Friday, January 14, 2011

DSD a GID in the DSM? WTF?!

The newest, 5th edition of the DSM, or Diagnostic and Statistical Manual of Mental Disorders is slated to come out in May 2013. The DSM is the standard reference for the American Psychiatric Association (APA), for use by mental health professionals to diagnose clients. Every few years, the APA gives the DSM a facelift by updating available information on various mental health "disorders." Sometimes, new states of mental being/health are identified as disorders requiring treatment, and less often, disorders are de-classified - that something thought to be a disorder actually isn't harmful, and doesn't require treatment (see: being gay). It's really important to consider what it means to classify something as a disorder versus just one of the many ways you can be as a person. People diagnosed with various "disorders" who state that their way of being is not, in fact, disordered, may fight to have their own way of being declassified from "disorder" status by petitioning and and reaching out to members of the APA. Since a date has been set for the publication of the forthcoming DSM, a lot of activists are getting ready to challenge current DSM listings - intersex folk included.

I was a bit shocked to learn that intersex individuals are ALREADY listed in the current (4th) edition of the DSM. When I saw that the APA labels intersex as a mental disorder, my face pulled into a grimace in like, five directions. This made no sense; if intersex was about bodies, the way one is born, what does it have to do with mental health? There's no obvious link there that should make a mental health classification seem reasonable. However, it's not so much that APA considers intersex to be a mental disorder, but that "gender dysphoria" ACCOMPANYING an intersex diagnosis is something special from other contexts in which gender dysphoria occurs. While gender dysphoria is not defined on the APA webpage, the Gender Dysphoria Organization defines it as the following:

" identified by psychologists and physicians, is a condition in which a person has been assigned one gender, usually on the basis of their sex at birth (compare intersex disorders), but identifies as belonging to another gender, and feels significant discomfort or being unable to deal with this condition."

This organization also states that gender dysphoria is usually applied to individuals identified as transgender, transsexual, or more rarely, to transvestites. Gender dysphoria has not been classically applied to our perception of intersex individuals (or "hermaphrodites" on this site, but let's let that go for now) because, again, intersex is about a biological way of being, not a psychological one.

The DSM-IV apparently thinks that having gender dysphoria being a non-intersex person is different from a person with gender dysphoria that IS intersex. This notion is very confusing. One would think that gender dysphoria should be defined in the same way, regardless of who exhibits it. Of course, how gender dysphoria manifests will differ from person to person, but why does intersex GD need a separate classification? It's because of this: intersex individuals are considered to be of "ambiguous" sex at birth. While all children are assigned a sex (& matching gender) at birth, clinicians and parents don't feel any moral qualms about confidently announcing, "It's a boy!", or "It's a girl!" because, for most people, the mix of body characteristics that they have all line up in one of two specific ways: they got all boy parts or all girl parts. (These parts aren't limited to external genitalia, but also include internal sex organs, hormone types, hormone levels, and chromosome types at birth. Later, once this individual develops, there's a bunch of sex characteristics that have a "male" and "female" form.) Intersex individuals, on the other hand, have a mix of traits traditionally considered male or female. Thus, people are much more upset and unsure about announcing that the child's a boy, or the child's a girl, because to some parents/clinicians, they are not sure what sex their child "really" is. The doctors, together with parents, assign a sex & gender to the child - in the best of cases, just nominally, until the child grows up and decides otherwise. In the worst of cases, they're also assigned through body alteration including, but not limited to, genital surgeries and hormone treatments, often at very young ages when individuals are too young to really consent to them.

Where does the mental disorder part come in? The implications of assinging sex to an "ambiguous" child follow along these lines: guardians/parents and clinicians that assign a sex (& a "matching" gender) to a intersex child expect that this child will identify with their assigned sex and behave in accordance to their gender roles. If that intersex individual doesn't feel that their assigned sex and gender are authentic, it's THEIR problem. The decision of parents and clinicians to "choose" a sex and gender for this child, though, was still totally appropriate.

Does this seriously make sense to anyone?

On the surface, the context does not necessarily seem different from the experiences of transgender individuals that are labeled with gender identity disorder (which is also absolute bullshit, and which trans individuals have been fighting for longer than intersex individuals have been in the books). In both cases, as a child grows up, whether that child has atypical sex anatomy or not, others should accept and embrace their gender identity if it happens to be different from the sex/gender they were initially assigned. Period. Ultimately, the DSM-IV slaps a GID diagnosis on them because they are trying to define themselves by who they actually are, and not by how others expect them to be. The difference in an intersex infant's case is that parents literally CHOOSE the sex of their children, at least for the few few years of their life. They could choose to initially raise their child as a boy or a girl. They pick. In an ideal world, where no one gives a flyin' fuck about sex and gender, parents wouldn't even be under pressure to "choose." That it would be feasible in any way for parents to raise their kids without people caring about sex or gender, or that those concepts weren't necessarily relevant. But our world is not like that at the moment. Parents have to pick. And if intersex individuals reject their sex/gender assignment when they get older, it adds another degree of WTF to the issue of GID.

As an analogy, let's say that all humans are either pink or blue. (Since we're ripping down normative concepts of sex and gender, we might as well poke a little fun at it, right?) Think like, your entire world is now New Directions-style in But I'm a Cheerleader - except the people are pink and blue, not the clothing/decor/everything. Kids that are born pink are expected to be girls. Kids that are born blue are expected to be boys. Individuals that say, "I know you say I'm pink/blue, but I'm actually blue/pink/magntenta/a beautiful rainbow," are labeled with a GID. This would be the case for transgender and gender non-conforming individuals. Now, let's say, for intersex people, sometimes individuals are born that are green. Green is not pink. Green is also not blue. Green is green. But we live in a pink and blue world, and green isn't an option. You can choose to have your child be pink or blue. So parents choose. Later, these kids will grow up, and say, I'm not pink/blue, I'm [something else, and that something is just as great]. One could say, "Well, we actually PICKED whether the individual was gonna be blue or pink in the first place. Turns out, whether they were born green, pink, or blue, you never know who your kid will be until they grow up! Honey, you're whoever you say you are. You know best." But instead, the idea is, "Um, no. You're REALLY pink/blue because WE SAID SO. If you don't agree, then you have GID."

Although our world is not filled quite-so-literally with pink and blue and green people, our world is as rigidly gendered as the fictitious one I made up. Parents will assign intersex individuals a sex & gender at birth to keep in line with social norms, and that's okay. Parents can still put the power in the hands of their intersex children regardless of what sex & gender they assign by listening to their kids and taking note of who their kids say that they are. If at any time, children state, "This is who I am," that happens to counter parents' initially assignments, parents can say, "Ok! This is who my kid is, and I'll let them be who they are," and make changes accordingly. This may mean using different pronouns, a wardrobe change, changing legal documents, or perhaps some or none of those things. Regardless, this way, intersex kids are still have the right to identify as WHO THEY ARE and be that person with parental support. This is a very different scenario from saying, "Hey! That's not who you are! The doctors and I decided that THIS is who you are. If you don't like it, it's YOUR problem!" (That problem, of course, would be none other than gender identity disorder, as defined by the APA.) This is also very different from going yet a step further, and saying, "We subjected you to all those surgeries and 'treatments' without your consent, and you're not HAPPY with them?! There's something wrong with you. Post-treatment, you're REALLY a [girl/boy] now!"

If intersex individuals were given the agency to be who they are, regardless of sex and gender assignments, intersex would not be listed in the DSM-IV right now. Since the intersex body changes how APA defines the clash between assigned sex/gender assignment and that individual's professed sex/gender, GID for intersex people is listed as a GIDNOS, or gender identity not otherwise specified. Other "disorders" falling under GIDNOS include "stress-related cross-dressing" or a fixation on removing one's testicles or penis without wanting to "be female." In other words, it seems anyone falling outside standard gender roles - in terms of gender identity, presentation, or performance - may be considered having a GIDNOS.

So, we've been talking about INTERSEX in the DSM, but some of you may be thinking, "Uh, didn't the title of this post reference DSD being in the DSM, and not intersex? When are we going to start talking about DSDs?" Now, dear reader! Thank you for your patience.

Yes, the possibility of putting DSD in the DSM-V is a very different ballgame from having already put intersex in the DSM-IV. Why? Well, we have previously discussed DSDs here and here and linked to OII's fantastic page to consider how DSD is very different from intersex. Basically, it provides further justification for calling intersex a medical condition instead of a healthy normal, way of being because "something wrong" happened during development. Using such medical jargon also makes it sound more...well, "science-y," which provides more legitimacy to the idea that it's a medical problem that needs to be fixed. The fact that DSDs = something wrong happened means that DSD = clinicians need to fix something!, justifying physically and psycho-emotionally harmful "treatments," often subjected to intersex people without their consent. The term DSD is also problematic in that it doesn't give intersex individuals a clear way to identify if their identity strongly resonates with being intersex. For example, I don't consider my sex male or female - I'm intersex. Period. So, if the use of DSD became more widespread, then how would I identify? I'm not male or female - I'm...disordered? Intersex individuals are NOT disordered, and don't deserve to be labeled as such. There's ample problems with the term DSD being in the DSM in general (and even more to discuss elsewhere), since the term itself is loaded with problems. The fact that DSD, though, makes intersex seem like a legitimate medical condition, though, reiforces that fact that those intersex individuals who counter initial sex & gender assignments have legitimate PSYCHOLOGICAL conditions, too. Thus, this justifies the inclusion of intersex individuals in the DSM in a way that was not evident in the current edition.

This also means that intersex would not be listed as a GIDNOS - as some sort of gender identity disorder that falls out of line with other more "typical" hallmarks of gender identity disorder. If you check out the "Proposed Revisions" tab for gender identity disorders for both children and for adolescents and adults, you'll see at the bottom of the text, under "Subtypes" that the manifestations of gender identity disorder may occur along with a DSD, or may occur without a DSD. So, if intersex + GID = GIDNOS within a person who happens to be intersex (and maybe there's a relationship there), then DSD + GID = the psychological disorder is caused by one's medical disorder. This means that the APA is sending a clear message to intersex individuals who counter their initial sex/gender assignments: "Look, the reason that you've got gender identity disorder is because you've got a DSD! DSD is a medical condition, meaning your body's development got screwed up somewhere along the line. The fact that you feel this way isn't because others made decisions for you they didn't have the right to make, or that they couldn't make with's because you're sick! And the APA is here to make sure you get better by accepting what others have chosen for you, before you, or anyone else, even knew who you were! Have fun with that!"

This is totally, utterly unacceptable and is yet another step removed from anything approaching logic.

If DSD gets added to the DSM, not only will DSD perhaps become more prevalent over the use of the term intersex, but intersex individuals will be fighting with psychological health professionals to convince them we're normal and there's nothing wrong with us. Transgender individuals have been fighting these similarly illogical and unjustifiable standards for years, and intersex individuals are going to be seen similarly - as individuals who may know what they want, but are still "sick," and need to justify themselves to others who apparently know more about who you should be than you, yourself, do.

There's definitely going to be fighting to not simply remove intersex from the DSM, but to prevent the inclusion of DSD as a form of GID. I'll keep you updated on what we can do - there's sure to be petitions, rousing discussion, and protest before any of this is finalized.

No matter what any governing body says, we're not disordered, and we don't need to be fixed. We are beautiful and healthy and normal and will never stop saying that.