I prepared this presentation for the 2013 Philadelphia Transgender Health Conference but did not have the opportunity to attend. It is a summary of recent changes to gender related diagnostic categories in the DSM-5, published last month by the American Psychiatric Association, and proposed changes for the ICD-11, scheduled for publication in 2015 by the World Health Organization. It is based on proposed revisions to the ICD-11 presented by Drs. Geoffrey Reed, Peggy Cohen-Kettenis and Richard Krueger at the National Transgender Health Summit in Oakland last month and on discussions at the Global Action for Trans* Equality (GATE) Civil Society Expert Working Group in Buenos Aires last April.
In my view, there are two primary issues in medical diagnostic policy for trans people. The first is harmful stigma and false stereotyping of mental defectiveness and sexual deviance, that was perpetuated by the former categories of Gender Identity Disorder (GID) and Transvestic Fetishism (TF) in the DSM-IV-TR. The second is access to medically necessary hormonal and/or surgical transition care, for those trans and transsexual people who need them. The latter requires some kind of diagnostic coding, but coding that is congruent with medical transition care, not contradictory to it. I have long felt that these two issues must be addressed together –not one at the expense of the other, or to benefit part of the trans community at the expense of harming another.
The DSM-5 Falls Short, Despite Some Significant Improvements
The new revisions for the Gender Dysphoria diagnosis in the DSM-5 are mostly positive. However they do not go nearly far enough. The change in title from Gender Identity Disorder (intended by its authors to mean “disordered” gender identity) to Gender Dysphoria (from a Greek root for distress) is a significant step forward. It represents a historic shift from gender identities that differ from birth assignment to distress with gender assignment and associated sex characteristics as the focus of the problem to be treated. This message is reinforced by the August 2012 Public Policy Statement from the American Psychiatric Association, affirming the medical necessity of hormonal and/or surgical transition care. In another positive change, the Gender Dysphoria category has been moved from the Sexual Disorders chapter of the DSM to a new chapter of its own. Non-binary queer-spectrum identities and expression are now acknowledged in the diagnostic criteria, and the APA Working Group has rejected pressure to add an “autogynephilia” specifier to falsely stereotype and sexualize trans women. Children can no longer be falsely diagnosed with this mental disorder label, strictly on the basis of nonconformity to birth assignment.
However, the fundamental problem remains that the need for medical transition treatment is still classed as a mental disorder. In the diagnostic criteria, desire for transition care is itself cast as symptomatic of mental illness, unfortunately reinforcing gender-reparative psychotherapies which suppress expression of this “desire” into the closet. The diagnostic criteria still contradict transition and still describe transition itself as symptomatic of mental illness. The criteria for children retain much of the archaic sexist language of the DSM-IV-TR that psychopathologizes gender nonconformity. Moreover, children who have happily socially transitioned are maligned by misgendering language in the new diagnosis.
More troubling is false-positive diagnosis for those who have happily completed transition. Thus, the GD diagnosis, and its controversial post-transition specifier, continue to contradict the proven efficacy of medical transition treatments. This contradiction may be used to support gender conversion/reparative psychotherapies– practices described as no longer ethical in the current WPATH Standards of Care.
Finally, the Transvestic Disorder category in the DSM-5 is even more harmful than its predecessor, Transvestic Fetishism. Punitive and scientifically capricious, it only serves to punish nonconformity to assigned birth roles and has no relevance to established definition of mental disorder. The Transvestic Disorder category has been expanded in the DSM-5 to implicate trans men as well as trans women, with a new specifier of “autoandrophilia,” apparently pulled from thin air without supporting research or clinical evidence.
The ICD-11, a Historic New Approach
The 11th Revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-11) is scheduled for publication in 2015 by the World Health Organization (WHO). It is a global diagnostic manual that contains chapters for both physical medical conditions and mental conditions. In contrast to the DSM-5, the ICD-11 holds promise for unprecedented forward progress on both issues of social stigma and barriers to medical transition care. At the National Transgender Health Summit in Oakland last month, members of the ICD-11 Working Group for Sexual Disorders and Sexual Health confirmed proposals for substantive changes in gender and transition related codings.
The Working Group has proposed a historic shift of transition related categories, now labeled “Gender Incongruence,” out of the Mental and Behavioural Disorders chapter (called F-Codes) entirely. It is to be placed in a new, non-psychiatric chapter, called “Certain conditions related to sexual health.” The Incongruence title is distinct from DSM-5 dysphoria title, to clarify that this is no longer a mental disorder coding. They have also proposed to eliminate victimless sexual paraphilia categories from the manual, including: F65.1: Transvestic fetishism. A similar category describing dual gender individuals, F64.1: Dual-role Transvestism, would be deleted as well. These changes have the potential for enormous progress in reducing both stigma and barriers to medical transition care, for those who need it. When implemented, they would effectively obsolete the new psychopathology categories of Gender Dysphoria and Transvestic Disorder in the DSM-5.
There are also questions and shortcomings in the current ICD-11 proposals. While the proposed children’s coding of Gender Incongruence of Childhood is no longer a mental disorder label, any pathologizing coding of happy gender nonconforming or socially transitioned children, who are too young to need any medical transition or puberty-blocking treatment, is highly controversial among clinicians, families and community members. The diagnostic criteria for children, like those in the DSM-5, still emphasize nonconformity to anachronistic gender stereotypes as symptomatic of sickness. The adult and adolescent criteria have copied ambiguous language from the DSM-5 that cast desire for transition, in itself, as pathological. Worse yet, false-positive diagnosis of happy post-transition subjects inadvertently contradicts rather than supports medical transition care.
The ICD-11 Working Group for Sexual Disorders and Sexual Health should be commended for advancing these historic reforms. However, it is important that Group members listen to the remaining concerns of community members and supportive care providers. Adults and adolescents needing access to medical transition care, or pubescent youth needing puberty blocking medications, require a clearer description of the problem to be treated. Young children, who may only need information, monitoring and support, have very different diagnostic needs and diagnostic risks than adults and adolescents.