DSM-5: gender dysphoria replaces disorder

In May 2013, the fifth edition of the DSM, the American Psychiatric Association’s manual of psychiatric diagnoses, was published. The diagnosis of gender identity disorder disappeared and was replaced by gender dysphoria.

What changed

The new name shifts the emphasis. It is not the identity itself that is considered a disorder, but the distress someone experiences because their gender does not correspond to their sex. For a diagnosis, this incongruence must have existed for at least six months and be accompanied by significant distress or limitations in daily functioning.

In the DSM-5, gender dysphoria was given its own chapter, separate from the sexual disorders and paraphilias under which the previous diagnosis had been classified. Separate criteria were introduced for children and for adolescents and adults.

The ICD-11 went further

With the revision of the ICD, the World Health Organization took this a step further. In the ICD-11, adopted in 2019 and in effect since 2022, the diagnosis is called gender incongruence. It is no longer listed among mental disorders, but in a chapter on sexual health.

In Dutch practice

The DSM-5 is also used in the Netherlands. A diagnosis of gender dysphoria or gender incongruence, made by a qualified healthcare professional, is required for medical treatment and for reimbursement by health insurers. More information about the criteria can be found on the pages about the DSM-5 and gender dysphoria and the ICD-11. To change the sex designation on a birth certificate, medical treatment has not been required in the Netherlands since 2014; a statement from an expert is still required.

The debate beforehand

The new edition was preceded by years of debate. Some advocacy organizations wanted to remove the diagnosis from the manual altogether, as had happened with homosexuality in 1973. Others warned that without a diagnosis, access to treatment and reimbursement by insurers could be jeopardized. The working group chose a middle ground: the diagnosis remained, but was given a name and description that put distress at the center. The diagnosis of transsexualism had first been included in 1980; see the DSM-III.

What the criteria involve

For adolescents and adults, the DSM-5 lists six characteristics, of which at least two must be present. Examples include a strong desire to be rid of one’s own sex characteristics and a strong desire to be treated as the other gender. The requirements for children are stricter: at least six of eight characteristics must be present, including in any case a strong desire or conviction that one is the other gender. In this way, the working group sought to prevent children from receiving a diagnosis simply because their behavior does not conform to what is customary for boys or girls.

The 2022 text revision

In 2022, the DSM-5-TR, a revised edition of the text, was published. The criteria remained unchanged, but the wording was revised. For example, desired gender was replaced by experienced gender, and the text no longer refers to birth sex but to the sex assigned at birth. These changes show how quickly language around this subject is evolving, including within psychiatry.

Meaning

Supporters see the change as a step toward reducing stigma: being transgender does not in itself mean having a mental illness. The diagnosis remained because it is needed in many countries to access and obtain reimbursement for care. Critics point out that the shift also has consequences for clinical practice: if identity is no longer the subject of assessment, less attention is paid to the question of where the dysphoria comes from.