The DSM-5 Diagnostic Criteria for Gender Dysphoria

Children

A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months’ duration, as manifested by at least six of the following (one of which must be Criterion A1):

1. A strong desire to be of the other gender or an insistence that one is the other gender (or some alternative gender different from one’s assigned gender)

2. In boys (assigned gender), a strong preference for cross-dressing or simulating female attire; or in girls (assigned gender), a strong preference for wearing only typical masculine clothing and a strong resistance to the wearing of typical feminine clothing

3. A strong preference for cross-gender roles in make-believe play or fantasy play

4. A strong preference for the toys, games, or activities stereotypically used or engaged in by the other gender

5. A strong preference for playmates of the other gender

6. In boys (assigned gender), a strong rejection of typically masculine toys, games, and activities and a strong avoidance of rough-and-tumble play; or in girls (assigned gender), a strong rejection of typically feminine toys, games, and activities

7. A strong dislike of one’s sexual anatomy

8. A strong desire for the primary and/or secondary sex characteristics that match one’s experienced gender

B. The condition is associated with clinically significant distress or impairment in social, school, or other important areas of functioning

Specify if:

With a disorder of sex development (e.g., a congenital adrenogenital disorder such as congenital adrenal hyperplasia or androgen insensitivity syndrome)

Adolescents and adults

A. 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)

B. The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning

Specify if:

With a disorder of sex development (e.g., a congenital adrenogenital disorder such as congenital adrenal hyperplasia or androgen insensitivity syndrome)

Specify if:

Posttransition: the individual has transitioned to full-time living in the desired gender (with or without legalization of gender change) and has undergone (or is preparing to have) at least one cross-sex medical procedure or treatment regimen – namely, regular cross-sex hormone treatment or gender reassignment surgery confirming the desired gender (e.g., penectomy, vaginoplasty in a natal male; mastectomy or phalloplasty in a natal female)

Note: Reprinted with the permission of the American Psychiatric Association

In contrast to DSM-IV-TR, which had two sets of clinical indicators (Criteria A and B), the symptom indicators in DSM-5 were merged into a single criterion set. The distinction in DSM-IV-TR was never supported by factor analytic studies, which all pointed to one underlying dimension [9, 15, 16].

The GD criteria for children are potentially more conservative than they were in DSM-IV-TR because the current A1 criterion (of a total of eight symptoms) is now a necessary symptom for the diagnosis (in total, 6/8 symptoms are required for the diagnosis). The A1 criterion pertains to the child’s “…strong desire to be of the other gender or an insistence that he or she is the other gender (or some alternative gender different from one’s assigned gender).” The tightening of the requirement for caseness will likely sharpen the distinction between a diagnosis of GD and normative variation.

As reviewed in Zucker [9], critics of the DSM-IV-TR diagnostic criteria were concerned that some children who showed pervasive cross-gender behavior, yet who did not express a desire to be of the other gender, might be inappropriately diagnosed with GD (false-positives). Secondary data analyses [5, 9] supported the idea that requiring the presence of a strong desire to be of the other gender, along with various surface expressions of gender incongruence, would probably raise the bar for caseness, with strong evidence for sensitivity and specificity.

For adolescents (and adults), the DSM-5 diagnostic criteria for GD moved to a more detailed polythetic format (six symptoms), replacing the somewhat sketchy criteria that were used in DSM-IV-TR. Secondary data analyses indicated that the presence of at least two indicators yielded a rate of 94.2 % sensitivity and 99.3 % specificity [5].

Whether or not individuals born with a physical intersex condition (now termed a disorder of sex development) (DSD) should be eligible for a diagnosis of GD has had a back-and-forth history since DSM-III [17]. Since the publication of DSM-IV in 1994, considerable additional evidence has accumulated that some individuals with a DSD experience GD and may wish to change their assigned gender [18, 19]. The percentage of such individuals who experience GD is syndrome dependent [20, 21]. From a phenomenological perspective, DSD individuals with GD have both similarities and differences to individuals with GD with no known DSD, and there are also similarities and differences in developmental trajectories [4, pp. 455–456]. Because the presence of a DSD is suggestive of a specific causal mechanism that may not be present in individuals without a diagnosable DSD, it was included as a specifier in DSM-5.

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