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Sexual Orientation versus Age of Onset as Bases for Typologies (Subtypes) for Gender Identity Disorder in Adolescents and Adults

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Abstract

The most widely used and influential typologies for transsexualism and gender identity disorder (GID) in adolescents and adults employ either sexual orientation or age of onset of GID-related symptoms as bases for categorization. This review compares these two typological approaches, with the goal of determining which one should be employed for the diagnosis of GID in Adolescents or Adults (or its successor diagnosis) in the forthcoming revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM). Typologies based on sexual orientation and age of onset of GID-related symptoms are roughly comparable in ease and reliability of subtype assignment. Typologies based on sexual orientation, however, employ subtypes that are less ambiguous and better suited to objective confirmation and that offer more concise, comprehensive clinical description. Typologies based on sexual orientation are also superior in their ability to predict treatment-related outcomes and comorbid psychopathology and to facilitate research. Commonly expressed objections to typologies based on sexual orientation are unpersuasive when examined closely. The DSM should continue to employ subtypes based on sexual orientation for the diagnosis of GID in Adolescents or Adults or its successor diagnosis.

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Notes

  1. The DSM-IV (APA, 1994) and DSM-IV-TR (APA, 2000) distinguish between subtypes and specifiers for diagnoses:

    Subtypes define mutually exclusive and jointly exhaustive phenomenological subgroupings within a diagnosis and are indicated by the instruction “specify type” in the criteria set….In contrast, specifiers are not intended to be mutually exclusive or jointly exhaustive and are indicated by the instruction “specify” or “specify if” in the criteria set. (APA, 2000, p. 1)

    In the DSM-IV and DSM-IV-TR, criteria sets for the diagnosis of GID in Adolescents or Adults include instructions to specify sexual orientation, i.e., sexually attraction to males, females, both, or neither (e.g., APA, 2000, p. 582). These four categories, however, are mutually exclusive and jointly exhaustive; consequently, they should properly be considered subtypes, not specifiers. In the DSM-III-R (APA, 1987), the criteria set for the diagnosis of Transsexualism includes an instruction to specify sexual orientation, i.e., asexual, homosexual, heterosexual, or unspecified (p. 76), but the accompanying text refers to these categories as “types” (p. 75). These four categories, too, are mutually exclusive and jointly exhaustive; according to the definitions of the DSM-IV and DSM-IV-TR, they would also be considered subtypes. In the DSM-III (APA, 1980), the criteria set for the diagnosis of Transsexualism includes subtype designations, based on prior sexual history, i.e., asexual, homosexual, heterosexual, or unspecified (p. 262). These categories are also mutually exclusive and jointly exhaustive, so their designation as subtypes is consistent with the definitions of the DSM-IV and DSM-IV-TR. Note that, in classification systems based on age of onset of GID-related symptoms, the binary categories that are typically employed (e.g., early- vs. late-onset, or primary vs. secondary) are also mutually exclusive and jointly exhaustive. According to the definitions of the DSM-IV and DSM-IV-TR, they would also be considered subtypes.

  2. Examples would include repeated objective demonstration (not just self-report) of sexual arousal with cross-dressing or cross-gender fantasy in significant numbers of gender dysphoric males who are demonstrably androphilic, or repeated failure to objectively demonstrate sexual arousal with cross-dressing or cross-gender fantasy in significant numbers of gender dysphoric males who are demonstrably gynephilic.

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  1. Department of Psychology, University of Lethbridge, Lethbridge, AB, Canada

    Anne A. Lawrence

  2. 6801 28th Avenue NE, Seattle, WA, 98115, USA

    Anne A. Lawrence

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Lawrence, A.A. Sexual Orientation versus Age of Onset as Bases for Typologies (Subtypes) for Gender Identity Disorder in Adolescents and Adults. Arch Sex Behav 39, 514–545 (2010). https://doi.org/10.1007/s10508-009-9594-3

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