What are the criteria for diagnosing gender dysphoria?

The latest DSM-5 defines gender dysphoria (APA, 2020) in adolescents and adults as a marked incongruence between one’s experienced/expressed gender and their assigned gender, lasting at least 6 months

Diagnosis is central to the way doctors work; seeing patterns and creating categories or ‘labels’ that have predictive (prognostic) value, a way of communicating information and scientific knowledge: whether it is about the progress of symptoms and organ involvement in tuberculosis or the various types of dementia. In healthcare systems diagnostic labels can also be a way of coding consultations and clinical interactions, which may be used for research, monitoring and resource allocation (or payments in private provision).

The diagnostic criteria for Gender Dysphoria (previously known as gender identify disorder) can be found in the Diagnostic and Statistical Manual of Mental Disorders (DSM), which is the American psychiatric guide widely used in the UK (‘Gender Dysphoria’, 2013). This book gets updated on a regular basis, and diagnostic descriptions develop to reflect changing social and cultural phenomena. Psychiatric disorders are biopsychosocial in aetiology (cause), so it is right that shifts in public attitudes and understandings should be reflected. A clear example is homosexuality, which was previously labelled as a mental disorder but removed from the DSM in 1973, and is now accepted as a normal sexual orientation. However, the situation is different in some countries, which still consider same sex attraction pathological or even criminal behaviour deserving of capital punishment.

The latest DSM-5 defines gender dysphoria (APA, 2020) in adolescents and adults as a marked incongruence between one’s experienced/expressed gender and their assigned gender, lasting at least 6 months, as manifested by at least two of the following:

  • A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or in young adolescents, the anticipated secondary sex characteristics)
  • A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics)
  • A strong desire for the primary and/or secondary sex characteristics of the other gender
  • A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender)
  • A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender)
  • A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender)

In order to meet criteria for the diagnosis, the condition must also be associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.

The DSM-5 defines gender dysphoria in children as a marked incongruence between one’s experienced/expressed gender and assigned gender, lasting at least 6 months, as manifested by at least six of the following (one of which must be the first criterion):

  • A strong desire to be of the other gender or an insistence that one is the other gender (or some alternative gender different from one’s assigned gender)
  • In boys (assigned gender), a strong preference for cross-dressing or simulating female attire; or in girls (assigned gender), a strong preference for wearing only typical masculine clothing and a strong resistance to the wearing of typical feminine clothing
  • A strong preference for cross-gender roles in make-believe play or fantasy play
  • A strong preference for the toys, games or activities stereotypically used or engaged in by the other gender
  • A strong preference for playmates of the other gender
  • In boys (assigned gender), a strong rejection of typically masculine toys, games, and activities and a strong avoidance of rough-and-tumble play; or in girls (assigned gender), a strong rejection of typically feminine toys, games, and activities
  • A strong dislike of one’s sexual anatomy
  • A strong desire for the physical sex characteristics that match one’s experienced gender

As with the diagnostic criteria for adolescents and adults, the condition must also be associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Clinicians considering these criteria in the context of what is known about child development must consider carefully how a child’s sense of incongruence might have arisen, including careful exploration of the reactions of those around the child, the family and environmental culture, as well as any adverse events impacting the child’s life. Underpinning the child’s experience is their personality as well as any neurodevelopmental conditions and psychiatric illnesses. It is important to take a careful developmental history and tease apart these different aspects in a holistic way. 

References:

APA (2020) What is Gender Dysphoria?, American Psychiatric Association. Available at: https://www.psychiatry.org/patients-families/gender-dysphoria/what-is-gender-dysphoria.

‘Gender Dysphoria’ (2013) in Diagnostic and Statistical Manual of Mental Disorders. American Psychiatric Association. doi: 10.1176/appi.books.9780890425596.dsm14.