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.
Moreover, 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)