GID Reform and the DSM

[leavingprov]

I just wanted to share this and start/continue a discussion about this issue. Would love to hear all of your thoughts on this matter.

http://pamshouseblend.com/diary/110...annual-apa-meeting-speaker-madeline-deutch-md

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Members don't see this ad.

 

[PsyDr]

eh,
while GID is undoubtedly a controversial diagnosis, her argument has some problems

1) retroactively change of birth records: this is not how the legal system works. for example: we do not get to say a marriage never happened even when it is annulled.

2) treatment preference: treatment is rarely based soley upon patietn preference. for example anorexics would rarely consent to a weigh gain program.

dr. deutch gives evidence of a 99% patient satisfaction as proof of the efficacy of gender reassignment surgery/hormonal replacement. she fails to discuss a 45 fold increase in risk of DVT, and an approximately 30 fold increase in suicide attempts.



3) significant distress: dr. deutch fails to utilize criteria A for any of the diagnoses she discusses, namely significant distress. a dx of transvestic fetishism would not be made without significant distress.

4) there is an ICD-9 code. has been for years.

 

[cara susanna]

How are they being forced into treatment?

 

[thewesternsky]

How are they being forced into treatment?

From what I understand: People who wish to transition are almost always required to receive psychological assessment prior to surgery/hormone therapy etc.

I assume this is what Deutch is referring to here:

"But no one forces these people into a psychotherapeutic environment. It is time to stop forcing the same on transgender people."

 

[futureapppsy2]

^
But people who get, say, gastric bypass surgery are forced to get psych assessment prior to surgery as well. I think some sort of psych assessment on adults before they undergo a major, elective (i.e., not immediately necessary) surgery might be a good idea in general.

 

[Wildcat06]

Good point futureapp. I think the two are very comparable. I see no harm in requiring counseling through this process. As PSYDR pointed out, the suicide rates for this group are disturbingly high as it is. I would hate to see what would happen in the absence of therapy...

 

[JockNerd]

I think it would be strange to NOT require therapy while undergoing transition.

I think GID obviously needs to get dropped from the DSM, but I'm not sure why the person in the link is convoluting transgender people with people who want sexual reassignment surgery. Not all transgender people transition, or want to.

 

[leavingprov]

eh,
while GID is undoubtedly a controversial diagnosis, her argument has some problems

1) retroactively change of birth records: this is not how the legal system works. for example: we do not get to say a marriage never happened even when it is annulled.

Not sure this is true--Doesn't it vary state by state, with some states permitting retroactively changing name and sex on a birth certificate and some not --- e.g. see http://www.drbecky.com/birthcert.html

But beyond the finer (and at times inaccurate) points of Dr. Deutch's argument, I am interested in learning more about all of your opinions as to how the field of psychology works with this diagnostic category and how GID should be changed or eliminated in the DSM. Also what is the role of the insurance companies (which she mentions) in all of this? Finally, how do you all see the existence of the GID category leading to larger problems (e.g. stigma of or discrimination against a group of people). I'm only beginning to educate myself about this issue but it is very interesting to me.

 

[PsyDr]

i made a mistake, i meant criteria C. apologies.


in regards to GID and its relationship to transgenderism, it is my opinion that the two are separate classifications.

GID refers to someone who is so distraught with the idea that their primary and secondary sexual characteristics are incongruous with their self perception that their functioning is impaired.

transgendered simply refers to someone whose perceived gender identity is incongruous with their socially defined gender.

or, to simplify: the difference is in the distress.

personally, i do not believe we should eliminate this category, only the misuse thereof.

 

[HenryHall]

But people who get, say, gastric bypass surgery are forced to get psych assessment prior to surgery as well. I think some sort of psych assessment on adults before they undergo a major, elective (i.e., not immediately necessary) surgery might be a good idea in general.

Good point futureapp. I think the two are very comparable. ...

The two are neither comparable nor analogous. One might say they are opposite.

Many transsexual people seeking genital reconstruction surgery are required to secure diagnosis of presence of a particular severe psychopathology.

Some obese people seeking bariatric surgery are required to secure clearance of absence significant psychopathologies.

Only one of the two is not iatrogenic and therein lies an opposite

The real question is how such misconceptions arise.

 

[futureapppsy2]

My point was that both are major, life-changing surgeries, and I don't think it's unreasonable to require some sort of psych assesment/consultation prior to initiating them.

 

[HenryHall]

My point was that both are major, life-changing surgeries, and I don't think it's unreasonable to require some sort of psych assesment/consultation prior to initiating them.

Let's agree to differ.

I think that inflicting stigmatizing iatrogenic harm by pathologizing a fictional severe mental disorder (the HBIGDA-SOCv6 requires not merely GID, but severe GID) by holding needed surgery hostage to the patient feigning non-existent distress is indeed unreasonable.

And many or most transsexual people do indeed feign distress so as to appease the psychiatrists, they have learned they must do that or be refused the somatic treatment they need.

So let's agree to differ on that, OK?

 

[PsyDr]

henryhall is referring to the standards of care for gender reassignment surgery which do require a dx of GID.

HH,

the posters on here most likely are unfamiliar with the standards of care. i am guessing they are simply supporting the idea of screening for behavioral variables that would complicate response to intervention.

 

[PsyDr]

Not sure this is true--Doesn't it vary state by state, with some states permitting retroactively changing name and sex on a birth certificate and some not.

interesting... this appears to be a point wherein statutory law violates common law.

 

[HenryHall]

Let's agree to differ.
I think that inflicting stigmatizing iatrogenic harm by ..
So let's agree to differ on that, OK?

Look, I don't mean to be rough, and I'm sorry if you are new to the field of transsexualism and feel like you just stumbled into a minefield.

That there be some form of psychological assessment for stability prior to surgery is, unfortunately, in this litigious society, not entirely unreasonable.

If assessment for Genital Reconstructive Surgery is to be like assessment for Bariatric surgery then that is not incompatible with what the activists are demanding. And that process begins with removal of GID and its brethren from the DSM.

We don't after all require diagnosis of Cancer Identity Disorder or Obesity Identity Disorder as a condition of surgery now do we?

All transmen ask is that they be treated like non-transmen. Corollary for transwomen. It is not to much to ask and they have given up on taking no for an answer.

If GID is not removed from DSM/ICD by medical authorities it will be removed by government edict. Sweden did this on 1/1/2009 for children, France did it on 5/15/2009 for children and adults, more will follow soon enough.

 

[HenryHall]

interesting... this appears to be a point wherein statutory law violates common law.

Obviously you never did lawschool.
Statutes have been supreme over Common Law for more than 250 years.

However it should be noted that legal sex, medical sex and scientific sex are each separate concepts are often not congruent one with the other. The least known is medical sex, that is quite simply the sex that best promotes health. Medicine is supposed to serve health rather than serve science when the two are in conflict as they are in this case.

 

[Ollie123]

Look, I don't mean to be rough, and I'm sorry if you are new to the field of transsexualism and feel like you just stumbled into a minefield.

That there be some form of psychological assessment for stability prior to surgery is, unfortunately, in this litigious society, not entirely unreasonable.

If assessment for Genital Reconstructive Surgery is to be like assessment for Bariatric surgery then that is not incompatible with what the activists are demanding. And that process begins with removal of GID and its brethren from the DSM.

We don't after all require diagnosis of Cancer Identity Disorder or Obesity Identity Disorder as a condition of surgery now do we?

All transmen ask is that they be treated like non-transmen. Corollary for transwomen. It is not to much to ask and they have given up on taking no for an answer.

If GID is not removed from DSM/ICD by medical authorities it will be removed by government edict. Sweden did this on 1/1/2009 for children, France did it on 5/15/2009 for children and adults, more will follow soon enough.

I might be wrong, but you seem somewhat upset by the attitudes of folks here and I'm not entirely sure why. I don't think anyone in this thread would disagree with the above. What you've said seems perfectly reasonable to me and seems pretty much in line with how most psychologists I know feel about this sort of thing. I actually think any substantial non-emergency surgery (elective or not) should be accompanied by a psych assessment though that may be my own bias as a health psychologist. Litigation is one facet, but its important to assess capacity for any elective surgery, and a proper psych eval for all major surgeries could reduce complications, mortality, etc. by a substantial margin.

 

[PsyDr]

HH,

you're right. i never "did" law school. just picked some stuff up while working in the courts. thanks for pointing that out.



"That there be some form of psychological assessment for stability prior to surgery is, unfortunately, in this litigious society, not entirely unreasonable."

you obviously never "did" psychology school. that is not the purpose of presurgical psychological assessment.

 

[HenryHall]

...
you obviously never "did" psychology school. that is not the purpose of presurgical psychological assessment.

Well you are right about the psychology school. Mazel tov

But the available evidence suggests that the purpose of presurgical psychological assessment really is all about litigation. And a lawschool training would therefore come in handy for people who do presurgical psychological assessments.

See what surgeon Marci Bowers (an acknowledged leader in this field) says:
http://www.marcibowers.com/grs/surgery.html

Requirements prior to surgery ... Psychiatric Evaluations - Per the WPATH Standards of Care, two (2) Psychiatric evaluations must be provided, ... In general, despite her misgivings about the Standards of Care, Dr. Bowers is required by the hospital and insurers to require two letters of approval (except patients who can document a real life experience of 5 years or more, in which case just one letter is required). Our rigid adherence to a standard of care allows Dr. Bowers and Mt. San Rafael Hospital to retain insurance for this important, but still rare, practice of medicine.

This says it plainly as can be, presurgical psychological assessment is absolutely required but would not be required if the malpractice insurers did not mandate it. Marci should know of course, she is postop trans herself as well as the (nowadays, twas not always so) leading surgeon Stateside in GRS surgery. As a surgeon, she still has to operate in just about the remotest part of the USA though to avoid the hatemongers determined to hurt transfolk.

For the benefit of those who don't know, an overwhelming majority of Americans who have GRS travel to Asia for surgery - precisely to avoid the damaging psychiatry otherwise required. For that reason, despite an explosion in demand worldwide, there are fewer surgeons in the USA doing this kind of work than there were 20 years ago and none have overfull order books. But when GID comes out of the DSM that will likely be reversed in short order.

See also:
http://www.psychiatrictimes.com/display/article/10168/1415037

May 19, 2009 APA 2009 Gender Identity Disorder: Has Accepted Practice Caused Harm?
Lois Wingerson ...

Even mainstream psychiatry is finally coming around to the view that the GID diagnosis does more harm than good. Finally! It has been a very long haul in the search for decency.

 

[PsyDGrrrl]

The TG community has been mixed on this issue. For some people, the recognition that they have a genuine "problem" (being in the wrong body) is not such a bad thing - for any insurance provider to cover any of the hormones/procedures/ surgeries, they need a diagnosis. So while in some ways it unnecessarily pathologizes people, it can also be a step towards getting the help they want/need in completing their transition.

 

[HenryHall]

The TG community has been mixed on this issue. For some people, the recognition that they have a genuine "problem" (being in the wrong body) is not such a bad thing - for any insurance provider to cover any of the hormones/procedures/ surgeries, they need a diagnosis. So while in some ways it unnecessarily pathologizes people, it can also be a step towards getting the help they want/need in completing their transition.

That's correct. Some might call it taking the King's shilling.

That is agreeing to be labelled as mentally ill when one isn't. Knowingly being tarred with the stigma of mental illness without being mentally ill. It's a criminal fraud conspiracy (since someone's money is involved at some point) to use a diagnosis merely because it facilitates treatment and not because it is genuine. The psychiatrists involved should do time in prison for their actions.

Shame on the mental health profession for their fecklessness. Sad for the transsexual people forced into dishonesty by the holding-hostage of medical treatment to compliance in a bogus diagnosis.

Please don't tell me that mental illness should not carry a stigma, that is true but. (1) The stigma of mental illness is real. (2) Transsexual people don't have a dog in that fight.

 

[cmuhooligan]

While I would never claim to be an expert on this topic, I do think that if the GID diagnosis is retained in DSM-V, it needs serious overhaul (especially in regard to the childhood diagnosis). For example, currently, a child doesn't even need to express a desire to be the other gender, but simply engage in gender atypical behaviors. This approach seems to be a bit too liberal in its diagnostic criteria, catching a lot of children who are simply "tomboys" or effeminate boys. I believe there is pretty good evidence that a sizable percentage of children diagnosed with GID no longer meet criteria as an adolescent or adult.

 

[PsyDr]

HH,

the purpose of a psychological presurgical eval is not for litigation purposes in the clinical arena. almost all the literature uses measures of positive outcome of surgical procedures NOT LITIGATION. insurance does not pay for legal purposes.

there is also a substantial difference between a psychiatric evaluation and a psychological eval.

 

[Wildcat06]

The psychiatrists involved should do time in prison for their actions.

Well that's a strong statement... What exactly would be the charge?

 

[HenryHall]

Well that's a strong statement... What exactly would be the charge?

Either criminal fraud, or conspiracy to fraud.

The elements of criminal fraud are: misrepresentation, intent, knowledge, and purpose. Tort fraud also requires damages. Conspiracy to fraud also requires inchoate agreement but does not require purpose.

Take for example a doctor who diagnoses ICD-10 F64.2 Gender Identity disorder of Childhood. If the doctor's purpose is to secure treatment, or payment or reimbursement for treatment then the intent and purpose prongs are satisfied. If the doctor is also aware that ICD-10 GIDC is listed as a disorder of adult personality and that the patient is a child then the knowledge prong is satisfied. If the doctor also reveals the diagnosis to a thrid party then the misrepresentation prong is also satisfied and criminal fraud is proven. See http://apps.who.int/classifications/apps/icd/icd10online/index.htm?gf60.htm+
If the patient's insurance company pays for the procedure following or if the doctor receives a fee from the patient or his or her parents then tort fraud is established. If the patient knows that he or she is not mentally ill but goes along with the bogus diagnosis to secure treatment (this is the usual case in transsexualism) and the doctor suspects that the patient has bamboozled then inchoate agreement is established and conspiracy to fraud is proven.

If brought to justice then sanctions may be fines, imprisonment (not for tort fraud), and an order to pay restitution.

The reason why this does not happen in practice is that the patient is blackmailed, if they elect to their assert their right to justice they will lose their change to get life saving medical treatment. And so the corrupt system flourishes until one day someone will hire a smart attorney and blow the whistle.

It all begins with that dishonest diagnosis - Gender Identity Disorder and snowballs from there.

 

[HenryHall]

the purpose of a psychological presurgical eval is not for litigation purposes in the clinical arena. almost all the literature uses measures of positive outcome of surgical procedures NOT LITIGATION. insurance does not pay for legal purposes. ...

We seem to have a genuine misunderstanding here.
I offered objective evidence to show what the purpose actually is.
You offered an opinion on what the purpose should be.

The two are entirely compatible, each with the other, both can be correct.