Gender Dysphoria Diagnosis (Part 4): DSM and ICD Diagnostic Criteria

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Part 1: GIDYQ-AA Personal Reflection
Part 2: Psychological Benefits of Diagnostic Confirmation 
Part 3: Childhood Gender Non-Conformity
~ Part 4 in the Gender Dysphoria Diagnosis series ~ 
Part 5
: GIDYQ-AA Full Text

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DSM-5

I frequently mention the diagnostic criteria for gender identity disorder and gender dysphoria in my posts, and I reference numerous research studies that also refer to these criteria. The diagnostic criteria are outlined in successive editions of the American Diagnostic and Statistical Manual of Mental Disorders (DSM) and the WHO International Statistical Classification of Diseases (ICD).

I thought it might be helpful to post all the different versions of the diagnostic criteria related to transsexualism, gender identity disorder, and gender dysphoria so that readers have more context for my previous posts. Presenting all the versions of the diagnostic criteria in chronological order also illustrates the evolution of these criteria over time.

The criteria posted below were extracted from hardcopies of the most recent DSM editions (DSM-IV-R and DSM-5) and an online ebook of ICD-10 accessed through a university server. I was unable to obtain hardcopies or online versions of earlier DSM editions so I have included here the abbreviated diagnostic criteria from the DSM-III and DSM-III-R as listed in the appendix of a review article discussing gender identity disorder diagnostic criteria. (Cohen-Kettenis 2009)

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DSM-III (1980)

Transsexualism (302.5x)
A. Sense of discomfort and inappropriateness about one’s anatomic sex.
B. Wish to be rid of one’s own genitals and to live as a member of the other sex.
C. The disturbance has been continuous (not limited to periods of stress) for at least 2 years.
D. Absence of physical intersex or genetic abnormality.
E. Not due to another mental disorder, such as Schizophrenia.

Sub-classification by predominant prior sexual history:
1 = asexual
2 = homosexual (same anatomic sex)
3 = heterosexual (other anatomic sex)
4 = unspecified

Atypical Gender Identity Disorder (302.85)
This is a residual category for coding disorders in gender identity that are not classifiable as a specific Gender Identity Disorder.

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DSM-III-R (1987)

Transsexualism (302.50)
A. Persistent discomfort and sense of inappropriateness about one’s assigned sex.
B. Persistent preoccupation for at least 2 years with getting rid of one’s primary and secondary sex characteristics and acquiring the sex characteristics of the other sex.
C. The person has reached puberty.

Specify history of sexual orientation: asexual, homosexual, heterosexual, or unspecified.

Gender Identity Disorder of Adolescence or Adulthood, Nontranssexual Type (GIDAANT) (302.85)
A. Persistent or recurrent discomfort and sense of inappropriateness about one’s assigned sex.
B. Persistent or recurrent cross-dressing in the role of the other sex, either in fantasy or actuality, but not for the purpose of sexual excitement (as in Transvestic Fetishism).
C. No persistent preoccupation (for at least 2 years) with getting rid of one’s primary and secondary sex characteristics and acquiring the sex characteristics of the other sex (as in Transsexualism).
D. The person has reached puberty.

Specify history of sexual orientation: asexual, homosexual, heterosexual, or unspecified.

Gender Identity Disorder Not Otherwise Specified (GIDNOS) (302.85)
Disorders in gender identity that are not classifiable as a specific Gender Identity Disorder. Examples:
1. Children with persistent cross-dressing without the other criteria for Gender Identity Disorder of Childhood.
2. Adults with transient, stress-related cross-dressing behavior.
3. Adults with the clinical features of Transsexualism of less than 2 years’ duration.
4. People who have a persistent preoccupation with castration or penectomy without a desire to acquire the sex characteristics of the other sex.

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ICD-10 (1993)

Gender Identity Disorders (F64)

Transsexualism (F64.0)
A. The individual desires to live and be accepted as a member of the opposite sex, usually accompanied by the wish to make his or her body as congruent as possible with the preferred sex through surgery and hormonal treatment.
B. The transsexual identity has been present persistently for at least two years.
C. The disorder is not a symptom of another mental disorder, such as schizophrenia, nor is it associated with chromosome abnormality.

Dual-Role Transvestism (F64.1)
A. The individual wears clothes of the opposite sex in order to experience temporarily membership of the opposite sex.
B. There is no sexual motivation for the cross-dressing.
C. The individual has no desire for a permanent change to the opposite sex.

Gender Identity Disorder of Childhood (F64.2)

For girls:
A. The individual shows persistent and intense distress about being a girl, and has a stated desire to be a boy (not merely a desire for any perceived cultural advantages to being a boy), or insists that she is a boy.
B. Either of the following must be present:
(1) persistent marked aversion to normative feminine clothing and insistence on wearing stereotypical masculine clothing, e.g. boys’ underwear and other accessories;
(2) persistent repudiation of female anatomic structures, as evidenced by at least on of the following:
(a) an assertion that she has, or will grow, a penis;
(b) rejection of urinating in a sitting position;
(c) assertion that she does not want to grow breasts or menstruate.
C. The girl has not yet reached puberty.
D. The disorder must have been present for at least 6 months.

For boys:
A. The individual shows persistent and intense distress about being a boy, and has an intense desire to be a girl or, more rarely, insists that he is a girl.
B. Either one of the following must be present:
(1) preoccupation with stereotypical female activities, as shown by a preference for either cross-dressing or simulating female attire, or by an intense desire to participate in the games and pastimes of girls and rejection of stereotypical male toys, games, and activities;
(2) persistent repudiation of male anatomical structures, as indicated by at least one of the following repeated assertions:
(a) that he will grow up to become a woman (not merely in that role);
(b) that his penis or testes are disgusting or will disappear;
(c) that it would be better not to have a penis or testes.
C. The boy has not yet reached puberty.
D. The disorder must have been present for at least 6 months.

Other Gender Identity Disorders (F64.8)

Gender Identity Disorder, Unspecified (F64.9)

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DSM-IV (1994) and DSM-IV-TR (2000)

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 towards 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:
302.6 Gender Identity Disorder in Children
302.85 Gender Identity Disorder in Adolescents or Adults

Specify if (for sexually mature individuals):
Sexually Attracted to Males
Sexually Attracted to Females
Sexually Attracted to Both
Sexually Attracted to Neither

Gender Identity Disorder Not Otherwise Specified (302.6)
This category is included for coding disorders in gender identity that are not classifiable as a specific Gender Identity Disorder. Examples include:
1. Intersex conditions (e.g., partial androgen insensitivity syndrome or congenital adrenal hyperplasia) and accompanying gender dysphoria.
2. Transient, stress-related cross-dressing behavior.
3. Persistent preoccupation with castration or penectomy without a desire to acquire the sex characteristics of the other sex.

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DSM-V (2013)

Gender Dysphoria in Children (302.6)
A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested by at least 6 of the following (one of which must be Criterion A1):

  1. A strong desire to be of the other gender or an insistence that he or she is the other gender.
  2. In boys, a strong preference for cross-dressing or simulating female attire; in girls, a strong preference for wearing only typical masculine clothing and a strong resistance to the wearing of typical feminine clothing.
  3. A strong preference for cross-gender roles in make-believe or fantasy play.
  4. A strong preference for the toys, games, or activities typical of the other gender.
  5. A strong preference for playmates of the other gender.
  6. In boys, a strong rejection of typically masculine toys, games, and activities and a strong avoidance of rough-and-tumble play; in girls, a strong rejection of typically feminine toys, games, and activities.
  7. A strong dislike of one’s sexual anatomy.
  8. A strong desire for the primary and/or secondary sex characteristics that match one’s experienced gender.

B. The condition is associated with clinically significant distress or impairment in social, school, or other important areas of functioning.

Specify if:
With a disorder of sex development (eg. a congenital adrenogenital disorder such as 255.2 congenital adrenal hyperplasia or 259.50 androgen insensitivity syndrome).
Coding note: code the disorder of sex development as well as gender dysphoria.

Gender Dysphoria in Adolescents and Adults (302.85)
A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested at least two of the following:

  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).
  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).
  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).

B. The condition is associated with clinically significant distress or impairment in social, school, or other important areas of functioning.

Specify if:
With a disorder of sex development (eg. a congenital adrenogenital disorder such as 255.2 congenital adrenal hyperplasia or 259.50 androgen insensitivity syndrome).
Coding note: code the disorder of sex development as well as gender dysphoria.

Specify if:
Post-transition: The individual has transitioned to full-time living in the desired gender (with or without legalization of gender change) and has undergone (or is preparing to have) at least one cross-sex medical procedure or treatment regimen – namely, regular cross-sex hormone treatment or gender reassignment surgery confirming the desired gender (eg. penectomy, vaginoplasty in a natal male; mastectomy or phalloplasty in a natal female).

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References

American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-IV-TR (4th ed, Text Revision). 2000. Washington, DC: American Psychiatric Association.

American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-5 (5th ed). 2013. Arlington, VA: American Psychiatric Association.

Cohen-Kettenis PT, Pfafflin F. The DSM diagnostic criteria for gender identity disorder in adolescents and adults. 2010. Archives of Sexual Behavior 39(2): 499-513. 

World Health Organization. ICD-10 Classification of Mental and Behavioural Disorders  Diagnostic Criteria for Research. 1993. Geneva, Switzerland: WHO. Accessed online. 

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