"Does a woman who strongly believes she was meant to be a man have a mental condition or a medical problem? Is a man who cross-dresses in need of psychological help? What about a boy who pretends to be a girl in make-believe games and chooses only female playmates?

The nation’s psychiatric establishment is wrestling with these questions, among others, as it works to overhaul its diagnostic manual for the first time in almost two decades. Advocates have spent years lobbying the American Psychiatric Association to rewrite or even remove the categories typically used to diagnose transgender people, arguing that terms like Gender Identity Disorder and Transvestic Fetishism promote discrimination by broad-brushing a diverse population with the stigma of mental illness.

“The label of mental defectiveness really places a burden on trans people to continually prove our competence in our affirmed roles,” Kelley Winters, a Colorado scholar who has helped lead the push for changes, said.

Although the association’s new Diagnostic and Statistical Manual of Mental Disorders is not scheduled to be printed until the end of the year, the updates are taking shape after three rounds of proposed changes. Professionals who have been part of or closely observing the amendment process say the latest wording, while not going as far as many advocates wanted, respects the broader shift in society’s understanding and acceptance of what it means to be transgender since the last major revision of the manual was published in 1994.

“All psychiatric diagnoses occur within a cultural context,” New York psychiatrist Jack Drescher, a member of the APA subcommittee working on the issue, said. “We know there is a whole community of people out there who are not seeking medical attention and live between the two binary categories (of male and female.) We wanted to send the message that the therapist’s job isn’t to pathologize.”"