Breaking down the gender dysphoria diagnosis
Diabetes can be diagnosed by a blood test. Breast cancer can be diagnosed with a biopsy. A broken bone can be diagnosed with an X-ray. There is no blood test, biopsy or X-ray that can diagnose mental health disorders.
Mental health disorders are diagnosed using the Diagnostic and Statistical Manual of Mental Disorders, commonly known as the DSM. According to the American Psychological Association, the first edition of this text was published in 1952. It was 32 pages and included 106 diagnoses. Over the years, this text has evolved. The most recent edition is the 947-page DSM-5, which was published in 2013 and includes roughly 300 diagnoses.
In 2022, the DSM-5-TR (the letters after the edition number stand for “text revision”) was published in order to update the 2013 publication of the DSM-5. Experts conducted literature reviews and evaluated the text to identify out-of-date material. The revisions also included clarifications to improve the ability of clinicians to make a diagnosis of a mental health disorder, facilitate clinical care and improve access to insurance coverage that supports mental health — a diagnosis is needed for insurance companies to pay for medical care.
The first two editions of the DSM contained no mention of gender identity. In 1980, the DSM-III was published and included the diagnosis of “transsexualism.” The Latin root of the prefix “trans” means movement or across. Hence, transsexualism refers to individuals who do not fully identify with the sex they were assigned at birth based on external genitalia and sex chromosomes. They want to “move” to a different gender identity.
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In 1994, the DSM-IV replaced the term “transsexualism” with “gender identity disorder” in adults and adolescents to reduce stigma. This term was eliminated in 2013 with the publication of the DSM–5 and was replaced with “gender dysphoria.” The Latin prefix “dys” means abnormal in medicine, and the term dysphoria is defined as a state of feeling uneasy or unwell.
It is important to note that according to the DSM-5-TR, the presence of gender variance or gender nonconformity is not in itself a mental disorder; rather, the reason it is a mental health disorder is because of the dysphoria that results from the distress caused by “the body and mind not aligning and/or societal marginalization of gender-variant people.”
Historically, the DSM has been called “the psychiatrist’s Bible.” Just like the Christian Bible, the study of mental health and scripture evolves. While the DSM is considered the authoritative volume that both defines and classifies mental disorders to improve diagnoses, treatment and research, there is much scholarly debate in the medical literature over what constitutes a diagnosis and what language should be used.
Science evolves through the questioning, critiquing and reviewing of our own work and that of others. This is the foundation of the peer review process in which scholarly work is reviewed by peers prior to publication to ensure the quality of research.
Topics related to gender are often difficult to discuss — all the more reason we need to learn about them. As we do this together, let’s challenge ourselves to recognize that disagreement is not the same as discrimination. We have a problem in health care with understanding how to truly best care for individuals with gender dysphoria, and it is time we had a serious conversation about it.
Susan Bane, M.D., Ph.D, is an associate professor of allied health and sport studies at Barton College and a physician.