Third Swing: My Comments to the APA for a Less Harmful Gender Dysphoria Category in the DSM-5


My objective for GID reform in DSM-5 is harm reduction– depathologizing gender identities, gender expressions or bodies that do not conform to birth-assigned gender stereotypes, while at the same time providing some kind of diagnostic coding for access to medical transition treatment for those who need it. I and others have suggested that diagnostic criteria based on distress and impairment, rather than difference from cultural gender stereotypes, offer a path for forward progress toward these goals. This post is an update to my earlier comments to the APA in June, 2011.

The  Gender Dysphoria (GD) criteria proposed by the Sexual and Gender Identity Disorders Work Group for the DSM-5 represent some forward progress on issues of social stigma and barriers to medical transition care, for those who need it. However, they do not go nearly far enough in clarifying that nonconformity to birth-assigned roles and victimization from societal prejudice do not constitute mental pathology. The improvements in the APA proposal so far include a more accurate title, removal of Sexual Orientation Subtyping, rejection of “autogynephilia” subtyping (suggested in the supporting text of the GID category in the DSM-IV-TR), recognition of suprabinary gender identities and expressions, recognition of youth distressed by anticipated pubertal characteristics, and reduced false-positive diagnosis of gender nonconforming children. However, the proposed GD criteria still fall short in serving the needs of transsexual individuals, who need access to medical transition care, or other gender-diverse people who may be ensnared by false-positive diagnosis.

The proposed Gender Dysphoria criteria continue to contradict social and medical transition by mis-characterizing transition itself as symptomatic of mental disorder and obfuscating the distress of gender dysphoria as the problem to be treated. The phrase “a strong desire,” repeated throughout the diagnostic criteria, is particularly problematic, suggesting that desire for relief from the distress of gender dysphoria is, in itself, irrational and mentally defective. This biased wording discourages transition care to relieve distress of gender dysphoria and instead advances gender-conversion psychotherapies intended to suppress the experienced gender identity and enforce birth-assigned roles. The World Professional Association for Transgender Health (WPATH) has stated that, “Such treatment is no longer considered ethical.” (SOC, Ver. 7, 2011)

Transitioned individuals who are highly functional and happy with their lives are forever diagnosable as mentally disordered under flawed criteria that reference characteracterics and assigned roles of natal sex rather than current status. For example, a post-transition adult who is happy in her or his affirmed role, wants to be treated like others of her/his affirmed gender, has typical feelings of those in her/his affirmed gender, and is distressed or unemployed because of external societal prejudice will forever meet criteria A (subcriteria 4, 5 and 6) and B and remain subject to false-positive diagnosis, regardless of how successfully her or his distress of gender dysphoria has been relieved. Once again, the proposed criteria effectively refute the proven efficacy of medical transition care. Political extremists and intolerant insurers, employers, and medical providers will continue to exploit these diagnostic flaws to deny access to transition care for those who need it. The World Professional Association for Transgender Health (WPATH) has affirmed the medical necessity of transition care for the treatment of gender dysphoria. (SOC, Ver. 7, 2011)

The criteria for children are slightly improved over the DSM-IV-TR, in that they can no longer be diagnosed on the basis of gender role nonconformity alone. However, the proposed criteria are unreasonably reliant on gender stereotype nonconformity. Five of eight proposed subcriteria for children are strictly based on gender role nonconformity, with no relevance to the definition of mental disorder. Behaviors and emotions considered ordinary or even exemplary for other (cisgender) children are mis-characterized as pathological for gender variant youth. This sends a harmful message that equates gender variance with sickness. As a consequence, children will continue to be punished, shamed and harmed for nonconformity to assigned birth roles.

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 (Lev, et al., 2010; Winters and Ehrbar 2010; Ehrbar, Winters and Gorton 2009). 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. Psychologist Anne Vitale (2010) has previously described this distress as deprivation of characteristics that are congruent with inner experienced gender identity, in addition to distress caused directly by characteristics that are incongruent.

Building on this prior work, I propose that gender role component of gender dysphoria, including distress with a current incongruent social gender role and distress with deprivation of congruent social gender expression, can be more concisely described as impairment of social function in a role congruent with a person’s experienced gender identity. I believe it is also important to include other important life functions, such as sexual function in a congruent
gender role. This language would provide a clearer understanding of the necessity of social and medical transition for those who need them.

These alternative criteria acknowledge that experienced gender identity may include elements of masculinity, femininity, both or neither and are not limited to binary gender 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 the following diagnostic criteria for the Gender Dysphoria for adults/adolescents and children–

A. Distress or impairment in life functioning caused by incongruence between persistent experienced gender identity and current physical sex characteristics in adults or adolescents who have reached the earlier of age 13 or Tanner Stage II of pubertal development, or with assigned gender role in children, manifested by at least one of the following indicators for a duration of at least 3 months. Incongruence, for this purpose, does not mean gender expression that is nonconforming to social stereotypes of assigned gender role or natal sex. Experienced gender identities may include alternative gender identities beyond binary stereotypes.

A1. Distress or discomfort with one’s current primary or secondary sex characteristics,
including sex hormone status for adolescents and adults, that are incongruent with
experienced gender identity, or with anticipated pubertal development associated with
natal sex.
A2. Distress or discomfort caused by deprivation of primary or secondary sex
characteristics, including sex hormone status, that are congruent with experienced
gender identity.
A3. Impairment in life functioning, including social and sexual functioning, in a role
congruent with experienced gender identity.

B. Distress, discomfort or impairment is clinically significant. Distress, discomfort or
impairment due to external prejudice or discrimination is not a basis for diagnosis.


World Professional Association for Transgender Health (2011), Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People,

Lev, A.I., Winters, K., Alie, L., Ansara, Y., Deutsch, M., Dickey, L., Ehrbar, R., Ehrensaft, D., Green, J., Meier, S., Richmond, K., Samons, S., Susset, F., (2010). “Response to Proposed DSM-5 Diagnostic Criteria. Professionals Concerned With Gender Diagnoses in the DSM.” Retrieved December 4, 2010 from:

Winters, K. and Ehrbar, R. (2010) “Beyond Conundrum: Strategies for Diagnostic Harm Reduction,” Journal of Gay & Lesbian Mental Health, 14:2, 130-139, April

Ehrbar, R., Winters, K., Gorton, N. (2009) “Revision Suggestions for Gender Related Diagnoses in the DSM and ICD,” The World Professional Association for Transgender Health (WPATH) 2009 XXI Biennial Symposium, Oslo, Norway,

Vitale, A. (2010) The Gendered Self: Further Commentary on the Transsexual Phenomenon, Lulu, http://


Copyright © 2012 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.

11 Responses to Third Swing: My Comments to the APA for a Less Harmful Gender Dysphoria Category in the DSM-5

  1. Pingback: Third Swing: My Comments to the APA for a Less Harmful Gender Dysphoria Category in the DSM-5 « Women Born Transsexual

  2. oatc says:

    Your suggestions would leave only transsexual people landed with the resulting mental disorder diagnosis, when research has shown that, once a social and medical transition is complete, we are above the norm for the general population on mental health indices. Such a condition is obviously not a mental disorder. The sufferers do not need, and are likely further harmed by the stigma and misunderstandings that result from such a misdiagnosis. To falsely maintain such a diagnosis simply in order to allow certain professionals to claim money, to the detriment of their patients, more than verges on fraud, and trashes ethics.

    But anyway, none of your suggestions or mine have a chance of passing the revision committee as it was established under the Bush presidency. Instead, in line with current HHS policy (HHS paying the bills), all the gender identity diagnoses need to be removed, at this revision, from the DSM, and thence the ICD. If certain medical treatments can instead be added to physical medicine sections of the ICD, fine. But if not there are already enough codes in there which can be suited. We have to agree on this. All other approaches lead to many more years of harm.

    And may I ask why you, despite being an adviser to TYFA, think “current physical sex characteristics” can only be significantly distressing in those “who have reached the earlier of age 13 or Tanner Stage II”? Is a child trying to cut off her penis at four insignificant? A ten-year-old turning her parts black with a band for a long period? Or an 11-year-old exclusively experiencing sexual desire that necessitates the totally other genitalia? Do you think any such child “changes their mind”? Why is transsexualism of children still considered so secret that it must not even be revealed by those discussing reform of the medical manuals that misdiagnose it?

    • gidreform says:

      My suggestion would exclude happy post-transition people from diagnosis altogether. In my view a transition related diagnostic coding is only needed for access to hormonal and/or surgical transition care. And I agree that mental classification of that Dx coding is a flawed classification. Please see the link below for the latest proposal by the WHO to move transition related codings altogether out of the psychiatric chapter of the ICD-11.

    • gidreform says:

      It’s the adult and adolescent diagnosis that would have a bound of Tanner II puberty or later. This is the coding that would be used for access to blockers in early adolescents and hormones and/or surgical care for later. My view is that children too young to receive blocker or medical transition care need to be left alone to express their authentic selves in a safe environment. It is not helpful to label their gender identities as mental or physical pathologies. For those young children who need access to special services or accommodations, I am now advocating non-pathologizing Z-codes in the ICD-11, which could be used in combination with existing anxiety/mood codings for the intensely distressed kids that you describe (I was there personally). Stay tuned for an upcoming post on these proposals.

  3. I find the abandonment of “Disorder” in Gender identity Disorder while introducing it for Intersex as disorders of sex development profoundly hypocritical. I likewise find the silence of Trans activists on this issue quite sad given their call for solidarity and support for their crusade to depathologise .
    WPATH and its affiliates is prime in using pathologising language to describe Intersex while proclaiming that same language as stigmatizing when applied to Transgender.

    • gidreform says:

      I agree that I and other trans community members and advocates have been too silent on issues and defamatory terminology impacting the IS community .

      • Enfranchise says:

        The responses by Enfranchise, the international human rights group of women with transsexual childhoods, to all the consultation opportunities provided by the APA in respect of proposed continued listings of sex- and gender-identity matters (of both children and adults) explicitly opposed adding intersex people to those listings, just as all the reasons to delete those listings were clearly stated.

        It seems clear that Intersex concerns, as well as those of transsexual children and people once transsexual but who continue to have these false and abusive diagnoses on our files, have been totally disregarded by this disgraceful travesty of a process. Instead, it seems, unethical and self-interested practitioners happy to use a false diagnosis as a means to income and furthering their research portfolio, and foolish people who have bowed to pressure from abusive administrators and practitioners who threaten to withdraw access to treatment unless they accept a fraudulent and false mental illness diagnosis, may have won for another decade or more.

        It is also important to note that, although this travesty was initiated with money and staff assistance from a Bush-era – and transphobic – federal administration’s DHHS, and thus is subject to federal equality and ethics policies, the LGBT-positive Obama administration seems to have entirely failed to challenge the way was it was structured to ensure the continuation of harm, or its outcome. Also that influential LGB groups and professionals seem to have involved themselves to also continue the abusive and fraudulent listings. GLAAD’s trumpeted misrepresentation of the outcome this week is a continuation of that. The influence of ignorant LGB groups upon the administration may explain its failure.

        These are huge betrayals which will harm many people – including very vulnerable children – over the coming years, unless – and there is still time – the federal authorities step in now to honor their own equality policies and require change.

        To be absolutely clear about this: the US government has funded the APA to continue official backing for statements and belief that people whose sex- and gender-identity does not match their sex at birth are “mad”, despite all evidence being of normal sanity by all other criteria. People who are the most likely to be denied human rights, abused and murdered, worldwide. People who the US State Department, and US-sponsored UN resolutions say they aim to save from discrimination. Not least those – especially children – whose very identity, and lives, are very often challenged daily by being abusively told they are “mad” and therefore deserve mistreatment, or – very specifically – are therefore incapable of knowing, or consenting to the medical assistance they need.

        Everyone knows that it is abuse to called someone “mad”. What does one call paying for that to be done officially, worldwide? What’s the word for doing that whilst mouthing equality policies, giving awards at swanky dinners, or making “It gets better” videos?

        BM-Enfranchise, London WC1N 3XX

  4. becky says:

    Is the mug in the photo actually real? I know someone who would kill for that!

  5. Pingback: A Wish for Wings that Work*, Part 2: A Cogent Definition of Gender Dysphoria for the SOC8 | Trans Policy Reform Blog

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