Journal of Homosexuality, 61:1288–1312, 2014

Copyright © Taylor & Francis Group, LLC

ISSN: 0091-8369 print/1540-3602 online
DOI: 10.1080/00918369.2014.926766

LGBTQs and the DSM-5: A Critical Queer

Response

ANDREA DALEY, PhD and NICK J. MULÉ, PhD

School of Social Work, York University, Toronto, Ontario, Canada

This article outlines a community-based collaboration in Toronto,

Canada that led to an official response to the APA’s call for com-
ments and suggestions regarding diagnostic criteria revisions for
the DSM-5 with a focus on disorders that have or may have an
impact on the lives of LGBTQ people. We identified two diagnostic
categories: gender dysphoria and paraphilias. The diagnostic cat-
egories and their respective disorders are deconstructed utilizing a
critical queer analysis with recommendations for change. In addi-
tion, we explore the limitations of the APA review process itself and
politics within the APA and the LGBTQ communities.

KEYWORDS DSM, LGBT, pathology, queer, sexual minority

The American Psychiatric Association (APA)’s latest revision of the Diagnostic

and Statistical Manual of Mental Disorders (DSM) provided an opportunity
to review existing diagnoses, the discourses that informed their existence
and implications for the recipients of such diagnoses. It was over a decade
since the last version was published and the new iteration of the DSM-5 was
released, thus allowing for a revisit and update from the many stakeholders
involved, including allied professionals, community members, and health
and social service organizations. The lesbian, gay, bisexual, transgender, and
queer (LGBTQ) communities represent one segment of stakeholders, albeit
they are highly diversified and non-monolithic. Nevertheless, the implications
of the DSM on LGBTQs are pronounced both historically and presently, and
applying a critical queer analysis to the review of the DSM assists us in
deconstructing contemporary implications for LGBTQs.

Address correspondence to Andrea Daley, School of Social Work, York University,

Ross Building, Room S809, 4700 Keele Street, Toronto, ON M3J 1P3, Canada. E-mail:
adaley@yorku.ca

1288
 LGBTQs and the DSM-5 1289

This article outlines a community-based collaboration in Toronto,

Canada that led to an official position and response to the APA’s call for
comments and suggestions regarding diagnostic criteria revisions for the
DSM-5. Literature to date on the DSM is reviewed regarding its socially con-
structed role in defining LGBTQ populations, a theoretical framework for
a critical queer analysis is provided, and two diagnostic categories, gender
dysphoria (GD) and paraphilias, are examined from a critical queer per-
spective. Importantly, while LGBTQ people may be affected by a range
of diagnoses including those seemingly unrelated to gender and sexual-
ity, our decision to include GD and paraphilias is based on their exclusive
focus on gender and sexuality. In addition, how concepts of traditional
notions of gender, race, and class within heteronormative constructs informs
the social construction of mental disorders within formalized psychiatric
structures that contribute to the oppression of LGBTQs is discussed, as
well as the limitations of the APA feedback and commentary process
itself.
This article is largely based on the official position statement adopted
through the community-based collaboration; however, there are revisions
from the original iteration of the position statement dated February 2010 in
response to the implementation of proposed DSM revisions as indicated on
the APA Web site at the time of writing. In addition, this article incorporates
the revised language of the DSM for relevant diagnostic categories (e.g.,
gender dysphoria rather than gender identity disorder). As such, the pre-
sented analysis diverts from the original position statement in two ways.
First, the analysis presented is limited to two diagnostic categories, GD
and paraphilias, with the exclusion of two diagnoses, Sexual Disorder Not
Otherwise Specified (NOS) and Hypersexuality, included in the original posi-
tion statement. The decision to remove the latter diagnoses from the analysis
is based on uncertainty as to whether and/or how they will be included
in the DSM-5. Second, the analysis is delimited or expanded to respond
to DSM revisions of June 2012 to relevant diagnostic criteria and specifiers
where required.

THE DIAGNOSTIC AND STATISTICAL MANUAL

The DSM is a document published by the APA featuring descriptions, symp-

toms, and other criteria that assist in the diagnosing of mental disorders. First
published in 1952, the DSM has since been revised four times, with the most
recent revision being the 2000 DSM-IV-TR (text revision; APA, 2000). The pur-
pose of the DSM is to provide clinicians who administer treatment to patients
with mental disorders, with a common language toward the goal of accurate
and consistent diagnosis. Additionally, the DSM establishes criteria for diag-
nosis that can guide research on psychiatric disorders. The DSM is focused
1290 A. Daley and N. J. Mulé

on diagnosis only and provides no recommendations on treatment, the idea

being that appropriate treatment will follow accurate diagnosis. Although
based in the United States, the DSM is a powerful psychiatric tool utilized in
numerous countries throughout the world by clinicians, researchers, psychi-
atric drug regulation agencies, health insurance companies, pharmaceutical
companies, and policy makers. The influence of the DSM in the fields of
mental health, medicine, and law demonstrates the depth and breadth of its
impact.

OVERVIEW OF GENDER DYSPHORIA AND PARAPHILIAS IN THE

DSM

The two diagnostic categories included in this analysis are listed in the DSM-
IV-TR version in the chapter, or supracategory, Sexual and Gender Identity
Disorders (APA, 1994). Implemented revisions to the DSM-5 at the time of
writing include structural changes that eliminate the supracategory, intro-
ducing instead gender dysphoria and paraphilias as two separate diagnostic
categories.

Gender Dysphoria
Gender Identity Disorders (GIDs) first became a diagnosis under the diag-
nostic title “Gender Dysphoria Syndrome” in 1980 with the publication of
the DSM-III (Cohen-Kettenis & Pfäfflin, 2009; Hill, Rozanski, Carfagnini,
& Willoughby, 2005). As a subclass in the diagnostic category of Sexual
Disorders, GIDs included the disorders of transsexualism and GID of child-
hood (GIDC; Winters, 2005). As an effect of revisions to the DSM-III in
1987, transsexualism and GIDC were moved from the class of Sexual
Disorders to the class of Disorder usually First Evident in Infancy, Childhood
or Adolescence (Winters, 2005); however, they were reinstated as Sexual
Disorders in 1994 with the publication of the DSM-IV. Currently, GIDC,
Gender Identity Disorder in Adolescents and Adults (GIDAA), and Gender
Identity Disorder Not Otherwise Specified (GIDNOS) are included in the
DSM-IV-TR under the broad diagnostic category of GIDs. As the subclass of
GIDs has expanded over time to capture a wider range of gender-variant
individuals, transgender people in a cross-sex role who are not transsexual
or distressed and gender-nonconforming children have become increasingly
diagnosable (Winters, 2005).
Opponents of the pathologizing of diverse expressions of gender have
voiced concerns and resistance since the inception of GIDs in the DSM-III
with increasing criticism from trans and trans ally activists and advocacy
 LGBTQs and the DSM-5 1291

groups, associations, and networks in the past several years. In particu-

lar, the GID diagnoses have been critiqued for their dependence on fixed,
dichotomous, and uniform categories of gender and associated gender role
expressions and behaviors and lack of reliability and validity of the diag-
nostic criteria (Cohen-Kettenis & Pfäfflin, 2009; Hill et al., 2005; Lev, 2005;
Meyer-Bahlburg, 2009).

Homosexuality
Homosexuality1 was classified as a “sociopathic personality disturbance” in
the 1952 inaugural publication of the DSM-I and reclassified as a sexual
deviation in the 1968 publication of the DSM-II (Drescher, 2009). In 1973,
the APA’s Board of Trustees voted to remove homosexuality from the DSM;
however, it was replaced in the 1974 printing of the DSM-II with the more
ambiguous diagnosis of “sexual orientation disturbance” (Drescher, 2009;
King, 2003). The removal of homosexuality from the DSM, through the intro-
duction of the “sexual orientation disturbance” diagnosis, has largely been
linked to gay activism in the wake of the 1969 Stonewall riots in New York
City after which activists organized both public protests and educational pan-
els at two annual meetings of the American Psychiatric Association (1971,
1972), and an internal deliberative process at the APA during this timeframe
that resulted in redefining mental disorder to the exclusion of homosexuality
(Drescher, 2009). Notwithstanding the declassification of homosexuality as
a mental disorder, a series of disorders introduced over the past 30 years
has allowed for the continued possibility of pathologizing lesbian, gay,
and bisexual people. For example, the diagnosis of Egodystonic Sexual
Orientation replaced Sexual Orientation Disturbance in the DSM-III and was
then replaced by the diagnosis of Sexual Disorder (NOS) when the DSM-
III was revised in 1987 (Drescher, 2009). The diagnosis of Sexual Disorder
(NOS) remained in the DSM-IV-TR version; however, it did not appear as a
diagnosis in proposed changes to the DSM-5.

Paraphilias
Pre-existing sins and crimes were pathologized by the medical model in the
19th century (Bullough & Bullough, 1977), and the term paraphilia was first
coined by Wilhelm Stekel (1930) in the 1920s. This was further popularized
by John Money (1990) as a means to categorize and diagnose unusual sex-
ual interests (Bullough, 1995; McCammon, Knox, & Schacht, 2004; Moser,
2001; Weiderman, 2003) that do not align with ideological norms (Money,
1990), views that continue to be supported today by some (Blanchard, 2009a,
2009b; Spitzer, 2005; Zucker, 2010). Yet others take a critical stance that
1292 A. Daley and N. J. Mulé

challenge rigid notions of sexuality toward promoting the understanding of

sexual diversity (Gabbard, 2007; Moser & Kleinplatz, 2005). For example, fol-
lowing an extensive review, Moser and Kleinplatz (2005) found no literature
to suggest most paraphilic assertions in the DSM. In fact, several studies con-
tradict the DSM text. What is lacking are objective data that would support
the classification of the paraphilias in mental disorders. By contrast, healthy
sexuality is not defined in the DSM. Although the DSM is meant to be inter-
preted by experienced and objective clinicians, Moser and Kleinplatz (2005)
argued that these clinical evaluations are subjective, as consensus does not
exist in the scientific literature. They argued that the paraphilia section should
ultimately be removed from the DSM, as the criteria for DSM diagnosis of
unusual sexual interests as pathological were found to be based on unproven
and untested assumptions, leading to misuse.

THEORETICAL FRAMEWORK: A CRITICAL QUEER ANALYSIS

This analysis of APA proposed changes to the diagnostic categories gender

dysphoria and paraphilias is guided by a critical queer framework. A critical
queer analysis challenges the notion of essential, fixed, and binary categories
of sex, gender, and sexuality while privileging the notion of sex, gender,
and sexuality as fluid and unstable, discursively produced cultural constructs
(Butler, 1999). Understood is that within a context of presumptive hetero-
sexuality that characterizes all social institutions, a relationship of coherence
between sex, gender, and sexuality is assumed whereby sex = gender =
sexuality, so that if one is female one should be feminine and this configu-
ration necessarily equates to heterosexuality (Butler, 1999). Alternatively, if
one is female and one is perceived to be masculine, they are constructed
as homosexual. As importantly, a critical queer perspective recognizes that
heteronormative notions of sex, gender, and sexuality are largely reflec-
tive of the norms and values associated with the dominant groups—White,
heterosexual, middle-class group (Metzl, 2009).
This analysis is also premised on the belief that the requirement of a
formal mental disorder diagnosis for access to health insurance coverage for
expensive and scarce medical interventions for transsexual,2 transgender,3
and genderqueer4 people constitutes a social process of “gate keeping.” This
exposes systemic abuses of power that influence personal identity. This is
oppressive, and it is counter to antidiscrimination and human rights pol-
icy and legislation in Canada related to sexual orientation fought for over
the past decades. For transgender and transsexual individuals, their explicit
inclusion in human rights legislation continues to evade them throughout
most of Canada.
 LGBTQs and the DSM-5 1293

METHODS

Upon the call by the APA for suggestions and feedback regarding the DSM-5,
the authors approached the Rainbow Health Network (RHN), of which they
are both members, with a proposal to initiate a community-based collab-
oration that included writing a position paper that would set out to make
recommendations on the proposed revisions to the DSM. The RHN is a
grassroots community group of LGBTQ-identified health care providers and
recipients based in Toronto, Ontario, Canada. It works to promote the health
and wellness of people of all gender identities and sexual orientations, as
well as intersex people (RHN, 2010a). The authors conducted a literature
review on the topic including suggested readings by community members
intimate with the issues, drafting a position statement for RHN and cir-
culating it to RHN’s membership Listserv for consensus in principle and
feedback on the content. Additionally, the authors consulted with represen-
tatives from the Canadian Professional Association for Transgender Health,
World Professional Association for Transgender Health, prominent members
of Toronto’s trans communities and a doctoral student specializing in youth
and sexuality.
The statement was revised and finalized based on the RHN consul-
tations. The position statement with recommendations was then formally
submitted to the APA DSM-5 via its online process. Since then, a clear lan-
guage version (RHN, 2010b) has been created and posted on RHN’s Web site
along with the original (RHN, 2010c). The community-based collaboration
has begun to disseminate the position statement (i.e., RHN Web site, confer-
ences, media), and this article is the authors’ contribution to the literature on
the contents as relevant to DSM revisions as indicated on the APA Web site
at the time of writing and process of the position statement. At press time,
we are in the process of organizing with RHN a public forum to present the
position statement as a means of public education and to encourage further
discussion on the topic.

THEMATIC CONCERNS: DSM-5 PROPOSED CHANGES

Our critical queer analysis gives rise to three primary thematic concerns in
relation to the “disorders” included in our position statement, including prob-
lems with diagnostic criteria; reliability and validity of the diagnoses; and
whether or not they actually constitute mental disorders. This section begins
with an overview of the RHN’s official position statement (Table 1) followed
by a description of each thematic concern and associated tables that detail
related elements of the community-based response (Tables 2–4). We con-
clude with an examination of concerns identified regarding the process and
politics of the DSM-5 review itself.
1294 A. Daley and N. J. Mulé

TABLE 1 Summary of RHN/Community-Based Position

Gender Dysphoria Children (GDC)

◦ Supports the removal of GDC from the DSM-5 given its likely potential to contribute to
the surveillance at best, and pathologizing at worst, of children’s diverse developmental
exploration, creativity and expression related to gender. More specifically, the removal
of GDC from the DSM-5 is integral to the eradication of the oppression, vis-à-vis
surveillance and pathologizing practices, of diverse and gender variant LGB children.
Gender Dysphoria Adolescents and Adults (GCAA)
◦ Support calls from transsexual and transgender communities for the inclusion of some
version of a diagnostic classification in the absence of structural change to the
requirement of a diagnosis of mental disorder for access to health insurance coverage.
Consequently, to enhance equitable access to medical procedures (e.g., sex
reassignment surgery) for trans people we support progressive movement toward the
eventual removal of GDAA from the DSM while adopting an ‘incremental reform’
position.
◦ Supports the name change from Gender Identity Disorder to Gender Dysphoria.
◦ Supports the removal of the ‘distress/impairment’ D Criterion and the inclusion of the B
Criterion.
◦ Support a cautious assessment of B Criterion to consider whether ‘distress’ or
‘impairment’ is due to sincere personal concern as to the state of one’s life and the
impact the paraphilia is having on it, or is such ‘distress’ or ‘impairment’ due to societal
pressures of normative lifestyles.
◦ Recommend the inclusion of gender distress as a specifier dimension in response to the
removal of distress/impairment and the inclusion of “B” Criterion and in recognition of
the potential need for mental health services in relation to genderism, societal
transphobia and/or internalized transphobia.
◦ Support the APA recommendation that a GD diagnosis be given on the basis of the “A”
criterion alone and that distress and/or impairment be evaluated separately and
independently
◦ Supports the replacement of the term sex with gender.
◦ Support the inclusion of post-transition as a specifier dimension (as a response to the
effect of replacing the term sex by gender).
◦ Supports the removal of the sexual orientation specifier (based on the recognized
fluidity of and challenge to measuring sexual orientations).
◦ Do not support the inclusion of sexual orientation as one of six dimensionalized
informational questions.
◦ Supports the addition with a disorder of sex development (DSD) and without a disorder
of sex development (DSD) as it will make it possible for people with a DSD to be given
a diagnosis of GDAA.
Paraphilias and Paraphilic Disorders
◦ Supports the distinction being made between paraphilias (sexually expressed behavior
is not pathologized) and paraphilic disorders (sexually expressed behavior is
pathologized).
◦ The removal of exhibitionistic disorder, fetishistic disorder, sexual masochism disorder,
sexual sadism disorder, and voyeuristic disorder ascertained by the A Criterion only, as
they are merely expressions of sexual behavior that provide sexual stimulation for
individuals engaging in them. Their inclusion has the potential of contributing to a
diagnostic environment of surveillance and regulation of sexual expression and
behaviours that fall outside normative notions.
◦ Support Frotteuristic Disorder based on both A and B Criteria.
◦ Oppose the expansion of the category of Pedophilic Disorder.
(Continued)
 LGBTQs and the DSM-5 1295

TABLE 1 (Continued)

◦ Oppose Transvestic Disorder as a paraphilia (based on A Criterion) and as a disorder

based on B Criterion.
◦ Support the moving of illegal sexual behaviors under from A Criterion of Paraphilic
Disorders Not Elsewhere Classified to B Criterion. Remove all legal sexual behaviors
from A Criterion.
◦ Support a cautious assessment of B to consider whether distress or impairment is due
to sincere personal concern as to the state of one’s life and the impact the paraphilia is
having on it, or is such distress or impairment due to societal pressures of normative
lifestyles that are sex negative and contribute to the repression of sexual pleasure to
sustain normative acceptable, respectable productivity in life?

Problem With Diagnostic Criteria: Ideologically Defined Disorders

A critical queer perspective is concerned with the reliance of the DSM on
dichotomized and uniform notions of gender and normalized expressions of
sexuality and the relative lack of attention to diversely racialized, classed, and
sexualized expressions of gender and sexuality that may fail to fit neatly into
such dichotomized and uniform notions of gender and normal/abnormal
sexuality. The gender- and sexuality-related disorders included in this anal-
ysis are determined using criteria that reflect and reinforce an unjust and
inequitable gendered, racialized, classed, and sexualized social order. A key
point that is argued is that the socio-political environment appears to have
more of an influence on the APA and DSM. A classic example that is referred
to time and again is the removal of homosexuality from the printing of the
1974 DSM-II (Conger, 1975). Once argued as being a mental disorder, the
APA failed in providing empirical evidence that homosexuality was such,
having to delist it for the most part (see notes above) due to pressure from
the lesbian and gay movement of the time. Suppe (1984) referred to this
as the APA resorting to the “codification of social mores” rather than scien-
tific warrant. Silverstein (1984) called it the inappropriate role of morality in
determining diagnoses, and Drescher (2009) referred to it as the implicit mor-
alizing of matters dealing with gender and sexual orientation within clinical
etiological theories, and the APA’s traditional ideations of normality. In this
regard, Flanagan (1992) stated, “gender, race, sexuality, and the dictates of
society all commingle to establish a definition of sanity or insanity” (p. 91).
Consequently, diagnoses of GD and paraphilias that rely on narrow construc-
tions of masculine/male and feminine/female and that assume normative
erotic expression may more accurately be conceptualized as ideologically
defined disorders (Hubert, 2002). Importantly, the notion of GDs constitut-
ing ideologically defined disorders as reflected in critiques of the rigidity
of dichotomous genders and gender roles as applied to the diagnosis of
GDC is commonly taken up by its opponents and LGBTQ activists as a
means to achieve compulsory heterosexuality or, rather, to avoid or prevent
homosexuality (Hill et al., 2005).
 TABLE 2 Problems with Diagnostic Criteria: Ideologically Defined Disorders

1. Reliance on narrow constructions of masculine/male and feminine/female.

2. Presumed stable, heteronormative, racialized, classed, dichotomized categories of ‘typical’ masculine and feminine behaviour and expression.
3. Relative lack of attention to diversely racialized, classed and sexualized expressions of gender and sexuality that may fail to fit neatly into such
dichotomized and uniform notions of gender.
4. The socio-political environment appears to have more of an influence on the APA and DSM.
5.Codification of social mores.

Gender Dysphoria Paraphilias and Paraphilic Disorders

GD in Children (GDC) Exhibitionistic, Fetishistic, Sexual Masochism, Sexual Sadism, and

Voyeuristic Disorders
◦ Diagnostic criteria of cross-gender identification, Criterion A and its ◦ Merely expressions of sexual behaviour that provide sexual stimulation
corresponding dimensional metrics continue to promote notions of for individuals engaging in them and thus have no place in the DSM-5,

1296
typically masculine and feminine clothing, roles and toys, games
and activities, and problematize cross-gendered play and
friendships (APA, 2011a) [1, 2, 3].
◦ Likely potential to contribute to the surveillance at best, and
pathologizing at worst, of children’s diverse developmental
exploration, creativity and expression related to gender. More
specifically, the removal of GDC from the DSM-5 is integral to the
eradication of the oppression, vis-à-vis surveillance and
pathologizing practices, of diverse and gender variant LGB children
[4, 6].
as their mere existence within the DSM risks pathologizing effects
(despite the supposed absence of the term ‘disorder’) as such sexually
expressed behaviours are termed ‘non-normative.’ [3-5].
◦ Inferred are normative notions of sexual expression and behaviours
based upon traditional, conventional, middle classed ideations of
acceptance and respectability [3-5].
◦ Removal of the Paraphilias ascertained by “A” criterion only [3-5].
◦ Utilizing “normophilic sexual interests and behavior” as the criteria by
which to measure severity ratings regarding a number of these
paraphilia are highly problematic based on its subjectivity. Doing so
becomes suspect of contributing to a conventionally restrictive and
constrictive normative approach to individuals who are sexually
aroused and stimulated by exhibitionism, fetishism, voyeurism as well
as sexual masochism/sadism and act upon the latter responsibly with
consensual partners [3-5].
 GD in Adolescents/Adults (GDAA)
◦ The inclusion of variant gender identities and expressions in the
DSM-5 functions to reify rigid socially constructed notions of
gender and sexuality generally while pathologizing variant and
diverse expressions of gender and sexuality [1, 2, 3, 4].
◦ The inclusion of both GDC and GDAA enforces:
◦ One or the other’ thinking as a result of perceived violations of
an assigned gender category [1, 2, 3, 4].
◦ Racialized and classed gendered patriarchal norms and ways of
being on children, adolescents, and adults. The DSM-5 Task Force
has taken steps (e.g., study group) to consider how gender, race
and ethnicity (note: class and sexuality is not addressed) affect the
diagnosis of mental illness generally, and whether there are
significant differences in incidence of mental illness among
racialized subgroups that might indicate a bias in currently used
diagnostic criteria. However, this approach is limited in that it
1297
continues to assume a singular expression of femininity and
masculinity respectively, based on a ‘white’ heterosexual referential
norm without critically examining how institutionalized racism,
classism and heterosexism are perpetuated through psychiatric
classification and diagnostic processes [3].
Exhibitionistic Disorder
◦ Concern is also raised regarding the three specified types6 being based
upon the concept of being ‘sexually attracted to’ as opposed to any
behaviours that are enacted. These specified types verge on psychiatric
control of sexual thoughts and feelings with potentially detrimental
surveillance, regulatory and pathological effects [3-5].
◦ Fetishistic Disorder
◦ Classist notions of normative sexuality is captured in the severity of
fetishes referring to ‘normophilic sexual interests and behaviours’;
revealing a subjective value judgment that socially constructs
pathology [3-5].
Transvestic Disorder
◦ The “A” criteria presents as problematic due to its gendered approach.
It is explicitly focused on natal males only without explanation,
implying that male-to-female cross-dressing is a psychiatric issue [1-5].
◦ The exclusion of natal females that engage in female-to-male
cross-dressing presents a subtle message of acceptability (to present as
male) or complete non-recognition. The targeting of natal males
presents a message of unacceptability (to present as female) with
misogynistic and sexist undertones, stigmatizing effects and blames
victims experiencing discrimination for their oppression. Inferred is a
classist contemporary westernized cultural bias [1-5].
◦ The dimensional metrics appear inconsistent with the proposed
revision in “A” criterion as they speak of ‘groom yourself as a member
of the opposite sex’ presenting a broader, if binary approach to
gender. Additionally, this subcategory perpetuates binary notions of
gender without any recognition of gender fluidity, pathologizing those
that challenge rigid gender roles by cross dressing. Also, “A” criterion
sexualizes the act of cross-dressing in natal males, which may not be
the case for all [1-5].
(Continued)
 TABLE 2 (Continued)

Gender Dysphoria Paraphilias and Paraphilic Disorders

◦ The three specificities7 are of great concern. Transvestic Disorder

linked to Fetishism raises the question why the wearing of certain
‘fabrics, materials, or garments’ should be pathologically deemed a
psychiatric disorder. And linking Transvestic Disorder to
Autogynephilia and Autoandrophilia is considered highly offensive to
trans women and men respectively as it theorizes reducing their
motives to fetishistic sexual gratification rather than their attempts at
achieving a harmonious gender identity. Even for those who engage in
such behaviors for sexual gratification with no intention to transition,
we question why this is considered pathological? Listing Transvestic
Disorder as a Paraphilia contributes to a conventionally restrictive and
constrictive normative approach to individuals who are sexually
aroused and stimulated by cross dressing or in a process that may lead

1298
to transitioning their gender at some point in the future [1-5].
Paraphilic Disorder Not Elsewhere Classified
◦ Appears to be a catch-all category8 that captures a distinct symptom
pattern that is not individually codified in the DSM. Examples include a
series of sexual behaviors that are problematic as some are illegal (i.e.,
necrophilia [corpses], zoophilia [animals]) and others are not (i.e.,
klismaphilia [enemas] and urophilia [urine]). Categorizing a number of
unspecified paraphilias, using an undefined ‘distinct symptom pattern’
casts a wide net, pointing to a subjective normative approach which
risks unfairly pathologizing individuals for having unconventional
sexual desires. This is further substantiated by the severity ratings
being based on “normophilic” sexual interests and behaviors.
A nuanced assessment is required to assess “distress or impairment,”
particularly for the legal paraphilias outlined [1-5].
 TABLE 3 Reliability and Validity of Diagnoses

1. Reliance of the DSM on socially constructed categories of gender and normative sexuality, as described above, and transgressions of such
socially constructed norms for diagnosis purposes, suggests a lack of reliability and validity for the sexual and gender identity diagnoses
included in this analysis.
2. Attempts to establish reliability and validity per se are problematic from a queer critical perspective as they tend to simplify and reduce the
shifting complexity of human thoughts, expressions and behaviours into restrictive categories. Engaging in this process constitutes a normalizing
project that inevitably results in the individualizing and pathologizing of diversity and difference as well as distress associated with the social
processes of oppression, discrimination and stigma.
3. Lack of reliability and validity for the sexual and gender identity diagnoses included in the analysis.

Gender Dysphoria Paraphilias and Paraphilic Disorders

GD in Adolescents/Adults (GDAA) All Paraphilias—Criterion A

◦ There has been little scientific evidence to support the reliability ◦ We question whether “recurrent and intense sexual arousal . . .
and validity of the diagnostic criteria as they relate to GD as manifested by fantasies, urges” can be a diagnostic as these
(Cohen-Kettenis & Pfäfflin, 2009; Hill et al., 2005; Lev, 2005; involve thoughts and internal arousings but not
Meyer-Bahlburg, 2009) [1]. enactments.

1299
◦ DSM has been critiqued, as a diagnostic tool, for its inability to
distinguish between gender nonconformity and gender
dysphoria (Hill et al., 2005) [1].
◦ The conflation of “attractions” and “internal arousings” with
behavior in relation to the diagnosis of paraphilias by the APA
appears to suggest significant limitations to the DSM, as a
diagnostic tool, in terms of the operationalized definitions of
these terms [2].
◦ We question whether ‘recurrent and intense sexual arousal . . .
as manifested by fantasies, urges’ can be a diagnostic measure in
“A” criterion as these involve thoughts and internal arousings
but not enactments [2].
Pedophilic Disorder
◦ The category of pedophilia is proposed to be expanded based
on highly questionable research [3].
◦ Pedohebephilia would expand the diagnosis of pedophilia to
include contact offenses or a pattern of desire for young people
across the age ranges of the new category of Hebephilia
(11–14) and the existing pedophilic diagnosis (11 or under).
(Continued)
 TABLE 3 (Continued)

Gender Dysphoria Paraphilias and Paraphilic Disorders

◦ The study by Blanchard (2009a) that proposes the increase to a

diagnostic category is methodologically flawed. Blanchard uses
a controversial and disputed device, the penile plethysmograph,
for measuring an individual’s desire and claims scientific
objectivity for the phallometry testing employed. This device has
proven controversial (Marshall & Fernandez, 2000; O’Donohue,
Regev, & Hagstrom, 2000; Simon & Schouten, 1991), yet he
claims scientific objectivity in the attribution of erotic age
preferences as an identity based on measuring minuet changes
in blood flow in an individual’s penis. We note, along with
others, that volumetric plethysmography testing, based on a

1300
biomedical model, is a radically reductionistic way of
“diagnosing” erotic identities as it ignores meaning-making
activities tied to a complex phenomenology of desire. Highly
gendered, this study does not include women in the research [3].
◦ This research has not been able to prove conclusively the
existence of such erotic age preferences, and has not developed
appropriate diagnostic criteria for assessing when and if it
constitutes a mental disorder [3].
◦ With the recent changes in the sexual age of consent in Canada,
where formerly, 14- and 15-year-olds were considered capable
of consenting relations, Blanchard’s research leans too heavily
on recent changes to the criminal law to buttress claims to new
pathological identities. Although Blanchard claims that he is not
 opportunistically taking advantage of recent legal changes, prior
to 2008 when the basic age of consent increased in Canada from
14 to 16 based on the neoconservative ideology of the
governing Conservatives, the cogency of his scientific claims
would have been very difficult if not impossible to mount [1].
◦ It disregards the wide developmental expanse between
11–14-year-olds, and the ability for young people to make
informed choices about the sexual relations they may desire.

1301
Nonnormative behaviour is scrutinized more in a homophobic
culture (Kinsman, 1987) and age discrepant relations are
especially vulnerable to pathologization. The latest iteration
emphasizes the psychological definition of Pedophilic Disorder
as a means of distancing itself from varying age of consent laws,
yet does not address how it can implicate the latter [1].
 TABLE 4 “Clinically Significant Distress/Impairment” Questioned

1. Concerned about what underlies the criteria of “clinically significant distress or impairment.” Will such presentations be taken at face value, or
will the assessment include a nuanced understanding of socially imposed repression that restricts people from being able to fully express
themselves?
2. Concept minority stress (Meyer, 1995). This concept de-individualizes and de-pathologizes distress and impairment while centering normative
responses to societal discrimination and oppression.
3. Efforts towards remediation and wellness address the social and cultural rather than the individual vis-à-vis diagnosis.
4. Those who transgress normative sexual and gender expressions become “disordered” by virtue of the diagnostic process that psychiatrizes or
pathologizes the effects of lesbophobia, biphobia, homophobia, transphobia, and hostility (i.e., distress related to sexual orientation and gender
identity).

1302
Gender Dysphoria Paraphilias and Paraphilic Disorder

GD in Adolescents/Adults (GDAA) All Paraphilic Disorders—B Criterion

RHO supports:
◦ Proposed name change from GID, which stigmatizes and
pathologizes diverse gender identities and expressions, to
Gender Dysphoria (GD), may more accurately capture the
relationship between assigned and experienced gender identity
for trans people. However, it is important to note that the term
GD does not avoid the potential of establishing a “natural”
association between distress and one’s experience of gender as
might be implied or interpreted [1].
◦ Causations of signs of “distress” or “impairment” need to be
carefully assessed as to their origins. Is such “distress” or
“impairment” due to sincere personal concern as to the state of
one’s life and the impact the paraphilia is having on it, or is such
‘distress’ or ‘impairment’ due to societal pressures of normative
lifestyles that are sex negative and contribute to the repression
of sexual pleasure in order to sustain normative “acceptable,”
“respectable” productivity in life? [1-4].
 ◦ The removal of the “distress/impairment” D Criterion as a ◦ Transvestic Disorder - “B” criterion is in danger of completely
prerequisite for the diagnosis of GD will foster eligibility for overlooking the implications of societal prejudice towards cross
health insurance and access to medical procedures and support dressers and the “distress” or “impairment” this may cause [1].
services for transsexual, transgender and gender queer people
who do not report gender-related distress due to gender
incongruence. This will also allow for the possibility of
non-biomedical conceptualizations of distress as a consequence
of genderism, societal transphobia and/or internalized
transphobia rather than inherent to a trans identity. Critically,
however, the addition of the “B” criterion or rather the diagnostic
criterion of “clinically significant distress or impairment in social,
occupational, or other important areas of functioning, or with a
significantly increased risk of suffering, such as distress or
disability” (APA, 2011b) will function to negate the benefits of
the removal the ‘distress/impairment’ criterion. In this regard, we

1303
support the APA recommendation that a GD diagnosis be given
on the basis of the “A” criterion alone and that distress and/or
impairment be evaluated separately and independently [1-4].
◦ Inclusion of gender distress as a specifier dimension in response
to the removal of distress/impairment and the inclusion of “B”
criterion and in recognition of the potential need for mental
health services in relation to genderism, societal transphobia
and/or internalized transphobia. In addition, the text
accompanying the diagnostic criteria should note that an
assessment of gender distress should not conflate distress that is
caused by genderism and societal transphobia with “clinically
significant distress or impairment” (e.g., mental illness) and
should consider a severity threshold in an effort to limit false
positive diagnoses of gender nonconforming persons [1-4].
1304 A. Daley and N. J. Mulé

Finally, a critical queer perspective does not support the notion of

ideologically defined disorders, as described above, by positing the pos-
sibility that structural and institutionalized adherence to rigid dichotomous
categories of genders within patriarchal society perpetuates the valorization
of Western masculinity while satisfying a misogynistic attempt to inoculate
boys and men from acting like girls and women. The reality for LGBTQ
populations as promoted by the LGBTQ movement is that there is a greater
degree of fluidity and variance in the expression of gender and sexuality
than the APA and DSM are acknowledging—and will allow. A critical queer
lens exposes the undermining of such realities.

Reliability and Validity of Diagnoses

The reliance of the DSM on socially constructed categories of gender and
normative sexuality, as described above, and transgressions of such socially
constructed norms for diagnosis purposes suggests a lack of reliability and
validity for the sexual and gender identity diagnoses included in this analy-
sis. Notwithstanding this possibility, there has been little scientific evidence
to support the reliability and validity of the criteria as they relate to GDs
(NARTH, 2010; Cohen-Kettenis & Pfäfflin, 2009; Zucker, 2009) and the
paraphilias (Moser & Kleinplatz, 2005). Zucker (2009) reported some evi-
dence of discriminant validity for GDC; however, studies have failed to report
on empirical evidence on inter-clinician agreement on the GDC diagnosis.
Critiques of the reliability and validity of these diagnostic categories in
the DSM-IV-TR have underscored the limitations of the DSM. For example,
the conflation of attractions and internal arousings with behavior in relation
to the diagnosis of paraphilias by the APA appears to suggest significant
limitations to the DSM, as a diagnostic tool, in terms of the operationalized
definitions of these terms. This limitation represents significant risk to LGBTQ
people who express diverse sexual expression by way of a dangerous level
of control over people’s thoughts and feelings, regardless of whether they are
acted on or not. Similarly, the DSM has been critiqued, as a diagnostic tool,
for its inability to distinguish between gender nonconformity and gender
dysphoria (Hill et al., 2005).
Attempts to establish reliability and validity per se are problematic from
a critical queer perspective as they tend to simplify and reduce the shifting
complexity of human thoughts, expressions, and behaviors into restrictive
categories. Engaging in this process constitutes a normalizing project that
inevitably results in the individualizing and pathologizing of diversity and
difference as well as distress associated with the social processes of oppres-
sion, discrimination, and stigma. Consequently, a critical queer perspective
questions the feasibility of supporting the GD and paraphilia diagnoses
included in this analysis through attempts to establish reliability and validity,
particularly given the lack of evidence of the latter.
 LGBTQs and the DSM-5 1305

“Clinically Significant Distress/Impairment” Questioned

The issue of whether or not GDs and the paraphilias are mental disorders
is clearly influenced by the arguments related to the notion of ideologically
defined disorders and reliability and validity as presented. In addition, and
more specifically, whether or not these diagnoses satisfy the “mental disor-
der” requirement of “individual distress or disability which are not a part
of normal development or culture” (APA, 1994) must be considered. From
the point of assessment, a critical queer perspective is very concerned about
what underlies the criteria of “clinically significant distress or impairment.”
Will such presentations be taken at face value, or will the assessment include
a nuanced understanding of socially imposed repression that restricts people
from being able to fully express themselves?
There is strong support for, and understanding of, distress and impair-
ment as a function of hostile and rejecting environments. This notion is
captured by the concept minority stress (Meyer, 1995). This concept de-
individualizes and de-pathologizes distress and impairment while centering
normative responses to societal discrimination and oppression. Doing so
does not deny or negate the physical, emotional, and mental pain and suf-
fering of people who experience discrimination and oppression but asks
that efforts toward remediation and wellness address the social and cultural
rather than the individual vis-à-vis diagnosis. It is possible that those who
transgress normative sexual and gender expressions become “disordered” by
virtue of the diagnostic process that psychiatrizes or pathologizes the effects
of lesbophobia, biphobia, homophobia, transphobia, and hostility (i.e., dis-
tress related to sexual orientation and gender identity). Thus, nonnormative
expressions of sexuality and gender continue to be diagnosable—in some
ways—within the context of psychiatry. This suggests a need to critically
question sources and meaning of distress that are implicated in the diag-
nostic process and the association between the strict enforcement of social
conformity and “madness.”

Process and Politics of the DSM-5 Review

Notwithstanding the thematic concerns identified as they relate to the pro-
posed content of the DSM-5 (and its ultimate iteration), the position and
response to the APA’s call for comments and suggestions regarding diag-
nostic criteria revisions for the DSM-5 as presented yielded two significant
points of interest. The first point of interest is the process with which the APA
elicited feedback. First, the APA needs to be commended for allowing the
input of a vast range of people to participate in this process. This included
clinicians, researchers, administrators, and persons/family members affected
by a mental disorder. Having the input of such a broad range of stakehold-
ers provided the APA with a comprehensive level of feedback to take into
1306 A. Daley and N. J. Mulé

consideration as they revised the DSM for its fifth iteration. Nevertheless, the
online review process was overly categorical in its design, in which feedback
needed to be word processed into a designated box per diagnosis. What this
did not allow for is a broader structural/systemic analysis (taken up here)
that considers the social construction of mental disorders, the influences of
race and class, the heteronormative and cisgendered pressures of society at
hegemonic proportions, and the stigmatization of those who do not express
themselves within the norm. This is a serious shortcoming that would have
provided invaluable input into some of the more pressing internal issues the
field of psychiatry is grappling with such as empirical evidence-based data
to substantiate their diagnoses (Carson, 1991), data gathering on dimensional
metrics that is not based on moralizing (Kendell, 2002) and to what extent
the implication of their work is helping rather than harming individuals and
their loved ones (Aldhous, 2009; Editorial, 2009).
The second point of interest addresses the politics of the DSM within
psychiatry and at the LGBTQ community level. Within the field of psychiatry,
debates ensue from the validity and utility of psychiatric diagnoses (Kendell
& Jablensky, 2003) to the differences in behavioral and scientific sexological
approaches to the DSM (McConaghy, 1999). Even the lead-up to the publica-
tion of the DSM-5 created much internal conflict within the field of psychiatry
as exposed by Aldhous (2009) in an article revealingly titled, “Psychiatry’s
Civil War” and a related editorial, “Time’s Up for Psychiatry’s Bible” (2009).
Both raise serious questions as to the spuriousness of psychiatry’s “scientific
methods” in determining mental disorders and caution about the deleteri-
ous effects on the public, concerns furthered by more recent observations
(Brooks, 2012) and research (Gaudiano & Zimmerman, 2012). By the end of
2012, the APA’s board of trustees approved a series of changes, updates, and
revisions to the DSM for the final version of DSM-5 (Grohol, 2012). Yet what
would have been considered a momentous accomplishment was declared
“a sad day for psychiatry” by Dr. Allen Frances (2012a), chair of the DSM-IV
Task Force, for its flawed process resulting in scientifically unsound work
and outcomes that are unsafe. Critiques regarding changes in DSM-5 were
shared by others (Brauser, 2012; Mestel, 2012) on many of the changes, as
well as the lack of cost–benefit analysis that is expected to see economic
gain for pharmaceuticals and increased human suffering for the diagnosed
(Frances, 2012b).
Not long after the Work Group on Sexual and Gender Identity Disorders
(WGSGID) was appointed to review the DSM for the new edition, the gender
and sexually diverse communities reacted with a series of concerns focused
mostly on issues related to the GID. The concerns range from the continued
stigmatization of trans people due to DSM diagnoses to fear of a complete
removal of the GID resulting in inaccessible medical intervention to learn-
ing that prominent psychologists Ray Blanchard was appointed to, and Ken
Zucker was appointed head of, the WGSGID. Both Zucker and Blanchard of
 LGBTQs and the DSM-5 1307

the Gender Identity Clinic at the Centre for Addictions and Mental Health in
Toronto have a notoriously conflictual relationship with the gender and sex-
ually diverse communities. Gender and sexually diverse community-based
groups set up Facebook pages, circulated petitions, and issued formal state-
ments (CPATH, 2010; WPATH, 2010; National Coalition for LGBTQ Health,
2010; GLMA, 2010; Egale Canada, 2010; RHN, 2010c) in protest.
The responses from the gender and sexually diverse communities are
based both on an understanding of how such diagnoses will affect their
lives and possessing the insight to recognize how politicized the process of
revising the DSM is. Over the course of the last half century, the DSM has
grown into a powerful mechanism that has the means of controlling sexual
behavior and defining normative gender concepts and labeling anything that
falls outside of this restricted purview as pathologically a mental disorder.
Although it is influential primarily in North America and parts of Europe, the
DSM has a global impact5 that can extend to “child custody decisions, self-
esteem, whether individuals are hired or fired, receive security clearances, or
have other rights or privileges curtailed” (Moser & Kleinplatz, 2005, p. 93).
Crime sentencing can be either mitigated or enhanced based on diagnoses.
Political agendas have been served and oppression of gender and sexually
diverse populations justified by the equating of unusual sexual interests and
gender variance with psychiatric diagnoses. This is not only a scientific issue
but also a human rights issue (Moser & Kleinplatz, 2005).
Importantly, the thematic concerns and points of interest related to the
process and politics of the APA review suggest that the proposed revisions
for the DSM-5 and its finalized version continue, in the tradition of earlier
iterations of the DSM, to serve a conventional, restrictive, and constrictive
normative agenda within which to contain sexual and gender expression that
abides by middle-class, White, heteronormative, and cisgenderist notions of
acceptability. Of course, what is not addressed is the potential damage done
to individuals who are more fluid and nontraditional in their gender and sex-
ual expressions, being stigmatized by a system that labels and pathologizes
rather than tries to understand and support. The continued classification
of diverse gender and sexual identities and expressions as clinical disor-
ders constitutes the ongoing surveillance, pathologizing, and regulating of
otherwise variant expressions of gender and sexuality.

CONCLUSION

This critical queer analysis of the diagnostic criteria revisions for the DSM-
5 related to the categories of gender dysphoria and paraphilias identified
three primary thematic concerns, including problems with diagnostic crite-
ria; reliability and validity of the diagnoses; and whether or not they actually
constitute mental disorders. In addition, our analysis examined concerns
1308 A. Daley and N. J. Mulé

regarding the process and politics of the DSM-5 review and suggested
increasing tensions within the field of psychiatry related to the spurious-
ness of its “scientific methods” in determining mental disorders. Importantly,
our analysis is aligned with feminist, anti-racist, and consumer/survivor/ex-
patient critiques of the psychiatric system that contest the regulatory role
of psychiatric diagnosis to police people who express themselves and
behave in ways that fail to adhere to the beliefs, values, and norms
of dominant social groups. More specifically, it constitutes an important
counterbalance to traditional and contemporary biomedical and scientific
efforts to classify, organize, and regulate sex, gender, and sexuality, as
objective, universal, and stable aspects of human behavior, toward the
project of rendering certain bodies “normal” and others “abnormal.” As
such, our critical queer analysis contributes to anti-oppressive, affirming,
and sex positive—non-pathologizing and destigmatizing—understandings of
diverse sexual orientations, gender identities, and expressions of gender and
sexuality.

NOTES
1. See Drescher (2009) for a more detailed account of the history of GIDs and homosexuality.
2. Transsexualism is a condition in which a person identifies with a physical sex different from
the one that they were born with or assigned in cases where ambiguity of the child’s sex organs led to
assigning them a physical sex. Retrieved from http://www.transunity.com/pages/genderqueer.html.
3. Transgender is the state of one’s gender identity (self-identification as male, female, both,
or neither) not matching one’s assigned gender (identification by others as male or female based on
physical/genetic sex). Retrieved from http://www.transunity.com/pages/genderqueer.html.
4. A catchall term for gender identities other than masculine or feminine. People who identify as
genderqueer may think of themselves as being both masculine and feminine, as being neither masculine
nor feminine, as having a combination of masculine and feminine personality characteristics, or as falling
completely outside the gender binary. Retrieved from http://www.transunity.com/pages/genderqueer.
html.
5. Interestingly, France became the first country in the world to remove transsexualism from an
official list of mental illnesses. Gender identity disorders was removed from a social security code article
related to “long-term psychiatric diseases” (New York Times, February 13, 2010).
6. Three specifications in relation to the Transvestic Fetishism criteria are “With fetishism (sexually
aroused by fabrics, materials, or garments)”; “With autogynephilia (sexually aroused by thought or image
of self as female); and “With Autoandrophilia (Sexually Aroused by Thought or Image of Self as Male)”
(APA 2010).
7. Three specified types of Exhibitionism are “Sexually attracted to exposing genitals to pubescent
or prepubescent individuals (generally younger than age 15); Sexually attracted to exposing genitals to
physically mature individuals (generally age 15 or older); equally sexually attracted to exposing genitals
to both age groups” (APA, 2010).
8. Paraphilic Disorders Not Elsewhere Classified: These paraphilias meet the criteria for a mental
disorder and for Paraphilic Disorders. Examples include, but are not limited to, sexual fantasies, urges,
or behaviors associated with Telephone Scatologia Disorder (obscene phone calls), Necrophilic Disorder
(corpses), Zoophilic Disorder (animals), Coprophilic Disorder (feces), Klismaphilic Disorder (enemas),
and Urophilic Disorder (urine). The fantasies, sexual urges, or behaviors have been present for at least
6 months and cause marked distress or impairment in social, occupational, or other important areas of
functioning. (APA, 2012).
 LGBTQs and the DSM-5 1309

REFERENCES

Aldhous, P. (2009). Psychiatry’s civil war. New Scientist, 2738. Retrieved from http://
www.newscientist.com/article/mg20427381.300-psychiatrys-civil-war.html
American Psychiatric Association (APA). (1994). Diagnostic and Statistical Manual
of Mental Disorders (DSM-IV-TR). Washington, DC: APA.
American Psychiatric Association (APA). (2000). Diagnostic and Statistical Manual
of Mental Disorders (DSM-IV-TR). Washington, DC: Author.
American Psychiatric Association (APA). (2010). DSM-5 development. Retrieved from
http://www.dsm5.org/proposedrevision/Pages/Paraphilias.aspx
American Psychiatric Association (APA). (2011a). DSM-5 development. Retrieved
from http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?
rid=192#
American Psychiatric Association (APA). (2011b). DSM-5 development. Retrieved
from http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?
rid=482#
American Psychiatric Association (APA). (2012). DSM-5 development. Retrieved from
http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid
Blanchard, R. (2009a). The DSM diagnostic criteria for pedophilia. Archives of Sexual
Behavior, 39(2), 304–316.
Blanchard, R. (2009b). The DSM diagnostic criteria for transvestic fetishism. Archives
of Sexual Behavior, 34, 439–446.
Brauser, D. (2012). Experts react to DSM-5 approval. Medscape Today (December 3).
Retrieved from http://www.medscape.com/viewarticle/775526
Brooks, M. (2012). Published DSM-5 field trial results prompt renewed criticism.
Medscape Today (November 14). Retrieved from http://www.medscape.com/
viewarticle/774475
Bullough, V. L. (1995). Science in the bedroom: A history of sex research. New York,
NY: Basic Books.
Bullough, V. L., & Bullough, B. (1977). Sin, sickness, and sanity. New York, NY:
New American Library.
Butler, J. (1999). Gender trouble: feminism and the subversion of identity (10th
anniversary ed.). (pp. 3–44). New York, NY: Routledge.
Canadian Professional Association for Transgender Health (CPATH). (2010). CPATH
position statement, DSM and ICD March 2010. Retrieved from http://www.
cpath.ca/wp-content/uploads/2010/05/CPATH_PS_Dx_0310-1.pdf
Carson, R. C. (1991). Dilemmas in the pathway of the DSM-IV. Journal of Abnormal
Psychology, 100, 302–307.
Conger, J. J. (1975). Proceedings of the American Psychological Association,
Incorporated, for the year 1974: Minutes of the annual meeting of
the Council of Representatives. American Psychologist, 30, 620–651,
quoted in American Psychological Association, Discrimination against
Homosexuals. Retrieved from http://www.cpath.ca/wp-content/uploads/2009/
08/COHEN-KETTENIS.DSM_.pdf
Cohen-Kettenis, P. T., & Pfäfflin F. (2009). The DSM diagnostic criteria for gen-
der identity disorder in adolescents and adults. Archives of Sexual Behavior,
doi:10.1007/s10508-009-9562-y
1310 A. Daley and N. J. Mulé

Drescher, J. (2009). Queer diagnoses: Parallels and contrasts in the history of

homosexuality, gender variance, and the diagnostic and statistical manual.
Archives of Sexual Behavior, doi:10.1007/s10508-009-9531-5
Egale Canada. (2010). Egale Canada’s comments on proposed DSM V . Toronto:
Author.
Editorial. (2009). Time’s up for psychiatry’s bible. New Scientist, 2738.
Retrieved from http://www.newscientist.com/article/mg20427382.400-times-up-
for-psychiatrys-bible.html
Flanagan, K. (1992). Madness as exile, madness as power: Bessie Head’s A Question
of Power. MAWA Review, 7, 90–93.
Frances, A. J. (2012a, December 2). DSM 5 is guide not bible—Ignore its
ten worst changes: APA approval of DSM-5 is a sad day for psychia-
try. Psychology Today. Retrieved from http://www.psychologytoday.com/blog/
dsm5-in-distress/201212/dsm-5-is-guide-not-bible-ignore-its-ten-worst-changes
Frances, A. J. (2012b, December 20). How many billions a year will the DSM-5 cost?
Bloomberg. Retrieved from http://www.bloomberg.com/news/2012-12-20/how-
many-billions-a-year-will-the-dsm-5-cost-.html
Gabbard, G. O. (2007). Gabbard’s treatments of psychiatric disorders. Arlington, VA:
American Psychiatric Press.
Gaudiano, B. A., & Zimmerman, M. (2012). Prevalence of attenuated psychotic symp-
toms and their relationship with DSM-IV diagnoses in a general psychiatric
outpatient clinic. Journal of Clinical Psychiatry. Retrieved from http://article.
psychiatrist.com/dao_1-login.asp?ID=10008052&RSID=90399506541510
Gay and Lesbian Medical Association (GLMA). (2010). Gender identity disorder
in children and adolescents. Retrieved from http://www.glma.org/index.
cfm?fuseaction=feature.showFeature&FeatureID=178&d:\CFusionMX7\verity\
Data\dummy.txt
Grohol, J. (2012). Final DSM 5 approved by American Psychiatric Association.
Psych Central. Retrieved from http://psychcentral.com/blog/archives/2012/12/
02/final-dsm-5-approved-by-american-psychiatric-association/
Hill, D., Rozanski, C., Carfagnini, J., & Willoughby, B. (2005). Gender identity disor-
ders in childhood and adolescence: A critical inquiry. In D. Karasic & J. Drescher
(Eds.), Sexual and gender diagnoses of the Diagnostic and Statistical Manual
(DSM): A reevaluation (pp. 7–34). New York, NY: Haworth Press.
Hubert, S. J. (2002). Questions of power: The politics of women’s madness narratives.
Newark, DE: University of Delaware Press.
Kendell, R., & Jablensky, A. (2003). Distinguishing between the validity and utility
of psychiatric diagnoses. American Journal of Psychiatry, 160(1), 4–12.
Kendell, R. E. (2002). Five criteria for an improved taxonomy of mental disorders.
In J. E. Helzer & J. Hudziak (Eds.), Defining psychopathology in the 21st cen-
tury: DSM-V and beyond (pp. 3–18). Washington, DC: American Psychiatric
Publishing.
King, M. (2003). Dropping the diagnosis of homosexuality: Did it change the lot of
gays and lesbians in Britain? Australian and New Zealand Journal of Psychiatry,
37, 684–688.
Lev, A. I. (2005). Disordering gender identity: Gender identity disorder in the DSM-
IV-TR. (2005). In D. Karasic & J. Drescher (Eds.), Sexual and gender diagnoses
 LGBTQs and the DSM-5 1311

of the Diagnostic and Statistical Manual (DSM): A reevaluation (pp. 35–70).

New York, NY: Haworth Press.
Marshall, W., & Fernandez, Y. M. (2000). Phallometric testing with sex offenders:
Limits to its value. Clinical Psychology Review, 20, 807–822.
McCammon, S., Knox, D., & Schacht, C. (2004). Choices in sexuality. Cincinnati, OH:
Atomic Dog Publishing.
McConaghy, N. (1999). Unresolved issues in scientific sexology. Archives of Sexual
Behavior, 28(4), 285–318.
Mestel, R. (2012). Changes to the psychiatrists’ bible, DSM: Some reactions. LA Times
(December 9). Retrieved from http://www.latimes.com/health/boostershots/la-
heb-dsm5-american-psychiatric-association-20121207,0,1392058.story
Metzl, J. M. (2009). The protest psychosis: How schizophrenia became a black disease.
Boston, MA: Beacon Press.
Meyer, I. H. (1995). Minority stress and mental health in gay men. Journal of Health
and Social Behavior, 36, 38–56.
Meyer-Bahlburg, H. F. L. (2009). From mental disorder to iatrogenic hypogonadism:
Dilemmas in conceptualizing gender identify variants as psychiatric conditions.
Archives of Sexual Behaviour, doi:10.1007/s10508-009-9532-4
Money, J. (1990). Gay, straight, and in-between: The sexology of erotic orientation.
New York, NY: Oxford University Press.
Moser, C. (2001). Paraphilia: A critique of a confused concept. In P. J. Kleinplatz
(Ed.), New directions in sex therapy: Innovations and alternatives (pp. 91–108).
Philadelphia, PA: Brunner-Routledge.
Moser, C., & Kleinplatz, P. J. (2005). DSM-IV-TR and the paraphilias: An argument
for removal. In D. Karasic & J. Drescher (Eds.), Sexual and gender diagnoses of
the Diagnostic and Statistical Manual (DSM): A reevaluation (pp. 91–109). New
York, NY: Haworth Press.
NARTH Scientific Advising Committee. Gender identity disorders in childhood and
adolescence: A critical inquiry and review of the Kenneth Zucker research.
Retrieved from http://pdfcast.org/pdf/gender-identity-disorders-in-childhood-
and-adolescence-a-critical-inquiry-and-review-of-the-kenneth-zucker-research.
National Coalition for LGBT Health. (2010). National Coalition for LGBT Health
Statement on DSM-5. Retrieved from http://lgbthealth.webolutionary.com/sites/
default/files/Statement%20on%20DSM-5%20from%20National%20Coalition%
20for%20LGBT%20Health.df.
O’Donohue, W., Regev, L. G., & Hagstrom, A. (2000). Problems with the DSM-IV
diagnosis of pedophilia. Sexual Abuse: A Journal of Research and Treatment,
12, 95–105.
Rainbow Health Network (RHN). (2010a). Retrieved from http://www.
rainbowhealthnetwork.ca/
Rainbow Health Network (RHN). (2010b). RHN position statement on DSM-V review:
Clear language version. Toronto, Canada: Author.
Rainbow Health Network (RHN). (2010c). RHN position statement on DSM-V review.
Toronto: Author.
Silverstein, C. (1984). The ethical and moral implications of sexual classification: A
commentary. Journal of Homosexuality, 9(4), 29–38.
1312 A. Daley and N. J. Mulé

Simon, W. T., & Schouten, P. G. W. (1991). Plethysography in the assessment and

treatment of sexual deviance: An overview. Archives of Sexual Behaviour, 20(1),
75–91.
Spitzer, R. L. (2005). Sexual and gender identity disorders: Discussion of questions
for DSM-V. In D. Karasic & J. Drescher (Eds.), Sexual and gender diagnoses
of the Diagnostic and Statistical Manual (DSM): A reevaluation (pp. 111–116).
New York, NY: Haworth Press.
Stekel, W. (1930). Sexual aberrations: The phenomenon of fetishism in relation to
sex, translated from the 1922 original German edition by S. Parker. New York,
NY: Liveright Publishing.
Suppe, F. (1984). Classifying sexual disorders: The Diagnostic and Statistical Manual
of the American Psychiatric Association. Journal of Homosexuality, 9(4), 9–28.
Weiderman, M. (2003). Paraphilia and fetishism. The Family Journal, 11, 315–332.
Winters, K. (2005). Gender dissonance: Diagnostic reform of gender identity disorder
for adults. In D. Karasic & J. Drescher (Eds.), Sexual and gender diagnoses
of the diagnostic and statistical manual (DSM): A reevaluation (pp. 71–90).
Binghamton, NY: Haworth Press.
World Professional Association for Transgender Health (WPATH). (2010). Response
of the World Professional Association for Transgender Health to the proposed
DSM 5 criteria for gender incongruence. Retrieved from http://www.wpath.
org/documents/WPATH%20Reaction%20to%20the%20proposed%20DSM%20-
%20Final.pdf
Zucker, K. (2009).The DSM diagnostic criteria for gender identity disorder in
children. Archives of Sexual Behavior doi:10.1007/s10508-009-9540-4
Zucker, K. (2010). Reports from the DSM-V Work Group on sexual and gender
identity disorders. Archives of Sexual Behavior, 39, 217–220.