American Psychiatric Association (APA) DSM-5, USA
[2/10/2010]
Gender Identity Disorder in Adolescents or Adults
PROPOSED REVISION
Gender Incongruence (in Adolescents or Adults) [1]
A. A marked incongruence between one’s experienced/ expressed gender
and assigned gender, of at least 6 months duration, as manifested by
2* or more of the following indicators: [2, 3, 4]
1. a marked incongruence between one’s experienced/ expressed gender
and primary and/or secondary sex characteristics (or, in young
adolescents, the anticipated secondary sex characteristics) [13, 16]
2. a strong desire to be rid of one’s primary and/or secondary sex
characteristics because of a marked incongruence with one’s
experienced/ expressed gender (or, in young adolescents, a desire to
prevent the development of the anticipated secondary sex
characteristics) [17]
3. a strong desire for the primary and/or secondary sex
characteristics of the other gender
4. a strong desire to be of the other gender (or some alternative
gender different from one’s assigned gender)
5. a strong desire to be treated as the other gender (or some
alternative gender different from one’s assigned gender)
6. a strong conviction that one has the typical feelings and reactions
of the other gender (or some alternative gender different from one’s
assigned gender)
Subtypes
With a disorder of sex development
Without a disorder of sex development
[14, 15, 16, 19]
RATIONALE
For the adult criteria, we propose, on a preliminary basis, the
requirement of only 2 indicators. This is based on a preliminary
secondary data analysis of 154 adolescent and adults patients with GID
compared to 684 controls (Deogracias et al., 2007; Singh et al.,
2010). From a 27-item dimensional measure of gender dysphoria, the
Gender Identity/Gender Dysphoria Questionnaire for Adolescents and
Adults (GIDYQ), we extracted five items that correspond to the
proposed A2-A6 indicators (we could not extract a corresponding item
for A1). Each item was rated on a 5-point response scale, ranging from
Never to Always, with the past 12 months as the time frame. For the
current analysis, we coded a symptom as present if the participant
endorsed one of the two most extreme response options (frequently or
always) and as absent if the participant endorsed one of the three
other options (never, rarely, sometimes). This yielded a true positive
rate of 94.2% and a false positive rate of 0.7%. Because the wording
of the items on the GIDYQ is not identical to the wording of the
proposed indicators, further validational work will be required during
field trials.
End notes
1. It is proposed that the name gender identity disorder (GID) be
replaced by “Gender Incongruence” (GI) because the latter is a
descriptive term that better reflects the core of the problem: an
incongruence between, on the one hand, what identity one experiences
and/or expresses and, on the other hand, how one is expected to live
based on one’s assigned gender (usually at birth) (Meyer-Bahlburg,
2009a; Winters, 2005). In a recent survey that we conducted among
consumer organizations for transgendered people (Vance et al., in
press), many very clearly indicated their rejection of the GID term
because, in their view, it contributes to the stigmatization of their
condition.
2. In addition to the proposed name change for the diagnosis (see
Endnote 1), there are 6 substantive proposed changes to the DSM-IV
descriptive and diagnostic material: (a) we have proposed a change in
conceptualization of the defining features by emphasizing the
phenomenon of “gender incongruence” in contrast to cross-gender
identification per se (Meyer-Bahlburg, 2009a); (b) we have proposed a
merging of the A and B clinical indicator criteria in DSM-IV (see
Endnotes 10, 13); (c) for the adolescent/adult criteria, we have
proposed a more detailed and specific set of polythetic indicators
than was the case in DSM-IV (Cohen-Kettenis & Pfäfflin, 2009; Zucker,
2006); (d) for the child criteria, we have proposed that the A1
indicator be necessary (but not sufficient) for the diagnosis of GI
(see Endnote 5); (e) we have proposed that the “distress/impairment”
criterion not be a prerequisite for the diagnosis of GI (see Endnote
15); and (f) we have proposed that subtyping by sexual attraction (for
adolescents/ adults) be eliminated (see Endnote 18) but that subtyping
by the presence or absence of a co-occurring disorder of sex
development (DSD) be introduced (see Endnote 14). As in DSM-IV, we
recommend one overarching diagnosis, GI, with separate,
developmentally- appropriate criteria sets for children vs.
adolescents/ adults. The text material will provide updated information
on developmental trajectory data for clients who received the GI
diagnosis in childhood vs. adolescence or adulthood.
The term “sex” has been replaced by assigned “gender” in order to make
the criteria applicable to individuals with a DSD (Meyer-Bahlburg,
2009b). During the course of physical sex differentiation, some
aspects of biological sex (e.g., 46,XY genes) may be incongruent with
other aspects (e.g., the external genitalia); thus, using the term
“sex” would be confusing. The change also makes it possible for
individuals who have successfully transitioned to “lose” the diagnosis
after satisfactory treatment. This resolves the problem that, in the
DSM-IV-TR, there was a lack of an “exit clause,” meaning that
individuals once diagnosed with GID will always be considered to have
the diagnosis, regardless of whether they have transitioned and are
psychosocially adjusted in the identified gender role (Winters, 2008).
The diagnosis will also be applicable to transitioned individuals who
have regrets, because they did not feel like the other gender after
all. For instance, a natal male living in the female role and having
regrets experiences an incongruence between the “newly assigned”
female gender and the experienced/ expressed (still or again male)
gender.
3. It has been recommended by the Workgroup to delete the “perceived
cultural advantages” proviso. This was also recommended by the DSM-IV
Subcommittee on Gender Identity Disorders (Bradley et al., 1991).
There is no reason to “impute” one causal explanation for GI at the
expense of others (Zucker, 1992, 2009).
4. The 6 month duration was introduced to make at least a minimal
distinction between very transient and persistent GI. The duration
criterion was decided upon by clinical consensus. However, there is no
clear empirical literature supporting this particular period (e.g., 3
months vs. 6 months or 6 months vs. 12 months). There was, however,
consensus among the group that a lower-bound duration of 6 months
would be unlikely to yield false positives.
13. In the DSM-IV, there are two sets of clinical indicators (Criteria
A and B). This distinction is not supported by factor analytic
studies. The existing studies suggest that the concept of GI is best
captured by one underlying dimension (Cohen-Kettenis & van Goozen,
1997; Deogracias et al., 2007; Green, 1987; Johnson et al., 2004;
Singh et al., 2010).
14. There is considerable evidence individuals with a DSD experience
GI and may wish to change from their assigned gender; the percentage
of such individuals who experience GI is syndrome-dependent
(Cohen-Kettenis, 2005; Dessens, Slijper, & Drop, 2005; Mazur, 2005;
Meyer-Bahlburg, 1994, 2005, 2009a, 2009b). From a phenomenologic
perspective, DSD individuals with GI have both similarities and
differences to individuals with GI with no known DSD. Developmental
trajectories also have similarities and differences. The presence of a
DSD is suggestive of a specific causal mechanism that may not be
present in individuals without a diagnosable DSD.
15. It is our recommendation that the GI diagnosis be given on the
basis of the A criterion alone and that distress and/or impairment
(the D criterion in DSM-IV) be evaluated separately and independently.
This definitional issue remains under discussion in the DSM-V Task
Force for all psychiatric disorders and may have to be revisited
pending the outcome of that discussion. Although there are studies
showing that adolescents and adults with the DSM-IV diagnosis of GID
function poorly, this type of impairment is by no means a universal
finding. In some studies, for example, adolescents or adults with GID
were found to generally function psychologically in the non-clinical
range (Cohen-Kettenis & Pfäfflin, 2009; Meyer-Bahlburg, 2009a).
Moreover, increased psychiatric problems in transsexuals appear to be
preceded by increased experiences of stigma (Nuttbrock et al., 2009).
Postulating “inherent distress” in case one desires to be rid of body
parts that do not fit one’s identity is, in the absence of data, also
questionable (Meyer-Bahlburg, 2009a).
16. Although the DSM-IV diagnosis of GID encompasses more than
transsexualism, it is still often used as an equivalent to
transsexualism (Sohn & Bosinski, 2007). For instance, a man can meet
the two core criteria if he only believes he has the typical feelings
of a woman and does not feel at ease with the male gender role. The
same holds for a woman who just frequently passes as a man (e.g., in
terms of first name, clothing, and/or haircut) and does not feel
comfortable living as a conventional woman. Someone having a GID
diagnosis based on these subcriteria clearly differs from a person who
identifies completely with the other gender, can only relax when
permanently living in the other gender role, has a strong aversion
against the sex characteristics of his/her body, and wants to adjust
his/her body as much as technically possible in the direction of the
desired sex. Those who are distressed by having problems with just one
of the two criteria (e.g., feeling uncomfortable living as a
conventional man or woman) will have a GIDNOS diagnosis. This is
highly confusing for clinicians. It perpetuates the search for the
“true transsexual” only, in order to identify the right candidates for
hormone and surgical treatment instead of facilitating clinicians to
assess the type and severity of any type of GI and offer appropriate
treatment. Furthermore, in the DSM-IV, gender identity and gender role
were described as a dichotomy (either male or female) rather than a
multi-category concept or spectrum (Bockting, 2008; Bornstein, 1994;
Ekins & King, 2006; Lev, 2007; Røn, 2002). The current formulation
makes more explicit that a conceptualization of GI acknowledging the
wide variation of conditions will make it less likely that only one
type of treatment is connected to the diagnosis. Taking the above
regarding the avoidance of male-female dichotomies into account, in
the new formulation, the focus is on the discrepancy between
experienced/ expressed gender (which can be either male, female,
in-between or otherwise) and assigned gender (in most societies male
or female) rather than cross-gender identification and same-gender
aversion (Cohen-Kettenis & Pfäfflin, 2009).
17. In referring to secondary sex characteristics, anticipation of the
development of secondary sex characteristics has been added for young
adolescents. Adolescents increasingly show up at gender identity
clinics requesting gender reassignment, before the first signs of
puberty are visible (Delemarre-van de Waal & Cohen-Kettenis, 2006;
Zucker & Cohen-Kettenis, 2008).
18. In contemporary clinical practice, sexual orientation per se plays
only a minor role in treatment protocols or decisions. Also, changes
as to the preferred gender of sex partner occur during or after
treatment (DeCuypere, Janes, & Rubens, 2005; Lawrence, 2005; Schroder
& Carroll, 1999). It can be difficult to assess sexual orientation in
individuals with a GI diagnosis, as they preoperatively might give
incorrect information in order to be approved for hormonal and
surgical treatment (Lawrence, 1999). Because sexual orientation
subtyping is of interest to researchers in the field, it is
recommended that reference to it be addressed in the text, but not as
a specifier. It should also be assessed as a dimensional construct.
19. The subworkgroup has had extensive discussion about the placement
of GI in the nomenclature for DSM-V, as the meta-structure of the
entire manual is under review. 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 (see
Meyer-Bahlburg, 2009a). Various alternative options to the current
placement are under consideration.
References
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302.85
SEVERITY
For Adolescents and Adults
Please complete the following questions: [Note to Task Force—these
first 4 questions are preliminary; the corresponding dimensional
questions for the categorical diagnosis are on the next page]
1. My current legal sex or gender (e.g., as listed under “sex” on my
passport or driver’s license, also called “assigned” gender) is:
a. Female
b. Male
c. Other (describe): ____________ _____
2. My confidence that I really am what my legal “sex” states (namely,
a girl/woman or boy/man) is:
a. None
b. Mild
c. Moderate
d. Strong
e. Very Stong
3. The way that I experience and express my true gender compared to my
legal sex or gender is:
a. Not at all different
b. Mildly different
c. Moderately different
d. Strongly different
e. Very Stongly different
4. I am distressed by feeling different from my legal sex or gender:
a. None
b. Mild
c. Moderate
d. Strong
e. Very Stong
Note to the Task Force: Definitions will be provided for primary and
secondary sex characteristics and “assigned sex” and “assigned
gender.” Questions A1-A6 are the dimensional metrics for the
corresponding categorical criteria.
For Questions 1-8, please circle the letter next to the statement that
applies to you the best.
A1. Over the past 6 months, how intense was your discomfort because
your primary and/or secondary sex characteristics do not match your
gender identity?
1. None
2. Mild
3. Moderate
4. Strong
5. Very Strong
A2. Over the past 6 months, how intense was your desire to be rid of
your primary and/or secondary sex characteristics because they do not
match your gender identity?
1. None
2. Mild
3. Moderate
4. Strong
5. Very Strong
A3. Over the past 6 months, how intense was your desire for the
primary and/or secondary sex characteristics of the other gender?
1. None
2. Mild
3. Moderate
4. Strong
5. Very Strong
A4. Over the past 6 months, how intense was your desire to be of the
other gender (or some gender different from your assigned gender)?
a. None
b. Mild
c. Moderate
d. Strong
e. Very Stong
A5. Over the past 6 months, how intense was your desire to be treated
as the other gender (or some gender different from your assigned
gender)?
a. None
b. Mild
c. Moderate
d. Strong
e. Very Stong
A6. Over the past 6 months, how intense was your conviction that you
have the typical feelings and reactions of the other gender (or some
gender different from your assigned gender)?
a. None
b. Mild
c. Moderate
d. Strong
e. Very Stong
7. Over the past 6 months, how would you describe your sexual
attraction to other people?
a. Sexually attracted to males
b. Sexually attracted to females
c. Sexually attracted to both males and females
d. Sexually attracted to neither males or females
e. Other (please describe): ____________ _________ _________ _________
8. How old were you when you first had the strong desire to be, or to
live in the gender role, of the other gender (or some gender different
from your assigned gender)?
a. Age 5 years or younger
b. Between 6 and 9 years
c. Between 10 and 12 years
d. Between 13 and 17 years
e. Age 18 years or older
DSM-IV
Gender Identity Disorder
A. A strong and persistent cross-gender identification (not merely a
desire for any perceived cultural advantages of being the other sex).
In children, the disturbance is manifested by four (or more) of the following:
1. Repeatedly stated desire to be, or insistence that he or she
is, the other sex
2. In boys, preference for cross-dressing or simulating female
attire; in girls, insistence on wearing only stereotypical masculine
clothing
3. Strong and persistent preferences for cross-sex roles in
make-believe play or persistent fantasies of being the other sex
4. Intense desire to participate in the stereotypical games and
pastimes of the other sex
5. Strong preference for playmates of the other sex
In adolescents and adults, the disturbance is manifested by symptoms
such as a stated desire to be the other sex, frequent passing as the
other sex, desire to live or be treated as the other sex, or the
conviction that he or she has the typical feelings and reactions of
the other sex.
B. Persistent discomfort with his or her sex or sense of
inappropriateness in the gender role of that sex.
In children, the disturbance is manifested by any of the following:
In boys, assertion that his penis or testes are disgusting or will
disappear or assertion that it would be better not to have a penis, or
aversion toward rough-and-tumble play and rejection of male
stereotypical toys, games, and activities;
In girls, rejection of urinating in a sitting position, assertion
that she has or will grow a penis, or assertion that she does not want
to grow breasts or menstruate, or marked aversion toward normative
feminine clothing.
In adolescents and adults, the disturbance is manifested by symptoms
such as preoccupation with getting rid of primary and secondary sex
characteristics (e.g., request for hormones, surgery, or other
procedures to physically alter sexual characteristics to simulate the
other sex) or belief that he or she was born the wrong sex.
C. The disturbance is not concurrent with a physical intersex condition.
D. The disturbance causes clinically significant distress or
impairment in social, occupational, or other important areas of
functioning.
Code based on current age
Specify if (for sexually mature individuals) :
Sexually Attracted to Males
Sexually Attracted to Females
Sexually Attracted to Both
Sexually Attracted to Neither
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