Commentary on Kraus' (2015) "classifying intersex in DSM-5: critical reflections on gender dysphoria".

A recurrent issue in the more recent editions of the Diagnostic andStatisticalManualofMentalDisorders (DSM)oftheAmerican Psychiatric Association (APA) has been whether patientinitiated gender change and the preceding dissatisfaction with the initially assigned gender (gender dysphoria) should be included as a psychiatric diagnosis and, if yes, whether that diagnosis should be limited to such a presentation shown by persons born with a healthy reproductive system or also be applied if it is shown by persons with congenital somatic intersexuality (in the current medical nomenclature included under disorders of sex development [DSD]) (Hughes, Houk, Ahmed, Lee, & LWPES/ESPE Consensus Group, 2006). DSM-5 stipulates for the diagnosis of Gender Dysphoria (GD)‘‘Specify if: With a disorder of sex development’’ (italics and boldface removed) and adds the‘‘Coding note: Code the disorder of sex development as well as gender dysphoria’’(American Psychiatric Association, 2013, pp. 451–459). In the view of Kraus (2015), GD thereby‘‘subsumes the physical condition under themental ‘disorder’.’’Kraus sees this conceptualization as‘‘the most significant change in the revised diagnosis’’and expresses numerous misgivings. In response, as a member of the respective DSM-5 Work Group (which was dissolved with the publication of DSM-5), I want to clarify the pertinentchangesmadefromDSM-IVandDSM-IV-TR(AmericanPsychiatricAssociation,1994,2000) toDSM-5. In the interest of space, I will only address the most salient ones (for other details, see Zucker et al., 2013). (1) Kraus’ (2015) critique, which culminates in the catchy but misleading phrase,‘‘when the controversial GID diagnosis exits the DSM, disorders of sex development enter’’(p. 1154), appears to be based on a misunderstanding that is already reflected in the titleofherarticle,‘‘ClassifyingIntersex inDSM5.’’ It is not the physical condition ‘‘disorder of sex development’’ (referring here to intersexuality as illustrated by the examples given in the DSM-5 criteria table on p. 453) that is ‘‘classified in DSM-5’’ or ‘‘subsumed’’ under mental disorder. Instead, what DSM-5 categorizes here as GD is a gender identity problem occurring in a person who also has a DSD/intersexcondition,provided therespectivepsychiatric/psychologic DSM-5 criteria for GD are met. The change is not ‘‘fundamental’’as Kraus suggests, because in DSM-IV, people with what then was called‘‘Gender Identity Disorder’’(GID) in association with an intersex condition were categorized as GID Not Otherwise Specified (GIDNOS). Also GIDNOS was a psychiatric diagnosis related to gender identity, just not as stringently defined as GID. Thus, in both DSM-IV and DSM-5, the psychologic/psychiatric condition of GD was/is categorized as a psychiatric diagnosis, not the intersex condition. In this regard, DSM-5 resembles the DSM-III (APA, 1980) and DSM-III-R (APA, 1987) diagnoses of Gender Identity Disorder of Childhood (GIDC) and the DSM-III-R diagnosis of Transsexualism (in adults): they only stipulated to note‘‘physical abnormalities of the sex organs’’(with GIDC) and‘‘physical intersexuality or a genetic abnormality’’(with Transsexualism), if also present, on Axis III (Physical Disorders and Conditions, i.e., not psychiatric diagnostic categories), but not to exclude persons with the combination of GID or Transsexualism and such somatic conditions from the gender identity-related diagnoses on Axis I (Clinical [psychiatric] Syndromes and V Codes]. & Heino F. L. Meyer-Bahlburg meyerb@nyspi.columbia.edu