The DSM, ICD and Transgender Pathologization

The Diagnostic and Statistical Manual of Mental Disorders (DSM) has been targeted by transgender advocates as a source of pathologization for transsexuals and transgender people (TSTG). The DSM is used by those attacking TSTG people when they assert that TSTG have a mental illness that should be treated instead of granting them their civil and political rights. Some hatemongers also assert the TSTG, like homosexuality can be cured. Transgender advocates point to the total deletion of homosexuality from the DSM in 1973 as a milestone in depathologization of homosexuality as a model for progress in TSTG depathologization. Members of the American Psychiatric Association (APA), which develops the DSM, are pushing back. What is this controversy all about, anyway? I did some investigation and found some surprising facts. I also found some dirty little secrets about the DSM. Turns out the DSM is a sham and is irrelevant to the real issues.

First, here are the basics. The DSM is basically a list of mental disorders with numeric codes that are used in billing insurance and in accounting in government health services. It is a way psychiatrists and psychologists to get paid for treating mental disorders — or so it would appear. In the truth is something else which I will discuss below. There have been five iterations of the DSM and the current one is DSM-5. There are currently four billing codes associated with TSTG behavior in the DSM. In the DSM-5 (sometimes referred to as DSM-V) they are gender dysphoria in children, gender dysphoria in adults, autogynephilia fetishism, and transvestic fetishism.

Feeling the heat from transgender advocates, it was with great fanfare that the APA replaced gender “identity disorders” with gender “dysphorias” in the DSM-5 this year. However, this was not such a big a victory for TSTG as it seemed.

For one, the gender dysphorias are still in the DSM-5 and the last two words in the DSM title are still “Mental Disorders.” Until the dysphoria categories are removed from the DSM altogether, they still indicate that TSTG people are mentally ill. Some argue that removal of these categories would prevent treatment of TSTG. They argue that TSTG could not get counseling to deal with the problems of TSTG. The counter argument is that there are lots of other non-pejorative billing categories that could be used. Indeed, although homosexuality is not in the DSM, homosexuals can still get counseling help. My experience supports this counter argument. I have been seeing psychologists since about 1991 for counseling and not once was a TSTG billing category used. I needed the counseling to help deal with my feelings of loneliness and anxiety, not to “cure” me of TSTG behavior which gave me peace.

The next reason that the dropping of “gender identity disorders” was not such a big victory is the retention of the autogynephilia fetishism and the transvestic fetishism billing categories in the DSM. No way is TSTG caused by these pseudo-scientific theories pointing to sexual arousal as the motivation for TSTG! They are not real scientific theories because they do not make predictions which can be tested. And the World Professional Association for Transgender Health (WPATH), the international group which sets guidelines for transgender treatment, agrees with me. They have said that there is not enough evidence to support autogynephilia to leave it in the DSM. Although, as we know, crossdressing can result in sexual arousal, the evidence indicates that this not sufficient to maintain crossdressing behavior. The sexual arousal fades with exposure and time and TSTG report that sexual arousal is not the reason that they crossdress. The obvious reason that these pejorative categories persist in the DSM-5 is that certain psychiatrists were on the APA committee on TSTG issues and they wanted support for their non-scientific theories.

The third reason that dropping “gender identity disorders” is not such a big victory is that the DSM still allows treating TSTG children and adults with “reparative therapies” a practice banned by WPATH. The DSM allows such “therapies” to be billed. Similar “therapies” for treating homosexuality have been banned by law in several U.S. states. Again, the reason that such therapies are allowed is due to the fact that they are practiced by some of the psychiatrists on the TSTG DSM task force

The final reason that we should not declare victory over the change to “gender dysphoria” is that, frankly, the DSM is a sham. It turns out that since 2003, the International Statistical Classification of Diseases and Related Health Problems (ICD) has been the governing insurance coding scheme in the United States and around the world. The ICD covers a wide range of phenomena, not just mental disorders. The ICD is developed by the World Health Organization and is the official coding scheme of the United States government because the ICD and not the DSM is compliant with Federal healthcare privacy law. It alone is compliant with the 1996 Healthcare Insurance Portability and Accountability, otherwise known as HIPAA.

So what happens to DSM coding? Turns out that since 2003, there has been a “harmonization” between the DSM and ICD, meaning that each DSM code points to an ICD code. Each DSM code is converted to an ICD code before submission for payment in the U.S. This is the dirty little secret about the DSM. The current ICD observed in the U.S., the ICD-9 contains only the “gender identity disorders” and not the “gender dysphorias” codes. The same applies to the ICD-10 which takes effect in October 2015 for the U.S but has been in effect in most other countries for many years. Although the “harmonization” of the DSM and ICD is held is secret, it is likely that the DSM “gender dysphorias” codes are converted to “gender identity disorder” codes before submission. So deletion of “gender identity disorder” and substitution of “gender dysphoria” in the DSM-5 is so much eyewash. The only good news about the ICD is that “autogynephilia” is not included in ICD-9 and ICD-10 but, however, “transvestic fetishism” is still included.

A new ICD-11 is currently under study and some of the study participants insist that it will be less pathologizing to TSTG. But the task force of psychiatrists have not proposed to delete TSTG categories altogether. Their rationale is that counseling and medical treatment of TSTG requires ICD categories. But as I pointed out above there is no reason why counseling to help TSTG deal with interpersonal problems should have separate categories from non-TSTG counseling and there is another way to handle medical treatment for transsexuals.

Transgender advocates should not waste their time trying to change the DSM because it has already been superseded by the ICD. We can expect that it will disappear in the future since it has no real significance. Instead their attention should be addressed towards the next iteration of the ICD which is ICD-11. Their goals ought to be to eliminate all TSTG categories and add codes for medical treatment of transsexuals in the categories reserved for hormone administration or plastic surgeries required for congenital conditions. As I have previously indicated that there is good evidence for DNA heritability and epigenetics as causal factors for TSTG. Insurance companies will cover treatments for congenital conditions. For example, many members of my wife’s family get bunions on their big toes because of their DNA. Not just the females in the family have them; all the males have them too. Although insurance will not cover bunions due to wearing high heels, they will cover congenital bunions. (It is not likely that all the males in her family wore high heels because they were transgender males or drag queens.)

We should be trying to get effective change by influencing the development of ICD-11 to depathologize TSTG coverage. The DSM is a sham and trying to change it is a waste of effort.

Tags: DSM-5, featured, gender dysphoria, gender identity disorder, ICD

Category: Transgender Body & Soul, Transgender Opinion