(Chinese translation by Xavier Chua)

性别障碍诊断

以下是《精神疾病诊断与统计手册第五版》（2013）中性别不安的诊断标准。在这种情况下，性别焦虑症不是跨性别的代名词，而是指人因与自己的身体或生活中的性别不一致而遭受的精神困扰。临床上必须有显著的痛苦和损伤才能够被诊断为性别不安。

医务人员建议将过渡治疗作为性别不安的治疗方法，因为这是唯一能持久有效地缓解烦躁不安的行动。

有些跨性别者的痛苦程度不足以使其衰弱，则可能没有资格诊断性别不安。他们可能仍然希望过渡，并能从过渡中受益。

《精神疾病诊断与统计手册第五版》成人和青少年性别不安的诊断标准

1. 在至少六个月的时间里，所分配的性别与经历或表达过的性别之间不匹配，其特征是至少具有以下两个或多个特征：
   1. 经历或表达的性别与青春期所得到的主要和/或次要性别特征不匹配
   2. 坚持要摆脱青春期所得到的主要或次要的生理性性特征
   3. 强烈渴望拥有其他性别的主要和/或次要性别特征
   4. .渴望身为其他性别
   5. 渴望被视为其他性别
   6. 有强烈的感觉或信念，认为他或她正在按照所认同的性别做出反应或拥有感觉。
2. 性别不安导致临床上明显的困扰和/或社会，职业和其他功能上出现障碍。遭受困扰或残疾的风险可能会增加。
3. 亚型可以是有或没有缺陷或性发育缺陷的。

《精神疾病诊断与统计手册第五版》儿童性别不安的诊断标准

1. 在至少六个月的时期里，有经历/有表达出的性别与出生时的性别之间有一定的区别。必须至少拥有以下六种特征：
   1. 坚强而强烈地渴望成为另一性，或坚持认为自己属于另一性
   2. 在男性中，偏爱更衣装，在女性儿童中，偏爱穿典型的男性服装，并且不喜欢或拒绝穿典型的女性服装
   3. 幻想在玩家家酒游戏或活动中扮演其他性别的角色
   4. 偏爱归异性典型的玩具，游戏或活动。
   5. 拒绝符合自己性别的玩具，游戏和活动。在男孩中，避免粗鲁的玩耍，在女孩中，拒绝典型的女性玩具和活动
   6. 偏好其他性别的同伴
   7. 不喜欢性器官。男孩可能讨厌自己的阴茎和睾丸，而女孩则讨厌坐下来小便。
   8. 渴望获得异性的主要和/或次要性别特征。
2. 性别不安导致临床上明显的困扰和/或导致社会，职业和其他的方面出现障碍。遭受困扰或残疾的风险可能会增加。
3. 亚型可以是有或没有缺陷或性发育缺陷的亚型。

注意：

尽管情况比《精神疾病诊断与统计手册第四版》(DSM-IV)或第三版(DSM-III)少，但上面列出的针对儿童的诊断标准仍然可能会产生一些误报。同时，许多跨性别儿童可能不符合该标准-例如，一个喜欢典型男性活动但充满强烈成为女生的渴望的跨性别女孩，尽管很可能会坚持作为跨性别女性只符合6个标准中的2个或3个。尽管一个女性化的男孩屡屡违背自己的意愿被迫进行男性活动，并可能表示希望摆脱这种挫败感而成为女孩（反之亦然），但至少会满足5个，甚至可能是全部6个标准，尽管这不太可能长大后依然是跨性别。

鉴于经常被重复声称80-90％的跨性别儿童是成长后没有性别焦虑症而不再成为跨性别成年人，而是成同性恋者，这一点很重要。其中许多研究针对的是根据DSM-III（1980），III-R（1987）和IV（1994）诊断的儿童。尤其是DSM-IV标准并没有要求孩子表达自己希望成为变性者的异性；他们只需要表现出强烈的性别非典型兴趣和行为模式（表现为游戏形式，偏爱的服装和玩伴的性别），在大多数情况下，这与他们的实际性别认同无关。

尽管DSM-III确实要求儿童表达强烈和持久的成为另一种性别的愿望，但它是出版在刻板印象的性别角色比现在更加僵化的时代。这就增加了这样的可能性，即这些孩子中很多想成为另一性的声明是他们对性别限制的无奈之举，而不是因为他们本身是男孩还是女孩而感到困扰。

成人同样无法避免这种性别定型观念和身份认同的融合。 DSM-III对女孩的性别焦虑症进行了如下描述：“患有这种疾病的女孩经常有男性同龄人群体，对运动和粗鲁的玩耍有强烈的兴趣，对玩洋娃娃或玩“家家酒”的兴趣不足。”

今天，我们知道这样的女孩是假小子，而不是变性男孩。因此，让人毫不奇怪的是，大多数这样的女孩长大后完全对自己的性别满足（男孩同样如此），但是这结果不能推论为超过非寻常兴趣的拥有对于自己已有的性别的不满的跨性别儿童，而且这些儿童并不会因为仅仅能够照自己所喜欢的样子穿衣或表现出的行为觉得自己的困扰减轻了。

Gender dysphoria, sometimes called gender incongruence, is a state of mismatch between the gender one is assigned at birth and the gender they wish to express themselves as.

It is important to note that dysphoria in itself is not a requirement for one to identify as transgender. Not all trans people have dysphoria; a transgender person may become more aware of their dysphoria as time passes, or even as they begin transition; they might also recognise or remember certain feelings that they’ve had in the past as signs of gender incongruence or dysphoria.

What is gender dysphoria?

Dysphoria is best described as a dissonance between self and body. Sometimes, it may be simplified as “a woman trapped in a man’s body” or “a man trapped in a woman’s body.”

It may be unseen in a person’s life, and this is especially true in people who transition later in age.

While gender identities are more likely to be formed in early childhood – with some expressing a wish to be the gender that they are as early as they were three – some trans people may be comfortable with stereotypically gendered clothes and activities as children and teenagers; others may repress their wants as they meet with resistance from society.

Some examples of gender dysphoria may include:

• Horror or revulsion when looking at or touching one’s external genitals, which trigger a strong desire to remove the offending organ
  • This might manifest as a persistent awareness of body parts that should not be there (like the weight of breasts, or the presence of testicles or a uterus), or awareness of a body part that isn’t there (a phantom vagina or penis)
• Depersonalisation and derealisation – a sense of detachment from your own thoughts, feelings, or body
• Feeling out of place while with peers of one’s assigned gender – for instance, AMAB trans people may find it difficult to be vulnerable around other men, something that might become evident when they go through National Service
• Shame or guilt when one is unable to fit into common gender roles
• Anger or sadness at being forced to cut one’s hair (for AMAB trans people) or being pressured to keep their hair long or wear makeup (for AFAB trans people)

The above is not an all-encompassing or definitive definition of what dysphoria is like. Dysphoria can often present in varied ways – for some, flinching when someone uses their birth name; for others, feeling a want to be connected to others of their gender, and distress when they can’t do so. Many describe a desire to repress their inner desires because of how society views gender or an inner belief that being transgender is deviant.

Medical authorities and experts recommend transitioning as a treatment for gender dysphoria or incongruence, as it is the only course of action that has proven effective in alleviating gender dysphoria.

What do experts say about gender dysphoria?

Medical experts largely state that transition is medically necessary and the only effective way to deal with dysphoria. Most will medically benefit from some form of transitioning, regardless of whether their dysphoria is clinically significant.

The Singapore Psychological Society states that conversion therapy – the act to impose a specific sexual orientation or gender identity on a person – is ineffective and possibly harmful to some, and exacerbates distress and poor mental health.

It follows the Ministry of Health’s recommendations on conversion therapy, which state that doctors and other healthcare professionals are expected to practice clinical ethics and consider and respect people’s preferences and circumstances (including sexual orientation) when providing care.

The American Psychiatric Association states that transition is medically necessary, while the American Medical Association agrees that delaying treatment for gender dysphoria can aggravate other health issues like depression and stress-related physical illnesses. The UK Royal College of Psychiatrists states that interventions that claim to convert trans people into cis people – or conversion therapy – is without scientific evidence and is unethical.

Multiple studies also find that transition dramatically reduces suicide risk, improving mental health and quality of life.

Is gender dysphoria a mental health disorder?

ICD-11, the list of mental and behavioural disorders compiled by the World Health Organisation, lists gender incongruence as a sexual health condition, a change from its previous edition, which bundled gender incongruence under the umbrella term gender identity disorder and listed it as a mental health condition.

The DSM-V, as compiled by the American Psychiatric Association, articulates explicitly that gender non-conformity in itself is not a mental disorder.

Still, both documents have definitions on gender incongruence and gender dysphoria, for several reasons:

• Some health systems – including Singapore’s – require a psychiatric evaluation before trans people can obtain gender-affirming care
• Insurers depend on either the ICD-11 or DSM-V to determine if your hospital bill should be reimbursed

ICD-11 definitions

DSM-V definitions