Dr. Kelley Winters Keynote Speech.

Here is the keynote speech Dr. Kelley Winters delivered at the Colorado Gold Rush Conference in Denver earlier this year.

A little about Dr. Winters from the TYFA website:

Dr. Kelley Winters is a writer and community advocate on issues of transgender medical policy. She is the founder of GID Reform Advocates, member of the World Professional Association for Transgender Health, and Advisory Board Member for the Matthew Shepard Foundation and TransYouth Family Allies. She has presented papers on the psychiatric classification of gender diversity at annual conventions of the American Psychiatric Association, the American Psychological Association, the American Counseling Association and the Association of Women in Psychology. Her articles have appeared in a number of psychology and psychiatry journals and in two books.

Kelley assisted in drafting the current human rights ordinances in Boulder and Denver, Colorado. She was instrumental in trans-positive reform of Colorado drivers license policy in 2006 and in adding Gender Identity and Expression to employment policies of the Hewlett-Packard Company. Kelley received the Colorado Pride Award from Equality Colorado in 1999 and the and 2002 Sonja’s Dream Lifetime Achievement Award and 2007 Melissa Chapman Award for Social Change from the Gender Identity Center of Colorado.

Dr. Winters also authors the GID Reform weblog which can be found here.

Gender identities and gender expression that differ from expectation of assigned birth sex remain very much classified as mental disorder and sexual deviance by the American Psychiatric Association. The consequences of this undeserved stigma to our human dignity, social legitimacy in our affirmed roles are enormous and devastating. We lose our jobs, our homes, our families, our children, our civil justice and our access to medical care to defamatory stereotypes that place an unfair burden of proof upon all gender transcendent people to continually demonstrate our sanity, our competence and our human worth.

The current diagnostic criteria of GID and TF describe transition itself as symptomatic of mental illness, especially so for gender nonconforming children and transwomen. This burdens our supportive medical and mental health providers to re-spin, to repackage, this flawed nomenclature as congruent with social and medical transition, when in fact it was written to contradict transition. As a consequence, only a privileged portion of us who need access to hormonal and/or surgical care are afforded access. Worse yet, trans youth and even adults remain subject to psychological gender reparative and cruel aversion "therapies" intended to shame affirmed gender identities into dark and solitary closets.

The Fifth Edition of the DSM is scheduled for publication by the American Psychiatric Association in 2013. It is the first major revision since 1994. Critical decisions for the diagnostic categories and criteria have already been considered, and the DSM-5 work group authoring the sex and gender categories was sadly stacked to favor bias intolerant of gender diversity. After a period of unprecedented secrecy, draft language for proposed gender diagnoses were disclosed on February 10^th for a period of public review and comment through April 20.

This is a pivotal point in the history of our community, as the DSM-5 will likely impact the lives, civil liberties and medical care of all gender-transcendent people through the 2020s.

In spite of the barriers that we face with mental health policymakers, I have hope for positive change in the DSM-5. The proposed Gender Incongruence diagnoses for adults, adolescents and children (formerly called Gender Identity Disorder) represent some forward progress on both issues of stigma and barriers to medical transition care-- the first forward progress that we have seen in 30 years of DSM revision.

Most significant, is a statement of explanation by the subcommittee that for the first time refutes the false myth of "disordered" gender identity:

"We have proposed a change in conceptualization of the defining features by emphasizing the phenomenon of 'gender incongruence' in contrast to cross-gender identification per se"

This clarification that diverse gender identities are not in themselves the focus of mental pathology is historically unprecedented, since the introduction of Transsexualism to the DSM in 1980. This statement alone provides a powerful educational tool to advocates for our community.

Moreover, the proposed Gender Incongruence category for children has been reformed so that children must show dissatisfaction with birth-sex assignment to meet the criteria and can no longer be diagnosed strictly on the basis of gender role nonconformity. Again, this is an unprecedented step forward for kids who transition in their social roles and for gender nonconforming kids who are not trans but were pathologized in the past.

However, much work is needed to clarify these new criteria so that they do not continue to diagnose difference. For example:

* "Incongruence" is not clearly defined to mean incongruence as experienced by the subject. It could still be misrepresented to mean nonconformity to cultural gender stereotypes.

* The new criteria have retreated from clinically significant distress as a focus of diagnosis, which supports the medical necessity of treatment.

* Ambiguous language continues to misrepresent transition and desire for medical transition care as symptomatic of mental illness.

* The offensive term "Disorder of Sex Development" is used to describe people born with intersex conditions.

* For children, nonconformity to anachronistic gender stereotypes is still emphasized as symptomatic of mental disorder.

* These categories are placed in the DSM section of Sexual Disorders, though describing emotions and behaviors that are not necessarily sexual.

In spite of these, I am for the first time optimistic that the DSM subcommittee authoring these Gender Incongruence diagnoses may be willing to listen to our concerns for more positive reform.

I believe that we stand at our own inflection point in the history of an affirming trans movement, one that our youth in this room will look back upon as adults.

As brothers and sisters in the community, as parents and allies, as medical and mental health providers, please lend your attention and your voices to issues of social stigma and transition medical care access that are rooted in these mental health policy decisions.

Statement on Gender Incongruence in Adolescents in the DSM-5

PRESS RELEASE

TransActive Education & Advocacy "TransActive"

FOR IMMEDIATE RELEASE

April 13, 2010

Contact: Jenn Burleton, Executive Director
Phone: 503-252-3000
Email: jenn@transactiveonline.org
Website: www.transactiveonline.org

TransActive Education & Advocacy Fully Endorses Statement by
"Professionals Concerned About Gender Diagnoses in the DSM"

We recognize that gender dysphoria in youth is a serious issue and may require medical intervention as well as therapeutic support. For those youth who identify as transgender or transsexual, or who express gender dysphoria and discomfort with their anatomical body, early intervention can alleviate future difficulties, and can assist young people to mature in their affirmed gender identity. This is consistent with the American Psychological Association’s goal of promoting “legal and social recognition of transgender individuals with their gender identity and expression” and is especially important for adolescents who typically lack the resources and authority to achieve this goal without clinician assistance.

Statement on Gender Incongruence in Adolescents in the DSM-5

by Professionals Concerned with Gender Diagnoses in the DSM

We are mental health and medical professionals, clinicians, researchers and scholars concerned about psychiatric nomenclature and diagnostic criteria for gender-variant, gender-nonconforming, transgender and transsexual people in the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), and call ourselves Professionals Concerned About Gender Diagnoses in the DSM. Below are our suggestions for the diagnosis of Gender Incongruence (in Adolescents) in the DSM 5.

Our group recommends a separate diagnostic category for adolescents. Adolescent issues are markedly different from those facing pre-pubescent children and those experienced by adults. Adolescent sexual and gender development are complex processes (Pleak 2009; Striepe & Tolman 2003) and should be clearly separated out with the DSM from the presenting issues of prepubescent children and/or adults.

We recognize that gender dysphoria in youth is a serious issue and may require medical intervention (Spack, 2009), as well as therapeutic support. For those youth who identify as transgender or transsexual, or who express gender dysphoria and discomfort with their anatomical body, early intervention can alleviate future difficulties, and can assist young people to mature in their affirmed gender identity (Cooper 1999). This is consistent with the American Psychological Association’s goal of promoting “legal and social recognition of transgender individuals with their gender identity and expression” (APA 2009, para. 18) and is especially important for adolescents who typically lack the resources and authority to achieve this goal without clinician assistance.

We also recognize the severe harm that can occur and the future problems that can be averted by clinician responsiveness to adolescents requesting assistance toward living in a manner consistent with their gender identities and expression. We therefore support providing reversible hormone blockers to teenagers who are capable of giving informed consent (Gross, 2001) based on scientific evidence that clearly documents successful outcomes for transitioning teenagers (Cohen-Kettenis, Delemarre-van de Waal, & Gooren, 2008). Many adolescents who are forced to wait to access hormones or hormone blockers access gender-aligning medications in dangerous environments without proper monitoring (Rosario, 2009); for this reason, we caution against a 6 month waiting limit, as adolescent mental health can deteriorate rapidly when youth are forced to endure the traumatic experience of daily life in bodies that do not meet their psychosocial needs.

We further caution clinicians against imposing specific packages of medical interventions or dictating the order in which youth receive particular medical interventions, as adolescents’ needs vary considerably and should be addressed, based on individual self-reported need or request.While medical intervention are essential for some youth, others may seek legal or social recognition without any gender-aligning medical interventions. Youth who are utilizing gender-aligning medical interventions, and those who have successfully transitioned without medical interventions, should be considered to have achieved gender alignment.

We believe the focus of this diagnosis should be on dysphoria (defined as distress, extreme discomfort, or an emotional state of dis-ease), because it is discomfort, not a particular gender identity or expression, that is the psychological issue. It is essential that the diagnostic criteria focus on anatomical distress or distress with current assigned gender role, with explicit verbalization from the youth that his or her current gender role or anatomical sex does not match his or her internal sense of gender. Gender dysphoria may also be manifested by distress or discomfort with deprivation (Vitale 2001) of social role or anatomy that is congruent with experienced gender identity. Experienced gender is not limited to fixed binary roles, but may encompass fluidity, masculinity, femininity, both, or neither.

It is important to note that social role transition, or Real Life Experience (WPATH 2001), and puberty blocking medical care in adolescence may have diagnostic value in clarifying gender dysphoria. While transition to an affirmed social role may relieve the distress of gender role dysphoria, transitioned youth may still suffer anatomic dysphoria and remain particularly distressed about anticipated pubertal changes associated with their natal sex. It must be carefully stated that the diagnostic threshold is distress related to assigned gender role or physical sex characteristics and not gender nonconformity due to social expectations of normative gender (Vanderburgh 2009).

Finally, we suggest restoration of a clinical significance criterion, which would clarify that distress, discomfort or impairment must meet a threshold of severity. This would limit false positive diagnosis of gender nonconforming youth who would not benefit from diagnosis. It is crucial, however, that this criterion exclude distress or impairment that is caused by societal prejudice or discrimination. To cast victimization as symptomatic of mental illness would inflict further harm upon victims of prejudice.

Our Suggested Diagnostic Criteria for Gender Incongruence in Adolescents:

A. In youth who have reached the earlier of age 13 or Tanner Stage II of pubertal development, a distressing sense of incongruence between persistent experienced or expressed gender and current physical sex characteristics or assigned gender role, as manifested by the youth’s self-report or documentable observation of at least one of the following indicators for a duration of at least 3 months. Incongruence, for this purpose, does not mean gender expression that is nonconforming to social stereotypes of assigned gender role or natal sex.

1. A distress or discomfort with living in the present gender or being perceived by others as the present gender, which is distinct from the experiences of discrimination or the societal expectations associated with that gender.

2. A distress or discomfort caused by deprivation of gender expression congruent with persistent experienced gender. Experienced gender may include alternative gender identities beyond binary stereotypes.

3. A distress or discomfort with one’s current primary or secondary sex characteristics that are incongruent with persistent experienced gender or with anticipated pubertal development associated with natal sex.

4. A distress or discomfort caused by deprivation of primary or secondary sex characteristics that are congruent with persistent experienced gender or with anticipated deprivation of congruent physical sex characteristics after puberty.

B. Distress or discomfort is clinically significant or causes impairment in social, educational or other important areas of functioning, and is not due to external prejudice or discrimination

References:

Cohen-Kettenis, P. T., Delemarre-van de Waal, H. A., & Gooren, L. J. G. (2008).The treatment of adolescent transsexuals: Changing insights. Journal of Sexual Medicine, 5(8), 1892–1897.

Cohen-Kettenis, P. et al. (2010). “Gender identity disorder in adolescents or adults,” American Psychiatric Association DSM-5 Development. Available online: http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=482#

Cooper, K. (1999). Practice with transgendered youth and their families. Journal of Gay & Lesbian Social Services: Issues in Practice, Policy & Research, 10, 111-129.

Gross, B. H. (2001). Informed consent. Annals of the American Psychotherapy Association, 4, 24.

Nuttbrock, L., Hwahng, S., Bockting. W., Rosenblum, A., Mason, M., Macri, M., & Becker J. (2010). Psychiatric impact of gender-related abuse across the life course of male-to-female transgender persons. Journal of Sex Research, 47(1), 12–23.

Pleak, R.R. (2009). Formation of transgender identities in adolescence. Journal of Gay &Lesbian Mental Health, 13(4), 282 -291.

Rosario, Vernon A.(2009). African-American transgender youth. Journal of Gay & Lesbian Mental Health, 13(4), 298 — 308.

Spack, Norman P. (2009). An endocrine perspective on the care of transgender adolescents’, Journal of Gay & Lesbian Mental Health, 13(4), 309 — 319.

Striepe, M.I, and Tolman, D. L. (2003). Mom, dad, I’m straight: The coming out of gender ideologies in adolescent sexual-identity development. Journal of Clinical Child and Adolescent Psychology, 32(4), 523-530.

Vitale A. M. (2001). Implications of being gender gysphoric: A developmental review, Gender and Psychoanalysis, An Interdisciplinary Journal, 6(2), 121-141.

World Professional Association for Transgender Health (2001). Standards of Care for Gender Identity Disorders Sixth Version, Available online: http://wpath.org/Documents2/socv6.pdf

Yunger, J.L., Carver, P.R, & Perry, D.G. (2004). Does gender identity influence children’s psychological well-being? Developmental Psychology, 40(4), 572–582.


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