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As one of our readers helpfully pointed out in reply to Kate’s awesome post and the resulting discussion on the future of feminism, there has been some question about whether or not being trans is still considered to be a mental disorder by the DSM.  In the DSM 5, the current version of the diagnostic and statistical manual that mental health clinicians use in the United States and elsewhere to diagnose their patients, the answer is no, though understanding why requires understanding DSM diagnostic procedures beyond the main criteria.  However, the updated diagnosis, now re-named “Gender dysphoria,” is not without its problems.  And unfortunately, the institutional pathologizing of Trans people and identities does not end with the DSM.

Since I do not identify as Trans, it is not my place to comment on how this impacts people who do.  The goal of this post is solely to shed light on some important things going on in our healthcare system.

This thing is the tip of the iceberg.

This is the tip of the iceberg.

Gender Dysphoria, renamed in 2014 from its original “Gender Identity Disorder” in the DSM-IV, refers to a feeling of distress (dysphoria) caused by a mismatch between a person’s gender identity and the gender identity that others ascribe to them based on visible sex characteristics, though these are not the only characteristics that define a person’s sex – see Luz’s awesome series about this. While the criteria by themselves would certainly pathologize people who identify as trans, the criteria go together with overall guidelines for diagnosis of any mental disorder.  According to these guidelines, an individual must experience either significant distress or significant dysfunction – difficulty with self-care, at work, or in their social life – caused by a condition in order for it to be considered a mental health diagnosis.

For example, an individual might have a compulsion to check the locks on their doors three times every morning before leaving for work.  However, if the checking did not take much time out of their day and the person did not feel upset about needing to check the locks, they would have compulsions typical of Obsessive Compulsive Disorder but would not be diagnosed with OCD. Similarly, a person who felt that their societally-ascribed gender or physical body did not match their self-identified gender, but for whom this was not distressing or impairing their ability to fully live their lives, would not meet for a Gender Dysphoria diagnosis.

Of course, there remains the question: why have Gender Dysphoria as a diagnosis at all, if the issue is the distress itself rather than the gender identity component? Shortly before releasing the DSM 5, the DSM’s committee on gender identity released a statement acknowledging this concern and outlining their reasons for this choice:

Persons experiencing gender dysphoria need a diagnostic term that protects their access to care and won’t be used against them in social, occupational, or legal areas.

When it comes to access to care, many of the treatment options for this condition include counseling, cross-sex hormones, gender reassignment surgery, and social and legal transition to the desired gender. To get insurance coverage for the medical treatments, individuals need a diagnosis. The Sexual and Gender Identity Disorders Work Group was concerned that removing the condition as a psychiatric diagnosis—as some had suggested—would jeopardize access to care.

Like it or not, the mental health care system is entering an era of managed care.  Clinicians who take insurance are obligated to justify the reasons for their treatment, both duration and type, to the insurance company. Without a formal diagnosis for an insurance company to hang their hat on, people can be legally denied coverage for their health needs. Even with a formal diagnosis, patients and providers often have to fight to convince insurance companies about common sense issues, such as extending a 4-month course of treatment by an extra 2 weeks if the patient needs more time with the therapy.  Increasingly, insurance companies are calling the shots about a patient’s treatment, not the care providers.  It is not an unreasonable concern that, given the high levels of transantagonism in our society, Trans individuals needing mental health support, hormone treatments, or surgery would not be able to receive it without a formal diagnosis of some kind.

Additionally, as Hex points out, while current research exploring the biological basis of genderqueer identities is a promising avenue toward affirming people’s Trans identities and guaranteeing medical access, classifying Trans identity as a purely biomedical “condition” poses the risk that individuals who identify as Trans, but who may not have a specific brain structure or hormone profile, could be denied transitional surgery and hormone treatments.  Moreover, Skylar adds, classifying Trans identity as purely biomedical pressures individuals who may not want to make physical changes, such as undergoing surgery or hormone treatment, to do so in order to receive social and legal recognition.

That said, having a mental health-oriented diagnostic label for gender dysphoria is not free of concerns. For example, there is no analogous “Sexual Orientation Dysphoria” diagnosis, despite the significant distress that many people feel when their sexual orientation does not match others’ expectations. Young adults who identify as gay, lesbian, bisexual, pansexual, and Trans are at higher risk of experiencing suicidal thoughts and other types of mental illness.  Yet to my knowledge, insurance will not cover therapy for such distress among LGB individuals until they reach the point of a diagnosable mental illness, such as attempted suicide. While insurance companies are highly excited about prevention for physiological conditions, such as providing full coverage for flu shots, they do not recognize the value of that same prevention approach to mental health. Therefore, it would undoubtedly expand the mental healthcare available to non-Trans LGB youth if Sexual Orientation Dysphoria were an official diagnosis that required insurance companies to cover treatment. It’s true that hormone treatments and surgery are not necessary parts of care for LGB individuals, whereas they are for many who identify Trans; that said, access to mental healthcare is still a big deal.  Receiving access to counseling while feeling distress over a person’s sexual orientation, before that distress becomes more severe, might cause these higher rates of depression, anxiety, substance misuse and attempted suicide to go down.

So the question stands – why would the DSM 5 committee include a diagnosis of Gender Dysphoria, yet no Sexual Orientation Dysphoria?  I’m pretty sure that if we got one of them on the phone and asked, the answer would be to avoid causing or exacerbating societal stigma.  It would be for the same reason that the queer community and medical activists fought for decades to remove homosexuality from being listed as a mental illness in the DSM.  If the thought of including a Sexual Orientation Dysphoria within the DSM makes us squirm, then is the switch from Gender Identity Disorder to Gender Dysphoria, which maintains aspects of Trans identity as part of the criteria for a mental illness within the DSM, truly unproblematic?  On the other hand, as Luz points out, “there’s a difference between ‘sexual orientation dysphoria’ and gender dysphoria in that gender dysphoria often involves a physical feeling of alienation and disconnect from one’s own body, thus a need for hormones/surgery.  That’s something that doesn’t necessarily have to do with societal stigma (though of course it’s informed by it).”

Lastly, although the DSM is the most popular diagnostic manual in the United States, the international healthcare community uses the International Statistical Classification of Diseases and Related Health Problems (ICD-10). The ICD-10 is a recognized diagnostic manual within the United States for mental health diagnoses, and its codes are used in medical centers here.  It is endorsed by the World Health Organization.  In the ICD-10, what the DSM now calls “Gender Dysphoria” is still listed under Gender Identity Disorders as “Transsexualism,” a title that clearly pathologizes Trans identity rather than any accompanying distress. Criterion C specifies that the conditions in A and B, of desiring to live as the “opposite sex” (erasing the experiences of intersex individuals) and feeling this way for at least 2 years, must not be “a symptom of another mental disorder.”  Unlike in the DSM 5, there is no ambiguity: the ICD-10 explicitly lists being Trans as a mental disorder.

The ICD-10 codes, combinations of letters and numbers with no identifiable meaning, are required for use in medical centers throughout the United States for billing purposes. However, mental health clinicians in the U.S. use DSM 5 labels and diagnostic criteria for the diagnosis itself. The purpose of the ICD-10 codes is so that if a patient travels internationally, their diagnosis can be communicated to healthcare providers there.  If a Trans person needs care outside the U.S., their clinician will be most familiar with, and likely use, the diagnoses and criteria that correspond with the ICD-10 codes.  Internationally, the ICD is used more widely than the DSM to diagnose patients seeking care, while the reverse is true for research.

Being Trans may no longer be listed as a mental disorder in the DSM 5, but institutional pathologization of Trans people and their identities does not end there.  It remains significant and pervasive throughout the international health community.  We have a long way to go.

Since I do not identify as Trans, my part in the conversation ends here. I can give you my take on what’s going on in the DSM and ICD, but it’s not my place to speak for people who live with this situation as their daily reality. If you are a Trans person who would like to share your experiences and feelings about how this impacts you, please consider doing so in the comments below or contacting us to write a guest post.  We want to hear your voice.