Gender as Illness: Issues of Psychiatric Classification

Copyright © 1997, Gender Identity Center of Colorado,Inc.

Reprinted in Taking Sides-Clashing Views on Controversial Issues in Sex and Gender,E.Paul,Ed.,Dushkin McGraw-Hill,Guilford CN,2000,pp. 31-38.

First presented at the 6th Annual ICTLEP Transgender Law and Employment Policy Conference

Houston,Texas,July 1997.

Katherine K. Wilson

Gender Identity Center of Colorado, Inc.
1455 Ammons Street, Suite 100
Lakewood, CO 80215

In our link page, we link with GIC Colorado,Inc. and


Twenty-three years after the American Psychiatric Association voted to delete homosexuality as a mental disorder, the inclusion of the diagnostic categories transvestic fetishism and gender identity disorder in the Diagnostic and Statistical Manual of Mental Disorders, or DSM, continues to raise questions of consistency, validity, and fairness. Recent revision of the DSM have made these diagnostic categories increasingly ambiguous and reflect a lack of consensus within the psychiatric profession. In this paper, issues of gender identity and expression are examined in light of current definitions of mental illness.


Mental illness in North America today is defined by the Fourth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) published by the American Psychiatric Association (1994). While homosexuality was removed as a mental disorder from the second edition of the DSM in 1973, transgender identity and expression remain in the psychiatric classification under the diagnostic codes 302.3, transvestic fetishism (TF), and 302.85, gender identity disorder (GID). Transvestism, from Latin roots meaning to wear the clothing of the opposite sex, appears in the psychiatric nomenclature since the term was coined by Magnus Hirschfeld (1910). Transsexualism, also termed by Hirschfeld (1923), first appeared in the DSM-III (1980) as a diagnostic category.

Advances in understanding cross-gender phenomena have brought changes to the DSM and controversy to the classification of gender disorders. The issues are complex. There is little question that the inclusion of gender nonconformity among psychosexual disorders worsens the burden of stigma that transgendered individuals face in society (Bolin, 1988). Yet, psychiatric classification remains the sole justification of medical necessity that is recognized by surgeons and endocrinologists who perform sexual reassignment procedures. Lacking a psychiatric diagnosis of transsexualism, or an alternative physiological diagnosis, such procedures might be less available to transsexuals.

At issue is the creeping ambiguity in defining gender disorders reflected in recent revisions of the DSM. The result is that a widening segment of gender non-conforming youth and adults are potentially subject to diagnosis of psychosexual disorder, severe stigma, and loss of civil liberty. The current diagnostic categories of transvestic fetishism and gender identity disorder may be easily interpreted to legitimize intolerance of gender diversity in the community, workplace, and courts.

In this paper, ambiguous and conflicting language in the DSM-IV and its supporting literature which serves to endorse harmful stereotypes of transgendered individuals is examined. This paper does not attempt to address the broader question of the appropriateness of classification of any gender role diversity as mental disorder.

Transvestic Fetishism, 302.3

The diagnostic criteria for transvestic fetishism (APA, 1994), formerly transvestism, are as follows:

Gender Identity Disorder of Adults, 302.85

The diagnostic criteria for gender identity disorder for adults and adolescents (APA, 1994), formerly transsexualism, are :

Gender Identity Disorder of Children, 302.85

The diagnostic criteria for gender identity disorder for children (APA, 1994) are :

Ambiguous Language

Many questions regarding the characterization of cross-gender identity and expression as mental disorders are unresolved in the mental health professions. In some instances, a lack of scientific consensus is reflected in increasingly ambiguous and conflicting language in recent revisions of the Diagnostic and Statistical Manual of Mental Disorders. The result is that a widening segment of gender non-conforming youth and adults are potentially subject to psychiatric diagnosis, severe stigma, and loss of civil liberty.

The Ambiguously Sexual Fetish

For example, criterion A of the transvestic fetishism disorder is grammatically ambiguous (Wilson & Hammond, 1996):

The description, "sexually arousing," could be interpreted to apply to only "fantasies" or to all three of "fantasies, sexual urges, or behaviors" with very different meaning. The first interpretation would implicate all recurrent cross-dressing behavior. This is consistent with the DSM-IV Casebook (Spitzer, ed., 1994, pp. 257-259), which recommends a TF diagnosis for a male whose crossdressing is not necessarily sexually motivated. The second would limit the diagnosis to only sexually motivated cross-dressing, as did the DSM-III-R (APA, 1987, p. 289), and imply the unlikely phrase, "sexually arousing sexual urges." Although labeled a "fetishism," it is not clearly stated whether or not transvestism must be sexual in nature to qualify for diagnosis. The distinction is left entirely to interpretation.

A Question of Degree

In another example, the Introduction to the DSM-IV (APA, 1994, p. xxii) states:

However, it is contradicted in the gender identity disorder section (p. 536):

The second statement implies that one may deviate from social expectation without a diagnostic label, but not too much. Conflicting language in the DSM serves the agendas of intolerant parents, relatives, and employers and their medical expert witnesses who seek to deny transgendered individuals their freedom, children and jobs.

Sexist Language

The transvestic fetishism and gender identity disorder categories contain sexist language that appears to presume the superiority or desirability of one gender role over another.

The Dress Code for Males

Criterion A of the transvestic fetishism disorder limits diagnosis to heterosexual males. Therefore, women are free to wear whatever they chose without a diagnosis of mental illness. This criterion serves to enforce a stricter standard of conformity for males than females. Its dual standard not only reflects the disparate positions that men and women hold in American society, but promotes them. The implication is that men hold more power and privilege than women, therefore biological males who emulate women are presumed irrational and mentally disordered while biological females who emulate males are not.

The Dress Code for Boys and Girls

In the case of gender non-conforming children and adolescents, the GID criteria are significantly broader in scope in the DSM-IV (APA, 1994, p. 537) than in earlier editions. Boys are once again held to a much stricter standard of conformity than girls. A preference for cross-dressing or simulating female attire meets the diagnostic criterion for boys but not for girls, who must insist on wearing only male clothing to merit diagnosis. References to "stereotypical " clothing, toys and activities of the other sex are imprecise in an American culture where much children's clothing is unisex and appropriate sex role is the subject of political debate.

Prejudicial Language

The gender disorders of the DSM-IV and its supporting publications contain wording that is insensitive to the prejudice that transgendered individuals face and, in one instance, particularly offensive.

The Label Fetish

The burden of social stigma suffered by transgendered people is worsened by medical classification (Bolin, 1988). Transvestic fetishism, in particular, is presented in a most demeaning manner. Transvestism in the DSM-III was renamed "transvestic fetishism" in the DSM-III-R (APA, 1987). This misleading label serves to sexualize a diagnosis that, as described earlier, does not clearly require a sexual context. Crossdressing by males very often represents a social expression of an inner sense of identity. In fact, the clinical literature cites many cases, considered diagnosable under transvestic fetishism, which present no sexual motivation for cross-dressing and by no means represent fetishism (Wise & Meyer, 1980). Moreover, the transvestic fetishism category is classified as a sexual paraphilia in the Sexual and Gender Identity Disorders section of the DSM-IV (APA, 1994, pp. 522-532):

This classification serves to legitimize stereotypes that unfairly associate cross-gender expression with criminal or harmful conduct.

The Fashion Plate

The DSM-IV Casebook (Spitzer, ed., 1994, pp. 257-9) presents the case of a retired male for whom a diagnosis of transvestic fetishism is recommended. The title of this section, "the Fashion Plate," is remarkably offensive and demeaning. It serves to ridicule an entire class of gender nonconforming males who have come to rely on the medical professions for understanding and compassion.

Clinical Significance Confusion

The focus of psychiatric classification in the early 1970s shifted from cause to consequence. Thomas Sasz's (1961) broad criticism of psychiatric nosology had a profound influence on the deletion of homosexuality from the DSM and later changes in the definition of mental illness (Zucker, 1995; Bayer, 1981). Consequently, distress and impairment became central to the definition of mental disorder in the DSM-IV (APA, 1994, p. xxi). A clinical significance criterion was added to all Sexual and Gender Identity disorders, including transvestic fetishism and gender identity disorder:

A Distressing Lack of Consensus

Distress and impairment are not specifically defined for transgendered people in the DSM-IV. They are left to the interpretation of the reader. Tolerant clinicians may infer that transgender identity or expression is not inherently impairing, but that societal intolerance and prejudice are to blame for the distress and internalized shame that transpeople often suffer (Brown, 1995). Intolerant clinicians may infer the opposite: that cross-gender identity or expression by definition constitutes an impairment regardless of the individual's happiness or well-being.

Both views are unfortunately justified by the current wording of the DSM-I and were not resolved within the APA when the criteria were written (Zucker & Blanchard, 1995). As a case in point, Zucker and others have pointed out that an identical clinical significance criterion to the pedophilia disorder could be interpreted to exclude ego syntonic (self-accepting) child molesters from diagnosis. The APA emphatically denied this, stating that pedophilia "by definition constitutes impairment" (APA, 1996). Clearly, the present GID and TF diagnoses may just as easily be interpreted to constitute impairment by definition and to implicate all transgendered individuals.

Views of inherent impairment and distress in transvestism and transsexualism rest on two threads, deviance from presumptions of biological function and association with other psychopathology (Wilson, 1997). These same arguments supported the pathologization of homosexuality before 1973, when they were rejected by the psychiatric community. They were based on studies of clinical subjects who did not constitute a representative gay, lesbian and bisexual population (Hooker, 1957), and failed to explain the existence of healthy constructive gays, lesbians and bisexuals in society (APA, 1980).

Rebuttals to theories of inherent transgender distress and impairment closely parallel those in the case of sexual orientation. Beginning with Ford and Beach (1951), anthropological research has revealed a long list of supernumerary gender roles among many non-European cultures (Bolin, 1987; Bullough, 1993; Williams, 1986). These were accepted, often highly respected, societal roles difficult to characterize as pathological. The medical presumption of gender essentialism, exactly two natural sexes determined by genitalia, has been challenged by a growing body of socio-cultural literature that considers gender a social construction, not a biological imperative (DeBeauvior, 1952; Kessler, 1978; Butler, 1990; Garber, 1992; Lorber, 1994). Psychiatric studies of clinical populations, like those of clinical gay and lesbian subjects in previous decades, have failed to consider the incidence of functional, well adjusted transgendered people and couples in society (Wilson, 1997).

Nevertheless, proponents of inherent transgender impairment dismiss the clinical significance criterion as "muddled" and having little import,

Blaming the Victim

Transgendered people do suffer distress and impairment from societal intolerance, discrimination, violence, undeserved shame, and denial of personal freedoms that ordinary men and women take for granted. The psychiatric interpretation of inherent transgender pathology serves to attribute the consequences of prejudice to its victims, neglecting the true cause of distress. It promotes treatment paradigms that are punitive rather than affirmative with the goal of conformity and not self-acceptance.

In stark contrast, the APA has articulated a growing compassion and understanding of the issues faced by gays, lesbians and bisexuals. An amicus brief filed by the American Psychological Association, the American Psychological Association, the National Association of Social Workers and the Colorado Psychological Association in the case of Romer vs. Evans (APA, et al., 1994) states the following:

Clearly, the American Psychiatric Association does not consider such distress symptomatic of mental disorder for gay and lesbian people as it does for transgendered people. Ironically, the same document acknowledges that gay and transgendered individuals face much the same discrimination: "Both gay men and lesbians are often associated with cross-sex characteristics."

A key point in the declassification of sexual orientation as a mental disorder was the distinction between distress or impairment caused by society and that believed inherent to homosexuality itself. It is unfortunate that, over two decades later, this distinction is left unresolved for the transgender disorders in the DSM-IV.

The Disordered Childhood

As stated previously, the diagnostic criteria for gender identity disorder of children were significantly broadened the DSM-IV (APA, 1994, p. 537) to the concern of civil rights advocates. A child may now be diagnosed with gender identity disorder without ever having stated any desire to be, or insistence of being, the other sex. Boys are inexplicably held to a much stricter standard of conformity than girls in their choice of clothing and activities. More puzzling is a criterion which lists a "strong preference for playmates of the other sex" as symptomatic, and seems to equate mental health with sexual discrimination.

The Prehomosexual Agenda

Author Phyllis Burke (1996) describes cases of children as young as age three institutionalized or treated with a diagnosis of gender identity disorder for widely varying gender nonconformity. She presents evidence of increasing use of GID for children suspected of being "prehomosexual," and not necessarily transsexual. Diagnosis and treatment is often at the insistence of non-accepting parents with the intent of changing a perceived homosexual orientation. Burke quotes Kenneth Zucker, of the GID subcommittee, that parents bring children to gender clinics for the most part "because they don't want their kid to be gay" (p. 100).

Zucker and Bradley (1995, p. 53) noted that "homosexuality is the most common postpubertal psychosexual outcome for children [with GID]." They defended the treatment of gender nonconforming children on three points: reduction of social ostracism, treatment of underlying psychopathology, and prevention of GID in adulthood (pp. 266-7). The first appears to shift the blame for the distress of discrimination from its inflictors to its victims. The second presumes theories of psychodynamic etiology which lack evidence in nonclinical populations (Wilson, 1997). With respect to the third, the authors conceded that,

This use of Gender Identity Disorder for children and youth was recently condemned by the National Gay and Lesbian Task Force (originally the National Gay Task Force, founded in 1973 to lobby against inclusion of homosexuality in the DSM-II, Lobel, 1996) and the San Francisco Human Rights Commission (1996) :

Far from promoting consistency in diagnosis and treatment, ambiguous and conflicting language in the DSM-IV has created much confusion and controversy. Interpretation of the Gender Identity Disorder and Transvestic Fetishism diagnostic criteria may range from a narrow definition of objective distress to an overinclusive loophole to the American Psychiatric Association decision to declassify homosexuality as a mental disorder.

Transsexualism Diluted

For sex reassignment procedures (SRS), the Standards of Care for the Hormonal and Surgical Sex Reassignment of Gender Dysphoric Persons, from the Harry Benjamin International Gender Dysphoria Association (1990), specifically require a diagnosis of transsexualism as listed in the DSM-III-R The rationale is that cross-gender identity is legitimized by psychiatric classification as a condition worthy of evaluation and treatment (Pauly, 1992; Bolin, 1988). By implication, SRS procedures might cease to be offered to transsexuals without a diagnosis to validate their medical necessity and justify their risks.

This rationale is inconsistent with the APA's decision to merge the DSM-III-R categories of transsexualism and gender identity disorder of adolescence or adulthood, nontranssexual type (GIDAANT) in the DSM-IV:

Curiously, the Harry Benjamin standards of care have not been revised since the publication of the DSM-IV or reconciled with its broader definition of gender identity disorder. If gender identity and not sexual orientation is defined as a mental illness for the purpose of legitimizing surgical and hormonal procedures, then two questions emerge: Why was GID expressly uncoupled from SRS approval criteria, and what is the purpose of diagnosing those who live in a cross-gendered role without surgery?

The Unmarked Exit

Transsexuals who openly face stigma and discrimination every day are poorly served by the DSM-IV. The label of psychiatric disorder burdens them to continually prove their mental competence. Fraught with murky and ambiguous language, gender identity disorder has failed to provide a compelling "medical necessity" for many hospitals and nearly all US insurers, who have dropped SRS procedures and coverage. Moreover, the current wording has no clear exit clause for post-operative transsexuals. It lists postsurgical complications as "associated physical examination findings" of individuals with GID (APA, 1994, p. 535).


American psychiatric perceptions of transgendered people are remarkably parallel to those for gay and lesbian people before the declassification of homosexuality as a mental disorder in 1973. The present diagnostic categories of gender identity disorder and transvestic fetishism, like homosexuality in past decades, may or may not meet current definitions of psychiatric disorder depending on subjective assumptions regarding "normal" sex and gender role and the distress of societal prejudice. Recent revisions of the Diagnostic and Statistical Manual of Mental Disorders have made these categories increasingly ambiguous and reflect a lack of consensus within the American Psychiatric Association. The result is that a widening segment of gender non-conforming youth and adults are potentially subject to diagnosis of psychosexual disorder, stigma and loss of civil liberty. Revising these diagnostic categories will not eliminate transgender stigma but may reduce its legitimacy, just as DSM reform did for homophobia in the 1970s. It is possible to define a diagnosis that specifically addresses the needs of transsexuals requiring medical sex reassignment, with criteria that are clearly and appropriately inclusive. It is time for the transgendered community to engage the psychiatric profession in a dialogue that promotes medical and public policies which, above all, do no harm to those they are intended to help.

References and Reading List

American Psychological Association, American Psychiatric Association, National Association of Social Workers, Inc., Colorado Psychological Association (October, 1994), Amicus brief in case of Romer vs. Evans, et al., United State Supreme Court, No 94-1039. [Online] Available:

American Psychiatric Association (1980). Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Washington, D.C.: Author.

American Psychiatric Association (1987). Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised, Washington, D.C.: Author.

American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Washington, D.C.: Author .

American Psychiatric Association (1996). "DSM-IV Questions and Answers." [On-line]. Available:

Bayer, R. (1981). Homosexuality and American Psychiatry, The Politics of Diagnosis. Princeton: Princeton University Press.

Bolin, A. (1987). "Transsexualism and the Limits of Traditional Analysis," American Behavioral Scientist, Vol. 31, No. 1, Sept. 1987, pp. 41-65.

Bolin, A. (1988) In Search of Eve, South Hadley MA:Bergin & Garvey.

Bradley, S., et al. (1991). "Interim Report of the DSM-IV Subcommittee on Gender Identity Disorders," Archives of Sexual Behavior, Vol. 20, 1991, No. 4, pp. 333-343.

Brown G. (1995). "Cross-dressing Men Often Lead Double Lives." The Menninger Letter. April 1995. pp. 4-5.

Bullough V. and Bollough, B. (1983). Cross Dressing, Sex, and Gender, University of Pennsylvania Press.

Burke, P. (1996). Gender Shock, Exploding the Myths of Male and Female, New York: Anchor Books.

Butler, J. (1990). Gender Trouble, Feminism and the Subversion of Identity, New York: Routledge, Chapman & Hall.

DeBeauvior, S. (1952). The Second Sex, NewYork:Alfred Knopf.

Ford, C. and Beach, F. (1951). Patterns of Sexual Behavior. New York: Harper and Brothers.

Garber, M. (1992). Vested Interests, Cross-Dressing and Cultural Anxiety, New York: Harper-Collins.

Harry Benjamin International Gender Dysphoria Association, Inc. (1990). Standards of Care for The Hormonal and Surgical Sex Reassignment of Gender Dysphoric Persons. Stanford, CA: Author.

Hirschfeld, M. (1910). Die Transvestiten. Leipzig: Max Spohr. English translation: Lombardi-Nash, M. (1991) Transvestites. New York: Prometheus Books.

Hirschfeld, M (1923). Die Intersexuelle Konstitution. Jahrbuch fur Sexuelle Zwischenstufen, 23, 3-27.

Hooker, E. (1956) "A Preliminary Analysis of Group Behavior of Homosexuals." Journal of Psychology. #41, p. 219.

Hooker, E. (1957). "The Adjustment of the Male Overt Homosexual," Journal of Projective Techniques, #21, p.18.

Kessler S. and McKenna, W. (1978). Gender: An Ethnomethodological Approach, New York: John Wiley.

Lobel, K. (1996) "NGLTF Statement on Gender Identity Disorder and Transgender People," Washington D. C.: National Gay and Lesbian Task Force. [Online] Available:

Lorber, J. (1994). Paradoxes of Gender, Yale University.

Pauly, I. (1992). "Terminology and Classification of Gender Identity Disorders," Interdisciplinary Approaches in Clinical Management, New York: Haworth Press.

San Francisco Human Rights Commission (1996). "Resolution Condemning the Use of Gender Identity Disorder Diagnosis Against Children and Youth," San Francisco: Author.

Spitzer, R., editor (1994) DSM-IV Casebook, A Learning Companion to the Diagnostic and Statistical Manual of Mental Disorders (fourth edition). Washington D. C.:American Psychiatric Press, Author.

Szasz, T. (1961). The Myth of Mental Illness. New York: Hoeber-Harper.

Williams, W. (1986). The Spirit and the Flesh: Sexual Diversity in American Indian Culture. Boston: Beacon Press.

Wilson, K. and Hammond, B. (1996, March). "Myth, Stereotype, and Cross-Gender Identity in the DSM-IV." Association for Women in Psychology, 21st Annual Feminist Psychology Conference, Portland OR. [Online] Available:

Wilson, K. (1997, April). "The Disparate Classification of Gender and Sexual Orientation in American Psychiatry," Psychiatry On-Line, [Online] Available: and

Wise, T., and Meyer, J. (1980). "The Border Area Between Transvestism and Gender Dysphoria: Transvestic Applicants for Sex Reassignment," Archives of Sexual Behavior, Vol. 9, pp. 327-342.

Zucker, K. and Blanchard, R. (1995) ."Transvestic Fetishism: Psychopathology and Theory," in Laws, D. and O'Donohue, W. (Eds.), Handbook of Sexual Deviance: Theory and Application, Guilford Press, New York, in press.

Zucker, K. and Bradley, S. (1995). Gender Identity Disorder and Psychosexual Problems in Children and Adolescents, New York: Guilford Press.


(1) Correspondence may be addressed to the author at the Gender Identity Center of Colorado, P.O. Box 480085, Denver CO, 80248-0085 or by email to

(2) This reasoning is curiously reminiscent of Alice's experience in Wonderland:

(Charles Dodgson {Lewis Caroll}, Alice's Adventures in Wonderland, 1865)