Gender Dysphoria and Gender Incongruence

Walter Bouman, Annelou de Vries, Guy T'Sjoen, Walter Pierre Bouman, Annelou LC de Vries, Guy T'Sjoen

• Publisher: Routledge
• Year: 2018
• ISBN:
  9781315446783
• Edition: 1
• Topic: Psicologia
• Subtopic: Storia e teoria della psicologia

There is a significant increase in people who self-diagnose as having gender dysphoria and gender incongruence. The number of people with gender dysphoria and gender incongruence who seek assessment, support and treatment at gender identity clinic services has increased substantially over the years globally, and in Europe, North America and Australia in particular. Many countries lack appropriate transgender healthcare services. People with gender dysphoria and/or gender incongruence are often victimized and discriminated against. This book gives an overview regarding mental health and quality of life issues across the life span within the evolving interdisciplinary field of transgender healthcare. The book is written for professionals who in their day-to-day job may encounter people with gender dysphoria and gender incongruence; and for students, teachers, educators, academics, and members of the public at large with an interest in this timely topic.

This book was originally published as a special issue of the International Review of Psychiatry.

Gender incongruence/gender dysphoria and its classification history

Titia F. Beek, Peggy T. Cohen-Kettenis and Baudewijntje P.C. Kreukels

Department of Medical Psychology & Center of Expertise on Gender Dysphoria, VU University Medical Center, Amsterdam, the Netherlands

ABSTRACT

In this article we discuss the changes in the Diagnostic and Statistical Manual of Mental Disorders (DSM) classification of gender identity-related conditions over time, and indicate how these changes were associated with the changes in conceptualization. A diagnosis of ‘transsexualism’ appeared first in DSM-III in 1980. This version also included a childhood diagnosis: gender identity disorder of childhood. As research about gender incongruence/gender dysphoria increased, the terminology, placement and criteria were reviewed in successive versions of the DSM. Changes in various aspects of the diagnosis, however, were not only based on research. Social and political factors contributed to the conceptualization of gender incongruence/gender dysphoria as well.

Introduction

The classification of a diagnosis is closely related to its conceptualization. This is very clear if we look at changes that have been made in classification systems such as the Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association (APA) and International Classification of Diseases and Health Related Problems (ICD) of the World Health Organization (WHO). In this article we will discuss the changes in classification of gender identity-related conditions over time, and indicate how these changes were associated with the changes in conceptualization. As DSM-5 has already been published, and the ICD-11 is expected to be published in 2017, and many of the conceptual issues are similar for both classification systems, this paper will focus primarily on the DSM.

Over the years, terminology has frequently been changed. If identities or behaviours are not in line with a person’s natal sex, we will use the term ‘gender incongruent’; ‘transgender’ will be used as an umbrella term to refer to all kinds of phenomena related to gender incongruence. It is a broader category than the well-known term ‘transsexual’.

The concepts of gender identity and gender dysphoria

Each adult individual has a number of identities, such as a national, racial, or professional identity (Kroger, 2007). One of the most fundamental and probably more stable identities is one’s gender identity. Gender identity refers to the extent to which people experience themselves to be like others of one gender. Feeling male or female is an important basis for interactions with others. Gender identity is usually expressed in a person’s gender role behaviour. Gender role concerns behaviours, attitudes, and personality traits which, within a given society and historical period, are typically attributed to, expected from, or preferred by individuals of one gender.

In most cases, gender identity and physical sex characteristics are congruent. A baby with male genitalia will be assigned to the male gender, and experience himself as male. Incongruence between the physical characteristics does occur, however, in some conditions. Disorders/differences of sex development (DSD) are congenital conditions in which the development of chromosomal, gonadal, or anatomical sex is atypical (Hughes et al., 2006). For instance, external female appearing genitalia may exist in a person with testes and 46 XY chromosomes. In such cases, the child is usually raised as a girl and has a female gender identity. Her identity thus will not be in line with some of her physical sex characteristics.

If a person experiences distress resulting from incongruence between gender identity and assigned gender (which happens usually at birth), this person is gender dysphoric. Gender dysphoric individuals may have DSD, but mostly have physical sex characteristics which all correspond with each other.

In their clinical research on DSD individuals, Schweizer and colleagues (2009) used an instrument that not only measures male and female gender identity, but also transgender identity and the certainty of belonging to a gender. Gender identity has become an increasingly complex concept. Both clinical researchers and cognitive developmental psychologists have made use of the concept of gender identity. At first, they mainly focused on cognitive components of gender identity (Fagot & Leinbach, 1985; Kohlberg, 1966; Ruble & Martin, 1998). More recently, researchers in this field gave more attention to affective components of gender identity, such as feelings of contentment with one’s gender (Egan & Perry, 2001), and they started studying its relationship with mental health. They also considered pressure felt for ‘gender conformity’ and compatibility felt with aspects of gender identity. Tobin et al. (2010) proposed a five-dimensional model, subdivided into: ‘membership knowledge of a gender category, gender centrality’ (the importance of gender to other identities), ‘gender contentedness’, ‘felt gender conformity’, and ‘felt gender typicality’, to conceptualize gender identity.

In clinical psychology and psychiatry, individuals who experienced distress because they did not identify with their assigned gender used to be known as ‘transsexuals’ (WHO, 1992) or individuals with a ‘gender identity disorder’ (GID) (APA, 2000). Recently the name of the diagnosis changed to ‘gender dysphoria’ (APA, 2013).

For more than a decade, the dimensionality and diversity of gender identity and gender problems have received increasing attention in the literature (e.g. Fausto-Sterling, 2000). It has been argued that individuals with gender incongruence do not necessarily experience a complete cross-gender identity, and may not always need clinical attention (e.g. Diamond & Butterworth, 2008; Lee, 2001). The gender identification of individuals now covers a wide spectrum of gender identity labels, such as; ‘third gender’, ‘pan-/poly-/or omnigendered’ or ‘gender fluid’, instead of ‘male’ and ‘female’ or even ‘transsexual’. These individuals may or may not experience distress and they may or may not want to live as the ‘other gender’ (see Cohen-Kettenis & Pfäfflin, 2010, for an overview). In case of conditions other than ‘classical’ transsexualism, treatment preferences may also differ from the standard hormone treatment and gender-related genital surgeries. Those who do not suffer from their gender incongruence are often called ‘gender variant’.

Until about 20 years ago, transgender phenomena were usually considered as psychopathological. Krafft-Ebing (1886) and Hirschfeld (1923), both psychiatrists, were among the first to describe individuals who wanted to live or were living as members of the other sex. Hirschfeld was also the first to refer gender dysphoric individuals for surgery (hormone treatment only became available in the 1950s). Many medical and mental health practitioners criticized the use of hormones and surgery as a solution to gender identity problems (e.g. McHugh, 1992), as they considered gender dysphoria a severe neurotic or a psychotic, delusional condition in need of psychotherapy and ‘reality testing’. The huge media attention for the transition of some individuals, such as Christine Jorgenson (a natal male who sought treatment in Europe and published her story), resulted in more psychiatric awareness of the concepts of gender dysphoria and the desire of gender dysphoric people to transition. Interest in studying the phenomenon also increased in professional circles. It was acknowledged that sexual orientation and transvestism had to be distinguished from transsexualism (as it was then called), and in 1975 and 1980 transsexualism was included in the ICD-9 and DSM-III, respectively. More recently the conceptualization of gender dysphoria (or gender incongruence as it will probably be called in the ICD-11) as a psychiatric condition has been challenged (Drescher, 2015; Drescher et al., 2012) (see below).

Overview of gender identity diagnoses in DSM and rationale for changes

The main changes and rationales for the successive DSM editions are described below. For each new edition of DSM, first the general changes are described, followed by a description of the changes that were specific to the gender identity diagnoses. Table 1 provides an overview of the diagnostic terms, codes, sections and main changes of gender identity diagnosis across the different DSM versions.

Table 1. Overview of the diagnostic terms, codes, sections and main changes of gender identity diagnosis across different DSM versions.

DSM version	Diagnostic term (and code)	Section	Main changes
DSM-III (1980)	Transsexualism (302.5x) GIDC (302.60) Atypical GID (302.85)	Psychosexual disorders	First descriptive, symptom-based diagnosis for transsexualismInclusion of a childhood diagnosis
DSM-III-R (1987)	Transsexualism (302.50) GIDC (302.60) GIDAANT (302.85) GIDNOS (302.85)	Disorders usually first evident in infancy, childhood, or adolescence	Inclusion of GIDAANTNew placement in section: Disorder usually first evident in infancy, childhood, or adolescence
DSM-IV (1994)/ DSM-IV-TR (2000)	GID in adolescents or adults (302.85) GIDC (302.6) GIDNOS (302.6)	Sexual and gender identity disorders	Placement in the new section ‘sexual and gender identity disorders’Adoption of the single diagnosis of GID that applied to children, adolescents, and adults Criteria became more similar for boys and girls
DSM-5 (2013)	GD in adolescents or adults (302.85) GD in children (302.6) Other specified gender dysphoria (302.6) Unspecified gender dysphoria (302.6)	Gender dysphoria	Name change and different placement into new GD section Narrower criteria for children Broader criteria for adults Focus on distress/dysphoria as the clinical problem and not on identity per se

GD, gender dysphoria; GID, gender identity disorder; GIDAANT, gender identity disorder of adolescence and adulthood, nontranssexual type; GIDC, gender identity disorder of childhood; GIDNOS, gender identity disorder not otherwise specified.

Core criteria

DSM-III – Introduction of diagnostic criteria for Transsexualism

The publication of the DSM-III (APA, 1980) changed the way mental health professionals as well as the public viewed mental disorders. Although the DSM-I through DSM-III were originally developed for use in the USA, the manual gained popularity internationally (APA, 1987).

Unlike its predecessors that reflected a clinically based model, and provided no clear descriptions or diagnostic criteria, the DSM-III viewed psychological or psychiatric disorders from a research-based medical model in which diagnoses were clearly defined and consisted of specified symptoms. Mayes & Horwitz (2005, p. 258) describe the changes in the following way:

with its symptom-based orientation, the DSM-III contributed significantly to a biological vision of mental health – which stresses the neurosciences, brain chemistry, and medications – superseding the psychosocial vision that had dominated for decades. This new framework focused on the symptoms of mental disorders rather than their causes and emphasized pharmacological treatments over talk therapy and behavioural changes.

While working towards publishing the DSM-III, field trials were conducted for the first time during DSM revision, which focussed mainly on assessing the interrater reliability of the draft criteria of high-prevalence disorders and the multiaxial structure of the DSM-III (APA, 1980, p. 467–472; Zucker & Spitzer, 2005). No systematic literature reviews or focused analyses were undertaken during the revision (Kupfer et al., 2002). Decisions on inclusion/exclusion of certain diagnoses and the exact criteria were made by individuals who were considered to be experts in the field (Zucker & Spitzer, 2005). Some argued, however, that this reliance on expert consensus, rather than systematic literature reviews and/or focused analyses ‘potentially allowed data to be either overlooked or, if they were at odds with the expert’s perspective, wilfully ignored’ (Kupfer, 2002, p. xvi). In the DSM III’s introduction, Robert Spitzer (often referred to as the ‘architect’ of DSM-III) acknowledges that the DSM-III is not perfect (APA, 1980, p. 8).

With regard to gender identity diagnoses, a diagnosis of ‘transsexualism’ appeared for the first time in the DSM-III under the diagnostic class of ‘psychosexual disorders’ (APA, 1980). Three ‘gender identity disorders’ were included in DSM-III: transsexualism, gender identity disorder of childhood (GIDC), and atypical gender identity disorder. The essential feature of these diagnoses was ‘an incongruence between anatomic sex and gender identity’ (APA, 1980, p. 261). For transsexualism, this essential feature was reflected in the presence of two main criteria: A) ‘a persistent sense of discomfort and inappropriateness about one’s anatomic sex’ and B) ‘a persistent wish to be rid of one’s genitals and to live as a member of the other sex’ (APA, 1980, p. 261–262). Other criteria were that this ‘disturbance’ had to be continuously present for at least two years, that it was not due to another mental disorder (e.g. schizophrenia) and that it was not associated with a physical intersex condition (APA, 1980, p. 261–262).

One essential feature (criterion A) for the gender identity disorder of childhood was a strongly and persistently stated desire to be a boy/girl, or insistence that she/he is a boy/girl (depending on assigned gender of the child) (APA, 1980, p. 265–266). Another important feature (criterion B) for natal girls was a persistent repudiation of female anatomic structures. Natal boys could either have a persistent repudiation of male anatomic structures or a ‘preoccupation with female stereotypical activities’ (APA, 1980, p. 266).

Another difference between girls and boys in the DSM-III criteria was that the B-criterion for girls relied on ...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Citation Information
• Notes on Contributors
• 1. Gender incongruence/gender dysphoria and its classification history
• 2. Gender dysphoria in childhood
• 3. Gender dysphoria in adolescence
• 4. Families in transition: A literature review
• 5. Mental health and gender dysphoria: A review of the literature
• 6. Non-suicidal self-injury and suicidality in trans people: A systematic review of the literature
• 7. Gender dysphoria and autism spectrum disorder: A narrative review
• 8. Body dissatisfaction and disordered eating in trans people: A systematic review of the literature
• 9. Non-binary or genderqueer genders
• 10. Sexual orientation of trans adults is not linked to outcome of transition-related health care, but worth asking
• 11. Fertility options in transgender people
• 12. Neuroimaging studies in people with gender incongruence
• Index