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Classifying Intersex in DSM-5: Critical Reflections on Gender Dysphoria

  • Special Section: DSM-5: Classifying Sex
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Abstract

The new diagnosis of Gender Dysphoria (GD) in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2013) defines intersex, renamed “Disorders of Sex Development” (DSD), as a specifier of GD. With this formulation, the status of intersex departs from prior editions, especially from the DSM-IV texts that defined intersex as an exclusion criterion for Gender Identity Disorder. Conversely, GD—with or without a DSD—can apply in the same manner to DSD and non-DSD individuals; it subsumes the physical condition under the mental “disorder.” This conceptualization, I suggest, is unprecedented in the history of the DSM. In my view, it is the most significant change in the revised diagnosis, and it raises the question of the suitability of psychiatric diagnosis for individuals with intersex/DSD. Unfortunately, this fundamental question was not raised during the revision process. This article examines, historically and conceptually, the different terms provided for intersex/DSD in the DSM in order to capture the significance of the DSD specifier, and the reasons why the risk of stigma and misdiagnosis, I argue, is increased in DSM-5 compared to DSM-IV. The DSM-5 formulation is paradoxically at variance with the clinical literature, with intersex/DSD and transgender being conceived as incommensurable terms in their diagnostic and treatment aspects. In this light, the removal of intersex/DSD from the DSM would seem a better way to achieve the purpose behind the revised diagnosis, which was to reduce stigma and the risk of misdiagnosis, and to provide the persons concerned with healthcare that caters to their specific needs.

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Notes

  1. The reason why the initial formulation in DSM-III excluded the presence of intersex, while the same diagnostic label permitted it in the revised edition remains obscure (see Meyer-Bahlburg, 1994, p. 23).

  2. The (five) axes and all the Not Otherwise Specified (NOS) categories were eliminated from DSM-5.

  3. As suggested, for example, by Diamond and Beh (2006) in response to the adoption of the DSD label in the Consensus Statement. On this issue, see also Feder and Karkazis (2008), Hinkle (2006), and Reis (2007).

  4. Drescher (2010) mentioned in passing corrective surgeries on intersex infants as an instance of the medical enforcement of gender binaries in Western societies. However, the implications of such surgeries in terms of mental healthcare or the GID revision were not discussed.

  5. It should be noted that the “Proposed Revision to the DSM-IV Diagnostic Criteria for Gender Identity Disorder in Children” by Zucker (2010) is the only DSM-5 report that proposed retaining the exclusion criterion for intersex, but the reason for this specific recommendation is not discussed. However, Zucker’s view on the DSD specifier option was that “debating the DSD was secondary to debating whether or not to delete GID from the DSM-5 in its entirety.” He further explained: “I was not prepared to argue for or against a DSD specifier until the subworkgroup made a decision about the larger issue. Personally, I have never had a strong feeling against its inclusion in one form or the other because I have seen many DSD children (and some adolescents or adults) with gender dysphoria who, in many ways, are indistinguishable in phenomenology from non-DSD-children with GD. So, I disagree strongly with your [the author] assertion about misdiagnosis. DSM is largely agnostic regarding etiology: a rose is a rose, regardless of what causes a plant to be a rose.” (K. J. Zucker, personal communication, August 30, 2014). On the DSM’s so-called agnosticism or “atheoretical” stance towards etiology, see my discussion about a non-personal etiological factor for GD (APA, 2013, p. 451) and Posttraumatic Stress Disorder (PTSD).

  6. Gender change initiated by intersex individuals has been documented before DSM-III, i.e., before the first formulation of psychosexual “disorders” in gender identity. At the time, these changes were, therefore, not defined as mental “disorders,” and medical treatment for intersex individuals desiring to change their sex did not depend on a psychiatric diagnosis. Money (1969) considered that such cases were partly due to the parents’ ambivalence about the sex assigned to their child at birth, while Stoller (1964) postulated a “silent,” “congenital, perhaps inherited, biological force” to account for these situations (pp. 224, 225).

  7. In fact, “assigned gender” in DSM-5 means “the sex recorded on the birth certificate.” I will return to this below (see also Lawrence, 2014, p. 1264).

  8. It remains the proposed name in the draft for the forthcoming 11th revision of the International Classification of Diseases by the World Health Organization.

  9. See the Harry Benjamin International Gender Dysphoria Association founded in 1979, now known as the WPATH; the “Interim Report of the DSM-IV Subcommittee on Gender Identity Disorders” (Bradley et al., 1991; Money 1994); the reports by the DSM-5 GID subworkgroup (Cohen-Kettenis & Pfäfflin, 2010; Drescher, 2010; Meyer-Bahlburg, 2010; Zucker, 2010); the “Response of the [WPATH] to the Proposed DSM-5 Criteria for Gender Incongruence” (De Cuypere et al., 2010), etc.

  10. For the initial February 2010 position statement, see https://oii.org.au/6576/organisation-intersex-international-position-statement-dsmv-draft-february-2010/. The submission was updated in June 2012 (Morgan, Wilson, & O’Brien, 2012).

  11. For an earlier activist statement about the reasons why GID was not an intersex condition either, see Koyama (n.d.).

  12. Technically, “assent” for minors. Ford (2001) discusses “The Fiction of Legal Parental Consent to Genital-Normalizing Surgery on Intersexed Infants.”

  13. See the agenda of the most influential intersex association over the last 2 decades (1993–2008), the Intersex Society of North America (ISNA; http://isna.org); see also, e.g., Intersex Initiative (http://www.intersexinitiative.org), the Androgen Insensitivity Syndrome Support Group (http://www.aissg.org/), OII International Network (http://oiiinternational.com), Zwischengeschlecht (http://zwischengeschlecht.org), etc.

  14. This quote is derived from the section entitled “G[ender] V[ariance] in Persons with Somatic Disorders of Sex Development (Intersexuality)” in the “Report of the American Psychiatric Association Task Force on Treatment of Gender Identity Disorder” (Byne et al., 2012, pp. 786–790).

  15. This shows more clearly in Houk and Lee (2008) than in Hughes et al. (2006) or Lee et al. (2006).

  16. As Koyama (n.d.) makes it precise, “most intersex people identify and live as ordinary men and women, and are gay, lesbian, bisexual, or straight.” See http://www.intersexinitiative.org/articles/intersex-faq.html.

  17. See the ISNA website: http://isna.org. See also Zwischengeschlecht (http://zwischengeschlecht.org).

  18. A typical example is ISNA. It was founded in political alliance with feminist, queer, and LGBT struggles for the rights to self-determination, but on the distinctive claim that “intersexuality [was] primarily a problem of stigma and trauma, not gender.”.

  19. See especially pp. 228–229, 232–234 in Meyer-Bahlburg (2009).

  20. Let’s recall here that OII’s initial statement was issued in February 2010.

  21. Initially, I wrote that options 2 and 3 were included in DSM-IV, since the final text both included intersex patients in the GIDNOS category (Option 2 in Meyer-Bahlburg, 1994) and excluded them from the GID diagnosis (Option 3). I thought these two options were not necessarily mutually exclusive in the DSM-IV report itself. However, Meyer-Bahlburg explained that “the recommended Option 3 made it into the DSM-IV Option book, but was overridden subsequently by the Task Force […] in favor of Option 2” (H. F. L. Meyer-Bahlburg, personal communication, September 10, 2014). It is unclear why the Task Force favored Option 2. Meyer-Bahlburg was not part of the “full Task Force” and did not participate in the final decision. However, if Option 3 was not included in DSM-IV, this means that the recommended option involved removing intersex from DSM-IV. This provides more convincing support for the point I make here and my overall argument.

  22. From a different perspective, Lawrence (2014, p. 1264) raises a similar question, but discusses it essentially for GD without a DSD.

  23. Such problems with the sex of reference were considered inherent to two options considered in the report: to continue the practice of DSM-III-R, or to use GIDNOS for all intersex individuals (options 1 and 2 respectively in Meyer-Bahlburg, 1994, pp. 33–35). Again, these options were discarded in favor of the recommendation to exclude individuals with physical intersex from GID.

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Acknowledgments

This paper was first presented at the CRASSH Conference, “Classifying Sex: Debating the DSM-5,” 4–5 July 2013, University of Cambridge, U.K. I offered an expanded discussion of my arguments at an invited lecture at the Centre de Recherche Psychanalyse, Médecine et Société (Paris, 19 November 2013). My thanks go here to Laurie Laufer for her kind invitation, and to the discussants, Thamy Ayouch and Vincent Bourseul. I also wish to thank Céline Lefève for inviting me to speak at the Centre Georges Canguilhem about a related issue (Paris, 5 November 2013). This article was written in part when I was a visiting professor at the Institut des Humanités de Paris (IHP)/Université Paris Diderot—Paris 7 in November 2013. I address my special thanks to Gabrielle Houbre and Fethi Benslama from the IHP for the opportunity to present my work in different contexts, and for the inspiring conversations during that month. Finally, I want to thank Véronique Mottier, Robbie Duschinsky, and Ken Zucker for their incisive remarks and constructive suggestions that helped improve my argument, Heino Meyer-Bahlburg for kindly answering a few questions about the DSM, and Romain Felli for his generous comments on an earlier draft.

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    Cynthia Kraus

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Kraus, C. Classifying Intersex in DSM-5: Critical Reflections on Gender Dysphoria. Arch Sex Behav 44, 1147–1163 (2015). https://doi.org/10.1007/s10508-015-0550-0

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