Thursday, May 15, 2008

Update on the DSM-V Issue

This crucial bit of information has come to us from Dr. Marshall Forstein. Please read it.

Before people get overly hysterical about the Gender Identity Work group for the DSM, some things need to be made clear.

The letter you are asking us to sign onto is inaccurate in many ways and does not help our cause. Let me clarify what I know as someone who has worked with the American Psychiatric Association for many years.

1- there are TWO professional associations: Both unfortunately go by A P A

a) one is the American Psychiatric Association [this is a MEDICAL society of physicians who specialize in psychiatry]

b) the other is the American Psychological Association [this is a non- medical society of psychologists who are not medical doctors but have a PhD or PsyD or EdD in psychology, either clinical or research or academic or all.]

The American PSYCHIATRIC Association is the organization that publishes the DSM. This is a guide to diagnosis and NOT to Treatment.

Dr. Zucker, although not my preferred choice to head the work group on Gender and Sexuality, does not decide himself what the American Psychiatric Association publishes in the next DSM. In fact, there is a lengthy, and complicated process of peer review based on PUBLISHED scientific literature- in fact, the way we got homosexuality OUT of the DSM [1973] was to force the scientific program committee to produce evidence that homosexuality was an illness, and then in 1989 we removed ego-dystonic homosexuality because there was no evidence to support it and we suggested that there was also ego-dystonic heterosexuality that was a phase of people coming to understand their inner nature.

Sexual orientation is NOT even an issue for the DSM committee to consider. Transgender Identity is a bit more complicated, especially in childhood. The DSM work group will struggle with these issues in coming up with criteria for what to diagnose as a true gender identity disorder. I WANT TO EMPHASIZE THAT TREATMENT RECOMMENDATIONS ARE NOT A PART OF THIS ENDEAVOR.

Any treatment recommendations that the American Psychiatric Association makes are the result of significant process of creating EVIDENCED based research.

I am currently the Chair of the Work group on Practices Guidelines on HIV Psychiatry for the American Psychiatric Association, and so am intimately aware of the process. Guidelines go through rigorous research review for controlled studies in order to make recommendations. Hundreds of people review these guidelines before publication, and the same will be true of the criteria set forth by the work group on the DSM gender identity subcommittee.

EVEN if there is literature out there that disturbs those of us who are comfortable with the concepts of transgender identity, unless it meets peer review by legitimate journals ( i.e. non religious based periodicals) it will not be considered in the development of criteria for diagnosis or treatment.

I hope that what I have written makes us pause a bit before we do something to alienate even our supporters and friends in the American Psychiatric and the American Psychological Association who have been very pro-gay and pro-trans in their deliberations so far. There will always be a vocal minority that claim otherwise, but the process is vetted by many people committed to scientific integrity and evidence.

I have alerted the Association of Gay and Lesbian Psychiatrists to the announcement of Dr Zucker's appointment and we will be addressing the implications of this within the psychiatric and psychological professional groups. I will also be talking with the Medical Director of the American Psychiatric Association and the Director of the Research group that oversees the DSM to convey the concerns that people have about the "transphobia" that may emerge.

In good conscience, however, I cannot sign a petition that is inaccurate and misleading - it may do far more harm than good. Clarity of the scientific evidence, asking the right questions of the committee, and addressing the criteria that will be put forth for review before it is ever considered ready for publication is the only way we will be taken seriously.

Please let me know how I can help to keep the issues clear.

Marshall Forstein, M.D.
Associate Professor of Psychiatry
Harvard Medical School Director, Adult Psychiatry Residency Training
The Cambridge Hospital
The Cambridge Health Alliance
1493 Cambridge Street
Cambridge, MA 02139

office 617-665-3449
mforstein [at]


May 9, 2008

The American Psychiatric Association has received inquiries about the DSM-V process, particularly concerns raised about the Sexual and Gender Identity Disorders Work Group.

The APA has a long-standing mission to provide guidelines for the diagnosis and treatment of mental disorders, based on the most current clinical and scientific knowledge. Through advocacy and education of the public and policymakers, the APA also affirms it commitment to reducing stigma and discrimination. The DSM addresses criteria for the diagnosis of mental disorders. The DSM does not provide treatment recommendations or guidelines. The APA is aware of the need for greater scientific and clinical consensus on the best treatments for individuals with Gender Identity Disorder (GID). Toward that end, the APA Board of Trustees voted to create a special APA Task Force to review the scientific and clinical literature on the treatment of GID. It is expected that members of the Task Force will be appointed shortly.

There are 13 DSM-V work groups. Collectively, the work group members will review all existing diagnostic categories in the current DSM. Each work group will be able to make proposals to revise existing diagnostic criteria, to consider new diagnostic categories, and to suggest deleting existing diagnostic categories. All DSM-V work group proposals will be based on a careful, balanced review and analysis of the best clinical and scientific data. Evidence accumulated from work group members and hundreds of additional advisors to the DSM-V effort will be considered before final recommendations are made.

The Sexual and Gender Identity Disorders Work Group, chaired by Kenneth J. Zucker, Ph.D., will have 13 members who will form three subcommittees:

--Gender Identity Disorders, chaired by Peggy T. Cohen-Kettenis, Ph.D.

--Paraphilias, chaired by Ray Blanchard, Ph.D.

--Sexual Dysfunctions, chaired by R. Taylor Segraves, M.D., Ph.D.

Each subcommittee will pursue its own charge, provide ongoing peer review, and consult with outside experts. The DSM-V is expected to be published in 2012.