Revision Suggestions for Gender Related Diagnoses in the DSM and ICD

Ehrbar, Randall D., Psy.D.
Winters, Kelley, Ph.D.
Gorton, R. Nicholas, M.D

a synopsis of the presentation to

The World Professional Association for Transgender Health (WPATH)
2009 XXI Biennial Symposium
June 19, 2009
Oslo, Norway

For the complete presentation text, please see

Starting with different beliefs and assumptions about appropriate diagnoses for transgender and gender variant individuals suffering from gender dysphoria, the members of this panel have reached similar conclusions about desirable changes to diagnostic categories in the next version of the DSM and ICD. Important points of agreement are that revised versions of diagnoses such as GID, Transsexualism, and GID in children 1) should center on gender dysphoria, which is distress associated with sexed characteristics of the body and/or social gender role, 2) should be large enough to encompass all of those who need it including those with non-binary gender identities, and those who do not wish to fully medically or socially transition to the “opposite” gender, 3) should be narrowly defined to only include those who are experiencing gender dysphoria (and are therefore presumably in need of treatment), not to those who are merely gender non-conforming. We will discuss the different premises and constructs on which the three authors base their conclusions and explore how despite these significant epistemological differences, the same conclusions become apparent. We will also discuss placement of diagnostic categories, nomenclature, “exit clauses” for trans-people who no longer experience gender dysphoria, cultural and sociopolitical significance of diagnostic categories and discourses around such categories, and appropriate diagnosis of distress primarily due to discrimination and oppression rather than gender dysphoria.


We come at this issue from a variety of different backgrounds and viewpoints differing on whether there should be a diagnosis at all or what kind of diagnosis it should be. When I first approached Dr. Nick Gorton and Dr. Kelley Winters they both were a bit skeptical, in fact, because they perceived that the other had very different viewpoints. Yet we agree about fundamental principles of treatment and rights for trans people. We may just differ in the ways that we think these things can best be accomplished. In the process of working on this talk we discovered that not only do we share common basic principles, but even had some common ground about utility of having a diagnosis and what such a diagnosis should look like if there is a diagnosis. . We were also able to generate compromises that could accommodate those areas where we do have fundamental differences. One of the first things we did in preparing for our talk was to write in 30 words or less our fundamental beliefs about diagnosing transgender people with an illness and what that does for the community.

What We Think:

  • Winters – Individuals whose gender identity or expression differ from assigned birth-sex are labeled mentally disordered in the DSM-IV-TR, inflicting harmful social stigma and barriers to transition care.
  • Ehrbar – Practically, diagnosis is needed for access. Conceptually, it makes sense to categorize gender dysphoria as a mental health disorder.
  • Gorton – GID (by any name) belongs in DSM-V. Revisions can foster acceptance among consumers without compromising scientific accuracy. Diagnosis facilitates insurance coverage and disability protections.

We also explicitly identified our common ground is with regard to access to care, non-discrimination, social justice, and civil rights. We have a good deal of common ground about how we think the world should be. In fact, we suspect that most if not all of the folks here at WPATH share these fundamental beliefs. , I It’s worth reminding ourselves that we do agree that trans and gender variant people shouldn’t be subject to discrimination, should have access to health care and should have civil rights and protections.

The Authors’ Shared Vision:

  • End discrimination on the basis of gender identity and expression
  • Gender identity and expression that differ from assigned birth sex do not, in themselves, constitute a mental disorder or an impairment in competence
  • Hormonal and/or surgical transition treatments to relieve gender dysphoria are medically necessary
  • Insurance and health care coverage for medically prescribed transition treatment
  • Legal recognition/documentation for all people that is consistent with their gender identity and expression.
  • Reform must fit everyone’s needs, but as a social justice movement we must weigh more heavily the needs of those least enfranchised.

Summary of Proposed Diagnosis:

  • Dx Criteria – Both A and B
    • A: Strong and persistent distress with physical sex characteristics, or ascribed social gender role, that is incongruent with persistent gender identity.

      B: Distress is clinically significant or causes impairment in social, occupational, or other important areas of functioning, when this distress or impairment is not solely due to external prejudice or discrimination.

  • GD in remission
    • No longer meets criteria, needs treatment to maintain remission

  • ‘Exit clause’
    • No longer meets criteria, doesn’t need treatment to maintain remission

Key Points:

  • It’s about Dysphoria, not difference from assigned birth sex
  • Respectful Language
  • Not too Big; Not too Little; but Just Right
  • Accurate Classification Placement
  • Remove Tranvestism/Fetishism Categories

Our main points are: 1) gender dysphoria is the conceptual center of the diagnosis, 2) use respectful language in nomenclature and description of individuals, 3) include those who are in need of inclusion, do not include those who should not be, 4) move the diagnosis out of the sexual and gender identity disorders chapter, 5) and remove transvestic fetishim.

About the Authors:

Randall Ehrbar is a clinical psychologist with extensive training and experience working with transgender clients. He has also been actively involved in the American Psychological Association’s efforts to address transgender concerns.

Kelley Winters is a writer and consultant on gender diversity issues in medical, employment and public policy.

Nicholas Gorton is a medical doctor who provides primary care to many transgender clients at Lyon Martin Health Services

Copyright © 2009 Randall Ehrbar, Kelley Winters, Nicholas Gorton