We are mental health and medical professionals, clinicians, researchers and scholars concerned about psychiatric nomenclature and diagnostic criteria for gender variant, gender nonconforming, transgender and transsexual people in the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), and call ourselves Professionals Concerned About Gender Diagnoses in the DSM. Below are our suggestions for the Gender Incongruence (in children) diagnosis in the DSM V.
First, we want to acknowledge the work of the DSM-5 gender identity disorders subworkgroup and commend the improvements proposed in this section from the DSM IV. Specifically, we find the inclusion of the criteria for gender dysphoria to be a major improvement as we believe this is the foundation of an appropriate diagnosis.
As a group however, we are very concerned about the inclusion of this diagnosis in any form. Many of us firmly believe it is developmentally inappropriate to diagnose children in regard to gender. The current diagnostic criteria are based in outmoded, sexist, and very specific culturally derived conceptualizations of “normal” gendered behavior for children, despite the fact that many children exhibit a range of “atypical” gender behavior without any sign of distress.
We firmly believe the focus of this diagnosis should be on dysphoria (defined as distress, extreme discomfort, or an emotional state of dis-ease), because it is discomfort, not a particular gender identity or expression, that is the psychological issue. We suggest the name of the diagnosis should be Gender Dysphoria of Childhood. If Gender Incongruence is the chosen term however, we strongly recommend a distinction be made between incongruence due to distress related to one’s gender identity and incongruence due to nonconformity as defined by social gender stereotypes.
It is essential that the diagnostic criteria focus on anatomical distress or distress with current assigned gender role, with explicit verbalization from the child that his or her current gender role or anatomical sex does not match his or her internal sense of gender. Gender dysphoria may also be manifested by distress or discomfort with deprivation (Vitale 2001) of social role or anatomy that is congruent with experienced gender identity. Experienced gender is not limited to fixed binary roles, but may encompass fluidity, masculinity, femininity, both, or neither.
It is important to note that social role transition, or Real Life Experience (WPATH 2001), in childhood may have diagnostic value in clarifying gender dysphoria. While transition to an affirmed social role may relieve the distress of gender role dysphoria, transitioned youth may still suffer anatomic dysphoria and remain particularly distressed about anticipated pubertal changes associated with their natal sex. It must be carefully stated that the diagnostic threshold is distress related to assigned gender role or physical sex characteristics and not gender nonconformity due to social expectations of normative gender (Vanderburgh 2009).
We also suggest restoration of a clinical significance criterion, which would clarify that distress, discomfort or impairment must meet a threshold of severity. This would limit false positive diagnosis of gender nonconforming children who would not benefit from diagnosis. It is crucial, however, that this criterion exclude distress or impairment that is caused by societal prejudice or discrimination. To cast victimization as symptomatic of mental illness would inflict further harm upon victims of prejudice.
In the context of normative developmental unfolding, a gender nonconforming very young child, particularly one who may be on the road to becoming gay, may go through a period that extends beyond the six months currently suggested (Zucker, et al., 2008). This is not about “gender incongruence” or “gender dysphoria,” but rather an expression of gender fluidity, and should not be the object of therapeutic intervention as it is not an indication of pathology. We further recommend that clinicians avoid assessing ‘gender dysphoria’ based on gender typicality (Hegarty, 2009). For example, some children who identify as boys and who were assigned as girls may appear “feminine” to clinicians, and some girls who were assigned as boys may appear “masculine.” Gender typicality and gender of affectional/sexual attractions in these children should not be used to determine which children have “gender dysphoria.”
Given the degree of violence, harassment and rejection a child who expresses non-normative gender faces even at young ages, in school as well as in the family, clinicians have an obligation to assess the level of stress the child may be experiencing as a result of this and to intervene systemically in order to address this issue and protect the child (Hill, Menvielle, Sica, & Johnson, 2010, Menvielle, 2009; Stone Fish & Harvey, 2005; Yunger, Carver, & Perry, 2004). The DSM should direct clinicians to use this diagnosis for the purposes of assisting children in achieving legal and social recognition consistent with their gender identity and expression (APA, 2009) and should for the purposes of identifying potential candidates who might request medical interventions to achieve gender alignment and/or to reduce dysphoria. The DSM should include specific instructions to clinicians that when children’s sexual orientations and gender expression do not conform to norms for their gender identity, their experienced/expressed gender identity should still be recognized as valid.
We believe that children should be immediately allowed to express themselves and have free right to wear the clothes they choose and to play the games they choose with the peers they choose at any age. If this behavior, dress, and peer choice does not cause dysphoria, no diagnosis is warranted. For children expressing gender incongruence related distress however, we recommend a time period of at least 3 months before a diagnosis is given.
Indicators 3, 4, and 6 reinforce a binary gender model and should be removed (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; 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).
Many of us firmly believe it is developmentally inappropriate to diagnose children in regard to their preferences for play. Many children exhibit a range of “atypical” gender behavior and play preferences without any sign of distress. We recommend eliminating simplistic binary sex role behaviors (i.e., toys, games, or types of play often associated with a particular gender) from the DSM. We also believe that Indicator 5 should be removed (5. a strong preference for playmates of the other gender).We believe preference for playmates has no place in diagnostic criteria for a psychiatric disorder.
Our group also believes that qualifiers regarding Disorders of Sexual Development should be removed. The Disorder of Sexual Development subtypes send an implicit message that having a developmental variation related to sexual physiology is a subset of being Gender Incongruent. We believe that the supporting text should describe the fact that some people with intersex variations desire medical transition treatments. However, we do not believe that intersex condition subtypes would add anything to the diagnostic framework. Additionally, the subtypes may potentially lack validity/reliability, since most social workers, counselors and psychologists are not trained to diagnose intersex conditions and most people do not know what sex chromosomes they have.
Our Suggested Diagnostic Criteria for Gender Dysphoria of Childhood:
A. A distressing sense of incongruence in childhood between the child’s persistent experienced or expressed gender and current physical sex characteristics or assigned gender role, as manifested by the child’s self-report or documentable observation of at least one of the following indicators for a duration of at least 3 months. Incongruence, for this purpose, does not mean gender expression that is nonconforming to social stereotypes of assigned gender role or natal sex.
1. A distress or discomfort with living in the present gender or being perceived by others as the present gender, which is distinct from the experiences of discrimination or the societal expectations associated with that gender.
2. A distress or discomfort caused by deprivation of gender expression congruent with persistent experienced gender or insistence that one has a gender that differs from the present gender. Experienced gender may include alternative gender identities beyond binary stereotypes.
3. A distress or discomfort with one’s current (and/or anticipated) primary or secondary sex characteristics that are incongruent with persistent experienced gender.
4. A distress or discomfort caused by deprivation of primary or secondary sex characteristics that are congruent with persistent experienced gender (including anticipated post-pubertal characteristics).
B. Distress or discomfort is clinically significant or causes impairment in social, educational or other important areas of functioning, and is not due to external prejudice or discrimination.
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