'Gender Identity Disorder' to Go the Way of Homosexuality

Western psychiatry's struggle to characterize those who do not identify with prescribed gender roles looks to be analogous to the history of homosexuality, which was a diagnosis (in at least some form) until 1987.

When asked, "What are you?" Cocoa Chandelier confidently replies, "I am māhu. Not ma-hu or mahU, but māhu."

In Native Hawaiian culture, māhu represents a third gender -- someone who embodies both male and female qualities. In old Hawai'i, māhus entertained the chiefs and people held them in high regard. Māhus distinctively had higher powers because they embodied the best of male and female qualities, making them confidants, kumu hulas (dance teachers) and spiritual leaders.

Native American epistemology has a similar concept of the two-spirit or third gendered individual. Native Activist and scholar Will Roscoe found documentation of third and even fourth genders in more than 150 North American tribes. In Samoa, the term fa'afafine refers to a biological man who lives as a woman. Samoans appreciate fa'afafine for their hard work and dedication to family, and for the large part offer them social acceptance.

Western psychiatry, on the other hand, is still trying to figure out how to conceptualize people like Chandelier. In May 2013, the American Psychiatric Association (APA) will unveil the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5). It has been thirteen years since the last update and eighteen years since the last edition. The field considers this the most anticipated advancement in the science of mental health.

Controversy surrounds DSM updates, especially in the area of sexual disorders. Most famously, homosexuality did not get fully removed as a diagnosis until 1987, and only after a long battle. In 1970, when the APA held its annual convention in San Francisco, gay rights activists disrupted the conference. In 1971, the protestors again appeared en force. Based on the research of Alfred Kinsey and Evelyn Hooker, the seventh printing of the DSM-II in 1974 de-listed homosexuality as a disorder, replacing it with the term sexual orientation disturbance. In 1980, the disorder changed to ego-dystonic homosexuality (EDH). The argument went that those who felt uncomfortable about their homosexuality should still be able to receive treatment. But the larger question was, why did so many people feel uncomfortable about their homosexuality? In 1987, ego-dystonic homosexuality went into the garbage heap of diagnoses. Neurosis, hysteria, combat exhaustion disorder and premenstural dysphoria have also died there.

It is hard not to see the parallels between the diagnosis of homosexuality and the latest heat around gender identity disorder (GID). At the annual APA meeting in San Francisco in 2009, protesters once again gathered to lobby against continued inclusion of this diagnosis in the DSM-5. During the comment period, GID received more comments than any other diagnosis up for discussion. It's worth reading the entire diagnosis, but the last version of the manual, the DSM-IV (TR), identifies the disorder as "a strong persistent cross-gender identification ... [and] a repeatedly stated desire to be, or insistence that he or she is, the other sex." Basically, the diagnosis is "transgendered."

To address the controversy surrounding GID, the DSM-5 plans to redefine the disorder as gender dysphoria (GD), moving it to a temporary condition. The APA states the change arose "in response to criticisms that the term was stigmatizing." Part of the APA's argument for keeping a version of GID has to do with providing medical attention and insurance reimbursement for transgendered individuals seeking counseling or gender reassignment surgery. This echoes the move from homosexuality to sexual orientation disturbance to ego-dystonic homosexuality.

An argument against there being any diagnosis for transsexual individuals, especially children and adolescents, is that therapists can use the GID or GD diagnosis to encourage them to adhere to prescribed gender roles based on biological sex. I have had parents come into my office asking me to work with their son who keeps wearing girl's clothes. The boy doesn't mind at all, the parents do.

Proposals have been put forward to use the term "social role dysphoria" to identify the distress that enforced social gender roles cause. The "problem" becomes the fault of rigid gender roles rather than of the individual, and the diagnosis would still offer reimbursement for gender reassignment surgery. The term sends a much different message: There's something wrong with rigid gender role categories versus there's something wrong with you.

I learned this lesson firsthand while backup dancing for Cocoa Chandelier, whom I naively called a drag queen. The DSM-IV calls this transvestic fetishism, as long as sexual arousal and some impairment occur. The DSM-5 will now call it transvestic disorder. Cocoa, however, does not fit these categories or that of GID or GD.

Cocoa, who is of Native Hawaiian, Filipino, Chinese, and German descent, performs in pageants around the country, choreographs for local theater productions and teaches dance at the university. She creates elaborate costumes, appearing as Cleopatra, Carmen Electra, or as himself. Social and occupational discrimination still exists, but she moves through these roles with what appears, from the outside, to be effortless ease.

I recall one of Cocoa's shows in particular, where she sat on a red bejeweled chariot, dressed in a gold spandex gown and a black wig as Cleopatra. We stood behind her in black leotards, fanning her with gold fans. Gold spray-painted cardboard pyramids glistened behind us. We simply accented Cocoa. I am reminded that my role as a backup dancer or as a psychologist is not to overshadow with fancy dance moves or labels, but to help bring forward the beauty that is already there.

Amelia Rachel Hokule’a Borofsky, Psy.D., is a community and clinical psychologist based in Hawaii and the Cook Islands. She teaches at Hawaii Pacific University and writes about health across different cultures.

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