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Archives of Sexual Behavior

, Volume 44, Issue 5, pp 1147–1163 | Cite as

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

  • Cynthia Kraus
Special Section: DSM-5: Classifying Sex

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.

Keywords

DSM-5 Gender identity disorder Gender incongruence Gender dysphoria Disorders of sex development Intersexuality 

Notes

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.

References

  1. American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: Author.Google Scholar
  2. American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders (3rd ed., rev.).Washington, DC: Author.Google Scholar
  3. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.Google Scholar
  4. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.Google Scholar
  5. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.Google Scholar
  6. Austin, J. L. (1975). How to do things with words. Oxford: Oxford University Press.CrossRefGoogle Scholar
  7. Benjamin, H. (1966). The transsexual phenomenon: A scientific report on transsexualism and sex conversion in the human male and female. New York: Julian Press.Google Scholar
  8. Bradley, S. J., Blanchard, R., Coates, S., Green, R., Levine, S. B., Meyer-Bahlburg, H. F., … Zucker, K. J. (1991). Interim report of the DSM-IV subcommittee on gender identity disorders. Archives of Sexual Behavior, 20, 333–343.Google Scholar
  9. Butler, J. (1990). Gender trouble: Feminism and the subversion of identity. New York: Routledge.Google Scholar
  10. Byne, W., Bradley S. J., Coleman E., Evan Eyler, A., Green, R., Menvielle, E. J., … Tompkins, D. A. (2012). Report of the American Psychiatric Association Task Force on Treatment of Gender Identity Disorder. Archives of Sexual Behavior, 41, 759–796. doi: 10.1007/s10508-012-9975-x.
  11. Cohen-Kettenis, P. T., & Pfäfflin, F. (2010). The DSM diagnostic criteria for gender identity disorder in adolescents and adults. Archives of Sexual Behavior, 39, 499–513. doi: 10.1007/s10508-009-9562-y.PubMedCrossRefGoogle Scholar
  12. De Cuypere, G., Knudson, G., & Bockting, W. (2010). Response of the World Professional Association for Transgender Health to the proposed DSM 5 criteria for gender incongruence. International Journal of Transgenderism, 12, 119–123. doi: 10.1080/15532739.15532010.15509214.CrossRefGoogle Scholar
  13. Diamond, M., & Beh, H. G. (2006). Variations of sex development instead of disorders of sex development [Electronic Letter to Hugues, I. A. et al. (2006). Consensus Statement on Management of Intersex Disorders], Archives of Disease in Childhood. Retrieved from http://adc.bmj.com/content/91/7/554.extract/reply#archdischild_el_2460.
  14. Dreger, A. D. (Ed.). (1999). Intersex in the age of ethics. Hagerstown, MD: University Publishing Group.Google Scholar
  15. Drescher, J. (2010). Queer diagnoses: Parallels and contrasts in the history of homosexuality, gender variance, and the diagnostic and statistical manual. Archives of Sexual Behavior, 39, 427–460. doi: 10.1007/s10508-009-9531-5.PubMedCrossRefGoogle Scholar
  16. Drescher, J. (2013). Controversies in gender diagnoses. LGBT Health, 1, 1–5. doi: 10.1089/lgbt.2013.1500.Google Scholar
  17. Drescher, J., Cohen-Kettenis, P., & Winter, S. (2012). Minding the body: Situating gender identity diagnoses in the ICD-11. International Review of Psychiatry, 24, 568–577. doi: 10.3109/09540261.2012.741575.PubMedCrossRefGoogle Scholar
  18. Fassin, D., & Rechtman, R. (2009). The empire of trauma: An inquiry into the condition of victimhood (R. Gomme, Trans.). Princeton, NJ: Princeton University Press.Google Scholar
  19. Fausto-Sterling, A. (2000). Sexing the body: Gender politics and the construction of sexuality. New York: Basic Books.Google Scholar
  20. Feder, E. K., & Karkazis, K. (2008). What’s in a name? The controversy over ‘Disorders of Sex Development’. The Hastings Center Report, 38(5), 33–36.PubMedCrossRefGoogle Scholar
  21. Fisk, N. M. (1973). Gender dysphoria syndrome (the how, what, and why of a disease). In D. R. Laub & P. Gandy (Eds.), Proceedings of the second interdisciplinary symposium on gender dysphoria syndrome (pp. 7–14). Stanford, CA: Stanford University Press.Google Scholar
  22. Fisk, N. M. (1974). Editorial: Gender dysphoria syndrome: The conceptualization that liberalizes indications for total gender reorientation and implies a broadly based multi-dimensional rehabilitative regimen. Western Journal of Medicine, 120, 386–391.PubMedCentralPubMedGoogle Scholar
  23. Ford, K. K. (2001). “First, do no harm”: The fiction of legal parental consent to genital-normalizing surgery on intersexed infants. Yale Law & Policy Review, 19, 469–488.Google Scholar
  24. Green, R., & Money, J. (Eds.). (1969). Transsexualism and sex reassignment. Baltimore: Johns Hopkins University Press.Google Scholar
  25. Hausmann, B. (1995). Changing sex: Transsexualism, technology, and the idea of gender. Durham, NC: Duke University Press.Google Scholar
  26. Hinkle, C. (2006). Thank you very much Dr. Diamond [Electronic Letter to Hugues, I. A. et al. (2006). Consensus Statement on Management of Intersex Disorders], Archives of Disease in Childhood. Retrieved from http://adc.bmj.com/content/91/7/554.extract/reply#archdischild_el_2460.
  27. Houk, C. P., & Lee, P. A. (2008). Consensus statement on terminology and management: Disorders of sex development. Sexual Development, 2, 172–180. doi: 10.1159/000152032.PubMedCrossRefGoogle Scholar
  28. Hughes, I. A., Houk, C., Ahmed, S. F., Lee, P. A., & LWPES/ESPE Consensus Group. (2006). Consensus statement on management of intersex disorders. Archives of Disease in Childhood, 91, 554–563. doi: 10.1016/j.jpurol.2006.03.004.PubMedCentralPubMedCrossRefGoogle Scholar
  29. Karasic, D., & Drescher, J. (Eds.). (2005). Sexual and gender diagnoses of the Diagnostic and Statistical Manual (DSM). New York: The Haworth Press.Google Scholar
  30. Karkazis, K. A. (2006). Early genital surgery to remain controversial. Pediatrics, 118, 814–815. doi: 10.1542/peds.2006-1067.PubMedCrossRefGoogle Scholar
  31. Karkazis, K. A. (2008). Fixing sex: Intersex, medical authority and lived experience. Durham, NC: Duke University Press.CrossRefGoogle Scholar
  32. Kessler, S. J. (1990). The medical construction of gender: Case management of intersexed infants. Signs, 16, 3–26.CrossRefGoogle Scholar
  33. Kessler, S. J. (1998). Lessons from the intersexed. New Brunswick, NJ: Rutgers University Press.Google Scholar
  34. Knudson, G., De Cuypere, G., & Bockting, W. (2010a). Process toward consensus on recommendations for revision of the DSM diagnoses of gender identity disorders by the World Professional Association for Transgender Health. International Journal of Transgenderism, 12, 54–59. doi: 10.1080/15532739.2010.509213.CrossRefGoogle Scholar
  35. Knudson, G., De Cuypere, G. D., & Bockting, W. (2010b). Recommendations for revision of the DSM diagnoses of gender identity disorders from the World Professional Association for Transgender Health. International Journal of Transgenderism, 12, 115–118. doi: 10.1080/15532739.2010.509215.CrossRefGoogle Scholar
  36. Kraus, C., Perrin, C., Rey, S., Gosselin, L., & Guillot, V. (2008). A qui appartiennent nos corps? Féminisme et luttes intersexes. Nouvelles Questions Féministes, 27, 4–15.Google Scholar
  37. Lawrence, A. A. (2014). Gender assignment dysphoria in the DSM-5. Archives of Sexual Behavior, 43, 1263–1266.PubMedCrossRefGoogle Scholar
  38. Lee, P. A., Houk, C. P., Ahmed, S. F., & Hughes, I. A. (2006). Consensus statement on management of intersex disorders. Pediatrics, 118(2), e488–e500. doi: 10.1542/peds.2006-0738.PubMedCrossRefGoogle Scholar
  39. Mazur, T., Colsman, M., & Sandberg, D. E. (2007). Intersex: Definition, examples, gender stability, and the case against merging with transsexualism. In R. Ettner, S. Monstrey, & A. E. Eyler (Eds.), Principles of transgender medicine and surgery (pp. 235–259). Binghamton, NY: Haworth Press.Google Scholar
  40. Meyer-Bahlburg, H. F. L. (1994). Intersexuality and the diagnosis of gender identity disorder. Archives of Sexual Behavior, 23, 21–40.PubMedCrossRefGoogle Scholar
  41. Meyer-Bahlburg, H. F. L. (2008). Treatment guidelines for children with disorders of sex development. Neuropsychiatrie de l’enfance et de l’adolescence, 56, 345–349. doi: 10.1016/j.neurenf.2008.1003.1010.CrossRefGoogle Scholar
  42. Meyer-Bahlburg, H. F. L. (2009). Variants of gender differentiation in somatic disorders of sex development: Recommendations for version 7 of the World Professional Association for Transgender Health’s Standards of Care. International Journal of Transgenderism, 11, 226–237. doi: 10.1080/15532730903439476.CrossRefGoogle Scholar
  43. Meyer-Bahlburg, H. F. L. (2010). From mental disorder to iatrogenic hypogonadism: Dilemmas in conceptualizing gender identity variants as psychiatric conditions. Archives of Sexual Behavior, 39, 461–476. doi: 10.1007/s10508-009-9532-4.PubMedCentralPubMedCrossRefGoogle Scholar
  44. Meyerowitz, J. (2002). How sex changed: A history of transsexualism in the United States. Cambridge, MA: Harvard University Press.Google Scholar
  45. Money, J. (1955). Hermaphroditism, gender and precocity in hyperadrenocorticism: Psychologic findings. Bulletin of the Johns Hopkins Hospital, 20, 253–264.Google Scholar
  46. Money, J. (1969). Sex reassignment as related to hermaphroditism and transsexualism. In R. Green & J. Money (Eds.), Transsexualism and sex reassignment (pp. 91–113). Baltimore, MD: Johns Hopkins University Press.Google Scholar
  47. Money, J. (1994). The concept of gender identity disorder in childhood and adolescence after 39 years. Journal of Sex and Marital Therapy, 20, 163–177.PubMedCrossRefGoogle Scholar
  48. Money, J., Hampson, J. G., & Hampson, J. L. (1955a). Hermaphroditism: Recommendations concerning assignment of sex, change of sex, and psychological management. Bulletin of Johns Hopkins Hospital, 97, 284–300.Google Scholar
  49. Money, J., Hampson, J. G., & Hampson, J. L. (1955b). Examination of some basic sexual concepts: Evidence of human hermaphroditism. Bulletin of Johns Hopkins Hospital, 97, 301–319.Google Scholar
  50. Morgan [pseud.], Wilson, G., & O’Brien, M. (2012). Submission on the draft Diagnostic and Statistical Manual of Mental Disorders 5th edition and the World Professional Association for Transgender Health 7th Standards of Care. Retrieved from http://oii.org.au/wp-content/uploads/downloads/2012/06/OII-Aus+NZ-DSM+SOC-Submission.pdf.
  51. Reis, E. (2007). Divergence or disorder? The politics of naming intersex. Perspectives in Biology and Medicine, 50, 535–543.PubMedCrossRefGoogle Scholar
  52. Richter-Appelt, H., & Sandberg, D. E. (2010). Should disorders of sex development be an exclusion criterion for gender identity disorder in DSM 5? International Journal of Transgenderism, 12, 94–99. doi: 10.1080/15532739.15532010.15515181.CrossRefGoogle Scholar
  53. Steiner, B. W., Blanchard, R., & Zucker, K. J. (1985). Introduction. In B. W. Steiner (Ed.), Gender dysphoria: Development, research, management (pp. 1–10). New York: Plenum Press.CrossRefGoogle Scholar
  54. Stoller, R. J. (1964). A contribution to the study of gender identity. International Journal of Psychoanalysis, 45, 220–226.PubMedGoogle Scholar
  55. Stoller, R. J. (1968). Sex and gender: The development of masculinity and femininity. London: Karnac Books.Google Scholar
  56. Swiss National Advisory Commission on Biomedical Ethics. (2012). On the management of differences of sex development. Ethical issues relating to ‘intersexuality’. Opinion No. 20/2012. Berne: Author.Google Scholar
  57. Vance, S. R, Jr, Cohen-Kettenis, P. T., Drescher, J., Meyer-Bahlburg, H. F. L., Pfäfflin, F., & Zucker, K. J. (2010). Opinions about the DSM gender identity disorder diagnosis: Results from an international survey administered to organizations concerned with the welfare of transgender people. International Journal of Transgenderism, 12, 1–14. doi: 10.1080/15532731003749087.CrossRefGoogle Scholar
  58. Koyama, E. (n.d.). Is Gender Identity Disorder an intersex condition? Retrieved from: http://www.intersexinitiative.org/articles/gid.html.
  59. Zucker, K. J. (2010). The DSM diagnostic criteria for gender identity disorder in children. Archives of Sexual Behavior, 39, 477–498. doi: 10.1007/s10508-10009-19540-10504.PubMedCrossRefGoogle Scholar
  60. Zucker, K. J., Cohen-Kettenis, P. T., Drescher, J., Meyer-Bahlburg, H. F. L., Pfäfflin, F., & Womack, W. M. (2013). Memo outlining evidence for change for gender identity disorder in the DSM-5. Archives of Sexual Behavior, 42, 901–914. doi: 10.1007/s10508-10013-10139-10504.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  1. 1.Institute of Social Sciences, Faculty of Social and Political SciencesUniversity of LausanneLausanneSwitzerland

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