Samenvatting
Summary literature of lectures 5 and 6
- Instelling
- Universiteit Van Amsterdam (UvA)
A Summary of the literature discussed in lectures 5 and 6 of the current topic course A Clinical Perspective of Today’s Issues.
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Voorbeeld van de inhoud
Lecture 5Davy (2015) The DSM-5 and the Politics of Diagnosing
Transpeople
Introduction
The aim of a DSM-5 workgroup on sexual and gender identity disorders was to reduce the stigma of
trans people, but at the same time making sure that de diagnosis would be accepted by insurance
companies and other funders of transitioning treatments. Gender Identity Disorder (GID) changed to
Gender Dysphoria (GD) in the DSM-5, but with somewhat similar criteria. De problem changed from
first an identity problem to now a distress caused by incongruence. But focus on distress in
problematic because:
1. People who do not chronically experience distress might not have access to treatment and
recognition
2. A diagnosis is perceived as misrepresenting the lives of trans people.
Diagnostic and Political Shifts
Till 1874 homosexuality was in the DSM. When removed it was first replaced by Egodystonic
Homosexuality (distress associated with homosexuality) and later it was completely left out.
Transsexualism and GID were introduced in the DSM-IV, because more people wanted transitioning
treatments. At first only ‘true transsexualism’ was recognized (people who underwent surgery and
experienced distress prior to surgery), but later there came room for people whose gender
expression was different form assigned sex, but did not seek treatment or had distress. In the DSM
the focus is on the body which is more about anatomic dysphoria than GD. Besides that, the DSM
criteria are based upon stereotypes of gender identity. There is much debate about biological
causation of gender and behaviour, and the existence of masculine or feminine behaviour is not
supported.
Politics of Citation
Scientific literature that was used in the DSM-5 workgroup, but it was derived from a select group of
sexologists. In the DSM-5 only autogynephilic or homosexual transsexuality are sexualities reported
with transwomen. Autogynephilic people are transwomen who are attracted to women. Some argue
that the subdivision of transwomen into autogynephilia or homosexual transsexuality is out of date.
Research shows that transwomen’s and ciswomen’s arousal when thinking about having sex as
women is similar. The view that transwomen that are attracted to men transition to make
themselves sexually attracted to heterosexual men (Benjamin, 1966) leads to stigmatization and
discrimination.
Rehearsing the Clinical Narrative
Trans people feel the need to report problems in a way that fits the “correct” trans narrative to
clinical psychiatrist to not be excluded from treatment. An example is enjoying the genitals of
assigned sex, while identifying with another gender is not correct trans. This skewed information
given to the clinicians has implications for the relevance of data derived from the clinics. It weakens
the significance of GD as a diagnosis for all transpeople. The DSM-5 criteria requires people to
behave in traditional gendered expressions even though there are no great behavioural differences
between genders in modern Western society.
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, Claiming an Intersex Embodiment
Some trans’ advocates associate gender identities with biological dispositions, caused by hormonal
influences in the fetus. These influences caused certain developments in the brain that can be
described as feminine or masculine. This way trans people can be seen as having intersex
characteristics. This will prove that being trans is a natural occurrence and this can help is social
acceptance. However, the biological view is problematic, since it proposes a binary sexed brain.
Neuroscientist explain that environment and experiences reshape the brain, and genes are not
directly linked to behaviour.
Self-Determination as Political Praxis
Some people wanted the DSM-5 to better reflect the distress gender incongruence causes, others
were more concerned about the issues surrounding insurance. So in the question if GD should be in
the DSM-5 there is a shift from clinical reasons to economic reasons. The Standard of Care 7 (SOC7)
was set up to address widespread problems regarding health services for trans people. They point
out that interventions should be based on the patients decisions and that GD does not have to be
present for treatment. Distress about gender might be caused by other reasons, e.g. rejection,
maltreatment or victimization. It is unclear how psychiatrist can differentiate between those causes
and the required cause for GD. There is also a group that argues that changing gender is a rational
self-determination and not a mental health disorder.
Zucker et al. (2013) Memo Outlining Evidence for
Change for Gender Identity Disorder in the DSM-5
In this article discusses the Memo Outlining Evidence for Change (MOEC) prepared by the GID
workgroup. The MOEC is a report about the justifications for changes in diagnostic categories. The
eleven proposed changes and the reasons why:
1. Change of name from GID to Gender Dysphoria (GD)
- GID is stigmatizing so first Gender Incongruence as name was proposed
- Avoiding presupposition about distress as requirement for diagnosis with gender
incongruence (distress sis still retained in DSM-5 with GD)
- Good that disorder was gone, but maybe easily misread and applied to people with
gender-atypical behaviour, so Gender Dysphoria was proposed
- GD pertains distress
2. Decoupling from sexual dysfunction and paraphilias (sexual arousal to atypical things)
- Sexual dysfunction is not really relevant to GID because if manifest in children
- Including it with paraphilias in stigmatizing
3. Change in introductory descriptor to point A Criterion
- Now the introductory is about the incongruence between expressed gender and
assigned gender for at least 6 months, instead of about cross gender identification
and the exclusion of perceived cultural advantages
- Incongruence better reflect the core of the problem
- Sex is replaced by assigned gender to include people with DSD, also it gives an exit
clause for people that have transitioned to no longer have GD
- Perceived cultural advantages lack is left out, because it excludes one causal
explanation, but GD is about a phenomenological approach
- 6 months was included to exclude very transient GD
4. Merge of point A and B
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