Beyond Conundrum: Strategies for Diagnostic Harm Reduction

Abstract

The current nosology in the Diagnostic & Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV TR), identifies those whose gender identities or expressions differ from their assigned birth sex as mentally ill. As the American Psychiatric Association (APA) prepares its fifth edition of the DSM, gender variant individuals face the stigma of mental disorder and sexual deviance resulting from this classification and/or worsened barriers to medical transition care that requires some form of diagnostic coding. We propose a solution following a harm reduction model in which the current Gender Identity Disorder (GID) diagnosis is replaced by one that distinguishes the normative distress of membership in a subjugated class from the distress of incongruence between anatomy and identity (historically termed gender dysphoria). We suggest renaming the diagnosis to clarify distress of gender dysphoria as the problem rather than gender identity itself. We recommend revision in the DSM-5 that would: (1) no longer promote gender identity conversion treatment, aimed at repressing gender identities and expressions that differ from birth assigned roles, (2) respect individual gender identities with appropriate pronouns and terms, (3) eliminate false-positive diagnosis of ego syntonic gender variant and posttransition individuals, (4) relocate the redefined GID diagnosis outside of the section of sexual disorders, and (5) eliminate the defamatory and stigmatizing category of transvestic fetishism. Finally, we urge the APA to issue position statements affirming that gender identity and expression that differ from assigned birth sex do not constitute mental disorder, while asserting the medical necessity of hormonal and surgical transition treatments for those who suffer painful distress with physical sex characteristics or ascribed birth-sex roles incongruent with their persistent gender identity.