This is what the DSM V will be stating:
Gender Dysphoria (in Adolescents or Adults)**
A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested by 2* or more of the following indicators: [2, 3, 4]**
1. a marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or, in young adolescents, the anticipated secondary sex characteristics) [13, 16]
2. a strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or, in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics) [17]
3. a strong desire for the primary and/or secondary sex characteristics of the other gender
4. a strong desire to be of the other gender (or some alternative gender different from one’s assigned gender)
5. a strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender)
6. a strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender)
B. The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning, or with a significantly increased risk of suffering, such as distress or disability**
Subtypes
With a disorder of sex development [14]
Without a disorder of sex development
See also: [15, 16, 19]
Specifier**
Post-transition, i.e., the individual has transitioned to full-time living in the desired gender (with or without legalization of gender change) and has undergone (or is undergoing) at least one cross-sex medical procedure or treatment regimen, namely, regular cross-sex hormone treatment or gender reassignment surgery confirming the desired gender (e.g., penectomy, vaginoplasty in a natal male, mastectomy, phalloplasty in a natal female).
Rationale
In this section we summarize the rationales for the revised posting of May 4, 2011.
*For the adult criteria, we propose, on a preliminary basis, the requirement of only 2 indicators. This is based on a preliminary secondary data analysis of 154 adolescent and adults patients with GID compared to 684 controls (Deogracias et al., 2007; Singh et al., 2010). From a 27-item dimensional measure of gender dysphoria, the Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults (GIDYQ), we extracted five items that correspond to the proposed A2-A6 indicators (we could not extract a corresponding item for A1). Each item was rated on a 5-point response scale, ranging from Never to Always, with the past 12 months as the time frame. For the current analysis, we coded a symptom as present if the participant endorsed one of the two most extreme response options (frequently or always) and as absent if the participant endorsed one of the three other options (never, rarely, sometimes). This yielded a true positive rate of 94.2% and a false positive rate of 0.7%. Because the wording of the items on the GIDYQ is not identical to the wording of the proposed indicators, further validational work will be required.
**In response to criticisms that the term was stigmatizing, we originally proposed to replace the term “Gender Identity Disorder” with Gender Incongruence. This was accompanied by a re-definition of the condition, revised criteria, eliminating the previous subtype pertaining to sexual attraction, and introducing a new subtype categorization that does not exclude such individuals with a somatic disorder of sex development (DSD). We chose the new term, Gender Incongruence, as descriptive and to avoid a presupposition of the presence of a clinically significant acute distress in all cases as a requirement for the diagnosis. In part, this was based on more general discussions in the DSM-5 Task Force on separating out the distress/impairment criterion and evaluating these parameters as a separate dimensions.
We also debated and discussed the merit of placing this condition in a special category apart from (formerly Axis-I) psychiatric diagnoses to reflect its unusual status as a mental condition treated with cross-sex hormones, gender reassignment surgery, and social and legal transition to the desired gender (particularly with regard to adolescents and adults). We chose not to make any decision between its categorization as a psychiatric or a medical condition and wished to avoid jeopardizing either insurance coverage or treatment access (Drescher, 2010).
On the open APA website, we received many favorable comments about the proposed name change, particularly with regard to the removal of the “Disorder” label from the name of the diagnosis. However, we also received many comments from reviewers of the open APA website as well as from members of the World Professional Association for Transgender Health (WPATH) expressing concerns that the new descriptive term could easily be misread as applying to individuals with gender-atypical behaviors who had no gender-identity problem. Many commentators recommended “gender dysphoria” as a semantically more appropriate term, because it expresses an aversive emotional component. In this regard, it should be noted that the term “gender dysphoria” has a long history in clinical sexology (see Fisk, 1973) and thus is one that is quite familiar to clinicians who specialize in this area. Also, we were not able to find a special placement of the condition in the developing organizational structure of the DSM-5, although it appears the gender diagnoses will be separated from the sexual dysfunctions and paraphilias. Furthermore, as the definition of “mental disorder” in the Introduction of DSM-IV-TR (American Psychiatric Association, 2000, p. xxxi), in addition to “present distress…or disability,” includes “a significantly increased risk of suffering death, pain, disability, or an important loss of freedom,” we added a correspondingly modified B criterion. As this is in line with the empirical evidence, this change permitted us to adopt the “gender dysphoria” term without presupposing the existence of acute or inherent distress at the time of diagnosis.
The addition of this specifier is prompted by the observation that many individuals, after transition, do not meet any more the criteria set for gender dysphoria as defined above; however, they continue to undergo chronic hormone treatment, further gender-confirming surgery, or intermittent psychotherapy/counseling to facilitate the adaptation to life in the desired gender and the social consequences of the transition. Although the concept of “post-transition” is modeled on the concept “in [partial or full] remission” as used for mood disorders, “remission” has implications in terms of symptom reduction that do not apply directly to gender dysphoria, given its unique status as a psychiatric category (see above). Cross-sex hormone treatment of gonadectomized individuals could, of course, be coded as treatment of hypogonadism, but this would not apply to individuals who have not undergone gonadectomy but receive hormone treatments. In the text, we will, however, also mention that the traditional course specifier of “full remission” does apply to many children with the diagnosis of Gender Dysphoria and, perhaps, for a small number of adolescents and adults.
**In response to reviewers' criticism, the proposed revision separates the 6 dimensionalized "Informational Questions" from the 6 dimensionalized Severity Questions. The Severity Questions represent dimensionalized versions of the 6 Point A criteria. The Informational Questions were added to collect specific data important for both clinical counseling and research, as they cover broad issues that are relevant for understanding a presenting patient's condition: A statement of the current legal/assigned "sex" or "gender" (Item 1), a rating of the degree of confidence in the subjective validity of that legal/assigned gender (Item 2), a rating of the degree of incongruence between assigned and experienced/expressed gender (Item 3), the degree of the distress, if any, resulting from that incongruence (Item 4), the patient's sexual orientation (Item 5), and the age of onset of a strong desire to live in a gender role different from the one assigned (Item 6). The distress item (4) was added because of the observation that acute distress may vary considerably across patients and the psychosocial contexts in which they experience an incongruence between assigned gender and experienced/expressed gender, as has been noted in the Rationale for adding Criterion B. The patient's sexual orientation and age-of-onset items are included because of the unresolved controversy about the utility and justification of the DSM-IV subtypes, which have been dropped from the DSM-5 criteria set, but will be addressed in the DSM-5 text, because these subtypes may reflect different pathways to gender dysphoria and are important to consider for research purposes.
End notes
These were the original notes from the February 2010 posting (with references updated).
1. It is proposed that the name gender identity disorder (GID) be replaced by “Gender Incongruence” (GI) because the latter is a descriptive term that better reflects the core of the problem: an incongruence between, on the one hand, what identity one experiences and/or expresses and, on the other hand, how one is expected to live based on one’s assigned gender (usually at birth) (Meyer-Bahlburg, 2009a; Winters, 2005). In a recent survey that we conducted among consumer organizations for transgendered people (Vance et al., in press), many very clearly indicated their rejection of the GID term because, in their view, it contributes to the stigmatization of their condition.
2. In addition to the proposed name change for the diagnosis (see Endnote 1), there are 6 substantive proposed changes to the DSM-IV descriptive and diagnostic material: (a) we have proposed a change in conceptualization of the defining features by emphasizing the phenomenon of “gender incongruence” in contrast to cross-gender identification per se (Meyer-Bahlburg, 2009a); (b) we have proposed a merging of the A and B clinical indicator criteria in DSM-IV (see Endnotes 10, 13); (c) for the adolescent/adult criteria, we have proposed a more detailed and specific set of polythetic indicators than was the case in DSM-IV (Cohen-Kettenis & Pfá¤fflin, 2009; Zucker, 2006); (d) for the child criteria, we have proposed that the A1 indicator be necessary (but not sufficient) for the diagnosis of GI (see Endnote 5); (e) we have proposed that the “distress/impairment” criterion not be a prerequisite for the diagnosis of GI (see Endnote 15); and (f) we have proposed that subtyping by sexual attraction (for adolescents/adults) be eliminated (see Endnote 18) but that subtyping by the presence or absence of a co-occurring disorder of sex development (DSD) be introduced (see Endnote 14). As in DSM-IV, we recommend one overarching diagnosis, GI, with separate, developmentally-appropriate criteria sets for children vs. adolescents/adults. The text material will provide updated information on developmental trajectory data for clients who received the GI diagnosis in childhood vs. adolescence or adulthood.
The term “sex” has been replaced by assigned “gender” in order to make the criteria applicable to individuals with a DSD (Meyer-Bahlburg, 2009b). During the course of physical sex differentiation, some aspects of biological sex (e.g., 46,XY genes) may be incongruent with other aspects (e.g., the external genitalia); thus, using the term “sex” would be confusing. The change also makes it possible for individuals who have successfully transitioned to “lose” the diagnosis after satisfactory treatment. This resolves the problem that, in the DSM-IV-TR, there was a lack of an “exit clause,” meaning that individuals once diagnosed with GID will always be considered to have the diagnosis, regardless of whether they have transitioned and are psychosocially adjusted in the identified gender role (Winters, 2008). The diagnosis will also be applicable to transitioned individuals who have regrets, because they did not feel like the other gender after all. For instance, a natal male living in the female role and having regrets experiences an incongruence between the “newly assigned” female gender and the experienced/expressed (still or again male) gender.
3. It has been recommended by the Workgroup to delete the “perceived cultural advantages” proviso. This was also recommended by the DSM-IV Subcommittee on Gender Identity Disorders (Bradley et al., 1991). There is no reason to “impute” one causal explanation for GI at the expense of others (Zucker, 1992, 2009).
4. The 6 month duration was introduced to make at least a minimal distinction between very transient and persistent GI. The duration criterion was decided upon by clinical consensus. However, there is no clear empirical literature supporting this particular period (e.g., 3 months vs. 6 months or 6 months vs. 12 months). There was, however, consensus among the group that a lower-bound duration of 6 months would be unlikely to yield false positives.
13. In the DSM-IV, there are two sets of clinical indicators (Criteria A and B). This distinction is not supported by factor analytic studies. The existing studies suggest that the concept of GI is best captured by one underlying dimension (Cohen-Kettenis & van Goozen, 1997; Deogracias et al., 2007; Green, 1987; Johnson et al., 2004; Singh et al., 2010).
14. There is considerable evidence individuals with a DSD experience GI and may wish to change from their assigned gender; the percentage of such individuals who experience GI is syndrome-dependent (Cohen-Kettenis, 2005; Dessens, Slijper, & Drop, 2005; Mazur, 2005; Meyer-Bahlburg, 1994, 2005, 2009a, 2009b). From a phenomenologic perspective, DSD individuals with GI have both similarities and differences to individuals with GI with no known DSD. Developmental trajectories also have similarities and differences. The presence of a DSD is suggestive of a specific causal mechanism that may not be present in individuals without a diagnosable DSD.
15. It is our recommendation that the GI diagnosis be given on the basis of the A criterion alone and that distress and/or impairment (the D criterion in DSM-IV) be evaluated separately and independently. This definitional issue remains under discussion in the DSM-V Task Force for all psychiatric disorders and may have to be revisited pending the outcome of that discussion. Although there are studies showing that adolescents and adults with the DSM-IV diagnosis of GID function poorly, this type of impairment is by no means a universal finding. In some studies, for example, adolescents or adults with GID were found to generally function psychologically in the non-clinical range (Cohen-Kettenis & Pfá¤fflin, 2009; Meyer-Bahlburg, 2009a). Moreover, increased psychiatric problems in transsexuals appear to be preceded by increased experiences of stigma (Nuttbrock et al., 2009). Postulating “inherent distress” in case one desires to be rid of body parts that do not fit one’s identity is, in the absence of data, also questionable (Meyer-Bahlburg, 2009a).
16. Although the DSM-IV diagnosis of GID encompasses more than transsexualism, it is still often used as an equivalent to transsexualism (Sohn & Bosinski, 2007). For instance, a man can meet the two core criteria if he only believes he has the typical feelings of a woman and does not feel at ease with the male gender role. The same holds for a woman who just frequently passes as a man (e.g., in terms of first name, clothing, and/or haircut) and does not feel comfortable living as a conventional woman. Someone having a GID diagnosis based on these subcriteria clearly differs from a person who identifies completely with the other gender, can only relax when permanently living in the other gender role, has a strong aversion against the sex characteristics of his/her body, and wants to adjust his/her body as much as technically possible in the direction of the desired sex. Those who are distressed by having problems with just one of the two criteria (e.g., feeling uncomfortable living as a conventional man or woman) will have a GIDNOS diagnosis. This is highly confusing for clinicians. It perpetuates the search for the “true transsexual” only, in order to identify the right candidates for hormone and surgical treatment instead of facilitating clinicians to assess the type and severity of any type of GI and offer appropriate treatment. Furthermore, in the DSM-IV, gender identity and gender role were described as a dichotomy (either male or female) rather than a multi-category concept or spectrum (Bockting, 2008; Bornstein, 1994; Drescher, 2010; Ekins & King, 2006; Lev, 2007; Rá¸n, 2002). The current formulation makes more explicit that a conceptualization of GI acknowledging the wide variation of conditions will make it less likely that only one type of treatment is connected to the diagnosis. Taking the above regarding the avoidance of male-female dichotomies into account, in the new formulation, the focus is on the discrepancy between experienced/expressed gender (which can be either male, female, in-between or otherwise) and assigned gender (in most societies male or female) rather than cross-gender identification and same-gender aversion (Cohen-Kettenis & Pfá¤fflin, 2009).
17. In referring to secondary sex characteristics, anticipation of the development of secondary sex characteristics has been added for young adolescents. Adolescents increasingly show up at gender identity clinics requesting gender reassignment, before the first signs of puberty are visible (Delemarre-van de Waal & Cohen-Kettenis, 2006; Zucker & Cohen-Kettenis, 2008).
18. In contemporary clinical practice, sexual orientation per se plays only a minor role in treatment protocols or decisions. Also, changes as to the preferred gender of sex partner occur during or after treatment (DeCuypere, Janes, & Rubens, 2005; Lawrence, 2005; Schroder & Carroll, 1999). It can be difficult to assess sexual orientation in individuals with a GI diagnosis, as they preoperatively might give incorrect information in order to be approved for hormonal and surgical treatment (Lawrence, 1999). Because sexual orientation subtyping is of interest to researchers in the field, it is recommended that reference to it be addressed in the text, but not as a specifier. It should also be assessed as a dimensional construct.
19. The subworkgroup has had extensive discussion about the placement of GI in the nomenclature for DSM-V, as the meta-structure of the entire manual is under review. The subworkgroup questions the rationale for the current DSM-IV chapter Sexual and Gender Identity Disorders, which contains three major classes of diagnoses: sexual dysfunctions, paraphilias, and gender identity disorders (see Meyer-Bahlburg, 2009a). Various alternative options to the current placement are under consideration.
For Adolescents and Adults
Dimensional Assessment for Gender Dysphoria in Adolescents or Adults
Questions A1-A6 are the dimensional metrics for the corresponding categorical criteria.
Instructions: Please circle the letter next to the statement that applies to you the best.
For Questions A1-A6, please circle the letter next to the statement that applies to you the best.
A1. Over the past 6 months, how intense was your discomfort because your primary and/or secondary sex characteristics do not match your gender identity?
a. None
b. Mild
c. Moderate
d. Strong
e. Very Strong
A2. Over the past 6 months, how intense was your desire to be rid of your primary and/or secondary sex characteristics because they do not match your gender identity?
a. None
b. Mild
c. Moderate
d. Strong
e. Very Strong
A3. Over the past 6 months, how intense was your desire for the primary and/or secondary sex characteristics of the other gender?
a. None
b. Mild
c. Moderate
d. Strong
e. Very Strong
A4. Over the past 6 months, how intense was your desire to be of the other gender (or some gender different from your assigned gender)?
a. None
b. Mild
c. Moderate
d. Strong
e. Very Strong
A5. Over the past 6 months, how intense was your desire to be treated as the other gender (or some gender different from your assigned gender)?
a. None
b. Mild
c. Moderate
d. Strong
e. Very Strong
A6. Over the past 6 months, how intense was your conviction that you have the typical feelings and reactions of the other gender (or some gender different from your assigned gender)?
a. None
b. Mild
c. Moderate
d. Strong
e. Very Strong
Informational Questions
Please complete the following questions:
1. My current legal sex or gender (e.g., as listed under "sex" on my passport or driver's license, also called "assigned" gender) is:
a. Female
b. Male
c. Other (describe): _________________
2. My confidence that I really am what my legal "sex" states (namely, a girl/woman or boy/man) is:
a. None
b. Mild
c. Moderate
d. Strong
e. Very Strong
3. The way that I experience and express my true gender compared to my legal sex or gender is:
a. Not at all different
b. Mildly different
c. Moderately different
d. Strongly different
e. Very Strongly different
4. How old were you when you first had the strong desire to be, or to live in the gender role, of the other gender (or some gender different from your assigned gender)?
a. Age 5 years or younger
b. Between 6 and 9 years
c. Between 10 and 12 years
d. Between 13 and 17 years
e. Age 18 years or older
f. Does not apply
5. I am distressed by feeling different from my legal sex or gender:
a. Not at all
b. Mildly
c. Moderately
d. Strongly
e. Very Strongly
6. Over the past 6 months, how would you describe your sexual attraction to other people?
a. Sexually attracted to males
b. Sexually attracted to females
c. Sexually attracted to both males and females
d. Sexually attracted to neither males or females
e. Other (please describe): _______________
Comments
Thank you
For including the whole piece, it's getting there. So one day we'll be seen as people not laboratory rats, now all we have to do is educate the rest of society.
Angharad
Angharad
Sigh
Sigh. I don't qualify. In going through this, I don't and would never qualify. Of the first six listed qualities that you need two of, I can honestly say that only #2 fits. I would really like to get rid of all sexual characteristics, but that is all.
It sucks to be me.
It's funny, I had been planning to write a blog on why most, if not nearly all, the people here don't have a Gender Identity Disorder, because they know what gender they are. It's just that their body is wrong, or not. Now though they won't have to put up with that horrible descriptor.
In reading this I wonder
One day they need to separate gender identity from gender role. I enjoy doing a lot of "male based" things. But I wanna be a girl. Again, that's why I don't believe in "gender roles." I just believe my body is "wrong."
So I can feel you there.
Qualifying
Well, yes. It covers my feelings. I just have one reservation: what the hell does sexuality have to do with gender?
Gender roles, indeed. That is one of the pitfalls of the TS 'process', that unless you can demonstrate sufficient 'femininity' you don't get ant further. We have all read the stories of doctors who will not sign off a patient unless they are 'pretty' enough, but there is also the need to be seen as the appropriate gender, so the roles, and the divide, get reinforced.
That is one of the reasons I gave my 'starter' character, in Something to Declare, a passion for playing rugby, an archetypically male pastime, but there are women's rugby teams. Hockey* is seen in British schools as a gril's game, but it is most definitely not in the rest of the world. Lacrosse, a native American combat simulation, is similarly seen as 'girly' over here. Confusing...
So, a rugby-playing TS in the UK would be seen as butch, a hockey player as femme. In India, the hockey player would be butch.
*In the world outside North America, hockey is played with a ball on grass, and ice hockey with a puck on, well, ice.
Sexuality
That's what ruffled my feathers, too. I am absolutely, 100% not attracted to men at all, but so are some natal women in that other category called Lesbian. Doesn't make my feelings about my "assigned" gender any less frustratingly real.
Regarding the changes in general though, I'll agree that this is still major progress otherwise. It'll be interesting to see how this plays out going forward.
What difference sexuality makes...
"[What] the hell does sexuality have to do with gender?"
Shrug. I have been kicking around on transgendered and transsexual only forums for quite a few years now... and that is not exactly a new question. Actually, I think many (if not most) TS ask that at some stage in their transitions -- usually shortly after being asked about their sexuality during a formal gender assessment as part of their diagnostic "treatment". Which is to say... it is a question I have encountered and thought about more than a few times, over the years.
I vaguely remember, as many others no doubt do, seeing questions about my sexuality on the [very long] questionnaire that was given to all new "clients" at the gender clinic I went to... and wondering much the same thing. What has *that* got to do with how I feel about my gender identity? After all... a woman can be "straight", lesbian, or bisexual... so what possible difference does it make to your gender identity as to whom you like to play around with?
Shrug. Although among my "medical background" education is three years of formal training in psychology, I am not a gender shrink. So my thoughts presented here should not be taken as definitive... merely "informed speculation". Truthfully, I probably learned far more about the specialty of "gender dysphoria" online, interacting with others having my own condition, than I ever learned in my formal education...
But my thoughts about these particular questions mostly boils down to simply this: humans are not solitary animals, spending most of their time alone. We are social beasts... "pack" animals, like wolves, if you prefer... and interactions between the individual and that individual's peer social group -- our personal "pack", the people we habitually hang out with -- are *immensely* important to our personality development. Sigh. "Being your own individual", and "don't listen to the opinions of others, be your own person" are cultural ideals... but not very realistic. Like it or not, we all actually *do* pay at least a little attention to what people around us think of our actions -- and the few who truly do not, generally have "other issues" that I don't want to get into right now. Suffice it to say, for the "average" person with "gender dysphoria"/"gender incongruence"... the opinions of others *does* matter, however much we wish it did not.
And that is where sexuality comes in, and why the shrinks ask about it. Not because of any direct correspondence between sexuality and gender identity (or gender role)... but simply because most transitioners are adults, and sex is an important part of adult life -- and one that is *hugely* impacted by one's preferred gender role.
Shrug. Before I transitioned, I was, like many (but by no means all) others, more "asexual" than really hetero-, homo-, or bi-sexual. I felt social pressure to be sexually active -- to have sex with women, since I was (usually) perceived to be a "guy" -- and, like most biological beings, I felt at least some physical pleasure from the act. (It is what we are "hard-wired" to feel, after all). But while physically capable of "procreation activities"... psychologically, inside me, I felt little interest in the whole thing. Mildly pleasurable...and expected of me... but not really worth the effort. Asexual, for the most part.
Not important... I just mention it as any discussion about the role of sex in transition usually reminds at least someone about the "oddity" of some transitioners apparent "flip" in sexual orientation. [The ones who go from "straight guy, attracted to women" to "straight woman, attracted to men"... or similar "reversals"]. I think the best explanation for this I have ever seen is a theory I first encountered in the writings of another "old timer" post op... who I won't name in this public forum, but who used to use the alias initials of "KG". The basic idea is, at least for those who were asexual before transition... (or thought they were "hetero" or "homosexual", but may not have been as "strongly" sexually defined as they thought they were)... that there are physical parts of our brain that are important to our sexual identity -- but those parts are "hormone activated". Children, for example, are *usually* asexual -- not particularly interested in sex, even if some of them have "discovered" it early. It can feel "nice" (assuming it is not forced on them)... but it is not that important to them. Then along comes puberty... surging hormone levels... and all bets are off.
Returning to KG's theory... pre-transition TS are much like physical children in some ways, in the sense that our bodies produce the "wrong" hormone. We have "sexual identity" parts of our brains, much like any others... but those "sex" brain cells are often still dormant -- inactivated, as the sex hormone activation sites on those brain cells are hard-wired to respond to a particular activation hormone... and that is the "wrong" one, for the rest of our physical body. Then we go on hormone replacement therapy ("HRT"), and flood our brains with the "right" hormone... and it is puberty time for us, regardless of our biological age. The brain hard-wiring *finally* receives the signal it was biologically programmed to respond to... and our sexual identity switches on. No longer the "mildly interested", "asexual" response of previous years -- which, child-like, lacking any strong biological imperative otherwise, could sometimes yield to social pressures and "assume" a false sexual orientation. Now, in the presence of the "right" sex hormone filling the previously dormant brain-cell activation receptors, our "true" sexual orientation is revealed... and sometimes, that does not align with what we had previously assumed it would be...
[As an aside... I personally subscribe to the theory that trans-folks are born that way, that the major "cause" of "gender dysphoria" is biological. That pre-natal hormone imbalances produce physical alterations in the brain's of gender incongruent individuals. My personal take on this, though, is that such hormone imbalances rarely happen identically. There is a broad spectrum of DSD ("Disorders of Sex Development", what used to be called "Intersexed") conditions, with a scale of possible degrees of physical "abnormalities", when such hormone difficulties impact on the genitals... and I suspect there is a similar spectrum of physical alterations to the brain structure from hormones. That within the "transgendered" spectrum, "crossdressers" may be "mostly" male, mentally, but are not all that dissimilar from TS -- that the hormonal changes in their brains may not have been as "extreme" as in a TS, but is still present to some lesser degree. (Well... at least among those CD's that feel "driven" to pursue their "hobby" -- I am aware that there truly are at least a few transvestites who do it for the thrill, or whatever, rather than because they must). That even among TS, there are varying degrees of physical brain cell differences, albeit probably smaller ones... which is something to keep in mind when reading what follows. I do not assume that everyone is identical, that anything I write will apply to everyone the same way. We are all unique... with possibly unique anatomy, as well as unique personalities... but, despite that, there are some "trends", or "patterns", that can be spotted in the TS population -- and what I am writing about here is such a pattern. My guess is it applies to many TS... perhaps, many TG's as well... but does it apply to a particular person? Only that person can decide...]
Shrug. As someone who once lived as a "gay" male for a time... and has also lived as a "lesbian" for a while... I am well aware that there are those in the rest of the Gay, Lesbian, and Bisexual community who really do not like trans-folks, for many reasons. One of those reasons sometimes being that we seem to be a flaw in their own "born that way" theory. It is a bit of a maxim to many gays and lesbians that one's sexual orientation can not be changed -- that they should just be who they were "born to be", since "no attempt to change one's sexual orientation can possibly work". Transsexuals seem to be an exception to that... as it is fairly well documented that *many* transsexuals do, in fact, switch their sexual orientations during transition. [Not all... but many]. This bugs quite a few GLB folks... so I think it is worth pointing out the "apparent" sexual orientation reversal among TS may in fact, if this theory is correct, be nothing of the sort. That we, as the GLB crowd assume, also have a "hard-wired" sexual orientation... we just are sometimes confused about what that orientation *is*, before HRT, as our "opposite wired" brain's have never really "grown up" before HRT, lacking the "right" hormonal cue...
So what has all this to do with why sexual orientation questions are important to gender identity assessments? Well, that is complicated... but part of it is that there is a very real chance that a transitioner's sexual orientation will change as they transition -- and while that may not be, technically, part of one's gender identity... it sure impacts the lives of the transitioners involved, in a major way. Which makes it important for the therapist monitoring that transition to know about it.
[As an aside... humans are complicated animals, whose minds can sometimes mask our biology. KG, for example, did not experience an "immediate" reversal in her sexual orientation when she started HRT -- quite the opposite. From what she wrote online, I gather that there was a considerable "lag time" between her transition, and her gradual acceptance that she was actually more interested in guys than women -- she has written that she was a lesbian for a decade or so after transition, before marrying a man. In my own case, I started out thinking I was a hetero-male, attracted to women... drifted into experimenting with guys... realized I was not a gay-male... transitioned... experimented with both males and females, both pre-op and post op... lived for a while (after surgery) in a serious "homosexual-female" relationship with a dyke lesbian... and eventually settled into a "heterosexual-female" relationship, married to a man -- but all of that took many years (over a decade, although I was fairly sure I would end up married to a man much sooner than that). Shrug. Social conditioning plays a part with our conscious minds -- most MtF transitioners grew up "expected" to date females, "expected" to be sexually attracted to them... and the habit of a lifetime is not something overcome overnight. But in time, biology has a way of gradually winning out...]
Returning to my earlier comments about pack animals, even if the transitioner does not experience any change in sexual orientation, our sexual orientation remains important to therapists -- and something they are entirely justified in asking about. Shrug. In deciding to transition, or not, one very important thing we need to do is define, at least to ourselves, informally, just what a man, and a woman, *is*, to us. What exactly it *is*, that bothers us about our current gender role... the way with interact with others in our "pack" as either a man or a woman... and why we want (need?) to transition into the other gender role. What, exactly, we hope to accomplish with this... and why it is important to us. This has far-reaching implications on many levels... but one of those levels is sexuality.
Shrug. Unless the transitioner is pre-puberty (and maybe not even then), sex is a part of our lives. We may chose to ignore it -- especially those of us who were, or are, asexual before or after transition -- but it is still a big factor, that needs to be taken into account. Were we attracted to females before, and expect to remain attracted to them? Then we will be becoming a lesbian -- and that has profound implications regarding our emergent female persona. Attracted to males, and expect to remain attracted to them? Again, the switch from "gay culture" to "straight woman" has an impact on our development, and needs to be addressed. Doing a "flip-flop", switching our apparent orientation? Whee... that can be a real roller-coaster, again with major personality and lifestyle change results...
Even for older transitioners, who may attempt to convince themselves that they are "beyond all that", sex remains something that must be considered. True, some may never have actual sexual intercourse with anyone, post transition (although far more *will*, than may initially *think* they will, in my experience in many years online). But even for those who only have sex with "themselves"... humans are sexual animals. "Sex sells"... and sex, or at least the implication of it, is all around us, every day. In the advertising we encounter... in the relationships of the people around us -- even if we are not "interested" in it, ourselves, it is nonetheless a topic that insinuates itself into our consciousness frequently. Some may try to tell themselves that it does not matter... but then, they usually still find themselves longing for the companionship, the closeness, of a relationship of some sort. And in our society, such adult relationships usually carry the implication of sex...
And then, after factoring all of the above in the equation... there is another little thing. Opening up the can of worms of "sexual orientation" allows the therapist to explore another realm of psychology... one's sexual fantasies. And regardless of whether you are attracted to males, females, both or neither... how one sees oneself in those fantasies is an important psychological clue. Are you a woman in those dreams? A man? That might still just be cultural conditioning... so it might not be relevant... but sometimes, with some patients, the mental transition has already happened enough that a "reversal" has happened -- and that can be important diagnostic information, in assessing a patient... and how "ready" they are to undertake something as profoundly life-impacting as transition...
So... "what the hell does sexuality have to do with gender"? A lot, actually. Not directly, usually... our exact sexual orientation is mostly not important, in itself. But indirectly? It has a *huge* impact on who we -- on who *anyone* -- becomes, as we mature our emergent post-transition personality... and thus, it is most definitely something any gender therapist *needs* to know about, and take into consideration.
"Sex is between the legs, gender is between the ears" may be true enough... but what we chose to do with those physical parts has a real impact on what goes on between the ears, and is therefore a legitimate question that needs to be asked when assessing one's gender identity, and possible changes to one's gender role...
Shrug. Just my two cents worth, idly whiling away some time on a hot summer day...
Doing the world a favor.
If we just dropped all pretense of most gender role, especially in clothing.
Very Hetero men are deluding themselves if they believe they've never worn a dress. Also, it doesn't make them Gay or Transsexual to have done it. A Kimono is a dress, so is a Toga and a Robe. Using those terms is truly just playing semantics and being in denial.
How is LaCrosse not rough and tumble? It's the one sport you're applauded in for kicking the shit out of the other player, albeit not as directly as hockey.
As far as Gender Identity and Sexual Orientation goes I do believe they are truly separate. However I believe that more often then not the two genes are closely linked and what effects one usually effects the other.
Last but not least, in terms of gender roles and dressing, the average person is Androgenous except when making a conscious effort to attract another person.
DSM V
Why can't society accept the entire spectrum of humanity? Would solve a lot of problems and make things a lot nicer for everybody
May Your Light Forever Shine
Thanks for posting this
My main concerns are the wording of several passages:
Wow! The authors must not get out much, huh? Psychiatric? that invalidates their earlier statement about avoiding stigma, doesn't it? No chance that it might just be due to a pathological agent?
Mighty generous of them :P As I said before, they must not get down from their mountain thrones much, being the gods they think themselves to be...
Oh, and lets not go into the whole sexual orientation thing...
I'm wondering how the V.A. will interpret this.
The V.A.'s prime reason for not doing SRS, FFS, Breast augmentation, etc has been that it's not what they consider MEDICALLY necessary. If the mental part of it is now gone, will they consider some, if not all, of the above mentioned things?
Cathy
As a T-woman, I do have a Y chromosome... it's just in cursive, pink script.
Interesting...
A few things I noticed (as an outsider looking in, so to speak):
a) the addition of "(or some alternative gender different from one’s assigned gender)" - they've acknowledged (point 16) that gender identity and gender role are a multi-category concept or spectrum (which can be either male, female, in-between or otherwise), rather than a dichotomy.
b) they considered placing GD in a category of its own, but decided not to in case it negatively affects clinical decisions / insurance cover.
c) they've recognised that sexual attraction is a minor component (and may be deliberately stated incorrectly to aid diagnosis, as well as the possibility of it changing during transition), so have removed it from the criteria for diagnosis, but they've left it in the informational section for research purposes.
d) it seems theoretically possible for those that view themselves as masculine women or feminine men to be covered under the guidelines.
So it seems to be a significant step in the right direction, although the placement of the condition and the inclusion of the sexual orientation question (without making it optional and clearly signposting it as not forming part of the diagnosis and for research purposes only) seem questionable.
As the right side of the brain controls the left side of the body, then only left-handers are in their right mind!