The DSM, or Diagnostic and Statistical Manual of Mental Disorders, is the American Psychological Association (APA) guidebook used by psychiatrists all around the world. It is currently undergoing revisions for a fifth edition, which has sparked controversy in many areas. Among these is its inclusion, for the first time, of intersex people.

Many transgender people have welcomed the DSM’s shift from referring to them as having ‘gender identity disorder’ to using the term ‘gender dysphoria’. This removes the stigma associated with the concept of disorder but means that, because they can still be said to have a recognised condition, they can still access treatment. The way gender dysphoria is defined, however, rests on a binary understanding of biological sex, so it is an awkward fit for intersex people.

Crucially, gender dysphoria places the emphasis on the person who wants to change, not on the world around them. The International Intersex Organisation (OII) have challenged this, noting the many intersex people are assigned a sex at birth on a best-guess basis and may be subject to surgery to reinforce that assignment. If they are unhappy with their bodies, this is often because doctors have made mistakes and misinterpreted their gender. Labelling them gender dysphoric protects the idea that doctors can never be wrong. It means that children whose behaviour is at odds with their assigned sex are seen as poorly adapted. Such children may be subjected to psychiatric treatment aimed at reinforcing approved gender behaviour, even though such treatment is increasingly seen as inappropriate, and potentially damaging, when applied to trans children.

“When a child is born with an atypical sex anatomy, often called a disorder of sex development (DSD) or intersex condition, doctors must sometimes make an educated guess about what gender assignment makes the most sense. If the child later decides that the guess was wrong, is that a sign that something is wrong with the child?” asks Anne Tamar-Mattis, executive director of Advocates for Informed Choice (AIC).

This version of the DSM has been subjected to heavy criticism for what is seen as the unnecessary medicalisation of natural behaviour. The British Psychological Society has expressed concern about the inclusion of intersex on this basis, arguing that many of the problems intersex people face have clear social causes. The APA argue that inclusion will make it easier for intersex people to access care through the WPATH guidelines designed to help trans people. These are, however, poorly designed to fit the needs of intersex people and are likely to need extensive revisions to be able to do so effectively.

“Many of my constituents, both affected adults and parents of affected children, are extremely upset by this proposed change. Psychological diagnoses ought not to carry stigma, but they still do and many intersex people do not feel that they should have to take on that stigma as a result of someone else’s incorrect decision,” says Tamar-Mattis.

Holly Greenberry of IntersexUK notes that the Gender Recognition Act expressly excludes intersex people and believes the proposed changes to the DSM would make such problems worse.

“IntersexUK believes the UK government unwittingly does not support Article 8 of the European Human Rights Act, when it comes to supporting equal rights for intersex / DSD individuals, thus preventing intersex / DSD individuals from accessing their right to privacy, family and freedoms, as experienced by people who are not affected with intersex conditions. To include intersex conditions / people within DSM-V and GID will not improve understanding of intersex within the ‘medical or legal community'; neither will it enhance the needed rights, equalities and ‘choices’ for people with intersex / DSD conditions.”

The OII, however, see some positive aspects to the DSM’s approach. It represents the first official recognition, at this level, that intersex people may grow up to feel at odds with their assigned genders. It also acknowledges that a significant number of intersex people experience their gender in complex ways and may not identify as either male or female. Importantly, it makes clear that intersex people who want to change their bodies to better fit their gender identities should be given full medical support. The problem is that it would fit poorly in the context of existing legislation in the UK and US, potentially eroding some of the rights intersex people have won.

For trans people, notes Tamar-Mattis, the stigma of being described in psychiatric terms is balanced by the gains that can be made from access to treatment. Intersex people, who already have access to treatment through other pathways, face being labelled as mentally ill simply for disagreeing with their doctors, for little benefit.