Classifying Intersex in DSM-5: Critical Reflections on Gender Dysphoria
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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.
KeywordsDSM-5 Gender identity disorder Gender incongruence Gender dysphoria Disorders of sex development Intersexuality
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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