This post is part of a series of guest posts on GPS by the graduate students in my Psychopathology course. As part of their work for the course, each student had to demonstrate mastery of the skill of “Educating the Public about Mental Health.” To that end, each student has to prepare two 1,000ish word posts on a particular class of mental disorders.
Untying Loose Ends: Advancements of the DSM-5 Concerning Sex and Gender by Adam Everson
Let’s be honest: the DSM has never been (and never will be) perfect. Now, this doesn’t mean the American Psychiatric Association just creates a giant ream of paper that is better off under a wobbly kitchen table than on the shelves of a clinician’s office (I mean – it’s not like the APA is publishing the phone book or anything). Instead, the DSM serves as an often useful guide and reference for practicing clinicians, educators, and students alike. But, that doesn’t necessary mean it gets things right all the time. It’s made by people who – turns out and despite what Dr. Laura thinks of herself – are not perfect. Just as a the meteorologist can predict a snowstorm on what turns out to be a calm day and the theoretical physicist can miscalculate the structure and characteristics of a wormhole, so too can the psychiatrist, psychologist or other mental health professional make an error in the existence of one mental disorder and how it relates to others.
In terms of sex and gender, the DSM-IV offered one category of diagnoses: Sexual and Gender Identity Disorders. While there was never really any reason provided in the DSM-IV for why this was, it just was. I guess one could argue these disorders kind of…sort of…eh…maybe (???) revolve around why and how and with whom one does “adult activities” and how he/she understands his/her role in those “activities.” I mean – that’s not really the best argument, but I guess it’s an argument for why these disorders are grouped together…
There are lots of factors that influence what goes on in the bedroom, but some of these disorders really don’t even pertain to the bedroom at all. One’s gender identity has very little to do with his/her sexual activities. While there do exist patterns between sexual orientation and gender identity, those two elements of sexuality can be – and turns out are – independent concepts. And yes, there can be a fear or avoidance of sexual activity with gender dysphoria (when one feels his/her experienced gender isn’t the same as the one he/she was biologically assigned), but that doesn’t mean gender dysphoria only pertains to sexual activity. And even in terms of some paraphilias does the bedroom not really play a part. If one has a frotteurism paraphilia, he/she finds touching and rubbing against a non-consenting person sexually arousing. So unless one’s bedroom is also a stop in the New York City subway system, chances are those unable to control these types of fantasies and urges will go beyond the bedroom to satisfy them.
With the introduction of the DSM-5 came many changes to the modern understanding and methods of diagnosing psychiatric disorders. While there are debates regarding how well the DSM-5 lived up to its expectation of revolutionizing the way people view mental disorders, there has been a dramatic change that has reformed our understanding of sex and gender in the context of psychopathology. The DSM-5, rather than one umbrella section, has separated sexual dysfunctions, gender dysphoria and paraphilic disorders into their own separate categories of diagnoses. The division of the Sexual and Gender Identity Disorders category was a major development. As psychology’s understanding of sexuality continues to develop, we have a better understanding as to how complicated the concept of sexuality is and how different the components that make up sexuality are.
Each edition of the DSM acts as an indicator of the scientific, political and cultural themes or advancements of its time. One crucial example of this is the declassification of homosexuality as a paraphilia. Up until 1974, homosexuality was considered a mental disorder in need of treatment in the DSM. However, after a demonstration by a group of gay activists in front the American Psychiatric Association Convention, the APA’s 1974 vote to remove the disorder from the manual became a milestone in the cultural and political development in the field’s understanding of sexuality and associated psychopathology. Later, research began to emerge indicating that while sexual dysfunctions, problematic paraphilias and gender incongruence can be treated with success, sexual orientation wasn’t really something psychotherapy or pharmaceuticals (or prayer) could change. In fact, sexual orientation wasn’t really an underlying, psychotic problem at all; it was more the difficulties in being a sexual minority in what could be an unaccepting culture that seemed to be the problem. It would be considered ludicrous for a psychiatrist to diagnose someone as having a problem simply because he/she, for example, was Asian during World War II. There never existed an “Asian” diagnosis, and there never will. Granted, individuals of Asian descent would likely have depressive or anxiety problems while living in World War II America, but that wouldn’t be because of their ethnicity. As such, sexual minorities don’t have a problem because of their sexuality, but instead because of what this minority membership can entail socially.
Gender dysphoria follows this same theme. The DSM-IV recognized gender dysphoria as “gender identity disorder,” suggesting it was one’s gender identity that seemed to be the problem. Yet, emerging evidence seems to indicate that the distress associated with an incongruence between one’s natal (biological) gender and his/her expressed gender typically will disappear after such treatment as sex reassignment surgery. If there is continuing depression, anxiety, or substance use, it is often the result of other underlying factors outside of the gender dysphoria. This advancement in science was recognized in the DSM-5 as it moved away from labeling someone as having a problem because of his/her gender identity.
Sexuality is the product of many social, cultural, personal and biological factors that are expressed in many different ways. Unlike in other categories outlined in the DSM that are centered around a central component (e.g., anxiety disorders, feeding and eating disorders, neurocognitive disorders or depressive disorders), there does not exist that core aspect that anchors sexual dysfunctions, gender dysphoria and paraphilic disorders together. There are major differences between one’s sexual attraction, one’s sexual performance, and one’s gender identity, and these differences need to be recognized. Each of these new categories are now independent because they recognize this advancement in thought/understanding and because they correspond to very different aspects of personality and psychopathology.