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On Thursday, April 20, 2010 the Center and the Callen-Lorde Community Health Center collaborated to submit a response on the proposed “Gender Incongruence” diagnosis in the American Psychiatric Association’s (APA) draft revision of the Diagnostic and Statistical Manual of Mental Disorders, version 5 (DSM-5), scheduled to be released in 2013. The Center and Callen-Lorde proposed that all diagnoses addressing gender non-conformity and identity be eliminated from the DSM-5 and went further by requesting the APA to formally renounce reparative therapy addressing gender non-conformity in children, adolescents and adults while supporting and advocating for a viable transgender-specific medical diagnosis in the International Classification of Diseases (ICD). In addition, the Center and Callen-Lorde requested that the APA include lesbian, gay, bisexual and transgender healthcare institutions and community centers in these reform processes. The response to “Gender Incongruence” was co-signed by 33 supporting institutions, healthcare and community centers and 63 individuals. The Center’s team in this collaboration was lead by Carrie Davis, Director of Adult Services, Ady Ben-Israel, Gender Identity Project Coordinator, Cristina Herrera, Gender Identity Project Counselor and Amy Henderson, Youth Enrichment Services Prevention Social Worker. Callen-Lorde’s team was lead by Katie Douglass, Director of Mental Health, and John Bennett, Mental Health Clinical Coordinator. The following is the Center and Callen-Lorde’s response.

To add your institution or your name to this list, please e-mail Ady Ben-Israel, Gender Identity Project Program Coordinator at ady@gaycenter.org. A list of co-signatories follows:

 

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American Psychiatric Association, DSM-5 Task Force
1000 Wilson Boulevard, Suite 1825
Arlington, VA 22209
Tuesday, April 20, 2010

Re: Comment on the proposed “Gender Incongruence” in the draft revision of the Diagnostic and Statistical Manual of Mental

Disorders, version 5 (DSM-5)
American Psychiatric Association:

The undersigned providers of and advocates for medical and mental health services to transgender and gender non-conforming communities welcome this opportunity to offer feedback and comment on the American Psychiatric Association’s draft revision diagnosis for Gender Identity Disorders (GID), “Gender Incongruence” (GI).

The lead organizations facilitating this response are Callen-Lorde Community Health Center and the Lesbian, Gay, Bisexual, and Transgender Community Center of New York City. Each of these organizations started providing community services in 1983 and together serve over 2,000 people of transgender experience with primary health care and hormone care as well as substance abuse, mental health, and community building services. Our organizations, as well as the other signatories to this letter, represent the largest settings providing health and social services to transgender and gender non-conforming people and their families in the United States.

We appreciate the APA’s proposed “Gender Incongruence”(GI) diagnosis is an effort intended to de-stigmatize gender non-conformity and improve transgender-identified people’s access to mental health care. We agree with the intention behind this effort; however, we endorse an alternative viewpoint, based on our years of collective practice knowledge. We believe GI will continue to inappropriately pathologize gender non-conformity, maintain barriers to medically necessary health care, and lend justification to gender based stigmatization and discrimination. Prior to addressing the reasons behind our recommendation, we would like to respectfully address the process by which the APA undertook this effort. From the vantage point of LGBT health and community centers, the conceptualization of “Gender Incongruence” occurred without valuable and necessary input from community providers who serve and are accountable to significant numbers of people affected by this diagnosis. The November 2008 Report of the DSM-V Sexual and Gender Identity Disorders Work Group indicates that the “sub-work group has addressed feedback from interested advocacy groups and other stakeholders… Surveys were sent to more than 60 organizations…” While other agencies have provided feedback in this process, we are concerned that the institutions that provide the bulk of medical and mental health services to transgender people nationwide were not asked for input. We have reached out to LGBT community health centers and LGBT community centers; none of these key, high-volume, client-centered, community-driven stakeholders seem to have been included in the research or vetting process. Without input from a representative sample of such organizations and their clients, the conclusions of the sub-work group regarding GI cannot be considered generalizable.

Our specific concerns regarding the validity and utility of the proposed inclusion of GI are as follows:

• Gender non-conformity is not a mental disorder: The proposed definition of a mental disorder in the DSM-V expressly prohibits the inclusion of diagnoses that are “primarily the result of social deviance or conflicts with society” (APA, 2010). The “Gender Incongruence” diagnosis inherently contradicts this tenet. Whereas the criteria for other psychiatric diagnoses are lists of symptoms that impair functioning, the proposed criteria for GI are a list of characteristics of gender non-conformity. There is no evidence or need for treatment that decreases gender non-conformity or crossdressing, as noted in “Transvestic Fetishism.” The GI diagnosis obfuscates the root cause of the distress many transgender people experience – pervasive discrimination. It is commonly acknowledged among mental health providers that being gay, bisexual or lesbian is not a disorder, but that the social impact of stigma, discrimination and homophobia can cause the individual great distress. GI falsely assigns dysfunction to the gender non-conforming person, rather than within the social environment.
• An inappropriate pathway to transgender-specific medical care: There is legitimate community concern that removal of a mental health diagnosis would limit access to transgender-specific medical care. While a minority has succeeded in using the legal system or in fulfilling their insurer’s requirements for coverage to access care, the majority of people needing transgender-specific medical care are denied coverage. GI maintains these barriers to care. Medical interventions are better substantiated by the use of medical diagnoses, not psychiatric diagnoses. Access to transgender-specific, medically necessary care can be directly and more effectively addressed by utilization of a revised medical diagnosis in the International Classification of Diseases (ICD). The psychiatric needs of transgender people are better addressed by existing psychiatric diagnoses.
• GI lays the groundwork for unethical and harmful reparative therapy: A GID diagnosis has historically been misused to justify treatment of “pre-homosexual” children in the hope of preventing or delaying the development of a positive and healthy gay or lesbian identity. With adults, transgender-specific medical intervention is often offered only if reparative therapy fails to relieve distress and improve social functioning. The GI diagnosis will continue to lend false credence to interventions that foster shame, encourage children and adults to betray their true selves, and delay healthy identity development. This practice is harmful and unethical.

In summary, we propose all diagnoses addressing gender non-conformity and identity be eliminated from the DSM-5. The mental health needs - when present - of gender non-conforming people are addressed by existing diagnoses. We ask the APA to formally renounce reparative therapy addressing gender non-conformity in children, adolescents and adults. We acknowledge that a diagnosis must exist for those who require medically necessary transgender-specific care, and ask the APA to advocate for a viable transgender-specific medical diagnosis in the ICD. Finally, we respectfully request that the APA include lesbian, gay, bisexual and transgender healthcare institutions and community centers in these processes.

Sincerely,
Callen-Lorde Community Health Center
The Lesbian, Gay, Bisexual & Transgender Community Center

Co-signing Institutions:

CenterLink: The Community of LGBT Centers, New York, NY
Brainpower Research and Development Services Inc
Brooklyn Community Pride Center, Brooklyn, NY
Capital District Gay and Lesbian Community Council, Albany, NY
Center on Halsted, Chicago, IL
The DC Center for the LGBT Community
Equality Ohio, Columbus, OH
The Gay Alliance in Rochester NY
Gay, Lesbian, Bisexual and Transgender Community Center of Colorado, Denver, CO
L.A. Gay & Lesbian Center, Los Angeles, CA
Legacy Community Health Services, Houston, TX
LGBT Community Center Coalition of Central Pennsylvania, Harrisburg, PA
The LOFT LGBT Community Services Center, White Plains, NY
Malecare, New York, NY
Mazzoni Center, Philadelphia, PA
Milwaukee LGBT Community Center, Milwaukee, WI
National Coalition of Anti-Violence Programs (NCAVP), New York, NY
National LGBT Cancer Network, New York, NY
New Mexico GLBTQ Centers, Las Cruces, NM
New York City Anti-Violence Project, New York, NY
New York Trans Rights Organization (NYTRO), White Plains, New York
Out With Cancer – The LGBT Cancer Project, New York, NY
Pride in Practice, Silver School of Social Work, New York University, New York, NY
Rainbow Heights Club, Brooklyn, NY
Sacramento Gay & Lesbian Center, Sacramento, CA
San Francisco LGBT Community Center, San Francisco, CA
Services and Advocacy for GLBT Elders (SAGE), New York, NY
Spectrum LGBT Center, San Rafael, CA
Third Root Community Health Center, Brooklyn, NY
YouthPride, Inc., Atlanta, GA

Co-signing institutions added after 4/20/10:

Agnodice Foundation, Lausanne, Switzerland
Lyon-Martin Health Services, San Francisco, CA
TransCentralPA, Harrisburg, PA

The following individuals have requested their names be added to this letter in show of support:

Alison Aldrich, LCSW, Clinical Assistant Professor, NYU Silver
School of Social Work, New York, NY
Alison Alpert, New York, NY
Angie Canelli, MA MHP LMHC NCC, Gender and Sexual Minority, Specialist, Seattle Counseling Service, Seattle, WA
Brenda Solomon, Ph.D., M.S.W., Graduate Program Coordinator and Associate Professor, Social Work at the University of Vermont, Burlington, VT
Craig Sloane, LCSW, New York, NY
David J. Brennan, MSW, PhD, Assistant Professor, Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, ON
David Steinberg, San Francisco, CA
Deanna Croce, LMSW, New York, NY
Dennis Holly
Devon Claridge, Brooklyn, NY
Dr. Karra Bikson, Assistant Professor, NYU Silver School of Social Work, New York, NY
E Maxwell Davis, Ph.D., LISW, Assistant Professor, Human Development & Women's Studies, California State University, East Bay, CA
Elizabeth Mullaugh, Board Secretary, LGBT Community Center of Central Pennsylvania, Harrisburg, PA
Fareen Ramji, LMSW, Brooklyn, NY
Foresta Castañeda, MSW, Middlebury, VT
Franklin Brooks, Ph.D., LCSW, Chairperson, Committee on Lesbian, Gay, Bisexual and Transgender Issues, National Association of Social Workers, Maine Chapter, Portland, ME
Helen Boyd, author and lecturer in Gender Studies, Lawrence University, Appleton, WI
Holly Rider-Milkovich, Director, Student Wellness Center. New York City College of Technology, New York, NY
Jane Mildred, MSW, MA, PhD, Amherst, MA
Jean Sienkewicz, MSW--Offender Re-Entry Housing Specialist, Burlington Housing Authority, Burlington VT
Jeff Brody, LMHC, ATR-BC, Licensed Mental Health Counselor, Board-Certified Art Therapist, Licensed School Adjustment Counselor, Braintree, MA
Jeremy D. Schwartz, MSW Candidate, Student Senator, NYU Silver School of Social Work, New York, NY
Jessie Jacobson, Los Angeles, CA
Joyce E. Garee, LMSW, Albany, NY
Justus Eisfeld, co-director, GATE - Global Advocates for Trans Equality, New York, NY
Karalyn Shimmyo, LMSW, Brooklyn, NY
Kayleen White, Thornbury, Victoria, Australia, former co-convenor of Victoria's TransGender Victoria
Laura Booker, LCSW, New York, NY
Lex Moran, New York, NY
Mauro Cabral, co-director, GATE - Global Advocates for Trans Equality, Córdoba, Argentina
Melissa Sklarz, New York, NY
Michael Miller, MSW Candidate, 2011, Silver School Of Social Work, New York University, New York, NY
Michelle Kay, MS, FNP, New York, NY
Misty L. Wall, PhD, MSSW, LCSW, Assistant Professor, School of Social Work, Boise State University, Boise, ID
Nerissa Belcher RN, Decatur, GA
Nickerson Hill, LMSW, Masters of Public Health Candidate, Center for the History and Ethics of Public Health, Columbia University Mailman School of Public Health, New York, NY
Nicole Paige, New York, NY
P. Swan, MSW, Seattle, WA
Paisley Currah, Professor, Brooklyn College-CUNY, Brooklyn, NY Pamela Bianco, Staten Island, NY
Pega Ren, Ed.D., Registered Clinical Counsellor, Board Certified Sexologist, Vancouver, British Columbia, Canada
Rebecca Capri-Durkee Transgender Health Advocate, Boston, MA Robin Mangini, New York, NY
Romy Reading, MA, New School for Social Research, New York, NY
Rosalyne Blumenstein LCSW ACHP-SW, Therapy2Go, Los Angeles, CA
Samuel Lurie, Director, Transgender Training and Advocacy Sand Chang, PhD, San Francisco, CA
Sari Surkis, MBA, MSW Candidate, New York, NY
Sean M. Endress, MA, LCSW, Albany, NY
Sebastian Colon-Otero, LMSW, Brooklyn, NY
Shelley Schwartz, Chappaqua NY
Sherry Tripepi, MSW, EqualityToledo, Toledo, OH
Stacey Peyer, MSW, LCSW, CalSWEC Field Consultant, CSULB Department of Social Work, Long Beach, CA
Steve Prentice, LMSW New York, NY
Steven Lipsky, LCSW, CASAC, New York, NY
Sue Langer, LCSW, New York, NY
Susan E. Roche, Ph.D., M.S.S.W., University of Vermont Department of Social Work, Burlington, VT
Tim Pierce, President, Community Alliance and Action Network, Joliet, IL
Toby C. Siegel, Astoria NY
Trey Polesky, MSW, Bloomington, IL
Tyler Blake Kim, New York, NY
Yosenio V. Lewis, Transgender Health Advocate, San Francisco, CA

The following individual has requested his name be added to this letter in show of support after 4/20/10:

Jase Schwartz, BA Psychology, MSW Candidate, Hunter College School of Social Work, New York, NY