Professionals Concerned with Gender Diagnoses in the DSM

Just another weblog

Statement on Gender Incongruence in Adolescents in the DSM-5

leave a comment »

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 diagnosis of Gender Incongruence (in Adolescents) in the DSM 5.

Our group recommends a separate diagnostic category for adolescents. Adolescent issues are markedly different from those facing pre-pubescent children and those experienced by adults. Adolescent sexual and gender development are complex processes (Pleak 2009; Striepe & Tolman 2003) and should be clearly separated out with the DSM from the presenting issues of prepubescent children and/or adults.

We recognize that gender dysphoria in youth is a serious issue and may require medical intervention (Spack, 2009), as well as therapeutic support. For those youth who identify as transgender or transsexual, or who express gender dysphoria and discomfort with their anatomical body, early intervention can alleviate future difficulties, and can assist young people to mature in their affirmed gender identity (Cooper 1999). This is consistent with the American Psychological Association’s goal of promoting “legal and social recognition of transgender individuals with their gender identity and expression” (APA 2009, para. 18) and is especially important for adolescents who typically lack the resources and authority to achieve this goal without clinician assistance.

We also recognize the severe harm that can occur and the future problems that can be averted by clinician responsiveness to adolescents requesting assistance toward living in a manner consistent with their gender identities and expression. We therefore support providing reversible hormone blockers to teenagers who are capable of giving informed consent (Gross, 2001) based on scientific evidence that clearly documents successful outcomes for transitioning teenagers (Cohen-Kettenis, Delemarre-van de Waal, & Gooren, 2008). Many adolescents who are forced to wait to access hormones or hormone blockers access gender-aligning medications in dangerous environments without proper monitoring (Rosario, 2009); for this reason, we caution against a 6 month waiting limit, as adolescent mental health can deteriorate rapidly when youth are forced to endure the traumatic experience of daily life in bodies that do not meet their psychosocial needs.

We further caution clinicians against imposing specific packages of medical interventions or dictating the order in which youth receive particular medical interventions, as adolescents’ needs vary considerably and should be addressed, based on individual self-reported need or request.While medical intervention are essential for some youth, others may seek legal or social recognition without any gender-aligning medical interventions. Youth who are utilizing gender-aligning medical interventions, and those who have successfully transitioned without medical interventions, should be considered to have achieved gender alignment.

We 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. It is essential that the diagnostic criteria focus on anatomical distress or distress with current assigned gender role, with explicit verbalization from the youth 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), and puberty blocking medical care in adolescence 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).

Finally, we 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 youth 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.

Our Suggested Diagnostic Criteria for Gender Incongruence in Adolescents:

A. In youth who have reached the earlier of age 13 or Tanner Stage II of pubertal development, a distressing sense of incongruence between persistent experienced or expressed gender and current physical sex characteristics or assigned gender role, as manifested by the youth’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. Experienced gender may include alternative gender identities beyond binary stereotypes.

    3. A distress or discomfort with one’s current primary or secondary sex characteristics that are incongruent with persistent experienced gender or with anticipated pubertal development associated with natal sex.

    4. A distress or discomfort caused by deprivation of primary or secondary sex characteristics that are congruent with persistent experienced gender or with anticipated deprivation of congruent physical sex characteristics after puberty.

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


Cohen-Kettenis, P. T., Delemarre-van de Waal, H. A., & Gooren, L. J. G. (2008).The treatment of adolescent transsexuals: Changing insights. Journal of Sexual Medicine, 5(8), 1892–1897.

Cohen-Kettenis, P. et al. (2010). “Gender identity disorder in adolescents or adults,” American Psychiatric Association DSM-5 Development. Available online:

Cooper, K. (1999). Practice with transgendered youth and their families. Journal of Gay & Lesbian Social Services: Issues in Practice, Policy & Research, 10, 111-129.

Gross, B. H. (2001). Informed consent. Annals of the American Psychotherapy Association, 4, 24.

Nuttbrock, L., Hwahng, S., Bockting. W., Rosenblum, A., Mason, M., Macri, M., & Becker J. (2010). Psychiatric impact of gender-related abuse across the life course of male-to-female transgender persons. Journal of Sex Research, 47(1), 12–23.

Pleak, R.R. (2009). Formation of transgender identities in adolescence. Journal of Gay &Lesbian Mental Health, 13(4), 282 -291.

Rosario, Vernon A.(2009). African-American transgender youth. Journal of Gay & Lesbian Mental Health, 13(4), 298 — 308.

Spack, Norman P. (2009). An endocrine perspective on the care of transgender adolescents’, Journal of Gay & Lesbian Mental Health, 13(4), 309 — 319.

Striepe, M.I, and Tolman, D. L. (2003). Mom, dad, I’m straight: The coming out of gender ideologies in adolescent sexual-identity development. Journal of Clinical Child and Adolescent Psychology, 32(4), 523-530.

Vitale A. M. (2001). Implications of being gender gysphoric: A developmental review, Gender and Psychoanalysis, An Interdisciplinary Journal, 6(2), 121-141.

World Professional Association for Transgender Health (2001). Standards of Care for Gender Identity Disorders Sixth Version, Available online:

Yunger, J.L., Carver, P.R, & Perry, D.G. (2004). Does gender identity influence children’s psychological well-being? Developmental Psychology, 40(4), 572–582.


Written by gidworkgroup

April 7, 2010 at 2:13 am

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Google+ photo

You are commenting using your Google+ account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )


Connecting to %s

%d bloggers like this: