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HISTORY-DSM I through DSM IV-TR

The American Psychological Association has published four benchmark editions of the DSM. It has also published two “Revised” editions. DSM I was published in 1952. DSM II was published in 1968. DSM III was published in 1980 and revised in 1987. The latest benchmark edition of the DSM, DSM IV was published in 1994 and revised in 2000. It is referred to as DSM IV -TR. DSM V has a projected publication of 2010.


Although both the DSM I and DSM II mention “Transvestism,” neither manual addresses the issue of gender identity per se. Gender Identity as a separate issue does not appear until the third edition. In DSM III a new category of disorders entitled Psychosexual Disorders appears. It introduces the term Transsexualism.

DSM III-R
In DSM III-R--published seven years later --the category of Psychosexual Disorders was removed all together. Instead gender variant issues are covered under a heading of Gender Identity Disorders and was listed alphabetically after the Eating Disorders.

DSM IV
In 1994, with the release of the DSM IV, the section entitled Gender Identity Disorders was replaced with the singular term, Gender Identity Disorder (GID)

The term “Transsexualism” was eliminated. Most importantly, perhaps is that GID was reclassified as being a sexual disorder rather then a category of its own. It is listed directly after Voyeurism and Paraphilia in the Sexual and Gender Identity Disorders section. Of note is that the authors of the DSM IV write about a preoccupation with cross-gender behavior as if the behavior is pathological.

Along with a large number of papers noting the efficacy of hormone replacement therapy in treating the gender variant condition, there have been several major papers worth noting as having presented physiological data that propose that much of an individual’s gender identity may depend on biological events outside of anyone’s control.

The first of these appeared In 1997 when Zhou and his colleagues published a study wherein they examined the volume of the central subdivision of the bed nucleus of the stria terminalis (BSTc) of the brain of six male-to-female transsexuals. They found that a female-sized BSTc was found in all of the subjects. This led them to declare that a female brain structure exists in genetically male transsexuals, supporting the hypothesis that gender identity develops as a result of an interaction between the developing brain and sex hormones in utero.

Three years later in 2000 Krujver et al. published a follow up study to that of Zhou. Krujver and his colleagues counted the number of somato statin-expressing neurons in the BSTc of 42 subjects in relation to sex, sexual orientation, gender identity, and past or present hormonal status. They had a similar finding.

They too concluded that“Sex reversal in the transsexual brain clearly support the paradigm that in transsexuals, sexual differentiation of the brain and genitals may go into opposite directions and point to a neurobiological basis of gender identity disorder.”

To add to this, we now have six papers over the last four years published in the Proceedings of the National Academy of Sciences of the USA describing a process known as defeminization --or the loss of the ability to display female-type behaviors in males. This ongoing area of research is based primarily on the fact that neonatal males --unlike neonatal females --produce androgens and estrodiol. Andrea Kudwa et. al., in a paper published just last month after concluding a number of experiments on mice concluded that

“ the development of neural sex differences is initiated by estradiol, which activates two processes in male neonates; masculinization, the development of male-type behaviors, and defeminization, the loss of the ability to display female-type behaviors”.

The mere fact that there is a specific process of masculinization and defeminization in the brain of the developing fetus and that it is sensitive to environmental disturbance such as the accidental or purposeful introduction of exogenous hormones, [DES for example] gives added credence to the possibility of there being a gender variant condition in a significant number of the population.

The “John/Joan,” David Reimer case.
Finally, it’s helpful to review the well-known David Reimer (aka “John/Joan”) case. This is the case where in 1972, an 8 month old boy--who lost his penis in a circumcision accident--was surgically, hormonally and socially reassigned as female. Although the case was reported in the literature as a success, giving many people to believe that conventional patterns of masculine and feminine behaviors can be altered by the way a child is raised, was in fact a failure.

Despite being raised as a girl, being told all his life that he was a girl, having what appeared to be female genitalia that he could compare with his twin brother’s penis and even after the administration of estrogen at puberty, David retained a strong sense of his male gendered self. Not only did he come to reject the concept of his being female, he also rejected the estrogen therapy soon after it was imposed on him.

Although he went on to get married as a man and serve as a step-father, he never really got over the trauma of his ordeal. He took his own life in May, 2004.

Phallic Inadequacy.

Until recently, it was standard practice sanctioned by the American Academy of Pediatrics to suggest that doctors “normalize” the genitals in all cases of genetic male neonates born with certain forms of ambiguous genitalia. Parents were routinely advised that in order to prevent severe psychosocial dysfunction it would be best to reassign their male child immediately to female and have the child undergo surgical bilateral orchiectomy and construction of a vulva. The parents were further advised never to tell anyone, especially the child, of the child’s true genetic background.

Three issues were cited:

1) The need for the parents to announce unequivocally the sex of their newborn.

2). The fact that it is easier to fashion a vulva surgically out of the available material than it is to enlarge a micropenis.

• and third, since gender identity was believed to be a social construct, it was thought that the child would have a more satisfying life as a girl than a boy without a functioning penis.

With the revelations of the Reimer case and the publication of other cases where intersex children rejected their assigned sex, some members of the medical profession began to rethink the advisability of reassigning male children as females simply because of what was deemed penile inadequacy.

Reiner and Gearhart, two physicians who until recently were associated with the departments of Psychiatry and Urology at Johns Hopkins University, assessed all 16 genetic males in their cloacal exstrophy clinic, 14 of which had undergone social, legal and surgical sex reassignment to females as neonates. The parents of the other two subjects refused the reassignment and the children were raised as boys.

The authors evaluated the sexual role and identity of the subjects as defined by their “persistent declaration of their sex.” They report that 8 of the 14 subjects assigned to the female sex had, over the course of the study, declared themselves to be male, whereas the 2 subjects assigned as male identified as male.

These findings support the emerging thesis that despite the still too commonly held believe, the genitals are not the seat of a gendered self. Nor is sex of rearing especially effective in permanently establishing an imposed sense of a gendered self. Indeed, Female-to-Male transsexual people also
bear witness to the power of a masculine psyche, regarless of genital
configuration.

Social Ramifications

In addition to the therapeutic concerns, there are political reasons to consider in this matter. As the transgender community has made gains in having their human rights acknowledged, the Christian Right in the USA has declared that helping people transition to their preferred gender role is immoral.

To add credence to the Religious Right’s argument they go to great lengths to point out that note the term Gender Identity Disorder comes from the DSM, a manual of mental disorders. They conclude, therefore, that since Gender Identity Disorder is a mental disorder, hormonal and surgical interventions leading to gender role transition should be replaced with long-term psychological care.

A typical example comes from The Traditional Values Collation web site:

Our medical profession does no favors to sexually confused individuals by physically altering them so they can pretend to be something they will never be. Surgeons who mutilate men and women who suffer from a Gender Identity Disorder should be condemned by their medical associates.

.....Gender confused individuals need long-term counseling not approval for what is clearly a mental disorder.”

...and there are far more similar examples online than I have time to quote here.

New thinking for DSM V
As the DSM prepares the next update, I urge the authors to consider that the cross-gender behavior typical of gender variant people is neither a sexual disorder nor a gender identity disorder. Rather it is an anxiety disorder secondary to physical and sociological gender expression deprivation. Rather than referring to the cluster of behaviors as “Transsexualism” or “Gender Identity Disorder” I propose here --as I have elsewhere--that the condition be refereed to as Gender Expression Deprivation Anxiety Disorder (GEDAD).

Here are some advantages to the new terminology:

• GEDAD tacitly recognizes that gender expression is a critical element in all that makes us human.

• GEDAD tacitly recognizes that gender expression is a dictate of birth. It is not negotiable and is not a life style choice.

• GEDAD tacitly acknowledges that gender expression-- as defined by the individual-- is vital to psychological health.

• GEDAD moves the locus of attention from the sexological to the psychological.

• Unlike GID, GEDAD does not connote disorder or confusion in someone presenting with gender issues. This should take away using the DSM to foster religious/political objections to gender role transition as part of the treatment plan.

• GEDAD describes what the presenting individual is actually experiencing.

• GEDAD can be posted in a directory of disorders allowing National Health Service or insurance coverage without the negativity Gender Identity Disorder currently incurs.

• GEDAD does not differentiate between adults, adolescence, children, MTFs, FTMs, Intersex, androphilic or autogynephilic gender variant people.

In Conclusion-- I’ll leave you with this quote from DSM IV. “It must be noted that DSM IV reflects a consensus about the classification and diagnosis of mental disorders derived at the time of its initial publication. New knowledge generated by research or clinical experience will undoubtedly lead to an increased understanding of the disorders included in DSM IV, to the identification of new disorders, and the removal of some disorders in future classifications.” The time has come to remove Gender Identity Disorder and replace it with a new classification: Gender Expression Deprivation Anxiety Disorder.


Anne Vitale Ph.D.
P.O. Box 1023
Point Reyes Station, California 94956

email-- Contact the author ----Please use the word INQUIRY in the Subject Line to by-pass my spam filter!

Copyright, 2005 by Anne Vitale, Ph.D. Dr. Vitale is a Licensed Psychologist specializing in gender related issues. Her office is located at 610 D Street, San Rafael CA 94901, (415) 456-4452. This Note may be reprinted in any non-profit organization's newsletter if Dr. Vitale's name and address appears with it. Other publications must obtain written permission from Dr. Vitale. A copy of any reprints must be sent to Dr. Vitale.