APA Releases 2nd Proposal to Replace GID in the DSM-5

Kelley Winters, Ph.D.
GID Reform Advocates
http://www.gidreform.org
kelley@gidreform.org

The Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association, is the medical and social definition of mental disorder throughout North America and strongly influences international nomenclature. There is broad recognition 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. However, the current psychiatric classifications of Gender Identity Disorder (GID) and Transvestic Fetishism (TF) in the Fourth Edition, Text Revision of the DSM (DSM-IV-TR) fall short of meeting this need and actually contradict transition by describing transition itself as symptomatic of mental disorder.

Today, the Sexual and Gender Identity Disorders Workgroup of the DSM-5 Task Force released a second revision to proposed diagnostic criteria to replace the Gender Identity Disorder category in the DSM-5.

Most significant, the ambiguously defined title of Gender Incongruence has been replaced by Gender Dysphoria (from a Greek root for distress). The work group noted that,

Many commentators recommended ‘gender dysphoria’ as a semantically more appropriate term, because it expresses an aversive emotional component. In this regard, it should be noted that the term ‘gender dysphoria’ has a long history in clinical sexology (see Fisk, 1973) and thus is one that is quite familiar to clinicians who specialize in this area.

A number of trans health organizations and clinicians have advocated nomenclature focused on distress with the wrong physical sex characteristics or the wrong social gender role rather than difference from expectations of assigned birth-sex. Despite some confusion between dysphoria and dysmorphia (delusional self-image) in the press and in the transcommunity, I think dysphoria more clearly communicates distress as the diagnostic focus than alternative terms and represents a positive step forward.

This revised proposal also re-introduces a clinical significance criterion, B, which clarifies that diagnosis requires distress or impairment that meets a clinical threshold. This criterion is present in the DSM-IV but was removed from the first DSM-5 proposal. Clinicians and medical providers who work with  affirmed/transitioned youth have voiced concerns that removal of the clinical significance criterion would further obscure the medical necessity of puberty delaying medications for adolescents who need them, as well as hormonal and surgical transition care later in life. The American Medical Association, the American Psychological Association, and the World Professional Association for Transgender Health have issued public statements clarifying the medical necessity of hormonal and/or surgical  transition treatments for those who suffer distress caused by deprivation of physical characteristics congruent with their gender identity, within established standards of care.

However, the specific wording of the clinical significance criterion will likely be debated among community and medical advocates in coming weeks. For example, the proposed wording fails to exclude distress or impairment caused by societal prejudice as a basis for diagnosis. This omission has historically been used to justify gender-reparative therapies on gender nonconforming youth– with an inference that victimhood of intolerance is symptomatic of mental illness.

The first diagnostic criterion is unfortunately unchanged from the first DSM-5 proposal. It ambiguously describes gender identity and a desire for transition related treatment as foci of pathology. The corresponding criterion for children is especially problematic, as it describes gender expression that differs from assigned birth roles as symptomatic of mental illness.

The work group also added a Post-transition specifier, intended to aid continued access to hormonal care after the distress of gender dysphoria has been relieved by transition. However, it will certainly raise controversy by blocking exit from the diagnosis to those whose distress has been successfully relieved by transition related care.

Finally, the work group noted that, “gender diagnoses will be separated from the sexual dysfunctions and paraphilias.” This change in categorical placement of the Gender Dysphoria category would also represent forward progress in the DSM-5, although many advocates and care providers have pushed to move the new diagnosis out of the Sexual and Gender Identity Disorders section altogether.

The second gender category of Transvestic Disorder remains in the DSM-5 proposal, despite broad opposition from the transcommunity, care providers and allies.

The deadline for public comments on this revised proposal is now June 15, 2011. Unfortunately, this will pass before the Symposium of the World Professional Association for Transgender Health (WPATH) in September. WPATH played an active role in providing feedback on the previous proposal in 2010. The DSM-5 Task Force has announced a third round of revisions  and another period of public feedback to follow.

Proposed Diagnostic Criteria for Gender Dysphoria (in Adolescents or Adults)**

See http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=482#

A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested by 2^* or more of the following indicators: [2, 3, 4]**

1. a marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or, in young adolescents, the anticipated secondary sex characteristics) [13, 16]

2. a strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or, in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics) [17]

3. a strong desire for the primary and/or secondary sex characteristics of the other gender

4. a strong desire to be of the other gender (or some alternative gender different from one’s assigned gender)

5. a strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender)

6. a strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender)

B. The condition is associated with 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**

Subtypes

With a disorder of sex development [14]

Without a disorder of sex development

See also: [15, 16, 19]

Specifier**

Post-transition, i.e., the individual has transitioned to full-time living in the desired gender (with or without legalization of gender change) and has undergone (or is undergoing) at least one cross-sex medical procedure or treatment regimen, namely, regular cross-sex hormone treatment or gender reassignment surgery confirming the desired gender (e.g., penectomy, vaginoplasty in a natal male, mastectomy, phalloplasty in a natal female).

Note: Three changes have been made since the initial website launch in February 2010: the name of the diagnosis, the addition of the B criterion, and the addition of a specifier. Definitions and criterion under A remain unchanged.

Proposed Diagnostic Criteria for Gender Dysphoria in Children

See http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=192

A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested by at least 6^* of the following indicators (including A1): [2, 3, 4]

1. a strong desire to be of the other gender or an insistence that he or she is the other gender (or some alternative gender different from one’s assigned gender) [5]

2. in boys, a strong preference for cross-dressing or simulating female attire; in girls, a strong preference for wearing only typical masculine clothing and a strong resistance to the wearing of typical feminine clothing [6]

3. a strong preference for cross-gender roles in make-believe or fantasy play [7]

4. a strong preference for the toys, games, or activities typical of the other gender [8]

5. a strong preference for playmates of the other gender [9]

6. in boys, a strong rejection of typically masculine toys, games, and activities and a strong avoidance of rough-and-tumble play; in girls, a strong rejection of typically feminine toys, games, and activities [10]

7. a strong dislike of one’s sexual anatomy [11]

8. a strong desire for the primary and/or secondary sex characteristics that match one’s experienced gender [12]

B. The condition is associated with 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.**

Subtypes

With a disorder of sex development [14]

Without a disorder of sex development]

See also [13, 15, 19]

Note: Two changes have been made since the initial website launch in February 2010: the name of the diagnosis and the addition of the B criterion. Definitions and criteria under A remain unchanged.