From Mental Disorder to Iatrogenic Hypogonadism: Dilemmas in Conceptualizing Gender Identity Variants as Psychiatric Conditions

Abstract

The categorization of gender identity variants (GIVs) as “mental disorders” in the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association (APA) is highly controversial among professionals as well as among persons with GIV. After providing a brief history of GIV categorizations in the DSM, this paper presents some of the major issues of the ongoing debate: GIV as psychopathology versus natural variation; definition of “impairment” and “distress” for GID; associated psychopathology and its relation to stigma; the stigma impact of the mental-disorder label itself; the unusual character of “sex reassignment surgery” as a psychiatric treatment; and the consequences for health and mental-health services if the disorder label is removed. Finally, several categorization options are examined: Retaining the GID category, but possibly modifying its grouping with other syndromes; narrowing the definition to dysphoria and taking “disorder” out of the label; categorizing GID as a neurological or medical rather than a psychiatric disorder; removing GID from both the DSM and the International Classification of Diseases (ICD); and creating a special category for GIV in the DSM. I conclude that--as also evident in other DSM categories--the decision on the categorization of GIVs cannot be achieved on a purely scientific basis, and that a consensus for a pragmatic compromise needs to be arrived at that accommodates both scientific considerations and the service needs of persons with GIVs.

The DSM Diagnostic Criteria for Gender Identity Disorder in Adolescents and Adults

“…It is currently unknown how often gender dysphoric applicants for treatment are indeed free of distress. It is conceivable that, in some, reported levels at the time of application are not high enough to qualify for a mental disorder, and there are arguments to delete the distress requirement altogether (see also Meyer-Bahlburg, 2009). However, a diagnosis without a distress criterion or without the assumption that distress is ''inherent'' to the diagnosis, may not be considered suitable for the reimbursement of treatment.…”

“…For postoperative individuals with regret, adjusted formulations are necessary. If the criteria would be used for individuals with DSD (but see Meyer-Bahlburg, 2009), the formulation of the criteria would also have to be adapted for this group.…”

“…The debate on whether GID should remain in the DSM (e.g., Winters, 2005) is a different one and will be discussed elsewhere by Meyer-Bahlburg (2009). Here, we assume that a diagnosis related to atypical gender identity will not be removed from the DSM.…”

“…Here, we assume that a diagnosis related to atypical gender identity will not be removed from the DSM. We will not focus on the meta-structure of the DSM diagnoses either, as this will also be addressed by Meyer-Bahlburg (2009). In our review, we will discuss criteria for both adolescents and adults.…”

Yes and yes again: are standards of care which require two referrals for genital reconstructive surgery ethical?

“…Instead it concerns a transformation of the body to align with the patient's subjective experience of gender (Meyer-Bahlburg, 2010). Consequently, there has been a long-standing concern, which continues to this day in some quarters, that "psychiatric" patients may be having their delusions colluded with, or at least that an irreversible decision may be made which is later regretted.…”