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DSM evolution

Over more than thirty years, the DSM shifted from "transsexualism" (DSM-III, 1980) via "gender identity disorder" (DSM-IV, 1994) to "gender dysphoria" (DSM-5, 2013). Since 2013, the diagnosis has focused on the distress and not on the identity itself (source).

DSM-III (1980): transsexualism and GID in children

In 1980, DSM-III introduced the first diagnosis related to gender identity in the DSM: "transsexualism" for adolescents and adults (source) and "gender identity disorder" for children only (source). In 1968, the psychoanalyst Robert Stoller had hypothesised in Sex and Gender that the sense of "core gender identity" arises from three sources: the anatomy and physiology of the genitals, the attitude of the environment towards the child's gender role, and a biological force (source); see Stoller.

DSM-IV (1994) and DSM-IV-TR (2000)

DSM-IV replaced "transsexualism" with "gender identity disorder" (GID), with separate criteria for "GID in children" and "GID in adolescents and adults" (source). Research from this period showed that most children with gender dysphoria no longer had it after puberty: in the study by Wallien and Cohen-Kettenis (2008) of 77 children, 27 percent were still gender dysphoric, 43 percent were not, and 30 percent could not be traced. Almost all of those whose dysphoria persisted had a homosexual or bisexual orientation; among those whose dysphoria desisted, half of the boys and all of the girls had a heterosexual orientation (source). See also desistance research.

Kenneth Zucker, chair of the DSM-5 work group on sexual and gender identity disorders, was dismissed from CAMH Toronto in 2015; the clinic was closed after an external review concluded that it was out of step with current clinical practice. Zucker sued CAMH, which in 2018 settled for 586,000 dollars and apologised for an incorrect statement about him in the report (source).

DSM-5 (2013): Gender Dysphoria

In 2013, the APA replaced "gender identity disorder" with "gender dysphoria". According to the APA, the diagnosis thereby focuses on the distress that some transgender people experience and not on transgender people or identities themselves; the DSM-5 explicitly states that "gender non-conformity is not in itself a mental disorder" (source). See also the parallel evolution of the ICD and the Yogyakarta Principles.

Since 2013, distress has been part of the diagnosis: the APA writes that gender dysphoria must be ego-dystonic to qualify as a diagnosis (source). Stephen Levine (2021) argues in Archives of Sexual Behavior for a comprehensive evaluation and calls it relevant and ethical to investigate which biological, social and psychological forces have led someone to adopt a new identity (source).

Implications for care

The Cass Review (2024) recommends that every child who comes to a British gender clinic is screened for autism and other neurodevelopmental conditions and receives a psychiatric assessment (source). Environmental Progress concludes from the WPATH Files (2024) that WPATH members know that children and young people cannot oversee the lifelong consequences of treatment. That is Environmental Progress's reading: of the members contacted, one person confirmed their own statements and another disputed the interpretation (source).

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