Evolution of Transsexuality-Related Diagnoses

DISCLAIMER: This article contains obsolete language that stems from the pathologization of realities that in no case are considered disorders by any reputable Psychology or Psychiatry institution, both at a national and international level. The language used in this article reflects the evolution of academic and health institutions throughout history and it is included here to reflect how the approach of institutions to social demands influences the categorization of the realities studied.

This article is a continuation of the one I recently published on the historical evolution of the diagnoses that the American Psychiatric Association attributed over the years to people with a non-normative sexual orientation. That is, with a sexual orientation other than heterosexuality.

The previous article would not make much sense if I did not also publish this one right after it, as the goal behind writing both of them is to observe how the evolution of the different diagnoses that have been assigned to people with non-normative sexual orientations is surprisingly similar to that of diagnoses assigned to trans people.

As in the previous article, I will now review the different diagnoses that the American Psychiatric Association has assigned to trans persons throughout the different editions of the DSM.

The first edition of the DSM does not explicitly mention transsexuality.

DSM-II proposes a category for Sexual Disorders, although it is limited and mostly focused on homosexuality and other “disorders of sexual deviance”. Transsexuality is not separated from other realities, but different forms of gender role nonconformity were broadly encompassed as Sexual Deviance.

DSM-III represented a significant change by introducing for the first time the term “Gender Identity Disorder” (GID), defined as a persistent incongruence between biological sex and the person’s experienced or expressed gender identity. This was an early attempt to formally recognize transsexuality within a clinical framework.

The diagnosis of GID was classified under a new chapter called “Psychosexual Disorders,” which also included other disorders related to sexuality. However, this classification was criticized for pathologizing gender identity not congruent with the sex assigned at birth.

In the revised version of DSM-III (DSM-III-R), the diagnosis of Gender Identity Disorder was maintained, but some modifications were made to the diagnostic criteria. Transsexuality was still seen as a mental disorder.

In DSM-IV, Gender Identity Disorder is retained, but distinctions are added for evaluations in children, adolescents and adults. This category caused controversy because of the implication that gender variants in childhood were seen as pathological.

The DSM-IV was revised in 2000. The diagnosis of “Gender Identity Disorder” was maintained with some modifications, maintaining the categories and criteria established in the previous version. The manual was still under criticism from the trans community and activists for continuing to include trans realities within pathologizing labels.

The publication of DSM-5 marked a major shift in how the American Psychiatric Association addresses transgenderism. The term “Gender Identity Disorder” was replaced with “Gender Dysphoria.” This change is exposed as an effort to reduce the stigma associated with the diagnosis by emphasizing that it is not the gender identity itself that is problematic, but the significant distress that a trans person may experience in the current context.

In addition, the DSM-5 introduced more detailed diagnostic criteria, differentiating gender dysphoria in children from that experienced in adolescents and adults. It was also explicitly recognized that not all people with gender incongruence experience significant dysphoria, in order to clarify that transsexuality is no longer inherently viewed as a mental disorder.

The DSM-5-TR (Diagnostic and Statistical Manual of Mental Disorders, Revised Text) represents a revision of the DSM-V, adding minor changes to the 2013 edition, including some key changes regarding gender dysphoria to reflect greater accuracy and awareness of the social reality being discussed:

The evolution of transgender-related diagnoses in the DSM manuals reflects an ongoing process of revision and updating as understanding of gender diversity advances. It is expected that future revisions will continue to depathologize trans identities and focus more on providing a supportive framework for those experiencing gender dysphoria, rather than classifying them within a pathological context.

The current category of “Gender Dysphoria” is not without controversy as it receives similar criticism as the category of “Egodystonic Homosexuality” did at the time. There are also arguments, of a more practical nature, in favor of it because of the requirement of insurers and health services for the presence of a diagnosis that justifies gender reassertion interventions in trans persons. However, some argue that there are already natural conditions, such as pregnancy, that require medical interventions without the need for a pathologizing diagnosis, so the same logic could be applied to interventions aimed at improving the quality of life of trans people.

Jorge Jiménez Castillo is a psychologist at SINEWS, where he practices in English and Spanish. He works daily with local and international populations and has a long history of studying the reality of the LGTBIQ+ community in and out of the clinic. He works from a cognitive-behavioral approach with evidence-based interventions and believes that in order to provide quality psychological care one must be aware of the inequalities that intersect with users and explore how they intersect with each other.