Gender Interrupted: Controversy & Concerns about Gender Identity Disorder (GID)
Kate Richmond, Ph.D. & Kate Sheese, B.A.
Muhlenberg College York University
What It Is:
According to the current DSM-IV-TR (American Psychiatric Association, 2000), criteria necessary for the diagnosis of Gender Identity Disorder are:
A. A strong persistent cross-gender identification (not merely a desire for any perceived cultural advantages of being the other sex). In children, the disturbance is manifested by four (or more) of the following:
1. Repeatedly stated desire to be, or insistence that he or she is, the other sex.
In adolescents and adults, the disturbance is manifested by symptoms such as a stated desire to be the other sex, frequent passing as the other sex, desire to live or be treated as the other sex, or the conviction that he or she has the typical feelings and reactions of the other sex.
B. Persistent discomfort with his or her sex or sense of inappropriateness in the gender role of that sex.
In children, the disturbance is manifested by any of the following:
· In boys, assertion that his penis or testes are disgusting or will disappear or assertion that it would be better not to have a penis, or aversion toward rough-and-tumble play and rejection of male stereotypical toys, games, and activities.
· In girls, rejection of urinating in a sitting position, assertion that she has or will grow a penis, or assertion that she does not want to grow breasts or menstruate, or marked aversion toward normative feminine clothing.
· In adolescents and adults, the disturbance is manifested by symptoms such as preoccupation with getting rid of primary and secondary sex characteristics (e.g., request for hormones, surgery, or other procedures to physically alter sexual characteristics to simulate the other sex) or belief that he or she was born the wrong sex.
C. The disturbance is not concurrent with physical intersex condition.
D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Controversy & Concerns: Gender Identity Disorder (GID) is the focus of considerable debate. One controversy concerning GID is that its current conceptualization depends on very rigid gender stereotypes, particularly in the case of children. In many ways, people, especially children, are being labelled as having a psychiatric disorder for not conforming to gender stereotypes which are social constructions, not reflections of universal “truths” about the nature of girls and boys or men and women. For example, according to criterion A for GID in children, the disorder can be identified when children show four (or more) of the following characteristics:
1. repeatedly stated desire to be, or insistence that he or she is, the other sex
2. in boys, preference for cross-dressing or simulating female attire; in girls, insistence on wearing only stereotypical clothing
3. strong and persistent preferences for cross-sex roles in make-believe play or persistent fantasies of being the other sex
4. intense desire to participate in the stereotypical games or pastimes of the other sex
5. strong preferences for playmates of the other sex
All but the first of these criteria have to do with culturally constructed stereotypes about how boys and girls should feel and behave. It should be pointed out as well that a child only needs to have four out of the five characteristics and thus can meet criterion A simply by not conforming to cultural stereotypes. The diagnosis thus serves as a form of “social policing” for appropriate gender-typical behavior.
Thus, the main concern about the current GID category is that it is somewhat misleading, because it suggests that gender-variant behavior is pathological. Unfortunately, this sometimes leads to unnecessary “reparative-therapies,” which can cause additional shame and harm, particularly among children (Langer & Martin, 2004). So-called reparative therapies, also known as conversion therapies, are interventions aimed at changing a person’s sexual orientation from gay to heterosexual. Reparative therapies were deemed unethical by the American Psychological Association in 1997. Because gender identity and sexual orientation are often intertwined, parents may be more likely to seek treatment for their child if they perceive their child’s atypical gender behavior as indicative of future homosexual tendencies. And of course gender-variant behavior is by no means consistently correlated with a particular sexual orientation. Some critics have claimed that GID provided a new way to pathologize homosexuality (Money, 1994; Sedgwick, 1990; Wilson, Griffin, & Wren, 2002). This claim has been denied by the psychiatric community but remains a contentious issue (Whittle, 2006; Zucker & Spitzer, 2005).
Furthermore, the DSM does not distinguish between distress implicit in gender dysphoria (discomfort and discontent with assigned birth sex) and distress that comes from social stigma and prejudice associated with violating sex/gender norms (Langer & Martin 2004). According to the DSM-IV-TR, the condition must “be considered a manifestation of a behavioural, psychological, or biological dysfunction in the individual” (American Psychiatric Association, 2000, p. xxx). It is likely that distress associated with GID results from others’ reactions to gender variance, rather than from the cross-gendered behaviour itself (Wilson et al, 2002). Wilson (1998) compared the GID debate to the arguments presented during the movement to eliminate homosexuality from the DSM. In 1973, the Board of Directors of the American Psychiatric Association pushed for the removal of homosexuality in the DSM. Despite some resistance, the membership of the American Psychiatric Association voted to remove homosexuality from the DSM in 1974. However, the diagnosis of Ego-dystonic Homosexuality remained in DSM III --- which undermined the very goal of removing antigay stigma in the DSM. Wilson argued that, during the movement to remove homosexuality from the DSM, the American Psychiatric Association rejected personal distress as a qualifier for mental disorders. She cited a brief filed by the American Psychiatric Association in 1994:
The harmful effects of prejudice, discrimination, and violence, however, are not limited to such bodily or pecuniary consequences . . . The effects can include depression . . . and efforts to rationalize the experience by viewing one’s victimization as just punishment. Gay people, like members of other groups that are subject to social prejudice, also frequently come to internalize society’s negative stereotypes. (p.7)
Wilson (1998) believes that many gender-variant people, similarly to those in the gay, lesbian, and bisexual community, face prejudice, discrimination and violence, which can result in high levels of distress. Thus, the authors of the current conceptualization of GID ignore the stress associated with being part of a marginalized group.
In addition to critiques of the diagnostic criteria, the GID diagnosis lacks reliability, meaning that different clinicians are not likely to give the diagnosis to the same people. In fact, among children, there is minimal empirical evidence of diagnostic reliability for GID for boys and none for girls (Langer & Martin, 2004). The DSM authors state that “To varying degrees, they adopt the behavior, dress and mannerisms of the other sex” (p. 577), as though notions of femininity and masculinity are clearly definable standards for all people. However, endorsements of traditional masculine and feminine norms vary among racial and ethnic groups, nationalities, life-stages, genders, and sexual orientations (Kimmel, 2004; Levant & Richmond, 2007), and among different cultural groups, there are differences in degrees of tolerance and acceptance of gender variance (Newman, 2002). Since gender norms vary, each clinician will have a different idea of how to decide where the line is drawn along these “varying degrees” between disordered and healthy.
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