“Gender Identity” Needs To Disappear

Box Man (1)

I have spent much of the past two years researching gender dysphoria and exploring what it means to be transgender. This process has often been frustrating and confusing, as I have had considerable difficulty reconciling my intense physical dysphoria related to the female aspects of my body with the absence of any internal sense of “gender identity”. But after this prolonged immersion in the online trans community, in-depth review of the scientific literature on trans issues, and personal experience with transgender support groups and mental health professionals, the most prominent source of my chronic confusion has become apparent.

The “gender identity” concept, typical transgender narratives, and the criteria for diagnosis of gender dysphoria all depend on gender stereotypes – stereotypes which are increasingly irrelevant in modern society and which research overwhelmingly suggests are cultural constructs with limited biological underpinning. “One of the first steps to liberating people from the cage that is gender is to challenge established gender norms.” (Reilly-Cooper 2016) I think the dependance of “gender identity” discourse, trans narratives, and gender dysphoria diagnostic criteria on these gender norms actually serves to reinforce outdated and restrictive stereotypes rather than dismantle or challenge those stereotypes.

Much of this post will directly quote statements made by other authors in scientific review papers or online articles (bold indicates my own added emphasis). My goal here is not to simply repeat what has already been so eloquently stated elsewhere. I refer readers to the sources referenced at the bottom of this post for more thorough discussion of various related issues.

Instead, I wish to organize these statements within a coherent framework. This framework demonstrates a troubling and self-reinforcing cycle: the concept of “gender identity” relies on problematic gender stereotypes, the typical trans narrative relies on “gender identity” as an explanation and justification for choices regarding transition, and the diagnostic criteria for gender dysphoria use conventional gender norms as the frame of reference for assessment and diagnosis. In a clinical context, trans people are thus motivated to present their experiences in a way that aligns with opposite-gender norms to facilitate diagnosis of gender dysphoria and gain access transition options. But aligning themselves with cross-gender stereotypes necessarily (and paradoxically) requires acknowledgment of the restrictive and oppressive nature of those stereotypes which are associated so strongly (but unjustifiably) with biological sex. To counter this contradiction, trans people then invoke the concept of a discrete and inborn “gender identity” to assert the legitimacy of their experience.

(Note: This is a lengthy post with dense content. However, my conclusions are carefully derived from in-depth analysis of the concepts and research outlined throughout this post, so I encourage readers to work their way through my arguments slowly and sequentially to fully understand my final conclusions).

(1) “Gender Identity” Concept

“Gender identity is a highly problematic concept.” (Hird 2003)

Typical trans narratives strongly emphasize behaviors and preferences that align with cross-gender stereotypes as evidence of an intrinsic “gender identity”, based on a faulty assumption that there are inherent qualitative differences between men and women to support the existence of those stereotypes in the first place. The conceptualization of “gender identity” as an innate internal property is the “crucial tension at the heart of gender identity politics”. (Reilly-Cooper 2016)

“In this research, ‘gender identity’ is characterized as a sense of oneself as male, female, or indeterminate, whereas ‘gender role’ is characterized as behaviors, personality traits, and interests that society applies to these aspects, and the way that people are measured against stereotypical attributes.(Davy 2015) But is it really possible to separate “gender identity” from those “stereotypical attributes” that constitute “gender role”? To what extent do those “stereotypical attributes”, and the values and judgments that society assigns to those attributes, contribute to the development of “gender identity”?

I think “gender identity” is best understood as a constructed cognitive self-perception arising from internalized cultural gender stereotypes. “Gender variance may be conceptualized, as gender variant people apparently already do, as a multidimensional or sometimes idiosyncratically conceptualized, multicategorical construct. (Cohen-Kettenis 2009) “It is clear from feminist research that behaviors are not intrinsically masculine or feminine, but change through time and in different spaces… Gender constructionist research suggests that biological imperatives are few in the human, and consist only of procreative imperatives. Other behavioral aspects such as sartorial preference, aggression, empathy, and intelligence, among a number of other characteristics, are not sex specific and are often adaptable recent research situates behavioral sex differences firmly within a social role model… This unresolved debate weakens any possibility of arguing that there is something inherent in masculine and feminine behaviors. (Trans) people have never been subjects of an independent masculine or feminine type, and combinations of what is deemed masculine or feminine at any one time can be found within all humans, albeit performed with different intensities.” (Davy 2015)

Indeed, research regarding the development of identity during childhood consistently describes “gender identity” as an aspect of self-perception that develops and evolves over time in response to many internal and external factors. Factors contributing to the construction of gender identity include genetics, hormones, socialization, and progressive cognitive understanding of gender. (Hines 2011, Reiner 2011) “Gender development is multidimensional, and developmental processes involved in each dimension are likely to differ.” (Hines 2011) Gender identity is an evolving sense of self as one sex or the other.” (Reiner 2011) Evidence suggesting that “gender identity” develops and changes over time in response to many different factors directly contradicts the commonly held belief that “gender identity” is an innate and immutable property. The low rate of persistence of childhood gender dysphoria into adolescence also contradicts the idea that “gender identity” is an inborn and unchanging entity.

Gender identity is woven pervasively throughout identity.” (Reiner 2011) It is also clear that “gender identity” is simply one of many facets of identity which develop over time. Therefore, “gender identity” cannot be regarded as something discrete and separate from overall identity, and “gender identity” cannot be regarded as immune to the internal and external factors contributing to the ongoing development of overall identity.

“The precise mechanisms of gender identity development are complex, the interactions of the mechanisms poorly understood, and the outcomes not entirely clear, except that children and adolescents nearly always dichotomize.” (Reiner 2011) This tendency to dichotomize “gender identity” reflects persistent societal adherence to opposing gender stereotypes. Gendered socialization and the influence of this socialization on cognitive understanding of gender are major factors contributing to the development of “gender identity”. Socialization factors also gain in importance, as parents and then peers and eventually teachers encourage children to engage in gender-typed play. The child also begins to develop the understanding that he or she is male or female, and this knowledge produces motivation to imitate the behavior of others of the same sex.” (Hines 2011) As described above, this gendered socialization occurs despite the overwhelming evidence demonstrating that gender stereotypes have limited biological underpinning and that behaviors, preferences, personality traits, and cognitive functioning are not sex-specific attributes. (Hines 2011, Davy 2015) It is well established that societal gender stereotypes vary widely across different cultures and across different historical time periods (Hird 2003). This argues against any innate human “gender identity” giving rise to subsequent behaviors and preferences stereotypically associated with biological sex. Rather, it supports the idea that socially constructed gender norms give rise to individual “gender identity”.

I think the biggest weakness of the “gender identity” concept is that it is promoted as being real, immutable, and innate (endogenous) yet it remains so vague and poorly defined by those who claim to experience it. “The [trans] advocates’ websites rarely offer any indication of what feeling like a man or a woman is like.” (Davy 2015) Attempts to describe what “feeling like a man” or “feeling like a woman” means invariably fall back on conventional societal (exogenous) masculine or feminine stereotypes. This creates a frustratingly circular logic: “gender identity” is a property that is supposedly experienced internally (and therefore cannot be denied by an external perspective) but which cannot be defined in any way separate from externally imposed gender norms.

This has been extremely perplexing for me. This is why I have tried very hard to describe my experience of gender dysphoria in a concrete and clearly defined way that does not depend on reference to an internal “gender identity”. My previous blog posts (here, here, and here) have recounted the distressing thoughts and emotions that arise in response to seeing or touching the female secondary sexual characteristics of my body. This is the only way I can explain my experience without resorting to dichotomous gender stereotypes.

I do not know WHY my female anatomy generates such intense distress for me. I only know that it DOES. It would certainly be convenient to say that my physical dysphoria is secondary to a mismatch between my anatomy and my “gender identity”. But I fail to understand the concept of “gender identity” and I refuse to align my personal preferences and behaviors and interests with problematic and oppressive gender stereotypes for the sake of convenience. My female body (and the irrational but undeniable distress arising from my perception of it) and my human personality (my preferences, behaviors, and interests) are two separate things. “Gender is the value system that ties desirable (and sometimes undesirable?) behaviours and characteristics to reproductive function. Once we’ve decoupled those behaviours and characteristics from reproductive function – which we should – and once we’ve rejected the idea that there are just two types of personality and that one is superior to the other – which we should – what can it possibly mean to continue to call this stuff ‘gender’? What meaning does the word ‘gender’ have here, that the word ‘personality’ cannot capture? (Reilly-Cooper 2016)

Some might argue that my claiming an absence of “gender identity” merely represents an “agender” or “non-binary” identity along a “gender spectrum”. But those terms are simply variations on the original “gender identity” concept, and therefore remain inapplicable. Rebecca Reilly-Cooper presents an excellent series of arguments explaining why the conceptualization of gender as a spectrum is not really any more progressive or inclusive than a gender binary with two opposite poles. Rather, the concept of gender as a spectrum is illogical. I encourage readers to review her essay in full but will summarize her conclusions here: “If gender identity is a spectrum, then we are all non-binary, because none of us inhabits the points represented by the ends of that spectrum… Once we recognize that the number of gender identities is potentially infinite, we are forced to concede that nobody is deep down cisgender, because nobody is assigned the correct gender… at birth. In fact, none of us was assigned a gender… at birth at all. We were placed into one of two sex classes on the basis of our potential reproductive function, determined by our external genitals. We were then raised in accordance with the socially prescribed gender norms for people of that sex. We are all educated and inculcated into one of two roles, long before we are able to express our beliefs about our innate gender identity, or to determine for ourselves the precise point at which we fall on the gender continuum. So defining transgender people as those who at birth were not assigned the correct place on the gender spectrum has the implication that every single one of us is transgender; there are no cisgender people. The logical conclusion of all this is: if gender is a spectrum, not a binary, then everyone is trans. Or alternatively, there are no trans people. Either way, this a profoundly unsatisfactory conclusion, and one that serves both to obscure the reality of female oppression, as well as to erase and invalidate the experiences of transsexual people. The way to avoid this conclusion is to realize that gender is not a spectrum. It’s not a spectrum, because it’s not an innate, internal essence or property. Gender is not a fact about persons that we must take as fixed and essential, and then build our social institutions around that fact. Gender is socially constructed all the way through, an externally imposed hierarchy, with two classes, occupying two value positions: male over female, man over woman, masculinity over femininity.” (Reilly-Cooper 2016)

(2) Typical Transgender Narratives

As a highly pathologized, stigmatized, and marginalized community, trans people are placed in a very difficult position with respect to how they describe their experience. In a clinical context, trans people must present their narrative in a way that meets the established diagnostic criteria for gender dysphoria (criteria which are based on “cross-gender identification” and evidence of behaviors and preferences stereotypically associated with the “other sex”) in order to gain access to transition therapies. In a public context, trans people must present their stories in a way that is understandable to society at large, in order to promote awareness and acceptance. Because gender stereotypes are so deeply woven into the fabric of our society, describing trans experiences in terms of strong preferences for opposite-sex stereotypes arising from an innate “gender identity” allows a publicly palatable and understandable (albeit oversimplified and problematic) narrative to emerge from within an already well-established gender framework.

“Research has suggested that adult transpeople often think that if they do not express stereotypical masculinities and femininities… they will not fit the model that may steer them to the transitioning healthcare pathways… many transpeople are reluctant to relay anything to gender clinic psychiatrists that might be viewed as different from the perceived “correct” trans narrative. In previous research, I have demonstrated that transpeople tend to tailor their clinical narratives because they realize that psychiatrists have the power to stop their transitioning process… transpeople retrospectively claim to have participated in stereotypically gendered play and behaviors when they have sought transitioning technologies, and have often interspersed expected gender inflections into their clinical narratives… These inflections seem inevitable because the diagnostic criteria expect cross-gendered play and behaviors to be performed prior to the granting of transitioning technologies…  the clinically expected expressions of gender do not correspond well to gender role play or leisure pursuits apparent in contemporary society.” (Davy 2015)

The typical or “correct” trans narrative seems to include these main elements: strong retrospective emphasis on the early onset of gender dysphoric feelings in childhood which persisted into adolescence and adulthood, gender dysphoric feelings arising primarily from discomfort with societal gender stereotypes, assertion of a supposedly intrinsic and fixed “gender identity”, and physical dysphoria portrayed as a secondary consequence of a primary mismatch between the brain’s “gender identity” and the body’s “assigned sex”. To put it more simply, the typical trans narrative says: from a young age my personality and preferences did not align with conventional binary gender roles and gender stereotypes, therefore I must have a cross-gender or non-binary “gender identity”, therefore I must be transgender, therefore I am trapped in the wrong body, therefore my body needs to be changed to align with my “gender identity”. “Transpeople have often defined their trans gender identities through a ‘‘wrong body’’ narrative.” (Davy 2015)

Typical trans narratives not only emphasize the concept of an innate “gender identity”, they also imply that this cross-sex “gender identity” is the result of pre-natal biological factors. “Trans advocates’ essentialist claims of gender dysphoria seem to assume that society will be more accepting of transpeople if they are understood to have been ‘‘born this way”… [due to] the relative power that biogenetic discourses maintain in society and particularly in medicine.” (Davy 2015) The etiology of gender dysphoria is not clearly understood, but one of the most common theories is that exposure to altered levels of sex hormones during fetal development leads to “sex-atypical cerebral programming that diverges from the sexual differentiation of the rest of the body”. (Hoekzema 2015) However, “no evidence thus far has linked normal variability in the early hormone environment to gender dysphoria.” (Hines 2011) Additionally, people with disorders of sexual development (intersex conditions) that do cause abnormal exposure to sex hormones in utero overwhelmingly maintain a “gender identity” that aligns with the sex they were assigned at birth, rather than with the sex that their pre-natal hormone exposure more closely mimics (Hines 2011, Reiner 2011). “The majority of intersex people identified their gender as their sex assigned at birth.” (Reiner 2011) For example, female fetuses (XX chromosomes) with congenital adrenal hyperplasia have a genetic defect in adrenal enzyme pathways that leads to accumulation of androgens (such as testosterone) in the fetus’ body and causes pre-natal virilization of the female genitals. These infants are assigned female at birth. Despite high levels of pre-natal androgen exposure and masculinized genitalia, 97% of women with CAH identity as female from childhood into adulthood (Hines 2011). Male fetuses (XY chromosomes) with androgen insensitivity syndrome have normal testes and normal androgen production but lack androgen receptor molecules, which means that testosterone produced by the testes has no effect on the developing fetus. Androgen insensitivity impairs the masculinization of male genitalia in the developing fetus and the development of male secondary sexual characteristics during puberty. These XY individuals are often raised as females (particularly in cases of complete androgen insensitivity) and maintain a female “gender identity” despite having a male chromosomal configuration. (Reiner 2011) These examples provides strong evidence that “gender identity” is influenced more strongly by socialization and external gender expectations than internal biological factors like sex hormone exposure or sex chromosomes.

The typical trans narrative centers around a supposedly innate “gender identity” as an explanation for their discomfort in the body and the social role associated with their biological sex and as justification for their choices regarding transition. But as I outlined above, the concept of “gender identity” as a fixed internal property has no logical or scientific basis and relies entirely on an external frame of reference (societal gender stereotypes). “Trans advocates’ essentialist claims of gender dysphoria… and the desire to transition to a particular gender tend to mirror the simplistic dualisms from biological research, in which masculinity and femininity are regarded as natural, rather than socially constructed, characteristics.” (Davy 2015) So the emphasis on, and continued perpetuation of, the “gender identity” concept by trans advocates only serves to reinforce outdated and oppressive stereotypes.

(3) Gender Dysphoria Diagnostic Criteria

“Gender dysphoria is not always a straightforward diagnosis. This can be ascribed to the fact that international classifications are quite general and have significant short-comings, there are no objective criteria, and gender dysphoria can present in a great diversity of forms, situations, and experiences.” (Fabris 2015)

Most of the medical and psychological research regarding gender dysphoria has been based on diagnostic criteria in the American Diagnostic and Statistical Manual of Mental Disorders (DSM). I have focused on articles published since 2000, which usually refer to the diagnostic criteria for gender identity disorders in the DSM-IV and DSM-IV-TR (published in 1994 and 2000, respectively) or the criteria for gender dysphoria in the DSM-5 (published in 2013). However, some recent studies still refer to the criteria for gender identity disorders in the WHO International Statistical Classification of Diseases, the ICD-10 (published in 1993).

With respect to the DSM criteria, there is a glaring lack of validity studies or evidence supporting inter-rater reliability in the diagnostic process (Cohen-Kettenis 2009). It has been suggested that validity of the DSM diagnostic criteria can be inferred from studies evaluating sex reassignment as a treatment procedure. “Sex reassignments based on DSM diagnoses primarily resulted in satisfying results, in terms of alleviating the discomfort about one’s sex or the ‘gender dysphoria.’ Although diagnosis and response to sex reassignment are not very closely connected, and the reported findings are certainly no ‘‘proof’’ of the correctness of the diagnosis, they suggest that the elements of the DSM diagnosis are clinically useful.” (Cohen-Kettenis 2009) However, in the studies referenced by that statement, most of the subjects underwent “complete” sex reassignment. So the inferred clinical utility of DSM criteria may only apply to those who desire all aspects of sex reassignment, which is not representative of the transition goals of all trans people. “Indeed, clinicians in gender identity clinics are increasingly confronted with treatment goals other than complete sex reassignment.” (Cohen-Kettenis 2009) So the utility of the existing diagnostic criteria is, at best, limited to a subpopulation of the diverse transgender community.

One of the primary criticisms regarding the diagnostic criteria for gender identity disorder in the DSM-IV and DSM-IV-TR was the inability of the criteria to reflect the diversity of gender variance. “A problem with the current criteria is that gender identity, gender role, and gender problems are conceptualized dichotomously rather than dimensionally. For instance, the DSM-IV text states that adults with gender identity disorder are preoccupied with their wish to live as a member of the other sex, manifested as an intense desire to adopt the role of the other sex or to acquire the physical appearance of the other sex through hormonal or surgical manipulation. Within the gender identity disorder criteria, a concept such as ‘‘cross-gender identification’’ also assumes that there are only two gender identity categories, male and female.” (Cohen-Kettenis 2009) I have previously discussed my frustration that even supposedly dimensional (rather than dichotomous) scales used to measure the intensity of gender dysphoria (such as the GIDYQ-AA) leave little room for non-binary responses, and interpretation of the questions on the survey relies heavily on the reader’s alignment with stereotypical roles behaviors associated with men and women.

Prior to publishing the updated version of the DSM (DSM-5) in 2013, a workgroup was developed to revise the gender identity disorder criteria. One of the biggest revisions was a change in diagnostic terminology from gender identity disorder to gender dysphoria, to emphasize the distress associated with gender variance as being a form of psychopathology rather than gender non-conformity being considered pathological in and of itself. The goal of the workgroup was to revise the criteria in a way that would help destigmatize trans people while maintaining a diagnostic category that medical insurance companies would accept to provide financial support for transition treatments. (Davy 2015)

However, despite those revisions, the current DSM-5 criteria for gender dysphoria remain problematic. “The diagnostic framework in the DSM-5 for all transpeople continues to be underpinned by essentialist, heteronormative assumptions that situate binary sexes – male and female – with corresponding genitalia as the anchor from which gender dysphoria is judged… I would argue that the criteria proposed by the DSM-5 are derived from stereotypes applied in the gender identity clinics serving transpeople, rather than empirically developed from biological imperatives.(Davy 2015)

Particularly disturbing is the fact that the research and clinical experience taken into account in revising the DSM-5 diagnostic criteria was based heavily on trans peoples’ clinical narratives, which (as I described above) are often tailored with added gender inflections to align more closely with the previously established criteria in order to gain access to transition options. “The DSM-5 Workgroup has disregarded the plethora of work in feminist social science which criticizes the inherency of gender roles, gender identities, and sex differences, as well as research in transgender studies that depicts non-dysphoric transpeople, desires for different embodiments, non-conventional transitioning trajectories, and sexualities. In the pre-publication reports, the Workgroup considered only the views and evidence derived from sexological research. As such, the review reflects a form of expert clinical consensus based on transpeople’s tailored narratives and questionable ideas around masculinity and femininity.(Davy 2015)

Such a narrow-minded approach to developing diagnostic criteria based on increasingly irrelevant and biologically unjustified gender stereotypes creates a self-perpetuating cycle: trans people present their experiences in ways that align with the criteria, and the criteria are then perceived as being reinforced and validated by their alignment with trans people’s narratives. “The criteria used to diagnose gender dysphoria help psychiatrists to determine whether someone is experiencing distress about incongruence with their experienced gender through a gender normative frame… Arguably, this leads to the situation where transpeople must express incongruent behavior and demonstrate to the psychiatrist that they have most often preferred activities that are traditionally gendered and opposite to those gender norms applied to their assigned sex at birth. Within the DSM-5, these traditional gendered expressions seem to be required in spite of the lack of stark behavioral differences between the genders in Western societies today.” (Davy 2015)

And the ongoing emphasis on “gender identity” as part of the typical trans narrative and as a core diagnostic criterion further reinforces restrictive societal stereotypes. “[Most gender clinic psychiatrists] adhere to gender identity as both ‘‘real’’ and fixed. This adherence then facilitates the continued use of highly stereotyped notions of gender to provide the framework for assessing and treating transsex individuals.” (Hird 2003)

Neither the diagnostic framework nor the professionals involved in the diagnostic process seem to recognize these problems. “Most of the clinicians seemed to take the view that individual solutions are to be sought rather than societal change – there was little suggestion that society requires any change… the clinician’s job is not to reinforce gender boundaries defined by society.” (Hird 2003)

(4) Transition as Self-Determination

I have outlined the major issues regarding the concept of “gender identity”, typical transgender narratives, and the criteria for diagnosis of gender dysphoria. I have expressed my concern that the continued dependence of “gender identity”, trans narratives, and diagnostic criteria on traditional gender norms serves to reinforce restrictive and damaging stereotypes.

My conclusion is that an inborn, immutable, intrinsic “gender identity” DOES NOT EXIST. “Gender identity” is a cognitive aspect of self-perception constructed from internalized societal gender stereotypes. The idea of an innate “gender identity” is a crutch that trans people are forced to use to legitimize their experience in the face of a society that revolves around these oppressive gender stereotypes and a psychiatric establishment that retains these troublesome stereotypes as the frame of reference for assessment and access to transition options.

A self-determination and human rights model of trans identities views the diagnostic use of stereotypical gendered expressions associated with boys/men and girls/women as erroneous, and that they have little to do with actual contemporary gender identity formations. Accordingly, any gendered expressions, regardless of which birth-assigned sex one is given, should not act as criteria for diagnosing transpeople.” (Davy 2015)

For those who argue that inclusion of gender variance under the umbrella of psychiatry is necessary to allow access to medical and legal transition options, I would point out that some countries have already set a precedent where this is not the case. “Psychiatric involvement in healthcare pathways and legal assistance for those people who want to have a different body and/or corrected legal gender assignment should not be a requirement. They have succeeded in securing this in France, Denmark, Argentina, and Malta. In these countries, transpeople are legally recognized and are given access to healthcare services despite psychiatry being removed as the gatekeeper, because of transpeople demanding healthcare and legal recognition through a self-determination model of gender variance.” (Davy 2015)

“The solution is not to reify gender by insisting on ever more gender categories that define the complexity of human personality in rigid and essentialist ways. The solution is to abolish gender altogether. We do not need gender. We would be better off without it. Gender as a hierarchy with two positions operates to naturalize and perpetuate the subordination of female people to male people, and constrains the development of individuals of both sexes… You do not need to have a deep, internal, essential experience of gender to be free to dress how you like, behave how you like, work how you like, love who you like… The solution to an oppressive system that puts people into pink and blue boxes is not to create more and more boxes that are any colour but blue or pink. The solution is to tear down the boxes altogether.” (Reilly-Cooper 2016)

“Gender identity” needs to disappear. “Transition” should be removed from a gender context and the term “transgender” should be rendered obsolete. Instead, the medical, legal, and social aspects involved in “transition” should be viewed – simply and respectfully – as a human right to self-determination. “Assuming an inner-self who desires such a transformation, gender transitions are thus situated in a non-essentialized experiential framework, anchored in self-determination.” (Davy 2015) People – ALL people, not just trans people – should be free to modify their physical attributes, adopt social roles, and pursue interests that align with their personal preferences and desires. We are all of us “transitioning” all the time, as we learn and grow and adapt to an ever-changing world. “Transition” (in a transgender context) is just one of many ways that people strive for self-expression that makes them feel comfortable. “Transition” (in a human context) is an ongoing process for each of us to create an authentic self in this vast ocean of human diversity.

“If there’s no meaning in it, that saves a world of trouble, you know, as we needn’t try to find any.”
– The King (Alice’s Adventures in Wonderland, 1865)

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References

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. 

Davy Z. The DSM-5 and the politics of diagnosing transpeople. 2015. Archives of Sexual Behavior 44(5): 1165-76. 

Fabris B, Bernardi S, Trombetta C. Cross-sex hormone therapy for gender dysphoria. 2015. Journal of Endocrinological Investigation 38(3): 269-82. 

Hines M. Gender development and the human brain. 2011. Annual Review of Neuroscience 34: 69-88. 

Hird MJ. A typical gender identity conference? Some disturbing reports from the therapeutic front lines. 2003. Feminism and Psychology, 13: 181–199. 

Hoekzema E, Schagen SE, Kreukels BPC, et al. Regional volumes and spatial volumetric distribution of gray matter in the gender dysphoric brain. 2015. Psychoneuroendocrinology 55: 59-71. 

Reilly-Cooper R. Gender is not a spectrum. 2016. Aeon. Accessed online 2016-07-10. (Quotes in this post were extracted from the Aeon article. However, a similar essay also appears on the author’s personal blog More Radical With Age“Gender is not a binary, it’s a spectrum: some problems”, January 2016).

Reiner WG, Townsend Reiner D. Thoughts on the nature of identity: disorders of sex development and gender identity. 2011. Child and Adolescent Psychiatric Clinics of North America 20(4): 627-38. 

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.