The DSM - Part II: reading the 7 versions of the DSM

Part I: history of the APA 

Part II:  reading the 7 versions of the DSM 

Part III: comments

DSM I, 1952 145 pages

There is no section for Homosexuality or anything trans.

However under *000-x50 Personality Trait Disturbance* we find:

*000-x63 Sexual deviation*

This diagnosis is reserved for deviant sexuality which is not symptomatic of more extensive syndromes, such as schizophrenic and obsessional reactions.

The term includes most of the cases formerly classed as "psychopathic personality with pathologic sexuality". The diagnosis will specify the type of the pathologic behavior, such as homosexuality, transvestism, pedophilia, fetishism and sexual sadism (including rape, sexual assault, mutilation). p38-9.

That is all. No details about Homosexuality or Transvestism.

There is no mention of Transsexualism at all - presumably transsexuals were regarded as a type of either Homosexuality or Transvestism.

DSM II, 1968 - Transvestism 136 pages

No significant change, but now recategorized:

V. Personality Disorders and Certain Other Non-Psychotic Mental Disorders

301 Personality disorders

302 Sexual Deviations

.0 Homosexuality

.1 Fetishism

.2 Pedophilia

.3 Transvestitism

.4 Exhibitionism

.5 Voyeurism

.6 Sadism

.7 Masochism

.8 Other sexual deviation

.9 Unspecified sexual deviation

303 Alcoholism

304 Drug Dependence

See p10, 44, 79

Gays and lesbians certainly objected to being bundled into this list and were agitating that the word ‘homosexuality’ be removed. This was supported by enough psychiatrists, psychologists and psychoanalysts in the younger generation, some of whom were part of the anti-psychiatry movement of the 1960s that had a wider criticism of what psychiatry had become. Homosexuality was a major topic at the 1971, 1972 and 1973 annual APA meetings. Robert Spitzer, who chaired a subcommittee looking into the issue, “reviewed the characteristics of the various mental disorders and concluded that, with the exception of homosexuality and perhaps some of the other ‘sexual deviations’, they all regularly caused subjective distress or were associated with generalized impairment in social effectiveness or functioning”. Having arrived at this novel definition of mental disorder, the Nomenclature Committee agreed that homosexuality per se was not one.

Several other APA committees and deliberative bodies then reviewed and accepted their work and recommendations. As a result, in December 1973, APA’s Board of Trustees voted to remove homosexuality from the DSM. Some psychiatrists, mainly from the psychoanalytic community, however, objected to the decision. They petitioned APA to hold a referendum asking the entire membership to vote either in support of or against the decision. The decision to remove was upheld by a 58% majority of 10,000 voting members.

A revision of DSM-II removed Homosexuality, but brought in a new diagnosis: Sexual Orientation Disturbance (SOD) for those who wanted to change.

DSM III, 1980 507 pages – Transsexuality as Gender Identity Disorder

DSM Task Force on PSYCHOSEXUAL DISORDERS

Anke A. Ehrhardt, Diane S. Fordney-Settlage, Richard Friedman, Paul Gebhard, Richard Green, Helen S. Kaplan, Judith B. Kuriansky, Harold I. Lief, Jon K. Meyer, John Money, Ethel Person, Lawrence Sharpe, Robert L. Spitzer, Robert J. Stoller, Arthur Zitrin.

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Homosexuality had been removed. Its replacement Sexual Orientation Disturbance (SOD) (where the patient wishes to be cured) was renamed Ego-Dystonic Homosexuality.

In compensation transsexualism is added in for the first time, and given the same 302 code as the Paraphilias.

For the first time the term ‘cross-dressing’ is used. It is used for both Transsexualism and Transvestism.

The section number 302 is renamed *Psychosexual Disorders*. 

The first of these is 

Gender identity disorders: p261-266

302.5x Transsexualism

302.60 Gender identity disorder of childhood

302.85 Atypical gender identity disorder

“Differential diagnosis. In effeminate homosexuality the individual displays behaviors characteristic of the opposite sex. However, such individuals have no desire to be of the other anatomic sex. In physical intersex the individual may have a disturbance in gender identity. However, the presence of abnormal sexual structures rules out the diagnosis of Transsexualism.

Other individuals with a disturbed gender identity may, in isolated periods of stress, wish to belong to the other sex and to be rid of their own genitals. In such cases the diagnosis Atypical Gender Identity Disorder should be considered, since the diagnosis of Transsexualism is made only when the disturbance has been continuous for at least two years. In Schizophrenia, there may be delusions of belonging to the other sex, but this is rare. The insistence by an indi- vidual with Transsexualism that he or she is of the other sex is, strictly speaking, not a delusion since what is invariably meant is that the individual feels like a member of the other sex rather than a true belief that he or she is a member of the other sex.”

Note that Transsexualism and Intersex are regarded as mutually exclusive categories.

The term Gender Identity Disorder (GID) was thereafter treated as a thing by many writers, mainly as a synonym for transsexualism - although GID of childhood could have been likewise treated.

The following five criteria are given for identifying a transsexual: a) Sense of discomfort and inappropriateness about one's anatomical sex. b) Wish to be rid of one's own genitals and to live as a member of the other sex. c) The disturbance has been continuous (not limited to periods of stress) for at least two years. d) Absence of physical intersex or genetic abnormality. e) Not due to another mental disorder, such as schizophrenia.' The 'x' at the end of the category code is to record prior sexual history: 1=asexual, 2=homosexual (same anatomical sex), 3=heterosexual (other anatomical sex), 0=unspecified.

Transsexualism prevalence is specified as “Apparently rare”

Children diagnosed at this time with “Gender identity disorder of childhood” were more gender non-conforming (GNC) than pre-transsexual. In practice, as would be shown in Richard Green’s The Sissy Boy Syndrome, in 1987, they were most likely to grow up to be gay. So this was in effect another residual gay category.

The Term ‘Paraphilia” to replace ‘Sexual Deviation” is introduced of which nine are listed, all with a 302 code. While Homosexuality is no longer listed, Transvestism and Fetishism remain and are discussed rather than just listed.

Fetishism (non-transvestic) has a diagnostic criterion: “The fetish objects are not limited to articles of female clothing used in cross-dressing (as in Transvestic Fetishism) or devices designed for the purpose of tactile genital stimulation (e.g., a vibrator).”

The Diagnostic Criteria for *302.30 Transvestism* (p269-270) are given as:

A. Recurrent and persistent cross-dressing by a *heterosexual male*.

B. Use of cross-dressing for the purpose of sexual excitement, at least initially in the course of the disorder.

C. Intense frustration when the cross-dressing is interfered with.

D. Does not meet the criteria for Transsexualism.

DSM III-R, 1987 598 pages

Subcommitte on Gender Identity Disorders

Anke Ehrhardt, Ethel Person, David McWhirter, Robert L. Spitzer, Heino Meyer-Bahlburg, Janet B. W. Williams, John Money, Kenneth J. Zucker.

Subcommittee on Paraphilias

Gene Abel, David Barlow, Judith Becker, Fred Berlin, Park Elliott Dietz, Raymond A. Knight, Vernon Quinsey, Robert L. Spitzer, Janet B. W. Williams.

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Ego-Dystonic Homosexuality was removed. It was obvious to psychiatrists that it was the result of earlier political compromises and that EDH did not meet the definition of a disorder in the new nosology. What about people who were ego-dystonic about their race or their height or their job?

A new section, Gender Identity Disorders in introduced separated from the Sexual Disorders section 300 pages later. However both sections continue to share the 302 code.

Gender Identity Disorders (p71-78) 

is now divided into:

302.60 Gender identity disorder of childhood

302.50 Transsexualism

302.85 Gender identity disorder of adolescence or adulthood, nontranssexual type (GIDAANT)

302.85 Gender identity disorder not otherwise specified.

Transsexualism is defined as:

A. Persistent discomfort and sense of inappropriateness about one’s assigned sex.

B. Persistent preoccupation for at least two years, with getting rid of one’s primary and secondary sex characteristics and acquiring the sex characteristics of the other sex.

C. The person has reached puberty.

Prevalence: “The estimated prevalence is one per 30,000 for males and one per 100,000 for females”. These prevalences were widely cited at the time, and occasionally are still repeated in the 2020s despite much evidence of greater frequency.

GIDAANT is defined as:

A. Persistent or recurrent discomfort and sense of inappropriateness about one's assigned sex. B. Persistent or recurrent cross-dressing in the role of the other sex, either in fantasy or actuality, but not for the purpose of sexual excitement (as in Transvestic Fetishism). C. No persistent preoccupation (for at least two years) with getting rid of one's primary and secondary sex characteristics and acquiring the sex characteristics of the other sex (as in Transsexualism). D. The person has reached puberty.

Gender identity disorder not otherwise specified is defined by examples:

(1) children with persistent cross-dressing without the other criteria for Gender Identity Disorder of Childhood (2) adults with transient, stress-related cross-dressing behavior (3) adults with the clinical features of Transsexualism of less than two years' duration (4) people who have a persistent preoccupation with castration or peotomy without a desire to acquire the sex characteristics of the other sex

Sexual Disorders: Paraphilias

Transvestism is renamed 302.30 Transvestic Fetishism (p288-289) , and is defined as:

A. Over a period of at least six months, in a heterosexual male, recurrent intense sexual urges and sexually arousing fantasies involving cross-dressing. B. The person has acted on these urges, or is markedly distressed by them. C. Does not meet the criteria for Gender Identity Disorder of Adolescence or Adulthood, Nontranssexual Type, or Transsexualism.

DSM IV, 1994 915 pages – Gender Identity Disorder

DSM Work Group for Sexual Disorders

Chester W. Schmidt, chairperson, Raul Schiavi, Leslie Schover, Taylor Seagraves, Thomas Nathan Wise

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302 Sexual and Gender Identity Disorders have now been recombined. Sexual Disfunctions is followed by Paraphilias is followed by Gender Identity Disorders. The Term ‘transsexualism’ is no longer used. The Term Gender Identity Disorder now subsumes three DSM-III-R diagnoses: Gender Identity Disorder of Childhood; Gender Identity Disorder of Adolescence or Adulthood, Nontranssexual Type (GIDAANT); and Transsexualism.

302.3 Transvestic Fetishism: (p530-531)

A. Over a period of at least 6 months, in a heterosexual male, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving cross-dressing. B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specify if: With Gender Dysphoria: if the person has persistent discomfort with gender role or identity.

Gender Identity Disorder: (p532-538)

302.6 Gender Identity Disorder in Children 302.85 Gender Identity Disorder in Adolescents or Adults

302.6 Gender Identity Disorder Not Otherwise Specified

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: 302.6 Gender Identity Disorder in Children 302.85 Gender Identity Disorder in Adolescents or Adults

302.6 Gender Identity Disorder Not Otherwise Specified

This category is included for coding disorders in gender identity that are not classifiable as a specific Gender Identity Disorder. Examples include

1. Intersex conditions (e.g., androgen insensitivity syndrome or congenital adrenal hyperplasia) and accompanying gender dysphoria

2. Transient, stress-related cross-dressing behavior

3. Persistent preoccupation with castration or penectomy without a desire to acquire the sex characteristics of the other sex

DSM-IV-TR 2000 955 pages

DSM Work Group for Sexual and Gender Identity Disorders

Chester W. Schmidt, R. Taylor Segraves, Thomas Nathan Wise, Kenneth J. Zucker .

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As in DSM-IV, sex and gender are grouped together. Sexual Disfunctions is followed by Paraphilias is followed by Gender Identity Disorders.

No significant difference from DSM-IV.

DSM-V, 2013 991 pages- Gender Dysphoria

DSM Work Group for Sexual and Gender Identity Disorders:

Kenneth J. Zucker, Chair, Lori Brotto, Text Coordinator, Martin P. Kafka, Irving M. Binik, Richard B. Krueger, Ray M. Blanchard, Niklas Langström, Peggy T. Cohen-Kettenis, Heino F.L. Meyer-Bahlburg, Jack Drescher, Friedemann Pfäfflin, Cynthia A. Graham, Robert Taylor Segraves.

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As in DSM-3-R, Gender Dysphoria and the Paraphilic Disorders are separated again (by over 200 pages).

Gender Identity Disorder (GID) is replaced by Gender Dysphoria in Adolescents and Adults, which is defined as distress related to the incongruence between assigned gender and gender identity. Gender Dysphoria in Children has more stringent requirements with behavioural criteria. These two were moved to their own section to retain access to insurance coverage rather than being removed . The new term “is more descriptive than the previous DSM-IV term gender identity disor­der and focuses on dysphoria as the clinical problem, not identity per se.”

Transvestic Fetishism has been renamed as Transvestic Disorder; Intersex has been replaced by the contentious term Disorders of Sex Development, thereby introducing another term using ‘disorder’ as it removes the term GID.

Gender Dysphoria (p451-459)

302.85 Gender Dysphoria in 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.

While in earlier versions of the DSM, one did not have GID if one were physically intersex, now the physician is merely to specify if:

“With a disorder of sex development (e.g., a congenital adrenogenital disorder such as 255.2 [E25.0] congenital adrenal hyperplasia or 259.50 [E34.50] androgen insensitivity syndrome).”

302.6 Gender Dysphoria in Children

Is very similar except that there are 8 items under A. and at least 6 must be manifested by the child.

302.3 Transvestic Disorder (p701-704)

“ Transvestic disorder occurs in heterosexual (or bisexual) adoles­cent and adult males (rarely in females) for whom cross-dressing behavior generates sex­ual excitement and causes distress and/or impairment without drawing their primary gender into question. It is occasionally accompanied by gender dysphoria. An individual with transvestic disorder who also has clinically significant gender dysphoria can be given both diagnoses. In many cases of late-onset gender dysphoria in gynephilic natal males, transvestic behavior with sexual excitement is a precursor.”

Defined as:

A. Over a period of at least 6 months, recurrent and intense sexual arousal from cross­-dressing, as manifested by fantasies, urges, or behaviors. B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impair­ment in social, occupational, or other important areas of functioning.

It is noted: “The presence of fetishism decreases the likelihood of gender dysphoria in men with trans­vestic disorder. The presence of autogynephilia increases the likelihood of gender dyspho­ria in men with transvestic disorder.” and “Transvestic disorder in men is often accompanied by autogynephilia (i.e., a male's paraphilic tendency to be sexually aroused by the thought or image of himself as a woman). Autogynephilic fantasies and behaviors may focus on the idea of exhibiting female phys­iological functions (e.g., lactation, menstruation), engaging in stereotypically feminine be­havior (e.g., knitting), or possessing female anatomy (e.g., breasts).”

Prevalence: “The prevalence of transvestic disorder is unknown. Transvestic disorder is rare in males and extremely rare in females. Fewer than 3% of males report having ever been sexually aroused by dressing in women's attire. The percentage of individuals who have cross­-dressed with sexual arousal more than once or a few times in their lifetimes would be even lower. The majority of males with transvestic disorder identify as heterosexual, although some individuals have occasional sexual interaction with other males, especially when they are cross-dressed.”

Given the DSM definition of Transvestic Disorder, this estimate of Prevalence may be too high, but of course if we consider all types of cross-dressing, it is too low.

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• Dylan Scholinski. The Last Time I Wore a Dress. Riverhead, 1998.

• Kelley Winters. Gender Madness in American Psychiatry: Essays from the struggle for Dignity. GIDReform.org, 2008.

• Susan Cooke. “Why GID Must Be Removed From the DSM”. Women Born Transsexual, September 2, 2009. Online.

• Cristan Williams. Disco Sexology. Online.

• Jack Molay. “On how American psychiatry persecutes transgender crossdreamers and crossdressers”. Crossdreamers, October 24, 2012. Online.

• Jack Drescher. "Out of DSM: Depathologizing Homosexuality”. Behavioral Sciences, 5, 4, 2015. Online.