Medical classification and diagnostic criteria for transsexualism The two relevant classification manuals used by health care professionals world-wide are the international ICD and the US-American DSM. They are both quite important for transsexuals, as they are typically directly used to diagnose transsexualism and provide the basis for health care plans specific to countries or health care associations. The ICD (“International Statistical Classification of Diseases and Related Health Problems”; or short “International Classification of Diseases”) is maintained by the World Health Organisation (WHO), the health authority within the United Nations. It provides a complete system for classifying all diseases that affect humans. ICD-10, the current version was published in 1992; an updated version, ICD-11, is planned for 2017. The DSM (“Diagnostic and Statistical Manual of Mental Disorders”) is published by the American Psychiatric Association and offers standard criteria for the classification of mental disorders. The latest version, DSM-5, was released in 2013. Their diagnostic criteria and categorisations are provided below. For the mismatch between the physical sexual characteristics/the assigned gender at birth and the gender a person identifies with, the ICD uses the terms “gender identity disorder” and “transsexualism”, the DSM calls it “gender dysphoria” ICD-10
The International Classification of Diseases (ICD), published by the World Health Organization is the standard diagnostic tool for epidemiology, health management and clinical purposes. It is used to classify diseases and other health problems recorded on many types of health and vital records including death certificates and health records. The current version, ICD-10, came into effect in 1994 and is planned to be replaced by ICD-11 in 2015. The diagnosis “transsexualism” is categorised under the sub-chapter of “gender identity disorders” together with “dual-role transvestism” and “gender identity disorder of childhood”. The terminology and classification reflects the state of science in 1990, when ICD-10 was developed. The DSM-5 in comparison, published in 2013, has benefitted from more than twenty years of additional research. Chapter V in ICD-10 lists “mental and behavioural disorders”, coded as F00 to F99. The sub-block F60 to F69 lists “disorders of adult personality and behaviour”. The ICD gives the following introduction to this block: “This block includes a variety of conditions and behaviour patterns of clinical significance which tend to be persistent and appear to be the expression of the individual's characteristic lifestyle and mode of relating to himself or herself and others. Some of these conditions and patterns of behaviour emerge early in the course of individual development, as a result of both constitutional factors and social experience, while others are acquired later in life. Specific personality disorders (F60.-), mixed and other personality disorders (F61.-), and enduring personality changes (F62.-) are deeply ingrained and enduring behaviour patterns, manifesting as inflexible responses to a broad range of personal and social situations. They represent extreme or significant deviations from the way in which the average individual in a given culture perceives, thinks, feels and, particularly, relates to others. Such behaviour patterns tend to be stable and to encompass multiple domains of behaviour and psychological functioning. They are frequently, but not always, associated with various degrees of subjective distress and problems of social performance.”
A desire to live and be accepted as a member of the opposite sex, usually accompanied by a sense of discomfort with, or inappropriateness of, one's anatomic sex, and a wish to have surgery and hormonal treatment to make one's body as congruent as possible with one's preferred sex. The wearing of clothes of the opposite sex for part of the individual's existence in order to enjoy the temporary experience of membership of the opposite sex, but without any desire for a more permanent sex change or associated surgical reassignment, and without sexual excitement accompanying the cross-dressing. Gender identity disorder of adolescence or adulthood, nontranssexual type Excludes: Fetishistic transvestism (F65.1) A disorder, usually first manifest during early childhood (and always well before puberty), characterized by a persistent and intense distress about assigned sex, together with a desire to be (or insistence that one is) of the other sex. There is a persistent preoccupation with the dress and activities of the opposite sex and repudiation of the individual's own sex. The diagnosis requires a profound disturbance of the normal gender identity; mere tomboyishness in girls or girlish behaviour in boys is not sufficient. Gender identity disorders in individuals who have reached or are entering puberty should not be classified here but in F66.-. Excludes: Egodystonic sexual orientation (F66.1); Sexual maturation disorder (F66.0) Gender-role disorder NOS
Includes: Paraphilias [This sub-chapter categorises fetishism; fetishistic transvestism; exhibitionism; voyeurism; paedophilia; sadomasochism; multiple disorders of sexual preference; other disorders of sexual preference; disorder of sexual preference, unspecified. Only some of the categories are listed below.] The wearing of clothes of the opposite sex principally to obtain sexual excitement and to create the appearance of a person of the opposite sex. Fetishistic transvestism is distinguished from transsexual transvestism by its clear association with sexual arousal and the strong desire to remove the clothing once orgasm occurs and sexual arousal declines. It can occur as an earlier phase in the development of transsexualism. Transvestic fetishism Sometimes more than one abnormal sexual preference occurs in one person and there is none of first rank. The most common combination is fetishism, transvestism and sadomasochism. Sexual deviation NOS
Note: Sexual orientation by itself is not to be regarded as a disorder. The patient suffers from uncertainty about his or her gender identity or sexual orientation, which causes anxiety or depression. Most commonly this occurs in adolescents who are not certain whether they are homosexual, heterosexual or bisexual in orientation, or in individuals who, after a period of apparently stable sexual orientation (often within a longstanding relationship), find that their sexual orientation is changing. The gender identity or sexual preference (heterosexual, homosexual, bisexual, or prepubertal) is not in doubt, but the individual wishes it were different because of associated psychological and behavioural disorders, and may seek treatment in order to change it. The gender identity or sexual orientation (heterosexual, homosexual, or bisexual) is responsible for difficulties in forming or maintaining a relationship with a sexual partner.
The ICD homepage (http://www.who.int/classifications/icd/en/) provides not only the current version of the catalogue (http://apps.who.int/classifications/apps/icd/icd10online/), but also additional guidelines for using the ICD. Two relevant documents are: The ICD-10 Classification of Mental and Behavioural Disorders
The 11th version of International Statistical Classification of Diseases and Related Health Problems (ICD-11) is scheduled for publication in 2015 by the World Health Organization. In this new version, it is planned to to create a new non-psychiatric chapter, called “Certain conditions related to sexual health”. The relevant categories within this chapter will be called “Gender incongruence”. This moves transsexuality out of the Mental and Behavioural Disorders chapter (called F-Codes) entirely and clarifies that it is no longer a mental disorder coding. Source: http://gidreform.wordpress.com/2013/06/13/gid-reform-in-the-dsm-5-and-icd-11-a-status-update/ More information: http://gidreform.wordpress.com/
The Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association, provides a common language and standard criteria for the classification of mental disorders. It is used, or relied upon, by clinicians, researchers, psychiatric drug regulation agencies, health insurance companies, pharmaceutical companies, the legal system, and policy makers. The current version, published in May 2013, is the DSM-5. In DSM-5, people whose gender at birth is contrary to the one they identify with will be diagnosed with “gender dysphoria”. This is a revision of the “gender identity disorder” category in DSM-IV. The Greek word “dysphoria” means discontent, feeling unwell or unhappy. It was chosen as a neutral description of the condition, to avoid making a value judgement, which is seen as inherent in the word “disorder”. Another term under discussion for DSM-5 was “gender incongruence”. The American Psychiatric Association makes it clear that gender nonconformity is not in itself a mental disorder. Only when clinically significant distress is also present, the diagnosis gender dysphoria is applied. In DSM-IV, gender identity disorder was grouped in the chapter “Sexual and Gender Identity Disorders” together with three relatively disparate diagnostic classes: gender identity disorders, sexual dysfunctions, and paraphilias. Gender identity disorder, however, is neither a sexual dysfunction nor a paraphilia. To reflect the current state of science which shows gender dysphoria to be a unique condition, gender dysphoria is now categorised separately as a new diagnostic class in DSM-5. The code for gender dysphoria is 302.85; gender dysphoria in children is coded separately as 320.6.
[Categories are: gender dysphoria (in adolescents or adults; gender dysphoria (in children); other specified gender dysphoria; unspecified gender dysphoria.] A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested by 2 or more of the following indicators: 1. A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or, in young adolescents, the anticipated secondary sex characteristics) [13, 16] 2. A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or, in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics) [17] 3. A strong desire for the primary and/or secondary sex characteristics of the other gender 4. A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender) 5. A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender) 6. A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender) B. The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning, or with a significantly increased risk of suffering, such as distress or disability. Subtypes
Specifier Post-transition, i.e., the individual has transitioned to full-time living in the desired gender (with or without legalization of gender change) and has undergone (or is undergoing) at least one cross-sex medical procedure or treatment regimen, namely, regular cross-sex hormone treatment or gender reassignment surgery confirming the desired gender (e.g., penectomy, vaginoplasty in a natal male, mastectomy, phalloplasty in a natal female). [The post-transition specifier has been added because after gender transition, many people no longer meet the criteria for gender dysphoria, but remain in need of treatments to improve life in the desired gender.] [The creation of a specific diagnosis for children reflects the lesser ability of children to have insight into what they are experiencing and ability to express it in the event that they have insight.] A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested by at least 6 of the following indicators (including A1): 1. A strong desire to be of the other gender or an insistence that he or she is the other gender 2. In boys, a strong preference for cross-dressing or simulating female attire; in girls, a strong preference for wearing only typical masculine clothing and a strong resistance to the wearing of typical feminine clothing 3. A strong preference for cross-gender roles in make-believe or fantasy play 4. A strong preference for the toys, games, or activities typical of the other gender 5. A strong preference for playmates of the other gender 6. In boys, a strong rejection of typically masculine toys, games, and activities and a strong avoidance of rough-and-tumble play; in girls, a strong rejection of typically feminine toys, games, and activities 7. A strong dislike of one’s sexual anatomy 8. A strong desire for the primary and/or secondary sex characteristics that match one’s experienced gender Subtypes
[Categories are: Delayed Ejaculation; Erectile Disorder; Female Orgasmic Disorder; Female Sexual Interest/Arousal Disorder; Genito-Pelvic Pain/Penetration Disorder; Male Hypoactive Sexual Desire Disorder; Premature (Early) Ejaculation; Substance/Medication-Induced Sexual Dysfunction; Other Specified Sexual Dysfunction; Unspecified Sexual Dysfunction.]
[Most people with atypical sexual interests do not have a mental disorder. For the diagnosis of a paraphilic disorder, the condition must reduce the patient’s quality of life or have the potential to harm others. With this in kind, DSM-5 clearly distinguishes between atypical sexual interests and mental disorders. Eight disorders were chosen for listing in DSM-5. It is recognized that many more paraphilias than those listed have been identified and described. Categories are: exhibitionistic disorder; fetishistic disorder; frotteuristic disorder; pedophilic disorder; sexual masochism disorder; sexual sadism disorder; transvestic disorder; voyeuristic disorder; other specified paraphilic disorder; unspecified paraphilic disorder. Only one category is listed below.] [For transvestic disorder, which identifies people who are sexually aroused by dressing as the opposite sex but who experience significant distress or impairment in their lives—socially or occupationally—because of their behavior. DSM-IV limited this behavior to heterosexual males; DSM-5 has no such restriction, opening the diagnosis to women or gay men who have this sexual interest. While the change could increase the number of people diagnosed with transvestic disorder, the requirement remains that individuals must experience significant distress or impairment because of their behavior.] A. Over a period of at least six months, in a male, recurrent and intense sexual fantasies, sexual urges, or sexual behaviors involving cross‑dressing. B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Specifier
Specifier
Official homepage of the DSM-5: http://www.dsm5.org/ |