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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 of Mental Disorders (DSM) of the American Psychiatric Association 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.

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Acknowledgments

Brief, preliminary versions of this paper were presented at the Annual Meeting of the American Academy of Child and Adolescent Psychiatry in Chicago, IL, October 28–November 2, 2008, and the Annual Meeting of the Society for Sex Therapy and Research in Arlington, VA, April 2–5, 2009. The draft of this paper benefitted from discussions among, and direct feedback from, the members of the GID Subworkgroup (Peggy T. Cohen-Kettenis, Jack Drescher, Friedemann Pfäfflin, Kenneth J. Zucker, and the author) of the Sexual and Gender Identity Disorders Work Group for DSM-V of the American Psychiatric Association, and from Jamison Green as Work Group Advisor. Although the author is a member of this APA Work Group, this paper does not represent the position of the Work Group or the APA, but the author’s own perspective. Patricia Connolly assisted in bibliographic work and in word processing. This work was supported, in part, by NIMH grant P30-MH-43530 (P.I.: Anke A. Ehrhardt, Ph.D.). Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders V Workgroup Reports (Copyright 2009), American Psychiatric Association.

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Meyer-Bahlburg, H.F.L. From Mental Disorder to Iatrogenic Hypogonadism: Dilemmas in Conceptualizing Gender Identity Variants as Psychiatric Conditions. Arch Sex Behav 39, 461–476 (2010). https://doi.org/10.1007/s10508-009-9532-4

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Keywords

  • Gender identity disorder
  • Transsexualism
  • Transgenderism
  • DSM-V
  • Mental illness