue for several years and they will continue to do so for several more, through at least 2012 when the DSM-V is finalized. We look forward to strengthening our relationships and positive communication channels with the many APA-affiliated professionals who are knowledgeable and understanding of transgender issues.

It is inconceivable that in the 21st century any credible scientist or medical professional would recommend any discredited treatment that would attempt to change a person’s core gender identity or sexual orientation. Such treatments have no empirical basis and are harmful. Importantly though, the DSM consists of diagnoses and not treatments. As such, the DSM-V will not offer any treatment recommendations for transgender people of any age.

The APA has created several mechanisms for thoughtful input into the DSM revision process from mental health professionals as well as laypeople affected by the DSM. We encourage transgender people and allies, especially mental health professionals, to utilize these systems to appropriately impact the process. In particular the APA has created a website through which written comments can be submitted. Additionally, as the DSM-V development process advances, working groups are charged with seeking the counsel and input of various advisers who will be selected from various clinicians, academics and other stakeholders. We will advocate for the inclusion of fair-minded advisors who are committed to providing only scientific, fair, reasonable and humane input. We are hopeful that these systems will help provide sufficient information to assure a fair and scientific process for the creation of the DSM-V.

Public acceptance of transgender people and anti-discrimination protections have been advancing swiftly. This is in large part due to scientific and medical advances, but also to the assertive, vigilant and intelligent activism of thousands of transgender people and our allies. While transgender people’s history with the psychiatric and medical professions has been, at times, fraught with misunderstanding and tainted by bigotry, we are optimistic that current and developing scientific research and clinical data will further the understanding of transgender issues among health care professionals and the public.

National Center for Transgender Equality (NCTE)

Transgender Law and Policy Institute (TLPI)

Transgender Law Center (TLC)

Transgender Youth Family Allies (TYFA)


May 30th, 2008

Blanchard is of concern for more than just “autogynephilia” and degrading tests. The other half of his etiology theory is “homosexual transsexualism,” which basically states that all MtFs who are attracted to males are essentially uber-homosexuals who transition because they think they’ve got a better chance at having lots of sex with str8 men transitioned than they would as ultra effeminate gay men. J. Michael Bailey’s “notorious” offensive and degrading book The Man Who Would Be Queen expounds at length on “homosexual transsexuals” as essentially nature’s way of providing guys with one night stands. According to Bailey, who is very tightly connected with the Blanchard-Zucker CAMH clique, “homosexual transsexuals” are “especially well suited to prostitution” and make it their mission in life to seduce any “single, heterosexual male” that they come across, but they’re incapable of committed relationships. Essentially, the book’s section on “homosexual transsexuals” reads like an invitation to commit rape. For this, Bailey draws high praise from Blanchard, Zucker, and the other CAMH clinicians.

The concern is that they’re aiming to spilt GID into diagnoses of “homosexual transsexualism” under sexual or gender disorders, and “autogynephilia” under paraphilias, meaning if you can’t convince your therapist that you’re exclusively attracted to guys, you’ll have to get diagnosed with a paraphilia to transition. (And if you can, then you get diagnosed as an uberslut.)


May 31st, 2008

I think Blanchard’s (and by extension, Bailey’s) views of autogynephilia have met with over-reaction by the trans community. But with a such a bad history with everyone who wants to diagnose us, who can blame us for being defensive? I think the autogynephile model does fit a few trans people, but it is not a complete model as Blanchard believes. So I am worried that in the next DSM, GID gets split into homosexual and heterosexual transexuals.

Remember, the DSM makes recommendation for treatment. Period. That’s explicitly stated. Even for non-controversial disorders where treatment is fairly obvious, the DSM does not specify treatment. Boo’s fear (above) that trans people will need such and such to transition because of the DSM is without base.

I also feel obligated to clarify that the Gender Identity Disorder does not include all transgender people – only those for whom their gender identity and body causes distress and lack of real world functioning. In my experience, very few trans people also have GID. But Zucker over-diagnoses it (in my opinion) because he equates gender identity as causing the distress whereas I think it’s almost always transphobic people that causes the distress. Regardless, that fact will also not change in the DSM V because it relies on the way every “disorder” is defined in the DSM.

Jim, you may want to do more research into Zucker. He’s Nicolosi’s equivalent in the ex-trans movement. Zucker wants nothing less than preventing as many children as possible from “becoming” trans and sees ex-gay-like therapy as the way to do it.


May 31st, 2008

Remember, the DSM makes recommendation for treatment.

No, that’s the SOC. The DSM describes diagnoses. (Or maybe you meant to write “makes no recommendation for treatment”?) In any event, if you want to transition the “official” way, you need a diagnosis to justify hormone and surgical treatment. Of course, more and more people are going farther and farther outside official channels to transition, which will only increase if Zucker and Blanchard have their way with DSM V. But if you want to use an American, Canadian, or European surgeon, you’ve pretty much got to have 2 letters officially stating that you have GID.

I think the autogynephile model does fit a few trans people, but it is not a complete model as Blanchard believes. So I am worried that in the next DSM, GID gets split into homosexual and heterosexual transexuals.

It doesn’t completely fit anyone. Even mega-AG cheerleader Anne Lawrence has made claims about herself that contradict it. But the issue isn’t what you or I or anyone else believes, except for the people sitting on the committees writing the diagnoses. That happens to include Blanchard and Zucker. Bailey included his hope that they’ll split the diagnosis in his book. I think they’re telegraphing what they’ll at least try.

Ms Assigned

May 31st, 2008

Ephilei writes:
> So I am worried that in the next DSM, GID gets split into homosexual and heterosexual transexuals.

If that were to happen then it would become illegal to use that diagnosis in Canada since it would conflict with anti-discrimination laws being based on sexual orientation. It would not be legal to use any diagnosis that differentiates in any way on a basis of sexual orientation.

Boo states:
> In any event, if you want to transition the “official” way, you need a diagnosis to justify hormone and surgical treatment.

That cannot affect the DSM process, the APA is at pains to point out that it is a diagnosis document and not a treatment document. Even if it were true that a GID diagnosis is useful because it opens the door to treatment that is not allowed to be taken into account when deciding whether to simply delete the diagnosis (which is what should will happen because stigma and shame is caused by the diagnosis existence, without the DSM the stigma will go, at this point all the DSM does for transfolk is to facilitate stigma and hate)

Jillian Barfield

June 17th, 2008

I agree with Ms. Assigned’s last comment to an extent. Without the stigma and shame, discrimination and resulting depression, there would be no ‘disorder’ to diagnose.

The DSM diagnosis of a mental disorder obviously causes a degree of stigmatization. The way I see it, the problem isn’t with trans-folk, it’s with the world’s perception of them and the resulting discriminatory behaviors displayed towards them.

The ‘diagnosis’ of transgenderism isn’t important. The underlying depression is what needs to be diagnosed.

Being TG is not an illness. Gender variance is present in every species in nature.

The reluctance of insurance companies to cover trans-people is pure and simple discrimination that helps perpetuate the stigma and is also one of the underlying causes of the depression.

Maybe by 2012, public opinion will change enough that the APA will consider alternate diagnoses criteria for ‘GID’ and put it into another category where it belongs.

It’s a physical problem with a physical cure.

That’s my opinion.



July 9th, 2008

Oops, I did mean “doesn’t make recommendations.” I believe it’s the intro of the DSM that discusses this.

Ms Assigned – The DSM belongs to the American Psychological Association, so I doubt they’ll take Canada into consideration. I believe Canada generally uses the DSM but makes adjustments occasionally.

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