Re: Comment on the proposed “Gender Incongruence” in the draft revision of the of the Diagnostic and Statistical Manual of Mental Disorders, version 5
American Psychiatric Association:
The undersigned providers of and advocates for medical and mental health services to transgender and gender non-conforming communities welcome this opportunity to offer feedback and comment on the American Psychiatric Association’s draft revision diagnosis for Gender Identity Disorders (GID), “Gender Incongruence” (GI).
The lead organizations facilitating this response are Callen-Lorde Community Health Center and the Lesbian, Gay, Bisexual, and Transgender Community Center of New York City. Each of these organizations started providing community services in 1983 and together serve over 2,000 people of transgender experience with primary health care and hormone care as well as substance abuse, mental health, and community building services. Our organizations, as well as the other signatories to this letter, represent the largest settings providing health and social services to transgender and gender non-conforming people and their families in the United States.
We appreciate the APA’s proposed “Gender Incongruence”(GI) diagnosis is an effort intended to de-stigmatize gender non-conformity and improve transgender-identified people’s access to mental health care. We agree with the intention behind this effort; however, we endorse an alternative viewpoint, based on our years of collective practice knowledge. We believe GI will continue to inappropriately pathologize gender non-conformity, maintain barriers to medically necessary health care, and lend justification to gender based stigmatization and discrimination.
Prior to addressing the reasons behind our recommendation, we would like to respectfully address the process by which the APA undertook this effort.
From the vantage point of LGBT health and community centers, the conceptualization of “Gender Incongruence” occurred without valuable and necessary input from community providers who serve and are accountable to significant numbers of people affected by this diagnosis. The November 2008 Report of the DSM-V Sexual and Gender Identity Disorders Work Group indicates that the “sub-work group has addressed feedback from interested advocacy groups and other stakeholders. Surveys were sent to more than 60 organizations.” While other agencies have provided feedback in this process, we are concerned that the institutions that provide the bulk of medical and mental health services to transgender people nationwide were not asked for input. We have reached out to LGBT community health centers and LGBT community centers; none of these key, high-volume, client-centered, community-driven stakeholders seem to have been included in the research or vetting process. Without input from a representative sample of such organizations and their clients, the conclusions of the sub-work group regarding GI cannot be considered generalizable.
Our specific concerns regarding the validity and utility of the proposed inclusion of GI are as follows:
– Gender non-conformity is not a mental disorder: The proposed definition of a mental disorder in the DSM-V expressly prohibits the inclusion of diagnoses that are “primarily the result of social deviance or conflicts with society” (APA, 2010). The “Gender Incongruence” diagnosis inherently contradicts this tenet. Whereas the criteria for other psychiatric diagnoses are lists of symptoms that impair functioning, the proposed criteria for GI are a list of characteristics of gender non-conformity. There is no evidence or need for treatment that decreases gender non-conformity or crossdressing, as noted in “Transvestic Fetishism.” The GI diagnosis obfuscates the root cause of the distress many transgender people experience – pervasive discrimination. It is commonly acknowledged among mental health providers that being gay, bisexual or lesbian is not a disorder, but that the social impact of stigma, discrimination and homophobia can cause the individual great distress. GI falsely assigns dysfunction to the gender non-conforming person, rather than within the social environment.
– An inappropriate pathway to transgender-specific medical care: There is legitimate community concern that removal of a mental health diagnosis would limit access to transgender-specific medical care. While a minority has succeeded in using the legal system or in fulfilling their insurer’s requirements for coverage to access care, the majority of people needing transgender-specific medical care are denied coverage. GI maintains these barriers to care. Medical interventions are better substantiated by the use of medical diagnoses, not psychiatric diagnoses. Access to transgender-specific, medically necessary care can be directly and more effectively addressed by utilization of a revised medical diagnosis in the International Classification of Diseases (ICD). The psychiatric needs of transgender people are better addressed by existing psychiatric diagnoses.
– GI lays the groundwork for unethical and harmful reparative therapy: A GID diagnosis has historically been misused to justify treatment of “pre-homosexual” children in the hope of preventing or delaying the development of a positive and healthy gay or lesbian identity. With adults, transgender-specific medical intervention is often offered only if reparative therapy fails to relieve distress and improve social functioning.
The GI diagnosis will continue to lend false credence to interventions that foster shame, encourage children and adults to betray their true selves, and delay healthy identity development. This practice is harmful and unethical.
In summary, we propose all diagnoses addressing gender non-conformity and identity be eliminated from the DSM-5. The mental health needs – when present – of gender non-conforming people are addressed by existing diagnoses. We ask the APA to formally renounce reparative therapy addressing gender non-conformity in children, adolescents and adults. We acknowledge that a diagnosis must exist for those who require medically necessary transgender-specific care, and ask the APA to advocate for a viable transgender-specific medical diagnosis in the ICD. Finally, we respectfully request that the APA include lesbian, gay, bisexual and transgender healthcare institutions and community centers in these processes.
Callen-Lorde Community Health Center
The Lesbian, Gay, Bisexual & Transgender Community Center of New York City More