Why feminists should be concerned with the impending revision of the DSM

By Julia Serano
The Diagnostic and Statistical Manual of Mental Disorders (DSM) has been called the “bible of mental illness” because it lists and defines all of the “official” psychiatric diagnoses according to the American Psychiatric Association. The DSM is in the early stages of undergoing its 5th major revision; each previous revision has seen the total number of mental disorders recognized (some might say invented) by the APA greatly increase. Last year, trans activists were particularly concerned to learn that Ken Zucker and Ray Blanchard had been named to play critical lead roles in determining the language of the DSM sections focusing on gender and sexuality, especially given that these researchers are well known for forwarding theories and therapies that are especially pathologizing and stigmatizing to gender-variant people.
Blanchard has recently presented some of his suggestions to revise the “Paraphilia” section of the DSM. In the past, this section has generally received little attention from feminists, as it has been primarily limited to several sexual crimes (e.g., pedophilia, frotteurism and exhibitionism) and a handful of other generally consensual but unnecessarily stigmatized sexual acts (such as fetishism and BDSM) that are considered “atypical” by sex researchers. However, there are two aspects of the proposed Paraphilia section revision that should be of great concern to feminists, as well as anyone else who is interested in gender and sexual equality.
Expanding “Paraphilia”
First, Blanchard is proposing a significant expansion of the DSM’s definition of “paraphilia” to include:
“any intense and persistent sexual interest other than sexual interest in genital stimulation or preparatory fondling with phenotypically normal, consenting adult human partners.”
The first concern here is the term “phenotypically normal” (meaning “normal” with regards to observable anatomical or behavioral traits). Thus, according to this definition, attraction to any person deemed by sex researchers to be “abnormal” or “atypical” could conceivably be diagnosed as paraphilic. So, do you happen to be attracted to, or in a relationship with, someone who is differently-abled or differently-sized? Or someone who is gender-variant in some way? Well congratulations, you may now be diagnosed with a paraphilia!
Seriously.


Blanchard and other like-minded sex researchers have coined words like Gynandromorphophilia (attraction to trans women), Andromimetophilia (attraction to trans men), Abasiophilia (attraction to people who are physically disabled), Acrotomophilia (attraction to amputees), Gerontophilia (attraction to elderly people), Fat Fetishism (attraction to fat people), etc., and have forwarded them in the medical literature to denote the presumed “paraphilic” nature of such attractions. This tendency reinforces the cultural belief that young, thin, able-bodied cisgender women and men are the only legitimate objects of sexual desire, and that you must be mentally disordered in some way if you are attracted to someone who falls outside of this ideal. It’s bad enough that such cultural norms exist in the first place, but to codify them in the DSM is a truly terrifying prospect.
Another frightening aspect of Blanchard’s proposal is that any sexual interest other than “genital stimulation or preparatory fondling” is now, by definition, a paraphilia. In his presentation, he claimed that paraphilias should include all “erotic interests that are not focused on copulatory or precopulatory behaviors, or the equivalent behaviors in same-sex adult partners.” Copulatory is defined as related to coitus or sexual intercourse (i.e., penetration sex). So, essentially, all forms of sexual arousal and expression that are not centered around penetration sex may now be considered paraphilias.
So, do you and your partner occasionally role-play or talk dirty to one another over the phone? Or engage in arousing play that is not intended to necessarily lead to “doing the deed”? Do you masturbate? Do you get a sexual charge from wearing a particularly sexy outfit or performing any act that falls outside of “genital stimulation or preparatory fondling”? Well, then congratulations, you can be diagnosed with a paraphilia!
“Transvestic Disorder,” Gender Inequality and the Sexualization of Feminine Gender Expression
Blanchard also wants to retain (with minor tweaking) the “Transvestic Fetishism” diagnosis from the previous DSM Paraphilia section; the new diagnosis is to be called “Transvestic Disorder.” Like it’s predecessor, it applies to “heterosexual males” who experience “recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving cross-dressing.” As Kelly Winters of GID Reform Advocates points out:
“Curiously, women and gay men are free to wear whatever clothing they chose without a label of mental illness. This criterion serves to enforce a stricter standard of conformity for straight males than women or gay men. Its dual standard not only reflects the social privilege of heterosexual males in American culture, but promotes it. One implication is that biological males who emulate women, with their lower social status, are presumed irrational and mentally disordered, while biological females who emulate males are not. A second implication stereotypically associates femininity and cross-dressing with male homosexuality and serves to punish straight males who transgress this stereotype.”
The “heterosexual male” nomenclature should also be of concern to many trans women, as Blanchard (and like-minded psychologists) routinely mis-describe lesbian-identified trans women as “heterosexual male transsexuals” in the medical literature. Since the Transvestic Disorder diagnosis does not explicitly exempt transsexuals, then a queer-identified trans woman (such as myself) could theoretically be diagnosed as having “Transvestic Disorder” any time that I have *any kind* of sexual urge while wearing women’s clothing. Since I wear women’s clothing pretty much every day of my life these days, my sexuality would presumably be considered perpetually transvestically disordered according to this diagnosis.
Kelley Winters has also written at length about how the vagueness of Transvestic Fetishism/Disorder wording enables the diagnosis of individuals who do not experience any sexual arousal in association with wearing women’s clothing. She argues:
“It serves to sexualize a diagnosis that does not clearly require a sexual context. Crossdressing by males very often represents a social expression of an inner sense of identity. In fact, the clinical literature cites many cases, considered diagnosable under transvestic fetishism, which present no sexual motivation for cross-dressing and by no means represent fetishism.”
We live in a heterosexual-male-centric culture, where femaleness and feminine gender expression are routinely sexualized, and where sexual symbolism is projected onto women’s clothing. For this reason, people (including psychologists such as Blanchard) regularly sexualize trans women, male crossdressers, and others on the trans feminine spectrum, and attribute sexual motives to us, even when no such motives exist. Thus, the Transvestic Disorder diagnosis both sexualizes people on the trans feminine spectrum, while simultaneously reinforcing the societal sexualization of women and feminine gender expression more generally.
Sexism and the DSM Paraphilia Section
Proponents of the DSM Paraphilia section would argue that paraphilia diagnoses are only applicable when the individual in question exhibits “significant distress or impairment” over their sexual urges. This ignores the fact that many happy and healthy individuals are sometimes diagnosed with paraphilias. Further, the mere fact that Transvestic Fetishism, Masochism and Sadism have been listed in the DSM (under the same category as several nonconsensual sexual crimes, no less) is regularly cited by those who wish to delegitimize or legally discriminate against male crossdressers and people who practice consensual BDSM. Labeling any form of gender or sexual expression as a “mental disorder” is necessarily stigmatizing and ignores the vast amount of gender and sexual variation that exists in the world.
It was not that long ago that Homosexuality and Nymphomania were listed in the “Sexual Deviation” (which was later renamed “Paraphilia”) section of the DSM. They were removed, in part, due to public pressure, as both diagnoses only served to reinforce cultural double standards (i.e., the idea that same-sex attraction is less legitimate that heterosexual attraction, and that women should exhibit less sexual interest than men, respectively). We have a word to describe double standards that exist with regards to sex, gender or sexuality–it’s called sexism.
The proposed revision of the DSM Paraphilia section is sexist in numerous ways. We, as feminists, should fight to have *all* forms of sexual expression that occur between consenting adults removed from the DSM entirely. And we should especially fight for the removal of “Transvestic Disorder” on the grounds that it sexualizes feminine gender expression and reinforces rigid cis-hetero-male-centric gender norms.
What you can do to help:
1) raise awareness about this issue in feminist circles.
2) contact the American Psychiatric Association and share your concern with them.
3) if you live in the San Francisco Bay Area, please come out to the protest of the upcoming American Psychiatric Association conference on Monday, May 18th between 6:00pm to 7:30pm in front of the Moscone Center. This protest will focus primarily on the removal of the trans-focused DSM diagnoses Gender Identity Disorder (GID) and Transvestic Disorder. While the GID diagnosis is of great concern to trans activists (including me), I did not discuss it here because it is not listed as a Paraphilia, and because (to the best of my knowledge) no information has been released regarding proposed revisions to GID in the next DSM.
For more information about the Paraphilia section of the DSM, I encourage you to read DSM-IV-TR and the Paraphilias: An Argument for Removal by Charles Moser and Peggy J. Kleinplatz.
For more info about “Transvestic Disorder,” check out Transvestic Disorder and Policy Dysfunction in the DSM-V by Kelly Winters. (Also, her blog and book provide excellent critiques of both the Transvestic Disorder and GID diagnoses).
Julia Serano is an Oakland, California-based writer, spoken word performer, trans activist, biologist, and author of Whipping Girl: A Transsexual Woman on Sexism and the Scapegoating of Femininity.

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66 Comments

  1. Mir
    Posted May 7, 2009 at 12:22 am | Permalink

    Indeed, indeed. It disincludes a whole swathe of people from ever being “normal enough” for it to be “right” to have a relationship with. And that is pretty damn sickening, IMHO.

  2. Synna
    Posted May 7, 2009 at 12:32 am | Permalink

    this, (to paraphrase another comment from another thread_ is why health care should not be a ‘for profit’ industry.

  3. Borea
    Posted May 7, 2009 at 1:10 am | Permalink

    As it’s been said elsewhere, one problem with the DSM is it’s created by a community of people trying to make money. Our health system needs to NOT be a for-profit system, for starters.
    As for making parahpila diagnoses useful tools… well, perhaps if it is seen as a more general symptom for deeper problems? Which seems to be what you’re suggesting.

  4. helen boyd
    Posted May 7, 2009 at 2:05 am | Permalink

    I’d like to add that the persistent labeling of only het males as transvestic fetishists is based on the old presumption that women don’t have / can’t desire the same way men do.

  5. Posted May 7, 2009 at 5:14 am | Permalink

    Yes it does make sense, and no, you’re not de-railing the topic through cis privilege.
    I had no idea that you’d be caught in the crossfire too. That’s my ablist privilege showing. Thanks for bringing this to my attention.
    It makes the issue even more important. You know sometimes, I really, really, really hate this Patriarchal BS. Blanchard and Zucker aren’t bad, just appallingly arrogant. They oppress and don’t even realise it.

  6. Posted May 7, 2009 at 6:06 am | Permalink

    A word in defence of Blanchard; he wrote:

    In this formulation, only problematic paraphilias would be called paraphilic disorders. To underscore that point, we propose to use the verb ascertain when talking about paraphilias and the verb diagnose when talking about paraphilic disorders.

    So you would not be diagnosed with a paraphilia for being sexually attracted to say, me – someone not phenotypically normal. You would be ascertained to be paraphiliac instead.
    Good luck getting a Judge or Jury to understand the difference in a custody case.
    You would only be diagnosed with a paraphiliac disorder if it would cause distress or impairment to you or others. For example, if your boss disapproved of intersexed people and fired you for being attracted to one.

  7. Posted May 7, 2009 at 9:07 am | Permalink

    Oh yes, and it doesn’t just pathologise masturbation, but……
    It gives a backdoor for rapists to claim an insanity defence. They have a “paraphiliac disorder”.

  8. -julia
    Posted May 7, 2009 at 12:07 pm | Permalink

    hi Helen,
    Yes, you are exactly right. I didn’t discuss that in this piece but I do talk about it in my book. “Paraphilias” are typically defined as occurring primarily or exclusively in males (with MTF spectrum folks being considered “male”). This notion is rooted in the ancient yet stupid assumption that males have sexual appetites and agency, while females do not. So paraphilias more generally, and transvesticism more specifically, are sexist in that way too.
    When I give presentations that debunk autogynephilia or transvestic fetishism, the biggest laugh I get by far is when I read Blanchard and Stoller quotes that argue that there are virtually no cases of women (or FTM spectrum folks) who get an erotic charge out of wearing men’s clothing. After everyone laughs, I usually follow by suggesting that they should get out more…
    (btw, if you’re interested, you can hear a version of that presentation that I gave at the recent IFGE conference: http://www.juliaserano.com/av/2_6_09-IFGE09.mp3

  9. SaveOurSkyline
    Posted May 8, 2009 at 4:42 pm | Permalink

    Adding additional paraphilia categories to the DSM-V is a red herring. The DSM-IV was actually a huge step forward for sensibility towards a rational, modern approach to fetishism because it changes the definition to indicate that the condition only applies if “…the disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning” (which will undoubtedly carry over into the DSM-V.)
    I.e., if it doesn’t cause distress, then it’s not a mental health issue. This is a perfect way to approach atypical non-harmful behavior. If a person’s behavior is causing them “clinically significant distress,” then it would certainly be helpful for mental health professionals to be able to refer to something in the literature which relates to the specific behavior of the patient.
    Being diagnosed with a paraphilia is not necessarily an indication that “there’s something wrong with the patient that needs to be fixed,” it can, instead, tell the professional that the patient needs help with self-acceptance issues or help with relating to other members of society, given the context of their unique behavior.

  10. Desmond Ravenstone
    Posted May 8, 2009 at 10:07 pm | Permalink

    When is a paraphilia not a paraphilia? If two people decide to try a little bondage, are they on the verge of mental illness? What about those of us in the BDSM community who regularly practice kink and function in society?
    And why isn’t there a “missionary-position” fetish, or a “lights-off-and-blinds-drawn” paraphilia? It seems that all of these labels are being applied to activities which contradict Victorian sensibilities. Even if a person’s particular sexual behavior is obviously harmful or inappropriate, shouldn’t we be asking the question of whether that behavior is a “disease” in itself, or a symptom of another problem (such as sociopathy or obsessive-compulsive disorder)?
    Charles Moser, Peggy Kleinplatz and other have argued for removing paraphilias from the DSM altogether. As radical as that sounds, feminists and other progressives should seriously examine and debate such a proposal. When the line between diagnosis and moral condemnation is that fuzzy, then we have to question the motivations and research behind those labels.

  11. Velderia
    Posted May 9, 2009 at 2:59 am | Permalink

    DSM? Isn’t that the same guide that actually has a listing for a disorder that involves a person loving math problems?
    Or being stoned? http://www.youtube.com/watch?v=Nbx4m5b7KLU&feature=related

  12. NADPH
    Posted May 10, 2009 at 3:38 pm | Permalink

    just because something is in the DSM does not guarantee or necessarily increase the chances that it will be covered by insurance. many insurance policies, for example, specifically exclude any medical treatment related to transsexualism, even though often those same treatments are included for non-trans members of the same insurance policy (i.e. hormone replacement therapy for ciswomen who have deficiencies in estrogen, or cismen who have deficiencies in testosterone, etc.).
    i know we’re specifically talking about paraphilia here and not GID. but GID is a good example of how being in the DSM provides all the disadvantages (being stigmatized, having a mental disorder diagnosis in your medical records, shifting the focus of the problem on the individual and not on societal intolerance and cisprivilege…), and rarely, if any, advantages.
    also, there are ways to invent/create diagnostic codes for billing purposes that do not involve pathologizing someone as mentally ill. dean spade, at a gender symposium at CU-Boulder, once suggested that he would like to see GID turned into some sort of “healthful condition” that requires medical attention. something similar to pregnancy (although there is a lot of fucked up history around pathologizing pregnancy, no doubt), which for most intents and purposes, under normal/uncomplicated circumstances, is not considered a disease or pathology, but nonetheless is a condition that requires medical attention and involvement.

  13. NADPH
    Posted May 10, 2009 at 3:38 pm | Permalink

    just because something is in the DSM does not guarantee or necessarily increase the chances that it will be covered by insurance. many insurance policies, for example, specifically exclude any medical treatment related to transsexualism, even though often those same treatments are included for non-trans members of the same insurance policy (i.e. hormone replacement therapy for ciswomen who have deficiencies in estrogen, or cismen who have deficiencies in testosterone, etc.).
    i know we’re specifically talking about paraphilia here and not GID. but GID is a good example of how being in the DSM provides all the disadvantages (being stigmatized, having a mental disorder diagnosis in your medical records, shifting the focus of the problem on the individual and not on societal intolerance and cisprivilege…), and rarely, if any, advantages.
    also, there are ways to invent/create diagnostic codes for billing purposes that do not involve pathologizing someone as mentally ill. dean spade, at a gender symposium at CU-Boulder, once suggested that he would like to see GID turned into some sort of “healthful condition” that requires medical attention. something similar to pregnancy (although there is a lot of fucked up history around pathologizing pregnancy, no doubt), which for most intents and purposes, under normal/uncomplicated circumstances, is not considered a disease or pathology, but nonetheless is a condition that requires medical attention and involvement.

  14. steepholm
    Posted May 14, 2009 at 1:14 pm | Permalink

    So, the more bigoted your boss, the more disordered you are deemed to be? Talk about victim blaming!

  15. steepholm
    Posted May 14, 2009 at 1:19 pm | Permalink

    Reverting to Zoe Brain’s point above, getting fired from one’s job would presumably count as an “impairment” in one’s occupational functioning. Does this mean that whether one has a disorder or not then becomes a function of the degree of one’s boss’s bigotry?

  16. Enfant
    Posted May 14, 2009 at 4:38 pm | Permalink

    This discussion is puzzling to me, because I’ve read Blanchard’s proposal, and I actually have a paraphilia–a big one–and I don’t see a problem with the proposed definition. It actually seems more accurate and less biased than what’s in the DSM now.
    Note that he specifically says a paraphilia is not a mental disorder, it’s just a characteristic. If it makes you miserable or screws up your life, then you might have a “paraphilic disorder”. But if it doesn’t, then it’s just a quirk.
    Falling in love with a specific transgender person and wanting to have sex with him or her is not a paraphilia. Being intensely fixated on the concept of sex with transgender people, to the exclusion of other sexual interests, might be a paraphilia. But even if it is, it still wouldn’t be a disorder, unless you were really, really unhappy about it.
    My own fetish doesn’t make me unhappy. On the contrary! It delights me, blisses me out, makes me feel passionate and alive and wonderful. I wish everyone was lucky enough to have one. But (alas for all you vanilla folk) my sexual tastes are not normal. It doesn’t bother me to say so.
    I have a paraphilia. I do not have a disorder. The proposed DSM text seems to agree. I’m okay with that.

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