The diagnosis of gender identity disorder (GID) is one of those handful of diagnoses that invoke passionate debate. With the fifth edition of APA’s diagnostic manual DSM-V now in the early planning stage, its authors will have to confront the contentious issue of whether the manual should again include the diagnosis of GID.
An APA annual meeting symposium in San Francisco in May showed just how much heat the debate can generate.
In fact, he insisted, GID is not a mental disorder at all. More than anything else, the criteria described reflect "the distress often experienced by parents" who have become "preoccupied with the negative aspects" of their son’s or daughter’s behavior as the child struggles to make sense of gender-related feelings, Hill maintained.
"Parents may inadvertently create" a problem in their children, he said, because they cannot come to grips with a child who does not easily fit into society’s approved gender roles and expectations.
"Psychoeducational approaches" directed at parents would do their children much more good than bringing them to therapy for a phantom disorder, Hill stressed. He urged a "parent-centered approach" to psychoeducation that encourages parents to accept their children "just the way they are," even if the parents’ inclination is to try to have the children’s feelings and behaviors somehow shifted back to the mainstream. Educational programs need to concentrate on teaching parents ways to help them and in turn their children understand that children may be comfortable in "nonstereotypical" gender roles, but they are not "sick."
Hill maintained that there are no valid rationales for treating youngsters who fit DSM’s criteria for GID (see box on page 32).
"There is little evidence of pathology" in these children, he said. "Researchers have been able to identify only minor distress sources in specific domains." Much of that distress arises from socialization problems, that is, "getting along with and being accepted by other kids."
He continued, "Gender roles are not clearly dichotomous, like DSM suggests they are."
The most "probable outcome" in children who meet GID diagnostic criteria, Hill stated, is homosexuality, "which is, of course, not a pathological outcome."
Hill likened so-called treatments for GID to "reparative therapies," which major mental health and professional organizations, including APA, have labeled "unethical and harmful" attempts to change sexual orientation.
He also noted that the DSM criteria allow a GID diagnosis without the individual’s having to meet the criterion of a "repeatedly stated desire to be, or insistence that he or she is, the other sex." Without this as a required factor, psychiatrists are left pathologizing nonconformist behaviors, he said.
If the DSM-V editors decide to keep GID in the manual, Hill wants them to include "tighter language" and "get rid of stereotypes and dichotomizing language." Also, if it remains, all five of the criteria under Section A must be required. Finally, he said, there should be "a moratorium on diagnosing and treating it" until research can show that it is a valid and treatable condition.
Katherine Wilson, Ph.D., a founder of the San Diego-based organization GID Reform Advocates and former outreach director of the Gender Identity Center of Colorado, disagrees with Hill on the value of a diagnosis based on gender identity. She insisted that it should remain in DSM, but not as a disorder.
Wilson believes that to reduce stigma, what’s now labeled GID should be replaced with a diagnosis "unambiguously defined by distress" rather than by "gender nonconformity." She took issue with the notion inherent in a psychiatric diagnosis of GID that cross-gender identity itself is not a legitimate mental and behavioral framework for some individuals, but rather a "perversion or defective development."
Wilson said that DSM fails to acknowledge that "many healthy, well-adjusted transsexual people exist" or to distinguish between such individuals and those who would benefit from a medical treatment.
She would like to see GID replaced with a term such as gender dysphoria, which would describe someone who is persistently distressed with his or her physical sex characteristics or with the limiting gender-based roles that society often imposes on men and women.
The current diagnosis, Wilson said, "poorly serves transgender and especially transitioning individuals," because it "contradicts the treatment goals for transsexuals who require sex-reassignment procedures."
A diagnosis based on dysphoria rather than evidence of "strong and persistent cross-gender identification" would be an important element in the long process leading up to sex-reassignment surgery, she added. It should also "exclude consequences of societal prejudice or intolerance" that are labeled as "symptomatic of mental illness," Wilson stated.
Psychiatrists and other physicians should assume that most transsexuals are "sane and responsible," Wilson stressed.
"Just as DSM reform reduced stigma surrounding same-sex orientation 30 years ago, reform of the gender identity disorder diagnosis holds similar promise today," she said.
The two prominent psychiatrists who served as the symposium’s discussants had serious disagreements with Hill’s and Wilson’s positions on the inclusion of GID in DSM.
Robert Spitzer, M.D., who chaired the work group that developed DSM-III (the volume that first included GID) and its revision, DSM-III-R, said that a key question regarding GID "is not where we place the boundary, but are there any cases of kids or adults for whom the diagnosis is appropriate?"
Spitzer maintained that certain behaviors "are part of being human—part of normal development." In all cultures, adults expect certain "essential" things to happen as children mature, and these always include fulfilling gender-based roles and engaging in gender-congruent behaviors. It is thus legitimate for psychiatrists to identify a disorder in which persons of one gender reject these roles and behaviors and assume those of the opposite sex. He rejected the view he ascribed to Hill that "everything is socially determined" and that straying far from those expectations is an acceptable variance of human behavior.
He also rejected Hill’s contention that "gender is not dichotomous," with everyone somewhere between the two poles. All humans are "biologically one or the other" sex, Spitzer stated, and cultures view gender as a "dichotomy."
The failure to identify with the gender with which one was born "is a dysfunction," he said.
Former APA president Paul J. Fink, M.D., also a symposium discussant, has worked with 40 transsexuals in the process of surgically changing their gender. His extensive experience with these individuals has demonstrated, he said, that transsexualism is, in fact, a valid psychiatric diagnosis.
Transsexualism "is not a normal sexual variant," said Fink, a professor of psychiatry at Temple University. He agreed that there is a dearth of research on GID, but warned against correcting that situation by "legitimizing behaviors that are actually disadvantageous" to the person. Psychiatrists "know there are times when we have to intervene," he emphasized.
Having GID as a diagnostic option, Fink said, helps him work with and help a patient, even if the work is helping the person prepare to have a sex-change operation. ▪