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The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Specify if: With Gender Dysphoria: if the person has persistent discomfort with gender role or identity. First, it is peculiar that this disorder is limited to heterosexual males. Apparently, women and gay men are free to wear whatever they chose without a diagnosis of mental illness. The description, sexually arousing, could be interpreted to apply to only fantasies or to all three of fantasies, sexual urges, or behaviors with very different meaning. The first interpretation would implicate all recurrent cross-dressing behavior. The second would limit the diagnosis to only sexually motivated cross-dressing and imply the unlikely phrase, sexually arousing sexual urges. Both interpretations are supported historically in previous DSM editions APA80,87 and by various conflicting remarks in the text of the DSM-IV. Although labeled a fetishism, it is not clearly stated whether or not transvestism must be sexual in nature to qualify for diagnosis.
The clinical significant criterion, D, was added to all conditions in the Sexual and Gender Identity Disorders section. The definition of distress or impairment lies at the heart of the issue of pathologization of gender expression. Dysfunction, Nonconformity, and Mental Disorder A third interpretation of these categories has been advanced by George Brown of the Veterans Administration Brown95 and is widely believed within the gender community Kirk95. It holds that the clinical significance criteria for Transvestic Fetishism and Gender Identity Disorder serve to exclude ego systonic or otherwise well adjusted transgendered subjects from medical diagnosis.
However, it is contradicted in the GID section: Gender Identity Disorder can be distinguished from simple nonconformity to stereo-typical sex role behavior by the extent and pervasiveness of the cross-gender wishes, interests, and activities. The second statement implies that you may deviate from social expectation without a diagnostic label, but not too much. Appendix four, the Annotated Listing of changes in DSM-IV, speaks of categories subsumed, not eliminated APA94. Nothing in the text of the DSM-IV Sexual and Gender Identity Disorders chapter or the supporting literature conveys an intent to depathologize any transgendered people who were classified in previous editions Bradley91, APA94b. Dysfunction, defined as distress or impairment, is the key issue in that all who grow up in a closet, suppressing their identity, experience distress. Therefore, no one is necessarily excluded by the clinical significance criteria. For example, a child molester who is not distressed or socially impaired by the condition would arguably be disqualified for a diagnosis of pedophilia. Kenneth Zucker and Ray Blanchard, members of the DSM-IV Subcommittee on Gender Identity Disorders, have noted that the question of whether distress is inherent to transvestism or imposed by social pressures is not resolved Zucker95. It is again not clearly defined who is ill and who is not, the judgement resting upon the personal values of the evaluator. No one has reasonably established why gender orientation is treated so differently in the DSM excepting differences in political organization and influence Bullough93. Contrary to the medical stereotype, I have met many people in the transgender community who are satisfied with their gender orientation, show no significant psychopathology, and function very well socially and occupationally. The Stigma of Psychosexual Disorder The burden of social stigma suffered by transgendered people is worsened by medical classification Bolin88. Transvestic Fetishism, in particular, is organized in the most damaging and demeaning manner possible, classified as a Sexual Paraphilia along with Pedophilia, Exhibitionism, Voyeurism, Frotteurism, Sadism and Masochism.
Most transsexuals do not necessarily hate their genitals Bornstein94, Bolin88, and reassignment surgery candidates in fact need the tissues to reconstruct new ones. The daredeviling crossdresser Brown95 represents victim bashing in that crossdressers who suffer discrimination or bigotry are blamed for risking getting caught. The presumption that non-transsexual crossdressing constitutes sexual deviance is implied by the very name, Transvestic Fetishism. This and the common association of sexual masochism with cross-gender expression Zucker95 exaggerate the significance of sex in gender and trivialize the role of social expression. Sexual motivation is said to be displaced by gender dysphoria in the Aging Transvestite Wise80 model, when it is more likely lessened with self-acceptance and increased freedom of expression. Finally, suggestions that favor surgical reassignment candidates with heterosexual outcomes APA94 deserve scrutiny. Distress, Impairment, and the Role of Social Intolerance Micheal Lewis, author of Shame, the Exposed Self , defines shame as a self perceived failure to meet self-imposed standards and a global attribution of failure to the total self Lewis95. This occurs at a surprisingly early age, between 18 and 36 months, when children internalize the values of the society around them. While not targeted specifically at socially marginalized groups, Lewis observations explain much about the experience of a closeted development. Are distress, depression and anxiety, attributed by the medical literature to gender expression, reasonable consequences of undeserved shame? Conversely, what are the implications of masquerading the body to fit the core identity? Given the harsh stigma associated with cross-gender identity, is it possible that sexual expression serves defensive purposes, representing denial or displacement? Does this explain the commonly reported transience of fetishistic crossdressing Bradley91, Wise80 more adequately than spontaneous development of transsexualism later in life? Again, the DSM fails to distinguish inherent distress from socially imposed distress, presuming the former. Socio-Cultural Considerations Anthropologist Anne Bolin noted the provincial nature of gender research with socio-cultural findings virtually ignored in medical policy Bolin87. There is substantial historical precedent for the enforcement of rigid gender roles by medical practitioners. For example, from the early to mid-1900s, women who exceeded the bounds of gender conformity in demanding civil rights and the right to vote were discredited and often institutionalized with a diagnosis of hysteria Mayor74. Homosexuality, as noted previously, was classified as mental illness until 1973, representing a violation of appropriate gender role. At the heart of the current medical policy is a presumption of gender essentialism, perpetuating the doctrine of two sexes, immutable, and determined by genitalia. A growing body of literature that considers gender a social construction, not a biological imperative DeBeauvior52, Kessler78, Butler90, Garber92, Lorber94, has been inexplicably disregarded. Other social considerations include the power inequity in transsexual psychotherapy and the validation of medical caregivers Bolin88. A therapist serving as a gatekeeper to the availability of surgical or hormonal treatment holds absolute power over a transsexual client. This undermines the therapeutic relationship, leaves the client little motivation for honest expression Blanchard88, and creates a distorted view of transgenderism by psychiatric caregivers reflected in the current medical policy. Finally, medical practitioners and researchers have a self-interest in the present diagnostic categories, which are perceived to lend respectability to gender work Pauly92, and legitimize association with transgendered subjects Bolin88. Cross-Cultural Supernumerary Gender Precedents Socio-cultural research has elucidated a growing list of supernumerary gender roles among many cultures Bolin87, Bullough93, Williams86. Summary Our examination of the present classification of Transvestic Fetishism and Gender Identity Disorder has raised substantive que...
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