COMMENTARY

New Diagnostic Codes Lessen Stigma for Transgender People

Jack Drescher, MD

Disclosures

September 11, 2017

Hi. I am Dr Jack Drescher, clinical professor of psychiatry at Columbia University in New York City and Distinguished Life Fellow of the American Psychiatric Association. I am here to talk a bit about my work on the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which came out in 2013, and the International Classification of Diseases, 11th edition (ICD-11), which is scheduled for publication in 2018.

I was a member of the DSM-5 workgroup on sexual and gender-identity disorders. That committee was charged with revising what the DSM-IV called sexual and gender-identity disorders. My particular sub-workgroup, which focused specifically on gender-identity disorders, was asked to reconcile calls to remove the diagnosis from the DSM because of its stigmatizing nature, similar to the removal of homosexuality as a diagnosis from the DSM-II in 1973.

Our workgroup concluded, however, that removal of the diagnosis could be quite problematic because in order to access services, you need a diagnosis. We were caught between access to care and the stigma associated with a psychiatric diagnosis. Stigma is not reason enough to remove a mental disorder diagnosis if one needs one.

We decided that we could not simply remove sexual and gender-identity disorders from the manual. Some suggested that we classify it with a V-code. As many of you know, V-codes are used for conditions that are not psychiatric disorders but may come to the attention of a mental health professional. But these conditions are not reimbursable by most insurance companies or by many national healthcare systems, and are not seen as requiring reimbursement. Thus, we could not classify it with a V-code. Instead, we decided to retain the diagnosis but make some changes that would reduce stigma.

Small, Meaningful Changes

One way to reduce stigma was to remove the word "disorder." We changed the name from gender-identity disorder to gender dysphoria. Gender dysphoria was a preexisting term in the literature. Many people who work in this area are aware of the term, and many people who opposed having a gender-identity disorder diagnosis were happy with the name change.

We also tried to narrow the diagnostic criteria, with the idea that you do not want to give people a diagnosis when they do not want one, and to reduce the number of false positives. We made the diagnostic criteria a bit stricter than in the DSM-IV.

Suppose a person with gender dysphoria undergoes treatment and has a legal name change. That person is no longer gender dysphoric. Does that mean that they do not have a diagnosis? True, they do not have symptoms of gender dysphoria, but they would have symptoms if they had not received the treatment. We introduced the notion of a post-transition specifier to the diagnostic manual. A person who has had treatment, who is not dysphoric but used to be dysphoric, can still have a diagnosis code. This was how we solved that problem in the DSM.

In addition, we removed the specifier for sexual orientation. There was a time when it mattered, for some reason, whether a person's sexual orientation was involved in making the decision to transition. For example, in the middle of the 20th century, if you were born a man, assigned male at birth, and you were attracted to women but you believed yourself to be a woman and wanted to undergo a transition, you could not tell the doctors that you were attracted to women. The doctors were only involved in making heterosexuals at the end of the treatment. They were not going to make any lesbians or gay men by transitioning people who, at the end, would be attracted to the same gender. That is not the case in terms of how clinicians practice today, but that was the case then. Thus, we removed the sexual orientation specifier because it is irrelevant to clinical work. Those were some of the DSM changes.

We also made a slight change at the international level. The World Health Organization's ICD-11 will come out in 2018. There was more flexibility in the ICD compared with the DSM, where a diagnosis is either in or out. The ICD includes all diagnoses, psychiatric and medical. The recommendation, which has been followed, is that the new diagnosis, called gender incongruence, will be moved from the mental disorder section to another chapter, called "Conditions Related to Sexual Health." This allows countries that have national healthcare systems to have a diagnosis code, to continue to provide care for people, and to reduce the stigma of a mental disorder.

Transgender people are a highly stigmatized patient population. This is one way to reduce the stigma. In reality, we do not know what causes transgender presentations. We do not know whether it is psychological or medical, just as we do not know why people are cisgender (non-transgender). The change offers a new diagnosis: gender incongruence.

Thanks for listening to me. This is Dr Jack Drescher.

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