Diane Ehrensaft, Ph.D.
Director of Mental Health
Child and Adolescent Gender Center
University of California Benioff Children’s Hospital
Associate Professor of Pediatrics, UCSF

A presentation to the Gender Infinity conference
Houston, TX
September, 2016
Posted here by permission

Presentation slides:


It’s Time to Update the Title of the International Journal of ‘Transgenderism’

Kelley Winters, Ph.D.
GID Reform Advocates

The International Journal of Transgenderism (IJT) is a quarterly academic journal on topics of transgender healthcare, policy and education, and it is the official journal of the World Professional Association for Transgender Health (WPATH). WPATH is best known for publication of internationally respected standards of care for trans people who require transition related hormonal and/or surgical treatment. The Journal was founded in 1998 and has been published by the U.K. based Taylor & Francis Group.

The IJT has a good reputation for reliable scholarship on trans issues among a cohort of sexology journals where attitudes and bias toward trans and gender diverse people are not always respectful. However, the term, “transgenderism,” in the title is anachronistic in the 21st Century. It reflects a historic pathological model of gender diversity, lacks focus on the aims of the journal and is widely considered derisive.

I call on the President and Board of Directors of WPATH, as well as the Editor and Editorial Board of the journal, to update the title of the International Journal of Transgenderism to:

The International Journal of Transgender Health.

The Merriam-Webster Dictionary defines the noun suffix, “ism,” in terms of acts or practices (such as racism and sexism); states or pathological conditions (such as barbarianism and alcoholism); or doctrines or political orthodoxies (such as Calvinism and conservatism). None of these meanings relate to the experience of being transgender. No other communities in LGBTQ spectra are called, “isms.” We don’t refer to our diverse populations with terms like “homosexualism,” “lesbianism,” or “queerism.”

Moreover, the term, “transgenderism” has a long history of defamatory use by those opposed to human rights and civil justice for trans individuals. Opponents prefer that term, because it conveys  illicitness and inspires fear. The theo-political extremist group, Focus on the Family, has published more than eight anti-trans position papers in recent years with the term, transgenderism, in their titles, including, “‘Transgenderism’ Brings Chaos from Order,” “Desensitizing Society on Transgenderism,” and “Title IX and Transgenderism: The New Threat in Your Child’s School.”

The GLAAD Media Reference Guide refers to “transgenderism” as a problematic term for social and historic reasons:

This is not a term commonly used by transgender people. This is a term used by anti-transgender activists to dehumanize transgender people and reduce who they are to “a condition.” Refer to being transgender instead, or refer to the transgender community. You can also refer to the movement for transgender equality.

Finally, in 2007, the Harry Benjamin International Gender Dysphoria Association (HBIGDA) changed its name to the World Professional Association for Transgender Health (WPATH) to clarify in its title the mission “to promote evidence based care, education, research, advocacy, public policy, and respect in transgender health.” It is time to align the title of WPATH’s scholarly journal to its mission and its message.


Note:  I am a member of the World Professional Association for Transgender Health. The opinion given here is solely my own.

Media Misinformation About Trans Youth: The Persistent 80% Desistance Myth

Kelley Winters, Ph.D.
GID Reform Advocates

Jesse Singal, Senior Editor at, has enlisted his New York Magazine blog in the promotion of the 80% “desistance” stereotype for gender dysphoric children and youth–the widely publicized presumption that painful distress with birth-assigned sex and gender are just a phase for the great majority of children who suffer it:

While the actual percentages vary from study to study, overall, it appears that about 80 percent of kids with gender dysphoria end up feeling okay, in the long run, with the bodies they were born into.

Singal praised the 80% “desistance” presumption as “solid scientific consensus” and boasted that “every”  study, not some, but “every study that has been conducted on this has found the same thing.” He scorned those who do not accept the 80% presumption (Tannehill 2016, Serano 2016, Olson and Durwood 2016) as “part of problem,” as essentially “ignoring” science, and preventing “intelligent, informed discussion.”

The real problem, however, is that Singal’s support for the 80% presumption and its promoters from the Toronto Clarke Institute/Centre for Addiction and Mental Health (CAMH) and the Dutch VU University Medical Center rests on a critical, misleading statement in this article:

It’s hard to imagine a kid meeting all the necessary criteria in the DSM-IV and not ‘actually’ being gender dysphoric… Since 63 percent of the subjects in Singh’s study met these criteria, this really wasn’t a sample of children who were ‘just’ gender nonconforming.

The author preceded these remarks with a listing of the 1994 Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV, APA, 1994)) diagnostic criteria for “Gender Identity Disorder of Children” (GIDC, 302.6) that were used for intake selection in childhood “desistance” studies in Toronto and Amsterdam, but the actual diagnostic criteria contradicted his conclusion. In fact, the DSM-IV Subcommittee on Gender Identity Disorders deliberately chose to allow diagnosis of GIDC without any “explicit wish to be of the opposite sex” (Bradley, et al., 1991)–a loophole that sidestepped gender dysphoria and was corrected in the DSM-5. Subcriterion 1 of Criterion A referenced nonbirth-assigned gender identity but was not required for diagnosis:

“1. Repeatedly stated desire to be, or insistence that he or she is, the other sex.”

Only four of five subcriteria were required to meet Criterion A, and all of the other four subcriteria described gender nonconforming behaviors. Therefore, children could be judged to meet criterion A strictly on the basis of gender nonconformity, with no indication of actual gender dysphoria or incongruent gender identity.

Criterion B referenced gender dysphoria (in the Fisk, 1973, sense of distress with physical sex characteristics or assigned gender roles) but once again had loopholes that allowed diagnosis because of behavioral gender nonconformity without evidence of actual gender dysphoria. Birth-assigned boys could meet criterion B with “aversion toward rough-and-tumble play and rejection of male stereotypical toys, games, and activities.” So could birth-assigned girls with a “marked aversion toward normative female clothing.”

Criterion C excluded diagnosis for children with intersex conditions.

Criterion D was the clinical significance criterion, added to almost all categories in the DSM-IV. It required significant distress or impairment in “social, occupational, or other important areas of functioning.” However, the GIDC supporting text in the DSM-IV Text Revision (DSM-IV-TR, APA 2000, p. 577) maintained that distress from societal prejudice, rather than from gender dysphoria itself, would meet criterion D according to its authors.

Gender nonconforming children with no actual evidence of gender dysphoria were very easily misdiagnosed with “Gender Identity Disorder of Children” because of flawed diagnostic criteria the DSM-IV. Those criteria, and, astonishingly, subthreshold fulfillment of them, were used for sample selection in questionable studies that to this day are cited to support the 80% “desistance” myth (Winters 2008, 2014).

Conflation of a much larger superset of gender nonconforming children with a much smaller subset of gender dysphoric kids is not “solid scientific consensus.” Gender nonconformity is not gender dysphoria. Children who were never gender dysphoric to begin with are not “desistant.”


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

S. Bradley, Ray Blanchard, et al. (1991). Interim Report of the DSM-IV Subcommittee on Gender Identity Disorder. Archives of Sexual Behavior, Vol. 20, 4, p. 339.

Fisk, N. (1973). Gender dysphoria syndrome. (The how, what, and why of a disease). In D. Laub & P. Gandy (Eds.), Proceedings of the second interdisciplinary symposium on gender dysphoria syndrome (pp. 7–14). Palo Alto, CA: Stanford University Press.

Olson, K. and Durwood, L. (2016) Are Parents Rushing to Turn Their Boys Into Girls? Slate, Jan. 14.

Serano, J. (2016)  placing Ken Zucker’s clinic in historical context. Whipping Girl, Feb. 9.

Singal, J. (2016). What’s Missing From the Conversation About Transgender Kids, Science of Us, New York Magazine, July 25.

Tannehill, B. (2016). The End of the Desistance Myth. Huffington Post: the Blog, Jul 18.

Winters, K. (2008). Disallowed Identities, Disaffirmed Childhood. GID Reform Blog: Issues on reform of the diagnostic categories of Gender Identity Disorder and Transvestic Fetishism in the DSM-5, Oct. 28.

Winters, K. (2014). Methodological Questions in Childhood Gender Identity ‘Desistence’ Research. 23rd World Professional Association for Transgender Health Biennial Symposium, Feb. 16, 2014, Bangkok, Thailand.

Zucker, K. and Bradley, S. (1995). Gender Identity Disorder and Psychosexual Problems in Children and Adolescents, Guilford Press, p58

There is Truly Nothing Wrong with These Children

A Guest Post by
Karen Adams,
a Colorado Mother
Founder, Transgender Youth Education & Support
PFLAG Boulder County

The proposed stigmatizing diagnosis of Gender Incongruence of Childhood should be completely removed from the ICD-11.

Having facilitated a family support group for 7 years, personally worked with over 100 families and connected online with hundreds more, I have a great deal of experience with gender-expansive children. For the past several years, the majority of families have been contacting our group when their children are younger than 10 years old. Most of the children have been on a clear path to transition, and have proceeded into medical transition at a later time. Others have displayed gender-nonconforming behavior, become comfortable with their gender expression for several years, returned to our support group at the onset of puberty, and started their medical transition shortly after. A significant percentage of children work through clarification of their identity and settle into something other than gender conformity or transition. I am only familiar with a small handful of children who have expressed a cross-gender identity who later settled into a comfort level with their assigned birth sex. What stands out most from my experiences is how incredibly unique each child and family can be. I often say that the only thing I know for certain, is that the next time I pick up the support line, I will hear a story that is unlike any other I’ve heard before.

Our families encourage each other to love their child unconditionally and share resources so parents can educate themselves regarding the medical, social, and legal implications of raising a gender-expansive child. The only time outside services are required prior to puberty are when the parents need support to accept and understand their child’s needs, or when the child needs assistance clarifying their gender identity.

Simply based on the extremely wide variation in identities and needs I observe, our prepubescent children, defy any sort of classification system. Services for these children should readily be available under more generic service codes.

Were I to identify any singular thing that would dramatically improve the lives of all gender-expansive children, it would that be that each and every one of them needs to know that there is nothing wrong with them. Even basic parental acceptance dramatically improves the life and mental health of our kids. This is something I have observed in nearly every gender expansive child I know. Children who live in more liberal areas, who are able to more fully integrate their gender identity due to greater community acceptance, thrive. Even with parents who powerfully support their child, it’s amazing to observe the positive changes children experience when they move from a stigmatizing community to one that celebrates them. There is truly nothing wrong with these children. Changing the perspective from an understanding of gender as a binary absolute to more accurately reflect the experiences of humanity is the only category modification that is needed. The proposed stigmatizing diagnosis of Gender Incongruence of Childhood should be completely removed from the ICD-11.

De-pathologising gender difference is probably the most important step that can be taken to dramatically improve the lives of gender-expansive children.  The World Health Organization (WHO) has an opportunity to help gender-expansive children experience their birthright: the love of their family and community.

The American Psychiatric Association Issues Historic Position Statements on Trans Issues

Kelley outside the 2009 Annual Meeting of the APANow don’t be sad
‘Cause two out of three ain’t bad
–Meat Loaf, 1977

On May 18, 2009, about 150 trans community members and allies gathered outside the Annual Meeting of the American Psychiatric Association in San Francisco to protest diagnostic policies that psychopathologize gender diversity. Bull horn in hand, I and others called upon the APA leadership to issue three public position statements in support of the dignity and health of trans and gender variant people:

  1. That gender identity and expression which differ from assigned birth sex do not, in themselves, constitute mental disorder or impairment in judgment or competence.
  2. That hormonal and/or surgical transition treatment, for those who need them, is medically necessary and should be covered by insurance and health care policies.
  3. That the APA opposes discrimination on the basis of gender identity or expression and supports legal recognition of all people according to their gender identity and expression.

A month later, over 400 supporters endorsed a letter to APA President Alan Schatzberg and President-elect Carol Bernstein urging passage of these policy statements. The APA had, after all, issued numerous similar statements in support of other marginalized groups in past years but had never made a single position statement supporting civil justice and health care access for trans and gender variant people.

The response from APA officials was silence– three years of it.

Then last week, on August 16, the APA announced two of these position statements, authored by Drs. Jack Drescher and Ellen Haller and approved by votes of the Assembly and Board of Trustees. The first acknowledged the efficacy and medical necessity of hormonal and/or surgical transition treatment and the barriers to accessing this care faced by those who need it. Similar transition care policy statements were issued in 2008 by the American Medical Association, the American Psychological Association, and the World Professional Association for Transgender Health (WPATH).

Position Statement on Access to Care for Transgender and Gender Variant Individuals

Therefore, the American Psychiatric Association:

  1. Recognizes that appropriately evaluated transgender and gender variant individuals can benefit greatly from medical and surgical gender transition treatments.
  2. Advocates for removal of barriers to care and supports both public and private health insurance coverage for gender transition treatment.
  3. Opposes categorical exclusions of coverage for such medically necessary treatment when prescribed by a physician.

The second position statement acknowledges harassment and discrimination that trans and gender variant people face in employment, education, parental rights and civil justice. It notes that trans people are frequently victimized in violent hate crimes and inappropriately assigned in gender-segregated facilities . Similar nondiscrimination statements were issued by the National Association of Social Workers in 1999, the American Psychological Association in 2008, and WPATH in 2010.

Position Statement on Discrimination Against Transgender and Gender Variant Individuals

Therefore, the American Psychiatric Association:

  1. Supports laws that protect the civil rights of transgender and gender variant individuals
  2. Urges the repeal of laws and policies that discriminate against transgender and gender variant individuals.
  3. Opposes all public and private discrimination against transgender and gender variant individuals in such areas as health care, employment, housing, public accommodation, education, and licensing.
  4. Declares that no burden of proof of such judgment, capacity, or reliability shall be placed upon these individuals greater than that imposed on any other persons.

Although the American Psychiatric Association lags years behind other leading medical and mental health associations in speaking out, these position statements represent an unprecedented shift in acceptance of human gender diversity by the APA leadership and membership. The background text to the discrimination statement notes:

In contrast to its strong affirmation of lesbian and gay civil rights since the 1973 decision to remove homosexuality from the DSM, APA has not issued position statements in support of transgender civil rights… Other organizations, including the American Medical Association and the American Psychological Association, have endorsed strong policy statements deploring the discrimination experienced by gender variant and transgender individuals and calling for laws to protect their civil rights .

The statement text reaffirms the role of advocacy in the APA mission: “ Speaking out firmly and professionally against discrimination and lack of equal civil rights is a critical advocacy role that the APA is uniquely positioned to take.”  Given the APA’s unique position in setting diagnostic policy that has been historically used to limit civil justice and transition care access for trans people, these position statements come far better late than never.

However, the APA statements fall short of debunking the false stereotype that gender difference is inherently pathological. The association’s ambivalence on the mental illness stereotype is reflected in the “Report of the American Psychiatric Association Task Force on Treatment of Gender Identity Disorder ,” published in June, 2012:

The Task Force could not reach a consensus regarding the question of whether or not persistent cross-gender identification sufficient to motivate an individual to seek sex reassignment, per se, is a form of psychopathology in the absence of clinically significant distress or impairment due to a self-perceived discrepancy between anatomical signifiers of sex and gender identity. 

In other words, this APA Treatment Task Force (a separate group from the DSM-5 Task Force) declined to refute the false stereotype of “disordered” gender identity. This is troublesome, because the proposed diagnostic criteria for the Gender Dysphoria category in the pending Fifth Edition of the APA’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5) continue to mischaracterize gender identities and expressions that do not conform to birth-assigned gender stereotypes as symptomatic of mental illness. By describing social and medical transition itself, or the desire for transition, as pathological, the new Gender Dysphoria diagnosis, like its controversial predecessor Gender Identity Disorder (GID), contradicts rather than supports the medical necessity of transition care that is affirmed in the new APA position statement. Even worse, the Transvestic Disorder category in the DSM-5 ascribes nonconforming gender expression and medical transition for many transsexual women and men to a defamatory false stereotype of sexual deviance and paraphilia. Ironically, the medical care statement acknowledges these contradictions in the DSM–

…the presence of the GID diagnosis in the DSM has not served its intended purpose of creating greater access to care–one of the major arguments for diagnostic retention .

Thankfully, there is evidence of change in attitudes toward gender diversity at the American Psychiatric Association. In 2010, the DSM-5 Task Force proposed to rename the widely despised Gender Identity Disorder title (intended to imply “disordered” gender identity) to Gender Incongruence and a further change in 2011 to Gender Dysphoria (from a Greek root for distress). These revisions were explained as a paradigm shift from diagnosing difference to a focus on incongruence or discrepancy that causes distress or impairment.

we have proposed a change in conceptualization of the defining features by emphasizing the phenomenon of ‘gender incongruence’ in contrast to cross-gender identification per se.

The APA Position Statement on Discrimination contains the APA’s strongest statement to date that gender difference is not disease:

Being transgender gender or variant implies no impairment in judgment, stability, reliability, or general social or vocational capabilities; 

The fourth bullet point of the APA Position repeats this key principle:

Declares that no burden of proof of such judgment, capacity, or reliability shall be placed upon these individuals greater than that imposed on any other persons. 

This particular wording is historically significant; it is paraphrased from a 1973 quote by Dr. Robert Spitzer, chief editor of the DSM-III and DSM-III-R, arguing to depathologize same sex orientation:

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.

Throughout his career, Spitzer has refused to apply this same reasoning to the plight of gender variant and especially transsexual people, who continue to bear a very similar burden.

Though long overdue, these position statements on Discrimination and Access to Care for Transgender and Gender Variant Individuals represent a historic step forward in reducing barriers to civil justice and transition care access. But they do not go far enough in deconstructing false stereotypes that equate gender diversity with mental sickness and sexual deviance. In the context of the proposed gender diagnoses in the DSM-5 and the recent treatment task force report, they represent a mixed message. In contrast, the World Professional Association for Transgender Health issued an unambiguous De-Psychopathologisation Statement in 2010 that provides a model for professional organizations that serve trans and gender diverse people:

The WPATH Board of Directors strongly urges the de-psychopathologisation of gender variance worldwide. The expression of gender characteristics, including identities, that are not stereotypically associated with one’s assigned sex at birth is a common and culturally-diverse human phenomenon which should not be judged as inherently pathological or negative. The psychopathologlisation [sic] of gender characteristics and identities reinforces or can prompt stigma, making prejudice and discrimination more likely, rendering transgender and transsexual people more vulnerable to social and legal marginalisation and exclusion, and increasing risks to mental and physical well-being.

Please join me in thanking Drs. Drescher and Haller and the American Psychiatric Association leadership for these policy statements that acknowledge the worth and dignity of trans and transsexual individuals. In addition, I urge the APA to issue a position statement that gender identity and expression which differ from assigned birth sex do not, in themselves, constitute mental disorder; to correct diagnostic criteria in the proposed Gender Dysphoria category that malign gender nonconforming expression and transition itself as pathological; and to delete the punitive and scientifically capricious Transvestic Disorder diagnosis from the DSM-5.

Copyright © 2012 Kelley Winters, Ph.D., GID Reform Advocates

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


Final Public Comment Period For Proposed DSM-5 Criteria Ends June 15

Kelley Winters, Ph.D.
GID Reform Advocates

The American Psychiatric Association announced a third and final period of public comment on proposed diagnostic criteria for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), ending June 15.  Criteria for the draft diagnostic categories of Gender Dysphoria in Children and Gender Dysphoria in Adolescents or Adults (formerly Gender Identity Disorder, or GID) are unchanged from the second round proposal in May, 2011. The Sexual and Gender Identity Disorders Workgroup of the DSM-5 Task Force only partially responded to concerns raised about the GID diagnosis by community advocates, allies and care providers. Their specific diagnostic criteria continue to characterize gender identities and expressions that differ from birth-assigned roles as pathological and therefore contradict access to medical transition care, for those who need it, rather than lower its barriers.

Worse yet, the punitive and scientifically capricious diagnosis of Transvestic Disorder (formerly Transvestic Fetishism) offers no medical justification for its continued inclusion in the diagnostic manual, despite growing insistence on its removal. Many in the trans and allied communities are outraged at defamatory “autogynephilia”/”autoandrophilia” specifiers in this diagnosis that falsely stereotype many transsexual women and men as self-obsessed sexual fetishists. An online petition, sponsored by The International Foundation for Gender Education (IFGE) now has over 6,700 signatures, calling for complete removal of the Transvestic Fetishism/Disorder category from the DSM.

What You Can Do Now

  1. Ask the APA to fix the Gender Dysphoria diagnosis– rejecting diagnostic criteria and categorical placement that currently contradict transition or depict transition itself as symptomatic of mental disorder. Ask them to clarify that nonconformity to birth-assigned roles and being victims of societal prejudice are not, in themselves, mental pathology. Demand that the APA remove the defamatory Transvestic Disorder diagnosis entirely. Go to the APA DSM-5 web site, click on “register now,” create a user account and enter your statement in the box. The deadline for this third period of public comment is June 15.
  2. Sign the IFGE sponsored petition to remove the cruelly hurtful Transvestic Disorder category from the DSM-5.
  3. Ask your local, national and international GLBTQ nonprofit organizations to issue public statements to clarify that nonconformity to birth-assigned roles and being victims of societal prejudice are not, in themselves, mental pathology.
  4. Ask mental health and medical professionals who work with the transcommunity to voice their concerns to the APA.
  5. Spread the word to your network of friends and allies.