Is Gender Dysphoria a Mental Disorder?

What is a mental illness? The most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the manual that aids many psychologists in diagnosis, states that part of the qualification of a mental disorder is for it to cause a “clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior” (DSM-5). If there is distress, noted as particularly important for the diagnosis, is a person who identifies with a gender other than the one they were assigned at birth experiencing a mental disorder? Does your opinion change knowing that the DSM-5 carries on to mention that a mental disorder may involve “a significantly increased risk of suffering death, pain, disability, or an important loss of freedom” (DSM-5)? Individuals with gender dysphoria may experience not only a loss of freedom, but also an increased risk of death due to a greater likelihood of committing suicide (see hyperlink above).

Now, to further complicate the issue, how does this effect our thinking about individuals who are born with female-looking genitalia and are assigned with a female gender identity at birth, but are genetically male? This is the case for individuals with with 5α-reductase-2 deficiency. The condition occurs when 5α-reductase-2 does not convert testosterone into dihydrotesosterone, which is involved in the development of male genitalia. The diagram below illustrates typical mammalian sex determination and development of male and female adult phenotypes:

Fifty-six to sixty-three percent of individuals with 5α-reductase-2 deficiency undergo gender role changes (Cohen-Kettenis, 2005). Are these individuals suffering from a mental disorder? My first instinct, because of the negative connotation of the word disorder, was to say no. To answer this question considering the existing research, let us look at the DSM-5 definition of Gender Dysphoria, the diagnosis most relevant to this issue. For adolescents and adults, this definition begins with “a marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months’ duration” (DSM-5). The DSM-5 carries on to state that the individual must express 2 out of 6 certain characteristics, such as “a strong conviction that one has the typical feelings and reactions of the other gender”. Notably, the manual proceeds: “Specify if: with a disorder of sex development (e.g., a congenital adrenogenital disorder…)” (DSM-5). Should this include those with 5α-reductase-2 deficiency?

If all of these individuals did undergo a gender identity switch we could postulate that the female gender assignment was a mistake and thus none of them have any sort of mental disorder. However, how can we make sense of the estimation that 36-44% of these individuals do not switch their gender identities from female to male? Are about half of these individuals experiencing Gender Dysphoria, and if so, which half? In addition, is it fair to say that someone has a mental disorder if the biological procedure of gender reassignment can essentially “fix” it? Perhaps the individuals who do not switch their gender identities from female to male do not have a disorder because they are at peace with their condition; individuals who do switch may be at peace as well, as they finally are able to live in the bodies they always wanted.

            I want to be very clear that I am not trying to make a radical statement that individuals with Gender Dysphoria may have a disorder, but simply to ask if this is what the DSM-5 is suggesting. Is the inclusion of Gender Dysphoria in the DSM-5 helpful, or does it fuel avoidable controversy?

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

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

Pappas, S. (2012). Mental health problems plague transgender kids. Retrevied from http://www.livescience.com/16110-transgender-teen-mental-health.html.

Pappas, S. (2011). Top 10 controversial psychiatric disorders. Retrieved from http://www.livescience.com/12908-top-10-controversial-psychiatric-disorders.html.

Sex determination in mammals is a process [image]. Retrieved 8 October, 2014, from: http://kcampbell.bio.umb.edu/MamTox/Presentations/Session13/Session13.html