Gender Dysphoria: New and Revised in DSM-5

This post is part of a series of guest posts on GPS by the graduate students in my Psychopathology course. As part of their work for the course, each student had to demonstrate mastery of the skill of “Educating the Public about Mental Health.” To that end, each student has to prepare three 1,000ish word posts on a particular class of mental disorders, with one of those focusing on changes made from the DSM-IV to the DSM-5.

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Gender Dysphoria:  New and Revised in DSM-5 by Lea Frizzell Tips

When the announcement was made in 2008 naming the members of the work groups designated to review and revise the DSM-5, quite a fuss was raised by a number of special interest groups who wanted to be sure their opinions in regard to the various entries in the DSM-IV-TR were known with the hope their influence would impact the new DSM-5 revision.  This was particularly true in regard to the category of Gender Identity Disorder (GID).  For a number of years, lobbyists have petitioned the American Psychiatric Association (APA) to consider the social effects the inclusion of GID as a mental disorder had on those individuals so diagnosed. In the advocates’ considered opinion, medically and legally, disorder means illness. Their position is that transgenders and transsexuals are not mentally ill.  Many, if not most, function well within their chosen lifestyle.  Only a rare few suffer from mental disorders and most of which developed as a result of the gender confusion experienced by individuals who have not yet decided his/her gender identity and/or by the cruelty of social stigmatization (Parry, 2013; Beredjick, 2012; Lowder, 2012).  In May of 2013, when the DSM-5 was released, it was very apparent that the members of the work group assigned to the task had listened (Bryne, et al., 2011).  Providing a page-long introduction to the newly isolated topic of Gender Dysphoria, the committee for the GID/Gender Dysphoria revision in the DSM-5 not only recognizes the social controversy surrounding gender identity, it further notes the social constructs involving gender are a result of biopsychosocial processes and are influenced by the culture the individual resides within.  To that end, the DSM-5 changed the language employed to describe the conditions discussed, shifted its perspective from mental illness as a result of sexual expression to one of distress and disability as a result of gender confusion and social rejection, and further specified the associated criteria to reflect those changes.

To provide for a more clear and concise discussion of the issue, DSM-5 included new (to the general population) vocabulary words to avoid potential sources of confusion. When discussing Gender Dysphoria, knowledge of the key terms is very helpful in understanding the topics under debate.

• The DSM-5 refers to sex or sexual when discussing the biological (reproductive capacity) characteristics of male or female (this includes the chromosomes, hormones, and genitalia associated with each sex).
• Gender is defined as the role and social identification of an individual as male or female independent of (but influenced by) biological characteristics.
• Gender assignment (aka natal gender) is the gender of male or female typically given at birth.
• Gender atypical or gender non-conforming are terms used to say behaviors under discussion are not typically associated with individuals of the same gender.
• Gender reassignment is the official change of gender (designated as male or female on a birth certificate, driver license, or passport).
• And two of the most important terms used when discussing gender dysphoria are descriptive of where in the process an individual might be transgender (those who either temporarily or permanently identify themselves as a gender other than their natal gender) and transsexual (those who have determined to undergo or have begun the social transition from one gender to another, either by cross-sex hormone treatment or through sex reassignment surgery).

Moreover, the DSM-5 changed its perspective from mental illness as a result of sexual expression to one of individual distress and disability as a result of gender confusion and social rejection, thereby excluding those transgenders and transsexuals who are adapting and functioning well within their environment.  The DSM-5 narrowed its focus to include only those individuals who suffer significant difficulty functioning in a social, occupational, or other   important cultural arena within a society as a result of the incongruence between their perceived gender and their natal gender. The DSM-5 removed as much of the language involving sexual orientation as possible, including entire sections involving the choices of sexual partners and non-specified sexual disorders. The differential diagnosis transvestic fetishism has been replaced with transvestic disorder and an additional condition, body dysmorphic disorder, was added.  Newly streamlined and renamed a more descriptive (less discriminating) identifying term, Gender Dysphoria is no longer considered a mental illness per se; there now exists a rare condition experienced by only a few people suffering significant functional disabilities under which they could qualify for mental health assistance and legal protection (American Psychiatric Publishing, 2013).

Other changes from DSM-IV-TR to DSM-5 include the language employed to list the criteria of the condition, the length of time the manifestation of the condition must be present, and the number of criteria need to diagnose gender dysphoria as opposed to gender identity disorder.  Each version of the DSM differentiates between the criteria required for the diagnosis for children, adolescents, and adults, however the DSM-5 more narrowly specifies Gender Dysphoria as “a marked incongruence between one’s experienced/expressed gender and assigned gender” as opposed to IV’s “strong and persistent cross-gender identification”.  DSM-5 notes the condition must be present for at least 6 months, while IV makes no mention of a length of time.  DSM-IV indicates that only four of the following criteria are necessary for diagnosis for children, while DSM-5 includes six:

1.  A strong desire to be or insistence that one is the other gender (5) / sex (IV).
2. A strong preference for the clothing stereotypically associated with the other gender (5) / sex (IV).
3. A strong preference for cross-gender roles in make-believe or fantasy play.
4. A strong preference for the toys, games, physical activities stereotypically used or engaged in by the other gender (5) / sex (IV).
5. A strong preference for playmates of the other gender (5) / sex (IV).

Here IV and 5 differentiate in how the information is presented, however the content is basically the same.

1.  A strong rejection of the stereotypical toys, games, and activities preferred by one’s assigned gender.
2. A strong dislike of one’s sexual anatomy.
3. A strong desire for the primary and/or sexual characteristics that match one’s experienced gender.

Again, DSM-5 is more specific in the number of criteria adolescents and adults must present (2), while DSM-IV states only that adolescents and adults must manifest the following:

1.  Preoccupation with getting rid of primary and secondary sex characteristics (requests hormones, surgery, or other procedures to physically alter sexual characteristics to simulate the other sex)
2. Belief that he/she was born the wrong sex.

DSM-5 goes on to additional criteria:

1. A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or in adolescents, the anticipated secondary sex characteristics)
2. A strong desire for the primary or secondary sex characteristics of the other gender.
3. A strong desire to be treated as the other gender.
4. A strong conviction that one has the typical feelings and reactions of the other gender.

So, a large number of changes, reflecting both social changes and empirical evidence, were made in the newest version of the DSM. Overall, the changes appear to be a positive move in helping to decrease some of the stigma surrounding gender dysphoria and reflective of good research.

References

American Psychiatric Association (2012).  Gender Dysphoria.  http://www.dsm5.org/Documents/Gender%20Dysphoria%20Fact%20Sheet.pdf

Beredjick, C. (2012, July 23). DSM-V to rename Gender Identity Disorder to Gender Dysphoria.  Advocate.com

http://www.advocate.com/politics/transgender/2012/07/23/dsm-replaces-gender-identity-disorder-gender-dysphoria

Bryne, W., Bradley, S., Coleman, E., Eyler, A.E., Green, R., Menvielle, E.J., Meyer-Bahlburg, H.F.L., Pleak, R.R., & Thompkins, D.A. (2011, July).  Report of the APA Task Force on Treatment of Gender Identity Disorder.  American Psychiatric Association

www.psych.org/File%20Library/Learn/Archives/rd2012_GID.pdf

Lowder, J. B. (2012).  Being Transgender is no longer a disorder:  The American Psychiatric Association salutes the T in LGBT.  Slate

http://www.slate.com/articles/health_and_science/medical_examiner/2012/12/dsm_revision_and_sexual_identity_gender_identity_disorder_replaced_by_gender.html

Parry, W. (2013, June 05).  Normal or not?  When one’s gender identity causes distress.  LiveScience FoxNews.  http://www.foxnews.com/health/2013/06/05/normal-or-not-when-one-gender-identity-causes-distress/