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APA Official Actions Report of the APA Task Force on Treatment of Gender Identity Disorder Approved by the Joint Reference Committee, July 2011 Approved by the Board of Trustees, September 2011 The findings, opinions, and conclusions of this report do not necessarily represent the views of the officers, trustees, or all members of the American Psychiatric Association. Views expressed are those of the authors." -- APA Operations Manual. William Byne M.D., Ph.D. (Chair)* Table of Contents Susan Bradley, M.D. Preface ........................................................................ 1 Executive Summary and Recommendations Eli Coleman, Ph.D. Evaluation of Levels of Evidence .............................. 3 Terminology .............................................................. 3 A. Evan Eyler, M.D., M.P.H. Synopses of Literature Reviews and Opinions with Respect to Recommendations ................................. 4 Richard Green, M.D., JD. Why APA Recommendations Are Needed for the Edgardo J. Menvielle, M.D., M.S.H.S. Treatment of GID ...................................................... 8 Recommendations for the APA ................................ 9 Heino F. L. Meyer-Bahlburg, Dr. rer. nat. Literature Reviews ....................................................... 10 Gender Variance in Childhood ................................. 10 Richard R. Pleak, M.D. Gender Variance in Adolescence.............................. 13 Gender Identity Concerns in Adulthood ................... 17 D. Andrew Tompkins, M.D. Gender Variance in Persons with Somatic Disorders of Sex Development (aka Intersexuality) …………… 26 Appendix I: Other APA Concerns Regarding Gender Variance 30 Appendix II: Other APA Concerns Regarding DSD .................. 30 References………………………………………………………. 31 ________________________________________________________________________________ (Am J Psychiatry 2012; Suppl., 1-35) Preface and charged by the Board of Trustees “to perform a critical After the announcement of the DSM-5 Work Group review of the literature on the treatment of Gender Identity membership in May 2008, the American Psychiatric Disorder at different ages and to present a report to the Association (APA) received many inquiries regarding the Board of Trustees.” The report “would include an opinion workgroup named to address the entities included under as to whether or not there is sufficient credible literature to Gender Identity Disorder (GID) in versions III through IV- take the next step and develop treatment recommenda- TR of the Diagnostic and Statistical Manual of Mental tions.” Disorders™ (DSM). These inquiries most often dealt with The Task Force commenced its work as the DSM-5™ treatment controversies regarding GID, especially in child- workgroups were deliberating. Questions, therefore, arose ren, rather than issues related specifically to the DSM text regarding the impact of potential differences between the and diagnostic criteria. In addition, the APA Committee on forthcoming DSM-5 and previous iterations of the DSM on Gay, Lesbian, and Bisexual Issues had previously raised the utility of the Task Force Report. Of particular concern concerns about the lack of evidence-based guidelines for was the question of whether or not the diagnostic entity GID, and questions about whether such guidelines could designated as GID would be carried forward into the DSM- and should be developed. 5. The Task Force concluded that most of the issues per- While the diagnosis and treatment of mental disorders taining to gender variance (GV) that lead individuals (or are inextricably linked, they are separate issues and the their parents in the case of minors) to seek mental health evaluation of treatments is not addressed by the DSM Work services would remain the same regardless of any changes Groups. The APA Board of Trustees, therefore, formed a in DSM nomenclature or diagnostic criteria. Any such task force on the treatment of GID under the oversight of changes to the DSM should, therefore, have minimal the Council on Research. Members of the GID Task Force impact on the utility of the Task Force Report. Since the were appointed by the APA President, Dr. Nada Stotland, DSM-5 would be published only after completion of work ______________________________________________________________________________________________________________ * The authors comprise the Task Force on Treatment of Gender Identity Disorder, APA Council on Research. We would like to thank the following for reading and providing comments on the initial draft of the report: Peggy T. Cohen-Kettenis, Ph.D., Jack Drescher, M.D., Sharon Preves, Ph.D., and Nada Stotland, M.D., as well as William Narrow, M.D., M.P.H., and Erin Dalder for APA staff support. DISCLOSURES: Dr. Coleman chairs the Sexual Health Advisory Committees for Church & Dwight and the Sinclair Institute. The other authors report no financial relationships with commercial interests. [Note added in print: Since the completion of this report, Version 7 of the WPATH SOC has been published and is available at www.wpath.org.] Am J Psychiatry 169:8, August 2012, data supplement. © Copyright, American Psychiatric Association, all rights reserved. 1 GENDER IDENTITY DISORDER by the Task Force, the evidence base available for consider- during conference calls and revised until approved by ation by the Task Force was necessarily based on prior group consensus. Because the consensus process involves diagnostic formulations. The Task Force chose to conduct compromise, all members of the Task Force do not its deliberations primarily in terms of the DSM-IV-TR™ necessarily agree with all views expressed within the formulations with reference to other formulations as report. The Task Force could not reach a consensus regard- necessary. ing the question of whether or not persistent cross-gender Although the charge to the Task Force was to comment identification sufficient to motivate an individual to seek on the feasibility of making treatment recommendations, sex reassignment, per se, is a form of psychopathology in questions arose in the initial conference calls regarding the the absence of clinically significant distress or impairment nature of the evidence base required by the APA for de- due to a self-perceived discrepancy between anatomical velopment of recommendations in the specific form of APA signifiers of sex and gender identity. Since this question practice guidelines. APA practice guidelines are defined as falls within the purview of the DSM Committee and is not systematically developed documents in a standardized for- central to the Task Force’s charge of evaluating treatment, mat that present patient care strategies to assist psychia- text suggesting a stand on this issue was deleted from the trists in clinical decision making. The APA’s Steering report. Similarly, a consensus could not be reached regard- Committee on Practice Guidelines (SCPG) both selects ing the legitimacy of particular goals of therapy with child- topics for guideline development and oversees their ren diagnosed with GID (e.g., prevention of transgen- development. According to the APA’s website derism or homosexuality) even when consistent with the (http://www.psychiatryonline.com/content.aspx?aID=58560) at the religious beliefs or sociocultural values of the parents or time the Task Force commenced it work in 2008 and primary caregivers. concluded it in May 2011, two of the criteria for topic selection by the SCPG are quality of the relevant data base and prevalence of the disorder. The randomized double EXECUTIVE SUMMARY AND blind control trial is the study design that affords the highest quality evidence regarding the comparative effi- RECOMMENDATIONS cacy of various treatment modalities; however, no such trials have been conducted to address any aspect of the This Task Force report assesses the current status of treatment of GID. Given the very nature of GID, such trials, evidence bearing on treatment, by mental health pro- or even unblinded trials with random assignment to treat- fessionals, of the entities included under GID in the DSM ment groups, are not likely to be forthcoming due to a lack (versions III through IV-TR) as well as gender dysphoria in of feasibility and/or ethical concerns. In addition to the individuals with somatic DSDs (designated as GID Not lack of evidence of the highest quality relevant to the treat- Otherwise Specified (GID NOS)) in DSM-IV-TR. The pri- ment of GID, GID is widely believed to be a rare phenol- mary aim of the report is to answer the question posed by menon (1)1 and likely to fall short of the SCPG’s criterion the APA Board of Trustees as to whether or not there is for prevalence. The Task Force, therefore, decided to con- sufficient credible literature to support development by the sider whether available evidence, together with clinical APA of treatment recommendations for GID. Separate consensus, constitutes a sufficient basis to support the sections of the report are addressed to GID in children, development of treatment recommendations, broadly adolescents, and adults as well as to GID NOS in individ- defined, in addition to assessing the quality of evidence uals with somatic DSDs. The Executive Summary provides relevant to the potential development of APA practice a synopsis of each of those sections (readers are referred to guidelines, as defined above. each primary section for full citations), together with an In order to address its charge, the Task Force divided opinion from the Task Force regarding
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