SAN FRANCISCO – 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 such as 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,” said Kelley Winters, a Colorado scholar who has helped lead the push for changes.