Kutchins and Kirk’s analysis provides a clue to understanding why homosexuality was stricken from the DSM, while, first, transsexuality, and, later, gender identity disorder became part of the nosology, or system of classification. One of the many profound effects of the gay liberation movement was the sudden shift in the way that gay men and lesbians thought about themselves and their sexual orientation. After Stonewall and the activism that followed in its wake, many people who might once have sought out psychiatrists and therapists hoping to be “cured” of their desires achieved a level of self-acceptance they had previously lacked. They no longer needed the services of psychiatrists because they no longer perceived themselves as ill. Transsexual people faced a far more complicated situation, however. Even if they didn’t consider themselves “sick” per se, they still needed to secure the services of health care providers. They needed endocrinologists and surgeons but, according to the Benjamin Standards of Care, they first needed to spend up to a year in therapy in order to secure the all-important “letter” from their therapist recommending hormones or surgery. They remain locked into the health care system in a way that gays and lesbians are not.
Dr. Ben Barres of Stanford described this painful conundrum very succinctly in our conversation in 2001. “I have very mixed feelings about this. I think if gay people weren’t victims of societal ignorance and maltreatment, most would be very happy and well-adjusted, whereas I’m not sure that is true for transsexuals, at least most transsexuals that I’ve met who grow up feeling that they are the wrong gender. So there’s a certain amount of pathology. Nevertheless, I don’t think that transgendered people need to be in the DSM any more than gays do. It’s unfair, just as unfair as it was for homosexuals.”
In DSM-III, published in 1980, “transsexualism” first appeared as a diagnostic category distinct from transvestic fetishism (cross-dressing for purposes of sexual excitement). The diagnosis was limited to “gender dysphoric individuals who demonstrated at least two years of continuous interest in removing their sexual anatomy and transforming their bodies and social roles.” The concept of gender dysphoria was developed by researchers at Stanford who realized that many of the adult patients presenting for treatment did not fit the profile of “classic” transsexualism. Dr. Norman Fisk, clinical instructor of psychiatry at Stanford School of Medicine and codeveloper of the Stanford Gender Identity Clinic, recalls that when the Stanford program was initiated, “due to inexperience and naivete we went about seeking so-called ideal candidates and a great emphasis was placed upon attempting to exclusively treat only classical or textbook cases of transsexualism.” The classical criteria included a lifelong sense or feeling of being a member of “the other sex,” early and persistent cross-dressing without any associated sexual excitement, and a “dislike or repugnance for homosexual behavior,” says Fisk. “We avidly searched for those patients who, if admitting to homosexual behavior at all, insisted that they always adopted a passive role and avoided the stimulation of their own genitals by their partner,” says Fisk.
As noted previously, researchers eventually realized that prospective candidates for sex reassignment were altering their life histories in order to meet the clinical criteria for “classic” transsexualism, to increase their chances of treatment. Rather than rejecting nonclassic patients outright or acceding to surgery on demand, the Stanford researchers conceived a novel solution. They created a “grooming clinic” for prospective patients, which became a kind of support group, “a group therapy situation in which individuals met on a once-per-month basis to exchange information, opinions, experiences and to mutually share feelings, successes, and failures.” The charm school/support group also enabled the Stanford researchers to develop long-term relationships with attendees and to gain “both time and increasing experience.” As a result of this ongoing follow-up, the staff at the clinic abandoned their previous “rigid and truly unrealistic diagnostic criteria” for transsexualism and developed an alternative diagnosis, “gender dysphoria syndrome.” Gender-dysphoric individuals were described as individuals who were “intensely and abidingly uncomfortable in their anatomic and genetic sex and their assigned gender” and who “functioned far more effectively and comfortably in their gender of choice, as clearly demonstrated by obvious and objective criteria.”
Following evolving psychiatric opinion, DSM-III TR (Text Revision), released in 1987, includes a third, more expansive, category: “Gender Identity Disorder of Adolescence or Adulthood, Non-Transsexual Type (GIDAANT).” The DSM-III TR authors write that GIDAANT “differs from Transvestic Fetishism in that the cross-dressing is not for the purpose of sexual excitement; it differs from Transsexualism in that there is no persistent preoccupation (for at least two years) with getting rid of one’s primary and secondary sex characteristics and acquiring the sex characteristics of the other sex.”
In 1994, the diagnosis of transsexualism was deleted from DSM-IV by combining its diagnostic criteria with those of GIDAANT and absorbing GID of childhood into the category. In “Gender Identity Disorder of Childhood, Adolescence or Adulthood,” the expressed desire for surgery now becomes only one of a number of criteria to be taken into consideration when making a diagnosis. The key elements of the diagnosis in both adults and children are “a strong and persistent cross-gender identification” and “a persistent discomfort with his or her sex and sense of appropriateness in the gender role of that sex.” The disturbance must also be sufficiently obvious or intense to cause “clinically significant distress or impairment in social, occupational, or other important areas of functioning.” Clearly, a far greater number of people meet these criteria than meet the more limited criteria for trans-sexualism. In shifting the focus from an expressed desire to change sex to cross-gender identification, distress, and impairment in functioning, the new diagnosis encompasses not only the relatively few individuals who desire sex reassignment, but also the far greater number who are perceived by themselves or by others to express some form of gender variance. However, in the absence of a strong desire for body modification, are the “distress and impairment” experienced by such individuals due to the disorder itself, or are they a consequence of the harassment and social ostracism gender-variant people endure?
Activists argue that the decision to delete homosexuality as a mental disorder from the seventh printing of the second edition of DSM-III and the subsequent creation of the diagnosis of gender identity disorder was a kind of psychiatric sleight of hand. Although the focus of the diagnosis has changed from deviant desire to subversive identity, the core of the diagnosis remains the same: the individual is not a “normal” male or female, and his or her deviance from the norm is conceived as illness or pathology. The diagnosis of gender identity disorder becomes a particularly troubling matter, activists say, when applied to children and adolescents. Four of the following behaviors must be present to justify a clinical diagnosis of gender identity disorder in children: (a) a repeatedly stated desire to be, or insistence that he or she is, the other sex; (b) in boys, a preference for cross-dressing or simulating female attire, and in girls, an insistence on wearing only stereotypical masculine clothing; (c) a strong and persistent preference for cross-sex roles in make-believe play or persistent fantasies of being the other sex; (d) an intense desire to participate in the stereotypical games and pastimes of the other sex; (e) a strong preference for playmates of the other sex.