Transition from gender identity disorder to gender dysphoria
Katsuki Harima:transition from gender identity disorder to gender dysphoria.
Journal of Japanese Association of Psychiatric Hospitals.2016.vol35.p29-31.

Transition from Gender Identity Disorder to Gender Dysphoria

Katsuki Harima
Harima Mental Clinic, Tokyo

Key words: gender identity disorder, gender dysphoria, transgender, depathologiation

The 5th edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was published by the American Psychiatric Association (APA) in 2013, replacing the 4th edition (DSM-IV-TR) (APA, 2013). The diagnostic term “Gender Identity Disorder” received a new name “Gender Dysphoria” in the DSM-5, and the new term was translated to “Seibetsu iwa” in Japanese. Not only the name of the disease but also its diagnostic criteria were substantially changed accordingly. These changes reflect recent controversies in the medical community and among transgender advocates. In this article, the controversies and major changes are described as well as their impact on Japan.

History of controversies
1. Evolution of transgender concept
The term “transsexual” had been used as a medical concept since the early 1900s, when seeking sex reassignment was recognized as a medical concept. “Gender Identity Disorder” has been officially used since the third edition of DSM (DSM-III) issued in 1980.
In contrast to the term that the medical community named and conceptualized, transgender individuals and advocates named, conceptualized, and developed the term “transgender.” In the United States, people who were uncomfortable with their birth gender, and Virginia Prince, the leader of a transgender community, proposed the term “transgenderism” as describing “people who live as full-time opposite gender, but have no intention of having genital surgery” at the end of the 1980s. This term was widely used as “transgender” in the 1990s. Now it is becoming a comprehensive term that includes all those excluded from traditional sexual concept, beyond the original narrow sense.
First, the evolution of the concept of transgender represents the reality that “there are wide variations in gender conditions beyond traditional gender concepts and those who want such conditions” rather than the stereotypical understanding that “people with gender identity disorder want physical transformation as much as possible, such as genital surgery.” Second, depathologiatzing transgender individuals occurred when they promoted the use of the term “transgender” rather than traditional diagnostic terms such as “transsexual” and “gender identity disorder.” Third, as a result of integration of the first and second outcomes, the new concept did not categorize transgender individuals who did not want surgery as “failures with gender identity disorder who did not undergo gender surgery,” but helps them to establish a unique gender identity.

2. Movement toward depathologiation
Gender identity disorder has been categorized as a disease in the DSM. Since the evolution of transgender concept, however, removing it from the classification of mental disorders has been proposed based on the idea that “atypical genders are forms of sexualities and it is wrong to categorize minorities as having a mental disorder.” This debate resembles the history of another sexual minority, homosexuals: from being immoral according to in Christian beliefs before the year 1900, to being classified as having a mental disease after the 1900s, followed by experiencing psychological difficulties because of prolonged suffering in 1980s (ego-dystonic homosexuality) to being normalized in terms of their sexuality and later removal from the mental disorder category. Similar to homosexuality, gender identity disorder began as being considered immoral at the beginning of the year 1900, and became a medical disease called “transsexualism.” The DSM-IV issued in 1994 had a new diagnostic criterion, Criterion D, “The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.” This situation is similar to that of homosexuality, which temporarily remained as a mental disorder as ego-dystonic homosexuality. From the same historical perspective as homosexuality, it is understandable that the classification of gender identity disorder is eliminated from the category of mental disorders.
Unlike homosexual individuals, however, many transgender individuals seek medical treatment including hormone treatment and surgery. Some people insisted that gender identity disorder should be a medical disease to classify subjects for medical treatment or practical reasons such as insurance coverage.

3. “Gender Dysphoria” in DSM-5
The topic of handling gender identity disorder in the diagnostic list of mental disorders gained attention amidst the debate of “depathologiation” vs. “retention as a disease.” As a result, the DSM-5 issued by the APA in 2013 retained the diagnostic name by replacing “Gender Identity Disorder” with “Gender Dysphoria.” Although it remained in the diagnostic list, the old name “Gender Identity Disorder” was abolished.

Major changes
The major changes in the DSM-5 and the backgrounds are described below.
1. Change of diagnostic term
First, it should be noted that the diagnostic term “Gender Identity Disorder” was changed to “Gender Dysphoria.” There was dissatisfaction about the diagnostic term “Gender Identity Disorder” among transgender individuals. “Gender Identity Disorder (Sei douitsu shogai)” represents disorder of gender identity but they did not believe that they had the disorder. “Sei douitsu” or “Sei jinin” is the Japanese translation of gender identity. Having a disorder of gender identity implies wrongly identifying own gender. However, transgender individuals do not feel that they have wrong gender identification, but that their “physical gender” is wrong. Consequently, “Gender Incongruence” was proposed in the draft of DSM-5. This term, however, was not familiar and therefore, “Gender Dysphoria” which has been used, was accepted. “Gender Dysphoria” means “distress with a marked incongruence between one’s experienced/expressed gender and assigned gender.”
2. Replacing the term “sex” with the new term “assigned gender”
The term “sex” expressing the difference in biological sex used in the DSM-IV-TR was replaced with “assigned gender” in the DSM-5. Biological sexual elements (e.g., 46XY chromosome) are sometimes inconsistent with other elements (e.g., external genitals). Therefore, the use of the term “sex” may cause confusion. “Assigned gender” refers to the male or female gender assigned by midwife/physician or others at birth.
3. Incorporating disorders of sex development
The description that “the disturbance is not concurrent with a physical intersex condition” was removed from the new diagnostic criteria, and it was proposed that disorders of sex development should also be described. The DSM-5 has the concept of disease that may include disorders of sex development. It was difficult to diagnose the patient with disorder of sex development and gender dysphoria, but such a differentiation is no longer needed in the DSM-5.
4. Free from the dichotomy between male and female
The DSM-IV-TR described sex as male or female. The DSM-5, however, has a new description: “the other gender (or some alternative gender different from one’s assigned gender).” Gender other than the opposite gender is included in DSM-5. In fact, when transgender individuals were asked about their gender, they replied in a variety of ways: “I am neither male nor female;” “I am the third gender;” and “I am in-between male and female.” Since the DSM-IV-TR assumed only male or female as categories, it was difficult to diagnose those who were neither of them. The DSM-5 includes various genders beyond male or female.
5. Change in the Diagnostic Criterion D
Criterion D which states that “The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning” in the DSM-IV-TR remains as the Diagnostic Criterion B with the similar description in the DSM-5; however, the wording was slightly changed.
First, the term “disturbance” was changed to “condition.” The term “disturbance” was avoided and a more neutral term “condition” was used instead, according to the movement of depathologiation.
Additionally, the term “cause” was changed to “is associated with.” The term “cause” suggests significant distress underlying the disease but the expression “is associated with” suggests including external factors such as social stigma and discrimination.
6. Elimination of subtyping on the basis of sexual orientation
The subtyping on the basis of sexual orientation in the DSM-IV-TR was eliminated.
Sexual orientation itself does not significantly affect clinical decisions. On the other hand, transgender individuals may provide inaccurate information to the physician because they may believe that they need to pretend to be a typical patient to receive hormone treatment or surgery. For example, those who want to become female from male may report that they are attracted to males even though they are sexually attracted to females. Consequently, it is difficult to accurately subtype their sexual orientation.
Recently, it is also known that sexual orientation for acquiring a sexual partner can be changed during or after treatment. For example, a male who once liked females now likes males more when he became feminine from being masculine. This causes the subtyping to be inaccurate and variable.
7. Summary
Major changes in the DSM-5 in the concept of gender are summarized in this article. Overall, it has a very wide implication:
・Physical gender includes not only typical male and female categories, but also disorders of sex development.
・Psychological gender also includes categories other than the typical male and female ones.
These are almost consistent with the transgender concept. Gender identity disorder and transsexuality are included in the medical concept that someone wants to convert to the opposite sex as much as possible through hormone treatment or surgery.
In contrast, the transgender concept represents various atypical genders beyond the medical concept. It may not necessarily be pathological. In the DSM-5, however, gender identity disorder was termed as “Gender Dysphoria,” which is closer to the transgender concept. In this regard, the traditional concept of gender identity disorder moves closer to the transgender concept. From a different perspective, it seems ironic that the diverse gender conditions, which were not recognized as pathological, are now incorporated into the medical diseases.

Conclusion – Response in Japan and ICD-11 trend
Gender identity disorder is the name of disease which has finally taken root in Japan in the last decade or so. It is widely used, including the field of law. In addition, it is not associated with discrimination or labeling at this moment. Therefore, many healthcare providers in Japan are reluctant to change the name. In Japan, the expansion of medical understanding of gender identity disorder has helped the understanding of treatment and some progress in legal contexts and protection of human rights, including the change of the sex registration in the last decade or so. “Respect for diversity” is difficult to be penetrated into the Japanese culture in which the family system and homogeneocity are valued. In this regard, I feel that many healthcare providers and transgender individuals prefer to continue to use gender identity disorder implying psychopathological conditions rather than gender dysphoria incorporating various genders.
However, it would be strange if the outdated name of the disease is still used only in Japan. Despite the strong influence, the DSM is a local diagnostic criteria set by “American” “psychiatrists.” From the perspective of more global diagnostic criteria, we should comply with the International Classification of Diseases (ICD). The ICD is under revision, and gender identity disorder will also be revised in the new edition, ICD-11. Reportedly, gender identity disorder will be removed from the mental disorder codes, and placed under the third group, “conditions related to sexual health” with sexual dysfunction. Gender identity disorder will be no longer a mental disorder. “Gender Incongruence” is a candidate for the new name of the disease. Gender incongruence implies sexual incongruity, and is different from gender dysphoria. The DSM-5 and ICD-11 have differing views regarding it being a mental disorder or not, and being termed as gender dysphoria or gender incongruence. In this sense, global controversies may continue.
In Japan, many people supported gender identity disorder as a pathological concept while few supported the concept of transgender depathologiation. From the international perspective, it was a rare phenomenon, but transgenderism has begun to be spread along with the LGBT movement since 2015. Since LGB stands for lesbians, bisexuals, and gays, as minorities in sexual orientation, they are different from transgender individuals. It is necessary to observe these movements in Japan.