(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。

These are the diagnostic criteria for Gender Incongruence in the DSM-V-TR (2022). Gender Dysphoria in this context is not synonymous with being transgender, and refers to the mental distress experienced by having a gender identity at odds with one’s physical body or lived gender. This distress has to be clinically significant for a diagnosis to be made.

Medical authorities recommend transitioning as the treatment for GD, as it is the only course of action that has proven effective in alleviating dysphoria. Some transgender people may not qualify for a diagnosis of Gender Dysphoria if their distress is not intense enough to be debilitating. They may still desire and benefit from transitioning.

“The DSM–5 articulates explicitly that “gender non-conformity is not in itself a mental disorder.” The 5th edition also includes a separate “gender dysphoria in children” diagnosis and for the first time allows the diagnosis to be given to individuals with disorders of sex development (DSD). DSM–5 also includes the optional “post-transition” specifier to indicate when a particular individual’s gender transition is complete. In this “post-transition” case, the diagnosis of gender dysphoria would no longer apply but the individual may still need ongoing medical care (e.g., hormonal treatment)”- from psychiatry.org.

 

DSM-5-TR Diagnostic Criteria for Gender Dysphoria in adults and adolescents

1. A definite mismatch between the assigned gender and experienced/expressed gender for at least 6 months duration as characterized by at least two or more of the following present –
   1. A marked incongruence between experienced or expressed gender and gender manifested by primary and/or secondary sex characteristics (or in young adolescents, the anticipated secondary sex characteristics)
   2. A strong or persistent desire to rid oneself of the primary or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics)
   3. A strong desire to possess the primary and/or secondary sex characteristics of the other gender
   4. A strong desire to be of the other gender
   5. A strong desire to be treated as the other gender
   6. A strong feeling or conviction that he or she is reacting or feeling in accordance with the identified gender
2. The gender dysphoria leads to clinically significant distress and/or social, occupational and other functioning impairment. There may be an increased risk of suffering distress or disability.
3. The subtypes may be ones with or without defects or defects in sexual development.

In order to meet criteria for the diagnosis, the condition must also be associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.

DSM-5-TR Diagnostic Criteria for Gender Dysphoria in children

1. A definite difference between experienced/expressed gender and the one assigned at birth of at least 6 months duration. At least six of the following must be present (one of which must be the first criterion):
   1. A strong desire to be of the other gender or an insistence that one is the other gender (or some alternative gender different from one’s assigned gender)
   2. In boys (assigned gender), a strong preference for cross-dressing or simulating female attire; or in girls (assigned gender), a strong preference for wearing only typical masculine clothing and a strong resistance to the wearing of typical feminine clothing
   3. A strong preference for cross-gender roles in make-believe play or fantasy play
   4. A strong preference for the toys, games or activities stereotypically used or engaged in by the other gender
   5. A strong preference for playmates of the other gender
   6. In boys (assigned gender), a strong rejection of typically masculine toys, games, and activities and a strong avoidance of rough-and-tumble play; or in girls (assigned gender), a strong rejection of typically feminine toys, games, and activities
   7. A strong dislike of one’s sexual anatomy
   8. A strong desire for the physical sex characteristics that match one’s experienced gender
2. The gender dysphoria leads to clinically significant distress and/or social, occupational and other functioning impairment. There may be an increased risk of suffering distress or disability.
3. The sub-types may be ones with or without defects or defects in sexual development.

To Note:

While it’s less the case than it was with the DSM-IV or DSM-III, the diagnostic criteria listed above for children is still likely to produce a few false positives. Many trans children meanwhile may not meet the criteria – for instance, a trans girl who enjoys typically masculine activities but has an intense, debilitating desire to be female would meet only 2 or 3 of the 6 required criteria, despite being very likely to persist in a transgender identity. Whereas an effeminate boy who is repeatedly forced into masculine activities against his will and might express a desire to be a girl out of that frustration (and vice versa) would meet at least 5 and perhaps even all 6 of the required criteria, despite being unlikely to grow up to be transgender.

This is important in light of the frequently repeated claim that a 80-90% of transgender children grow out of their gender dysphoria and do not become transgender adults but instead gay or lesbian. Many of those studies were done on children diagnosed under the DSM-III (1980), III-R (1987) and IV (1994). The DSM-IV criteria in particular did not require children to express a desire to be the other sex in order to be considered transgender; they merely needed to exhibit a strong pattern of gender-atypical interests and behaviour (manifested in forms of play, preferred clothing, and gender of playmates), which in most cases has no bearing on their actual gender identity.

While the DSM-III did require children to express a strong and persistent desire to be the other gender, it was also published during a time where stereotypical gender roles were a lot more rigid than they are today. This raises the possibility that many of those children’s declarations of wanting to be the other sex were the result of their frustration with gendered restrictions, rather than distress at being a boy or girl per se.

Adults were likewise not immune to this conflation of gender stereotypes and identity. The DSM-III described gender dysphoria in girls as follows: “Girls with this disorder regularly have male peer groups, an avid interest in sports and rough-and-tumble play, and a lack of interest in playing with dolls or playing “house”.”

Today, we know such girls to be tomboys, not transgender boys. It is thus no surprise that the majority of such girls grew up to be perfectly content as women (and likewise for boys), but this result cannot be extrapolated to transgender children whose distress extends beyond merely having atypical interests for their sex, and who do not find this distress eliminated by merely being given the freedom to act and dress as they like.