Queer Diagnoses Parallels and Contrasts in the History of Homosexuality, Gender Variance, and the Diagnostic and Statistical Manual (DSM) Review and Recommendations Prepared for the DSM-V Sexual and Gender Identity Disorders Work Group

Nor did the diagnostic change immediately end psychiatry’s pathologizing of some presentations of homosexuality. For in “homosexuality’s” place, the DSM-II contained a new diagnosis: Sexual Orientation Disturbance (SOD). This diagnosis regarded homosexuality as an illness if an individual with same-sex attractions found them distressing and wanted to change (Spitzer, 1981; Stoller et al., 1973). The new diagnosis served the purpose of legitimizing the practice of sexual conversion therapies (and presumably justified insurance reimbursement for those interventions as well), even if homosexuality per se was no longer considered an illness. The new diagnosis of SOD also allowed for the unlikely possibility that a person unhappy about a heterosexual orientation could seek treatment to become gay.

In 1980, DSM-III dropped SOD and in its place substituted “Ego Dystonic Homosexuality” (EDH) (Spitzer, 1981). However, it was obvious to psychiatrists more than a decade later that the inclusion first of SOD, and later EDH, had been the result of earlier political compromises and that neither diagnosis met the definition of a disorder in the new nosology (Mass, 1990a, 1990b). Otherwise, all kinds of identity disturbances could be considered psychiatric disorders. “Should people of color unhappy about their race be considered mentally ill?” critics asked. What about short people unhappy about their height? Why not ego-dystonic masturbation (Mass, 1990a)? As a result, ego-dystonic homosexuality was removed from the next revision, DSM-III-R, in 1987 (Krajeski, 1996). In so doing, the APA implicitly accepted a normal variant view of homosexuality in a way that had not been possible fourteen years earlier.

Other diagnostic systems would eventually follow suit. In 1992, the World Health Organization (WHO, 1992) removed “homosexuality” from the Tenth Edition of the International Classification of Diseases (ICD-10), replacing it with a diagnosis similar to Ego-Dystonic Homosexuality (Nakajima, 2003).

The World Health Organization (1992) followed the DSM-III’s lead in 1992’s ICD-10 and included the diagnoses of transsexualism and gender identity disorder of childhood.

It should be noted that while the two GID diagnoses are grouped together in DSM, treatment approaches for GIDC seem at marked variance from the treatment philosophy of GID in adolescents and adults. In the latter case, successful treatment of gender dysphoria through sexual reassignment seems relatively uncontroversial. However, there is much controversy about the treatment of GIDC. Until recently, in cases of GIDC in very young children, treating gender dysphoria to prevent transition in later life was felt to be a legitimate goal. Only when such efforts fail would transition be sanctioned (Wallien & Cohen-Kettenis, 2008; Zucker, 2008a, b).

It is beyond the scope of this paper to review all the issues in the debates regarding appropriate treatment of gender variant children. It should be noted, however, that changing cultural attitudes about what exactly constitutes “appropriate” expressions of gender are leading some clinicians to encourage parents in helping their children transition at earlier ages (Kennedy, 2008; Rosin, 2008; Spiegel, 2008a, b). Furthermore, as in the case of homosexuality in the 1970s, LGBT advocacy groups have had some recent successes in changing professional opinions about GID diagnoses. For example, in November 2008, “After repeated contacts” from the Swedish Association for Sexuality Education (RFSU) and the Swedish Federation for Lesbian, Gay, Bisexual and Transgender Rights (RFSL), the Swedish National Board of Health and Welfare (Transvestitism no longer, 2008), a governmental agency made Sweden the first country to remove the GIDC diagnosis from the Swedish version of the ICD-10, citing its potential, along with five other diagnoses, of being offensive and contributing to prejudice. The Swedish diagnostic manual, however, will retain the Transsexualism diagnosis in order to continue providing sex reassignment.

Traditionally, religion has played a strong role in codifying socially acceptable expressions of gender and sexuality. Gender beliefs about the proper roles of men and women are firmly rooted in Judeo-Christian and other traditions that regard gender role transgressions as grounds for censure and castigation--even punishment by death. Given the historical conflation of gender expression and sexual orientation, biblical prohibitions against homosexuality are at times framed in language that describes men as transgressing their “natural” (that is, God-given) gender roles:

In addition to condemning sexual transgressions, some biblical passages touch upon what would today be referred to as transvestism and transsexualism. For example, Deuteronomy 22:5 explicitly forbids cross-dressing: “The apparel of a man shall not be upon a woman and a man shall not wear woman’s garments for anyone who does these is an abomination to the Lord.” In orthodox Jewish traditions, Leviticus 22:24, “And one that is bruised, or crushed, or broken, or cut in the testicles, shall ye not offer unto the Lord; and in your land shall ye not make the like,” is interpreted as a prohibition against castrating both animals and human beings and is taken to forbid sex reassignment surgery.

For centuries, religious views and the legal consequences of those prohibitions held sway. However, accompanying the rise of Western secularism, in the mid-19th century, scientific and medical explanatory models of nature sought to supplant religious and supernatural explanations. Yet “as ecclesiastical authority began to wane with the rise of the modern state, the religious abhorrence of homosexual practices was carried over into secular law” (Bayer, 1981, p. 17).

In the process of casting a critical, scientific eye on a range of what were then deemed to be socially unacceptable behaviors, many “sins” would eventually come to be classified as “illnesses”: demonic possession redefined as insanity, drunkenness as alcoholism, and sodomy as an illness called homosexuality. Bayer (1981) contends that this was a model “inspired by the vision of a thoroughly deterministic science of human action. It rejected the ‘pre-modern’ stress on will and the concomitant moral categories of right and wrong. Instead it sought the causes of deviance in forces beyond the control of the individual” (Bayer, 1981, p. 18).

Yet, by the mid-20th century, critics of psychiatry and the medical profession would argue that psychiatric disorders merely reflected existing social attitudes and prejudices and that they were often nothing more than forms of social control. The most telling example of medicine’s history of diagnostic excess--and one easily held up for ridicule--is drapetomania, a 19th century “disorder of slaves who have a tendency to run away from their owner due to an inborn propensity for wanderlust” (Schwartz, 1998, p. 357). Szasz (1960), a psychiatrist, psychoanalyst, and spokesperson for a nascent anti-psychiatry movement, declared mental illnesses to be myths, no more than metaphors for physical illness. He characterized psychiatric nomenclature as an effort by mental health practitioners to exercise control in the guise of “providing treatment” for individuals by first defining them as “patients” and then labeling their thoughts, feelings and behaviors as “symptoms” of imaginary “diseases.” For Szasz (1965, 1974a), psychiatry’s diagnosis of homosexuality was a prototypical example of social control as was the medical model of drug addiction and the concomitant criminalization of drug users.

Although few psychiatrists today would accept Szasz’s line of reasoning, particularly his theory of schizophrenia (Szasz, 1974b), his arguments regarding the social context of diagnosing mental disorders are not completely without merit. For example, the first edition of the DSM (APA, 1952) explicitly and non-self consciously articulated a role for social values in making a diagnosis of the overarching category of sociopathic personality disturbances which included homosexuality: “Individuals to be placed in this category are ill primarily in terms of society and conformity with the prevailing cultural milieu, and not only in terms of personal discomfort and relations with other individuals” (p. 38, italics added).

While physicians and psychiatrists are often accused of seeking power and control, there are also altruistic reasons for turning “sinners” into “patients”: the medical model’s promise of hope for treatment and cure. An ill person was not necessarily responsible for his or her “symptoms,” and, in the best of circumstances, would benefit from therapeutic compassion rather than religious judgment and condemnation.

The stigma of psychiatric illness and the paternalism of medical practitioners notwithstanding, many “homosexuals” accepted, if not embraced, the medical model as an alternative to religious and legal condemnation. While some saw in the illness model hopes for a “cure,” Bayer (1981) sees a more practical concern:

Since the threat of criminal prosecution was the immediate danger, it is not surprising that homosexuals did not attack the standard psychiatric view of sexual deviation. With professional support hard to come by, it would have been surprising if those attempting to foster legal reform had diverted energy to the attack of those who argued that homosexuality was an inappropriate target of the criminal law (pp. 67-68).

By the 1950s and 1960s, ambivalence toward the medical model would play out in the publications of the American homophile movement as its members and allies openly debated the relative social merits and costs of pathologizing homosexuality. For example, Cory (1965) spoke not only for retaining the medical model but also defended the mental health professionals coming under attack from an increasingly militant homophile movement:

Once the name was Edmund Bergler [1956]; today it is Albert Ellis . . . I am more and more convinced that the homophile movement in the United States . . . will do great harm to its struggle if it gets into a head-on clash with men of science whose work it finds threatening: and that there is nothing inconsistent between acceptance of the work of psychotherapists who report success, nay cure, and the struggle for the right to participate in the joys of life for those who cannot, will not or do not undergo such change (pp. 8-9).

By the mid-1960s, Cory’s approach--advocating for gay people to have access to treatment of their homosexuality and for the gay community to collaborate with psychiatrists who pathologized homosexuality--was rejected by American homophile groups. Following the 1969 Stonewall riots, the “homophile movement” evolved into “gay liberation” and repudiated the medical model of homosexuality. The rest, as they say, is history.

Undoubtedly trans individuals in 1980, seeing a psychiatric diagnosis as the key to obtaining medical and surgical treatment, did not criticize Transsexualism’s inclusion in the DSM-III. However, since treatment for gender dysphoric children focused on preventing adult transsexualism, and in the case of some clinicians who claimed they were preventing homosexuality and cross-dressing (Rekers et al, 1977), GIDC received a much chillier reception. Some activists and academics in the field of queer theory (Mass, 1990b; Sedgwick, 1991) asserted that the new diagnosis was a ruse perpetrated by psychiatrists to prevent homosexuality in adults. Zucker and Spitzer (2005) refuted that interpretation of historical events on the basis of three reasons: (1) there was no need for a veiled backdoor diagnosis to prevent homosexuality because DSM-III [still] contained the diagnosis of ego-dystonic homosexuality; (2) that EDH was itself eventually removed from the DSM-III-R because of a lack of any empirical basis to support the diagnosis; and (3) “several clinicians and scientists who argued in favor of delisting homosexuality from the DSM-II were members of the DSM-III subcommittee on psychosexual disorders that recommended the inclusion of the GIDC diagnosis in DSM-III” (p. 35).

Why would the same experts who persuasively and successfully argued for removal of homosexuality from the DSM-II advocate for including the GID diagnoses in the DSM-III? As the following history reveals, what seems paradoxical today is the result of decisions made by individuals who lived in a different time with different ideas, different social values regarding gender, and different clinical and social agendas.

In the 1970s, professional advocates of the medical model of transsexualism found themselves arguing against a common psychiatric belief that saw trans people as severely mentally disturbed. Using an alternative medical model of illness, albeit one less pathologizing than the theories of neurosis and psychosis they opposed, they expanded professional awareness and knowledge about gender identity and sex reassignment and were eventually successful in changing psychiatric and medical opinions regarding the authenticity of trans subjectivities. As a result, they created increased possibilities for anatomically dysphoric transgender individuals to obtain the treatment they needed to live their lives unnoticed and unmolested as member of the other sex. Yet ironically, partially as a result of changes they helped bring about (authenticating and, through the DSM and later the ICD-10, solidifying a medical category of individual known as the “transsexual”) and partially due to circumstances beyond their control (the closing of university-affiliated gender clinics following the publication of Meyer & Reter’s 1979 controversial follow-up study claiming SRS confers no objective advantage in terms of social rehabilitation), cultural attitudes about gender would also change, perhaps in ways these medical pioneers never envisioned.

For example, the early transsexualism medical literature gives little indication of professional encouragement to live one’s post-transition life as an openly trans person. Christine Jorgensen, who did come out as an openly trans woman, was a rare exception. Instead, early professional proponents of sex reassignment seemed more likely to endorse (at least in their published writings) postoperative assimilation, which meant living unobtrusively as a member of the other sex. Benjamin (1966), for example, in discussing the results of male-to-female sex reassignment, noted that “several factors have to be considered: the physical and mental health, the emotional state, the social status, as compared to that before the change; the attitude of the family, the position in society, and last but by no means least, the sex life, largely dependent upon the adequacy of the newly created female genitals, especially the vagina” (p. 150). For an end result “to be assessed good, the total life situation had to be successful as well as the sex life. A good integration into the world of women with acceptance by society and by the families was essential” (p. 151, emphasis added). Similarly, the gender clinics at Johns Hopkins and other academic centers supported a treatment model of assimilation into cisgender culture. However, by the 1980s:

The closing of [most] U.S. gender clinics created a treatment vacuum which resulted in the slow development of a market economy for the treatment of transsexualism. Free from the restrictive policies of the gender programs, transsexuals began to orchestrate their own sex reassignments, choosing services and service providers in an a la carte fashion. Long kept out of communication with one another by privacy requirements of gender clinics and by the insistence of the clinics that to be “proper” transsexuals they must blend into society and disappear, transsexuals began communicating with one another, seeking and providing information and comparing notes . . . By 1985, there were a number of support groups and regional conferences which welcomed both crossdressers and transsexuals. Around 1990, transsexuals, who had been conspicuously absent from the literature, began to publish, adding their voices to those of feminist scholars . . . (Denny, 2002, p. 40).

One consequence of less medical control of postoperative living and an increased contact among individuals were newly formed trans communities that proposed a:

As increasing numbers of trans individuals began to come out of their closets, the gay liberation movement once again evolved and expanded more broadly into advocacy for lesbian, gay, bisexual and transgender (LGBT) civil rights. Sexual orientation and transgender identities, once conflated, and only recently separated from each other as discrete categories, now found common political cause. One historical fact supporting such a political alliance was that many of the protestors at the 1969 Stonewall riots were transgender (Duberman 1994; Stryker, 2007). There was also a very practical reason for the embrace of trans inclusion: those who oppose gay rights “see lesbian, gay, bisexual, and queer people’s interests as being almost the same, if not identical, to those of trans people” (Devor, 2002, p. 6). Trans inclusion would accelerate in the 1990s, as many national LGB advocacy organizations amended their mission statements to include gender identity and transgender people.

Because the transgender community is so much smaller than the lesbian, gay, and bisexual one, members of the former have successfully increased their cultural and political clout by aligning with the latter as an ostensibly united LGBT community. Trans advocacy today encompasses civil rights, access to care, and promoting greater tolerance of gender variance not just in trans individuals, but also in society in general (Drescher, 2002e; Wilchins, 1997).

At the time of the 1973 APA decision, organized psychiatry was not yet prepared to call homosexuality a normal variant of human sexuality. However, the diagnostic revision did end organized medicine’s formal participation in the social stigmatization of homosexuality. The APA decision shifted debate about homosexuality into the moral and political realms by depriving religious, governmental, military, media, and educational institutions of medical or scientific rationalization for discrimination.

With psychiatry no longer officially participating in stigmatization, a historically unprecedented social acceptance of gay men and women gradually ensued. Whether the APA role was causal, as this author has asserted (2006c) or a bellwether of wider social changes is open to debate. Nevertheless, those who accepted scientific authority on such matters gradually came to accept the APA position and a new cultural perspective emerged: (1) if homosexuality is not an illness, and (2) if one does not literally accept biblical prohibitions against homosexuality, and (3) if contemporary, secular democracy separates church and state, and (4) if openly gay people are able and prepared to function as productive citizens, then what is wrong with being gay? And if there is nothing wrong with being gay, then what moral and legal principles should the larger society endorse in helping gay people openly live their lives (Drescher, 2002c, 2006b)?

There has been ample consideration of these questions in the last four decades and consequently much has changed. In 1973, “homosexual behavior” was illegal in most of the 50 United States. The 1970s began the proliferation of local and eventually state civil rights ordinances making discrimination on the basis of sexual orientation illegal. As acceptance of gay people increased, by 2003, three quarters of the states had repealed their sodomy laws. Then, on June 26, 2003, the US Supreme Court made a 6-3 historic ruling in Lawrence and Garner v Texas to overturn the country’s remaining sodomy laws. National and state governments are increasingly addressing the rights of same-sex couples to adopt and to act as foster parents to children.

Even some religious organizations have changed their views on homosexuality. In 2005, United Church of Christ became the first mainline Christian denomination to support same-sex marriage. Major religious groups that permit same-sex unions but that do not give them the same status as marriage include the Episcopal Church, the Evangelical Lutheran Church, and Reform Judaism. Reform Judaism now trains openly gay and lesbian rabbis.

Most telling in the movement for normalization has been the rapidly-changing landscape of same-sex marriage. At the time of this writing, marriage equality can be found in Belgium, Canada, the Netherlands, Norway, South Africa, Spain, Sweden and six US states: Connecticut, Iowa, Maine, Massachusetts, New Hampshire and Vermont. At least five more US states are expected to follow suit in the next few years. Israel now recognizes same-sex marriages performed in other countries. Similarly, while New York State and Rhode Island do not presently allow same-sex couples to marry, they recognize gay marriages performed elsewhere. Civil unions for same-sex couples in New Jersey may soon be upgraded to marriage. This progress has been significant, despite some energetic counter-movements, such as the federal Definition of Marriage Act (DOMA), many recent U.S. state constitutional amendments, and the 2008 referendum overturning California's Proposition 8. US states with domestic partnerships include California, Hawaii, Maine, Oregon and Washington. Numerous local municipalities and corporations throughout North America, Europe, and Latin America offer some form of legal relationship rights for same-sex couples. In addition to upgrading their current civil unions law to offering full marriage equality, many national and state governments are also addressing the rights of same-sex couples to adopt and to act as foster parents to children. These events are the result of changing cultural norms and they have had a significant impact in rapidly changing cultural views on “appropriate” expressions of gender as well.

The movement for transgender civil rights has followed more slowly in the wake of the larger gay rights movement, although the pace of the latter has picked up remarkably in the last decade. In the 1970s, with rare exceptions, local municipalities offering anti-discrimination protections on the basis of sexual orientation did not include gender identity protections (National Gay & Lesbian Task Force, 2007). By the late 1990s, as trans inclusion became a focus of LGBT civil rights organizations, it was rare to find a state or municipality that did not introduce anti-discrimination protections for sexual orientation and gender identity at the same time. In recent years, anti-discrimination protections and/or hate crime laws for gender identity have been enacted at the statewide level in California (2003), Colorado (2005), Connecticut (2004), Hawaii (2003), Illinoius (2005), Iowa (2007), Maine (2005), New Jersey (2006), New Mexico (2003), Oregon (2007), Pennsylvania (2002), Vermont (2007), and Washington (2006) (NGLTF, 2008).

These civil rights advances notwithstanding, many in the LGBT movement are critical of psychiatry’s GID diagnoses. Like the gay community that argued to be taken out of an earlier diagnostic nosology, the trans community has adopted similar normalizing arguments to make the case for removal. These include:

Given the sensitivities involved and the civil rights issues at stake, the push for a normative view of transgenderism, as in the case of homosexuality almost four decades ago, has led to passionate and, at times polemical, calls for a reconsideration of the GID diagnoses:

Ironically, psychiatric diagnosis has also served a humanistic purpose, sometimes for the same groups that it oppresses. Psychiatric classification can initially increase public empathy for people who are seen as suffering from a “disease” and can even enable oppressed groups to be treated more humanely, but classification comes at the cost of reinforcing the belief that certain behaviors are deviant, subnormal, or pathological, and therefore less deserving of genuinely equal rights. Thus, the removal of homosexuality from the DSM was a watershed event in gay rights history and it foreshadowed the direction of the transgender rights movement today . . . [T]rans people have largely stopped thinking of themselves as “disordered’’ or suffering from a “psychiatric disease.” They are not as likely to have an uncritical gratitude towards the benevolent and sometimes not so benevolent healers who are the gatekeepers of medical services. Mental health professionals are especially problematic for those who want body modification, because they control access to surgeons and doctors who can prescribe hormones . . . Transactivists are recognizing that pathologizing transgenderism is, in the end, more harmful than helpful (Nichols, 2008, p. 476-477).

Similar normalizing arguments, less polemical but no less passionate, are made by Winters (2005), who writes:

The Gender Identity Disorder diagnosis has divided the transgender community and mental health professions alike, on the premise that relief of social stigma associated with psychosexual diagnosis must inevitably be traded against access to sex reassignment procedures for those who require them. In truth, the current GID category fails transgender, and especially transitioning transsexual individuals, on both counts. Gender variant people face barriers to social legitimacy and civil rights under medical policy that terms their gender identity as mental disorder and labels ordinary gender expressions as sexual deviance. At the same time, transsexual individuals who suffer gender dysphoria, that is distress with their physical sex characteristics or their associated social roles, face obstacles to sex reassignment treatment posed by a diagnosis of disordered gender identity. By labeling a person’s identity, which is discordant with her or his natal sex, as disordered, GID implies that identity and not the body is that which needs be fixed. By its title and diagnostic criteria, the diagnosis contradicts treatment goals that correct the body (p. 72).

In the tradition of Cass (1979), who created a model of gay identity formation, Devor (2004) proposes a normalizing, 14-stage model of transsexual identity formation. Like an earlier generation of gay activists who turned to scientific findings to support their movements normalizing arguments, trans writers do so as well:

There have also been studies that have examined a small, sexually dimorphic region of the brain known as the BSTc. Researchers found that the structure of the BSTc region in trans women more closely resembles that of most women, while in trans men it resembles that of most men [Zhou et al, 1995; Kruijver et al, 2000; Garcia-Falgueras & Swaab, 2008]. Like all brain research, such studies have certain limitations and caveats, but they do suggest that our brains may be hardwired to expect our bodies to be female or male, independent of our socialization or the appearance of our bodies (Serano, 2007, p. 81, italics added).

Much as the gay liberation movement spent many years citing the Kinsey studies’ “10%” statistic to argue that their numbers were too large to be ignored, trans activists also see higher prevalence rates as both an antidote to invisibility as well as furthering the cause of acceptance:

Finally, in the tradition of queer theory, what constitutes “normal” gender is deconstructed from an outsider’s perspective. Just as heterosexuals were asked to look at their heterosexism, transgender writers explicate cisgenderism or cissexualism to the less gender dissonant:

Table 1 lists some of the parallels between homosexuality and gender variance as they relate to psychiatric diagnosis.

Gay activists of the mid-20th century were fighting both for civil rights and sexual liberation. Toward that end, and to keep medical practitioners from unnecessarily meddling in gay people’s lives, most of them wanted out of the DSM. The same approach is undoubtedly true for transgender people who are not anatomically dyshporic and who therefore see no reason why mental health professionals should judge them in the language of psychiatric diagnosis.

Among those who do seek to transition, there are activists and supporters who wish to retain the psychiatric diagnosis as a needed step in obtaining medical treatment. Some might unfavorably be compared to Donald Webster Cory, an early homophile activist who held a distinctly minority position that gay people should cooperate with psychiatrists in order to obtain medical treatment of their homosexuality.

There are also trans activists who would prefer that psychiatry not meddle in their decision to transition and that mental health professionals should forego their currently assigned gate-keeping role of determining psychological fitness for transition. As they seek a diminished role for psychiatry, they advocate for increased access to physicians providing medical and surgical care for transition. Some suggest placing transsexualism as a “medical” rather than a “psychiatric” diagnosis of the ICD (unlike the DSM, there is no American equivalent to the non-psychiatric section of the ICD). However, it is not clear whether such an approach would be amenable to the World Health Organization committees presently charged with updating the ICD.

Presently, however, where either insurance or national health care systems cover these procedures, it is a psychiatric diagnosis that currently justifies “medical necessity” for such care. So while removal from the DSM led to a liberating and immediate “cure” (Drescher, 2002f) for members of the gay community, a similar approach with GID could have unintended, adverse treatment consequences, particularly for the anatomically dysphoric transgender individuals seeking or in need of medical transition.

As in the case of EDH, there are voices seeking a middle ground between avoiding the stigma of having a diagnosis while at the same time justifying the need for medical and surgical treatment. In an effort to resolve the contradictory moral implications between narratives of pathology and normal variation, conventional language can be stretched in a variety of ways as a balance is sought between avoiding stigma and obtaining needed services and social concessions:

It took the gay-rights movement 30 years to shift from the Stonewall riots to gay marriage; now its transgender wing, long considered the most subversive, is striving for suburban normalcy too. The change is fueled mostly by a community of parents who, like many parents of this generation, are open to letting even preschool children define their own needs. Faced with skeptical neighbors and school officials, parents at the [Trans Health] conference discussed how to use the kind of quasi-therapeutic language that, these days, inspires deference: tell the school the child has a “medical condition” or a “hormonal imbalance” that can be treated later, suggested a conference speaker, Kim Pearson; using terms like gender-identity disorder or birth defect would be going too far, she advised. The point was to take the situation out of the realm of deep pathology or mental illness, while at the same time separating it from voluntary behavior, and to put it into the idiom of garden-variety “challenge” (Rosin, 2008).

From the perspective of clinicians, Levine and Solomon (2009) self-consciously, and somewhat defensively, try to parse out the conflict between normal variant and pathological models of transsexualism. Although they say, “Our work begins with the belief that GID is a fact of nature,” (p. 51), by which one might presume they think of transgenderism as a natural condition, they nevertheless assert:

1. In a nosological sense, GID are [sic] forms of psychopathology;

2. Gender identity disorders are typically co-morbid with other psychopathologies;

3. The promotion of civil rights for the transgendered can obscure professional perceptions of psychopathology;

4. Ethical obligations require professionals to communicate the uncertainties about the long-term outcome of gender transition and sex reassignment surgery (SRS) (p. 41).

Levine and Solomon then go on to make a spirited defense for retaining the language of psychopathology needed as a separate category of discourse required for the clinical work. Despite the obvious narrative contradictions of their approach, they argue that such language should imply no moral judgments about the patients:

There are three advantages to the designation of a pattern of behavior as a disorder. The first is that professionals with a scientific background are more likely to study the origins, consequences, and treatment of disorders than other patterns. Scientific study offers the possibility of new knowledge and efficacious treatment based on evidence. The second is that third-party payment for evaluation and therapy services is linked to diagnoses. There is no insurance coverage for unofficial problems. The third is that some of the suffering attendant to these patterns can be ameliorated (pp. 43-44).

To repeat efforts to straddle the contradictory implications of having a diagnosis (bad, disordered) while putting forth a narrative of normal variation (good, natural) can be seen as trying to foster an environment in which offering medical and surgical treatment does not imply stigma or judgment.

The Washington Psychiatric Society Task Force on GID (2009) similarly struggles to find language that “maximizes” access to medical, surgical, and mental health care while mitigating the potentially discriminatory uses of the diagnostic categories to restrict access to public accommodations. The report notes, “In the current absence of means to resolve this dilemma satisfactorily (e.g., structural reform of the health care system), we propose revisions to the diagnostic categories available to care for gender variant persons (pp. 1-2). In their struggle to find reconciling language, they even propose what might be called a “bookkeeping” solution: that GIDC be removed from the DSM and replaced with the V-Code of Child/Adolescent Gender Variance. This diagnosis would be applicable until age 18 and presumably flag those gender variant children (and their families) who seek some form of psychological treatment. While this would reduce stigma by defining gender variance before age eighteen as a subject of clinical attention rather than a psychiatric disorder, the redefinition would only exacerbate the access to care problem as third party payers rarely reimburse V-codes.

Following the events of 1973 and with subsequent generational changes in the organization, APA gradually became a more socially conscious group. Given psychiatry’s historical role in stigmatizing homosexuality in mind, and thanks to the efforts of a growing number of openly gay, lesbian and bisexual psychiatrists coming out in the organization (Ashley, 2002; Barber, 2003, 2008; Hire, 2001), APA continued to expand its public positions regarding gay and lesbian civil rights. In 1990, APA issued a statement opposing “exclusion and dismissal from the armed services on the basis of sexual orientation.” In 1992, APA called on “all international health organizations, psychiatric organizations, and individual psychiatrists in other countries to urge the repeal in their own countries of legislation that penalizes homosexual acts by consenting adults in private.”

In 1998, APA issued a statement opposing “any psychiatric treatment, such as ‘reparative’ or ‘conversion’ therapy, that is based on the assumption that homosexuality per se is a mental disorder or is based on the a priori assumption that the patient should change his or her homosexual orientation.” In 2000, APA strengthened the statement, recommending, “ethical practitioners refrain from attempts to change individuals’ sexual orientation.”

Then, in 2000, following Vermont’s passage of civil unions laws, APA endorsed “the legal recognition of same-sex unions and their associated legal rights, benefits and responsibilities.” In 2002, APA called for “initiatives allowing same-sex couples to adopt and co-parent children and supports all the associated legal rights, benefits, and responsibilities which arrive from such initiatives.”

In 2003, APA signed onto an amicus brief for the gay plaintiffs in the US Supreme Court case of Lawrence and Garner v. Texas. This historic Supreme Court decision abolished discriminatory US sodomy laws that criminalized homosexuality.

In 2005, after Massachusetts’ 2004 legalization of marriage equality, APA issued a statement supporting “the legal recognition of same-sex civil marriage with all rights, benefits and responsibilities conferred by civil marriage, and opposes restrictions to those same rights, benefits, and responsibilities.”

In 2006, APA created the John Fryer Award for “a public figure who has made significant contributions to LGBT mental health.” Named for the once-disguised Dr. H Anonymous’ alter ego, the award’s first recipients were Frank Kameny and Barbara Gittings, two of the gay activists who thirty-five years earlier brought the issue of psychiatric stigmatization of homosexuality to APA’s attention (Gittings, 2008).

The Caucus of Gay, Lesbian, and Bisexual Members of the American Psychiatric Association (CGLBM-APA) was established in the mid 1970s and is active within APA to this day. In 1978, APA created a task force on gay and lesbian issues that in 1981 was upgraded to a standing Committee on Gay, Lesbian and Bisexual (GLB) Issues. While originally charged to focus on GLB issues, a revised charge was approved and updated in 2004 to include trans issues as well. Due to a 2009 restructuring of APA governance, the Committee on GLB issues (among scores of others) was “sunsetted” and the GLB Caucus is now the de facto APA component charged with addressing LGBT issues.

It contrast to its strong affirmation of LGB civil rights after the 1973 decision to remove homosexuality from the DSM, APA has not issued position statements in support of transgender civil rights. One explanation for this disparity may be that there are hundreds of openly LGB psychiatrists advocating for organizational awareness of LGB rights, both within APA as well as in its allied organization, the Association of Gay and Lesbian Psychiatrists (AGLP). There are very few visible trans psychiatrists within either organization.

As the Committee on GLB Issues often functioned as the default clearinghouse for queries to the APA about trans issues; however, in 1997 the Committee drafted a Committee Report: The Diagnostic Category of Gender Identity Disorder (GID). Its heretofore unpublished recommendations included

The draft report appears not to have been widely distributed within APA and is not accessible via a search of APA’s website. To this author’s knowledge, no action was taken on any of the report’s recommendations. In fact, prior to the recent DSM controversies (Chibbaro, 2008; Osborn, 2008), APA’s only official public statements regarding transgender people are the DSM’s GID diagnoses and transvestic fetishism.

Further, while it is often asserted that the DSM (and ICD) diagnoses provide the only pathways to insurance reimbursement for trans individuals seeking medical assistance, APA has issued no treatment guidelines for either GIDC or adult GID. This omission is in stark contrast to an increasing proliferation of APA practice guidelines for other DSM diagnoses. In addition, the absence of a formal APA opinion about treatment of a diagnosis of its own creation has contributed to an ongoing, troubling problem: many health care insurers and other third party payers claim that SRS is an “experimental treatment,” an “elective treatment,” or “not medically necessary” and therefore not reimbursable or covered under most insurance plans nor is treatment accessible to wards of governmental agencies, such as foster care and prison systems. In other words, the presence of the GID diagnosis in the DSM is not serving its intended purpose of creating greater access to care--one of the major arguments for diagnostic retention.

In an effort to address this longstanding omission, APA’s Board of Trustees voted in December 2007 to create a special Task Force to review the scientific and clinical literature on the treatment of GID. That Task Force was convened in 2008 and is presently reviewing the published literature on treatment issues.

Table 2 lists some of the contrasts between homosexuality and gender variance as they relate to psychiatric diagnosis.

--Either endorse them as the American Medical Association has done; or

--Develop and publish APA’s own practice guidelines for whatever DSM gender diagnoses are modified and retained in a manner consistent with established clinical practices, input from patients, and the empirical data base;