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Sex and Gender Identity Disorders
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Empirical studies were evaluated to determine whether Gender Identity Disorder (GID) in children meets the Diagnostic and Statistical Manual of Mental Disorders-4th Edition (DSM-IV, American Psychiatric Association, 1994) definitional criteria of mental disorder. Specifically, we examined whether GID in children is associated with (a) present distress; (b) present disability; (c) a significantly increased risk of suffering death, pain, disability, or an important loss of freedom; and if (d) GID represents dysfunction in the individual or is simply deviant behavior or a conflict between the individual and society. The evaluation indicates that children who experience a sense of inappropriateness in the culturally prescribed gender role of their sex but do not experience discomfort with their biological sex should not be considered to have GID. Because of flaws in the DSM-IV definition of mental disorder, and limitations of the current research base, there is insufficient evidence to make any conclusive statement regarding children who experience discomfort with their biological sex. The concluding recommendation is that, given current knowledge, the diagnostic category of GID in children in its current form should not appear in future editions of the DSM.
The DSM-IV-TR (2000) sets its own standards for inclusion of diagnoses and for changes in its text. The Paraphilia section is analyzed from the perspective of how well the DSM meets those standards. The concept of Paraphilias as psychopathology was analyzed and assessed critically to determine if it meets the definition of a mental disorder presented in the DSM; it does not. The Paraphilia diagnostic category was critiqued for logic, consistency, clarity, and whether it constitutes a distinct mental disorder. The DSM presents “facts” to substantiate various points made in the text. The veracity of these “facts” was scrutinized. Little evidence was found in their support. Problems with the tradition of equating particular sexual interests with psychopathology were highlighted. It was concluded that the Paraphilia section is so severely flawed that its removal from the DSM is advocated.
The World Professional Association for Transgender Health (WPATH) conducted a consensus process in order to develop recommendations for the refinement of diagnoses for Gender Identity Disorders and Transvestic Fetishism for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM 5). This article is the report of the work group on Transvestic Fetishism. It reviews the history of the diagnosis of Transvestic Fetishism in the DSM, the current DSM-IV-TR classification, and the prevalence and characteristics of the phenomenon of transvestic fetishism. The problems with the current diagnostic classification are reviewed. Based on the consensus process, a new diagnostic label and diagnostic criteria are presented. The new diagnosis is Transvestic Disorder, defined by two criteria: (a) recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving cross-dressing and (b) the fantasies, sexual urges, or behaviors are causing clinical distress or impairment in important areas of psychological functioning; that is, the distress is not solely due to external prejudice, stigma, or oppression.
The DSM-IV-TR diagnosis Gender Identity Disorder Not Otherwise Specified (GID NOS) is used to describe individuals who have gender issues but do not meet the current criteria for GID. As part of a consensus process conducted by the World Professional Association for Transgender Health, the authors make the following recommendations for DSM 5: removal from the chapter on sexual disorders, more specific diagnostic criteria, retention of clinical significance criteria, and removal of exclusionary criteria of Intersex/Disorders of Sex Development. Changes to the existing clinical examples were also recommended, suggesting additional clinical examples that encompass a broader range of gender-variance and more commonly found transgender presentations. The diagnosis must reflect the severity of the clinical issues that represent legitimate identity experiences and possible need for gender-confirming treatments.
This consensus statement is an executive summary of several papers resulting from a 2009 consensus process comprising nine work groups and 37 members of the World Professional Association for Transgender Health (WPATH). The purpose of this group was to put forth recommendations for the upcoming revision of the DSM with respect to the Gender Identity Disorder diagnoses. The consensus process was collaborative, interdisciplinary, and evidence based. A majority (but not all) of the participants believed that a diagnosis related to Gender Identity Disorder should remain in the DSM, and many advocated changes in name, diagnostic criteria, and placement within the DSM. The proposed name is Gender Dysphoria, and the diagnostic criteria should be distress based. Placement should be outside the chapter on Sexual Disorders and possibly within Psychiatric Disorders Related to a Medical Condition. If there were to be a diagnostic category for childhood, there should also be separate categories for adults and adolescents. A Not Otherwise Specified category should be retained, and Disorders of Sex Development should not be an exclusionary criterion for Gender Dysphoria.
The DSM-IV-TR category of Gender Identity Disorder (GID; American Psychiatric Association, 2000) is limited to persons with typical somatosexual development who experience “strong and persistent cross-gender identification” as well as a “persistent discomfort with his or her sex or sense of inappropriateness in the gender role of that sex.” The presence of a concurrent “physical intersex condition” rules out the unqualified diagnosis. However, a person with atypical somatic sex development experiencing, for example, gender dysphoria, could still be diagnosed with a GID, but with the Not Otherwise Specified (NOS) qualifier. The DSM 5 committee charged with developing the criteria for GID must now decide whether persons born with atypical somatic sex should automatically be excluded from consideration as having GID or be potentially diagnosable. The question addressed here is whether persons born with atypical somatic sex who are experiencing gender dysphoria should potentially be diagnosable using (a) the unqualified criteria for GID or (b) a qualified GID, such as under the NOS category (i.e., continuing the practice of DSM-IV-TR) or should not be diagnosed with GID (qualified or unqualified).
The authors discuss the process that the American Psychiatric Association and its task force, workgroups, and subworkgroup on Gender Identity Disorder (GID) have proceeded with in order to explore the scientific data supporting, refuting, and suggesting change in the diagnosis of Gender Identity Disorder in Adults, Children, and Adolescents in preparation for the publication of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Discussion includes how the subworkgroup has begun a process of inquiry into the matter with attention to the varieties of positions from around the world, in different organizations, among individuals of different identities, races, ethnicities, genders or gender identities, and different relationships to the issue. How this group has then proceeded with reviews of the literature, consultation with various experts, and the development of a consensus is detailed. The complexities of this type of undertaking are elucidated.
The purpose of this investigation was to develop a useful conceptual model of optimal sexuality by identifying and describing its elements. Semi-structured interviews were conducted with 64 key informants, i.e., 44 individuals who reported having experienced "great sex" and 20 sex therapists. Subsequently, phenomenologically-oriented content analysis was performed on interview transcripts. Eight major components were identified: being present, connection, deep sexual and erotic intimacy, extraordinary communication, interpersonal risk-taking and exploration, authenticity, vulnerability and transcendence. Clinical implications of these findings are considered, including the need for sex therapists to acquire and transmit new methods and skills. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Over the last 20 years, Ray Blanchard, Ph.D., with a variety of coauthors and collaborators, has proposed a theory that links the sexual orientation of male-to-female transsexuals with the presence or absence of autogynephilia (erotic arousal by the thought or image of "himself" as a woman). Blanchard's Autogynephilia Theory suggests that the association between sexual orientation and autogynephilia among male-to-female transsexuals is clinically important and the association is always (or almost always) present. Although the theory has been criticized by clinicians, researchers, and transsexuals themselves, it has not been critiqued in a peer-reviewed article previously. This article will attempt to fill that gap. Key studies on which the theory is based will be analyzed and alternative interpretations of the data presented. I conclude that although autogynephilia exists, the theory is flawed.
In a series of important but now highly controversial articles, Blanchard examined associations of sexual orientation and transvestic fetishism among male-to-female (MTF) transgender persons in Toronto, Canada. Transvestic fetishism was rare among the homosexuals but prevalent among the non-homosexuals. Subtypes of non-homosexual MTFs (heterosexual, bisexual, and asexual) were consistently high with regard to transvestic fetishism. Non-linear associations of a continuous measurement of sexual attraction to women (gynephilia) and transvestic fetishism were interpreted in terms of an etiological hypothesis in which transvestic fetishism interferes with the early development of heterosexuality. Blanchard concluded that homosexual versus non-homosexual sexual orientation is a dominant and etiologically significant axis for evaluating and understanding this population. We further assessed these findings among 571 MTFs from the New York City metropolitan area. Using the Life Chart Interview, multiple measurements of transvestic fetishism were obtained and classified as lifetime, lifecourse persistent, adolescent limited, and adult onset. Large (but not deterministic) differences in lifetime, lifecourse persistent, and adolescent limited transvestic fetishism were found between the homosexuals and non-homosexuals. Contrary to Blanchard, differences in transvestic fetishism were observed across subtypes of the non-homosexuals, and linear (not curvilinear) associations were found along a continuous measurement of gynephilia and transvestic fetishism. Age and ethnicity, in addition to sexual orientation, were found to be statistically significant predictors of transvestic fetishism. The clinical, etiological, and sociopolitical implications of these findings are discussed.
Hypersexual Disorder is proposed as a new psychiatric disorder for consideration in the Sexual Disorders section for DSM-V. Historical precedents describing hypersexual behaviors as well as the antecedent representations and proposals for inclusion of such a condition in the previous DSM manuals are reviewed. Epidemiological as well as clinical evidence is presented suggesting that non-paraphilic "excesses" of sexual behavior (i.e., hypersexual behaviors and disorders) can be accompanied by both clinically significant personal distress and social and medical morbidity. The research literature describing comorbid Axis I and Axis II psychiatric disorders and a purported relationship between Axis I disorders and Hypersexual Disorder is discussed. Based on an extensive review of the literature, Hypersexual Disorder is conceptualized as primarily a nonparaphilic sexual desire disorder with an impulsivity component. Specific polythetic diagnostic criteria, as well as behavioral specifiers, are proposed, intended to integrate empirically based contributions from various putative pathophysiological perspectives, including dysregulation of sexual arousal and desire, sexual impulsivity, sexual addiction, and sexual compulsivity.
There are at least two different criteria for assessing pedophilia in men: absolute ascertainment (their sexual interest in children is intense) and relative ascertainment (their sexual interest in children is greater than their interest in adults). The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, 3rd edition (DSM-III) used relative ascertainment in its diagnostic criteria for pedophilia; this was abandoned and replaced by absolute ascertainment in the DSM-III-R and all subsequent editions. The present study was conducted to demonstrate the continuing need for relative ascertainment, particularly in the laboratory assessment of pedophilia. A total of 402 heterosexual men were selected from a database of patients referred to a specialty clinic. These had undergone phallometric testing, a psychophysiological procedure in which their penile blood volume was monitored while they were presented with a standardized set of laboratory stimuli depicting male and female children, pubescents, and adults.The 130 men selected for the Teleiophilic Profile group responded substantially to prepubescent girls but even more to adult women; the 272 men selected for the Pedophilic Profile group responded weakly to prepubescent girls but even less to adult women. In terms of absolute magnitude, every patient in the Pedophilic Profile group had a lesser penile response to prepubescent girls than every patient in the Teleiophilic Profile group. Nevertheless, the Pedophilic Profile group had a significantly greater number of known sexual offenses against prepubescent girls, indicating that they contained a higher proportion of true pedophiles. These results dramatically demonstrate the utility-or perhaps necessity-of relative ascertainment in the laboratory assessment of erotic age-preference.
In this article, I review the diagnostic criteria for Gender Identity Disorder (GID) in children as they were formulated in the DSM-III, DSM-III-R, and DSM-IV. The article focuses on the cumulative evidence for diagnostic reliability and validity. It does not address the broader conceptual discussion regarding GID as "disorder," as this issue is addressed in a companion article by Meyer-Bahlburg (2009). This article addresses criticisms of the GID criteria for children which, in my view, can be addressed by extant empirical data. Based in part on reanalysis of data, I conclude that the persistent desire to be of the other gender should, in contrast to DSM-IV, be a necessary symptom for the diagnosis. If anything, this would result in a tightening of the diagnostic criteria and may result in a better separation of children with GID from children who display marked gender variance, but without the desire to be of the other gender.
The American Psychiatric Association (APA) is in the process of revising its Diagnostic and Statistical Manual (DSM), with the DSM-V having an anticipated publication date of 2012. As part of that ongoing process, in May 2008, APA announced its appointment of the Work Group on Sexual and Gender Identity Disorders (WGSGID). The announcement generated a flurry of concerned and anxious responses in the lesbian, gay, bisexual, and transgender (LGBT) community, mostly focused on the status of the diagnostic categories of Gender Identity Disorder (GID) (for both children 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 disorder and that perpetuating DSM-IV-TR's GID diagnoses in the DSM-V would further stigmatize and cause harm to transgender individuals. Other advocates in the trans community expressed concern that deleting GID would lead to denying medical and surgical care for transgender adults. This review explores how criticisms of the existing GID diagnoses parallel and contrast with earlier historical events that led APA to remove homosexuality from the DSM in 1973. It begins with a brief introduction to binary formulations that lead not only to linkages of sexual orientation and gender identity, but also to scientific and clinical etiological theories that implicitly moralize about matters of sexuality and gender. Next is a review of the history of how homosexuality came to be removed from the DSM-II in 1973 and how, not long thereafter, the GID diagnoses found their way into DSM-III in 1980. Similarities and differences in the relationships of homosexuality and gender identity to psychiatric and medical thinking are elucidated. Following a discussion of these issues, the author recommends changes in the DSM-V and some internal and public actions that the American Psychiatric Association should take.
Hypoactive Sexual Desire Disorder (HSDD) is one of two sexual desire disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM) and is defined by the monosymptomatic criterion "persistently or recurrently deficient (or absent) sexual fantasies and desire for sexual activity" that causes "marked distress or interpersonal difficulty." This article reviews the diagnosis of HSDD in prior and current (DSM-IV-TR) editions of the DSM, critiques the existing criteria, and proposes criteria for consideration in DSM-V. Problems in coming to a clear operational definition of desire, the fact that sexual activity often occurs in the absence of desire for women, conceptual issues in understanding untriggered versus responsive desire, the relative infrequency of unprovoked sexual fantasies in women, and the significant overlap between desire and arousal are reviewed and highlight the need for revised DSM criteria for HSDD that accurately reflect women's experiences. The article concludes with the recommendation that desire and arousal be combined into one disorder with polythetic criteria.
This paper contains the author's report on pedophilia, submitted on June 2, 2008, to the work group charged with revising the diagnoses concerning sexual and gender identity disorders for the fifth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM). The author reviews the previously published criticisms and empirical research concerning the diagnostic criteria for pedophilia and presents criticism and relevant research of his own. The review shows that the DSM diagnostic criteria for pedophilia have repeatedly been criticized as unsatisfactory on logical or conceptual grounds, and that published empirical studies on the reliability and validity of these criteria have produced ambiguous results. It therefore seems that the current (i.e., DSM-IV-TR) diagnostic criteria need to be examined with an openness to major changes in the DSM-V.
This paper contains the author's report on transvestism, submitted on July 31, 2008, to the work group charged with revising the diagnoses concerning sexual and gender identity disorders for the fifth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM). In the first part of this report, the author reviews differences among previous editions of the DSM as a convenient way to illustrate problems with the nomenclature and uncertainties in the descriptive pathology of transvestism. He concludes this part by proposing a revised set of diagnostic criteria, including a new set of specifiers. In the second part, he presents a secondary analysis of a pre-existing dataset in order to investigate the utility of the proposed specifiers.
Sex therapy, which can be considered a form of brief cognitive/ behavioral therapy, is often dated from the 1970 publication of Masters and Johnson’s Human Sexual Inadequacy, although elements of the sex therapy treatment programs had been used by behavioral and rational-emotive therapists for many years previously. In contrast to psycho-dynamic or other “depth” therapy approaches, sex therapy focuses on anxiety reduction, skill training, and specific behavioral procedures to eliminate the target problem (Lopiccolo, 1990).
What is the nature of eroticism? What is the role of eroticism in sexual interaction? The answers to these questions are explored as are their implications for the understanding and treatment of sexual desire problems. To the extent that sexuality has typically been defined in the sex therapy literature in terms of a pattern of physiological and observable, behavioral events, the phenomenology of erotic experience has been overlooked. Eroticism involves the intent to contact and arouse another. The erotic experience is to be found with a partner who values enhancing sexual pleasure for each other for its own sake rather than as a means to a goal, for example, tension release, orgasm, intercourse. The erotic encounter involves the shared exploration of sexual wishes, dreams, and fantasies. It is argued that eroticism is a central component in the maintenance of sexual desire. The absence of eroticism is linked to the prevalence of chronic sexual dissatisfaction and inhibited sexual desire among those who are otherwise fully functional. The taboos surrounding sexual arousal and the seeking of sexual pleasure are examined. The value of eroticism for the individual and the couple is discussed in terms of deepening of self-knowledge, self-affirmation, mutual trust, and intimacy. Implications for clinicians are addressed. A shift in paradigms is recommended from the prevailing one, focusing on sexual function versus dysfunction, to another that emphasizes the potential for sharing erotic experience.
Vaginismus has typically been treated using behaviorally oriented sex therapy. The treatment of choice has been systematic desensitization with the use of graded vaginal dilators. The prevailing model is described, and its underlying assumptions and implications are explored and evaluated. A critique of the conventional treatment paradigm is offered. An alternative way of understanding sexual problems and how to deal with them in therapy originates in existential-experiential psychotherapy. Although this model has been applied to the study and treatment of sexual concerns infrequently, this approach may be of particular value to sex therapists. The conception of the problem, the goals of therapy, and therapy process are described from this perspective. Therapists working with such a model attempt to promote awareness, choice, embodiment, sexual potential, and integration. A case illustration of therapy with a client presenting with vaginismus is presented. The advantages of using an experientially oriented approach are discussed.
The discourse in sex therapy is increasingly dominated by the language and imagery of machines in disrepair. Humanistic psychologyhas a role to play in challenging the pharmaceutical industry forownership of this discourse. From a humanistic standpoint, we arewell situated to question the assumptions underlying the biomedical model. Viagra™ may produce rigid erections while creating newdifficulties for the forgotten man, conveniently attached, for thepartner who wants to be desired, or for the couple. Newpharmacological interventions too often produce the same old effects and sideeffects (e.g., reductionism, desensitization, alienation, fragmentation,mechanization). The prevailing “Viagra™ mindset” is contested byreviewing the problems associated with this way of thinking aboutsexuality and sexual dysfunction. An alternate experiential approachto dealing with sexual issues and concerns in therapy is described.Three clinical illustrations of Experiential Psychotherapy as a wayof working with erectile dysfunction in therapy are presented.
The commencement of bisexual behavior and the ontogenesis of a bisexual orientation was studied in order to aid in the better understanding of how sexual behavior patterns begin and change. The investigation was conducted through in‐depth interviews held in California, Oregon, and Washington with the first 50 female volunteers gathered from a variety of sources who met the study requirements. Those requirements were that each subject, at the time of her first sexual contact with another female, (a) was married; (b) was at least 30 years of age; (c) was engaged in swinging; (d) was enjoying sex with males; and (e) had no history, prior to age 30, of a sexual attraction to females. “Multi‐female” and “multi‐male” sexual activity are terms introduced to remove the ambiguity and mislabeling which results from defining sexual activity between all persons of the same sex as necessarily homosexual. Subjects typically revealed a high incidence of early and continuing autosexual and heterosexual activity and current high frequencies of sexual activity with each sex. Influences facilitating a typical subject's initial and subsequent sexual activity with females were found to be her husband, other swingers, and the general swinging environment—the husband's influence usually being of paramount importance. It was concluded that those influences, perhaps together with a predisposition toward gaining perceived fulfillment of felt needs through sexual activity, will result in some heterosexual females engaging in multi‐female sexual activity and eventually adopting a self‐identified bisexual orientation.
This article outlines recommendations for the World Professional Association for Transgender Health's (WPATH) Standards of Care (SOC) regarding the roles, responsibilities, and tasks of the mental health provider in assessing eligibility and readiness for medical and surgical treatment of gender nonconforming, transgender, and transsexual clients. It reflects a reconceptualization of the role of the mental health provider as a gender specialist and an advocate and educator for transgender people and their families utilizing a nonpathologizing assessment process. This article reflects a need for clinical SOC that minimize the role of “gatekeeping,” and increase the use of informed consent and harm-reduction procedures, while still providing guidelines for psychosocial evaluation. Recommendations are made for less pathologizing nomenclature, clearer definitions for the professional qualifications of those specializing in working with gender-variant people, and increased collaboration across disciplines. Suggestions are made for the SOC to recognize greater diversity in gender expression and identity, increased focus on the families and occupational environments of transgender people, and a broader view of gender issues throughout the lifecycle. Guidelines for psychosocial assessment and referral letters to physicians are outlined, including proposals to revisit the professional qualifications of letter writers and the need for two letters for surgical assessment. It is suggested that WPATH take leadership in the training and credentialing of gender specialists. These recommendations require a reorganization of the format of the SOC that will create a state-of-the-art standard of health care for transgender, transsexual, and gender nonconforming people and ensure the provision of high-quality clinical services for those individuals and their families.
El tratamiento de los trastornos de género está dirigido por estandares salidos de la Asociación Mundial Profesional para la Salud de los Trastornos de Género (WPATH). Aunque no definitivos, los criterios de eligibilidad a un tratamiento hormonal y/o a la cirugía de conversión sexual de la WPATH, incluyen una participación psicoterapéutica. Además, se pide a los candidatos a la cirugía de conversión sexual vivir al menos un año de dedicación permanente en el rol de género preferido, periodo designado por el numero de experiencia de vida real (EVR). El razonamiento subjacente al EVR es de preparar al cliente en la medida de lo posible a tomar una decisión estando enteramente acorde con la realidad, tratándose de una cirugía irreversible. La psicoterapia puede jugar un rol importante para la proyección de la experiencia de vida real y el desarrollo de la resistencia frente a los inevitables desafios psicosociales. Las tareas del profesional de salud mental incluyen la evaluación de la identidad de género y el impacto de este estigma durante el ajuste psicológico; el tratamiento de los problemas de salud mental; el tratameinto de los problemas de salud mental coexistentes; la confrontación a la transfobia internalizada; el permiso de explorar el género y la sexualidad; la gestión del rol desempeñado;el apoyo y las recomendaciones durante el EVR y su contexto. Además, el deseo de cambiar “de sexo” de una manera binaria y la realidad de vivir como una persona de género variable pueden ser completammente diferentes; la psicoterapia puede facilitar el duelo de la pérdida del ideal para hacer sitio a un nivel mas profundo de aceptación de su identidad de transgénero (en oposición a masculino y femenino).
It seems surprising that there should be so much controversy surrounding sexual arousal and desire. How much is sufficient? How much is too much? What is the relationship between arousal and desire? Is there a difference between sexual arousal and/or desire in men versus women? Some of the conceptual, research and clinical considerations for understanding our evolving views of sexual arousal and desire problems are discussed below. This article will begin with a brief resumé of the history of classification of arousal and desire problems, will continue by grappling with the intermingling of arousal and desire and will conclude by discussing changes in the conceptual context surrounding arousal and desire over the last 25 years. Please note that, unfortunately, there is a pronounced tendency in the literature to focus on low desire in women and overlook low desire in men, let alone gay men, except as curiosities and anomalies (Maurice, 2007). This may stem from broader social norms that define "sex" as penis-in-vagina intercourse, the implications of which are explored below. It is regrettable that this article is therefore limited by the heterosexist bias in the literature
The authors of this article, both of whom work as legal advocates for transgender individuals and their families and supporters, use actual examples of people they have fought for and worked with in order to illustrate the importance of a better understanding, more consensus and greater clarification of the specific qualities and needs of transgender individuals by the medical community and to convey the importance of health professionals, especially mental health professionals, taking an active role in using their expertise and experience to explain sometimes very complex issues to the public, to courts, and to legislators. Special attention is drawn to the importance of helping interested parties understand that gender is determined by identity and not by postoperative apparent anatomy.
Thirty couples in which the female partners suffered from vaginismus were treated by sex therapy. Of the 30 couples, 80% had a positive outcome, these gains being sustained at three months follow up. The only prognostic indicator of importance was the extent to which couples were carrying out the homework assignments by the time of the third treatment session. The generally superior outcome of sex therapy for vaginismus by comparison with other female sexual dysfunctions is probably due to the very specific nature of the dysfunction in most cases and because couples with this problem have better general relationships, less psychopathology and higher motivation for treatment than other couples who enter sex therapy.
Since its appearance in 1980, the diagnostic category “gender identity disorder” (GID) in the Diagnostic and Statistical Manual of Mental Disorders (DSM) has sparked concern among gender variant people and their advocates that it contributes to hurtful stigma and social barriers faced by gender variant individuals, while at the same time it contradicts the medical legitimacy of sex reassignment for the treatment of gender dysphoria. This paper examines the GID diagnosis of adults and adolescents and the social and medical consequences posed by its implication of “disordered” gender identity. Parallels are drawn to the removal of homosexuality and ego dystonic homosexuality from the DSM in the 1970s and '80s. At issue is the label of mental illness for behaviors that are otherwise ordinary or even exemplary based only on natal anatomical sex. Finally, a path forward is proposed to replace GID with a new diagnosis unambiguously defined by chronic distress rather than social nonconformity.
When the World Professional Association of Transgender Health (WPATH) was asked to provide input into the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM 5) process regarding the revision of the Gender Identity Disorder (GID) diagnosis, it quickly became apparent that there was a lack of professional consensus within the field as to whether or not this diagnosis should be retained and, if so, whether GID is best conceptualized as a mental health disorder or as a non-mental health physical disorder. Addressing this lack of consensus was the first issue the WPATH Consensus Statement work groups faced. By acknowledging the arguments on both sides and accepting the lack of consensus on the retention of the diagnosis, the work groups were able to reach agreement upon recommendations for diagnostic revision, should a diagnosis be retained in DSM 5. Thus, starting from standpoints with fundamental differences, and representing a constituency (WPATH members) with widely different views, it was possible to reach consensus on shared concerns and make substantive recommendations. This article outlines the lack of agreement regarding the existence of a GID diagnosis and arguments on both side of the issue. This fundamental area of disagreement has a long history and is likely to continue to inform the field of transgender health for some time to come.
The current nosology in the Diagnostic & Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV TR), identifies those whose gender identities or expressions differ from their assigned birth sex as mentally ill. As the American Psychiatric Association (APA) prepares its fifth edition of the DSM, gender variant individuals face the stigma of mental disorder and sexual deviance resulting from this classification and/or worsened barriers to medical transition care that requires some form of diagnostic coding. We propose a solution following a harm reduction model in which the current Gender Identity Disorder (GID) diagnosis is replaced by one that distinguishes the normative distress of membership in a subjugated class from the distress of incongruence between anatomy and identity (historically termed gender dysphoria). We suggest renaming the diagnosis to clarify distress of gender dysphoria as the problem rather than gender identity itself. We recommend revision in the DSM-5 that would: (1) no longer promote gender identity conversion treatment, aimed at repressing gender identities and expressions that differ from birth assigned roles, (2) respect individual gender identities with appropriate pronouns and terms, (3) eliminate false-positive diagnosis of ego syntonic gender variant and posttransition individuals, (4) relocate the redefined GID diagnosis outside of the section of sexual disorders, and (5) eliminate the defamatory and stigmatizing category of transvestic fetishism. Finally, we urge the APA to issue position statements affirming that gender identity and expression that differ from assigned birth sex do not constitute mental disorder, while asserting the medical necessity of hormonal and surgical transition treatments for those who suffer painful distress with physical sex characteristics or ascribed birth-sex roles incongruent with their persistent gender identity.
Introduction:
There are few published guidelines for the management of sexual dysfunctions in men and women, despite the prevalence and lack of attention to these problems. Disorders of sexual function in men include erectile dysfunction, orgasm/ejaculation disorders, priapism, and Peyronie's disease.
Aim:
To provide evidence-based and expert-opinion consensus guidelines for the clinical management of men's sexual dysfunctions.
Methods:
An International Consultation in collaboration with major urological and sexual medicine societies assembled over 200 multidisciplinary experts from 60 countries into 17 consultation committees. Committee members established the scope and objectives for each chapter. Following intensive review of available data and publications, committees developed evidence-based guidelines in each area.
Main outcome measure:
New algorithms and guidelines for assessment and treatment of men's sexual dysfunction were developed. The Oxford system of evidence-based review was systematically applied. Expert opinion was based on systematic grading of the medical literature, in addition to cultural and ethical considerations.
Results:
Recommendations and guidelines for men's sexual dysfunction are presented. These guidelines were developed as evidence-based, patient-centered, and multidisciplinary in focus. For the clinical assessment and diagnosis of ED, a basic evaluation was recommended for all patients, with optional and specialized testing reserved for special cases. A new treatment algorithm is proposed. This algorithm provides a clinically relevant guideline for managing ED in the large majority of men. New treatment guidelines and algorithms are provided for men's orgasm and ejaculation disorders, including premature ejaculation, retrograde and delayed ejaculation. Finally, expert opinion-based guidelines for the clinical management of priapism and Peyronie's disease are provided.
Conclusions:
Additional research is needed to validate and extend these guidelines. Nonetheless, this summary encompasses the recommendations concerning men's sexual dysfunctions presented at the 2nd International Consultation on Sexual Medicine in Paris, France, June 28-July 1, 2003.
For many years, different views have existed regarding etiology and treatment of premature ejaculation (PE). On one hand it was argued that PE is caused by psychological factors, like unresolved unconscious conflicts, relationship problems, and/or self-learned behaviour. On the other hand, it has been argued that PE is caused by either somatic factors, like hypersensitivity of the glans penis, a higher cortical representation of the pudendal nerve, or neurobiological factors, like disturbances in the central serotonergic neurotransmission and serotonergic receptor functioning. Until recently, there has not been a theory integrating these different views. Recenty, Waldinger emphasized that the occurrence of PE does not automatically imply the existence of a male sexual disorder. PE is a frequent males sexual complaint, but its occurrence is not always the result of mental or physical pathology. Therefore, Waldinger proposed a new classification of PE for the pending DSM-V. According to this new classification there are four PE syndromes; lifelong PE, acquired PE, natural variable PE and premature-like ejaculatory dysfunction. These syndrome are distinguished by the duration of the IELT, frequency of complaints, its course in lifetime, etiology, pathophysiology and treatment. For example, men with lifelong PE usually ejaculate within 1 minute after penetration from about the first sexual encounters. As this disorder is also recognized in male rats, it is highly likely that this disorder is mainly neurobiologically determined. These men need drug treatment to delay ejaculation. In contrast, the new defined category of men with premature-like ejaculatory dysfunction complain of PE while having normal IELT (3-7 minutes) and even long IELTs (10-25 minutes). As the IELT is normal and there is nothing biologically disturbed in these men, it is very likely that this syndrome is mainly psychological and perhaps even culturally determined. These men should not be treated with medication, but with counselling, psycho-education or psychotherapy in order to learn how to cope with their complaints. Acquired PE may be psychologically or somatically determined. These men need either counselling or psychotherapy, or adequate treatment of the underlying somatic disorder (thyroid or urological diseases). Lastly, a second new defined category are men with natural variable PE. These men only occasionally have early ejaculations. There is no indication that occasional occurrence of PE is either related to psychological or somatic pathology. Therefore it is assumed that natural variable PE is only a manifestation of normal ejaculatory performance. In case of seeking treatment, these men need reassurance or counselling. The new classification of PE integrates both psychological as neurobiological etiologies and pathophysiologies of PE. These different etiologies determine the different treatments of PE, which is either medication, somatic treatment, psychotherapy, counselling, psychoeducation or reassurance.
The Diagnostic and Statistical Manual of Mental Disorders, 4th Ed., text revision (DSM-IV-TR) criteria for premature ejaculation (PE) have been criticized on multiple grounds including that the criteria lack precision, that the requirement of marked distress is inappropriate, and that the specification of etiological subtypes should be deleted. Since these criteria were originally adopted, there has been a tremendous gain in knowledge concerning PE.
The goal of this manuscript is to review evidence relevant to diagnostic criteria for PE published since 1990.
Medline searches from 1990 forward were conducted using the terms PE, rapid ejaculation, ejaculatory disorder, and intravaginal ejaculatory latency. Early drafts of proposed alterations in diagnostic criteria were submitted to advisors.
Expert opinion was based on review of evidence-based medical literature.
The literature search indicated possible alterations in diagnostic criteria for PE.
It is recommended that the Diagnostic and Statistical Manual committee adopt criteria similar to those adopted by the International Society of Sexual Medicine. It is proposed that lifelong PE in heterosexual men be defined as ejaculation occurring within approximately 1 minute of vaginal penetration on 75% of occasions for at least 6 months. Field trials will be necessary to determine if these criteria can be applied to acquired PE and whether analogous criteria can be applied to ejaculatory latencies in other sexual activities. Serious consideration should be given to changing the name from PE to rapid ejaculation. The subtypes indicating etiology should be eliminated.
Women's sexual dysfunction includes reduced interest/incentives for sexual engagement, difficulties with becoming subjectively and/or genitally aroused, difficulties in triggering desire during sexual engagement, orgasm disorder, and sexual pain.
To update the recommendations published in 2004, from the 2nd International Consultation on Sexual Medicine (ICSM) pertaining to the diagnosis and treatment of women's sexual dysfunctions.
A third international consultation in collaboration with the major sexual medicine associations assembled over 186 multidisciplinary experts from 33 countries into 25 committees. Twenty one experts from six countries contributed to the Recommendations on Sexual Dysfunctions in Women.
Expert opinion was based on grading of evidence-based medical literature, widespread internal committee discussion, public presentation, and debate.
A comprehensive assessment of medical, sexual, and psychosocial history is recommended for diagnosis and management. Indications for general and focused pelvic genital examination are identified. Evidence based recommendations for further revisions of definitions for sexual disorders are given. An evidence based approach to management is provided. Extensive references are provided in the full ICSM reports.
There remains a need for more research and scientific reporting on the optimal management of women's sexual dysfunctions including multidisciplinary approaches.
This is a report of a cross-sectional study on paraphilia-associated sexual arousal patterns (PASAP) among men in a metropolitan city in Germany, EU.
To determine the prevalence of PASAP during sexual fantasies, fantasies accompanying masturbation, and real-life sociosexual behavior.
In a cross-sectional study, self-reported sexual history data were collected by questionnaire from 367 volunteers recruited from a community sample of 1,915 men aged 40-79 years.
The Derogatis Symptom Checklist-Revised (SCL-90-R) and the Life Satisfaction Questionnaire (LSQ; German original, Fragebogen zur Lebenszufriedenheit, [FLZ]) were administered to obtain a general subjective health measure and a measure of general as well as sex life satisfaction. The Questionnaire on Sexual Experiences and Behaviour was administered to comprehensively assess all relevant sexo-medical data. Results. The percent of men that reported at least one PASAP was 62.4%. In 1.7% of cases, PASAP were reported to have caused distress. The presence of PASAP was associated with a higher likelihood of being single (odds ratio [OR] 2.6; 95%; confidence interval [CI] 1.047-6.640), masturbating at least once per week (OR 4.4; 95%; CI 1.773-10.914), or having a low general subjective health score (OR 11.9; 95%; CI 2.601-54.553). Pedophilic PASAP in sexual fantasies and in real-life sociosexual behavior was reported by 9.5% and 3.8% of participants, respectively.
The findings suggest that paraphilia-related experience can not be regarded as unusual from a normative perspective. At the same time, many men experience PASAP without accompanying problem awareness or distress, even when PASAP contents are associated with potentially causing harm to others. In view of the relevance for sex life and relationship satisfaction, presence of PASAP should be assessed in all sexual medicine consultations. Future research should focus on conditions in which PASAP reach clinical significance in the sense of mental disorders.
The categorization of gender identity variants (GIVs) as "mental disorders" in the Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association is highly controversial among professionals as well as among persons with GIV. After providing a brief history of GIV categorizations in the DSM, this paper presents some of the major issues of the ongoing debate: GIV as psychopathology versus natural variation; definition of "impairment" and "distress" for GID; associated psychopathology and its relation to stigma; the stigma impact of the mental-disorder label itself; the unusual character of "sex reassignment surgery" as a psychiatric treatment; and the consequences for health and mental-health services if the disorder label is removed. Finally, several categorization options are examined: Retaining the GID category, but possibly modifying its grouping with other syndromes; narrowing the definition to dysphoria and taking "disorder" out of the label; categorizing GID as a neurological or medical rather than a psychiatric disorder; removing GID from both the DSM and the International Classification of Diseases (ICD); and creating a special category for GIV in the DSM. I conclude that-as also evident in other DSM categories-the decision on the categorization of GIVs cannot be achieved on a purely scientific basis, and that a consensus for a pragmatic compromise needs to be arrived at that accommodates both scientific considerations and the service needs of persons with GIVs.
Vaginal spasm has been considered the defining diagnostic characteristic of vaginismus for approximately 150 years. This remarkable consensus, based primarily on expert clinical opinion, is preserved in the DSM-IV-TR. The available empirical research, however, does not support this definition nor does it support the validity of the DSM-IV-TR distinction between vaginismus and dyspareunia. The small body of research concerning other possible ways or methods of diagnosing vaginismus is critically reviewed. Based on this review, it is proposed that the diagnoses of vaginismus and dyspareunia be collapsed into a single diagnostic entity called "genito-pelvic pain/penetration disorder." This diagnostic category is defined according to the following five dimensions: percentage success of vaginal penetration; pain with vaginal penetration; fear of vaginal penetration or of genito-pelvic pain during vaginal penetration; pelvic floor muscle dysfunction; medical co-morbidity.
The DSM-IV-TR attempted to create a unitary category of dyspareunia based on the criterion of genital pain that interfered with sexual intercourse. This classificatory emphasis of interference with intercourse is reviewed and evaluated from both theoretical and empirical points of view. Neither of these points of view was found to support the notion of dyspareunia as a unitary disorder or its inclusion in the DSM-V as a sexual dysfunction. It seems highly likely that there are different syndromes of dyspareunia and that what is currently termed "superficial dyspareunia" cannot be differentiated reliably from vaginismus. It is proposed that the diagnoses of vaginismus and dyspareunia be collapsed into a single diagnostic entity called genito-pelvic pain/penetration disorder. This diagnostic category is defined according to five dimensions: percentage success of vaginal penetration; pain with vaginal penetration; fear of vaginal penetration or of genito-pelvic pain during vaginal penetration; pelvic floor muscle dysfunction; medical co-morbidity.