Sexual Orientation and Gender Identity Change Efforts, Part 4: The Diagnostic Problem

Sexual Orientation and Gender Identity Change Efforts, Part 4: The Diagnostic Problem
August 30, 2021

This blog series is drawing from the research paper: “The Problems with Correlating Sexual Orientation Change Efforts and Gender Identity Change Efforts,” available for free here. Written by Drs. Paul Eddy and Preston Sprinkle.

Sexual Orientation Change Efforts (SOCE) and so-called Gender Identity Change Efforts (GICE) might overlap in some ways, as I pointed out in the first post, but they present many other differences, which we looked at in the previous two posts. In our second post, we looked at the language problem inherent in correlating SOCE and GICE, and then in our third post, we looked at the ontological problem. In this fourth post, I want us to consider areas of difference between SOCE and GICE that constitute what I call the diagnostic problem.


Put simply: gender dysphoria is listed in the DSM-5 as a diagnosable mental condition while homosexuality is not.[1] Richard Green, a lawyer and one of the most experienced researchers in the area of childhood gender dysphoria, draws attention to these diagnostic differences:  


Whereas homosexuality per se was dropped by the APA as a disorder in 1973, in 1980, gender identity disorder was added…gender dysphoria remains in the current DSM (Fifth Edition). Therefore, the argument against attempting to modify sexual orientation because it is not a disorder is not symmetrical with attempts to modify or treat gender dysphoria.


Green goes on to question the conflation of SOCE and GICE in recent legislative bans on conversion therapy: “recent legislation with its conflation of sexual orientation and gender identity remains psychologically incoherent.[2]

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There are some, of course, who would love to see gender dysphoria removed from the DSM altogether. They say that trans*-related diagnosis should never have been placed in the DSM to begin with and should be removed as soon as possible. Anything less is seen a direct assault on the depathologization of trans* people.[3]


However, not everyone within the trans* community supports the removal of GD from the DSM. In fact, it was a sector of the trans* community and their allies who were putting pressure on the psychiatric powers-that-be to add a trans*-related diagnosis into the DSMin the first place.[4] And many within the trans* community today continue to argue that retaining a trans* related diagnosis in the DSM is important. In a cross-cultural survey of 201 organizations dedicate to the well-being of transgender people—representing perspectives from North America, Latin America, Europe, Africa, Asia, and Oceana—55.8% stated that trans-related diagnoses should be removed from the DSM. This means that 44.2% believed that a diagnosis should be retained. For those defending retention, the primary reason was “healthcare reimbursement.”[5]


And that’s the sticking point in this debate: In the world of medical insurance, diagnostic codes are required for such things as indicating diagnoses and treatments, and—importantly—determining financial costs, insurance coverage, and reimbursements. This means that removing trans*-related diagnostic codes from the DSM could threaten the ability of trans* people to submit valid insurance claims for coverage of medical transition-related costs. In light of this, one could argue that trans* people don’t actually see gender dysphoria as a mental disorder; they simply need it to be viewed as such in order to get insurance coverage for surgeries.


But there’s another sticking point has to do with the depathologization of trans* people mentioned above. Some believe that listing gender dysphoria in the Diagnostic and Statistical Manual of Mental Disorders paints trans* people with the stigma of being mentally ill. This concern, though, has its own catch-22: reducing trans*-related stigma (by removing GD from the DSM) comes at the expense of “the perpetuation of existing stigma and prejudices against the mentally ill.”[6] In other words, the more that trans* activists and allies strive to legitimate trans* experience by distancing it from mental illness, the more they inadvertently stigmatizes and marginalizes people with mental illnesses.


It's beyond the scope of our blog series to sort all this out. Obviously, the removal vs. retention debate is complex and comes with potentially significant ramifications either way. Our point is simply what we noted at the beginning: gender dysphoria is listed in the DSM as a mental disorder while homosexuality is not. This indicates that SOCE are attempting to treat something that, from a psychological standpoint, needs no treatment. But gender dysphoria does need treatment. Labeling such treatment as GICE—the assumed cousin of SOCE—confuses the issue and helps no one.


Some will say, though, that the only reason trans* people are distressed and have dysphoria is due lack of societal acceptance. It’s our transphobic society that causes someone to even have gender dysphoria.


This is a reasonable line of thinking, but fails to appreciate the inherently distressing nature of gender dysphoria itself.



Gender Dysphoria Is Inherently Distressing


Both gay and trans* people might experience a kind of stress from living in a homophobic and transphobic society. Scholars have developed what’s called the Minority Stress Model for making sense of this socially induced stress. The data shows that the MSM is able to explain a good deal of the mental and emotional distress and illness experienced by sexual minority populations.[7] When applied to sexual orientation, the MSM argument is pretty straightforward: If we rid the culture of all social stigma and pathologization concerning homosexuality and bisexuality, and if all same-sex relationships were accepted and celebrated in the way that heterosexual relationships are today, then LGB people would not have any higher rates of mental health problems than any other sector of the populace. Take away the socially induced minority stress, then you take away all distress that comes with being same-sex attracted.


However, can this same logic be applied to trans* experiences? Certainly the answer is, in part, yes. Whatever minority stress that gay people experience will also be experienced by trans* people. But the MSM doesn’t explain another feature of trans* experiences: the mere experience of gender incongruence/dysphoria itself is distressing.


A research team led by M. Paz Galupo has recognized that lack of social acceptance (the MSM) is not the only cause of distress.[8] Gender dysphoria is itself inherently distressing, apart from social factors. How did they discover this? They listened to actual trans* people. Another research team did the same. They listened to trans* people describe the inherent distress they experience, apart from any clear social factors. For instance:


Have you ever tried putting together a puzzle and attempted to shove a piece in that doesn’t fit? . . . So now imagine that your body is the puzzle and almost none of the pieces fit together no matter how hard you press or how many different combinations you try. That’s what gender dysphoria feels like to me. (24-year-old Afro-Indigenous transgender man)[9]


Seeing genitalia that does not match my gender identity beats me down. A painful war between my mind and body goes on [Hispanic trans man, age 18][10]


Something is always missing, or something ever feels right . . . . I’m a Lego set that came with the wrong pieces. I do not feel real. I do not want to be what I am. (18-year-old White transgender woman).[11]


being trapped in the rotting carcass of some stage creature (37-year-old transgender woman).[12]


It feels like a knife in me (18-year-old nonbinary participant).


. . . excruciatingly painful. That is all I can say . . . . [l]ike I’m being tortured in my own body, every day. As if there is no end to my suffering [20-year-old White transgender man][13]



Gay people don’t describe their sexual orientation in this way. Whatever shame or distress they experience is due solely to social factors. Trans* people (who have gender dysphoria) experience both—social stress and the inherent suffering that comes with gender dysphoria.


This brings us back to our main point: no “change” is needed for gay people, even if some aspects of society should change. But there is a change that gender dysphoric people want—the reduction or elimination of their dysphoria. And this is why correlating SOCE with GICE is misinformed and can lead to the kind of harm some people say they’re trying to combat. By scaring off therapeutic care with warnings of SOCE, people with gender dysphoria are unable to explore less invasive ways of treating their dysphoria.  



[1] For a helpful survey of the history and evolution of gender identity-related diagnoses in both the DSM and the ICD, see Jack Drescher, “Gender Identity Diagnoses: History and Controversies,” in Kreukels, Steensma, and de Vries, eds., Gender Dysphoria and Disorders of Sex Development, 137-50 (see esp. 140-44).

[2] Richard Green, “Banning Therapy to Change Sexual Orientation or Gender Identity in Patients Under 18,” Journal of the American Academy of Psychiatry Law 45/1 (2017), 7–11 (here p. 8, 10).

[3] Robert D. Davies and Madeline D. Davies, “The (Slow) Depathologizing of Gender Incongruence,” Journal of Nervous and Mental Disease 208/2 (2020), 152-54.

[4] See Friedemann Pfäfflin, “Identity: A Historical and Political Reflection,” in Kreukels, Steensma, and de Vries, eds., Gender Dysphoria and Disorders of Sex Development, 131-46

[5] S. R. Vance, P. T. Cohen-Kettenis, J. Drescher, H. F. L. Meyer-Bahlburg, F. Pfäfflin, and K. J. Zucker, “Opinions about the DSM Gender Identity Diagnosis: Results from an International Survey Administered to Organizations Concerned with the Welfare of Transgender People,” International Journal of Transgenderism 12/1 (2010), 1-24. E.g., C. Richards, J. Arcelus, J. Barrett, W. Pierre Bouman, P. Lenihan, S. Lorimer, S. Murjan, and L. Seal, “Trans is Not a Disorder – But Should Still Receive Funding,” Sexual and Relationship Therapy 30/3 (2015), 309-13.

[6] Drescher, “Gender Identity Diagnoses: History and Controversies,” 146.

[7] E.g., Catelan, Costa, and de Macedo Lisboa, “Psychological Interventions for Transgender Persons”; Jody L. Herman, Taylor N. T. Brown, and Ann P. Haas, Suicide Thoughts and Attempts Among Transgender Adults: Findings from the 2015 U.S. Transgender Survey (Los Angeles: Williams Institute, 2019), 30.

[8] Again, this is in keeping with Ilan Meyer’s own reminder that his MSM was never intended to function as an all-encompassing theory; see Meyer, Pachankis, and Klein, “Do Genes Explain Sexual Minority Mental Health Disparities?” Meyer himself has critically reflected on some of the ways in which others have used his MSM in a haphazard and methodologically troubling fashion. See Sharon Schwartz and Ilan H. Meyer, “Mental Health Disparities Research: The Impact of Within and Between Group Analyses on Tests of Social Stress Hypotheses,” Social Science & Medicine 70/8 (2010), 1111– 18. See also Frost, “Benefits and Challenges of Health Disparities and Social Stress Frameworks for Research on Sexual and Gender Minority Health,” 462.

[9] Ibid., 4.

[10] Ibid.

[11] Ibid., 5.

[12] Ibid.

[13] Ibid.