From Gender Madness to Gender From Gender Madness to Gender Wellness in the ICD-11Wellness in the ICD-11

Kelley Winters, Ph.D.Kelley Winters, Ph.D.GID Reform AdvocatesGID Reform Advocates

Global Action for Trans* EqualityGlobal Action for Trans* Equality

Photo by Kelley Winters Images Photography

From Gender Madness to Gender Wellness in the ICD-11

Global Action for Trans* Equality (GATE)

Civil Society Expert Working Group

Buenos Aires, April 4-6, 2013

. Photo by Kelley Winters Images Photography

Recommendation for trans* related codings

The Challenge: Gender Diversity nomenclature in the DSM and ICD has historically emphasized

enforcement of birth-assigned gender roles

“The expression of gender characteristics, including identities, that are not stereotypically associated with one’s assigned sex at birth is a common and culturally-diverse human phenomenon which should not be judged as inherently pathological or negative...”

--May, 2010, WPATH Board of Directors

Principle 1: Depsychopathologization

Principle 2: Medical Necessity of Transition Care

“An established body of medical research demonstrates the effectiveness and medical necessity of mental health care, hormone therapy and sex reassignment surgery as forms of therapeutic treatment...”

“Health experts in GID, including WPATH, have rejected the myth that such treatments are ‘cosmetic’ or ‘experimental’ and have recognized that these treatments can provide safe and effective treatment for a serious health condition.”

American Medical Association Resolution 122 (2008)

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Stop Trans Pathologization Movement Protest, Barcelona, 2010Stop Trans Pathologization Movement Protest, Barcelona, 2010

Principle 3: Human Rights and Self Determination Models of Gender Diversity and Transition

History of Gender Dx in the DSM

➢DSM-I (1952) none➢DSM-II (1968) Sexual Deviations: Transvestitism➢DSM-III (1980) Psychosexual Disorders: Transsexualism➢Gender identity disorder of childhood➢DSM-III-R (1987) Disorders usually first evident in infancy, childhood or adolescence: Transsexualism, GID of childhood, GIDAANT➢DSM-IV (1994) Sexual and gender identity disorders: GIDAA, GIDC, Transvestic Fetishism➢DSM-IV-TR (2000) same➢DSM-5 (2013) Gender dysphoria: GDAA, GDC; Sexual Disorders: Transvestic Disorders

--Drescher, Cohen-Kettenis, Winter (2012)

History of Gender Dx in the ICD

➢ICD-6 (1948) none➢ICD-7 (1955) none➢ICD-8 (1965) Sexual deviations: Transvestitism ➢ICD-9 (1975) Sexual deviations: Trans-sexualism, TV➢ICD-10 (1990) Gender identity disorders: TS, Dual Role TV, GIDC, Other GID, GID Unspecified➢ICD-11 (2015) We need codings with less harm and more clinical utility!

--Drescher, Cohen-Kettenis, Winter (2012)

International Classification of Diseases, published by the WHO,contains both mental and physical diagnostic categories

Childhood Gender Nonconformity Dx

Children do not have medical needs, related to gender diversity, that require a specific diagnosis. Instead, their primary needs are for information, counseling, and support. (Winter 2013).

Photo by Dawn Hebert

GATE Recommendation for Childhood Diagnosis in the ICD-11

➢ Delete Gender Identity Disorder in Childhood (F64.2) from Chapter V --Mental and behavioural disorders.➢ Reject proposals for new Gender Incongruence pathology coding in other chapters.➢ Existing and modified Z-codes (Chapter XXI) for gender nonconforming children who are not mentally or physically disordered but may require services, counseling and accommodations to provide safe spaces to be themselves at school.

Chapter XXI: Factors influencing health status and contact with health services

(ICD-10: Z00-Z99)

(a) When a person who may or may not be sick encounters the health services for some specific purpose...

(b) When some circumstance or problem is present which influences the person's health status but is not in itself a current illness or injury...

http://apps.who.int/classifications/icd10/browse/2010/en#/XXI

Clinical Utility: possible needs

1) Access to supportive counseling

2) Access to school in authentic roles.

3) Modify/contextualize anxiety and mood Dx

4) Establish history prior to puberty and blocker Rx

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Z55-Z65 ...socioeconomic/psychosocial

Z60.4 category: ‘Exclusion and rejection on the basis of personal characteristics, such as unusual physical appearance, sexual orientation, illness, behaviour, or gender identity OR expression.

Z55-Z65 ...socioeconomic/psychosocial

Z60.5 category: ‘Persecution or discrimination, perceived or real, on the basis of membership of some group (as defined by skin colour, religion, ethnic origin, sexual orientation, gender identity OR expression, etc.) rather than personal characteristics.’

Z70-Z76 ...other circumstances

Recommend Code Z70.4: Counseling for a child to support gender identity (or expression?) that differ from birth assignment.

Recommend Code Z70.2x: Counseling for families and service providers related to gender identity or expression of a child.

GATE Recommendation for Adult/Adolescent Diagnosis in the ICD-11

➢ Remove Gender Identity Disorders (F64) from Chapter V --Mental and behavioural disorders.➢ Remove Fetishistic transvestism (F65.1) and F66.1 Sexual Orientation from the ICD➢ Placement of AA coding in new non-F chapter.➢ Gender Incongruence title remains ambiguously pathologizing of gender difference➢ Consider people who medically transition, who neither experience such incongruence or describe their biological body negatively.

GATE Discussion: Coding Approach Affirmingthe positive impact of medical transition

➢ Title: Health Care related to Gender Transition➢ Avoid pathologizing spectra of diverse bodies and gender identities➢ Avoid requirement for narrative of suffering➢ Focus on Alignment and Balance: those health care interventions trans* people may require to change their primary and/or secondary sex characteristics sufficiently to align their body and gender identity. ➢ A process-based category rather than a diagnosis-based category

Appendix f: Coding Focus on Medical Necessity of Transition (or Blocker) Care

A) (1) Distress with current or anticipated (for youth) incongruent sex characteristics or hormone status.

OR (2) deprivation of sex characteristics that are congruent with gender identity.

OR (3) impairment or loss of function in living an authentic congruent role.

B) The gender incongruence must have been continuously present for at least several months

NOTE: Distress, discomfort or impairment due to external prejudice is a societal pathology and not a basis for diagnosis. Congruence/Incongruence refers to the experience of the individual, not the judgement of others.

Appendix f: based on prior work by:

Lev, A.I., Winters, K., Alie, L., Ansara, Y., Deutsch, M., Dickey, L., Ehrbar, R., Ehrensaft, D., Green, J., Meier, S., Richmond, K., Samons, S., Susset, F., (2010). “Response to Proposed DSM-5 Diagnostic Criteria. Professionals Concerned With Gender Diagnoses in the DSM.” Retrieved December 4, 2010 from: http://professionals.gidreform.org

Vitale, A. (2010) The Gendered Self: Further Commentary on the Transsexual Phenomenon, Lulu, http://http://www.avitale.com/

Winters, K. and Ehrbar, R. (2010) “Beyond Conundrum: Strategies for Diagnostic Harm Reduction,” Journal of Gay & Lesbian Mental Health, 14:2, 130-139, April