Diagnosis vs. Treatment: The Horns of a False Dilemma

Kelley Winters, Ph.D.

GID Reform Advocates




The transgender community has been divided by fear that we must chose between access to corrective hormonal and surgical procedures to support transition and the stigma of mental illness imposed by the current diagnosis of Gender Identity Disorder(GID)[1] This schism has allowed little dialogue and no progress on GID reform in nearly three decades. However, the GID diagnosis has failed our community on both points. Transsexual individuals are poorly served by a diagnosis that both stigmatizes us as mentally deficient and sexually deviant and at the same time undermines the legitimacy of social transition and medical procedures that are often dismissed as “elective,””cosmetic,” or as reinforcing mental disorder.


Gender Identity Disorder in the Diagnostic and Statistical Manual of Mental Disorders[2] has imposed stigma of mental illness and sexual deviance upon people who meet no scientific definition of mental disorder[3]. It does not acknowledge the existence of many healthy, well-adjusted transsexual and gender variant people or justify why we are labeled as mentally ill. 


I have heard countless narratives of suffering inflicted by the stereotype of mental illness and “disordered” gender identity, and I have experienced it myself. We lose our families, our children, our homes, jobs, civil liberties, access to medical care and our physical safety. With each heartbreak, we’re almost invariably told the same thing – that we’re “nuts,” that our identities and affirmed roles are madness and deviance. The following statement by Dr. Robert Spitzer at the 1973 annual meeting of the American Psychiatric Association remains as true today for transgender people as it was for gay and lesbian people then:


“In the past, homosexuals have been denied civil rights in many areas of life on the ground that because they suffer from a “mental illness” the burden of proof is on them to demonstrate their competence, reliability, or mental stability.”[4]


The current GID diagnosis places a similar burden of proof upon gender variant individuals to prove our competence, with consequences of social stigma and denied civil rights.  It harms those it was intended to help. For example, 


“Transsexuals suffer from ‘mental pathologies,’ are ineligible for admission to Roman Catholic religious orders and should be expelled if they have already entered the priesthood or religious life,” the Vatican says in new directives.”[5]


Simultaneously, GID in the DSM-IV-TR undermines and even contradicts social transition and the medical necessity of hormonal and surgical treatments that relieve the distress of gender dysphoria, defined here as a persistent distress with one’s current or anticipated physical sexual characteristics or current ascribed gender role [6]. For example, Paul McHugh, M.D., former psychiatrist-in-chief at Johns Hopkins Hospital, used GID diagnosis as a key reason to eliminate gender confirming surgeries there:


 “I concluded that to provide a surgical alteration to the body of these unfortunate people was to collaborate with a mental disorder rather than to treat it.”[7]


Dr. Paul Fedoroff of the Centre for Addiction and Mental Health (formerly the Clarke Institute of Psychiatry) cited the psychiatric diagnosis to urge elimination of gender confirming surgeries in Ontario in 2000,


“TS [transsexualism, in reference to the GID diagnosis] is also unique for being the only psychiatric disorder in which the defining symptom is facilitated, rather than ameliorated, by the ‘treatment.’ … It is the only psychiatric disorder in which no attempt is made to alter the presenting core symptom.”[8]


Paradoxically, the GID diagnosis has been defended as necessary for access to hormonal and surgical transition procedures.  It is required by Standards of Care of the World Professional Association for Transgender Health [9], and GID is cited in legal actions to gain access to these procedures.  Attorney Shannon Minter, head counsel for the National Center for Lesbian Rights was quoted in The Advocate,


“’When we go to court to advocate for transsexual people to get medical treatment in a whole variety of circumstances, from kids in foster care to prisoners on Medicaid,’ the GID diagnosis is used to show that treatment is medically necessary.”[10]


Dr. Nick Gorton echoed longstanding fears that access to hormonal and surgical procedures would be lost if the GID were removed entirely,


“Loss of the DSM diagnostic category for GID will endanger the access to care, psychological well being, and in some cases, the very life of countless disenfranchised transgender people who are dependent on the medical and psychiatric justification for access to care.”[11]


Gender dysphoric transpeople have therefore assumed that we must suffer degradation and stigma by the current GID diagnosis or forfeit lifesaving medical transition procedures. But has our community been impaled on the horns of a false dilemma?


Are hormonal and surgical procedures available to transitioning individuals because of the current diagnosis of “disordered” gender identity or in spite of it? Because the GID criteria and supporting text are tailored to contradict transition and pathologize birth-role nonconformity[3], affirming and tolerant professionals are burdened to re-construe GID in more positive and supportive way for transitioning clients. For example, last month the American Medical Association passed a historic resolution, “Removing Financial Barriers to Care for Transgender Patients.” It reinterpreted GID to emphasize distress and de-emphasize difference:


“… a persistent discomfort with one’s assigned sex and with  one’s primary and secondary sex characteristics, which causes intense emotional pain and suffering.” [12]


The AMA statement is perhaps a model for what the GID diagnosis should become.


The current GID diagnosis and its doctrine of “disordered” gender identity have failed the trans-community on both issues of harmful psychosexual stigma and barriers to medical care access. The DSM-V Sexual and Gender Identity Disorders work group has an opportunity to correct both failures with new diagnostic nomenclature based on scientific standards of distress and impairment rather than intolerance of social role nonconformity and difference from assigned birth sex. 




[1]  This essay is expanded from K. Winters, “Harm Reduction for Gender Disorders in the DSM-V,” Philadelphia Trans Health Conference, May 2008.


[2] American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, Washington, D.C., 2000.


[3] K. Winters, “Gender Dissonance: Diagnostic Reform of Gender Identity Disorder for Adults,” Sexual and Gender Diagnoses of the Diagnostic and Statistical Manual (DSM),  Ed.  Dan Karasic, MD. and Jack Drescher, MD., Haworth Press, 2005;  co-published in Journal of Psychology & Human Sexuality, vol. 17 issue 3,  pp. 71-89,  2005.


[4] R. Spitzer, “A Proposal About Homosexuality and the APA Nomenclature: Homosexuality as an Irregular Form of Sexual Behavior and Sexual Orientation Disturbance as a Psychiatric Disorder,” American Journal of Psychiatry, Vol. 130, No. 11, November 1973 p.1216


[5] N. Winfield, Associated Press, “Vatican Denounces Transsexuals,” Newsday, Jan 2003.


[6] Working definition of Gender dysphoria by Dr. Randall Ehrbar and I following our panel presentations at the 2007 convention of the American Psychological Association. It is defined in glossary of the DSM-IV-TR as “A persistent aversion toward some of all of those physical characteristics or social roles that connote one’s own biological sex.” (p. 823)


[7] P. McHugh, “Surgical Sex,” First Things 147:34-38, http://www.firstthings.com/ftissues/ft0411/articles/mchugh.htm , 2004.


[8] J. Fedoroff, “The Case Against Publicly Funded Transsexual Surgery,” Psychiatry Rounds, Vol 4, Issue 2, April 2000.


[9] World Professional Association for Transgender Health  (formerly HBIGDA), “Standards of Care for The Hormonal and Surgical Sex Reassignment of Gender Dysphoric Persons,” http://wpath.org/Documents2/socv6.pdf , 2001 


[10] S. Rochman, “What’s Up, Doc?” The Advocate, http://www.advocate.com/issue_story_ektid50125.asp , Nov 2007.


[11] R.N. Gorton,  “Transgender as Mental Illness: Nosology, Social Justice, and the. Tarnished Golden Mean,”  www.Nickgorton.org/misc/work/private_research/transgender_as_mental_illness.pdf , 2006.


[12] American Medical Association, “Resolution 122, Removing Financial Barriers to Care for Transgender Patients,”  http://www.ama-assn.org/ama1/pub/upload/mm/16/a08_hod_resolutions.pdf, June 2008.


Copyright © 2008 Kelley Winters, GID Reform Advocates

About Kelley
Dr. Kelley Winters is a writer and consultant on issues of gender diversity in medical and public policy. She is the author of Gender Madness in American Psychiatry: Essays from the Struggle for Dignity (2008) and a past member of the International Advisory Panel for the World Professional Association for Transgender Health (WPATH) Standards of Care, the Global Action for Trans* Equality (GATE) Expert Working Group, and the Advisory Boards for TransYouth Family Allies (TYFA). She was recognized in the 2013 Trans 100 Inaugural List for work supporting the transgender community in the US. Kelley has presented papers and presentations on gender policy issues at annual conventions of the American Psychiatric Association, the American Psychological Association, the American Counseling Association and the Association of Women in Psychology. Kelley wanders the highways of America in an old Mazda, ever in search of comfort food.

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