After long debate, some controversy, and many internal revisions, the American Psychological Association (APA) printed its fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in May 2013.
Within this latest revision of what is hailed as the industry’s “bible” of diagnostic criteria for mental illness in the U.S., there were several interesting changes and more recommendations for changes to the next revision.
Some of the revisions have been considered, by and large, good for the industry and the people it serves — such as the removal of the confusing “axis” criteria which forced clinicians to place patients into confusing categories (e.g., placing people with personality disorders under the same axis — an ill-defined concept in itself — along with those people believed to have “mental retardation,” another category that has now been changed).
Other changes to this fifth revision of the DSM are facing a negative reception by the public, if not by the majority of mental health workers. One such change is the removal of Asperger’s disorder. Now, the symptoms for Asperger’s will be incorporated under a more dimensional approach covered by a diagnosis for autism spectrum disorders (ASD). It is important to note that some do see this change as a positive step, however.
The removal of dementia as a diagnosis and the insertion of “mild neurocognitive impairment” may be more troubling. The term “mild” in itself is open-ended and many are worried this terminology could lead clinicians to erroneously diagnose individuals with a mental illness who experience normal memory deterioration and other cognitive changes related to aging.
Being Transgender in the Age of DSM-5
While the above changes have been widely discussed in news media, one historic change to the DSM-5 may have been missed by many Americans. The previous mental illness diagnosis of “gender identity disorder” has been removed. What remains is a diagnosis for “gender dysphoria.” Gender dysphoria is said to occur when a person experiences a mismatch between their biological sex and their internal experience of gender identity to the degree that it causes uneasiness, anxiety, frustration, or sadness.
Gender identity disorder (GID), also referred to as transsexualism, had previously been lobbied for removal from the DSM by activist groups. Now that it has been removed and replaced by gender dysphoria, many in the LGBT activist community are celebrating, but many are worried. Having a classification which characterized transgender people as mentally ill gave potentially transphobic individuals leverage with which to discriminate against trans people. But no longer having the classification leaves advocates worried that trans people are left with no recourse for gaining insurance benefits for needed gender reassignment surgeries or with little legal support in defending discriminating legal actions against them such as terminations on the basis of gender identity or custody actions.
By way of example, The Advocate reported on a custody case in Utah in which a woman stands to lose the children she fathered prior to her transition. Using her GID status (made prior to the DSM’s fifth revision), the opposing counsel is arguing that the woman be denied custody on the basis of a “severe, chronic mental illness that might be harmful to the child.” In a Decatur, Georgia, case, a mother was sued for custody on the grounds that she was unfit due to her “nontraditional lifestyle.” This mother, divorced for seven years, was involved in a long-term relationship with a man who had been transitioned for 10 years. She lost her case.
Back in Georgia, Vandy Beth Glenn, fired from her job as an editor and proofreader at the Office of the General Assembly on the day her superior learned of her decision to transition to female brought a case of discrimination against the General Assembly with the support of Lambda Legal. She won her case, despite her diagnosis of GID (or possibly because of it) even though Georgia had no protections for trans people and still has none. And yet, the matter of discrimination against trans people is hardly as simple as classification under DSM criteria. In a circumstantial reversal, transgender employees like Megan Wallent of software giant Microsoft are eligible for what may be an unprecedented transgender healthcare program, a benefit package which pays for gender therapy and offers $10,000 in lifetime benefits for surgeries and other medical treatments, such as hormone therapy.
Transgender parents facing custody battles post-DSM’s fifth revision may be better off without the stigmatizing label of mental illness, but it can hardly be stated that Microsoft’s transgender healthcare program is the industry norm. Furthermore, in most states in the US, people can still be fired simply for being transgendered. Currently, 34 states lack laws that protect employees from discrimination based on gender identity, and 29 states lack laws with sexual orientation protections. While the Employment Non-Discrimination Act (ENDA) has been proposed to the Senate more than once, there remains no federal law prohibiting employment discrimination on the basis of sexual orientation or gender identity. Without such protections, and with the malignant history of discrimination, as well as a too-recently-removed label of mental illness, trans people still face an uphill battle.
Forty years after the removal of homosexuality from the APA’s diagnostic bible for mental illness, trans people — often marginalized further within the LGBT community — are beginning to see change. Trans and mental healthcare advocates are demanding further revisions to the DSM so that adults who have already transitioned, children who simply do not meet gender stereotypes in dress or behavior, and others whose symptoms are the result of familial and societal prejudice will not fall into the hegemonic rabbit hole of mental illness by way of rote categorization. There are benefits and risks to the new revision to the APA’s manual of mental illness, but on the whole, America is seeing that, in the words of activist and writer Dan Savage, “it gets better.”