The Diagnostic and Statistical Manual of Mental Disorders, they have not addressed concerns about their "Gender Dysphoria" diagnosis.]]>"/> The Diagnostic and Statistical Manual of Mental Disorders, they have not addressed concerns about their "Gender Dysphoria" diagnosis.]]>"/>

Kelley Winters

Proposed Gender Dysphoria Diagnosis in DSM-5

Filed By Kelley Winters | June 07, 2011 5:00 PM | comments

Filed in: Action Alerts, The Movement, Transgender & Intersex
Tags: American Psychiatric Association, DSM V, gender dysphoria, gender identity disorder, transgender

For decades, the diagnosis of Gender Identity Disorder (GID) in The Diagnostic and Statistical Manual of Mental Disorders (DSM) has drawn protest from trans and transsexual communities, their allies and supportive medical and mental health professionals for its depiction of gender diversity, gender transition and medical transition care as mental illness and sexual deviance. However, many community advocates and supportive medical professionals agree that some kind of diagnostic coding is necessary to facilitate access to medical and/or surgical transition care for those trans and transsexual people who need it. There is a need to replace the GID category with diagnostic nomenclature that is consistent with transition care, for those who need it, rather than contradicting transition care. The American Psychiatric Association is requesting public input until June 15 on its newest proposed revisions to the GID category for the Fifth Edition of the DSM.

The Sexual and Gender Identity Disorders Workgroup of the APA's DSM-5 Task Force has partially responded to concerns about the GID diagnosis in the fifth edition of The Diagnostic and Statistical Manual of Mental Disorders. For example, the derogatory title of "Gender Identity Disorder" (intended to imply "disordered" gender identity) has been replaced with "Gender Dysphoria," from a Greek root for distress. DSM-5 authors have expressed a desire to focus on distress with incongruent physical characteristics and assigned gender roles rather than on difference.

DSM.jpgMoreover, the workgroup has articulated a historic shift in diagnostic focus away from the stereotype 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 sé.

However, the workgroup has not reflected these principles in the diagnostic criteria for gender dysphoria. They retain much of the flawed language from the DSM-IV, casting differences from birth-assigned roles and desires for medical transition treatment as symptoms of mental disorder. Worse yet, post-transition people who are happy with their bodies and affirmed roles remain entrapped by the diagnostic criteria and specifiers - they are permanently labeled as mentally and sexually disordered. The proposed diagnostic criteria and categorical placement in the DSM-5 continue to contradict transition and describe transition itself as pathological.

A New Distress-based Diagnostic Paradigm

An international group of mental health and medical clinicians, researchers, and scholars, Professionals Concerned With Gender Diagnoses in the DSM, has proposed alternative diagnostic nomenclature based on distress rather than nonconformity. These include anatomic dysphoria (painful distress with current physical sex characteristics) as well as social role dysphoria (distress with ascribed or enforced social gender roles that are incongruent with one's inner-experienced gender identity).

For children and adolescents, these alternative criteria include distress with anticipated physical sex characteristics that would result if the youth were forced to endure pubertal development associated with natal sex. For those who require a post-transition diagnostic coding for continued access to hormonal therapy, the criteria include sex hormone status. Based on prior work by psychologist Anne Vitale, this distress may also be described as deprivation of physical characteristics or social gender expression that are congruent with inner experienced gender identity.

The resulting four-cornered definition of gender dysphoria, encompassing direct distress and deprivation distress around anatomic sex and ascribed/assigned gender, provides a cogent definition of the problem to be treated with medical transition care. It addresses prior false-positive and false-negative diagnostic concerns and does not contradict the treatment.

These alternative criteria acknowledge that experienced gender identity may include elements of masculinity, femininity, both, or neither and are not limited to binary Western stereotypes. They also define clinically significant distress and impairment to include barriers to functioning in one's experienced congruent gender role and exclude victimization by social prejudice and discrimination.

Suggested Diagnostic Criteria for Gender Dysphoria in the DSM-5

I would like to suggest that the APA adopt new diagnostic criteria for the gender dysphoria categories for children and adults/adolescents that are based on the following summary of work from the Concerned Professionals group:

A. A distressing sense of incongruence between persistent experienced or expressed gender and current physical sex characteristics or ascribed gender role in adults, or in adolescents who have reached the age 13 or Tanner Stage II of pubertal development. Incongruence, for this purpose, does not mean gender expression that is nonconforming to social stereotypes of assigned gender role or natal sex. The incongruence should be manifested by at least one of the following indicators for a duration of at least three months:

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, including sex hormone status, 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, including sex hormone status, that are congruent with persistent experienced gender.

B. Distress or discomfort is clinically significant or represents impairment in major life functions in a role congruent with experienced gender identity. Distress or impairment due to external prejudice or discrimination is not a basis for diagnosis.

Regardless of the wording chosen for the DSM-5, these alternative criteria for Gender Dysphoria may be used in clinical practice today to inform treatment by clarifying the problem being treated. These alternative criteria may serve to facilitate clearer communication between primary care, medical specialty, and mental health providers, and they can enable patients and families of transitioning youth to make more informed decisions on treatment options.

What You Can Do Now

1. Ask the APA to reject diagnostic criteria and categorical placement for the Gender Dysphoria diagnosis that contradict transition or depict transition as symptomatic of mental disorder. Ask them to clarify that nonconformity to birth-assigned roles and being victims of societal prejudice do not alone constitute mental pathology. Go to the APA DSM-5 Gender Dysphoria pages for children and adults/adolescents, click on "Register Now," create a user account, and enter your statement in the box. The deadline for this second period of public comment is June 15.

2. Ask your local, national, and international GLBTQ non-profit organizations to issue public statements to clarify that nonconformity to birth-assigned roles and being victims of societal prejudice do not alone constitute mental pathology.

3. Ask mental health and medical professionals who work with the trans community to voice their concerns to the APA.

4. Spread the word to your network of friends and allies.

(Cross-posted at the GID Reform Advocates Blog)

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I saw the Anderson Cooper 360 report tonight on the Sissy Boy Expirements and I must say that it really drove the point home on how dangerous viewing gender nonconformity as a mental illness can be. Thank you for this article.

This is so true. I was heartbroken to hear the tragic end of this story on CNN. Although the victim, Kirk Murphy, was cis and gay, his tormentor, Dr. George Rent-Boy Rekers, was preoccupied with "the primary prevention of adult transsexualism or similar adult sex-role deviation" Cruel conversion therapies remain very much a trans issue today.

My take on this? It isn't worth writing to the APA. I think they're a corrupt organization. There may be a few people associated with the organization who mean well but it is my impression that a re-read of Group Psychology and the Ego might be in order. There is so much drug money running through the key institutions involved where many of the members of the workgroup are employed that it is doubtful whether there would be any good faith capitulations on the part of most of them. This whole subject is ridiculous.

Think about the CAMH where workgroup chairman works. Think about the origins of the program where he works:

"The practice of aversion therapy was influenced by "Treatment of Male Homosexuality through Conditioning", an article published by the Czech doctors J. Srnec and Kurt Freund in the International Journal of Sexology in 1953. Srnec and Freund‘s procedure, conducted in Czechoslovakia, involved giving patients coffee or tea mixed with emetine, then subcutaneous injections with a mixture of substances, before showing them pictures of nude men while the drugs made them vomit. Patients were next shown pictures of women after being injected with testosterone. This was repeated between five to ten times per patient. Srnec and Freund stated that of twenty five men who were subjected to this procedure, ten “achieved predominant heterosexuality at practically full sexual activity.” They expressed the hope that the method they described could eventually be replaced by something more effective.[1]"

Very competent people? I doubt it. Sounds like a bunch of quacks to me. I could tell you about my experience with therapy. Essentially diagnosed with adult ADD. Offered medications I know would have been bad for me in spite of an understanding of my situation that my therapist was aware of that I am not free to go into here. I know what my circumstances are and how far back they go. I don't know the specifics, however, because I have been kept in the dark since adolescence. There is no compromising with these people. They are mostly corrupt. Let them do what they want. I don't think the APA is worth a hill of beans. What a bunch of pompous jerks, including Jack Drescher and his "gender variance". What's the problem? He can easily enough find a dress at Lane Bryant that would flatter his ungainly stature. Why don't these people leave us alone. Why don't endocrinologists and surgeons take the lead, offer treatment to those who obviously need it, insist on not practicing without the informed consent of the patient, stop listening to the parents, leave the little kiddies alone and just let people be.

I am wondering if perhaps those that seek MEDICAL intervention and achieve much needed psycho/sexual congruence via SRS are not deemed "cured" and consequently "freed" from the diagnosis of mental illness.

This is a good question. The current GID criteria and the proposed Gender Dysphoria criteria are written to contradict social and medical transition and mis-characterize transition itself as symptomatic of mental disorder. Transitioned individuals who are highly functional and happy with their lives are forever diagnosable as mentally disordered, according to the proposed criteria. For example, a post-transition person who is happy in her or his affirmed role, wants to be treated like others of her/his affirmed gender, has typical feelings of those in her/his affirmed gender, and is distressed or unemployed because of societal prejudice will forever meet criteria A (subcriteria 4, 5 and 6) and B and remain diagnosable as mentally ill, regardless of how successfully her or his distress of gender dysphoria has been relieved. Intolerant political groups, insurers, employers, and medical providers will continue to use this as an excuse to deny access to transition care. It is time for the APA to clarify in the Gender Dysphoria diagnosis that nonconformity to birth-assigned roles and victimization from societal prejudice do not constitute mental pathology.

Funny, that is what I thought the new entry was supposed to do. If it doesn't how is it any different from what they have in there now?

I knew given the ppl who are in charge of this section that they would never give up pathology for trans ppl.

Oh, and Sam, nice invalidation of those awful TG crossdressers. And yeah, I consider your positions bigoted, too, and hate this whole TS not TG crusade, thank you very much.

Good question, Carol. The Gender Identity Disorders subworkgroup, responsible for the Gender Dysphoria (GD) category (a part of Zucker's Sexual and Gender Identity Disorders Work Group), is led by Dr. Peggy Cohen-Kettenis from the Netherlands. I think she is one of the more respectable researchers in the field. The proposed GD diagnosis makes some forward progress in several ways, but it does not go nearly far enough in clarifying that nonconformity to birth-assigned roles and victimization from societal prejudice do not constitute mental pathology. The improvements in the APA proposal so far include a better title, removal of Sexual Orientation Subtyping, rejection of Blanchard's "autogynephilia" subtyping (in the supporting text of the dsm-iv-tr), recognition of suprabinary gender identities and expressions, recognition of youth distressed by anticipated pubertal characteristics, and no longer allowing diagnosis of youth strictly on the basis of nonconforming gender expression. However, the proposed GD criteria are still far from helpful to transsexual individuals who need access to medical transition care or to other trans or gender-diverse people who may be ensnared by false-positive diagnosis. These shortcomings are described in more detail at the GID Reform Advocates site.

So few comments?

Thank you to you and your colleagues for continuing to work on this. I know that this is a painstaking process, and you've been committed to trying to find a harm-reduction model that minimizes stigmatization while still enabling access for those who depend on a diagnosis to be able to receive treatment. I know it's not always popular to seek out a viable middle-ground on the issue.

I've forwarded your analysis and suggestions to a number of folks I know who have been monitoring and/or involved with this process.

Thanks so much, Mercedes. CNN coverage of the tragic story of Kirk Murphy and the horrendous UCLA "sissy boy project" underscores the urgency of replacing the GID diagnosis, which implicitly promotes gender-reparative therapies, with nomenclature that is consistent with access to medical transition treatment for those who need it. The next opportunity to reform the DSM may not occur for another 20 years.


As you know, the suggested changes fit very well with my particular viewpoints, and work extraordinarily well with the work and focus that I have in my efforts.

I have indeed written in to respond to the issue, and I've pulled resources from the community that I work in to join me in calling for this change.

It is important, as well, in my mind, for us as members of the community to engage our providers directly in this dialog. That is, to have our physicians and therapists and social service providers address this issue both personally and professionally.

Getting the "on the ground" input is also a key factor in the new team behind the DSM (which looks a lot like the old team, at times). And yet, they are consistently stymied in doing so by an unwillingness of the providers to become involved in what strikes them as a politicized process.

Far too often, the industry and institution is perceived as a bleak eyed boogeyman, as opposed to a vast network of individuals who rel on this work -- it is not a matter of politics here, it is a matter of just and honest medical treatment.

Asking our providers to stand up for us will have far more impact on the process -- as Anne's example shows (among others, including your own).

And a part of the reason for it being so important is the underlying resistance to such stems from an ongoing mental process in many of those behind the scenes that as we are the subjects of this disordered outlook, our views are not as heavily weighed.

We can change that by showing that we are not the only ones -- that those who deal with far more of us than many of the names behind the scenes do also see things through the lens we do.

You're so right, Antonia, about how we need mental health providers, whose business comes from the transcommunity, to speak out on these issues. These clinicians hold the real data about transitioning people that policymakers within the cold stone walls of the Clarke Institute never see. BTW, I'm not a provider -- just an old engineer and a dissident.

"So few comments?"

Well, for me, it seems that the ppl who have the say over this are arrogant bastards who are typical psychiatrists in that they are dismissive of lay ppl in general, and the ppl with the 'illness' they specialize in treating in particular. It seems they are going to do what they are going to do.

And really, the whole DSM (and the practice of psychiatry) are set up based on an illness model rather than holistically (as is one of their fave instruments, the MMPI, where the best you can do is have lack of disorder, no strengths). So of course anything is going to be cast from a negative perspective.

I did think that supposedly in the new version ppl who transitioned were *cured*, but doesn't sound like this is the case...

You wrote:

Well, for me, it seems that the ppl who have the say over this are arrogant bastards who are typical psychiatrists in that they are dismissive of lay ppl in general, and the ppl with the 'illness' they specialize in treating in particular. It seems they are going to do what they are going to do.

All the more reason to recruit trans-affirming medical professionals to comment. I wish it weren't so, and we could be taken more seriously, but at least we do have some allies we can count on.