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Antihomosexual prejudice has diminished in the United States, but still remains a severe problem in many quarters of society. One of the most common aspects of discrimination against gay and lesbian people is the use of devaluing and disparaging gender-role epithets such as "fag" or "sissy," for example.
Should such abuse be grounds for removing the diagnosis of gender identity disorder (GID) in children from the DSM, as Dr. Richard Isay suggested in "Viewpoints" in the November 21, 1997, Psychiatric News?
From the perspective of a psychiatrist who served as an adviser to the gender identity disorders committee of DSM-IV, I believe there are many reasons why this would be a mistake.
The disorder begins early in childhood, often at age 3 or 4 or even earlier and usually affects boys. Follow-up studies indicate that most children with GID grow up to become gay adults. Most gay adults, however, have not had childhood GID. Therapists who specialize in treating these children do not believe that it is possible to predict the sexual orientation that evolves later in development. Clinicians are responsible to all children with GID, not just those who grow up to become gay men.
The introduction of DSM-III ushered in a way of diagnosing psychiatric disorders that was radically different from previous editions of DSM. DSM-III was based on the idea that groups of symptoms and traits covary to form disorders. A number of specific behaviors had to be simultaneously present for a psychiatric diagnosis to be made. Isolated symptoms or traits usually have no specificity.
Thus, even though many gay men were the targets of prejudice when they were children because of some behaviors that are criteria for the diagnosis of childhood GID, these isolated behaviors do not constitute a disorder. Nor do they discriminate between gay and nongay men. For example, many adult cross-dressers are actually heterosexual.
In considering whether a particular diagnostic category should be in DSM, psychiatrists should rely on published studies in addition to the experiences of clinicians. Review of empirical findings about a particular subject is a process analogous to peer review of a journal article. Conclusions must not be based on the opinions of authorities or the advocacy of particular groups.
Sometimes advocates for deletion of childhood GID from the DSM suggest that the reasons for its inclusion are the same as had been true of homosexuality. This is not the case. Studies comparing homosexual and heterosexual people indicate that there are no differences in prevalence of psychopathology or level of functioning.
Comparisons between children with GID and others indicate, however, that children with GID have more psychopathology. Most clinicians who have experience working with these children agree that the reason for the psychopathology is not simple social discrimination because the boys are feminized. There is disagreement among experts about what the criteria for the disorder presently called GID should be. There is consensus, however, that the children are psychiatrically disturbed. Elimination of the diagnosis would mean that patients now in this category would not be able to have their psychiatric treatment expenses reimbursed by insurance companies.
Social discrimination unfortunately is directed against people in many groups, some psychiatrically disturbed, some not. Psychiatrists, while being sensitive to the consequences of discrimination, should not delete psychiatric disorders from DSM simply because of such abuse.