Medical textbook changes definition of 'gender dysphoria' after citation in Florida's guidelines on 'trans' youth

After Florida's Surgeon General Dr. Joseph Ladapo issued guidance rejecting the Biden administration's "affirmation only" approach for "gender dysphoria," the world's bestselling medical textbook removed the definition of "gender dysphoria" from its website.

That April 20 guidance from Florida cited the Merck Manual of Diagnosis and Therapy, which stated that: "gender dysphoria is characterized by a strong, persistent cross-gender identification associated with anxiety, depression, irritability, and often a wish to live as a gender different from the one associated with the sex assigned at birth."

Florida had cited the book in guidance recommending against gender transitions for children. The Merck Manual apparently asked Florida to adjust their guidance after the definition was changed after the citation.

Ladapo shared the message from Merck Manuals on Twitter, saying "Where have we seen this before? Political activism disguised as scientific advancement. Medicine cannot be a weapon used to divide communities, and Florida's guidance will not change due to political pressure."

Per the tweet, Merck wrote:

"We saw that you recently cited the Merck Manuals in the recent DOH Treatment of Gender Dysphoria for Children and Adolescents Guidelines that went out on April 20th. We were in the process of updating our online chapter on that subject so I wanted to make sure you had the latest information. This information is reflected in your active link Merck Manuals in the guidelines, but some of the verbiage you reference in quotes has not been omitted as a result of the update which went live on our site at the end of April.

"Below," the email continued, "is the language that we would like removed from the guidelines since the chapter link so longer has that language as per the update. We are happy to have you link and in fact appreciate it since our independent author on the topic is very well respected in the area of transgender medicine and on the WPATH board. We typically grant permission for links to our content, but it is not absolutely necessary since we are a free resource.

"However, in this instance, I could have checked and told you the content was being updated. We wouldn't want your guidelines to be incorrect as the reference in the quotes (below in yellow) includes content that has changed. We would appreciate it if you could update the guidelines by removing the sentence in yellow below."

Prior to the removal, the manual specified that "Gender dysphoria is characterized by a strong, persistent cross-gender identification associated with anxiety, depression, irritability, and often a wish to live as a gender different from the one associated with the sex assigned at birth."

The professional version of the Merck Manual has a lengthy section on gender dysphoria. The consumer version also described gender dysphoria. Under the "sex, gender, and identity section," definitions relating to gender identity are laid out.

The section on gender dysphoria that follows shows an adjusted definition:

"Gender dysphoria: For most people, there is congruity between their biologic (birth) sex, gender identity, and gender role. However, those with gender dysphoria experience some degree of incongruity between their birth sex and their gender identity.

"Gender incongruity, or gender nonconformity, itself is not considered a disorder. Some members of the transgender community consider even extreme forms of gender nonconformity to be simply a normal variant in human gender identity and expression. However, when the perceived mismatch between birth sex and felt gender identity causes someone significant distress or disability, a diagnosis of gender dysphoria may be appropriate—the focus being on the person's distress rather than on the presence of gender incongruity. The distress is typically a combination of anxiety, depression, and irritability. People with severe gender dysphoria, previously referred to as transsexual people, may experience severe, disturbing, and long-standing symptoms and usually have a strong wish to change their body medically and/or surgically to make their body more closely align with their gender identity."

Merck Manuals go into the symptoms of gender dysphoria in children, saying: "Childhood gender dysphoria often manifests by age 2 to 3 years. Children with gender dysphoria commonly do the following: Prefer cross-dressing, Insist that they are of the other sex, Wish that they would wake up as the other sex, Prefer participating in the stereotypical games and activities of the other sex, Have negative feelings toward their genitals."

"For example, a young girl may insist she will grow a penis and become a boy; she may stand to urinate. A boy may fantasize about being female and avoid rough-and-tumble play and competitive games. He may sit to urinate and wish to be rid of his penis and testes. For boys, distress at the physical changes of puberty is often followed by a request during adolescence for feminizing somatic treatments. Most children with gender dysphoria are not evaluated until they are age 6 to 9, at a point when gender dysphoria is already chronic."

Florida stands firm against the social or medical gender transition of children.