US - A new manual for diagnosing diseases of the psyche is about to be unveiled… [2010-02-04 The Economist]

http://www.economist.com/sciencetechnology/displaystory.cfm?story_id=15450623

Science & technology

Psychiatric diagnosis

That way, madness lies
A new manual for diagnosing diseases of the psyche is about to be unveiled

Feb 04th 2010

From The Economist print edition

ON FEBRUARY 10th the world of psychiatry will be asked, metaphorically, to lie on the couch and answer questions about the state it thinks it is in. For that is the day the American Psychiatric Association (APA) plans to release a draft of the fifth version of its Diagnostic and Statistical Manual of Mental Disorders (DSM-V). Mental illness carrying the stigma that it does, and the brain being as little-understood as it is, revising the DSM is always a controversial undertaking. This time, however, some of the questions asked of the process are likely to be particularly probing.

The DSM, the first version of which was published in 1952, lists recognised psychological disorders and the symptoms used to diagnose them. In the United States, what is in it influences whether someone will be diagnosed with an illness at all, how he will be treated if he is so diagnosed, and whether his insurance company will pay for that treatment. Researchers in other countries generally defer to the DSM, too, making the manual’s definitions a lingua franca for the science of medical psychology. And, perhaps most profoundly, the DSM influences how mental illness is understood by society at large.

A new DSM, then, is an important document. The APA has been working on the latest revision since 1999, and will not release the final version until May 2013. But some people are already accusing it of excessive secrecy and being too ambitious about the changes it proposes. Those critics will be picking over the draft next week to see if their fears have been realised.


Manual dexterity

The original DSM reflected the “psychodynamic” view of mental illness, in which problems were thought to result from an interplay between personality and life history. (Think Freud, Jung and long hours recounting your childhood and dreams.) The third version, which was published in 1980, took a more medical approach. Mental illnesses were seen as distinct and classifiable, like physical diseases. DSM-III came with checklists of symptoms that allowed straightforward, unambiguous diagnosis. Psychiatry began to seem less like an art form and more like a science.

DSM-III also introduced many more diagnoses than had appeared before. These included attention-deficit disorder, post-traumatic stress disorder and social phobia. In fact, the number of specific diagnoses more than doubled between DSM-I and DSM-III, from 106 to 265. DSM-IV, published in 1994, increased the number to 297, but left the underlying model alone.

The APA’s DSM-V task force, however, has suggested it would like to introduce a “new paradigm” into the manual. It wants to recognise that many conditions, such as anxiety and depression, tend to overlap, so that a diagnosis of only one or the other does not always make sense. The new version of the DSM is also expected to include a “dimensional” component, one that considers the severity as well as the nature of symptoms. This could lead to the paradoxical situation of a symptom (minor depression, for example) being classified as being below the threshold for the diagnosis of a disease, but nevertheless still being regarded as a problem—leaving the individual so diagnosed in a weird medical limbo.

The chairmen of two previous DSM task forces have been particularly critical of the present effort. In a letter to Psychiatric Times, written last June, for example, Allen Frances, a psychiatrist at Duke University who chaired the DSM-IV task force, accused his successors of being too secretive, and of closing themselves off from outside opinion. He also worried that adding dimensional ratings to the DSM could lead to many more diagnoses based on symptoms that would previously have placed an individual in the normal range. Pharmaceutical companies, eager to expand their markets, would be tempted to pounce on these new “patients”. Dr Frances was supported by Robert Spitzer, a professor of psychiatry at Columbia University who was chairman of the DSM-III task force.

Members of the present task force, led by Alan Schatzberg, president of the APA, fired back a letter pointing out that they have held conferences, presented papers and consulted more than 200 outside advisers. They also accused Dr Frances and Dr Spitzer of having a financial interest in books based on the DSM-IV criteria. The two admit to receiving royalties, but say it has nothing to do with their criticism.

In the meantime, particular groups who may or may not be classified as “diseased” are also concerned about what ends up in the manual. Some of those with Asperger’s syndrome—who find it hard to “read” the emotional states and intentions of others, but have otherwise typical intellectual faculties—are worried by hints that their condition might be included under the more general heading of “autism spectrum disorder”. That would lump them with people whose intelligence is profoundly impaired. Transsexuals, meanwhile, want the diagnoses of “gender identity disorder” and “transvestic fetishism” that the new DSM is expected to promulgate changed to be more respectful and less judgmental. In fact, any changes to the list of sexual disorders, including a possible new category called “hypersexual disorder”, are bound to get attention.

February 10th will be the first chance most people, including the critics, have to look at the document. When they do, the criticism is likely to get louder. After all, the effort to classify and categorise disorders of something as complex as the human mind—especially when that categorisation is done by committee—is unlikely to please everybody. It will be interesting to see what direction the new DSM is going in, and whether it stands up to analysis.

--

© The Economist Newspaper Limited 2010.

Cuba - STATEMENT ON DESPATHOLOGIZATION OF TRANSSEXUALISM. Cuban Multidisciplinary Society for Sexuality Studies… [2010-01-24 ILGA]

http://ilga.org/ilga/en/article/mg7Y7pB1Rg

STATEMENT ON DESPATHOLOGIZATION OF TRANSSEXUALISM. Cuban Multidisciplinary Society for Sexuality Studies

in CUBA

24/01/2010

The Sexual Diversity section of the Cuban Multidisciplinary Society for the Study of Sexuality (SOCUMES) proposed the adoption of the following Declaration in its General Assembly of Members on 18 January 2010 in Havana, based on a proposal made by the National Commission for Comprehensive Care of Transsexual People, of the National Center for Sexual Education (CENESEX).

.....

Recalling the current inclusion of transsexuality as a mental disorder in the Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV) published by American Psychiatric Association (APA) and the International Classification of Diseases (ICD-10) of the World Health Organization (WHO);

Recalling also that the Standards of Care adopted in Cuba by the National Commission for Comprehensive Care of Transsexual People rely on those published by the World Professional Association for Transgender Health (WPATH), which also includes the classification of the Diagnostic and Statistical Manual of Mental Disorders and International Classification of Diseases E-10;

Considering that the American Psychiatric Association will publish in 2012 the fifth version of the above mentioned manual and that the chief and other specialists of the working group responsible for the review have recently proposed the non-removal of this category, as well as the application of corrective psychological therapy to children, to the sex assigned at birth;

Taking into account the concern expressed by individuals and human rights groups at the international level regarding this issue,

Considering that all transgender people—including transsexuality, transvestites and intersex people—may be vulnerable to marginalization, discrimination and stigma, based on the socially regulated binary approach that recognizes only two gender identities: male and female;

Considering also that the above classifications perpetuate and deepen social discrimination against these groups, causing irreversible physical and psychological damage that can lead these people to commit suicide;

Considering in addition that transsexuality and other transgender expressions are not an option for a lifestyle and that the modifications to their bodies have no cosmetic intentions. It is a right and an inner need to live with the gender identity which the person feels to belong;

Recalling the Yogyakarta Principles on the application of international human rights law in relation to sexual orientation and gender identity, especially Principle 18 on "Protection from Medical Abuses" which, among other things, make States and governments responsible to “ensure that any medical or psychological treatment or counseling does not, explicitly or implicitly, treat sexual orientation and gender identity as medical conditions to be treated, cured or suppressed”;

Considering that the right to public health and universal free access to its services are guaranteed by the Cuban government for all, but still requires additional laws to fully protect the rights of transgender people;

Recalling Resolution 126 of Public Health Ministry, of 4 June 2008, which regulates the procedures involved in health care for transsexuals;

Recognizing that multidisciplinary care provided by the National Commission for Comprehensive Care of Transsexual People, since its foundation in 1979 until today, has led to a remarkable improvement in the quality of life of transsexual people and their families.

Express our support for the removal of transsexuality from the international classification of mental disorder, especially in the DSM-V update to be published in 2010.

Reject the application of psychological therapies for transgender people, in order to reverse their gender identity, as well as sex reassignment surgeries performed to those under 18 years old.

Reaffirm that transsexuality and other transgender identities are expressions of sexual diversity, to which it must be ensured all psychological, medical and surgical treatments required to alleviate alterations to the mental health of these individuals, as a result of stigma and discrimination.

Also reaffirm that the implementation of these procedures respects sexual rights of each person, and are consistent with bio-ethical principles of autonomy, nonmaleficence, beneficence and justice.

Reaffirm in addition that transgender care should be comprehensive, beyond just medical and psychological care, to ensure recognition and respect for their individual rights.

Reiterate the need to consider all necessary legislations to ensure recognition of these rights, especially the Gender Identity Bill, which includes the identity change regardless sex reassignment surgery performance.

Call for a broader implementation of educational strategies regarding sexual orientation and gender identity at all levels of education and to the general population, as stated in the National Program for Sexual Education.

Reaffirm the need to include the attention to transgendered people in comprehensive social policies of the State and Government of Cuba, in correspondence with the “Declaration of the General Assembly of the United Nations, condemning the violation of human rights based on sexual orientation and identity gender ", supported by Cuba on 18 December 2008.

Havana, 22 January 2010

--

© Copyright 2009, ILGA

US - Researchers may have uncovered the mechanism by which progesterone prevents preterm birth… [2010-02-05 PhysOrg]

http://www.physorg.com/news184569229.html

Research

Researchers may have uncovered the mechanism by which progesterone prevents preterm birth

February 05, 2010

Researchers at Yale School of Medicine believe they may have discovered how the hormone progesterone acts to prevent preterm birth.

The findings will be presented at the Annual Scientific Meeting of the Society for Maternal-Fetal Medicine (SMFM) in Chicago by Errol Norwitz, M.D., professor in the Department of Obstetrics, Gynecology < http://www.physorg.com/tags/gynecology/ > & Reproductive Sciences at Yale.

Preterm birth< http://www.physorg.com/tags/preterm+birth/ >—delivery prior to 37 weeks gestation—has become increasingly common over the past 40 years. Currently, one in eight pregnancies in the U.S. are delivered prematurely. These premature infants are at least seven times more likely to die or have long-term neurologic injury compared with infants delivered at term. Efforts to date to prevent preterm birth have been largely unsuccessful. Several recent studies have suggested that progesterone supplementation from weeks 16-20 of gestation through 36 weeks may prevent preterm birth in about one-third of high-risk women, but the molecular mechanism by which progesterone acts was not known until now.

One-third of preterm birth is linked to premature rupture of the fetal membranes. Prior studies have suggested that rupture results from weakening of the membranes by apoptosis (programmed cell death). Norwitz and his Yale colleagues have shown for the first time that progesterone can prevent apoptosis in fetal membranes.

"We were able to demonstrate that progesterone prevents apoptosis in an artificial environment in the laboratory in which we stimulated healthy fetal membranes with pro-inflammatory mediators," said Norwitz. "Interestingly, and somewhat unexpectedly, we also saw an inhibition of apoptosis under basal conditions without the presence of pro-inflammatory mediators. This suggests that the same mechanism may also be important for the normal onset of labor at term."

Provided by Yale University (news http://www.physorg.com/partners/yale-university/ : web http://www.yale.edu/index.html )

--

© PhysOrg.com 2003-2009

Italy - The artist Novella Parigini put America's first transsexual Christine Jorgensen in a horse buggy and paraded her round Rome… [2010-02-07 The Guardian]

http://www.guardian.co.uk/film/2010/feb/07/memoirs-fellini-film-sex-debauchery

World cinema

Memoirs shed new light on La Dolce Vita era of drugs, sex and debauchery
The character played by Marcello Mastroianni in Federico Fellini's classic film was partly based on a gossip columnist now writing his own account of Rome's scandalous 1950s

Tom Kington
The Observer,   Sunday 07 February 2010

When the gossip columnist Victor Ciuffa emerged blinking from a private viewing of La Dolce Vita in Rome in February 1960, he had one thought in his mind: the film he had just watched amounted to his life played out on the screen.

Federico Fellini's classic depiction of decadent American starlets and persistent photographers changed cinema forever. Now the journalist who chronicled 1950s life on Rome's glitzy Via Veneto and briefed Fellini for his film has decided to give his own definitive account of the era. As far as Ciuffa, now 77, is concerned, 50 years later he is setting the record straight, by writing La Dolce Vita, Minute by Minute.

"The real Dolce Vita started in Rome years before the cafés opened on Via Veneto and had as much to do with mys terious deaths, drug abuse and debauched Roman aristocrats as with Hollywood," he said. While photographers such as Tazio Secchiaroli have long been seen as inspirations for Paparazzo, the character in La Dolce Vita who gave celebrity-chasing photographers their name, Ciuffa claims he provided source material for the cynical columnist-about-town, played to laconic perfection by Marcello Mastroianni. "Ciuffa lived that period intensely; I am sure Fellini was inspired by the work he was doing," said Elio Sorci, another photographer who prowled Via Veneto at the time.

Like Mastroianni's character, Ciuffa enjoyed a middle-class provincial upbringing before plunging into the Rome demi-monde by chance. His first big assignment as a cub reporter was the mysterious death in 1953 of Wilma Montesi, a 21-year-old whose body was found on a beach at Ostia, Rome's port. Witnesses suggested Montesi had been dumped in the sea after overdosing at a sex-and-drugs party attended by the cream of Rome's aristocracy, held at a hunting lodge on land owned by Italy's former royal family, the House of Savoy.

"The Dolce Vita started at that party," said Ciuffa. "I noticed that witnesses were regulars at a bar on Via del Babuino, which was the hangout for existentialists and artists living on Via Margutta, led by the artist Novella Parigini [2010-02-07 BLS: 1921-04-29 - 1993-09-30 < http://www.novellaparigini.com/ >], who caused a stir when she put America's first transsexual, Christine Jorgensen, in a horse buggy and paraded her round Rome." The city's aristocrats were prowling for foreign girls to invite back to their palazzi, a scene later re created in La Dolce Vita. A then unknown Ursula Andress dated a count until he threw a bottle at her head during a row. The Felixstowe-born actress Dawn Addams became a princess in 1954 when she married into a family descended from a general in the Roman empire.

Fifty years on, for Ciuffa the memories are still fresh. Such as the time, in June 1956, when a well-known pusher who had been exiled by Mussolini to Calabria before the war got into a fight in a bar. He was accused of passing off bicarbonate of soda as cocaine. "The police arrived and arrested a count, a marquis and a prince," said Ciuffa. The bar owner decided to shut down, but in 1958 quietly reopened for business at the Café de Paris on Via Veneto, which became a magnet for US actors arriving at the big hotels on the street. As the Dolce Vita took off, Hollywood was discovering the low cost of film-making in Rome and the high jinks to be had.

Soon working as a gossip columnist at Corriere d'Informazione, Ciuffa was first to write up a scandalous striptease by a Turkish dancer in a Trastevere nightclub in November 1958, which finally alerted the world to the licentious and wealthy lifestyle that became known as the Dolce Vita. On that particular night, the Swedish actress Anita Ekberg danced barefoot, a scene she would recreate in Fellini's film, before Aiche Nana stripped to her knickers, egged on by the usual crowd of "aristos", who fled when the police arrived.

"I received the photos taken by Tazio Secchiaroli the next morning and rang the police. 'Nothing happened,' they said. 'If you journalists don't talk about this, nothing happened.' I wrote a long story and by lunchtime news vendors in Milan were yelling 'Scandal'." By this time Ciuffa was meeting Fellini regularly at the Café de Paris before the director started filming La Dolce Vita in 1959. "He wanted to hear about the parties that I was going to."

As the appetite for celebrity gossip exploded, stars grinning at the camera were no longer good enough. "Many shots of actors brawling with photographers were arranged by both parties in advance," said Ciuffa, who was not shy of creating news on a dull night. "We found two cigar-smoking Cubans at the Café de Paris who agreed to deliver roses at 2am to Ava Gardner's address. Her assistant called the police, who arrested the Cubans. Sometimes you needed to make it up."

Despite keeping a satirical tone in his articles, Ciuffa was taken aback when he saw La Dolce Vita at a preview held by Fellini. "When I saw the film, I realised how celebrity warps characters and the stars who flocked to Via Veneto saw themselves as gods," he said.

From that day on, Ciuffa adopted the pen name Ugo Naldi for his gossip column. "I really considered stopping, but I needed the money. My editor was in the habit of calling up to say, 'Send me a piece that will give this paper an erection!' "

--

© Guardian News and Media Limited 2010

US - Pastor Cheri Holdridge of the Village Church in Toledo offers support, sanctuary to Toledo's transgender community… [2010-01-08 Toledo Blade]

http://toledoblade.com/apps/pbcs.dll/article?AID=/20100208/NEWS16/2080320

February 08, 2010

Pastor offers support, sanctuary to area's transgender community

By CLAUDIA BOYD-BARRETT
BLADE STAFF WRITER

Some secrets are so big, there is no safe place to tell them.

The Rev. Cheri Holdridge is hoping to change that by turning her Village Church in Toledo into a safe place.

On Feb. 28, the church and two Ohio organizations will host the first meeting of a Transgender Support Group. They want to provide members of the city's little-known transgender community with a space where they can talk and be understood.

"It's not safe to be transgender in this country, let alone this part of the country," said Sherri Tripepi, executive director of Equality Toledo, which is helping set up the group with Pastor Holdridge and Columbus-based TransOhio. "That's why it's important to have safe environments for these people."

"Transgender" or "transsexual" people identify themselves with a different gender than the one they were born with. Many struggle to repress this identity for years, fearing rejection or humiliation at the hands of those closest to them. Most commonly, transsexuals dress at least some of the time as members of the opposite sex, although a few undergo surgery or hormone treatment to physically alter their gender.

No one is sure how many transgender individuals are in Toledo, but Pastor Holdridge and Ms. Tripepi said requests for a support group have been building for some time. They said transgender people are difficult to count because admitting they're transexual could risk the loss of their job or an apartment, or cause the alienation of family and friends.

Pastor Holdridge said the isolation faced by many transsexuals became clear to her when she opened her church in October.

"Someone transgender came to my church the first day it opened," Pastor Holdridge said. "She was really scared. She'd been rejected by other churches and she was so happy to find a place and a pastor that would accept her."

That person, who attends Pastor Holdridge's church at 3992 Monroe St. every Sunday, can't wait for the support group to start.

Speaking to The Blade on condition of anonymity, the 60-year-old man recently began hormone treatment to become a woman. He said he only realized nine months ago that he was transsexual. He said it had been impossible to find help or support in Toledo.

"When I started through this, there was nobody in the Toledo area. I had nobody to talk to," he said. "That's why we need this support group." He explained he had felt like a female since the age of 4 or 5 years old, but could never admit those feelings.

"All my life I've struggled with something, and never knew what it was," said the individual, who lived until recently as a straight, married man with two children. "It's hard to explain it to somebody and get them to understand … but I'm happy for the first time in my life."

Explanations for transgenderism range from the social to the biological. Experts have pointed to factors that include genetics, prenatal hormone levels, and early social experiences. Incidences of transsexual behavior, such as crossdressing, have been noted throughout history.

There are no definitive figures on the prevalence of transgenderism, although it affects men more often than women. The American Psychological Association puts the number of transsexuals at about 1 in 10,000 biological males and 1 in 30,000 biological females.

Some researchers argue transexualism is more common. A study by Lynn Conway, an activist for transgender people and a professor at the University of Michigan, suggested at least one in 500 people could be transsexual.

Pastor Holdridge expects the support group will start with just a few people. She said the group is open, not just to transsexuals themselves, but also to their family members and friends who are trying to understand and support them.

Not all transsexuals can afford sex-change surgery, which costs thousands of dollars, and the transition from one gender to the other is a drawn-out process involving therapy and contemplation. Pastor Holdridge says the group will be as much a place for practical advice on the options available to transgender people as it is for emotional support.

Pastor Holdridge's lone transgender congregant is confident she'll have plenty of company.

"I would say there are a lot more [transsexuals] than we think there are," she said. "It's going to be interesting to see once the group gets started how many show up."

-

Contact Claudia Boyd-Barrett at:
cbarrett@theblade.com
or 419-724-6272

--

Copyright 2010 The Blade.  

US - DSM-V Draft Gender Identity Disorder Stays… [2010-02-10 MedPage Today]

http://www.medpagetoday.com/Psychiatry/GeneralPsychiatry/18399     

Wednesday, February 10, 2010   

General Psychiatry
   
DSM-V Draft Promises Big Changes in Some Psychiatric Diagnoses

By John Gever
Senior Editor
MedPage Today

Substantial changes are in the offing for the "psychiatrist's bible," the Diagnostic and Statistical Manual of Mental Disorders, according to a draft of the forthcoming fifth edition.

The American Psychiatric Association (APA) has posted the draft of DSM-V on a special Web site, www.dsm5.org< http://www.psych.org/dsmv.aspx >, to obtain comments from its members, other members of the mental health community, and the public.

At a telephone press briefing before the draft's release, members of the APA team leading the DSM revision highlighted several substantial innovations they are proposing:

   • Recategorizing learning disorders, including creation of a single diagnostic category for autism and other socialization disorders, and replacing the controversial term "mental retardation" with "intellectual disability"
   • Eliminating "substance abuse" and "substance dependence" as disorders, to be replaced with a single "addiction and related disorders" category
   • Creating a "behavioral addictions" category that will include addictions to gambling but not to the Internet or sex
   • Offering a new assessment tool for suicide risk
   • Including a category of "risk syndromes" for psychosis and cognitive impairment, intended to capture mild versions of these conditions that do not always progress to full-blown psychotic disorders or dementia, but often do
   • Adding a new disorder in children, "temper dysregulation with dysphoria," for persistent negative mood with bursts of rage
   • Revising criteria for some eating disorders, including creation of a separate "binge eating disorder" distinct from bulimia
   • Using "dimensional assessments" to account for severity of symptoms, especially those that appear in multiple diagnostic categories

The APA will accept comments through April 20. The work groups managing the revision will consider them and make further changes as needed to the draft, said David Kupfer, MD, of the University of Pittsburgh, chairman of the DSM-V task force.

The draft diagnostic criteria will then undergo two years of field testing. The final DSM-V is scheduled for release in May 2013, a year later than originally planned< http://www.medpagetoday.com/Psychiatry/GeneralPsychiatry/17482 >.


New Categories for Dyslexia, Autism

In the area of neurodevelopmental disorders, DSM-V will put dyslexia and dyscalculia -- reflecting disabilities of reading and mathematics, respectively -- into a new category of learning disabilities.

Autism, Asperger's syndrome, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified will make up the new "autism and related disorders" category.

The head of the APA's work group on substance-related disorders, Charles O'Brien, MD, PhD, of the University of Pennsylvania, told reporters on the press call that substance dependence and abuse had no basis in the research on addictions.

"We unanimously agreed that . . . there really isn't evidence for an intermediate stage [short of addiction] that is now known as abuse," he said. Instead, there will be substance use disorders for each of the major types of drugs that cause problems, such as alcohol.

He added that the term "dependence" was problematic as a psychiatric diagnosis because some types of physical dependence are "completely normal" for some medications, such as opioid painkillers.

In fact, under the draft, DSM-V will include "discontinuation syndromes" to allow physicians to properly assess symptoms of withdrawal from psychoactive substances, including caffeine, O'Brien said.

He also said his work group had considered including sex and Internet addictions as disorders, but decided there was insufficient evidence to allow development of reliable diagnostic criteria for them.

Consequently, gambling addiction is slated to be the only disorder formally listed in the behavioral addictions category.

But O'Brien added that, under current plans, sex and Internet addictions would be included in an appendix to DSM-V, intended to encourage additional research that could lead to their inclusion in future editions.

Carole Lieberman, MD, a Beverly Hills, Calif., psychiatrist who appears frequently on television, regretted the omission of Internet addiction.

Contacted for comment by MedPage Today and ABC News, Lieberman said in an e-mail that behavioral addictions are a worthy category. "But why would it not include 'Internet addiction,'" she wrote. "Could it be that the psychiatrists involved do not want to acknowledge that their own Internet usage could meet the criteria for addiction?"

Lieberman added that compulsive shopping was another form of behavioral addiction that deserves recognition.


Dimensional and Risk Assessments

APA leaders also emphasized the two new suicide risk assessment scales planned for DSM-V, one for adolescents and one for adults.

David Shaffer, MD, of Columbia University, told reporters on the press call that suicide nearly always occurs in the context of some psychiatric disorder, but not always depression.

The new risk assessment tools focus on risk factors such as impulsive behavior, heavy drinking, and chronic severe pain and illness.

In DSM-IV, suicidal ideation is treated as a symptom of major depression and certain other disorders.

Shaffer also explained the genesis of the proposed new childhood disorder, temper dysregulation with dysphoria (TDD).

"About 40% to 60% of the cases [seen by child psychiatrists] will be children who are doing things that other people don't want them to do," he said. Many of these are children who are "stubborn and resistant and disobedient and moody."

There is currently a recognized syndrome known as oppositional defiant disorder, but some children also display severe aggression and negative moods that go beyond mere stubbornness, according to Shaffer.

Such children are often tagged as having juvenile bipolar disorder, but research has shown that the label is often inappropriate, since they usually do not qualify for a bipolar disorder diagnosis when they reach adulthood, although they remain dysfunctional. More often, these children are diagnosed as depressed when they become adults.

He said the addition of TDD would better describe the severity and frequency of irritable behavior while also recognizing the mood disorder that goes with it.

Another innovation in DSM-V will be the extensive use of so-called dimensional assessments. Whereas DSM-IV relied heavily on present-absent symptom checklists, the new edition will include severity scales for symptoms, such as anxiety or insomnia, that may appear to larger or smaller degrees in many different mental illnesses.

Darrel Regier, MD, MPH, the APA's research director, said such checklists "don't always fit the reality that someone with a mental disorder experiences." Often, a symptom like insomnia isn't on the checklist for a particular disorder, he said, "but they can still affect patients' lives and affect the treatment planning."

Incorporating quantitative dimensional assessments should allow clinicians to develop treatment and response-monitoring plans better tailored to individual patients' needs, Regier said.

But Lieberman foresaw problems with the dimensional assessments. "I don't think [they] will add anything but confusion," she said in an e-mail. "As it is now, people don't really make use of the subcategories that there are to describe severity of symptoms. Instead, I see this as a tool that insurance companies could well co-opt to try to deny benefits."


Gender Identity Disorder Stays

A closely watched issue in the DSM-V revision has been whether to change or do away with gender identity disorder, now listed in DSM-IV. At this point, the draft retains the designation but with some changes, officials said.

People who consider themselves "transgendered" have long criticized DSM-IV and previous editions for labeling them with a mental disease when their problems, they believe, are purely somatic -- that is, they have the wrong genitalia and hormonal balance.

At the APA's annual meeting last May, members of the transgender community made a case < http://www.medpagetoday.com/MeetingCoverage/APA/14270 > for dropping gender identity disorder from DSM-V, but keeping some kind of "gender variance" diagnosis as a medical condition. Such an approach would eliminate the stigma of a psychiatric diagnosis while leaving a pathway for third-party payment for gender transition treatments, they said.

William Narrow, MD, the APA's research director for DSM-V, told reporters that the draft does remove the term "disorder" from the condition when applied to children, renaming it as "gender incongruence."

For adults, gender identity disorder will remain in DSM-V but with substantially altered diagnostic criteria, Narrow said.

But APA officials said the organization planned more discussions with members of the transgender community.

Kupfer, the DSM-V task force chairman, stressed that further changes in many diagnostic categories are likely following the comment period and field trials.

Final revisions will be submitted in 2012 for approval by the APA's two governing bodies, the Assembly and the board of trustees.

-

This article was developed in collaboration with ABC News.

-

Related Article(s):

   • DSM-V Publication Pushed Back to 2013 < http://www.medpagetoday.com/Psychiatry/GeneralPsychiatry/17482 >
   • APA: Major Changes Loom for Bible of Mental Health < http://www.medpagetoday.com/Psychiatry/GeneralPsychiatry/14270 >

--

© 2004-2010 MedPage Today, LLC.

US - DSM-5 Proposed Revision GID in Adolescents or Adults… [2010-02-10 APA dsm5.org]

http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=193

American Psychiatric Association DSM-5 Development

302.85
Gender Identity Disorder in Adolescents or Adults

PROPOSED REVISION

Gender Incongruence (in Adolescents or Adults) [1]

A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested by 2* or more of the following indicators: [2, 3, 4]

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) [13, 16]

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) [17]

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)


Subtypes

With a disorder of sex development

Without a disorder of sex development

[14, 15, 16, 19]

……

http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=193#

302.85
Gender Identity Disorder in Adolescents or Adults

RATIONALE

For the adult criteria, we propose, on a preliminary basis, the requirement of only 2 indicators. This is based on a preliminary secondary data analysis of 154 adolescent and adults patients with GID compared to 684 controls (Deogracias et al., 2007; Singh et al., 2010). From a 27-item dimensional measure of gender dysphoria, the Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults (GIDYQ), we extracted five items that correspond to the proposed A2-A6 indicators (we could not extract a corresponding item for A1). Each item was rated on a 5-point response scale, ranging from Never to Always, with the past 12 months as the time frame. For the current analysis, we coded a symptom as present if the participant endorsed one of the two most extreme response options (frequently or always) and as absent if the participant endorsed one of the three other options (never, rarely, sometimes). This yielded a true positive rate of 94.2% and a false positive rate of 0.7%. Because the wording of the items on the GIDYQ is not identical to the wording of the proposed indicators, further validational work will be required during field trials.


End notes

1. It is proposed that the name gender identity disorder (GID) be replaced by “Gender Incongruence” (GI) because the latter is a descriptive term that better reflects the core of the problem: an incongruence between, on the one hand, what identity one experiences and/or expresses and, on the other hand, how one is expected to live based on one’s assigned gender (usually at birth) (Meyer-Bahlburg, 2009a; Winters, 2005). In a recent survey that we conducted among consumer organizations for transgendered people (Vance et al., in press), many very clearly indicated their rejection of the GID term because, in their view, it contributes to the stigmatization of their condition.

2. In addition to the proposed name change for the diagnosis (see Endnote 1), there are 6  substantive proposed changes to the DSM-IV descriptive and diagnostic material: (a) we have proposed a change in conceptualization of the defining features by emphasizing the phenomenon of “gender incongruence” in contrast to cross-gender identification per se (Meyer-Bahlburg, 2009a); (b) we have proposed a merging of the A and B clinical indicator criteria in DSM-IV (see Endnotes 10, 13); (c) for the adolescent/adult criteria, we have proposed a more detailed and specific set of polythetic indicators than was the case in DSM-IV (Cohen-Kettenis & Pfäfflin, 2009; Zucker, 2006); (d) for the child criteria, we have proposed that the A1 indicator be necessary (but not sufficient) for the diagnosis of GI (see Endnote 5); (e) we have proposed that the “distress/impairment” criterion not be a prerequisite for the diagnosis of GI (see Endnote 15); and (f) we have proposed that subtyping by sexual attraction (for adolescents/adults) be eliminated (see Endnote 18) but that subtyping by the presence or absence of a co-occurring disorder of sex development (DSD) be introduced (see Endnote 14). As in DSM-IV, we recommend one overarching diagnosis, GI, with separate, developmentally-appropriate criteria sets for children vs. adolescents/adults. The text material will provide updated information on developmental trajectory data for clients who received the GI diagnosis in childhood vs. adolescence or adulthood.

The term “sex” has been replaced by assigned “gender” in order to make the criteria applicable  to individuals with a DSD (Meyer-Bahlburg, 2009b). During the course of physical sex differentiation, some aspects of biological sex (e.g., 46,XY genes) may be incongruent with other aspects (e.g., the external genitalia); thus, using the term “sex” would be confusing. The change also makes it possible for individuals who have successfully transitioned to “lose” the diagnosis after satisfactory treatment. This resolves the problem that, in the DSM-IV-TR, there was a lack of an “exit clause,” meaning that individuals once diagnosed with GID will always be considered to have the diagnosis, regardless of whether they have transitioned and are psychosocially adjusted in the identified gender role (Winters, 2008). The diagnosis will also be applicable to transitioned individuals who have regrets, because they did not feel like the other gender after all. For instance, a natal male living in the female role and having regrets experiences an incongruence between the “newly assigned” female gender and the experienced/expressed (still or again male) gender.

3. It has been recommended by the Workgroup to delete the “perceived cultural advantages” proviso. This was also recommended by the DSM-IV Subcommittee on Gender Identity Disorders (Bradley et al., 1991). There is no reason to “impute” one causal explanation for GI at the expense of others (Zucker, 1992, 2009).

4. The 6 month duration was introduced to make at least a minimal distinction between very transient and persistent GI. The duration criterion was decided upon by clinical consensus. However, there is no clear empirical literature supporting this particular period (e.g., 3 months vs. 6 months or 6 months vs. 12 months). There was, however, consensus among the group that a lower-bound duration of 6 months would be unlikely to yield false positives.

13. In the DSM-IV, there are two sets of clinical indicators (Criteria A and B). This distinction is not supported by factor analytic studies. The existing studies suggest that the concept of GI is best captured by one underlying dimension (Cohen-Kettenis & van Goozen, 1997; Deogracias et al., 2007; Green, 1987; Johnson et al., 2004; Singh et al., 2010).

14. There is considerable evidence individuals with a DSD experience GI and may wish to change from their assigned gender; the percentage of such individuals who experience GI is syndrome-dependent (Cohen-Kettenis, 2005; Dessens, Slijper, & Drop, 2005; Mazur, 2005; Meyer-Bahlburg, 1994, 2005, 2009a, 2009b). From a phenomenologic perspective, DSD individuals with GI have both similarities and differences to individuals with GI with no known DSD. Developmental trajectories also have similarities and differences. The presence of a DSD is suggestive of a specific causal mechanism that may not be present in individuals without a diagnosable DSD.

15. It is our recommendation that the GI diagnosis be given on the basis of the A criterion alone and that distress and/or impairment (the D criterion in DSM-IV) be evaluated separately and independently. This definitional issue remains under discussion in the DSM-V Task Force for all psychiatric disorders and may have to be revisited pending the outcome of that discussion. Although there are studies showing that adolescents and adults with the DSM-IV diagnosis of GID function poorly, this type of impairment is by no means a universal finding. In some studies, for example, adolescents or adults with GID were found to generally function psychologically in the non-clinical range (Cohen-Kettenis & Pfäfflin, 2009; Meyer-Bahlburg, 2009a). Moreover, increased psychiatric problems in transsexuals appear to be preceded by increased experiences of stigma (Nuttbrock et al., 2009). Postulating “inherent distress” in case one desires to be rid of body parts that do not fit one’s identity is, in the absence of data, also questionable (Meyer-Bahlburg, 2009a).

16. Although the DSM-IV diagnosis of GID encompasses more than transsexualism, it is still often used as an equivalent to transsexualism (Sohn & Bosinski, 2007). For instance, a man can meet the two core criteria if he only believes he has the typical feelings of a woman and does not feel at ease with the male gender role. The same holds for a woman who just frequently passes as a man (e.g., in terms of first name, clothing, and/or haircut) and does not feel comfortable living as a conventional woman. Someone having a GID diagnosis based on these subcriteria clearly differs from a person who identifies completely with the other gender, can only relax when permanently living in the other gender role, has a strong aversion against the sex characteristics of his/her body, and wants to adjust his/her body as much as technically possible in the direction of the desired sex. Those who are distressed by having problems with just one of the two criteria (e.g., feeling uncomfortable living as a conventional man or woman) will have a GIDNOS diagnosis. This is highly confusing for clinicians. It perpetuates the search for the “true transsexual” only, in order to identify the right candidates for hormone and surgical treatment instead of facilitating clinicians to assess the type and severity of any type of GI and offer appropriate treatment. Furthermore, in the DSM-IV, gender identity and gender role were described as a dichotomy (either male or female) rather than a multi-category concept or spectrum (Bockting, 2008; Bornstein, 1994; Ekins & King, 2006; Lev, 2007; Røn, 2002). The current formulation makes more explicit that a conceptualization of GI acknowledging the wide variation of conditions will make it less likely that only one type of treatment is connected to the diagnosis. Taking the above regarding the avoidance of male-female dichotomies into account, in the new formulation, the focus is on the discrepancy between experienced/expressed gender (which can be either male, female, in-between or otherwise) and assigned gender (in most societies male or female) rather than cross-gender identification and same-gender aversion (Cohen-Kettenis & Pfäfflin, 2009).

17. In referring to secondary sex characteristics, anticipation of the development of secondary sex characteristics has been added for young adolescents. Adolescents increasingly show up at gender identity clinics requesting gender reassignment, before the first signs of puberty are visible (Delemarre-van de Waal & Cohen-Kettenis, 2006; Zucker & Cohen-Kettenis, 2008).

18. In contemporary clinical practice, sexual orientation per se plays only a minor role in treatment protocols or decisions. Also, changes as to the preferred gender of sex partner occur during or after treatment (DeCuypere, Janes, & Rubens, 2005; Lawrence, 2005; Schroder & Carroll, 1999). It can be difficult to assess sexual orientation in individuals with a GI diagnosis, as they preoperatively might give incorrect information in order to be approved for hormonal and surgical treatment (Lawrence, 1999). Because sexual orientation subtyping is of interest to researchers in the field, it is recommended that reference to it be addressed in the text, but not as a specifier. It should also be assessed as a dimensional construct.

19. The subworkgroup has had extensive discussion about the placement of GI in the nomenclature for DSM-V, as the meta-structure of the entire manual is under review. The subworkgroup questions the rationale for the current DSM-IV chapter Sexual and Gender Identity Disorders, which contains three major classes of diagnoses: sexual dysfunctions, paraphilias, and gender identity disorders (see Meyer-Bahlburg, 2009a). Various alternative options to the current placement are under consideration.


References

Bockting, W. O. (2008). Psychotherapy and the real-life experience: From gender dichotomy to gender diversity.Sexologies, 17, 211-224.

Bornstein, K. (1994). Gender outlaw: On men, women and the rest of us. London: Routledge.

Bradley, S. J., Blanchard, R., Coates, S., Green, R., Levine, S. B., Meyer-Bahlburg, H. F. L., et al. (1991). Interim report of the DSM-IV subcommittee on gender identity disorders. Archives of Sexual Behavior, 20, 333-343.

Cohen-Kettenis, P. T. (2005). Gender change in 46,XY persons with 5α-reductase-2-deficiency and 17β-hydroxysteroid dehydrogenase-3 deficiency. Archives of Sexual Behavior, 34, 399-410.

Cohen-Kettenis, P. T., & Pfäfflin, F. (2009). The DSM diagnostic criteria for adolescents and adults. Archives of Sexual Behavior, doi: 10.1007/s10508-009-9562-y.

Cohen-Kettenis, P. T., & van Goozen, S. H. M. (1997). Sex reassignment of adolescent transsexuals: A follow-up study. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 263-271.

De Cuypere, G., Janes, C., & Rubens, R. (1995). Psychosocial functioning of transsexuals in Belgium. Acta Psychiatrica Scandinavica, 91, 180-184.

Delemarre-van de Waal, H. A., & Cohen-Kettenis, P. T. (2006). Clinical management of gender identity disorder in adolescents: A protocol on psychological and paediatric endocrinology aspects. European Journal of Endocrinology, 155(Suppl. 1), S131-S137.

Deogracias, J. J., Johnson, L. L., Meyer-Bahlburg, H. F. L., Kessler, S. J., Schober, J. M., & Zucker, K. J. (2007). The Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults. Journal of Sex Research, 44, 370-379.

Dessens, A. B., Slijper, F. M. E., & Drop, S. L. S. (2005). Gender dysphoria and gender change in chromosomal females with congenital adrenal hyperplasia. Archives of Sexual Behavior, 34, 389-397.

Ekins, R., & King, D. (2006). The transgender phenomenon. London, CA: Sage.

Green, R. (1987). The "sissy-boy syndrome" and the development of homosexuality. New Haven, CT: Yale University Press.

Johnson, L. L., Bradley, S. J., Birkenfeld-Adams, A. S., Radzins Kuksis, M. A., Maing, D. M., & Zucker, K. J. (2004). A parent-report Gender Identity Questionnaire for Children. Archives of Sexual Behavior, 33, 105-116.

Lawrence, A. A. (1999). [Letter to the Editor]. Archives of Sexual Behavior, 28, 581-583.

Lawrence, A. A. (2005). Sexuality before and after male-to-female sex reassignment surgery. Archives of Sexual Behavior 34, 147-166.

Lev, A. I. (2007). Transgender communities: Developing identity through connection. In K. J. Bieschke, R. M. Perez, & K. A. Debord (Eds.), Handbook of counseling and psychotherapy with lesbian, gay, bisexual, and transgender clients(2nd ed., pp. 147-175). Washington, DC: American Psychological Association.

Mazur, T. (2005). Gender dysphoria and gender change in androgen insensitivity or micropenis. Archives of Sexual Behavior, 34, 411-421.

Meyer-Bahlburg, H. F. L. (1994). Intersexuality and the diagnosis of gender identity disorder. Archives of Sexual Behavior, 23, 21-40

Meyer-Bahlburg, H. F. L. (2005). Gender identity outcome in female-raised 46,XY persons with penile agenesis, cloacal exstrophy of the bladder, or penile ablation. Archives of Sexual Behavior, 34, 423-438.

Meyer-Bahlburg, H. F. L. (2009a). From mental disorder to iatrogenic hypogonadism: Dilemmas    in conceptualizing gender identity variants as psychiatric conditions. Archives of Sexual Behavior, doi: 10.1007/s10508-009-9532-4.

Meyer-Bahlburg, H. F. L. (2009b). Variants of gender differentiation in somatic disorders of sex development: Recommendations for Version 7 of the World Professional Association for Transgendered Health's Standards of Care.International Journal of Transgenderism, 11, 226-237.

Nuttbrock, L., Hwahng, S., Bockting, W., Rosenblum, A., Mason, H., Macri, M., et al. (2009). Psychiatric impact of gender-related abuse across the life course of male to female transgender persons. Journal of Sex Research, doi: 10.1080/00224-490903062258.

Røn K. (2002). ‘Either/or’ and ‘both/neither’: Discursive tensions in transgender politics. Signs, 27, 501-522.

Schroder, M., & Carroll, R. (1999). Sexological outcomes of gender reassignment surgery. Journal of Sex Education and Therapy, 24, 137-146.

Singh, D., Deogracias J. J., Johnson, L. L., Bradley, S. J., Kibblewhite, S. J., Owen-Anderson, A., et al. (2010). The Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults: Further validity evidence. Journal of Sex Research, 47, 49-58.

Sohn, M., & Bosinski, H. A. G. (2007). Gender identity disorders: Diagnostic and surgical aspects. Journal of Sexual Medicine, 4, 1193-1208.

Vance, S., Cohen-Kettenis, P.T., Drescher, J., Meyer-Bahlburg, H. F. L., Pfäfflin, F., & Zucker, K. J. (in press). Transgender advocacy groups’ opinions on the current DSM gender identity disorder diagnosis: Results from an international survey. International Journal of Transgenderism.

Winters, K. (2005). Gender dissonance: Diagnostic reform of gender identity disorder for adults. Journal of Psychology and Human Sexuality, 17, 71-89.

Winters, K. (2008). Gender madness in American psychiatry: Essays from the struggle for dignity. Dillon, CO: GID Reform Advocates.

Zucker, K. J. (1992). Gender identity disorder. In S. R. Hooper, G. W. Hynd, & R. E. Mattison (Eds.), Child psychopathology: Diagnostic criteria and clinical assessment (pp. 305-342). Hillsdale, NJ: Erlbaum.

Zucker, K. J. (2006). Gender identity disorder. In D. A. Wolfe & E. J. Mash (Eds.), Behavioral and emotional disorders in adolescents: Nature, assessment, and treatment (pp. 535-562). New York: Guilford Press.

Zucker, K. J. (2009). The DSM diagnostic criteria for gender identity disorder in children. Archives of Sexual Behavior, doi: 10.1007/s10508-009-9540-4.

Zucker, K. J., & Cohen-Kettenis, P. T. (2008). Gender identity disorder in children and adolescents. In D. L. Rowland & L. Incrocci (Eds.), Handbook of sexual and gender identity disorders (pp. 376-422). New York: Wiley & Sons.

Zucker, K. J., Green, R., Bradley, S. J., Williams, K., Rebach, H. M., & Hood, J. E. (1998). Gender identity disorder of childhood: Diagnostic issues. In T. A. Widiger, A. J. Frances, H. A. Pincus, R. Ross, M. B. First, W. Davis, & M. Kline (Eds.), DSM-IV sourcebook (Vol. 4, pp. 503-512). Washington, DC: American Psychiatric Association.

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302.85
Gender Identity Disorder in Adolescents or Adults

SEVERITY

For Adolescents and Adults  

Please complete the following questions: [Note to Task Force—these first 4 questions are preliminary; the corresponding dimensional questions for the categorical diagnosis are on the next page]

1. My current legal sex or gender (e.g., as listed under “sex” on my passport or driver’s license,  also called “assigned” gender) is:

a. Female
b. Male
c. Other (describe): _________________


2. My confidence that I really am what my legal “sex” states (namely, a girl/woman or boy/man)  is:

a. None
b. Mild
c. Moderate
d. Strong
e. Very Strong


3. The way that I experience and express my true gender compared to my legal sex or gender is:

a. Not at all different
b. Mildly different
c. Moderately different
d. Strongly different
e. Very Strongly different


4. I am distressed by feeling different from my legal sex or gender:

a. None
b. Mild
c. Moderate
d. Strong
e. Very Strong

Note to the Task Force: Definitions will be provided for primary and secondary sex characteristics and “assigned sex” and “assigned gender.” Questions A1-A6 are the dimensional metrics for the corresponding categorical criteria.

For Questions 1-8, please circle the letter next to the statement that applies to you the best.

A1. Over the past 6 months, how intense was your discomfort because your primary and/or secondary sex characteristics do not match your gender identity?

None
Mild  
Moderate
Strong
Very Strong


A2. Over the past 6 months, how intense was your desire to be rid of your primary and/or secondary sex characteristics because they do not match your gender identity?

None
Mild
Moderate
Strong
Very Strong


A3. Over the past 6 months, how intense was your desire for the primary and/or secondary sex characteristics of the other gender?

None
Mild
Moderate
Strong
Very Strong


A4. Over the past 6 months, how intense was your desire to be of the other gender (or some gender different from your assigned gender)?

a. None
b. Mild
c. Moderate
d. Strong
e. Very Strong


A5. Over the past 6 months, how intense was your desire to be treated as the other gender (or some gender different from your assigned gender)?

a. None
b. Mild
c. Moderate
d. Strong
e. Very Stong


A6. Over the past 6 months, how intense was your conviction that you have the typical feelings and reactions of the other gender (or some gender different from your assigned gender)?  

a. None
b. Mild
c. Moderate
d. Strong
e. Very Strong


7. Over the past 6 months, how would you describe your sexual attraction to other people?

a. Sexually attracted to males
b. Sexually attracted to females
c. Sexually attracted to both males and females
d. Sexually attracted to neither males or females
e. Other (please describe): _______________________________________


8. How old were you when you first had the strong desire to be, or to live in the gender role, of the other gender (or some gender different from your assigned gender)?

a. Age 5 years or younger
b. Between 6 and 9 years
c. Between 10 and 12 years
d. Between 13 and 17 years
e. Age 18 years or older

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302.85
Gender Identity Disorder in Adolescents or Adults

DSM-IV

Gender Identity Disorder

A. A strong and persistent cross-gender identification (not merely a desire for any perceived cultural advantages of being the other sex).

In children, the disturbance is manifested by four (or more) of the following:

   1. Repeatedly stated desire to be, or insistence that he or she is, the other sex

   2. In boys, preference for cross-dressing or simulating female attire; in girls, insistence on wearing only stereotypical masculine clothing

   3. Strong and persistent preferences for cross-sex roles in make-believe play or persistent fantasies of being the other sex

   4. Intense desire to participate in the stereotypical games and pastimes of the other sex

   5. Strong preference for playmates of the other sex

In adolescents and adults, the disturbance is manifested by symptoms such as a stated desire to be the other sex, frequent passing as the other sex, desire to live or be treated as the other sex, or the conviction that he or she has the typical feelings and reactions of the other sex.

B. Persistent discomfort with his or her sex or sense of inappropriateness in the gender role of that sex.

In children, the disturbance is manifested by any of the following:

   In boys, assertion that his penis or testes are disgusting or will disappear or assertion that it would be better not to have a penis, or aversion toward rough-and-tumble play and rejection of male stereotypical toys, games, and activities;

   In girls, rejection of urinating in a sitting position, assertion that she has or will grow a penis, or assertion that she does not want to grow breasts or menstruate, or marked aversion toward normative feminine clothing.

In adolescents and adults, the disturbance is manifested by symptoms such as preoccupation with getting rid of primary and secondary sex characteristics (e.g., request for hormones, surgery, or other procedures to physically alter sexual characteristics to simulate the other sex) or belief that he or she was born the wrong sex.

C. The disturbance is not concurrent with a physical intersex condition.

D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Code based on current age


Specify if (for sexually mature individuals):

Sexually Attracted to Males

Sexually Attracted to Females

Sexually Attracted to Both

Sexually Attracted to Neither

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