“Diagnosing” Gender? Categorizing Gender-Identity Variants in the Anthropocene

  • Heino F. L. Meyer-BahlburgEmail author
Special Section: Transgender Identities Emerging During Adolescence


In recent decades, two interrelated major controversies have been unfolding in the area of sex/gender research. (1) Are gender-identity variants to be understood as psychopathology or natural variation? (2) Is gender (and perhaps even sex) better conceptualized as binary or non-binary? The answer depends on the conceptual context and related considerations of utility. In the context of evolutionary biology, marked variants of sex and gender decrease reproductive success and are, thereby, deemed pathologic. In the present era of the anthropocene, however, the material conditions underlying the traditional division of labor between the sexes and the role of reproductive success have dramatically changed. These changes decrease the psychosocial importance of the binary gender distinction, provide more freedom for non-binary gender expression and identity formation, and render the distinction of pathologic and non-pathologic less useful, unless gender dysphoria develops secondary to a psychiatric condition. Although most people state their gender identity in the form of a nominal category, most self-report or interview-based ratings and multi-item scales of gender expression and/or identity show continuous distributions, either unimodal-asymmetric or bimodal, depending on whether they are designed for one or both of the traditional genders. Similarly, the rating scales of androgen-influenced variants of the genitalia—usually designed for one of the traditional sexes—typically represent a unipolar-asymmetric continuum. However, the binary gender system remains the primary framework against which individuals evaluate themselves. For those who develop gender dysphoria, assistance by mental-health service providers continues to be important.


Gender dysphoria Transgender Gender and society Assessment of sex and gender 


Compliance with Ethical Standards

Conflict of interest

The author declares that he has no conflict of interest.

Human and Animal Rights

This article does not contain any studies with human participants or animals performed by the author.


  1. Ahmed, S. F., Khwaja, O., & Hughes, I. A. (2000). The role of a clinical score in the assessment of ambiguous genitalia. British Journal of Urology International, 85, 120–124.CrossRefGoogle Scholar
  2. Alipour, M. (2017). Islamic shari’a law, neotraditionalist Muslim scholars and transgender sex-reassignment surgery: A case study of Ayatollah Khomeini’s and Sheikh al-Tantawi’s fatwas. International Journal of Transgenderism, 18, 91–103.CrossRefGoogle Scholar
  3. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Press.Google Scholar
  4. Bashamboo, A., Eozenou, C., Rojo, S., & McElreavey, K. (2017). Anomalies in human sex determination provide unique insights into the complex genetic interactions of early gonad development. Clinical Genetics, 91, 143–156.CrossRefGoogle Scholar
  5. Bauer, G. R., Braimoh, J., Scheim, A. L., & Dharma, C. (2017). Transgender-inclusive measures of sex/gender for population surveys: Mixed-methods evaluation and recommendations. PLoS ONE, 12(5), e0178043.CrossRefGoogle Scholar
  6. Berenbaum, S. A. (1999). Effects of early androgens on sex-typed activities and interests in adolescents with congenital adrenal hyperplasia. Hormones and Behavior, 35, 102–110.CrossRefGoogle Scholar
  7. Bockting, W. (2008). Psychotherapy and the real-life experience: From gender dichotomy to gender diversity. Sexologies, 17, 211–224.CrossRefGoogle Scholar
  8. Brunskell-Evans, H., & Moore, M. (Eds.). (2018). Transgender children and young people: Born in your own body. Newcastle upon Tyne: Cambridge Scholars Publishing.Google Scholar
  9. Cohen-Kettenis, P. T., & van Goozen, S. H. M. (1997). Sex reassignment of adolescent transsexuals: A follow-up study. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 263–271.CrossRefGoogle Scholar
  10. Cull, M. L., & Simmonds, M. (2010). Importance of support groups for intersex (disorders of sex development) patients, families and the medical profession. Sexual Development, 4, 310–312. Scholar
  11. Daston, L., & Park, K. (1995). The hermaphrodite and the orders of nature. GLQ: A Journal of Gay and Lesbian Studies, 1, 419–438.CrossRefGoogle Scholar
  12. Deogracias, J. J., Johnson, L. L., Meyer-Bahlburg, H. F. L., Kessler, S. J., Schober, J. M., & Zucker, K. J. (2007). The Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults. Journal of Sex Research, 44, 370–379.CrossRefGoogle Scholar
  13. Deutsch, M. B., Green, J., Keatley, J., Mayer, G., Hastings, J., & Hall, A. M. (2013). Electronic medical records and the transgender patient: Recommendations from the World Professional Association for Transgender Health EMR Working Group. Journal of the American Medical Informatics Association, 20, 700–703.CrossRefGoogle Scholar
  14. Egan, S. K., & Perry, D. G. (2001). Gender identity: A multidimensional analysis with implications for psychosocial adjustment. Developmental Psychology, 37, 451–463.CrossRefGoogle Scholar
  15. Epelman, M., Dinan, D., Gee, M. S., Servaes, S., Lee, E. Y., & Darge, K. (2013). Müllerian duct and related anomalies in children and adolescents. Magnetic Resonance Imaging Clinics of North America, 21, 773–789.CrossRefGoogle Scholar
  16. Fausto-Sterling, A. (2012). Sex/gender: Biology in a social world. New York: Routledge/Taylor & Francis.Google Scholar
  17. Freese, J., Klement, R. J., Ruiz-Núñez, B., Schwarz, S., & Lötzerich, H. (2018). The sedentary (r)evolution: Have we lost our metabolic flexibility? (Version 2). F1000Research, 6, 1787.CrossRefGoogle Scholar
  18. Frontera, W. R., Hughes, V. A., Lutz, K. J., & Evans, W. J. (1991). A cross-sectional study of muscle strength and mass in 45- to 78-yr-old men and women. Journal of Applied Physiology, 71, 644–650.CrossRefGoogle Scholar
  19. Gender Identity in U.S. Surveillance (GenIUSS) Group. (2014). Best practices for asking questions to identify transgender and other gender minority respondents on population-based surveys. Los Angeles, CA: The Williams Institute.Google Scholar
  20. Golombok, S., & Rust, J. (1993). The Pre-school Activities Inventory: A standardized assessment of gender role in children. Psychological Assessment, 5, 131–136.CrossRefGoogle Scholar
  21. Grady, H., & Soy, A. (2017). The midwife who saved intersex babies (BBC World Service, Kenya). Retrieved November 13, 2018 from
  22. Grellert, E. A., Newcomb, M. D., & Bentler, P. M. (1982). Childhood play activities of male and female homosexuals and heterosexuals. Archives of Sexual Behavior, 11, 451–478.CrossRefGoogle Scholar
  23. Guillamon, A., Junque, C., & Gómez-Gil, E. (2016). A review of the status of brain structure research in transsexualism. Archives of Sexual Behavior, 45, 1615–1648.CrossRefGoogle Scholar
  24. Hames, R., Garfield, Z., & Garfield, M. (2017). Is male androphilia a context-dependent cross-cultural universal? Archives of Sexual Behavior, 46, 63–71.CrossRefGoogle Scholar
  25. Hansen, W. (1996). Phlegon of Tralles’ Book of Marvels. Exeter, UK: Exeter University Press.Google Scholar
  26. Hicklin, A. (2017). Intersex and proud: Model Hanne Gaby Odiele on finally celebrating her body. The Guardian. Retrieved November 13, 2018 from
  27. Hyde, J. S., Bigler, R. S., Joel, D., Tate, C. C., & van Anders, S. M. (2018). The future of sex and gender in psychology: Five challenges to the gender binary. American Psychologist. Scholar
  28. Jacobs, S.-E., Thomas, W., & Lang, S. (Eds.). (1997). Two-spirit people: Native American gender identity, sexuality, and spirituality. Urbana, IL: University of Illinois Press.Google Scholar
  29. Janssen, I., Heymsfield, S. B., Wang, Z. M., & Ross, R. (2000). Skeletal muscle mass and distribution in 468 men and women aged 18–88 yr. Journal of Applied Physiology, 89, 81–88.CrossRefGoogle Scholar
  30. Johnson, L. L., Bradley, S. J., Birkenfeld-Adams, A. S., Kuksis, M. A., Maing, D. M., Mitchell, J. N., & Zucker, K. J. (2004). A parent-report Gender Identity Questionnaire for Children. Archives of Sexual Behavior, 33, 105–116.CrossRefGoogle Scholar
  31. Kelly, R. L. (2013). The lifeways of hunter-gatherers: The foraging spectrum. New York: Cambridge University Press.CrossRefGoogle Scholar
  32. Kreukels, B. P. C., Köhler, B., Nordenström, A., Roehle, R., Thyen, U., Bouvattier, C., … on behalf of the dsd-LIFE group. (2018). Gender dysphoria and gender change in disorders of sex development/intersex conditions: Results from the dsd-LIFE study. Journal of Sexual Medicine, 15, 777–785.CrossRefGoogle Scholar
  33. Latorre Román, P. Á., Moreno Del Castillo, R., Lucena Zurita, M., Salas Sánchez, J., Garcia-Pinillos, F., & Mora López, D. (2017). Physical fitness in preschool children: Association with sex, age and weight status. Child: Care, Health, Development, 43, 267–273.Google Scholar
  34. Laurson, K. R., Saint-Maurice, P. F., Welk, G. J., & Eisenmann, J. C. (2017). Reference curves for field tests of musculoskeletal fitness in U.S. children and adolescents: The 2012 NHANES National Youth Fitness Survey. Journal of Strength & Conditioning Research, 31, 2075–2082.CrossRefGoogle Scholar
  35. Levine, S. B., & Solomon, A. (2009). Meanings and political implications of “psychopathology” in a gender identity clinic: A report of 10 cases. Journal of Sex and Marital Therapy, 35, 40–57.CrossRefGoogle Scholar
  36. Lippa, R. (1995). Gender-related individual differences and psychological assessment in terms of the Big Five and circumplex models. Journal of Personality and Social Psychology, 69, 1184–1202.CrossRefGoogle Scholar
  37. Littman, L. (2017). Rapid onset of gender dysphoria in adolescents and young adults: A descriptive study. Poster presented at the meeting of the Society for Adolescent Health and Medicine, March 8–11, New Orleans, LA.Google Scholar
  38. Littman, L. (2018). Rapid onset of gender dysphoria in adolescents and young adults: A study of parental reports. PLoS ONE, 13(8), e0202330.CrossRefGoogle Scholar
  39. Macintosh, A. A., Pinhasi, R., & Stock, J. T. (2017). Prehistoric women’s manual labor exceeded that of athletes through the first 5500 years of farming in Central Europe. Science Advances, 3(11), eaao3893.CrossRefGoogle Scholar
  40. McCarthy, M. M., & Nugent, B. M. (2015). At the frontier of epigenetics of brain sex differences. Frontiers in Behavioral Neuroscience, 9, 221. Scholar
  41. McKay, M. J., Baldwin, J. N., Ferreira, P., Simic, M., Vanicek, N., Burns, J., & 1000 Norms Project Consortium. (2017). Normative reference values for strength and flexibility of 1,000 children and adults. Neurology, 88, 36–43.CrossRefGoogle Scholar
  42. Meijer, J. H., Eeckhout, G. M., van Vierken, R. H. T., & de Vries, A. L. C. (2017). Gender dysphoria and co-existing psychosis: Review and four case examples of successful gender affirmative treatment. LGBT Health, 4, 106–114.CrossRefGoogle Scholar
  43. Meyer-Bahlburg, H. F. L. (2010). From mental disorder to iatrogenic hypogonadism: Dilemmas in conceptualizing gender identity variants as psychiatric conditions. Archives of Sexual Behavior, 39, 461–476. Scholar
  44. Meyer-Bahlburg, H. F. L. (2011). Gender monitoring and gender reassignment of children and adolescents with a somatic disorder of sex development. Child and Adolescent Psychiatric Clinics of North America, 20, 639–649.CrossRefGoogle Scholar
  45. Meyer-Bahlburg, H. F. L., Baratz Dalke, K., Berenbaum, S. A., Cohen-Kettenis, P. T., Hines, M., & Schober, J. M. (2016). Gender assignment, reassignment, and outcome in disorders of sex development: Update of the 2005 Consensus Conference. Hormone Research in Paediatrics, 85, 112–118.CrossRefGoogle Scholar
  46. Meyer-Bahlburg, H. F. L., Dolezal, C., Baker, S. W., Ehrhardt, A. A., & New, M. I. (2006a). Gender development in women with congenital adrenal hyperplasia as a function of disorder severity. Archives of Sexual Behavior, 35, 667–684.CrossRefGoogle Scholar
  47. Meyer-Bahlburg, H. F. L., Dolezal, C., Baker, S. W., & New, M. I. (2008). Sexual orientation in women with classical or non-classical congenital adrenal hyperplasia as a function of degree of prenatal androgen excess. Archives of Sexual Behavior, 37, 85–99.CrossRefGoogle Scholar
  48. Meyer-Bahlburg, H. F. L., Dolezal, C., Zucker, K. J., Kessler, S. J., Schober, J. M., & New, M. I. (2006b). The Recalled Childhood Gender Questionnaire-Revised: A psychometric analysis in a sample of women with congenital adrenal hyperplasia. Journal of Sex Research, 43, 364–367.CrossRefGoogle Scholar
  49. Meyer-Bahlburg, H. F. L., Sandberg, D. E., Dolezal, C. L., & Yager, T. J. (1994a). Gender-related assessment of childhood play. Journal of Abnormal Child Psychology, 22, 643–660.CrossRefGoogle Scholar
  50. Meyer-Bahlburg, H. F. L., Sandberg, D. E., Yager, T. J., Dolezal, C. L., & Ehrhardt, A. A. (1994b). Questionnaire scales for the assessment of atypical gender development in girls and boys. Journal of Psychology and Human Sexuality, 6, 19–39.CrossRefGoogle Scholar
  51. Morin, S., Keefe, D., & Naftolin, F. (2014). The separation of sexual activity and reproduction in human social evolution. Advances in Experimental Medicine and Biology, 814, 159–167.CrossRefGoogle Scholar
  52. Morris, A. (2018). It’s a Theyby! Is it possible to raise your child entirely without gender from birth? Some parents are trying. New York Magazine. Retrieved November 13, 2018 from
  53. Mueller, S. C., De Cuypere, G., & T’Sjoen, G. (2017). Transgender research in the 21st century: A selective critical review from a neurocognitive perspective. American Journal of Psychiatry, 174, 1155–1162.CrossRefGoogle Scholar
  54. Nanda, S. (1999). The Hijras of India: Neither man nor woman (2nd ed.). Belmont, CA: Wadsworth.Google Scholar
  55. Nugent, B. M., Wright, C. L., Shetty, A. C., Hodes, G. E., Lenz, K. M., Mahurkar, A., … McCarthy, M. M. (2015). Brain feminization requires active repression of masculinization via DNA methylation. Nature Neuroscience, 18, 690–697.CrossRefGoogle Scholar
  56. Orlofsky, J. L., Ramsden, M. W., & Cohen, R. S. (1982). Development of the Revised Sex-Role Behavior Scale. Journal of Personality Assessment, 46, 632–638.CrossRefGoogle Scholar
  57. Pernoud, R. (1962). Jeanne d’Arc par elle-même et par ses témoins. Paris: Seuil. (English translation: Joan of Arc: By herself and her witnesses. Lanham, MD: Scarborough House, 1994)Google Scholar
  58. Polderman, T. J. C., Kreukels, B. P. C., Irwig, M. S., Beach, L., Chan, Y.-M., Derks, E. M., … International Gender Diversity Genomics Consortium. (2018). The biological contributions to gender identity and gender diversity: Bringing data to the table. Behavior Genetics, 48, 95–108. Scholar
  59. Prader, A. (1954). Der Genitalbefund beim Pseudohermaphroditismus femininus des kongenitalen adrenogenitalen Syndroms [Genital findings in the female pseudo-hermaphroditism of the congenital adrenogenital syndrome]. Helvetica Paediatrica Acta, 9, 231–248.PubMedGoogle Scholar
  60. Puts, D. (2016). Human sexual selection. Current Opinion in Psychology, 7, 28–32.CrossRefGoogle Scholar
  61. Quigley, C. A., De Bellis, A., Marschke, K. B., el-Awady, M. K., Wilson, E. M., & French, F. S. (1995). Androgen receptor defects: Historical, clinical, and molecular perspectives. Endocrine Reviews, 16, 271–321.PubMedGoogle Scholar
  62. Reed, G. M., Drescher, J., Krueger, R. B., Atalla, E., Cochran, S. D., First, M. B., … Saxena, S. (2016). Disorders related to sexuality and gender identity in the ICD-11: Revising the ICD-10 classification based on current scientific evidence, best clinical practices, and human rights considerations. World Psychiatry, 15, 205–221.CrossRefGoogle Scholar
  63. Reisner, S. L., Deutsch, M. B., Bhasin, S., Bockting, W., Brown, G. R., Feldman, J., … Goodman, M. (2016). Advancing methods for US transgender health research. Current Opinion in Endocrinology, Diabetes, and Obesity, 23, 198–207.CrossRefGoogle Scholar
  64. Reisner, S. L., Greytak, E. A., Parsons, J. T., & Ybarra, M. L. (2015). Gender minority social stress in adolescence: Disparities in adolescent bullying and substance use by gender identity. Journal of Sex Research, 52, 243–256.CrossRefGoogle Scholar
  65. Richards, C., Bouman, W. P., & Barker, M.-J. (Eds.). (2018). Genderqueer and non-binary genders. Basingstoke, UK: Palgrave-Macmillan.Google Scholar
  66. Rind, E., & Jones, A. (2014). Declining physical activity and the socio-cultural context of the geography of industrial restructuring: A novel conceptual framework. Journal of Physical Activity and Health, 11, 683–692.CrossRefGoogle Scholar
  67. Rind, E., Jones, A., & Southall, H. (2014). How is post-industrial decline associated with the geography of physical activity? Evidence from the Health Survey for England. Social Science and Medicine, 104, 88–97.CrossRefGoogle Scholar
  68. Roser, M. (2018). Child mortality. Retrieved November 13, 2018 from
  69. Rubin, D. A. (2017). Intersex matters: Biomedical embodiment, gender regulation, and transnational activism. Albany, NY: State University of New York Press.Google Scholar
  70. Schneider, C., Cerwenka, S., Nieder, T. O., Briken, P., Cohen-Kettenis, P. T., De Cuypere, G., … Richter-Appelt, H. (2016). Measuring gender dysphoria: A multicenter examination and comparison of the Utrecht Gender Dysphoria Scale and the Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults. Archives of Sexual Behavior, 45, 551–558.CrossRefGoogle Scholar
  71. Schwarz, K., Fontanari, A. M. V., Mueller, A., Soll, B., da Silva, D. C., Salvador, J., … Lobato, M. I. R. (2016). Neural correlates of psychosis and gender dysphoria in an adult male. Archives of Sexual Behavior, 45, 761–765.CrossRefGoogle Scholar
  72. Schweizer, K., Brunner, F., Handford, C., & Richter-Appelt, H. (2013). Gender experience and satisfaction with gender allocation in adults with diverse intersex conditions (divergences of sex development, DSD). Psychology & Sexuality, 5, 56–82.CrossRefGoogle Scholar
  73. Shi, L., Zhang, Z., & Su, B. (2016). Sex biased gene expression profiling of human brains at major developmental stages. Scientific Reports, 6, 21181. Scholar
  74. Shutts, K., Kenward, B., Falk, H., Ivegran, A., & Fawcett, C. (2017). Early preschool environments and gender: Effects of gender pedagogy in Sweden. Journal of Experimental Child Psychology, 162, 1–17.CrossRefGoogle Scholar
  75. Singh, D., Deogracias, J. J., Johnson, L. L., Bradley, S. J., Kibblewhite, S. J., Owen-Anderson, A., … Zucker, K. J. (2010). The Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults: Further validity evidence. Journal of Sex Research, 47, 49–58.CrossRefGoogle Scholar
  76. Sinnecker, G. H. G., Hiort, O., Dibbelt, L., Albers, N., Dörr, H. G., Hauß, H., … Kruse, K. (1996). Phenotypic classification of male pseudohermaphroditism due to steroid 5α-reductase 2 deficiency. American Journal of Medical Genetics, 63, 223–230.CrossRefGoogle Scholar
  77. Smith, E. S., Junger, J., Derntl, B., & Habel, U. (2015). The transsexual brain: A review of findings on the neural basis of transsexualism. Neuroscience and Biobehavioral Reviews, 59, 251–266.CrossRefGoogle Scholar
  78. Storms, M. D. (1979). Sex role identity and its relationship to sex role attributes and sex role stereotypes. Journal of Personality and Social Psychology, 37, 1779–1789.CrossRefGoogle Scholar
  79. Tamar-Mattis, S., Gamarel, K. E., Kantor, A., Baratz, A., Tamar-Mattis, A., & Operario, D. (2018). Identifying and counting individuals with differences of sex development conditions in population health research. LGBT Health, 5, 320–324.CrossRefGoogle Scholar
  80. Trevathan, W. R. (2010). Ancient bodies, modern lives. How evolution has shaped women’s health. New York, NY: Oxford University Press.Google Scholar
  81. Trevathan, W. R., Smith, E. O., & McKenna, J. J. (2008). Introduction and overview of evolutionary medicine. In W. R. Trevathan, E. O. Smith, & J. J. McKenna (Eds.), Evolutionary medicine and health: New perspectives (pp. 1–54). Oxford: Oxford University Press.Google Scholar
  82. van der Miesen, A. I. R., Nabbijohn, A. N., Santarossa, A., & VanderLaan, D. P. (2018). Behavioral and emotional problems in gender-nonconforming children: A Canadian community-based study. Journal of the American Academy of Child and Adolescent Psychiatry, 57, 491–499.CrossRefGoogle Scholar
  83. VanderLaan, D. P., Ren, Z., & Vasey, P. L. (2013). Male androphilia in the ancestral environment: An ethnological analysis. Human Nature, 24, 375–401.CrossRefGoogle Scholar
  84. Verfassungsgerichtshof. (2018). Entscheidung G 77/2018. Accessed 30 June 2018.
  85. World Economic Forum. (2017). The global gender gap report 2017. Retrieved December 3, 2108 from
  86. World Health Organization. (2018). ICD-11. Retrieved November 13, 2108 from
  87. Yang, X., Schadt, E. E., Wang, S., Wang, H., Arnold, A. P., Ingram-Drake, L., … Lusis, A. J. (2006). Tissue-specific expression and regulation of sexually dimorphic genes in mice. Genome Research, 16, 995–1004.CrossRefGoogle Scholar
  88. Zalasiewicz, J., Williams, M., Haywood, A., & Ellis, M. (2011). The Anthropocene: A new epoch of geological time? Philosophical Transactions. Series A, Mathematical, Physical, and Engineering Sciences, 369, 835–841. Scholar
  89. Zucker, K. J. (2005). Measurement of psychosexual differentiation. Archives of Sexual Behavior, 34, 375–388.CrossRefGoogle Scholar
  90. Zucker, K. J., Bradley, S. J., Lowry Sullivan, C. B., Kuksis, M., Birkenfeld-Adams, A., & Mitchell, J. N. (1993). A gender identity interview for children. Journal of Personality Assessment, 61, 443–456.CrossRefGoogle Scholar
  91. Zucker, K. J., Cohen-Kettenis, P. T., Drescher, J., Meyer-Bahlburg, H. F. L., Pfäfflin, F., & Womack, W. M. (2013). Memo outlining evidence for change for gender identity disorder in the DSM-5. Archives of Sexual Behavior, 42, 901–914. Scholar
  92. Zucker, K. J., Lawrence, A. A., & Kreukels, B. P. C. (2016). Gender dysphoria in adults. Annual Review of Clinical Psychology, 12, 20.1-20.31.CrossRefGoogle Scholar
  93. Zucker, K. J., Mitchell, J. N., Bradley, S. J., Tkachuk, J., Cantor, J. M., & Allin, S. M. (2006). The Recalled Childhood Gender Identity/Gender Role Questionnaire: Psychometric properties. Sex Roles, 54, 469–483.CrossRefGoogle Scholar

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Authors and Affiliations

  1. 1.Department of Psychiatry, NYS Psychiatric InstituteVagelos College of Physicians and Surgeons of Columbia UniversityNew YorkUSA

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