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The DSM-5 Diagnostic Criteria for Gender Dysphoria
Abstract
This chapter provides a summary of the DSM-5 diagnosis of gender dysphoria, including the changes to the criteria and the rationales regarding conceptual shifts. It reviews the substantive changes from the previous diagnosis of gender identity disorder as it was conceptualized and operationalized in DSM-IV.
... Under the argument of reducing the stigma of these initially classified mental disorders and sexual paraphilias, the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) of the American Psychiatric Association reclassified the disorder gender dysphoria into a separate category (Garg, Elshimy & Marwaha, 2020). Increasingly, transgender activists want it removed altogether as homosexualism once was (Zucker, 2015). ...
This article reviews the goals, history, and impact of the new gender identity politics. Based on the Yogyakarta Principles, these new ideas and policies will profoundly affect the rights of women and girls worldwide. The Principles are a document from an international meeting about sexual orientation and gender identity in 2006. In 2017, the document was updated to the Yogyakarta Principles Plus 10. The Principles recommend legal changes by states worldwide, resulting in the erasure of sex as a legal and cultural category. These principles have been widely used to lobby for legal changes resulting in profound structural changes that lead to undermining and eliminating protections for women and girls from sex-based discrimination and state obligations to achieve de facto sex equality. One of the most far-reaching recommendations is “States [national governments] must abolish all legal records of sex from all legal documents, including birth certificates and passports.” These recommendations are being implemented globally, although they have never been discussed or adopted by member states or any international organization, nor were any official women’s organizations consulted. This article was written by a collective of many feminist activists, researchers, and specialist service providers from Europe, Asia, North America, Latin America, and Africa who met every week at the Women’s Declaration International (WDI) sessions. They collected evidence and collaborated on creating this document from 2019 to 2022.
... Is gender identity "a volitional choice?" This question might sound trivial, but to those who experience gender incongruence (GI) and the ensuring dysphoria, it is of relevance (Zucker 2015;Beek et al. 2016). GI is defined as a marked incongruence between one's experienced gender and one's gender assigned at birth. ...
Gender incongruence (GI) is characterized by a feeling of estrangement from the own body in the context of self. GI is often described in people who identify as transgender. The underlying mechanisms are unknown. Data from MRI measurements and tests of own body perception triggered us to pose a model that GI in transgender persons (TGI) could be associated with a disconnection within the brain circuits mediating the perception of own body as self. This is a departure from a previous model of sex atypical cerebral dimorphism, introducing a concept that better accords with a core feature of TGI. The present MRI study of 54 hormone naive transmen (TrM), 38 transwomen (TrW), 44 cismen and 41 ciswomen show that cortical gyrification, a metric that reflects early maturation of cerebral cortex, is significantly lower in transgender compared with cisgender participants. This reduction is limited to the occipito-parietal cortex and the sensory motor cortex, regions encoding own body image and body ownership. Moreover, the cortical gyrification correlated inversely with own body-self incongruence in these regions. These novel data suggest that GI in TGI may originate in the neurodevelopment of body image encoding regions. The results add potentially to understanding neurobiological contributors to gender identity.
... Thus, a person realising that most of their preferred activities are male-associated might feel themselves to inhabit a male gender, irrespective of their biological sex. Conversely, another person may have a predominantly male gender expression but feel themselves to be purely female because of their biological sex, so gender identity can be completely different from gender expression (Pullen Sansfaçon et al., 2020;Zucker, 2015). Gender nonconformity in this sense of gender expression differing from gender identity is common, but not universal, in the lesbian and gay community, for example (Mackay, 2019;Rieger et al., 2010). ...
Purpose
Although gender identities influence how people present themselves on social media, previous studies have tested pre-specified dimensions of difference, potentially overlooking other differences and ignoring nonbinary users.
Design/methodology/approach
Word association thematic analysis was used to systematically check for fine-grained statistically significant gender differences in Twitter profile descriptions between 409,487 UK-based female, male, and nonbinary users in 2020. A series of statistical tests systematically identified 1,474 differences at the individual word level, and a follow up thematic analysis grouped these words into themes.
Findings
The results reflect offline variations in interests and in jobs. They also show differences in personal disclosures, as reflected by words, with females mentioning qualifications, relationships, pets, and illnesses much more, nonbinaries discussing sexuality more, and males declaring political and sports affiliations more. Other themes were internally imbalanced, including personal appearance (e.g. male: beardy; female: redhead), self-evaluations (e.g. male: legend; nonbinary: witch; female: feisty), and gender identity (e.g. male: dude; nonbinary: enby; female: queen).
Research limitations
The methods are affected by linguistic styles and probably under-report nonbinary differences.
Practical implications
The gender differences found may inform gender theory, and aid social web communicators and marketers.
Originality/value
The results show a much wider range of gender expression differences than previously acknowledged for any social media site.
... The UW definition is however correct in that while intersex and transgender are often conflated, intersex is a unique although rare genetic condition, and unlike transgender (formally known as gender dysphoria) it is not a mental disorder. (Zucker, 2015) White privilege -UW: -Refers to the unquestioned and unearned set of advantages, entitlements, benefits and choices bestowed on people solely because they are white. Generally, white people who experience such privilege do so without being conscious of it." ...
The basic principles of modern sociolinguistic engineering as a tool for population indoctrination, subjugation, and control have their beginnings in the strategies designed by Joseph Goebbels of the NAZI regime and also those of the USSR. The redefinition of semantics is a dangerous tool used by propagandists to influence the individuals' sense of reality using language on a psychological level. This creates a populace that is more willing to follow harmful ideologies. The study will investigate existing legislation of Australia, the United Kingdom, the United States of America, and Canada about guarantees on free speech especially in academia, and the classification of hate speech. This study further looks at a microcosm of language used by the diversity, Inclusion, and Equity" movement focusing on an analysis of a glossary created by the University of Washington. It also discusses some terminology that is similarly erroneous but not included in the glossary. The history of terminology and their development is discussed as well as the scientific and linguistic validity of the provided semantic definitions in contrast to the original semantics. The study found that sociolinguistic engineering was taking place in universities and wider society which follows the historic pattern of the Third Reich and USSR. The study recommends that universities and education systems desist from such indoctrination and return to the traditional academic foundations of open inquiry and critical thinking.
Transgender identities and health are highly politicized in the United States leading to restrictions on relevant data collection in national health surveillance systems. This has serious implications on transgender population health research; an urgent area of study given the systemic discrimination faced by transgender individuals and the resultant social and health inequities. In this precarious political climate, obtaining high-quality data for research is challenging and in recent years, two data sources have formed the foundation of transgender health research in the United States, namely the 2015 United States Transgender Study and the Behavioral Risk Factor Surveillance System (BRFSS) after the launch of the optional Sexual Orientation and Gender Identity Module in 2014. While useful, there are serious challenges to using these data to study transgender health, specifically related to survey weighting methodologies, ascertainment of gender identity, and study design. In this article, we detail these challenges and discuss the strengths and weaknesses of various methodological approaches that have been implemented as well as clarify several common errors that exist in the literature. We feel that this contribution is necessary to provide accurate interpretation of the evidence that currently informs policy and priority setting for transgender population health and will provide vital insights for future studies with these now ubiquitous sources of data in the field.
Recent studies have found trans individuals to experience high rates of eating disorders. Prior studies have mixed findings of eating disorder rates of trans/nonbinary people with eating disorders. Recent and prior studies, though, have primarily originated within Public Health and Psychology, with little to no research examining trans/nonbinary people’s experiences with eating disorders in the field of Sociology. As such, we analyzed 16 blogs and vlogs (video blogs) of trans/nonbinary people speaking and/or writing about the onset of their eating disorders, reasons for development of eating disorders, and experiences in accessing treatment. Content analysis of these blogs and vlogs serve as an exploratory analysis to provide suggestions for future research, including: institutional cisnormativity in eating disorder treatment, the use of eating disorders as a way of coping with the anxieties of doing gender in a binary society, and the relations of body dysmorphia and gender dysphoria.
In this paper I review how the notion of gender is understood in psychiatry, specifically in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). First, I examine the contraposition between sex and gender, and argue that it is still retained by DSM-5, even though with some caveats. Second, I claim that, even if genderqueer people are not pathologized and gender pluralism is the background assumption, some diagnostic criteria still conceal a residue of gender dualism and essentialism. Third, I consider gender dysphoria, which is characterized by an incongruence between one's experienced or expressed gender and one's assigned gender; since this condition pertains to distress and disability, not to the incongruence per se, it does not pathologize transgender people. Still, I contend that it should be removed from DSM-5 for theoretical reasons.
Résumé
La prise en charge des enfants et adolescents porteurs d’un diagnostic de Désordre de développement du sexe (DDS) est aujourd’hui une question en débat et en discussion tant sur le plan des pratiques soignantes, que sur le champ social et politique. Une des préoccupations centrales des équipes de soins engagées autour de la prise en charge et l’accompagnement des personnes porteuses d’un DDS et de pouvoir proposer une prise en charge la plus efficiente dans l’objectif de promouvoir le meilleur épanouissement possible des personnes concernées. Si l’un des points centraux des échanges actuels porte sur la question des indications de prises en charge médicochirurgicales précoces, la question se porte tout autant sur la place et les modalités d’assignation de genre d’un enfant à sa naissance et des différentes conséquences pour lui dans sa vie future. La question du devenir des enfants nés et porteurs d’un DDS en termes d’inscription dans une identité de genre est étudiée depuis les années 1950 et s’est développée sur des présupposés théoriques très divers ; du champ psychodynamique et psychanalytique à des présupposés biologiques. La littérature scientifique est particulièrement hétérogène sur le sujet et recoupe des méthodologies de type reports d’expérience, des études cas témoins comme des méthodologies issues de l’Evidence Based Medecine. En appui des éléments issus de la littérature scientifique et en appui d’un travail collaboratif du réseau national des Centres de référence maladies rares du développement génital: du fœtus à l’adulte, ce travail vise à définir les contours des modalités d’organisation et des aspects déontologiques actuels des équipes engagées autour de cette activité sur le territoire français.
While reports showing a link between prenatal androgen exposure and human gender role behavior are consistent and the effects are robust, associations to gender identity or cross-gender identification are less clear. The aim of the current study was to investigate potential cross-gender identification in girls exposed prenatally to high concentrations of androgens due to classical congenital adrenal hyperplasia (CAH). Assessment included two standardized measures and a short parent interview assessing frequency of behavioral features of cross-gender identification as conceptualized in Part A of the diagnostic criteria for gender identity disorder (GID) in the DSM-IV-TR. Next, because existing measures may have conflated gender role behavior with gender identity and because the distinction is potentially informative, we factor analyzed items from the measures which included both gender identity and gender role items to establish the independence of the two constructs. Participants were 43 girls and 38 boys with CAH and 41 unaffected female and 31 unaffected male relatives, aged 4- to 11-years. Girls with CAH had more cross-gender responses than female controls on all three measures of cross-gender identification as well as on a composite measure of gender identity independent of gender role behavior. Furthermore, parent report indicated that 5/39 (12.8 %) of the girls with CAH exhibited cross-gender behavior in all five behavioral domains which comprise the cross-gender identification component of GID compared to 0/105 (0.0 %) of the children in the other three groups combined. These data suggest that girls exposed to high concentrations of androgens prenatally are more likely to show cross-gender identification than girls without CAH or boys with and without CAH. Our findings suggest that prenatal androgen exposure could play a role in gender identity development in healthy children, and may be relevant to gender assignment in cases of prenatal hormone disruption, including, in particular, cases of severely virilized 46, XX CAH.
This consensus statement is an executive summary of several papers resulting from a 2009 consensus process comprising nine work groups and 37 members of the World Professional Association for Transgender Health (WPATH). The purpose of this group was to put forth recommendations for the upcoming revision of the DSM with respect to the Gender Identity Disorder diagnoses. The consensus process was collaborative, interdisciplinary, and evidence based. A majority (but not all) of the participants believed that a diagnosis related to Gender Identity Disorder should remain in the DSM, and many advocated changes in name, diagnostic criteria, and placement within the DSM. The proposed name is Gender Dysphoria, and the diagnostic criteria should be distress based. Placement should be outside the chapter on Sexual Disorders and possibly within Psychiatric Disorders Related to a Medical Condition. If there were to be a diagnostic category for childhood, there should also be separate categories for adults and adolescents. A Not Otherwise Specified category should be retained, and Disorders of Sex Development should not be an exclusionary criterion for Gender Dysphoria.
A survey on various issues related to the DSM-IV-TR gender identity disorder diagnosis was conducted among 201 organizations concerned with the welfare of transgender people from North America, Europe, Africa, Asia, Oceania, and Latin America. Forty-three organizations from all continents completed the survey. A majority of 55.8% believed the diagnosis should be excluded from the 2013 edition. The major reason for wanting to keep the diagnosis in the DSM was health care reimbursement. Regardless of whether groups were for or against the removal of the diagnosis, the survey revealed a broad consensus that if the diagnosis remains in the DSM, there needs to be an overhaul of the name, criteria, and language to minimize stigmatization of transgender individuals.
The DSM-IV-TR category of Gender Identity Disorder (GID; American Psychiatric Association, 2000) is limited to persons with typical somatosexual development who experience “strong and persistent cross-gender identification” as well as a “persistent discomfort with his or her sex or sense of inappropriateness in the gender role of that sex.” The presence of a concurrent “physical intersex condition” rules out the unqualified diagnosis. However, a person with atypical somatic sex development experiencing, for example, gender dysphoria, could still be diagnosed with a GID, but with the Not Otherwise Specified (NOS) qualifier. The DSM 5 committee charged with developing the criteria for GID must now decide whether persons born with atypical somatic sex should automatically be excluded from consideration as having GID or be potentially diagnosable. The question addressed here is whether persons born with atypical somatic sex who are experiencing gender dysphoria should potentially be diagnosable using (a) the unqualified criteria for GID or (b) a qualified GID, such as under the NOS category (i.e., continuing the practice of DSM-IV-TR) or should not be diagnosed with GID (qualified or unqualified).
This study provided a descriptive and quantitative comparative analysis of data from an assessment protocol for adolescents referred clinically for gender identity disorder (n = 192; 105 boys, 87 girls) or transvestic fetishism (n = 137, all boys). The protocol included information on demographics, behavior problems, and psychosexual measures. Gender identity disorder and transvestic fetishism youth had high rates of general behavior problems and poor peer relations. On the psychosexual measures, gender identity disorder patients had considerably greater cross-gender behavior and gender dysphoria than did transvestic fetishism youth and other control youth. Male gender identity disorder patients classified as having a nonhomosexual sexual orientation (in relation to birth sex) reported more indicators of transvestic fetishism than did male gender identity disorder patients classified as having a homosexual sexual orientation (in relation to birth sex). The percentage of transvestic fetishism youth and male gender identity disorder patients with a nonhomosexual sexual orientation self-reported similar degrees of behaviors pertaining to transvestic fetishism. Last, male and female gender identity disorder patients with a homosexual sexual orientation had more recalled cross-gender behavior during childhood and more concurrent cross-gender behavior and gender dysphoria than did patients with a nonhomosexual sexual orientation. The authors discuss the clinical utility of their assessment protocol.
Many individuals born with genital ambiguity and related conditions (recently recategorized as disorders of sex development [DSD]) experience gender uncertainty or gender dysphoria, and some may undergo self-initiated gender change. Whether these phenomena are sufficiently similar to the presentations of gender identity variants (GIVs) in non-DSD persons (gender identity disorder [GID] in current psychiatric terminology) to warrant the application of identical diagnostic criteria and treatment approaches is under debate. This review takes the position that the differences in phenomena, context of presentation, etiology, and treatment settings are so large that identical diagnoses and treatment approaches are not justified and may be detrimental to the individuals in need of care, although more systematic comparisons are needed for definitive conclusions. On the other hand, there is increasing overlap of DSD and non-DSD individuals with gender problems in professional care personnel, assessment methods, aspects of medical and psychosocial management, and support groups and gender activism. Thus, a comprehensive revision of the Standards of Care (SOC) needs to include pertinent material on DSD, and clinicians caring for individuals with GIV should be acquainted with the key clinical issues in both. The remainder of this article summarizes the limited information available for DSD on the issues addressed in the sixth edition of the SOC for non-DSD GIV.
Studies involving patients with gender identity disorder (GID) are inconsistent with regard to outcomes and often difficult to compare because of the vague descriptions of the diagnostic process. A multisite study is needed to scrutinize the utility and generality of different aspects of the diagnostic criteria for GID.
To investigate the way in which the diagnosis-specific Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision criteria for GID were used to reach a psychiatric diagnosis in four European countries: the Netherlands (Amsterdam), Norway (Oslo), Germany (Hamburg), and Belgium (Ghent). The main goal was to compare item (symptom) characteristics across countries.
The current study included all new applicants to the four GID clinics who were seen between January 2007 and March 2009, were at least 16 years of age at their first visit, and had completed the diagnostic assessment (N = 214, mean age = 32 ± 12.2 years). Mokken scale analysis, a form of Nonparametric Item Response Theory (NIRT) was performed.
Operationalization and quantification of the core criteria A and B resulted in a 23-item score sheet that was filled out by the participating clinicians after they had made a diagnosis.
We found that, when ordering the 23 items according to their means for each country separately, the rank ordering was similar among the four countries for 21 of the items. Furthermore, only one scale emerged, which combined criteria A and B when all data were analyzed together.
Our results indicate that patients' symptoms were interpreted in a similar fashion in all four countries. However, we did not find support for the treatment of A and B as two separate criteria. We recommend the use of NIRT in future studies, especially in studies with small sample sizes and/or with data that show a poor fit to parametric IRT models.
The most widely used and influential typologies for transsexualism and gender identity disorder (GID) in adolescents and adults employ either sexual orientation or age of onset of GID-related symptoms as bases for categorization. This review compares these two typological approaches, with the goal of determining which one should be employed for the diagnosis of GID in Adolescents or Adults (or its successor diagnosis) in the forthcoming revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM). Typologies based on sexual orientation and age of onset of GID-related symptoms are roughly comparable in ease and reliability of subtype assignment. Typologies based on sexual orientation, however, employ subtypes that are less ambiguous and better suited to objective confirmation and that offer more concise, comprehensive clinical description. Typologies based on sexual orientation are also superior in their ability to predict treatment-related outcomes and comorbid psychopathology and to facilitate research. Commonly expressed objections to typologies based on sexual orientation are unpersuasive when examined closely. The DSM should continue to employ subtypes based on sexual orientation for the diagnosis of GID in Adolescents or Adults or its successor diagnosis.