Arch Sex Behav DOI 10.1007/s10508-009-9531-5 ORIGINAL PAPER Queer Diagnoses: Parallels and Contrasts in the History of Homosexuality, Gender Variance, and the Diagnostic and Statistical Manual Jack Drescher Ó American Psychiatric Association 2009 Abstract The American Psychiatric Association (APA) is Similarities and differences in the relationships of homo- in the process of revising its Diagnostic and Statistical Man- sexuality and gender identity to psychiatric and medical th- ual (DSM), with the DSM-V having an anticipated publica- inking are elucidated. Following a discussion of these issues, tion date of 2012. As part of that ongoing process, in May the author recommends changes in the DSM-V and some in- 2008, APA announced its appointment of the Work Group on ternal and public actions that the American Psychiatric Asso- Sexual and Gender Identity Disorders (WGSGID). The ann- ciation should take. ouncement generated a flurry of concerned and anxious res- ponses in the lesbian, gay, bisexual, and transgender (LGBT) Keywords American Psychiatric Association Á DSM-V Á community, mostly focused on the status of the diagnostic Gender variance Á Gender identity disorder Á Homosexuality Á categories of Gender Identity Disorder (GID) (for both chil- Transgender dren and adolescents and adults). Activists argued, as in the case of homosexuality in the 1970s, that it is wrong to label expressions of gender variance as symptoms of a mental dis- order and that perpetuating DSM-IV-TR’s GID diagnoses in It was six men of Hindustan the DSM-V would further stigmatize and cause harm to trans- To learning much inclined, gender individuals. Other advocates in the trans community Who went to see the Elephant expressed concern that deleting GID would lead to denying (Though all of them were blind) medical and surgical care for transgender adults. This review That each by observation explores how criticisms of the existing GID diagnoses par- Might satisfy the mind. allel and contrast with earlier historicalevents that led APA to The first approached the Elephant remove homosexuality from the DSM in 1973. It begins with And happening to fall a brief introduction to binary formulations that lead not only Against his broad and sturdy side to linkages of sexual orientation and gender identity, but also At once began to bawl: to scientific and clinical etiological theories that implicitly ‘‘Bless me, it seems the Elephant moralize about matters of sexuality and gender. Next is a Is very like a wall’’. review of the history of how homosexuality came to be re- moved from the DSM-II in 1973 and how, not long thereafter, The second, feeling of his tusk, the GID diagnoses found their way into DSM-III in 1980. Cried, ‘‘Ho! What have we here So very round and smooth and sharp? To me ‘tis mighty clear This wonder of an Elephant J. Drescher (&) Is very like a spear’’. Department of Psychiatry and Behavioral Sciences, New York Medical College, 440 West 24th St., Suite 1A, The third approached the animal, New York, NY 10011, USA And happening to take e-mail: [email protected] 123 Arch Sex Behav The squirming trunk within his hands, and Gender Identity Disorders (WGSGID),2 one of 13 Work Then boldly up and spake: Groups participating in the DSM-V revision process. ‘‘I see,’’ quoth he, ‘‘the Elephant Prior to the WGSGID appointments, media interest in the Is very like a snake.’’ DSM process had primarily focused on possible conflicts of interests of psychiatrists with financial ties to the pharma- The Fourth reached out an eager hand, ceutical industry (Garber, 2007). However, the announce- And felt about the knee. ment of the WGSGID appointments and the group’s charge ‘‘What most this wondrous beast is like generated a flurry of concerned and anxious responses in the Is mighty plain,’’ quoth he; lesbian, gay, bisexual, and transgender (LGBT) community ‘‘‘Tis clear enough the Elephant and blogosphere, mostly focused on the status of the diagnos- Is very like a tree!’’ tic categories of Gender Identity Disorder (GID) of Adoles- The Fifth, who chanced to touch the ear, cence and Adulthood and GID of Childhood (GIDC).3 These Said: ‘‘E’en the blindest man controversies were subsequently taken up in the LGBT press Can tell what this resembles most; (Chibbaro, 2008; Osborne, 2008) and, shortly afterwards, the Deny the fact who can, mainstream media (Carey, 2008) and professional newslet- This marvel of an Elephant ters (Melby, 2009) began reporting about them as well. The Is very like a fan!’’ issues LGBT activists raised related to GID and the DSM are summarized below: The Sixth no sooner had begun About the beast to grope, 1. As in the case of homosexuality in the 1970s, it is wrong Than, seizing on the swinging tail for psychiatrists and other mental health professionals to That fell within his scope, label expressions of gender variance4 as symptoms of a ‘‘I see,’’ quoth he, ‘‘the Elephant mental disorder and perpetuating DSM-IV-TR’s GID Is very like a rope!’’ diagnoses in the DSM-V would further stigmatize and cause harm to transgender individuals, already a highly And so these men of Hindustan vulnerable and stigmatized population. Disputed loud and long, 2. Some members and advocates of the trans community Each in his own opinion expressed concern that deleting GID from the DSM-V Exceeding stiff and strong, would lead third party payers to deny access to care for Though each was partly in the right those transgender adults already struggling with inade- And all were in the wrong. quate private and pubic sources of healthcare funding for John Godfrey Saxe, The Blindmen and the Elephant medical and surgical care. (1873) 3. Retention of the GID diagnoses would eventually lead to putting the diagnosis of ‘‘homosexuality,’’removed from the DSM-II in 1973, back into the psychiatric manual. Introduction 4. Clinical efforts with gender variant children aimed at getting them to reject their felt gender identity and to accept their natal sex were unscientific, unethical, and misguided. Act- ‘‘We are in a new era in which diagnosis has such social ivists labeled such efforts a form of ‘‘reparative therapy.’’ and political implications that one is constantly on the front lines fighting on issues our forebears were spared.’’ Robert Stoller, M.D.1 2 The13WGSGIDmembersareKennethJ.Zucker,Ph.D.(Chair),Irving The American Psychiatric Association (APA) is in the pro- M. Binik, Ph.D., Ray Blanchard, Ph.D., Lori Brotto, Ph.D., Peggy T. cess of revising its Diagnostic and Statistical Manual (DSM), Cohen-Kettenis, Ph.D., Jack Drescher, M.D., Cynthia Graham, Ph.D., with the DSM-V having an anticipated publication date of 2012 Martin P. Kafka, M.D., Richard B. Krueger, M.D., Niklas La˚ngstro¨m, M.D., Ph.D., Heino F. L. Meyer-Bahlburg, Dr. rer. nat., Friedemann (Kupfer, First, & Regier, 2002; Phillips, First, & Pincus, 2003). Pfa¨fflin, M.D., and Robert Taylor Segraves, M.D., Ph.D. As part of that ongoing process, in May 2008, APA announced 3 In DSM-IV-TR, there is only one diagnosis—GID—with separate the appointment of the members of the Work Group on Sexual criteria sets for children vs. adolescents/adults. 4 Following Meyer-Bahlburg (2009), ‘‘Thenomenclature in the area of gender variations continues to be in flux, in regard to both the descriptive terms used by professionals, and, even more so, the identity terms adopt- ed by persons with GIV [Gender-Identity-Variants].’’ Where possible, this author will use the term ‘‘gender variance’’ to refer to individuals 1 Cited in Bayer (1981, p. 10). with gender atypical behavior or self presentations. 123 Arch Sex Behav 5. Internet bloggers and petitioners widely circulated ad homi- What is normal sexuality [or normal gender]? What is nem accusations and attacks against individual members of the role of sexuality [or the role of gender] in human the WGSGID who were characterized as prejudiced against existence? Do the brute requirements of species’ sur- transgender individuals (i.e., transphobic).5 Some profes- vival compel an answer to the question of whether ho- sionals petitioned the APA to ‘‘balance’’ the work group mosexuality [or whether gender variance] is a disorder? appointments with more ‘‘trans positive’’ members.6 Fears How should social values influence psychiatry and help were raised that these individuals would use their position to to define the concept of mental illness? What is the app- influence the Work Group in ways that would further exac- ropriate scope of a nosology of psychiatric disorders? erbate stigma and prejudice against the trans community. How should conflicts over such issues be resolved? How should the opposing principles of democracy and There is no factual basis to the rumors that APA, which authority be brought to bear in such matters? (Bayer, issued a 2005 position statement supporting civil marriage 1981,p.4) equality for gay people,7 might restore homosexuality to the DSM nor have these assertions been made by anyone affili- As in the case of homosexuality, arguments for removal of ated with APA or the DSM process (Osborne, 2008). What the ‘‘trans diagnoses’’ include societal intolerance of differ- constitutes a reparative therapy is addressed briefly later in ence, the human cost of diagnostic stigmatization, using the this review. Meyer-Bahlburg (2009), in a related DSM re- language of psychopathology to describe what some consider view, takes up the issue of how medical treatment of gender to be normal behaviors and feelings and, finally, inappropri- variance might be conceptualized with or without the GID ately focusing psychiatric attention on individual diversity diagnosis in greater detail. Also in related reports, Cohen- rather than opposing the social forces that oppress sexual and Kettenis and Pfa¨fflin (2009) and Zucker (2009) review the gender nonconformity.9 diagnostic criteria of the existing GID diagnoses.