What do you need, to get a diagnosis of gender dysphoria? This is the Diagnostic and Statistical Manual of the American Psychiatric Association definition of gender dysphoria:
A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested by at least two of the following:
1. a marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or, in young adolescents, the anticipated secondary sex characteristics).
2. a strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or, in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics).
3. a strong desire for the primary and/or secondary sex characteristics of the other gender.
4. a strong desire to be of the other gender (or some alternative gender different from one’s assigned gender).
5. a strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender).
6. a strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender).
Under “Diagnostic features” it notes that “There must also be evidence of distress about this incongruence. Experienced gender may include alternative gender identities beyond binary stereotypes… Adults feel uncomfortable being regarded by others, or functioning in society, as members of their assigned gender.”
Medicine is practical. Doctors don’t make people conform to a particular ideal Wellness, but help us continue to function. This definition is focused on the patients, and what we believe, desire and experience.
You don’t need to desire to change sex characteristics. Secondary sex characteristics include facial hair, or the lack of it, so a desire to change that, rather than gonads or genitals, is enough. So the attempt of some gender critical feminists to distinguish between transsexuals (acceptable) and transgender (not) is not backed up by the APA.
Alternative gender identities: the diagnosis recognises non-binary people. It does not state that the appropriate treatment will be hormones or body alteration, but at least recognises they exist. Private doctors may be more keen to give the patient what they want, so recommend surgery or hormones.
The evidence of “distress” is a fudge. Many of us are not distressed by our gender, but by society’s (perceived) response to it. I know I am a woman, but other people rejecting that distresses me. And, I decided that to be distressed by others’ responses gave them too much power over me. I accept that some people think I am a man. I am not going to waste any energy trying to persuade them otherwise, and I am not going to get upset about it. And, being seen as a woman is not necessary for friendship or politeness: they could see me as a transwoman but think that’s OK.
Yet, if you are not distressed, you are not ill. Being trans is not an illness, it is just a way people are. That means the diagnosis would change to something like gender incongruence in the proposed ICD, as it is only necessary for psychiatrists to intervene if someone wants genital surgery. You might like the backing of a psychiatrist- yes, I really am like this, I am a trans woman- but that is more the province of social scientists than of doctors.
The conviction that one has the feelings and reactions of the other gender does not fit me either. I am a gender critical feminist. I don’t think either gender is so limited, and the feelings of both are the same. I believe the reactions are culturally conditioned rather than innate. I believe my feelings and reactions fit the feminine stereotype far better than the masculine.
The convictions need to have lasted six months for diagnosis. There is no need for The Script, a claim that the feelings have lasted since childhood. But the longer the feelings have lasted, the more likely it is that they will persist, so treatment is less risky.
DSM V estimates prevalence at 0.005% to 0.014% in natal males and 0.002-0.003% in natal females. Other estimates go from 0.1-1%.
It’s all a botched job. It is trying to create a working definition for a varied human phenomenon, and people may try to fit that definition to get what we want.
Clare Flourish 