In 2013, the American Psychiatric Association (APA) completed a several year process of revising the Diagnostic and Statistical Manual of Mental Disorders (DSM) and published the fifth edition of the book (DSM-5).1 During that time, there were objections to retaining DSM's gender identity disorder diagnoses2 and there were calls to remove them, just as homosexuality had been removed from DSM-II3 in 1973.4 At the conclusion of DSM-5's revision process, the gender diagnoses were retained, albeit in altered form and bearing a new name: gender dysphoria.5,6
While serving as a member of the DSM-5 Workgroup on Sexual and Gender Identity Disorders, I reviewed and published a history of how both homosexuality and the gender diagnoses found their way into DSM, and how, eventually, homosexuality was removed.7 I presently serve on the World Health Organization's (WHO) Working Group on Sexual Disorders and Sexual Health. This article presents the history of the gender diagnoses in DSM and in the International Statistical Classification of Diseases and Related Health Problems (ICD) as well as what will happen to gender diagnoses after the ICD-11 revision process.
Today, expressions of gender variance or gender nonconformity are frequently subsumed by the popular term “transgender.” Members of the transgender community prefer using nonmedical and subsequently nonpathologizing terms to describe themselves, much as gay people today prefer not describing themselves with the medical term “homosexual.” The term “gender diagnoses” includes the many names given to these diagnoses in the two diagnostic manuals, including gender identity disorder, transsexualism, transvestism, gender dysphoria, and gender incongruence (GI).
Gender Variance as a Psychiatric Diagnosis
Medical interest in transgender presentations began in the 19th century.8 Magnus Hirschfeld9 is usually credited as the first person to distinguish the desires of homosexuality (having partners of the same sex) from those of what would eventually be called transsexualism (living as the other sex). Although physicians in Europe began experimenting with gender reassignment surgery (GRS; historically referred to as sex reassignment surgery) in the 1920s, these procedures came to popular attention when an American, George Jorgensen, went to Denmark to undergo GRS, returning to the United States in 1952 as trans woman Christine Jorgensen.10
At the time of Jorgensen's GRS and for several decades afterward, many health care professionals criticized these procedures. Green11 surveyed 400 physicians including psychiatrists, urologists, gynecologists, and general medical practitioners. The majority opposed providing gender reassignment treatments for what they perceived to be either a severe neurotic or psychotic, delusional condition in need of psychotherapy and “reality testing.” However, these views are no longer maintained in either psychiatric or general medical thought or practice. In the 21st century, international expert guidelines support transition in carefully evaluated people,12 although only a minority of national health care systems worldwide now cover medical services for gender affirmation.13 In both ICD and DSM, gender diagnoses have shifted over time.
ICD-614 (1948), the first version of ICD to include mental disorders, had no diagnosis of transsexualism; nor did it appear in ICD-715 (1955). The ICD-816 (1965) category of “sexual deviations” included the new diagnosis of transvestitism (Table 1). ICD-816 did not provide definitions of diagnostic categories, so the intended meaning of transvestitism is unclear. Historically, however, the alternative spelling, transvestism, was an early synonym for what later came to be called transsexualism (Hamburger et al.17 in 1953 used the term “transvestism” in describing Jorgensen's surgery).
Gender Diagnoses in ICD
In ICD-918 (1975), transvestitism was replaced by two new diagnoses. One was transvestism, defined as a “Sexual deviation in which sexual pleasure is derived from dressing in clothes of the opposite sex. There is no consistent attempt to take on the identity or behavior of the opposite sex.” The other was transsexualism (sic). This diagnostic separation was probably created to accommodate growing research about clinical presentations and treatment of transsexualism. Both diagnoses, however, were still classified as “sexual deviations” (Table 1).
ICD-1019 (1990) significantly reorganized the classification system and included new gender diagnoses reflecting a growing body of clinical experience and research. Under disorders of adult behavior and personality appeared a new category of gender identity disorders (F64) that included five diagnoses: transsexualism; dual-role transvestism; gender identity disorder of childhood; other gender identity disorders; and gender identity disorder, unspecified (Table 1).
Presently, preliminary proposals for ICD-11's revision are underway. WHO's Working Group on the Classification of Sexual Disorders and Sexual Health has proposed a name change of the diagnosis to GI and recommended the entire diagnostic category be moved outside ICD's mental disorders section.20 It appears they will be moved into a new section called Conditions Related to Sexual Health (Table 1).
In DSM, gender diagnoses made a novel appearance followed by category migration and renaming as well. As in ICDs 6–8, no diagnosis appears in either DSM-I21 (1952) or DSM-II3 (1968) (Table 2). In 1980, however, a revamped DSM-III22 abandoned psychodynamic theorizing of the first two manuals and adopted a neo-Kraepelian, descriptive, symptom-based framework drawing upon contemporary research findings. Zucker and Spitzer23 summarize the vicissitudes of the current gender diagnoses from DSM-III through DSM, fourth edition, text revision (DSM-IV-TR). Among the parameters cited for inclusion in DSM-III were “clinical utility, acceptability to clinicians of various theoretical persuasions, reliability, and validity” (p. 36).23 They noted that by the 1970s there was an emerging clinical and research literature and a clear description of the phenomenology of gender identity disorder of childhood (GIDC), such that “expert consensus clearly concluded that there was sufficient indication of clinical usefulness and acceptability” (p. 37) for the condition to be included in DSM-III.23
Gender Diagnoses in DSM
Over time, in addition to name changes, the diagnostic category migrated across DSM chapters. In DSM-III22 (1980), both GIDC and transsexualism are listed among psychosexual disorders. In DSM-III-R24 (1987), both are moved to disorders usually first evident in infancy, childhood, or adolescence. In DSM-IV25 (1994) and DSM-IV-TR26 (2000), they moved again to a new parent category, sexual and gender identity disorders, and transsexualism was renamed gender identity disorder in adolescents or adults. The diagnoses were clustered with the paraphilias and sexual dysfunctions (Table 2).
DSM-51 contains many changes from previous editions,4 including:
A name change was made to gender dysphoria (GD);
GD includes separate, developmentally appropriate criteria sets for GD in children (prepubescent) and GD in adolescents and adults;
GD has been moved into its own section separate from sexual dysfunctions and paraphilias;
GD includes a new specifier, “with a disorder of sex development (DSD),” for people with intersex conditions who develop GD symptoms, in contrast to DSM-IV-TR26 where the presence of a somatic intersex condition was considered an exclusionary criterion in making a GI diagnosis;
GD includes a new “posttransition” specifier for older adolescents and adults who have transitioned to full-time living in the desired gender;
DSM-51 no longer uses the sexual orientation specifier of DSM-IV-TR26 because it has no clinical relevance in the treatment of GD.
A challenge faced by both the DSM and ICD workgroups was finding a way to balance two conflicting concerns: maintaining access to care (which requires retaining a medical diagnosis) while trying to reduce stigma associated with a psychiatric diagnosis.7,20
With DSM-5, activists urged the APA to either delete the gender diagnoses or reassign them V-codes (the equivalent of ICD Z-codes). These are codes used in clinical situations where the focus of the psychiatric encounter involves no psychiatric diagnosis (eg, a Partner Relational Problem in which neither partner has symptoms that meet criteria for a behavioral health condition). As US insurers do not reimburse for V-codes, neither option was considered satisfactory by workgroup members because both would deprive people of a diagnosis needed to access medical treatment. In addition, transgender civil rights advocacy groups in the US have used gender diagnoses successfully in court battles as a way to improve access to care for incarcerated transgender prisoners and to argue for coverage from government insurers. This is because in the US denial of necessary medical care to incarcerated people is considered “cruel and unusual punishment” in violation of the country's constitution.
The APA's decision to retain DSM-5 gender diagnoses had the intended effect of improving access to care. For example, in May 2014, the US Department of Health and Human Services (HHS) reversed a long-standing ruling classifying gender reassignment treatment as “experimental” and not reimbursable by Medicare.27 HHS's reversal was based, in part, on the reasoning that DSM-IV-TR's GID diagnosis and DSM-5's GD diagnosis represented the view of American psychiatry that they were medical conditions requiring treatment.27
Further, in February 2015, the US military approved feminizing hormone treatment for Chelsea Manning, a trans woman and former intelligence analyst convicted and incarcerated for espionage. The military deemed her treatment “medically appropriate and necessary.”28 The decision marks the first time the US Department of Defense authorized hormone treatment for an active service member. In my opinion, removing the GD diagnosis from DSM-5 before the anticipated forthcoming changes in ICD-11 (see above) would have undermined arguments for Manning receiving necessary care.
Finally, the APA, subsequent to the DSM-51 deliberative process on gender diagnoses, issued two position statements. The first supports access to care,29 and the second puts the APA on record as opposing discrimination against transgender people.30 The APA also appointed a task force to review and recommend treatment guidelines for transgender people.31
In contrast to the APA, the ICD's workgroup has different options for resolving conflict between access to care and stigma. This is because DSM contains only a listing of mental disorders used by psychiatrists and other mental health professionals, whereas ICD contains all the diagnoses used by all medical specialties. Given this flexibility, it was recommended that the gender diagnoses be retained so that insurers and national health care systems would cover treatment. However, also recommended was moving the diagnoses out of the mental disorders section and into some less stigmatizing chapter of ICD.20,32 This recommendation appears to have been accepted. It is not certain if such a move by the WHO will lead to removing the gender diagnoses from DSM-5.1
Controversies about gender diagnoses still continue. DSM-51 and ICD-11 both include gender diagnoses for prepubescent children, who do not usually receive either medical or surgical treatment. As part of ICD-11's revision process, draft proposals for gender diagnoses were published online.33 One advocacy group, Global Action for Trans Equality (GATE),34 presented arguments for removing the child diagnosis similar to those aimed earlier at DSM by Hill et al.35 GATE34 argued that (1) there is no “clear consensus among researchers and health care providers with regard to the need for or global applicability of such a diagnosis;” (2) “gender variance in childhood does not require any medical interventions such as hormone therapy or surgical procedures;” and (3) “attaching a medical diagnosis to gender diversity in childhood contradicts WHO's commitment to respecting rather than pathologizing sexual diversity.” Unfortunately, GATE's alternative is relying upon ICD's Z-codes, which are usually not reimbursable, as a rationale for providing needed services to gender variant children and their families.
Nevertheless, gender variant children often require psychosocial support.31,32,36–38 Among professionals in this area, there is broad consensus that children with GI require access to care that is often complex and involves interventions with families and social environments. Further, there is a paucity of research distinguishing prepubescent children whose GI desists from those with GI that persists into adolescence. Thus, more research is needed to guide caretakers and clinicians in the complex clinical interventions and decision-making processes surrounding gender incongruent prepubescent children. Retaining a child GI diagnosis would improve the chances that needed research will be funded and conducted.
Finally, retaining a childhood diagnosis alerts clinicians that a prepubescent child's clinical presentation does not seamlessly develop into an adolescent and adult diagnosis and that an adult diagnosis does not always evolve from a childhood diagnosis. Delineating separate diagnoses also provides an opportunity for developing and implementing distinct, diagnostically based treatment pathways and standards of care in health systems. Hopefully, this will reduce medical, psychologic, and behavioral risks and improve outcomes for those who do go on to develop a transgender identity as adolescents and adults.32
Psychiatric diagnoses have a long history of generating controversy, hearkening back to when decisions about what is and what is not a mental disorder rested solely upon the theories of medical practitioners. The most ridiculous example of medicine's history of diagnostic excess is drapetomania, a 19th century “disorder of slaves who have a tendency to run away from their owner due to an inborn propensity for wanderlust.”39 Similarly, the diagnostic history of homosexuality and gender variance supports arguments that unlike pure medical diagnoses, such as kidney or heart failure, psychiatric formulations are subjective, culture bound, and reflect societal efforts to control the behavior of citizens.40
As times and cultural attitudes change, so have beliefs about what constitutes a mental disorder.41 Forty years after the APA's decision to remove homosexuality from the DSM, marriage equality (ie, same-sex marriage) is now the law of the land in many countries.20ICD diagnoses of “normal spontaneous delivery” (JA80) and “normal menopause” (HD00.3) were long ago “medicalized” as a way to provide access to care, despite being natural life events and not “pathologic” in any strict sense. Perhaps in some not too distant future, the gender diagnoses in the ICD will be seen the same way.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Press; 2013.
- Karasic D, Drescher J. Sexual and Gender Diagnoses of the Diagnostic and Statistical Manual (DSM): A Reevaluation. New York, NY: Routledge; 2005.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 2nd ed. Washington, DC: American Psychiatric Publishing; 1968.
- Bayer R. Homosexuality and American Psychiatry: The Politics of Diagnosis. New York, NY: Basic Books; 1981.
- Zucker KJ, Cohen-Kettenis PT, Drescher J, Meyer-Bahlburg HFL, Pfäfflin F, Womack WM. Memo outlining evidence for change for gender identity disorder in the DSM-5. Arch Sex Behav. 2013;42:901–914. doi:10.1007/s10508-013-0139-4 [CrossRef]
- Zucker KJ, Duschinsky R. Dilemmas encountered by the Sexual and Gender Identity Disorders Work Group for DSM-5: an interview with Kenneth J. Zucker. Psychol Sex. 2016;7(1):23–33.
- Drescher J. Queer diagnoses: parallels and contrasts in the history of homosexuality, gender variance, and the Diagnostic and Statistical Manual (DSM). Arch Sex Behav. 2010;39:427–460. doi:10.1007/s10508-009-9531-5 [CrossRef]
- Krafft-Ebing R (translated by ). Psychopathia Sexualis. New York, NY: Putnam; 1965.
- Hirschfeld M. Die intersexuelle konstitution. Jahr Sex Zwischenstufen. 1923;23:3–27.
- Jorgensen C. Christine Jorgensen: A Personal Autobiography. New York, NY: Paul S. Ericksson, Inc; 1967.
- Green R. Attitudes toward transsexualism and sex-reassignment procedures. In: Green R, Money J, eds. Transsexualism and Sex Reassignment. Baltimore, MD: The Johns Hopkins University Press; 1969:235–251.
- World Professional Association for Transgender Health (WPATH). Standards of care for the health of transsexual, transgender, and gender non-conforming people. 7th version. http://www.wpath.org/. Accessed April 15, 2016.
- Kreukels BP, Haraldsen IR, De Cuypere G, Richter-Appelt H, Gijs L, Cohen-Kettenis PT. A European network for the investigation of gender incongruence: the ENIGI initiative. Eur Psychiatry. 2012;27:445–450. doi:10.1016/j.eurpsy.2010.04.009 [CrossRef]
- World Health Organization. International Classification of Diseases and Related Health Problems. 6th revision. Geneva, Switzerland: World Health Organization; 1948.
- World Health Organization. International Classification of Diseases and Related Health Problems. 7th revision. Geneva, Switzerland: World Health Organization; 1955.
- World Health Organization. International Classification of Diseases and Related Health Problems. 8th revision. Geneva, Switzerland: World Health Organization; 1965.
- Hamburger C, Stürup GK, Dahl-Iversen E. Transvestism: hormonal, psychiatric, and surgical treatment. JAMA. 1953;12(6):391–396. doi:10.1001/jama.1953.03690050015006 [CrossRef]
- World Health Organization. International Classification of Diseases and Related Health Problems. 9th revision. Geneva, Switzerland: World Health Organization; 1975.
- World Health Organization. International Classification of Diseases and Related Health Problems. 10th revision. Geneva, Switzerland: World Health Organization; 1990.
- Drescher J, Cohen-Kettenis PT, Winter S. Minding the body: situating gender diagnoses in the ICD-11. Int Rev Psychiatry. 2012;24:568–577. doi:10.3109/09540261.2012.741575 [CrossRef]
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Washington, DC: American Psychiatric Publishing; 1952.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 3rd ed. Washington, DC: American Psychiatric Publishing; 1980.
- Zucker KJ, Spitzer RL. Was the gender identity disorder of childhood diagnosis introduced into DSM-III as a backdoor maneuver to replace homosexuality? A historical note. J Sex Marital Ther. 2005; 31:31–42. doi:10.1080/00926230590475251 [CrossRef]
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 3rd edition—Revised. Washington, DC: American Psychiatric Publishing; 1987.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th edition. Washington, DC: American Psychiatric Publishing; 1994.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders [text revision]. 4th ed. Washington, DC: American Psychiatric Publishing; 2000.
- US Department of Health and Human Services. NCD 140.3, Transsexual surgery: decision. http://www.hhs.gov/dab/decisions/dabdecisions/dab2576.pdf. Accessed April 20, 2015
- Associated Press. Chelsea Manning's hormone treatment ok'd, but not long hair. February13, 2015; http://baltimore.cbslocal.com/2015/02/13/chelsea-mannings-hormone-treatment-okd-but-not-long-hair/. Accessed April 15, 2016.
- American Psychiatric Association. Position statement on access to care for transgender and gender variant individuals. https://www.psychiatry.org/home/search-results?g=74c7a3e8-7736-499b-a45d-c25567b5e078&Page=2. Accessed April 26, 2016.
- American Psychiatric Association. Position statement on discrimination against transgender and gender variant individuals. https://www.psychiatry.org/home/search-results?k=transgender. Accessed April 26, 2016.
- Byne W, Bradley SJ, Coleman E, et al. Report of the American Psychiatric Association task force on treatment of gender identity disorder. Arch Sex Behav. 2012;41:759–796. doi:10.1007/s10508-012-9975-x [CrossRef]
- Drescher J, Cohen-Kettenis PT, Reed GM. Gender incongruence of childhood in the ICD-11: controversies, proposal, and rationale. Lancet Psychiatry. 2016;3(3):297–304. doi:10.1016/S2215-0366(15)00586-6 [CrossRef]
- World Health Organization. Gender Incongruence of Childhood: Draft. Clinical Description and Diagnostic Guidelines. Unpublished internal document. Geneva, Switzerland: WHO Press; November25, 2013.
- Global Action for Trans Equality. Critique and alternative proposal to the “gender incongruence of childhood” category in ICD-11. Report on the GATE Civil Society Expert Working Group Meeting; Buenos Aires, Argentina, April 4–6, 2013. http://globaltransaction.files.wordpress.com/2012/03/critique-and-alternative-proposal-to-the-_gender-incongruence-of-childhood_-category-in-icd-11.pdf. Accessed April 15, 2016.
- Hill DB, Rozanski C, Carfagnini J, Willoughby B. Gender identity disorders in childhood and adolescence: a critical inquiry. Int J Sex Health. 2007;19:57–74. doi:10.1300/J514v19n01_07 [CrossRef]
- Drescher J, Byne W. Treating Transgender Children and Adolescents: An Interdisciplinary Discussion. New York, NY: Routledge; 2013.
- Drescher J. Controversies in gender diagnoses. J LGBT Health. 2014;1:9–15.
- Drescher J, Pula J. Ethical issues raised by the treatment of gender variant prepubescent children. Hastings Cent Rep. 2014;44(Suppl 4):S17–22. doi:10.1002/hast.365 [CrossRef]
- Schwartz S. The role of values in the nature/nurture debate about psychiatric disorders. Soc Psychiatry Psychiatr Epidemiol. 1998;33:356–362. doi:10.1007/s001270050066 [CrossRef]
- Szasz TS. The myth of mental illness. Am Psychol. 1960;15:113–118. doi:10.1037/h0046535 [CrossRef]
- Greco M. What is the DSM? Diagnostic manual, cultural icon, political battleground: an overview with suggestions for a critical research agenda. Psychol Sex. 2016;7(1)6–22.
Gender Diagnoses in ICD
||Gender identity disorders
Gender identity disorder of childhood
Other gender identity disorders
Gender identity disorder (unspecified)
||Conditions related to sexual health (proposed)
||Gender incongruence of adolescents and adults
Gender incongruence of children (proposed)
Gender Diagnoses in DSM
Gender identity disorder of childhood
||Disorders usually first evident in infancy, childhood, or adolescence
Gender identity disorder of childhood
Gender identity disorder of adolescence and adulthood, nontranssexual type
||Sexual and gender identity disorders
||Gender identity disorder in adolescents or adults
Gender identity disorder in children
||Gender dysphoria in adolescents or adults
Gender dysphoria in children