DSM-III: transsexualism becomes a psychiatric diagnosis

In 1980, the third edition of the DSM, the American Psychiatric Association’s manual of psychiatric diagnoses, was published. For the first time, it included diagnoses related to gender identity: transsexualism in adolescents and adults, and gender identity disorder in children.

What the DSM-III established

The diagnosis of transsexualism required a persistent feeling of discomfort with one’s sex and a desire to get rid of one’s sex characteristics and live as a person of the other sex. There was a separate diagnosis for children. Both were classified as psychosexual disorders.

The connection with homosexuality

In 1973, the American Psychiatric Association decided that homosexuality should no longer be considered a disorder; the distinction between the two is discussed on the page about gender and sexuality. Some critics later argued that the new diagnosis for children was a disguised replacement for it. In 2005, psychologists Kenneth Zucker and Robert Spitzer, both involved in the manual, rejected that claim: according to them, the diagnosis arose from clinical research that had begun as early as the 1960s.

Later editions

In the 1994 DSM-IV, the diagnoses were merged into gender identity disorder. In 2013, the DSM-5 replaced that name with gender dysphoria; see DSM-5: gender dysphoria replaces disorder.

What is the DSM

DSM stands for Diagnostic and Statistical Manual of Mental Disorders. The first edition was published in 1952, and the second in 1968. The third edition, produced under the direction of psychiatrist Robert Spitzer, broke with the past. For the first time, each disorder was given a list of precisely defined characteristics, so that different doctors would arrive at the same diagnosis for the same patient. This also made the manual the standard for research and treatment outside the United States. In the Netherlands, the DSM is used alongside the World Health Organization’s international classification of diseases, the ICD.

The ICD

The World Health Organization had already included transsexualism in the ninth edition of the ICD, adopted in 1975. The tenth edition, published in 1990, introduced a separate group of gender identity disorders, with diagnoses for adults and children. The two classification systems then developed in the same direction, until the ICD-11 removed the diagnosis from the chapter on mental disorders in 2019.

The 1987 revision

In the revised third edition, the DSM-III-R, published in 1987, the diagnoses were moved to the group of disorders that usually begin in childhood or adolescence. A diagnosis was also added for adolescents and adults with persistent discomfort about their sex but without a desire for surgery. In this way, the manual acknowledged that not everyone experiencing these feelings wants a complete physical transition. This idea was later developed further in the broader concept of gender dysphoria.

Significance

The inclusion in the DSM-III coincided with the first international treatment guidelines, which had been published a year earlier; see the first Standards of Care. Together, they gave treatment a defined structure: a psychiatrist or psychologist made the diagnosis, and only then could hormone therapy and, if appropriate, surgery follow. This framework was followed in most countries for decades.

An official diagnosis made research, treatment, and reimbursement possible, and gave doctors a common language. At the same time, it meant that transsexualism was classified as a mental disorder. That tension between access to care and stigma continues to shape the debate about the diagnosis of gender dysphoria to this day.