Gender Troubles: What’s Wrong With the WHO Proposal for Gender Incongruence in Childhood, by Dr. Sam Winter

Guest Post by
Sam Winter, Ph.D.
Faculty of Education,
University of Hong Kong.
Previously a member of the
World Health Organization (WHO)
Working Group on Sexual Disorders and Sexual Health.

[Formatted pdf version of this paper]

As most visitors to the GIDReform Advocates site will know, the World Health Organization (WHO) diagnostic manual (commonly known as the International Classification of Diseases) is currently under revision. The new edition, ICD-11, is slated for approval in 2017. I was a member of the WHO Working Group on Sexual Disorders and Sexual Health (WGSDSH), the eleven-member group which proposed a number of revisions relevant to trans people. The original WHO plans, for all our proposals to be loaded in October 2012 onto a website, for all the world to see (and comment on), never happened. Indeed, the WHO Secretariat running the show have imposed, apparently as it suits them and somewhat inconsistently, fairly onerous confidentiality rules which have prevented WGSDSH members and others from openly sharing what is going on. That said, WHO has shown itself to be comfortable with releasing material from time to time, particularly at academic conferences, as well as in the odd journal article.

One such article, in late 2012, was the one by Jack Drescher, Peggy Cohen-Kettenis and myself (all of us WGSDSH members) in which we reported a key proposal, that current ICD diagnoses commonly used with trans people (the flagship diagnosis for adolescents and adults being transsexualism) should be replaced by one called gender incongruence, and that this diagnosis should be moved out of ICD’s Chapter 5 (Mental and Behavioural Disorders) and into another chapter. Our rationale was that it was important to retain access to gender affirming healthcare for those trans people who needed it, but that the classification as a mental disorder actually undermined that goal, as well as adding to stigma. Our preference was for placement in a stand-alone chapter, but (with this prospect unlikely) an alternative was placement in a broad chapter on sexual and gender-related health.

In a corner of a little table within that article we were able to mention that the proposal was actually for two gender incongruence diagnoses: Gender Incongruence of Adults and Adolescents (GIAA), and Gender Incongruence of Childhood, for children below the age of puberty (GIC).

The appointment to the WGSDSH was for two years. The two years is well and truly over. It has been a long time since WHO Geneva wrote to me about anything. I do not know whether the WGSDSH still exists. If it does I assume I am no longer a member. So now I can talk.

The GIC proposal has been hatched in a small WGSDSH sub-group consisting of three members (in which my voice was a minority). It was never properly discussed in the full WGSDSH. I had misgivings about the proposal. The case for a diagnosis, to be used with gender different children below the age of puberty, seemed uncertain. My misgivings grew as a result of discussions with trans activists. They continued to grow as reports came in from independent reviewers contracted by WHO to look over the WGSDSH proposals. My attempts to have the GIC proposal discussed in the full WGSDSH were stifled by the WHO Secretariat. It became clear to me that WHO was committed to going ahead with the GIC proposal, at least as far as field trials, and that I would have to work against this proposal from the outside.

The arguments for GIC (commonly that it is needed to justify the existence of specialist clinics, for training purposes, to generate research) really don’t stand up to scrutiny. Worse, the GIC case was entirely undermined by the fact that we (WGSDSH and WHO) were making entirely different proposals in regard to young people exploring (and learning to become comfortable expressing) their sexual orientation. The proposal was that disease diagnoses for these individuals should be removed. And yet here we were, proposing a disease diagnosis for young children exploring (and learning to become comfortable expressing) their gender identity. It seemed to me that there was a hypocrisy at play, and a transphobic hypocrisy at that.

Finally, with Cochran et al’s new paper in the WHO Bulletin which makes public for the first time the proposals for the sexual orientation diagnoses, I am able to release a report I wrote last year, first of all for the WPATH ICD Consensus Meeting in San Francisco (the one that split 14:14 on the GIC proposal) and then for the Global Action for Trans* Equality (GATE) Experts’ Meeting in Buenos Aires (the one that produced alternative proposals for meeting the needs of gender different children).

The opposition to the GIC proposal has now become a worldwide chorus. As well as the voices of GATE, and voices within WPATH, there is the International Campaign Stop Trans Pathologisation (STP), which recently focused its campaign on fighting the pathologisation of children. Participants at a recent trans health conference in South Africa are developing a Cape Town Declaration calling on WHO to discard the proposal. Several other community and professional groups are discussing the issue and can be expected to voice their opposition in the future.

In order to facilitate the debate, I offer here on GIDReform a reduced version of the paper I wrote for the earlier two meetings (WPATH Consensus and GATE Experts’). Some of you may have read it as an Appendix to the WPATH ICD Meeting Report (pages 58-67).This paper makes reference to other documents available to participants at the WPATH Consensus Meeting, but not included here. Readers can access some of those documents, cited in the report of that meeting.

Arguments against the proposed Gender Incongruence in Childhood diagnosis.

In this document I present arguments against the draft proposal for a diagnosis of gender incongruence in childhood (‘GIC’).

Briefly, I believe that the proposed GIC diagnosis pathologises patterns of development that should not be pathologised, that the diagnosis is inconsistent with the approach the Working Group proposes for other children and youth (including, importantly, homosexual youth), that the pathologisation carries risks for the gender-different child (and indeed for the broader work of the Working Group), and that there are alternative ways of providing health care services for gender-different children (plus their parents, teachers and others) who may need such services.

In short the argument is for de-pathologising, rather than simply de-psychopathologising, gender difference in childhood.

A few words about my role in this process. I am the member of the WGSDSH1 (the ‘Working Group’) which has worked on developing the draft proposals you have in your papers. I was also in the small subgroup which worked on the draft gender incongruence proposals, again in your papers. With the other two members of that subgroup I am a co-author of the Minding the Body paper,2 which argues for removal of transgender diagnoses from ICD Chapter 5 (Mental and Behavioural Disorders), and which has, in the table on p570, drawn wide attention to a proposed child diagnosis.

I, like others, have misgivings about the GIC proposal; a proposal which focuses on gender incongruent children below the age of puberty. My concerns have grown in recent months, largely as a result of discussions with professionals and scholars working in the field. Letters from the following persons not at the meeting have been made available to participants at this meeting: Dr Elizabeth Riley (counseling psychologist working in Sydney, Australia), Dr Lisa Griffin (clinical psychologist, working in Virginia, USA), Dr Antonia Caretto (clinical psychologist, Michigan, USA), Dr Kelley Winters (author of the book Gender madness in American psychiatry, currently resident in Florida USA), and Dr Arnaud de Villiers, medical clinician and activist on transgender health issues in Africa (Cape Town, South Africa). They all express some sort of misgiving about the child diagnosis, and many argue the sort of strategies I argue for here. Indeed my ideas have in some cases been shaped by their own.

Please note that my own misgivings place me in a minority (of one) in the small subgroup which has worked on the Working Group gender incongruence diagnoses. As you might expect, I am therefore not a co-author of the Background Discussion Document3 (provided by WHO and among your papers), recently prepared (I assume) by the other two subgroup members.

I am comfortable sharing my perspective on the proposed GIC diagnosis. My contribution to this debate is my acquaintance with the broader aspects of health and rights for transgender people, particularly as those things apply in Asia.

Here are my arguments in more detail.4

1: The view of gender-different children as sick and in need of health care is a culturally-specific one, not only modern but also peculiarly Western in origin.

It is clear that many transgender people worldwide5 live in cultures that are more accepting of gender difference than is the case in much of the West. Many of these cultures have a long history of inclusivity in regard to such persons,6 inclusivity that was anathema to European colonists and missionaries,7 but some of which survives to this day.8 In these cultures there are often a range of identities available to young children who grow up gender-different.9 Many of these roles had (or indeed still have) particular social, cultural, or even spiritual or religious significance.10 Today, in parts of the global south and east, many such children begin to identify in another gender quite early in life, doing so before puberty, and are recognized by others as being members of their affirmed gender group, even if in the modern world there are often, at home and school, limits to the degree to which they can express that identity. Those limits in any case often loosen by the time they approach school-leaving age.

Many individuals growing up in these social environments appear to enjoy (in childhood, adolescence and adulthood) relatively good psychological adjustment (despite sometimes having to endure broader societal stigma).11 Though a gender-different child’s gender identity and expression may not be universally celebrated by parents and teachers, that identity and expression tends to be accepted by them as diversity rather than mental or medical disorder. In thirteen years working in with transgender people in Asia I recall very few informing me that their parents had taken them to see a doctor when they were a child. Asian transgender activists who have written to me since my arrival in San Francisco a couple days ago confirm that it is relatively rare for parents to do so.

The view of gender-different children as sick is therefore a somewhat culture-specific one; not only modern but also peculiarly Western. (And it is a view that may aggravate whatever societal stigma is out there, but I’ll come back to that point later).

Now let’s consider what health care we actually provide to these ‘sick’ children (those who according to this Working Group proposal would be diagnosed as gender incongruent).

2: Gender-different children have no need of hormones or surgery, or any other somatic gender health care. Insofar as they may benefit from any health care services at all (and an indeterminate number may not need it) their needs are focused on accessing counseling and (perhaps) other mental health care.

They may need support and information to help in exploration of their gender issues (for example ‘Who am I?’, ‘What shall I do about it?’), ways of dealing with the challenges arising from gender expression (for example ‘Why won’t people let me be who I want?’, ‘Why do they treat me the way they do?’, ‘How should I handle this?’) and arising from any bodily concerns they may have (for example ‘Why do I feel this way about my body?’, ‘What can I do about it?’, ‘When?’, ‘With what effects?’). Parents, teachers and siblings may also benefit from some support information about gender issues, and from counseling as to how they should respond to their child’s gender issues.

I suggest all this provides no justification for a transgender specific and pathologising diagnosis of the sort the GIC represents. Consider, for comparison, other children with identity issues, or who find themselves confronted by circumstances (either in or out of their control) which bring them pain. An ethnic minority boy may want to explore his ethnic identity, and deal with the difficult or painful challenges of living in a racist society. But we do not diagnose him as having an ethnic disorder. A girl with divorced parents may need to explore difficult or painful family issues, and deal with unkind teasing at school. But we do not diagnose her as having a divorce disorder. A girl and her parents may want her to be top in the class, and she may feel great pain for not achieving this, and experience rejection at home. But we do not give her a diagnosis of educational aspiration disorder. In all these cases the child needs (and a health care provider would hopefully seek to provide) information, support and a more supportive environment that enables the child’s development. But he or she would do this without pathologising the child who finds him/herself in this situation. It is difficult to see why it should be different for gender-different children.

What about those relatively few gender-different children who actually experience clinically significant distress about their situation. They may feel suicidal. They may be on the verge of self harm. For them there are already diagnoses available, the same diagnoses that might be used with a child clinically depressed or anxious in regard to ethnic minority status, parental separation or inadequate achievement. Of course, one would want to ensure that such diagnoses are not used to justify gender reparative care. But this is where Z codes can come in (more on this later)

One does not have to think of the ethnic minority child, the child from a broken family or the child with unmet achievement goals to see an inconsistency in the way the needs of the gender-different child are addressed. A comparison is even closer to home – gay and lesbian youth. And that leads us to the next section.

3: There is a grave inconsistency in the way the Working Group proposes to address the health care needs of (on one hand) gay and lesbian youth and (on the other) gender-different children.

The WHO Working Group has recommended deletion of the entire F66 block (‘psychological and behavioural disorders associated with sexual development and orientation’). Used with youth, F66.0 (sexual maturation disorder) currently pathologises the teenager who is distressed about his uncertain sexual orientation. F66.1 (ego-dystonic sexual orientation) currently pathologises the teenager who, knowing his or her sexual orientation, wishes it were different. The first youth needs support in exploring his or her sexual identity, and the second youth needs help in coming to terms with it, learning to feel comfortable expressing it, and dealing with the stigma and prejudice that comes from expressing it. These are needs that are directly analogous to those of gender-different children.

F66.0 and F66.1 (and a third diagnosis, F66.2 (sexual relationship disorder)) are widely regarded as providing a final repository for the thinking that underpinned the old homosexuality diagnosis (after all, how many youth are distressed by the possibility they may eventually turn out heterosexual, or about the actual fact that they are?). Part of the concern over the F66 block is that it raises possibilities for psychopathologising sexual variation, and for prompting or justifying stigma and human rights abuses, including sexual reparative therapy.

Few reputable clinicians would disagree with the proposed deletion of Block F66, or with the proposal that those with sexual orientation issues who would genuinely benefit from mental health care could be provided access to it by other diagnostic means. Significantly, the Working Group proposes that Z Codes may be used in these cases.

The F66 proposals present a gravely inconsistent approach. The inconsistency is in the way we address the mental health care needs of (on one hand) the gay and lesbian teenager exploring and coming to terms with his or her sexual orientation (and the expression thereof) and (on the other) the gender-different child exploring and coming to terms with his or her gender identity (and expression thereof). For lesbian and gay youth the move is away from diagnosis that pathologises. For gender-different children the Working Group proposes that a pathologising approach continues.

This inconsistency is all the more perplexing in view of the fact that, despite their names, the current sexual maturation disorder and ego-dystonic sexual orientation diagnoses (both proposed for removal) both explicitly incorporate gender identity.12

4: There are important implications for the prospects of removing the proposed gender incongruence diagnoses from Chapter 5.

The GIC diagnosis, a transgender specific diagnosis affording access only to mental health care, may conceivably come at the price of failure in broader moves to remove both diagnoses (GIC and GIAA13) from Chapter 5. Let me explain why I think this.

a. Undermining the case for removal of GIC from Chapter 5. A recommendation for a GIC diagnosis – a diagnosis aimed to facilitate health care that is exclusively mental health care – is fundamentally inconsistent with a recommendation to remove that diagnosis from Chapter 5 (the mental and behavioural disorders chapter). Indeed, with mental health care the only sort of help to be provided to the child, Chapter 5 would appear to be an obvious place for the diagnosis. The case for de-psychopathologisation of childhood gender difference is therefore undermined, and the case for retaining the child diagnosis in Chapter 5 is inevitably left in place for all those who would use it. This carries risks for ( a ) reduced recognition of gender status (e.g. the little transgender girl seen as a mentally disordered boy), ( b ) increased stigma, and ( c ) increased use of gender reparative approaches.

With regard to gender reparative approaches, the removal of F66.0 and F66.1 (diagnoses that have been used, for example in Hong Kong, to justify sexual reparative therapy) may increase the risk that some mental health care providers will resort to child gender reparative approaches, rationalised in terms of attempting to catch incipient homosexuality early and nip it in the bud. I suggest that this risk would be even higher if the proposal to remove the GIC diagnosis from Chapter 5 were to be rejected.14

b. Undermining the case for removal of GIAA. In view of the sibling relationship between GIC and GIAA (a relationship which is noted in the GIC Background Discussion Document) the case for removing the latter from Chapter 5 may also be undermined. The prospect that both diagnoses might stay in Chapter 5 is as alarming for transgender people in the global south and east as it would be for transgender people elsewhere. The idea that transgender people are mentally disordered already has a foothold there, and it appears to contribute to the stigma that sometimes blights transgender people’s lives. A recent research study in five Asian countries, as well as in the UK and USA, indicates that in Asia, as elsewhere, people who believe that transgender people suffer from a mental disorder also tend to harbour prejudiced attitudes towards them– attitudes which, if expressed in discriminatory behavior, would act to push transgender people towards the margins of society (Winter et al, 2009).

Those working in the West (or in countries influenced by the modern Western discourse on psychopathologisation) may sometimes forget that support for removal of the trans diagnoses from Chapter 5 is less than universal; there are plenty of clinicians worldwide who take a different view. Significantly, dissent was evident even among the experts WHO recently invited to review the Working Group proposals. One, from a place other than North America or Western Europe, remarked on the longstanding and broad consensus among health experts in his country that gender incongruence conditions are mental disorders, disorders that obviously involved a distortion of mental processes contributing to the formation of sexual identity.

In May 2015, the World Health Assembly, the governing body of WHO, is due to vote on ICD-11. Some proposals will no doubt prove more contentious than others. Insofar as there are clinicians and scholars internationally who share the views of the above reviewer, and (either as individuals or through their professional associations) have the ear of their governments, there is a risk that the proposal to remove GIC (and by extension GIAA) from Chapter 5 will be undermined.


With so many problems plaguing the GIC diagnosis, what is the way forward? The rest of this paper presents ideas. They are the product of long discussions (face to face and by e mail, with clinicians, scholars and activists worldwide.

A way forward.

An important way forward is provided by the non-pathologising Z codes.15 As is evident from the introductory material in the Z-Code chapter, these codes are designed for circumstances matching those in which gender-different children are liable to find themselves. 16

Importantly, the Working Group document which provides a rationale for deleting the F66 proposals notes that Z codes are an alternative (and less pathologising) way of providing health care to those with sexual orientation issues who are currently at risk of receiving a F66 diagnoses. Particularly relevant here is a section entitled ‘What is a disorder vs. a perceived need for mental health services?’ I quote:

……the ICD is structured to allow for two possibilities. First, the individual might have a clinically recognizable set of set of symptoms related to particular life circumstances, such as relationship distress, that is not a mental disorder, but it co-occurs with a recognizable mental disorder, such as Major Depression. In this situation, the diagnosis of Major Depression is applied. In the second situation, the individual may have a clinically recognizable set of symptoms, or ’problems’ but no underlying disorder. In this case, a Z category may be selected. The Z categories recognize that individuals can and do seek services, including mental health services, in the absence of a current mental health or behavioural disorder. For example, requesting help for tobacco cessation in the absence of tobacco dependency (Z72.0), or for assistance in developing coping skills when targeted for discrimination (Z62.5) are both types of presenting concerns that could result in classification with a Z category. A health encounter in which the person is requesting information about sexual matters in the absence of a mental disorder could be classified using a Z category as well. In this way, the ICD distinguishes between mental disorders and perceived need for mental health services in the absence of a diagnosable disorder.17

The Working Group then goes on to make three recommendations, as follows:

a) The deletion of the F66 categories in their entirety: As the review above demonstrates, the F66 categories do not meet the requirements for retention in the ICD-11. There is no evidence that they improve clinical utility, and reason to believe they create harm; no evidence of public health surveillance need; no evidence of research needs in order to track mental health morbidity; and the categories themselves raise significant human rights concerns.

b) The revision of several of the Z70 categories to better address sexual health and sexual relationship concerns at a more general level. These changes would focus more clearly on common reasons for seeking services as well as remove unnecessary focus on sexual orientation that currently lacks justification.

c) The revision of the descriptions of the Z60.4 and Z60.5 categories to encompass sexual orientation concerns. These changes would facilitate accurate coding of personal distress resulting from experiences with anti-gay stigma, and may also be useful as a part of public health surveillance to track human rights concerns related to sexual orientation. 18

A similar approach can be taken with those children liable, under current proposals, to be diagnosed with the pathologising GIC category. There are a number of Z codes that could prove relevant to the needs of gender-different children, to document examinations and other health encounters.

At the WPATH Consensus Meeting I presented proposals for ways in which the Z Codes could be used to facilitate appropriate health care for those gender-different children who might benefit from it, as well as to document contact with health care services. I argued that these codes could be used to help children explore and express their gender identities (and to support their efforts to cope with stigma) in the same way that the Working Group is proposing that the Z Codes could be used with gay and lesbian youth exploring and expressing their sexual orientation (and, again, to support their efforts to cope with stigma).

A more detailed proposal for using ICD-11 Z Codes to facilitate access to support services for trans and gender different children was developed at the GATE (Global Action for Trans* Equality) Consensus Meeting in Buenos Aires, April 2013.1920 It recommended revisions to include gender identity, gender expression as well as sexual orientation in codes:

Z60.4- “Exclusion and rejection on the basis of personal characteristics…”

Z60.5- “Persecution or discrimination, perceived or real, on the
basis of membership of some group…”

Z70.4- “Counseling for a child to support gender identity or
expression that differ from birth assignment.”

Z70.2x- “Counseling for families and service providers related to
gender identity or expression of a child.”

Importantly, where a child is genuinely suffering from anxiety and mood disorders associated with gender difference, Z Codes can be used to specify the nature of the distress, thereby enabling appropriate health care for the child involved. Further, when a child reaches puberty and is in need of puberty blockers (where they are available), Z Codes can be used to document a history of gender difference, thereby ensuring a prompt diagnosis of GIAA.21 Finally, when a gender-different child seeks adaptation at school (or elsewhere) to accommodate his or her gender difference, Z Codes can be used to provide a basis for the case being made.

In short, it is clear to me that Z Codes can play an important and appropriate role in provision of health care for gender-different children in their pre-puberty years, covering a wide range of encounters with health care providers, and a variety of health care-related services appropriate to their needs.

It is to be hoped that a Z Code approach with gender-different children will make it more likely that such children do indeed grow up comfortable with their gender; in the words of Jazz, liking who they are.



1 The WHO Working Group on Sexual Health and Sexual Disorders

2 Drescher, Cohen-Kettenis and Winter (2012)

3 Background Discussion Document on Proposed ICD-11 Category of Gender Incongruence of Childhood.

4 Childhood gender diagnoses have been the subject of much criticism. The Background Discussion Document on GIC to which I referred earlier reviewed some of the published critiques in the area, most of them in relation to the old DSM-IV diagnosis, gender identity disorder of childhood. I will not revisit that research here. I will add though, that the above document neglects to mention publications by experienced clinicians advocating gender affirmative approaches in work with these children and critical of less affirmative (and even repressive) approaches (Ehrensaft, 2011). Other recent additions to the literature are three Australian papers examining the views of three groups of stakeholder (parents of gender-different children, professionals, and transgender adults) on the needs of needs of gender-different children and their parents. Together they indicate concurrence on the importance of freedom of expression, acceptance, respect and support for the children, and for information and support for the parents (Riley et al, 2011a,b, 2012).

5 In the Asia-Pacific alone there are an estimated 9 to 9.5 million (UNDP 2012).

6 See for example Coleman et al (1992) and Urbani (2006) in relation to Myanmar; Matzner (2001) discussing Hawai’i; Schmidt (2001) discussing Samoa; Graham (2001, 2002) and Graham-Davies (2007) discussing Sulawesi in Indonesia; Jackson (2003) discussing Thailand; and Nanda (2000a,b,c) discussing Thailand, the Philippines, India and across Polynesia. Also see Peletz (2006, 2009) for a more general discussion of cultures of ‘gender pluralism’ in pre-modern Southeast Asia.

7 See for example Nanda (1990, 2000a), Brewer (1998, 2001).

8 For example Graham-Davies (2007); Vasey and Bartlett (2007).

9 For a (non-exhaustive) list of around 50 identity labels used in the Asia-Pacific by and/or for (those we in the West would call) transgender women see UNDP (2012)

10 A recent WHO Asia-Pacific regional consultation on transgender health, having drawn up a working definition of transgender, was at pains to add in an explanatory note: “Transgender persons in Asia and the Pacific often identify themselves in ways that are locally, socially, culturally, religiously, or spiritually defined.” (WHO 2013, page 18, current author’s emphasis).

11 I should stress that gender-different children in the global south and east don’t always find acceptance at home and school; not even in the most inclusive societies. Nor does it mean broader societal acceptance when the child reaches adulthood. The very real difficulties facing transgender people across the Asia-Pacific, particularly in the least inclusive societies, are very well documented. For a review of much of the research see UNDP (2012).

12 So does sexual relationship disorder, though in this case children with gender identity issues are not included.

13 Gender incongruence of adolescence and adulthood.

14 WPATH deems gender reparative approaches with children as unethical. “Treatment aimed at trying to change a person’s gender identity and expression to become more congruent with sex assigned at birth has been attempted in the past without success [references supplied], particularly in the long term [references supplied]. Such treatment is no longer considered ethical.” (WPATH, 2011, p16).

15 Z00-Z13 Persons encountering health services for examination and investigation; Z20-Z29 Persons with potential health hazards related to communicable diseases; Z30-Z39 Persons encountering health services in circumstances related to reproduction; Z40-Z54 Persons encountering health services for specific procedures and health care; Z55-Z65 Persons with potential health hazards related to socioeconomic and psychosocial circumstances; Z70-Z76 Persons encountering health services in other circumstances; Z80-Z99 Persons with potential health hazards related to family and personal history and certain conditions influencing health status.

16 Categories Z00-Z99 are provided for occasions when circumstances other than a disease, injury or external cause classifiable to categories A00-Y89 are recorded as “diagnoses” or “problems”. This can arise in two main ways:When a person who may or may not be sick encounters the health services for some specific purpose, such as to receive limited care or service for a current condition, to donate an organ or tissue, to receive prophylactic vaccination or to discuss a problem which is in itself not a disease or injury.

When some circumstance or problem is present which influences the person’s health status but is not in itself a current illness or injury. Such factors may be elicited during population surveys, when the person may or may not be currently sick, or be recorded as an additional factor to be borne in mind when the person is receiving care for some illness or injury.

ICD-10 online, at

17 Rationale for the Deletion of the F66 Categories in the ICD-11, p3.

18 Ibid. p21.

19 Global Action for Trans* Equality (2013) “Critique and Alternative Proposal to the ‘Gender Incongruence of Childhood’ Category in ICD-11,” GATE Civil Society Expert Working Group, Buenos Aires, April 4.

20 Winters, K. (2013) “From Gender Madness to Gender Wellness in the ICD-11,” National Transgender Health Summit, Oakland, CA, May.

21 Gender incongruence of adolescence and adulthood.


Reference list:

Brewer, C. (1998). Baylan, asog, transvestism, and sodomy: gender, sexuality and the sacred in early colonial Philippines. Intersections: Gender, History and Culture in the Asian Context. Retrieved 15th March 201 from

Brewer, C. (2001). Holy confrontation: religion, gender and sexuality in the Philippines, 1521-1685. Manila: Institute of Women’s Studies, St. Scholastica’s College.

Coleman, E., Colgan, P., & Gooren, L. (1992). Male cross-gender behavior in Myanmar (Burma): A description of the acault. Archives of Sexual Behavior, 21, 3, 313-321.

Drescher,J., Cohen-Kettenis,P. and Winter,S. (2012) Minding the Body. International Review of Psychiatry, December 2012; 24(6): 568–577

Ehrensaft,D. (2011) Gender born, gender made, raising healthy gender non-conforming children. New York: The Experiment Publishing.

Global Action for Trans* Equality (2013) “Critique and Alternative Proposal to the ‘Gender Incongruence of Childhood’ Category in ICD-11,” GATE Civil Society Expert Working Group, Buenos Aires, April 4.

Graham, S. (2001). Negotiating gender: ‘Calalai’ in Bugis society. Intersections: Gender, History and Culture in the Asian Context, 6.

Graham, S. (2002). Priests and gender in South Sulawesi, Indonesia Retrieved 14th August, 2011, from http://

Graham-Davies, S. (2007). Challenging gender norms: five genders among Bugis in Indonesia. Belmont: Thomas Wadsworth.

Jackson, P. (2003). Performative genders, perverse desires: a bio history of Thailand’s same-sex and transgender cultures. Intersections: Gender, History and Culture in the Asian Context, 9.Retrieved 30th March 2012 from

Matzner, A. (2001). ‘O au no keia’: voices from Hawaii’s Mahu and transgender communities. Bloomington: Xlibris.

Nanda, S. (1990). Neither man nor woman: the Hijras of India. Belmont, California,

Nanda, S. (2000a). Hijra and Sadhin: neither man nor woman in India. In Nanda, S. (Ed.), Gender diversity: cross- cultural variations. Long Grove, Illinois: Waveland Press.

Nanda, S. (2000b). Transgendered males in Thailand and the Philippines. In Nanda, S. (Ed.), Gender diversity: cross-cultural variations. Long Grove, Illinois: Waveland Press.

Nanda, S. (2000c). Liminal gender roles in Polynesia. In Nanda, S. (Ed.) Gender Diversity: Cross-Cultural Variations. Prospect Heights: Waveland Press.

Peletz, M. G. (2006). Transgenderism and gender pluralism in Southeast Asia since early modern times. Current Anthropology, 47, 2, 309-340.

Peletz, M. G. (2009). Gender pluralism: southeast Asia since early modern times. New York: Routledge.

Riley, E., Gomathi, S., Clemson, L and Diamond D (2011a). The needs of gender-variant children and their parents according to health professionals. International Journal of Transgenderism, 13:54–63, 2011

Riley, E., Gomathi, S., Clemson, L and Diamond D (2011b). The needs of gender variant children and their parents: a parent survey. International Journal of Sexual Health, 23:181–195, 2011

Riley,E., Clemson,L, Sithathan, G. and Diamond,M. (2012). Surviving a gender variant childhood: the views of transgender adults on the needs of gender variant children and their parents. Journal of Sex & Marital Therapy, 00:1–22, 2012

Schmidt, J. (2001). Redefining fa’afafine: Western discourses and the construction of transgenderism in Samoa. Intersections: Gender, History and Culture in the Asian Context, 6. Retrieved March 30th 2012 from intersections.

UNDP (2012).: Lost in Transition: Transgender People, Rights and HIV Vulnerability in the Asia-Pacific Region. Bangkok: UNDP Asia-Pacific Office.

Urbani, E.R. (2006). Because Buddha was a man: the ambiguousness of spirit mediums in Mandalay. Amsterdam, Netherlands: MA Thesis, Department of Sociology and Anthropology, University of Amsterdam.

Vasey, P. L., & Bartlett, N. H. (2007). What can the Samoan “fa’afafine” teach us about the western concept of gender identity disorder in childhood? Perspectives in Biology and Medicine, 50, 4, 481-490.

WHO (2009), International statistical classification of diseases and related health problems. – 10th revision, 2008 edition. Geneva: WHO

WHO (2013) Consultation on HIV, STI and
other Health Needs of Transgender People in Asia and the Pacific. Report of meeting 11-13 September 2012. Manila: WHO Regional Office for the Western Pacific.

Winters, K. (2008). Gender Madness in American Psychiatry: Essays from the struggle for Dignity, GID Reform Advocates,

Winters, K. (2013) “From Gender Madness to Gender Wellness in the ICD-11,” National Transgender Health Summit, Oakland, CA, May.



Winter,S., Chalungsooth,P., Teh Y.K., Rojanalert,N., Maneerat, K., Wong Y.W., Beaumont, A., Ho, M.W., L., Gomez, F., and Macapagal, R.A. (2009). Transpeople, transprejudice and pathologisation: a seven-country factor analytic study. International Journal of Sexual Health, 21, 2: 96-118.

WPATH (2011). Standards of care for the health of transsexual, transgender, and gender nonconforming people (seventh version). WPATH.

Gender Dysphoria Diagnosis to be Moved Out of Sexual Disorders Chapter of DSM-5

Protest at 2009 APA Annual Meeting (photo Kelley Winters)

Protest at 2009 APA Annual Meeting (photo Kelley Winters)

Dr. Jack Drescher,  a member of the subworkgroup on Gender Identity Disorders of the DSM-5 Workgroup on Sexual and Gender Identity Disorders, confirmed yesterday that the Gender Dysphoria Diagnosis will be removed from the sexual disorders chapter and placed in a separate category in the Diagnostic and Statistical Manual of Mental Disorders:

 GD is supposed to be placed in a chapter of its own, no longer linked with sexual dysfunctions and paraphilias (which will also have chapters of their own)

This reclassification, along with the change in title from Gender Identity Disorder to Gender Dysphoria, is a significant improvement in the diagnostic coding used for access to medical transition care, for trans and transsexual people who need it. Preceding diagnoses of Transsexualism/Gender Identity Disorders were grouped with “psychosexual” disorders in the DSM-III. They were briefly moved to the class of Disorders Usually First Evident in Infancy, Childhood or Adolescence in the DSM-III-R in 1987 but were returned to the sexual disorders chapter in the  DSM-IV, and DSM-IV-TR. Community advocates and supportive medical providers have long raised concern that this placement was clinically misleading and reinforced false stereotypes about gender diversity. Gender identity  is not specifically related to sexuality, sexual orientation or sexual dysfunction. Political and religious extremists have  exploited the sexual disorder grouping in the DSM to sexualize gender diversity and defame trans people as deviant. Trans and transsexual individuals have consequently lost their jobs, homes, families, children, and civil justice.

The DSM-5 working group responsible for sexual and gender diagnoses hinted at a possible change in diagnostic placement in February, 2010, stating

The subworkgroup questions the rationale for the current DSM-IV chapter Sexual and Gender Identity Disorders, which contains three major classes of diagnoses: sexual dysfunctions, paraphilias, and gender identity disorders… Various alternative options to the current placement are under consideration.

The decision to separate the revised Gender Dysphoria category from sexual disorders is consistent with a previous determination by the working group to remove sexual orientation specifiers from the diagnostic criteria. While many shortcomings remain in the proposed Gender Dysphoria diagnosis, this change in placement in the DSM represents forward progress for trans and especially transsexual individuals.

Unfortunately, the DSM-5 Task Force and APA Board of Trustees retained the Transvestic Disorder category in the sexual disorders chapter. Previous known as Transvestic Fetishism, it is grouped with paraphilic diagnoses such as pedophilia and exhibitionism and authored by Dr. Raymond Blanchard of the Toronto Centre for Addiction and Mental Health (formerly called the Clarke Institute of Psychiatry). This punitive and scientifically capricious category maligns many gender variant people, including transsexual women and men, as mentally ill and sexually deviant, purely on the basis of nonconforming gender expression. It is written to promote Blanchard’s unfounded theories of “autogynephilia” and “autoandrophilia” that conflate social and medical gender transition with fetishism. More than 7000 people have signed an online petition, sponsored by the International Foundation for Gender Education (IFGE), calling for the removal of this harmful diagnosis from the DSM.

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


These Aren’t the Droids You’re Looking For: Gender Diversity, Scapegoating and Erasure in Medicine and Media

Kelley Winters, Ph.D.
GID Reform Advocates

On the April 18th broadcast of The Rachel Maddow Show, Dr. Maddow reported an “explosive revelation” that Psychiatrist Robert Spitzer had rescinded his controversial 2001 claim that sexual conversion, or sexual reparative, psychotherapies can change sexual orientation in gay and lesbian people. Quoting an interview of Dr. Spitzer in The American Prospect, Maddow celebrated the historical significance of Spitzer’s reversal for the gay rights movement, calling it,

step one in what we’re now going to see as a real change, a real reckoning, in antigay politics.

Sadly, Dr. Maddow only told half of the story. For four decades, Robert Spitzer has played pivotal roles in mental health policies, not only on sexual orientation, but on gender diversity as well. This week, Rachel Maddow and other journalists turned a blind eye to Dr. Spitzer’s failure to retract a lifetime of trans psychopathologization, stereotyping gender identities and expression that differ from assigned birth roles as mental disease. This omission speaks to the marginal status of trans people within the GLbt rights movement and progressive media, as much as Spitzer’s omission speaks to trans marginalization by mental health policymakers. Shifting stigma from one oppressed class to a more oppressed class is not real change.

At the 1973 annual meeting of the American Psychiatric Association, Robert Spitzer played a central role in arguing for declassification of same-sex orientation as mental illness:

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.

This led to the gradual deletion of sexual orientation categories from the Diagnostic and Statistical Manual of Mental Disorders (DSM) between 1973 and 1987. The DSM is published by the American Psychiatric Association and remains the medical and cultural definition of mental disorder in North America. As Chairman of the DSM-III and DSM-III-R Task Forces and chief editor of the diagnostic manual, Spitzer oversaw removal of the last major vestige of gay diagnosis, “Ego-dystonic Homosexuality,” from version III-R.

However, while depathologizing same-sex orientation, Dr. Spitzer simultaneously directed a massive expansion of trans-pathology diagnoses in the DSM. In 1980, a new category of Gender Identity Disorders (GID), including a Transsexualism (TS) diagnosis, was added to the class of Psychosexual Disorders in the DSM-III. The TS coding was paradoxical and controversial for many trans people. Many community advocates and medical providers agreed (and do today) that some kind of diagnostic coding was necessary to facilitate access to medical and/or surgical transition care for those trans and transsexual people who needed it.  On the other hand, defining a medical transition coding as a mental illness, rather than a treatable medical condition, contradicted access to hormonal and/or surgical transition care and encouraged gender conversion, or gender-reparative, psychotherapies— unsubstantiated treatments attempting to change gender identity and shame trans and TS people into the closets of their assigned birth roles.  Vulnerable trans and gender nonconforming youth were targeted and institutionalized as a consequence of diagnostic criteria based on nonconformity to birth-assigned stereotypes.

In the DSM III-R, Dr. Spitzer’s Task Force expanded the diagnostic criteria for children to emphasize gender role nonconformity for birth-assigned girls, including “persistent marked aversion to normative feminine clothing” (whatever that means).  Even more damaging, a new category was added, Gender Identity Disorder of Adolescence or Adulthood, Nontranssexual Type (GIDAANT), to psychopathologize for the first time the gender identities of trans people who did not need access to medical transition care.

The disorder of Transvestism in the DSM-III was renamed “Transvestic Fetishism” in the DSM-III-R, to further stigmatize crossdressing or gender nonconformity by birth-assigned males as sexual obsession. This change served to sexualize a diagnosis that did not clearly require a sexual context in its diagnostic criteria.  The DSM-IV Casebook, edited by Dr. Spitzer in 1994, went even further in pathologizing gender nonconformity, recommending a Transvestic Fetishism diagnosis for a self-accepting bigender male, whose crossdressing was not necessarily erotically motivated and whose primary distress was his spouse’s intolerance.

In 2001, Robert Spitzer tacked to the political right on sexual orientation, presenting a paper entitled,”Can Some Gay Men and Lesbians Change Their Sexual Orientation? 200 Participants Reporting a Change from Homosexual to Heterosexual Orientation,” to the Annual Meeting of the American Psychiatric Association. It was published in the Archives of Sexual Behavior two years later. Spitzer promoted sexual conversion, or sexual-reparative, psychotherapies as “a rational choice” and affirmed their efficacy, stating,

there is evidence that change in sexual orientation following some form of reparative therapy does occur in some gay men and lesbians.

Moreover, Spitzer denied mounting evidence that sexual-reparative psychotherapies cause harm and even criticized the American Psychiatric Association for denouncing the practice as unethical.  At the same time, he revealed his bias on gender diversity and gender conversion therapies, describing “a greater sense of masculinity in males, and femininity in females,” as a therapeutic “benefit.”

By 2003, Dr. Spitzer’s statements had drawn a firestorm of dissent from GLB communities and supportive mental health professionals. Wayne Besen, founder of Truth Wins Out, characterized Spitzer’s study as,

just the latest attempt by the political religious right to gain legitimacy for their arguments by teaming up with a supposedly unbiased scientist.

Indeed, antigay extremists, including the National Association for Research & Therapy of Homosexuality (NARTH), embraced the Spitzer paper as mainstream endorsement of their sexual-reparative psychotherapies:

These results would seem to contradict the position statements of the major mental health organizations in the United States, which claim there is no scientific basis for believing psychotherapy effective in addressing same-sex attraction. Yet Spitzer reports evidence of change in both sexes…

Spitzer’s response to mounting criticism of his scientific rigor was to backpedal from his “rational choice” position, clarifying, “Of course no one chooses to be homosexual and no one chooses to be heterosexual.” At the very same time, however, he doubled down on his characterization of trans people as mentally defective.

2003 APA Annual Meeting

Sexual and Gender Identity Disorders symposium from the 2003 APA Annual Meeting. From the left, Drs. Karasic (speaking), Hill, Winters, Moser, Drescher, Spitzer (front), and Fink.

In May, 2003, Dr. Spitzer and I presented papers to a symposium entitled, “Sexual and Gender Identity Disorders: Questions for the DSM-V” at the Annual Meeting of the American Psychiatric Association. The only trans person and non-clinical scholar in the session, I sat on the left side of the stage table with presenters advocating reform of the Gender Identity Disorder (GID) and paraphilia diagnoses in the DSM-5. At the far right end of the table, Spitzer joined former APA President Dr. Paul Fink in defending the status quo. Spitzer wasted no time in invoking the worn stereotype of disordered gender identity:

Children normally develop a sense of gender identity. It is not taught—it just happens. I would argue that by itself, the failure to develop a gender identity that is congruent with biological gender is a dysfunction.

He continued, plodding down a path of cave-man essentialism:

In all cultures, young boys want to play with boys, Young girls want to play with girls… If you are interested in evolutionary psychology, you ask yourself could that have some survival value? The answer is yes. Thousands of years ago when men were more likely to be in hunting and women were more likely to be in the nurturing role, if you were a young boy you would do better if you spent your time with other boys with whom, when you were older, you would go to the hunt.

And Spitzer didn’t stop there, adding,  “…in all cultures, gender is recognized as a dichotomy.”

This could not be further from the truth. Global human history holds a great many indigenous cultures with more than two recognized sex and gender roles.  These include Tahitian and Hawaiian Mahu, Madagascar Sekrata, Hindu Tantric and Hijra Sects, Islamic Xanith, Khawal, and Sufi traditions and numerous Native American, or First Nation, Two Spirit traditions, and many others.

At the 2003 APA Meeting, Dr. Spitzer disparaged gender variant identities and expressions as pathological if they did not serve functions that he termed, “expected.” In my 2008 book, Gender Madness in American Psychiatry: Essays from the Struggle for Dignity, I questioned his evolutionary speculations,

who gets to decide what is ‘expected’? From whose perch of social privilege is American psychiatry to pass judgment upon the evolutionary worthiness of a class of people who have survived since human antiquity?

In the May, 2006, issue of Congressional Quarterly Researcher, Robert Spitzer debated UC San Francisco psychiatrist Dan Karasic on the question of GID as a mental illness. Spitzer used his most defamatory language to date to argue that well adjusted post-transition adults should continue to be regarded as mentally ill, so long as they deviate from their birth-assigned sex roles:

Granted that hormone therapy or surgery may now be the only treatment that we can now offer the adult with GID… But surely something remains profoundly wrong psychologically with individuals who are uncomfortable with their biological sex and insist that their biological sex is of the opposite sex. The only diagnosis that is appropriate for such cases is GID.

In issues of social discrimination, historic context matters. Cisgender GLB people had every right to their outrage at Spitzer’s 2001 attack on their dignity. This week, they had cause to celebrate his retraction. Wayne Besen noted that,

Spitzer just kicked out the final leg from the stool on which the proponents of ‘ex-gay’ therapy based their already shaky claims of success.

Perhaps, but trans and especially transsexual people are not celebrating. Dr. Spitzer and like-minded policymakers in American Psychiatry have long kicked the the legs from under our human legitimacy, and the rush to his redemption in progressive media has cast our issues aside once again.

We too have been injured by Robert Spitzer’s role in perpetuating defamatory stereotypes of mental “dysfunction” and deviance. Trans people continue to lose our jobs, homes, children, families, dignity and civil justice because of these stereotypes and continue to face predatory gender conversion psychotherapies. These stereotypes lie behind every extremist political campaign that demeans our most basic civil rights as “bathroom bills.” These stereotypes lie behind military discrimination and government policies that still malign us as “mentally unfit.” These stereotypes convince parents and school officials to dismiss trans youth as “confused” or going through “a phase.” Trans communities have waited more than two decades for a retraction or an apology from Dr. Spitzer. and we are still waiting.

Copyright © 2012 Kelley Winters, GID Reform Advocates

A Taxing Question of Medical Necessity

Kelley Winters, Ph.D.
GID Reform Advocates

Many trans and especially transsexual Americans were relieved this week by the U.S. Tax Court decision to reverse earlier IRS positions and allow costs of hormonal and surgical transition care to be deducted as medical expenses. The ruling concluded:

Petitioner has shown that her hormone therapy and sex reassignment surgery treated disease within the meaning of section 213 and were therefore not cosmetic surgery. Thus petitioner’s expenditures for these procedures were for “medical care” as defined in section 213(d)(1)(A), for which a deduction is allowed under section 213(a).

However, this recognition of the legitimacy of medical transition came at a cost to the dignity of transsexual women and men. It relied on the flawed diagnostic nomenclature of Gender Identity Disorder (GID) in the Diagnostic and Statistical Manual of Mental Disorders (DSM) and its implication of mentally “disordered” gender identity. Paradoxically, this case fueled opposition to medical transition access, based on the current wording of the very same GID classification and its more virulent companion diagnosis of Transvestic Fetishism. While the Tax Court decision underscored the utility of some kind of diagnostic coding for those who need access to hormonal or surgical transition care, it also illustrated the urgency of reforming the GID diagnosis and removing the Transvestic Fetishism category in the next revision of the DSM, published by the American Psychiatric Association (APA).

Ms. Rhiannon O’Donnabhain underwent corrective genital surgery in 2001 and claimed a tax deduction for surgical and hormonal treatment expenses as well as the cost of a breast augmentation procedure. Her courageous nine year battle with the IRS to affirm the medical legitimacy of her transition care took a tortuous off-again, on-again path among the potholes of politics and prejudice.

Although the IRS initially issued a full refund to Rhiannon, a tax examiner denied her deduction in July, 2002. He declared her surgical and hormonal care to be “cosmetic” and therefore excluded as a deductible medical expense under section 231(d)(9) of the Internal Revenue Code. She appealed, represented by Gay and Lesbian Advocates and Defenders (GLAD). Attorney Karen Loewy argued that,

Any notion that medical treatment for a transgender person is purely cosmetic is based on misunderstanding and prejudice, not medical science.

In November, 2004, the IRS reversed the examiner’s decision and allowed Rhiannon to deduct her surgical expenses as medically necessary and professionally prescribed. However, political extremist groups responded by pressuring the Bush Administration to deny tax deductions for all medical transition care. They based their arguments on the same psychiatric classification of GID that GLAD cited to win the appeal. The following month, Rev. Louis Sheldon, chairman of the Traditional Values Coalition (TVC), wrote IRS Commissioner Mark Everson:

[B]y giving this tax deduction, your agency will be encouraging other mentally disturbed individuals to consider such surgery as an unneeded surgical procedure for what is a troubled mind–not a troubled body.

The IRS caved to political pressure in October, 2005. IRS Branch Chief Thomas Moffitt issued a Memorandum of Chief Counsel Advice that reversed the decision of the appeals officer and once again denied Rhiannon’s deduction of medical transition expenses. Moffitt demeaned Rhiannon with maligning pronouns of her assigned birth sex and concluded,

In light of the Congressional emphasis on denying a deduction for procedures relating to appearance in all but a few circumstances and the controversy surrounding whether GRS is a treatment for an illness or disease, the materials submitted do not support a deduction.

Astonishingly, Moffit based his ruling, not on respected medical literature, but on a political magazine called First Things, published by the Institute on Religion and Public Life. He cited an article by psychiatrist Paul McHugh, known for employing false stereotypes of mental pathology to terminate gender confirming surgeries at John Hopkins Hospital in the 1970s . McHugh mocked post-operative transsexual women as “caricatures” and invoked the current classification of mental disorder to discredit medical transition care:

Once again 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.

Finally, Chief Moffit erected an addition political barrier, unprecedented for other minorities, to transsexual citizens seeking equal treatment under the tax code:

Only an unequivocal expression of Congressional intent that expenses of this type qualify under section 213 would justify the allowance of the deduction in this case.

Civil justice advocates were outraged at such tactics by the Bush Administration. Professor Lynn Conway noted,

To deny such people medical deductions for the medical correction of their bodies – people who often face extreme financial and employment difficulties during their transitions – is unfair and inhumane. The claim that such people require a special “act of Congress” before being treated fairly exudes not only ignorance and intolerance, but also open Executive Branch hostility towards gender variant people.

Berkeley tax attorney Donald Read commented in the San Francisco Chronicle

The IRS should not allow religious views to impact the administration of our tax laws… We all should be concerned about the politicization of the IRS, not only against gay and transgender people, but in all its forms.

Rhiannon’s suit was heard by the U.S. Tax Court in July, 2007. She was again represented by the GLAD legal staff as well as co-counsel from the Boston firm of Sullivan & Worcester.

Senior IRS attorney John Mikalchus repeated the party line from the TVC and Paul McHugh that transition in itself represents psychopathology, citing the current GID diagnosis. He stated that surgery, hormones and other transition treatments do not cure cross-gender identification but “reinforce” it.

Mikalchus also invoked the second gender diagnosis of Transvestic Fetishism, speculating that many transsexual women seeking corrective transition surgeries are afflicted with a paraphilic sexual preoccupation with dressing as women. The APA fueled this false stereotype with publication of the DSM-IV in 1994, where TF was expanded to specifically include transsexual women who are attracted to other women. Mikalchus further belittled Rhiannon with the term, “autogynephilia,” an unsupported derogatory theory promoted by Toronto sexologist Raymond Blanchard, associating male-to-female transition with a narcissistic sexual arousal at “the thought or image of oneself as a woman.” Dr. Blanchard was largely responsible for the current Transvestic Fetishism diagnosis in the DSM-IV. As chairman of the APA’s Paraphilias Subcommittee for the pending DSM edition, he has recently proposed expanding the TF diagnosis with the title, Transvestic Disorder, and adding “Autogynephilia” as a diagnostic specifier.

Despite these barriers, the Tax Court ultimately rejected the IRS portrayal of transition as pathological and its associated medical care as “cosmetic.” On February 2, 2010, the Court ruled that Rhiannon’s hormonal and surgical transition treatments —

were for the treatment of disease within the meaning of § 213(d)(1)(A) & (9)(B), I.R.C. and thus not “cosmetic surgery” excluded from the definition of deductible “medical care” by § 213(d)(9)(A), I.R.C. [paraphrased]

A 69 page majority opinion, authored by Judge Joseph Gale, once again reversed the IRS denial and allowed Rhiannon to deduct her expenses for hormonal medications and corrective genital surgery (although it denied a deduction for her breast augmentation expenses). Their decision rested upon an interpretation of the GID diagnosis as “a serious, psychologically debilitating condition,” rather than a demeaning indictment of “disordered” gender identity. Although political extremists and the IRS attempted to exploit conflicting and ambiguous language in the current GID nomenclature, the GLAD legal team and expert witness Dr. George Brown successfully clarified that severe persistent distress with current physical sex characteristics (often termed anatomical dysphoria) is the true focus of medical transition treatment. In spite of the shortcomings of the current Gender Identity Disorder and Transvestic Fetishism diagnoses, they persuaded the Court that the necessity and efficacy of these treatments in relieving this debilitating distress is well established. Jennifer Levi, Director of GLAD’s Transgender Rights Project, noted,

In this landmark ruling, the Tax Court affirmed the consensus position of the medical establishment that transition-related medical care is essential for many transgender people.

However, the political fragility of this ruling and the contradictory role of the GID and TF diagnoses in establishing the medical necessity of transition treatments are underscored by the dissenting opinion (p. 119-139) of Judge David Gustafson. Joined by four other judges, he opposed allowing a deduction for transition surgeries, stating:

One could analyze the GID patient’s problem in one of two ways: (1) His anatomical maleness is normative, and his perceived femaleness is the problem. Or (2) his perceived femaleness is normative, and his anatomical maleness is the problem. If one assumes option 2, then one could say that SRS does “treat” his GID by bringing his problematic male body into simulated conformity (as much as is possible) with his authentic female mind. However, the medical consensus as described in the record of this case is in stark opposition to the latter characterization and can be reconciled only with option 1: Petitioner’s male body was healthy, and his mind was disordered in its female self- perception.

In its present form, the diagnostic criteria and supporting text of the GID diagnosis can all too easily be inferred in Gustafson’s second context of “disordered” gender identity, in contradiction to the medical necessity of hormonal and surgical transition treatments. If the intention of the Internal Revenue Service was to punish transsexual people for nonconformity to their assigned birth roles, the American Psychiatric Association, inadvertently or not, handed them blunt instruments of oppression with the current GID and TF diagnoses. Rhiannon herself said it best,

It’s a Catch-22. I have to accept the stigma of being labeled as having a disorder [or] a mental condition … in order to get benefits. I haven’t liked this diagnosis from the very beginning. But I’ve got to play the game.

This week, on February 10, the American Psychiatric Association is scheduled to release draft diagnostic criteria for the Fifth Edition of the DSM for public review. In the DSM-V, the APA has an opportunity to correct the shortcomings and ambiguities of the GID diagnosis that pose barriers to civil justice and access to medical care: (1) clarifying distress as the diagnostic focus rather than nonconformity to assigned birth sex roles; (2) excluding from diagnosis those who suffer no distress or impairment with their bodies or ascribed social gender; (3) clarifying that transition is therapeutic and not pathological; and (4) removing maligning pronouns and terms that disrespect the affirmed identities of transitioned individuals. The APA also has an opportunity to remove the Transvestic Fetishism category that is purely punitive and defamatory to many transwomen.

An American hero in the struggle for dignity and equality, Rhiannon O’Donnabhain deserves better from mental health policymakers. We all do.