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ESSENTIALS OF DIAGNOSIS
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Different sets of criteria are used in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) to diagnose Gender Dysphoria (GD) in children vs. adolescents. (American Psychiatric Association, 2013). Both criteria sets emphasize incongruence between the experienced gender and the gender assigned at birth. The experienced gender can be either a traditional opposite-sex gender identity or some alternative, nontraditional gender identity that is inconsistent with the culturally specific gender roles associated with being a "man" or "woman." As with many diagnoses, an essential criterion is the presence of clinically significant distress or impairment of functioning in one or more important areas (e.g., social relationships, school). One should specify whether GD co-occurs with a disorder of sex development (DSD). For adolescents, one should also specify whether the patient has undergone a gender transition, including medical procedures to align the patient's physical appearance with his or her experienced gender identity.
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In the forthcoming ICD-11, which is slated for publication in 2018, several revisions have been proposed to the ICD-10 diagnoses of Transsexualism and Gender Identity Disorder of Childhood: (1) to rename these two diagnoses as Gender Incongruence of Adolescents and Adults and Gender Incongruence of Childhood; (2) for the child diagnosis, that it cannot be diagnosed before the age of 5 years and that the "incongruence" must be of at least 2 years in duration (unlike 6 months in the DSM-5); and (3) perhaps of most importance, to move these diagnoses out of the ICD section on Mental and Behavioural Disorders into a new section provisionally termed Conditions Related to Sexual Health (Drescher et al, 2012, 2016).
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The proposal to create a new section of the ICD-11 to accommodate gender identity diagnoses has been influenced, in part, by some clinicians and transgender activists/organizations who want to "depathologize" and destigmatize gender dysphoria or gender incongruence (Drescher, 2015), yet at the same time to retain access to care, including mental health services, and insurance coverage for biomedical procedures, such as sex-reassignment (or "gender-affirming") surgery. The renaming of the diagnosis to Gender Incongruence (as opposed to Gender Dysphoria as it is now called in the DSM-5) is because the proposed diagnosis does not require "distress" or impairment, as it does in the DSM-5. It is also of note that retaining any diagnosis at all for children is hotly contested. For example, a survey of members of the World Professional Association for Transgender Health found that about half were in favor of retention in the ICD and half were in favor of deletion (De Cuypere et al, in press). Apart from these conceptual changes, one should note that the proposed rationale for a lower bound age of 5 years for the diagnosis in children has, as of yet, not been made clear. One could argue that this proposal is to alert clinicians to be cautious in offering any type of treatment recommendation for very young children; on ...