Intersex and the DSM

UPDATE: OII Australia and OII Aotearoa have released a submission on the DSM-5, which can be read here [PDF] in June 2012. This submission supersedes the following position statement.

The American Psychiatric Association (APA) is currently rewriting the Diagnostic and Statistic Manual (DSM). This will be its fifth full revision, the DSM-V. See:

The DSM sets out the diagnostic criteria for all mental illnesses recognized by the APA.

Countries outside the United States of America use the DSM widely. Australia is one such country. Australian psychiatrists contribute to the DSM and use it as their standard for diagnosis.

There is no Australian equivalent to the DSM.

The World Health Organisation also has a diagnostic manual that lays down criteria for mental illness diagnosis. It is called the International Statistical Classification of Diseases and Related Health Problems (ICD) and is in its tenth revision. See:

The ICD-10 has significant differences to the DSM in the classification of some mental disorders. The diagnoses of intersex and transsexualism are two areas where the ICD-10 and the DSM-V have significant differences in diagnostic criteria and treatment recommendations.

Previous versions of the DSM have diagnosed homosexuality – both gays and lesbians – as a mental disorder. This classification was not removed from the DSM by the APA until 1986 despite some other associations removing it as a disorder as early as 1973. See: and

Transsexualism was included in the DSM in its third revision DSM-III as Gender Identity Disorder (GID). Another category was also created in that revision, Gender Identity Disorder Not Otherwise Specified (GIDNOS).

Intersex individuals cannot be diagnosed as suffering from GID under current guidelines because of Criterion C: Not Due to an Intersex Condition (DSM-IV, page 1081 – not available online, however OII Australia holds a PDF extract).

GIDNOS was used in the DSM to diagnose intersex individuals who rejected their birth assignment as suffering from a thought disorder.

The revision of the DSM now classifies transsexualism as Gender Incongruence. This is thought to be less stigmatizing than “disordered”. See:

Gender Incongruence has three types in the revision:

  1. Gender incongruence in children. See:
  2. Gender incongruence in adults. See:
  3. Gender incongruence not otherwise specified. This is a work in progress. See:

The revision of the DSM continues to pathologize intersex individuals who have rejected their birth assignment as suffering from a thought disorder.

The DSM-V revision goes further than DSM-IV as describing intersex as being a Disorder of Sexual Development (DSD). This despite rejecting ‘disorder’ and using ‘incongruence’. Because the former is thought to be pathologizing, the DSM proposes to “disorder” sex differences rather than call them intersex as they have done in previous versions. See the draft proposals, Subtypes, With a Disorder of Sexual Development and Without a Disorder of Sexual Development at

OII Australia’s comments:

UPDATE: OII Australia and OII Aotearoa have released a submission on the DSM-5, which can be read here [PDF] in June 2012. This submission supersedes the following position statement.

OII Australia considers the revision of the DSM to be less acceptable than its predecessor the DSM-IV. The DSM-IV was unacceptable to intersex and to OII Australia.

All versions of the DSM have pathologized intersex who reject their birth assignment or who do not adopt a sex/gender binary identity.

The DSM blames the assigned and not the assignor for the rejection of birth assignments. That is, the assigning doctor is never wrong despite the child being born intersex and the sex of the child being unknown. If the child later disagrees with the verdict of the assigning doctor then they will be diagnosed with a thought disorder.

The DSM continues to regard unusual bodies and non-conforming sex or gender behaviour as at least problematic and consistently as disease. This is in keeping with the DSM’s traditional understanding of sex binary heterosexual relationships as being normal. The APA has run rabid over human sex, sexuality and gender diversity, screaming “disease!”

The primary mental health issue for intersex is trauma caused by exclusion, marginalization and pathologization of their differences. No version of the DSM attempts to address this.

The DSM now uses the pathologizing DSD language of the Chicago Conference. The DSM does this despite concluding that Gender identity Disorder is too stigmatizing. See: and

OII Australia board members’ comments:

What is happening here is that people who have (or been treated for) a “Disorder of Sex Development”, and who reject their assignment are now pulled into the main category of GID, as one of two subtypes, people with DSD, as opposed to people without DSD. It is interesting that the rejection of assignment is identified, rather than a specific wish or need to live as the ‘other’ gender.

In terms of treatment, this may make some people’s lives easier – if they have a positive desire or will to live as the gender other than that assigned them. On the other hand, people who hated the gender they were assigned, but are as equally uncomfortable as the ‘other’ gender, possibly wishing they didn’t have to deal with all this gender construct anyway, are left in a precarious position.

When we reject the assignment made upon us if it is not a positive choice for another gender, the treatment options are unclear. Not that there may necessarily need to be treatment. Nevertheless, we get a GID diagnosis. There is no acceptance that if this is a disorder – OII Australia does not think it is a disorder if intersex reject a non-consensual gender assignment – then it is an idiopathic disorder which arises from misassignment and failure to conform to the reinforcement of that gender.