Disordered Identities: The Focus of Pathology


Kelley Winters, Ph.D.

GID Reform Advocates



Two weeks after the American Medical Association passed a historic resolution supporting health insurance coverage for gender confirming endocrine and surgical care [1], Dr. David Stevens of the Christian Medical & Dental Associations slurred this medically necessary care as “mutilation” by stereotyping transsexual women and men as mentally ill,


“…mutilation of the body is wrong, and it’s sad that these people have this psychological disorder — but it should be treated from a psychological perspective,” [2]


What is truly sad, this derogatory stereotype is rooted in flaws of the classification of Gender Identity Disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association (APA).  Indeed, the focus of pathology in successive revisions of the DSM has shifted further from gender dysphoria (defined here as a persistent distress with one’s current or anticipated physical sexual characteristics or current ascribed gender role [3]) toward nonconformity with assigned birth sex [4]. Consequently, barriers to social legitimacy and access to transition related medical care remain insurmountable for many gender dysphoric individuals.


Gender identity disorders first appeared in the class of Psychosexual Disorders in the DSM-III [5, p. 261] with more focus on gender dysphoria than today. The Transsexualism diagnosis was defined by a persistent sense of discomfort and inappropriateness about one’s anatomic sex and desire to live as a member of the “opposite” (affirmed) sex [p. 263]. Gender Identity Disorder of Childhood was characterized by a strong and persistent stated desire to be, or insistence that one is of, the other (affirmed) sex. For natal males only, diagnostic criteria included nonconformity to gender stereotypes [p.265].


In the DSM III-R [6] Gender Identity Disorders were moved out of Psychosexual Disorders to the class of Disorders Usually First Evident in Infancy, Childhood or Adolescence [p. 71] in recognition of gender identity origin in early life [p.424]. Although this reclassification was a positive change, the diagnostic criteria for children were broadened to include gender role nonconformity for natal girls, such as “persistent marked aversion to normative feminine clothing” [p.73].  Worse yet, a new category was added, Gender Identity Disorder of Adolescence or Adulthood, Nontranssexual Type (GIDAANT) [p. 76], defined by discomfort about one’s assigned birth sex and gender expression outside of the assigned role in fantasy or actuality [p. 77].  For the first time, non-transsexual gender variant individuals comfortable and well adjusted in cross-sex roles full time or part-time were classified as mentally ill under a Gender Identity Disorder.


In the DSM-IV [7], Gender Identity Disorders were once again classified as sexual disorders, now called Sexual and Gender Identity Disorders [p. 493], rekindling the stereotype of sexual deviance. A single expanded Gender Identity Disorder diagnosis combined the DSM-III categories of Transsexualism, Gender Identity Disorder of Childhood and GIDAANT.  Unlike prior editions, the DSM-IV encouraged concurrent diagnoses of GID and Transvestic Fetishism (TF) [p. 536], making the stigma of fetishism a social issue for male-to-female transsexual women. Gender Dysphoria was obfuscated in criterion B by the phrase, “Or a belief that he or she was born the wrong sex.” [p.581]  Thus, transitioned adults no longer gender dysphoric would be pathologized by their belief rather than their distress. Diagnostic criteria for children were again broadened to place a greater emphasis on nonconformity to social sex stereotypes. These implicated as mentally ill children with no evidence of gender dysphoria [8]. 


A clinical significance criterion was added to GID, TF and most diagnoses in the DSM-IV, well intended to require clinically significant distress or impairment to meet the accepted definition of mental disorder [7, p.7].  Unfortunately, it failed to distinguish intrinsic distress of gender dysphoria from that caused by external societal prejudice and intolerance, what Dr. Evelyn Hooker termed “ego defensive” response [9].  Therefore, the clinical significance criterion failed to counter the stereotype that all gender variance is disordered. The criterion was brushed aside by Drs. Kenneth Zucker and Ray Blanchard (members of the Sexual and Gender Identity Disorders subcommittees for the DSM-IV and DSM-V editions) as “muddled” and having “little import” [10]. However this position appears to conflict with the APA’s definition of mental disorder:


“a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress… or disability… or with a significantly increased risk of suffering, pain, disability, or an important loss of freedom… Whatever its original cause, it must currently be considered a manifestation of a behavioral, psychological, or biological dysfunction in the individual.”  [11, p. xxxi]


The shift in focus from gender dysphoria to gender nonconformity in the DSM has implicated a growing number of gender variant people with mental disorder and sexual deviance who meet no standard of “dysfunction in the individual.” It has exacerbated barriers to medical care and social intolerance. It has poorly served the purpose of diagnostic nomenclature given by the current World Professional Association for Transgender Health (WPATH) Standards of Care:


“The use of a formal diagnosis is often important in offering relief, providing health insurance coverage, and guiding research to provide more effective future treatments” [12]


In sharp contrast to the American Psychiatric Association policy, the American Medical Association last month reinterpreted GID as “a serious medical condition” rather than mental or sexual disorder, characterized by distress rather than nonconformity to assigned birth role:


“a persistent discomfort with one’s assigned sex and with  one’s primary and secondary sex characteristics, which causes intense  emotional pain and suffering;” [1]


Moreover, the American Psychological Association Task Force on Gender Identity, Gender Variance and Intersex Conditions stated in 2006,


“Many transgender people do not experience their transgender feelings and traits to be distressing or disabling, which implies that being transgender does not constitute a mental disorder per se.” [13]


In the DSM-V, there is opportunity for the American Psychiatric Association to realign with contemporary attitudes about gender diversity among its peer organizations, to refocus the GID diagnostic criteria on distress with physical sex characteristics or distress with assigned birth role or ascribed social role that are incongruent with inner gender identity.  There is an opportunity for the APA to clarify in the supporting text and in public policy statement that, in the absence of dysphoria, gender identity and expression that vary from assigned birth sex are not, in themselves, mental disorder.



[1] 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.


[2] C. Butts, “Transgenderism — purely psychological?” OneNewsNow,  http://www.onenewsnow.com/Culture/Default.aspx?id=161948 , July 2, 2008.


[3] 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)


[4] 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.


[5] American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Third Edition, 1980


[6] American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised, 1987


[7] American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, 1994


[8] K. Winters, under pen-name K. Wilson,  “The Disparate Classification of Gender and Sexual Orientation in American Psychiatry,” 1998 Annual Meeting of the American Psychiatric Association, Workshop IW57, Transgender Issues, Toronto, Ontario Canada, June 1998. This paper is a revised and expanded version of a previous article of the same title, published in Psychiatry On-Line, The International Forum for Psychiatry, Priory Lodge Education, Ltd., April, 1997, www.priory.co.uk/psych.htm. The original article is available on-line at www.priory.com/psych/disparat.htm.


[9] E. Hooker, E., “A Preliminary Analysis of Group Behavior of Homosexuals.” Journal of Psychology. #41, p. 219, 1956


[10] K. Zucker and R. Blanchard, “Transvestic Fetishism: Psychopathology and Theory,” in D. Laws and W. O’Donohue (Eds.), Sexual Deviance: Theory and Application, Guilford Press, New York, 1997, p. 258.


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


[12] World Professional Association for Transgender Health (formerly Harry Benjamin International Gender Dysphoria Association) “Standards of Care for Gender Identity Disorders,” Sixth Version, http://wpath.org/Documents2/socv6.pdf , 2001


[13] American Psychological Association, “Answers to Your Questions About Transgender Individuals and Gender Identity,”   APA Task Force on Gender Identity, Gender Variance and Intersex Conditions, http://www.apa.org/topics/transgender.html, 2006.


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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