Medicalization: the case of gender identity disorder and DSM-5

GID

The Changing Discourse on GID

The public discourse on homosexuality and gender-orientation differences is one that is in state of steady of evolution. Once treated strictly as anathema and still today even criminalized in many parts of the United States under sodomy laws, homosexuality is increasingly recognized as an alternative lifestyle. Part of this recognition has been the gradual improvement of the medical and therapeutic communities' shared understanding of this orientation. Indeed, the historical treatment of homosexuality and gender-orientation differences as psychiatric disorders has not only contributed to the negative cultural perception of homosexuality but has also prevented many in these demographics from receiving real and meaningful therapeutic support. The impetus to 'cure' homosexuality or gender orientation differences has simultaneously deprived many individuals an opportunity for true psychiatric treatment for depression, anxiety disorders and the host of other conditions that may accompany the experience of cultural exclusion or otherness.

The DSM has long been the source for classifying and understanding a whole catalogue of psychological conditions. And at one juncture, its inclusion of homosexuality registered as a strong statement against the cultural acceptance of sexual orientation differences. But as the literature on this subject demonstrates, the DSM is subject to change as our understanding of certain conditions achieves cultural evolution. To this point, according to the text by Grush (2013), "the DSM-5 incorporates many more changes that have psychiatrists locked in heated debate, but Wiznitzer noted that these tensions will always exist as long as doctors continue to learn more about the human brain. 'Homosexuality used to be in the DSM as a psychiatric disorder; that was two versions ago," Wiznitzer said. "Autism wasn't even in the first two versions of the DSM, it was childhood schizophrenia. Then we changed the criteria over time. Basically anytime you change something, it's always met with resistance.'" (p. 3)

This is evidenced in the present debate, which concerns the removal of Gender Identity Disorder (GID) from the manual. The condition has been replaced by the more sensitively labeled Gender Dysphoria terminology, which implies not that the gender orientation is itself a disorder but that the difficulty of the subject to reconcile gender identity confusion should be treated. Though there has been some resistance from those in the medical and therapeutic communities that still hold the belief that homosexuality and gender identity variants can be 'cured,' the change is largely being met with nuanced discussion.

Indeed, this change is important and potentially highlights a positive path on the discussion of mental health support for homosexual or transgender individuals. In particular, it expands the conversation on treating such individuals separately from their sexually orientation. According to the text by Bryant, this new evolution of the DSM "illustrates the process through which scientific knowledge about gender-variant children was initially constructed and points to the key constitutive role of debates, both among professionals and between professionals and lay critics, in shaping that knowledge." (Bryant, p. 24)

In the past, identification of gender-variant individuals as afflicted by pathology had been based on a combination of cultural prejudice and, perhaps even more directly, basic misunderstanding. Certainly, the very face that the condition had been treated and categorized as a disorder would help to magnify this misunderstanding by causing the therapeutic process to overlook some very fundamental stressors related to gender-variance. Such is to say that a great many stressors relate to the matter of being culturally or socially isolated or otherwise compelled by the therapeutic process to believe that certain core identity traits are 'wrong.' These stressors are distinct and separate from the stressors related to understanding one's own identity and gender orientation which, if treated properly, should be reconciled without ever attacking the core 'rightness' or 'wrongness' of one's gender orientation.

This denotes, and Bryant supports this interpretation, that therapy has not only failed gender variant individuals through its application of past DSM classification but that it has been destructive to the mental health and identity reconciliation of many gender-variant individuals. Bryant "shows how critiques have been central in shaping both the diagnosis and the evaluation and treatment practices associated with it, but that these critiques have often been incorporated in ways that jettison their most important critical components. Further by focusing on adult sexual outcomes (homosexuality), a frame initially developed by the gender researchers themselves, critics have largely missed an opportunity to rethinkl menta health support for gender-variant children in terms of general psychological health instead of narrow psycho-sexual outcomes." (Bryant, p. 24)

In many ways, this failure of mental health support would be quite similar to the slow uptake of treatment for HIV / AIDS. This is to say that the cultural disapproval of homosexuality or gender variance had allowed this public health issue to be relegated as a lower priority for the medical community. Moreover, it also promoted the notion that AIDS was a function of the broader medical condition of homosexuality. According to Conrad & Angell (2004), "some social scientists have suggested that AIDS remedicalized homosexuality. Phillip Kayal argues in his 1987 book Bearing Virtues: Gay Men's Health Crisis and the Politics of AIDS: "The present situation of Gay AIDS is akin to previous 'medicalization of homosexuality' wherein gays are defined as both biologically and psychologically sick" (p.197). Sociologist Steven Epstein in a 1988 article claims that, because gay men were some of the first individuals to contract AIDS, the illness was framed as a "gay disease" both among public health workers and most Americans generally. According to Epstein, being gay was perceived within popular culture as a 'symptom' of AIDS." (Conrad & Angell, p. 35)