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Was the Gender Identity Disorder of Childhood Diagnosis Introduced into DSM-III as a Backdoor Maneuver to Replace Homosexuality? A Historical Note

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Abstract

Over the years, the DSM diagnosis of gender identity disorder (and its predecessors gender identity disorder of childhood [GIDC] and transsexualism) has attracted controversy as a mental disorder, for its diagnostic criteria, as a target of therapeutic intervention, and for its relationship to a homosexual sexual orientation. Another point of controversy is the claim that the diagnosis of GIDC was introduced into the DSM-III in 1980 as a kind of "backdoor maneuver" to replace homosexuality, which was deleted from the DSM-II in 1973. In this article, we challenge this historical interpretation and provide an alternative account of how the GIDC diagnosis (and transsexualism) became part of psychiatric nosology in the DSM-III. We argue that GIDC was included as a psychiatric diagnosis because it met the generally accepted criteria used by the framers of DSM-IIIfor inclusion (for example, clinical utility, acceptability to clinicians of various theoretical persuasions, and an empirical database to propose explicit diagnostic criteria that could be tested for reliability and validity). In this respect, the entry of GIDC into the psychiatric nomenclature was guided by the reliance on "expert consensus" (research clinicians)--the same mechanism that led to the introduction of many new psychiatric diagnoses, including those for which systematic field trials were not available when the DSM-III was published.
Journal of Sex & Marital Therapy, 31:31–42, 2005
Copyright © 2005 Brunner-Routledge
ISSN: 0092-623X print
DOI: 10.1080/00926230590475251
Was the Gender Identity Disorder of Childhood
Diagnosis Introduced into DSM-III as a
Backdoor Maneuver to Replace Homosexuality?
A Historical Note
KENNETH J. ZUCKER
Centre for Addiction and Mental Health, Toronto, Ontario, Canada
ROBERT L. SPITZER
New York State Psychiatric Institute, New York, New York, USA
Over the years, the DSM diagnosis of gender identity disorder (and
its predecessors gender identity disorder of childhood [GIDC] and
transsexualism) has attracted controversy as a mental disorder, for
its diagnostic criteria, as a target of therapeutic intervention, and
for its relationship to a homosexual sexual orientation. Another
point of controversy is the claim that the diagnosis of GIDC was in-
troduced into the DSM-III in 1980 as a kind of “backdoor maneu-
ver” to replace homosexuality, which was deleted from the DSM-II
in 1973. In this article, we challenge this historical interpretation
and provide an alternative account of how the GIDC diagnosis (and
transsexualism) became part of psychiatric nosology in the DSM-III.
We argue that GIDC was included as a psychiatric diagnosis be-
cause it met the generally accepted criteria used by the framers of
DSM-III for inclusion (for example, clinical utility, acceptablility
to clinicians of various theoretical persuasions, and an empirical
database to propose explicit diagnostic criteria that could be tested
for reliability and validity). In this respect, the entry of GIDC into
the psychiatric nomenclature was guided by the reliance on “ex-
pert consensus” (research clinicians)—the same mechanism that
led to the introduction of many new psychiatric diagnoses, includ-
ing those for which systematic field trials were not available when
the DSM-III was published.
Address correspondence to Kenneth J. Zucker, Child and Adolescent Gender Identity
Clinic, Child Psychiatry Program, Centre for Addiction and Mental Health—Clarke Division,
250 College Street, Toronto, Ontario M5T 1R8, Canada. E-mail: Ken
Zucker@camh.net
31
32 K. J. Zucker and R. L. Spitzer
In the third edition of the Diagnostic and Statistical Manual of Mental Dis-
orders (DSM-III; American Psychiatric Association, 1980), there appeared for
the first time two psychiatric diagnoses pertaining to gender dysphoria in chil-
dren, adolescents, and adults: gender identity disorder of childhood (GIDC)
and transsexualism (the latter was to be used for adolescents and adults).
In the DSM-III-R (APA, 1987), a third diagnosis was added: gender iden-
tity disorder of adolescence and adulthood, nontranssexual type. In DSM-IV
(APA, 1994, 2000), this last diagnosis was eliminated (“sunsetted”), and the
diagnoses of GIDC and transsexualism were collapsed into one overarch-
ing diagnosis, gender identity disorder (GID), with different criteria sets for
children versus adolescents and adults (cf. Pincus, Frances, Davis, First, &
Widiger, 1992, p. 114).
Over the years, the diagnosis of GID (and its predecessors GIDC and
transsexualism) has attracted controversy as a mental disorder, for its diag-
nostic criteria, as a target of therapeutic intervention, and for its relation-
ship to a homosexual sexual orientation (see, for example, Bartlett, Vasey,
& Bukowski, 2000; Bem, 1993; Ehrensaft, 2001; Feder, 1997; Isay, 1997;
McCarthy, 2003; Menvielle, 1998; Minter, 1999; Moore, 2002; Richardson,
1996, 1999; Rosenberg, 2002). Although these issues are by no means re-
solved, they have been debated and discussed in detail elsewhere (see,
for example, Bradley & Zucker, 1998, 2003; Cohen-Kettenis, 2001; Cohen-
Kettenis & Pf
¨
afflin, 2003; Green, 1987; Meyer-Bahlburg, 1999, 2002; Zucker,
1999a, 1999b, 2003a; Zucker & Bradley, 1995). As the American Psychiatric
Association moves toward the planning of DSM-V (Kupfer, First, & Regier,
2002), it is likely that all of these matters will be subject to even more intense
scrutiny and debate.
In this article, we examine one point of controversy: the claim that the
diagnosis of GIDC was introduced into the DSM-III as a kind of “backdoor
maneuver” to replace homosexuality, which was deleted from the DSM-II
(APA, 1968) in 1973 (for a review, see Bayer, 1981; Bayer & Spitzer, 1982;
Spitzer, 1981). Our aim is to challenge this historical interpretation and to pro-
vide an alternative account of how the GIDC diagnosis (and transsexualism)
became part of psychiatric nosology in the DSM-III.
Even before the publication of DSM-III, critics objected to the treat-
ment of children who displayed marked cross-gender behavior, arguing that
there was nothing inherently wrong, disadvantageous, or maladaptive about
a child who displayed such behavior as opposed to traditionally gender-
typical behavior. Indeed, such critics charged that treatments designed to
modify marked cross-gender behavior in children were, wittingly or not,
perpetuating traditional gender stereotypes about what was “appropriate”
gender-related behavior for a boy or a girl (Nordyke, Baer, Etzel, & LeBlanc,
1977; Winkler, 1977). Post-DSM-III, this line of criticism has continued (e.g.,
Corbett, 1996, 1998; Haldeman, 2000; Menvielle & Tuerk, 2002; Neisen, 1992;
Pickstone-Taylor, 2003).
Gender Identity Disorder in Children and the DSM 33
In the 1970s, with the publication of descriptive, etiological, and treat-
ment studies on children whose behavior was consistent with the later
DSM-III diagnostic criteria for GIDC, other critics claimed that there was
little evidence that persistent and pervasive patterns of cross-gender behav-
ior were associated with a person’s later sexual orientation (e.g., Serbin,
1980). At the time, this was an important issue because some clinicians
(definitely not all) who treated cross-gender-identified children cited pre-
vention of later homosexuality as one of their explicit goals (e.g., Rekers,
1977).
The assertion that there is no empirical evidence regarding the rela-
tionship between patterns of childhood sex-typed behavior and sexual ori-
entation has now been proven to be incorrect. Bailey and Zucker’s (1995)
meta-analysis on the relation between childhood sex-typed behavior and
sexual orientation in adults, as assessed by retrospective studies, showed
clearly that the two variables had a substantial association. On average,
gay men and lesbians recalled more cross-gender behavior than their same-
sex heterosexual counterparts, with a mean effect size, using Cohen’s d,
of 1.31 and 0.96 for heterosexual versus homosexual men and heterosex-
ual versus homosexual women, respectively. To our knowledge, no ret-
rospective study published since the Bailey and Zucker meta-analysis has
contradicted these findings (Zucker, Mitchell, Bradley, Tkachuk, & Allin,
2004).
Moreover, Green’s (1987) prospective follow-up study showed that a
large majority of his feminine boys developed a later bisexual or homosex-
ual sexual orientation, compared with virtually none of his control group
boys. Other studies showed a high rate of a homosexual sexual orienta-
tion in pervasively feminine boys (Money & Russo, 1979; Zuger, 1984),
and there is now some indication that a homosexual sexual orientation is
overrepresented in girls who show pervasive masculine behavior during
childhood (Cohen-Kettenis, 2001; Zucker, 2004). There also is clearer ev-
idence now that a minority of children with GID show a persistence of
it into adolescence and young adulthood, culminating in the request for
both hormonal and surgical sex-reassignment, with a co-occuring homo-
sexual sexual orientation (Cohen-Kettenis, 2001; Cohen-Kettenis & Pf
¨
afflin,
2003; Zucker, 2003b). There also is some evidence that a minority of GID
children develop a heterosexual sexual orientation, without co-occuring
GID. Taken together, then, there appear to be a range of developmen-
tal outcomes for children with GID, although the data to date suggest
that a homosexual sexual orientation without co-occurring GID is the most
common.
Given the connection between GID in childhood and a later homosexual
sexual orientation, a number of critics have claimed that the GIDC diagnosis
was included in the DSM-III as an indirect method of preventing the de-
velopment of a later homosexual sexual orientation. Sedgwick (1991), in a
34 K. J. Zucker and R. L. Spitzer
critique of books by Friedman (1988) and Green (1987), appeared to hint at
a link:
The same DSM-III that ... was the first that did not contain an entry for
“homosexuality,” was also the first that did contain a new diagnosis ...
Gender Identity Disorder of Childhood. ... While the decision to remove
“homosexuality” from DSM-III was a highly polemicized and public one,
accomplished only under intense pressure from gay activists ... the ad-
dition to DSM-III of “Gender Identity Disorder of Childhood” appears to
have attracted virtually no outside attention. (p. 20)
Bem (1993) acknowledged the influence of clinical work on adult trans-
sexuals in leading to the introduction of both GIDC and transsexualism into
the DSM-III (a point on which we concur; see below) but made a stronger
connection than Sedgwick:
Ironically, this first official pathologizing of gender identity disorders ap-
peared in the same DSM in which, for the first time in psychiatric history,
there was no official pathologizing of homosexuality. Perhaps this was no
coincidence. Perhaps the psychiatric establishment still believed so com-
pletely in the pathology of gender nonconformity that if the politics of the
times would not allow it to express that belief through homosexuality,
then it would express it where and how it could. (pp. 106–107)
Nine years later, Bem’s views were summarized by Wilson, Griffin, and
Wren (2002) as follows:
Bem (1993) suggested, more politically, that it [i.e., the introduction of
GID for children and adolescents] may have occurred in response to the
removal of homosexuality from the same edition; a decision that occurred
in the context of affirmative gay and lesbian politics. (p. 339)
Morgan (2000) appeared to endorse the GID-homosexuality connection
more directly:
In 1973 ... the American Psychiatric Association ... voted to delete ho-
mosexuality as a mental disorder from the ... [DSM-II]. ... Seven years
later, with the 1980 publication of the [DSM-III], a new mental disorder
appeared which some say ... filled the vacancy left by the declassifica-
tion of homosexuality. This new mental disorder was designated Gender
Identity Disorder. (p. 1)
Moore (2002) was even more blunt: “the GID diagnosis ... is an attempt
to prevent adult homosexuality via psychiatric intervention with children”
(p. 1).
Gender Identity Disorder in Children and the DSM 35
Most recently, McCarthy (2003) asserted the following:
In 1973, the American Psychological [sic] Association voted to eliminate
homosexuality from the [DSM]. Not coincidentally, the catch-all diagno-
sis of “Gender Dysphoria Syndrome” (GDS)
1
was introduced that year;
GDS encompassed cross-dressers, transsexuals, homosexuals, and oth-
ers, and it was not by chance that these disparate identities were seen as
one and the same. The construction of GDS allowed clinicians to con-
tinue to pathologize gay people. ... Since homosexuality is no longer
considered pathological, GID is now used as a diagnosis for gay and les-
bian adolescents who are viewed as in need of treatment, which includes
hospitalization and medication. (pp. 35–36)
In this article we argue that, for three reasons, this historical interpretation of
the introduction of the GIDC diagnosis is inaccurate.
First, in the DSM-III, there was no need for any kind of veiled backdoor
diagnosis, because it contained the diagnosis of ego-dystonic homosexual-
ity. The inclusion of this diagnosis in the DSM-III represented a compromise
among the various clinicians and scientists who had argued in favor of delist-
ing homosexuality from the DSM-II (Bayer & Spitzer, 1982; Spitzer, 1981).
Second, ego-dystonic homosexuality was delisted from the DSM-III-R,
because it was argued that “empirical data [did] not support the diagnosis,
that it [was] inappropriate to label culturally induced homophobia as a mental
disorder, that the diagnosis was rarely used clinically, and that few articles
in the scientific literature [used] the concept” (Krajeski, 1996, p. 26; see also
Cohler & Galatzer-Levy, 2000, pp. 290–294; Marmor, 1980). Nonetheless, it
should be noted that in DSM-III-R, DSM-IV, and DSM-IV-TR (APA, 2000) there
remains the residual diagnosis of sexual disorder not otherwise specified, and
one example is that of a person who experiences “marked distress about his
or her sexual orientation.” Again, there is no need for a backdoor diagnosis
to replace homosexuality as it appeared in the DSM-II.
Third, several clinicians and scientists who argued in favor of delisting
homosexuality from the DSM-II (e.g., Green, 1972; Friedman, 1988; Stoller,
1973) were members of the DSM-III subcommittee on psychosexual disor-
ders that recommended the inclusion of the GIDC diagnosis in DSM-III. To
our knowledge, no one has ever interviewed any of these individuals to
see if they had either a conscious or unconscious intent to use the GIDC
diagnosis as a replacement for the diagnosis of homosexuality. Given these
members’ advocacy for deleting homosexuality as a diagnosis, it is difficult
to understand why the claim has been made that there was some insidious
1
DSM certainly did not introduce the “catch-all diagnosis” of gender dysphoria syndrome
in 1973. The term was coined by Fisk (1973), a surgeon. McCarthy (2003), however, did not
credit Fisk, and it is unclear from the passage if she believed that it had been adopted for use
in DSM-II.
36 K. J. Zucker and R. L. Spitzer
effort to introduce the GIDC diagnosis into the DSM-III as some kind of
veiled effort to prevent homosexuality (or to treat it in its immature form).
Indeed, the second author (RLS), who chaired all of the DSM-III Advisory
Committees, can recall no instance in which the members of the psychosex-
ual disorders subcommittee discussed inclusion of the GIDC diagnosis for
this reason.
Of course, this is not to say that some clinicians offer treatment for
children with GID, in part, to prevent homosexuality or that some parents
request treatment, in part, for the same reason. There is clear evidence that
this is sometimes the case (see, for example, Pleak, 1999; Zucker & Bradley,
1995, pp. 267–269; see also de Ahumada, 2003; Nicolosi & Nicolosi, 2002), so,
in this respect, we are in agreement with the critics. But, as has been argued
elsewhere (Zucker, 1999a; Zucker & Bradley, 1995), this is a separate matter
unrelated to the decision-making process that led the framers of DSM-III to
recognize GIDC as a psychiatric disorder in its own right.
If GIDC was not introduced into the DSM-III for the reason claimed by
the critics, it is a legitimate question to ask on what basis the diagnosis was
recommended for inclusion in the manual. The conceptual framework that
guided DSM-III, including delineation of the definition of mental disorder,
has been described in detail elsewhere (Spitzer & Endicott, 1978). For the
purpose of this discussion, however, it is sufficient to rely on text material
from the DSM-III (APA, 1980, pp. 1–12) regarding various parameters that
were considered in the inclusion of specific diagnostic categories. Among
others, these included clinical utility, acceptability to clinicians of various
theoretical persuasions, reliability, and validity. In DSM-III, it is noted that
there were 14 advisory committees that considered various domains of psy-
chiatric difficulties, one of which was psychosexual disorders.
As noted by Spitzer (1991) and Davis et al. (1998), DSM-III continued the
DSM-I (APA, 1952) and DSM-II tradition in its reliance on “expert consensus.”
In contrast to the two prior editions, however, DSM-III (as well as DSM-III-R
and DSM-IV) placed much greater emphasis on the establishment of explicit
diagnostic criteria (what some have termed a “neo-Kraepelian” paradigm),
which would increase the likelihood of establishing a putative disorder’s
reliability and validity (Spitzer, 1991; Widiger, Frances, Pincus, & Davis, 1990;
Widiger, Frances, Pincus, Davis, & First, 1991). Clearly, this was one of the
more novel, if not radical, departures from the two previous editions, which
lacked explicit diagnostic criteria (see Horwitz, 2002, pp. 66–82). Thus, one
can examine in Appendix F in DSM-III the results of field trials that provided
data on interrater reliability for some of the diagnoses that appeared in the
manual. Inspection of this appendix, however, indicates that no field trials
were conducted for the diagnoses of GIDC or transsexualism. Of course,
not all of the diagnoses (a total of 265, according to Pincus et al. [1992]),
including the new ones, that appeared in the DSM-III were subjected to
field trials. Indeed, it was explicitly noted in the DSM-III that “for most of
Gender Identity Disorder in Children and the DSM 37
the categories the diagnostic criteria are based on clinical judgment, and
have not yet been fully validated by data about such important correlates as
clinical course, outcome, family history, and treatment response” (APA, 1980,
p. 8). The greatest time was clearly devoted to field trials for high-prevalence
disorders. If the introduction of GIDC and transsexualism into the DSM-III
was not justified on the basis of formal field trials, what other considerations
were relied on?
During the 1960s, North American psychiatry had begun to take a look
at the phenomenon of transsexualism in adults (see, for example, Green
& Money, 1969; Stoller, 1968). It became apparent that psychiatrists and
other mental-health professionals had become increasingly aware of the phe-
nomenon, that is, of adult patients reporting substantial distress about their
gender identity and seeking treatment for it, typically hormonal and surgical
sex-reassignment. Indeed, there were enough observed cases that it was pos-
sible in the 1960s to establish the first university- and hospital-based gender
identity clinics for adults (Meyerowitz, 2002; Pauly & Edgerton, 1986). Many
clinicians and researchers were writing about transsexualism, and by 1980,
there was a large enough database to support its uniqueness as a clinical
entity and a great deal of empirical research that examined its phenomenol-
ogy, natural history, psychologic and biologic correlates, and so forth. Thus,
by the time DSM-III was in its planning phase in the mid-1970s, there were
sufficient clinical data available to describe the phenomenon, to propose di-
agnostic criteria, and so on. At the same time, there also was an emerging
clinical and research literature on children who expressed the desire to be of
the opposite sex, leading to a similar situation, that is, there was a clear de-
scription of the phenomenology, development of diagnostic criteria, and so
on (e.g., Green, 1974; Stoller, 1968, 1975). Although research on both GIDC
and transsexualism likely lagged behind other psychiatric phenomena with
much higher prevalence rates, expert consensus clearly concluded that there
was sufficient indication of clinical usefulness and acceptability for these two
disorders to be considered for the DSM-III. In this respect, the reliance on
expert consensus regarding parameters that justified inclusion was probably
not much different from the many other DSM diagnoses, such as borderline
personality disorder or narcissistic personality disorder, that had not been
subjected to more systematic field trials.
Although it is well-recognized that GID has a very low prevalence in
the general population (Cohen-Kettenis & Pf
¨
afflin, 2003), the past 25 years
since DSM-III has seen a fair amount of both basic and applied research on
the phenomenon (for reviews, see Cohen-Kettenis & Gooren, 1999; Cohen-
Kettenis & Pf
¨
afflin, 2003; Zucker, 2002, in press; Zucker & Bradley, 1995). It
is unlikely that such research would have been possible without its recog-
nition in the DSM as a clinical phenomenon worthy of such attention. As
the American Psychiatric Association develops its plans for DSM-V (Kupfer
et al., 2002), it is clear that some critics will argue for the removal of GID
38 K. J. Zucker and R. L. Spitzer
as a psychiatric disorder (e.g., Isay, 1997). Others will argue for its retention,
with a continued critical examination of the diagnostic criteria that relies on
empirical evidence for modification (Zucker, 2003c). As this debate evolves,
we hope that this article has provided an adequate historical analysis that
challenges revisionist arguments about the putative origin of the inclusion of
the GIDC diagnosis in the DSM-III. Inaccurate claims about the origins of the
GIDC diagnosis are not helpful to constructive debate and dialogue.
REFERENCES
American Psychiatric Association. (1952). Diagnostic and statistical manual: Mental
disorders.Washington, DC: Author.
American Psychiatric Association. (1968). Diagnostic and statistical manual of mental
disorders (2nd ed.). Washington, DC: Author.
American Psychiatric Association. (1980). Diagnostic and statistical manual of mental
disorders (3rd ed.). Washington, DC: Author.
American Psychiatric Association. (1987). Diagnostic and statistical manual of mental
disorders (3rd ed., rev.). Washington, DC: Author.
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental
disorders (4th ed.). Washington, DC: Author.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental
disorders (4th ed., Text rev.). Washington, DC: Author.
Bailey, J. M., & Zucker, K. J. (1995). Childhood sex-typed behavior and sexual orienta-
tion: A conceptual analysis and quantitative review. Developmental Psychology,
31, 43–55.
Bartlett, N. H., Vasey, P. L., & Bukowski, W. M. (2000). Is gender identity disorder in
children a mental disorder? Sex Roles, 43, 753–785.
Bayer, R. (1981). Homosexuality and American psychiatry: The politics of diagnosis.
New York: Basic Books.
Bayer, R., & Spitzer, R. L. (1982). Edited correspondence on the status of homosex-
uality in DSM-III. Journal of the History of the Behavioral Sciences, 18, 32–52.
Bem, S. L. (1993). The lenses of gender: Transforming the debate on sexual inequality.
New Haven, CT: Yale University Press.
Bradley, S. J., & Zucker, K. J. (1998). Reply to Menvielle [Letter to the editor]. Journal
of the American Academy of Child and Adolescent Psychiatry, 37, 244–245.
Bradley, S. J., & Zucker, K. J. (2003). [Letter to the editor]. Journal of the American
Academy of Child and Adolescent Psychiatry, 42, 266–268.
Cohen-Kettenis, P. T. (2001). Gender identity disorder in DSM ? [Letter to the editor].
Journal of the American Academy of Child and Adolescent Psychiatry, 40, 391.
Cohen-Kettenis, P. T., & Gooren, L. J. G. (1999). Transsexualism: A review of etiology,
diagnosis and treatment. Journal of Psychosomatic Research, 46, 315–333.
Cohen-Kettenis, P. T., & Pf
¨
afflin, F. (2003). Transgenderism and intersexuality in
childhood and adolescence: Making choices. Thousand Oaks, CA: Sage.
Cohler, B. J., & Galatzer-Levy, R. M. (2000). The course of gay and lesbian lives: Social
and psychoanalytic perspectives. Chicago: University of Chicago Press.
Gender Identity Disorder in Children and the DSM 39
Corbett, K. (1996). Homosexual boyhood: Notes on girlyboys. Gender & Psychoanal-
ysis, 1, 429–461.
Corbett, K. (1998). Cross-gendered identifications and homosexual boyhood: Toward
a more complex theory of gender. American Journal of Orthopsychiatry, 68,
352–360.
Davis, W., Widiger, T. A., Frances, A. J., Pincus, H. A., Ross, R., & First, M. B. (1998).
Introduction to the final volume. In T. A. Widiger, A. J. Frances, H. A. Pincus,
R. Ross, M. B. First, W. Davis, & M. Kline (Eds.), DSM-IV sourcebook (Vol. 4,
pp. 1–15). Washington, DC: American Psychiatric Association.
de Ahumada, L. C. B. (2003). Clinical notes on a case of transvestism in a child.
International Journal of Psychoanalysis, 83, 291–313.
Ehrensaft, D. (2001, April). Raising girlyboys: A parent’s perspective. Paper presented
at the spring meeting of the APA Division 39, Santa Fe, NM.
Feder, E. K. (1997). Disciplining the family: The case of gender identity disorder.
Philosophical Studies, 85, 195–211.
Fisk, N. (1973). Gender dysphoria syndrome (The how, what, and why of a dis-
ease). In D. Laub & P. Gandy (Eds.), Proceedings of the second interdisciplinary
symposium on gender dysphoria syndrome (pp. 7–14). Palo Alto, CA: Stanford
University Press.
Friedman, R. C. (1988). Male homosexuality: A contemporary psychoanalytic perspec-
tive. New Haven, CT: Yale University Press.
Green, R. (1972). Homosexuality as a mental illness. International Journal of Psy-
chiatry, 10, 77–98.
Green, R. (1974). Sexual identity conflict in children and adults. New York: Basic
Books.
Green, R. (1987). The “sissy boy syndrome” and the development of homosexuality.
New Haven, CT: Yale University Press.
Green, R., & Money, J. (Eds.). (1969). Transsexualism and sex reassignment. Balti-
more, MD: The Johns Hopkins Press.
Haldeman, D. C. (2000). Gender atypical youth: Clinical and social issues. School
Psychology Review, 29, 192–200.
Horwitz, A. V. (2002). Creating mental illness. Chicago: University of Chicago Press.
Isay, R. A. (1997, November 21). Remove gender identity disorder in DSM. Psychiatric
News, 32(22), 9, 13.
Krajeski, J. (1996). Homosexuality and the mental health professions: A contemporary
history. In R. P. Cabaj & T. S. Stein (Eds.), Textbook of homosexuality and mental
health (pp. 17–31). Washington, DC: American Psychiatric Press.
Kupfer, D. J., First, M. B., & Regier, D. A. (Eds.). (2002). Aresearch agenda for DSM-V.
Washington, DC: American Psychiatric Association.
Marmor, J. (1980). Epilogue: Homosexuality and the issue of mental illness. In
J. Marmor (Ed.), Homosexual behavior: A modern reappraisal (pp. 391–402).
New York: Basic Books.
McCarthy, L. (2003). Off that spectrum entirely: A study of female-bodied transgender-
identified individuals. Unpublished doctoral dissertation, University of Mas-
sachusetts Amherst, Amherst, MA.
Menvielle, E. J. (1998). Gender identity disorder [Letter to the editor]. Journal of the
American Academy of Child and Adolescent Psychiatry, 37, 243–244.
40 K. J. Zucker and R. L. Spitzer
Menvielle, E. J., & Tuerk, C. (2002). A support group for parents of gender non-
conforming boys. Journal of the American Academy of Child and Adolescent
Psychiatry, 41, 1010–1013.
Meyer-Bahlburg, H. F. L. (1999). Variants of gender differentiation. In P. Steinhausen
&F.C.Verhulst (Eds.), Risks and outcomes in developmental psychopathology
(pp. 299–313). New York: Oxford University Press.
Meyer-Bahlburg, H. F. L. (2002). Gender identity disorder in young boys: A parent-
and peer-based treatment protocol. Clinical Child Psychology and Psychiatry,
7, 360–377.
Meyerowitz, J. (2002). How sex changed: A history of transsexuality in the United
States. Cambridge, MA: Harvard University Press.
Minter, S. (1999). Diagnosis and treatment of gender identity disorder in children.
In M. Rottnek (Ed.), Sissies & tomboys: Gender nonconformity & homosexual
childhood (pp. 9–33). New York: New York University Press.
Money, J., & Russo, A. J. (1979). Homosexual outcome of discordant gender iden-
tity/role: Longitudinal follow-up. Journal of Pediatric Psychology, 4, 29–41.
Moore, S. M. (2002). Diagnosis for a straight planet: A critique of gender identity
disorder for children and adolescents in the DSM-IV. Unpublished doctoral dis-
sertation, The Wright Institute, Berkeley, CA.
Morgan, N. L. (2000). Defining normal gender behavior: Therapeutic implications
arising from psychologists’ sex-role expectations and attitudes towards lesbians
and gays. Unpublished doctoral dissertation, American Schools of Professional
Psychology, San Francisco Bay Area Campus, Point Richmond, CA.
Neisen, J. (1992). Gender identity disorder of childhood: By whose standard and
for what purpose? A response to Rekers and Morey. Journal of Psychology &
Human Sexuality, 5, 65–67.
Nicolosi, J., & Nicolosi, L. A. (2002). A parent’s guide to preventing homosexuality.
Downers Grove, IL: InterVarsity Press.
Nordyke, N. S., Baer, D. M., Etzel, B. C., & LeBlanc, J. M. (1977). Implications of the
stereotyping and modification of sex role. Journal of Applied Behavior Analysis,
10, 553–557.
Pauly, I. B., & Edgerton, M. T. (1986). The gender identity movement: A growing
surgical-psychiatric liaison. Archives of Sexual Behavior, 15, 315–329.
Pickstone-Taylor, S. D. (2003). Children with gender nonconformity [Letter to the
editor]. Journal of the American Academy of Child and Adolescent Psychiatry,
42, 266.
Pincus, H. A., Frances, A., Davis, W. W., First, M. B., & Widiger, T. A. (1992). DSM-
IV and new diagnostic categories: Holding the line on proliferation. American
Journal of Psychiatry, 149, 112–117.
Pleak, R. R. (1999). Ethical issues in diagnosing and treating gender-dysphoric chil-
dren and adolescents. In M. Rottnek (Ed.), Sissies & tomboys: Gender noncon-
formity & homosexual childhood (pp. 34–51). New York: New York University
Press.
Rekers, G. A. (1977). Atypical gender development and psychosocial adjustment.
Journal of Applied Behavior Analysis, 10, 559–571.
Richardson, J. (1996). Setting limits on gender health. Harvard Review of Psychiatry,
4, 49–53.
Gender Identity Disorder in Children and the DSM 41
Richardson, J. (1999). Response: Finding the disorder in gender identity disorder.
Harvard Review of Psychiatry, 7, 43–50.
Rosenberg, M. (2002). Children with gender identity issues and their parents in in-
dividual and group treatment. Journal of the American Academy of Child and
Adolescent Psychiatry, 41, 619–621.
Sedgwick, E. K. (1991). How to bring your kids up gay. Social Text, 9, 18–27.
Serbin, L. A. (1980). Sex-role socialization: A field in transition. In B. B. Lahey &
A. E. Kazdin (Eds.), Advances in clinical child psychology (Vol. 3, pp. 41–96).
New York: Plenum Press.
Spitzer, R. L. (1981). The diagnostic status of homosexuality in DSM-III: A reformu-
lation of the issues. American Journal of Psychiatry, 138, 210–215.
Spitzer, R. L. (1991). An outsider-insider’s views about revising the DSMs. Journal of
Abnormal Psychology, 100, 294–296.
Spitzer, R. L., & Endicott, J. (1978). Medical and mental disorder: Proposed definition
and criteria. In R. L. Spitzer & D. F. Klein (Eds.), Critical issues in psychiatric
diagnosis (pp. 15–39). New York: Raven Press.
Stoller, R. J. (1968). Sex and gender (Vol. I). The development of masculinity and
femininity. New York: Jason Aronson.
Stoller, R. J. (1973). Criteria for psychiatric diagnosis. American Journal of Psychiatry,
130, 1207–1208.
Stoller, R. J. (1975). Sex and gender (Vol. II). The transsexual experiment. London:
Hogarth Press.
Widiger, T. A., Frances, A. J., Pincus, H. A., & Davis, W. W. (1990). DSM-IV literature
reviews: Rationale, process, and limitations. Journal of Psychopathology and
Behavioral Assessment, 12, 189–202.
Widiger, T. A., Frances, A. J., Pincus, H. A., Davis, W. W., & First, M. B. (1991). Toward
an empirical classification for the DSM-IV. Journal of Abnormal Psychology, 100,
280–288.
Wilson, I., Griffin, C., & Wren, B. (2002). The validity of the diagnosis of gender
identity disorder (child and adolescent criteria). Clinical Child Psychology and
Psychiatry, 7, 335–351.
Winkler, R. C. (1977). What types of sex-role behavior should behavior modifiers
promote? Journal of Applied Behavior Analysis, 10, 549–552.
Zucker, K. J. (1999a). Gender identity disorder in the DSM-IV [Letter to the editor].
Journal of Sex & Marital Therapy, 25, 5–9.
Zucker, K. J. (1999b). Commentary on Richardson’s (1996) “Setting Limits on Gender
Health.” Harvard Review of Psychiatry, 7, 37–42.
Zucker, K. J. (2002) Gender identity disorder. In M. Rutter & E. Taylor (Eds.),
Child and adolescent psychiatry (4th ed., pp. 737–753). Oxford: Blackwell
Science.
Zucker, K. J. (2003a, October 17). GID not “phantom disorder” [Letter to the editor].
Psychiatric News, 38(20), 30.
Zucker, K. J. (2003b, September). Persistence and desistance of gender identity disor-
der in children [Discussant]. Paper presented at the Harry Benjamin International
Gender Dysphoria Association, Gent, Belgium.
Zucker, K. J. (2003c, September). Debating DSM. Paper presented at the Harry
Benjamin International Gender Dysphoria Association, Gent, Belgium.
42 K. J. Zucker and R. L. Spitzer
Zucker, K. J. (2004). Gender identity disorder. In D. Bell, S. L. Foster, and E. J.
Mash (Eds.), Behavioral and emotional problems in girls. New York: Kluwer
Academic/Plenum Press, pp. 285–319.
Zucker, K. J. (in press). Gender identity disorder. In D. A. Wolfe & E. J. Mash (Eds.),
Behavioral and emotional disorders in adolescents: Nature, assessment, and
treatment. New York: Guilford Press.
Zucker, K. J., & Bradley, S. J. (1995). Gender identity disorder and psychosexual
problems in children and adolescents. New York: Guilford Press.
Zucker, K. J., Mitchell, J. N., Bradley, S. J., Tkachuk, J., & Allin, S. (2004). The Recalled
Childhood Gender Identity/Gender Role Questionnaire: Psychometric properties.
Manuscript submitted for publication.
Zuger, B. (1984). Early effeminate behavior in boys: Outcome and significance for
homosexuality. Journal of Nervous and Mental Disease, 172, 90–97.
... With a significant emphasis on psychoanalytic theories of normal and pathological mental functioning, the GID diagnoses or anything equivalent did not appear in either one (APA, 1952(APA, , 1968. By 1980, however, a newly revamped DSM-III would abandon the psychodynamic theories informing the first two volumes and instead adopt a neo-Kraepelian, descriptive, symptom-based framework drawing upon contemporary research findings (Spiegel, 2005;Zucker & Spitzer, 2005). In that shift, a growing body of research on child and adult gender identity found its way into the manual. ...
... In that shift, a growing body of research on child and adult gender identity found its way into the manual. Zucker and Spitzer (2005) summarize the vicissitudes of the current gender diagnoses from DSM-III through DSM-IV-TR: ...
... Some activists and academics in the field of queer theory (Mass, 1990b;Sedgwick, 1991) asserted that the new diagnosis was a ruse perpetrated by psychiatrists to prevent homosexuality in adults. 58 Zucker and Spitzer (2005) refuted that interpretation of historical events on the basis of three reasons: (1) there was no need for a veiled backdoor diagnosis to prevent homosexuality because DSM-III [still] contained the diagnosis of ego-dystonic homosexuality; (2) that EDH was itself eventually removed from the DSM-III-R because of a lack of any empirical basis to support the diagnosis; and (3) ''several clinicians and scientists who argued in favor of delisting homosexuality from the DSM-II were members of 56 The most notable organizations in this movement were the Mattachine Society for men and the Daughters of Bilitis for women. The Mattachine Review and DOB's The Ladder would publish numerous articles debating normalizing versus pathologizing models. ...
... Besides providing mutual enjoyment, wellbeing and happiness for the two marriage partners, sexual activities also contribute to the production of children and, ultimately, have been sustaining human creation since ancient times. Any deviational sexual orientation, relationship and modification of heterosexual behavior due to biopsychosocial, cultural and environmental factors, community beliefs and biased arguments, and polarized theories and political overtures were considered abnormal and pathological in the past and even currently in some corners of the world [1][2][3][4]. The research literature before and after 1973, beyond this paper, is replete with huge scientific information including sexual abuse and views of opponents and proponents directed towards lesbian, gay, bigender, and transsexuals and queer (LGBTQ), transgender incongruence, transvestic disorder, gender dysphoria, gender variance, sexual orientation and paraphilias [5][6][7][8][9][10][11]. Overall, the word homosexuality is replaced by high-risk homosexual behavior linked with life styles (ICD-10) and high risk heterosexual behavior and both diagnostic indexes have problem with life style and gender dysphoria (DSM-III-V). ...
... The topic of homosexual and now gay behavior is strongly politicized and enmeshed with complex biological, psychological, social and cultural views and changing attitudes, i.e., wrong to tolerance to negative, spurred by younger people mostly females and social media, controversial diverging theories and multiple concepts and definitions [2,4,5,7,10,[13][14][15][16]. Despite modernized attitudes of western nations towards homosexual behavior/LGBTQ, which indeed has been effectively transforming traditional views of eastern world including China [17]; awfully biased views are still quite apparent against gay people that include harassment, transgender rights, and employment inequalities especially in military, based on sexual bigotry in the developed world [13,14].Though Jones and Koshes (1995) presented supporting evidence in the past that homosexuals should have equal recruitment opportunities in military [18] and this trend has been further consolidated overtime. ...
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... Included in the chapter on 'Conditions related to sexual health' ICD-11's primary focus is experience of incongruence between experienced gender and assigned sex; In ICD-11, distress and functional impairment are described as common associated features, particularly in disapproving social environments, but are not required; in contrast, DSM-5 requires clinically significant distress or impairment for diagnosis. Body Integrity Dysphoria is a differential diagnosis DSM-III to DSM-IV-TR Zucker and Spitzer (2005) summarised the mutations of the gender diagnoses from DSM-III through DSM-IV-TR. In the DSM-III (1980), there appeared for the first time two psychiatric diagnoses in children, adolescents, and adults: gender identity disorder of childhood (GIDC) and transsexualism, the latter concerning adolescents and adults. ...
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... Il sottocomitato predisposto alla revisione della diagnosi affermò di voler ridurre le differenze tra maschi e femmine, criticate da diversi autori (vedi ad es. Zucker & Spitzer, 2005), e per questo motivo il criterio riguardante il desiderio espresso di essere del sesso opposto divenne lo stesso per i due generi. Un'altra novità era che lo stesso criterio non era più richiesto per una diagnosi nel DSm-IV, sulla base del fatto che -come dimostravano le esperienze cliniche -nella maggior parte dei bambini con identità di genere non conforme, tale desiderio solo di rado è verbalizzato (Bradley et al., 1991). ...
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Chapter
The development of sex-role behavior in children has been studied extensively in North America over the past five decades. Interest in this aspect of early childhood socialization originally derived fom psychoanalytic theories regarding the importance of same-sex “identification” in the normal development of the child’s personality. According to this position, biological factors determine the basic psychosexual “conflicts” which a male or female must face and resolve during childhood (hence Freud’s oft-quoted “anatomy is destiny”, [1961]). However, the specific form of this “conflict resolution” was thought to be determined by environmental influences and the particular experiences of the individual. The establishment of “appropriate” sex-role identification during early childhood was regarded as critical for an individual’s later sexual, psychological, and societal functioning. Further, satisfactory “resolution” of sex-role identification was viewed as a difficult and delicate process which might easily be disrupted, leading to later sexual and psychological dysfunction.