Memo outlining evidence for change for gender identity disorder in the DSM-5

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

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.

Treatment for gender dysphoria in children: the new legal, ethical and clinical landscape

Gender dysphoria is a condition in which a child's subjectively felt identity and gender are not congruent with her or his biological sex. Because of this, the child suffers clinically significant distress or impairment in social functioning. The Family Court of Australia has recently received an increasing number of applications seeking authorisation for the provision of hormones to treat gender dysphoria in children. Some medical procedures and interventions performed on children are of such a grave nature that court authorisation must be obtained to render them lawful. These procedures are referred to as special medical procedures. Hormonal therapy for the treatment of gender dysphoria in children is provided in two stages occurring years apart. Until recently, both stages of treatment were regarded by courts as special medical treatments, meaning court authorisation had to be provided for both stages. In a significant recent development, courts have drawn a distinction between the two stages of treatment, permitting parents to consent to the first stage. In addition, it has been held that a child who is determined by a court to be Gillick competent can consent to stage 2 treatment. The new legal developments concerning treatment for gender dysphoria are of ethical, clinical and practical importance to children and their families, and to medical practitioners treating children with gender dysphoria. Medical practitioners should benefit from an understanding of the recent developments in legal principles. This will ensure that they have up-to-date information about the circumstances under which treatment may be conducted with parental consent, and those in which they must seek court authorisation.