Dr. Jillian T. Weiss

WPATH Statement on Gender Identity Disorder

Filed By Dr. Jillian T. Weiss | May 27, 2010 10:30 AM | comments

Filed in: The Movement, Transgender & Intersex
Tags: gender identity disorder, GID, GID reform, WPATH

There's been a lot of controversy in the trans community over whether "Gender Identity Disorder" should be removed from the Diagnostic and Statistical Manual of the American Psychiatric Association, and from the World Health Organization's psychiatric manuals as well.

I've been unsure about the best response to this issue. On the one hand, I do not feel that being transsexual or transgender is a "mental disorder." I feel that the main problem for trans people is the social response to their gender, not that there is some internal conflict. This isn't a disease, a pathology. Just like homosexuality isn't a disease and they took that one off the books in 1972.

On the other hand, having a medical diagnosis can help with getting employers to understand that this is "real." It can also help with coverage of some costs from insurers and government-funded health programs. Also, some trans people believe that it is "disorder" in the sense that there is a miswiring or "birth defect."

I tend to agree with the ones who want to take this "disorder" off the books.

The World Professional Association for Transgender Health has now weighed in on the issue.

FOR IMMEDIATE RELEASE

May 26, 2010

The WPATH Board of Directors strongly urges the de-psychopathologisation of gender variance worldwide. 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. The psychopathologlisation of gender characteristics and identities reinforces or can prompt stigma, making prejudice and discrimination more likely, rendering transgender and transsexual people more vulnerable to social and legal marginalisation and exclusion, and increasing risks to mental and physical well-being. WPATH urges governmental and medical professional organizations to review their policies and practices to eliminate stigma toward gender-variant people.

www.wpath.org

Interestingly, the APA is revising its Diagnostic and Statistical Manual, and is considering changing "Gender Identity Disorder" to "Gender Incongruence." WPATH published their response to that here.

What do you think? Is it a good idea to take this off the books entirely? Is the "gender incongruence" label a good idea?


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The WPATH statement on de-psychopathologisation of gender variance is well written and badly needed. It does not call for elimination of all diagnostic coding that would enable access to transition medical care for the portion of the transcommunity who needs them. Rather, it states that gender expression and gender identities which differ from stereotypes of assigned birth sex do not in themselves constitute mental disorder.

The accompanying WPATH statement on the proposed DSM-5 criteria for Gender Incongruence further clarifies that diagnostic coding in the DSM-5 to enable transition medical care should focus on distress rather than gender identity and expression. These two statements offer a path forward for harm reduction of gender diagnosis in the DSM-5. I hope that the American Psychiatric Association will listen.

However, WPATH remains disappointingly silent on the defamatory and dehumanizing diagnosis of Transvestic Disorder in the DSM-5, which has just recently been expanded to implicate butch women and transmen, in addition to crossdressing males and transwomen. The limitation to male birth-assignment has just been removed from the diagnostic criteria, and a new offensive term, "autoandrophilia," has been added as a diagnostic specifier. Please add your name and voice to the IFGE petition to remove Transvestic Disorder from the DSM-5.

Dr Jill, I'm in the mixed emotions camp on that as well.

diddlygrl | May 27, 2010 2:04 PM

"A rose by any other name."

Gender Identity Disorder or Gender Incongruence would be used the same way, to pathologise the transgender community. If they are going to delist it then they need to not come up with a substitute term with which to label us.

Considering many insurance policies specifically have riders against covering transition costs including surgery, I don't think it matters one jot if it is listed or not.

I actually think it needs to stay in some manner. It requires medical treatment, so it needs medical recognition. If you completely remove medical recognition, there goes any chance of saying it's not cosmetic.

But, I think it needs to be worded in such a way that reflects the problem isn't that individual has an identity that doesn't match the birth sex, but more that the problem is the mismatch itself and once the mismatch is alleviated, then the patient is cured. Which means that once a transsexual transitions to satisfaction, they're cured.

I want to comment on the suggestion to shift it be a disorder (new name or not, it's still in the "sexuality and gender disorders" category) only if there is significant distress. On face it seems valid and useful, but if you have to have the diagnosis in order to get access to treatment or coverage by insurance, then you still have to place yourself under that label. I mean, I may have passed any significant distress I once had around being trans, however, I'm going to be taking hormones for the rest of my life and have various other medical issues that I'll have to deal with and it would be nice to keep that covered.

As for insurance coverage in general, there's the beginning of a major shift as a lot of employers are realizing that they can request trans-inclusive insurance, often at no additional cost. Especially when the HRC corporate equality index is set to only give perfect scores to those with trans-inclusive insurance and trans health needs become a rising issue for LGBT advocacy organizations, I foresee a lot changing. Regardless of where it is listed or what it is called, the medical community has a consensus that trans related care is medically necessary, so I'm not too worried. But we need to be thinking about a possible future where trans-inclusive insurance is a lot more common.

Tobi, you raise a great question about diagnostic coding for ongoing post-transition access to hormone prescriptions. Those of us facing this issue fall into two groups: those whose medical records are corrected to reflect our affirmed gender and those whose records are not corrected. For the first group, various hormone deficiency codings can often be used without reference to GID or trans-status. In fact, many employers (such as my own pre-retirement corp.) specifically reject health care claims with a GID diagnosis. MDs tell me that a significant number of transfolk in the second group need some kind of a trans-specific coding for hormone access. For distress-based harm reduction proposals for the DSM-5, several solutions to this issue have been suggested. For example, the Gender Dysphoria/Dissonance proposal by Ehrbar, myself and Gorton at the 09 WPATH Symposium included an "in remission" specifier for just this purpose. My personal favorite solution is to include in the diagnostic criteria distress with anticipated changes to physical sex characteristics that would result if hormone treatment were discontinued. Similar "anticipated" wording has already been suggested for pre-adolescents who need access to puberty delaying treatment.

However, the first order of business for hormone access is to reform the current GID diagnostic criteria that contradict transition treatment altogether and describe transition itself as symptomatic of mental illness. Intolerant employers (including my own), insurers, courts and clinicians use the current GID criteria to deny transition care, while covering gender-reparative psychotherapies in its stead. The proposed DSM-5 Gender Incongruence criteria are so ambiguously worded, that they may be interpreted to contradict transition as well.

Kelley, what a wonderfully detailed answer. I especially like the "anticipated" wording. There are some times, though, that corrected documentation is not sufficient that would be good to have on the radar as well. Personally, with my body no longer produces testosterone, I've recently discovered that I greatly benefit from having a small dose of it proscribed to me. While my insurance does cover trans related stuff, the computer system automatically rejects the claim because I'm listed as female and supposedly women never need testosterone. But I can collect my receipts and file the claim in a non-computerized manner and get this medication covered. Perhaps they ought to consider covering testosterone for anyone who's T levels are significantly below averages for their gender, but in the meantime the only way I can get it covered as a part of my hormone regimen for the GID diagnosis.

(They did offer the possibility of listing me as male in order to get it, but in addition to being personally distasteful, they would probably stop covering my estrogen.)

Other sex-specific health care needs and treatments are also automatically denied when trans people's bodies don't meet the medical expectations for our genders. I don't necessarily think that a GID diagnosis is the best way or even an effective way to deal with this, but it's a part of what's on my radar when thinking about it. Especially as, currently, most health care plans exclude trans related care. But as I pointed out in my other comment that may change in the next 5-10 years and we should be thinking about the best policy both for the present and the comparatively near future.

This is a bit scary. Lets see Gender Incongruence abbreviated would be GI which is also the abbreviation to describe Gastrointestinal and that my friends would also refer to the bowels. So are they in kind thinking we are full of s#@t. Just a thought.

I, for one, would like to see GID reclassified and removed from DSM, with the exception of social anxieties/other factors experienced as a result of being trans. The fact that one is trans should not be defined by DSM, but rather in a more clinical diagnosis, whereby we may be granted health coverage for all procedures we need and as endorsed by AMA.

The approach that my job takes, which is safety related, is that I must prove my sanity once I declare my intent to transition in order to work... they are purely concerned about the psychological aspects of what they believe GID to be (to the point that it would be better for me to be performing my duties with GID anxiety than transition and be anxiety-free - my own little DADT conundrum). We need to continue to push for a physiologic, not psychological, diagnosis, with proper assurance that we can receive medical reimbursement as a consequence.

They depathologized transsexualism out here in France earlier this year, but it didn't change the (lack of) access to medical treatments trans people have. Then again, the whole system is different.

My biggest concern in the change in terms is how it can be used once again by insurance companies to weasel out of coverage of any medical issues in connection to being Transgender. I mean for years the insurance companies have included riders in their policies that exclude coverage for any Transgender related treatments. Now as I understand it, if the health care reform eliminates the "pre-existing medical condition" which most insurance companies used to hide behind, will they now just say, well there is nothing wrong with you so there is no reason for treatment to be covered. I know there will be insurance companies trying to claim that treatment for Transgender people is ineffective and point to studies done decades ago by groups that would be in support of what amounts to a just say no approach to treatment of the condition as well. So I am not sure exactly what these changes will mean for us but I am sure of one thing, chances are it will not be a positive one if the insurance industry has anything to say about it.

I know some get around it by claiming it's "experimental."

Insurance companies can offer whatever excuses or internal justifications they want but it's about PR, not legality. As long as it's written down in the policy, an insurance company is allowed to exclude any treatment or procedure they want -- even things that are medically necessary and proven effective. On the flip side, they can include treatment that is neither. The only real check is whether or not organizations will purchase that policy.

So long as employers are willing to purchase plans with trans exclusion clauses, trans related health care will be excluded no matter how valid the case for it is. And once employers realize that in most cases trans inclusive coverage carries no additional costs, is recommended by the APA, validated by the IRS, can greatly impact a few employees and help them attract the best talent, they will begin to request trans inclusive policies. If the DSM were to remove it, along with a statement that it's still legitimate and treatment is medically necessary, but it isn't a psychological disorder, I don't imagine that would greatly change things.

WPATH released two items recently; first was the Association's response to the DSM-5 draft changes to the GID diagnosis, which is a PDF file of 9 double-spaced pages, available via a link from the WPATH homepage at www.wpath.org as you describe. This document is about the Gender Identity Disorder diagnostic revision.

The second item is the "de-psychopathologisation" statement that is reproduced above (thanks, Jillian). As Kelley Winters stated so ably above, this statement does NOT call for the removal of the GID diagnosis or of any medical diagnosis or insurance codes for transition-related treatments. It specifically calls for an end to institutionalized stigma directed toward gender-variance. It expressly states that gender expression that does not correspond to one's assigned sex at birth does not constitute a mental disorder.

Just because there are mental health diagnoses that currently describe various manifestations of gender variance is not an excuse to discriminate against gender-variant people.

The fact that these two items were released in close time proximity doesn't imply anything about removal of the GID diagnosis. WPATH's Medical Necessity Clarification Statement, released in June, 2008 (also available on the WPATH site) specifically urges insurance schemes to cover transition-related medical treatments and services. There's a lot of confusion, I think, about WPATH, its SOC, the APA's DSM, and insurance coverage issues (which are governed by state laws and internal insurance company policies). Each of these "policy" institutions has power over our lives, but the connections between them are not easily negotiated in a way that supports our concerns. WPATH, as the smallest organization, is the most closely focused on our issues, and is the most easily accessed, and the least powerful player. The DSM is concerned with MUCH more that our issues, but we have people engaged in that process who are friendly to us, as well as people who don't understand us at all. And insurance companies are about making money, not being fair or magnanimous. There are many strategies available to us to influence these three players, and making positive change is a long-term effort that is going to require engagement from a lot of people. Breaking down the insurance barriers is going to take both a legislative approach and a business-based approach. DSM is not within our control, even though we can lobby for the approach we want. WPATH is becoming more attentive to us and more proactive in using its particular influence. But WPATH does not control the diagnosis, or whether it is removed from DSM.

And I have to add that I agree with Kelley about the TD/TF issue. The new draft language developed by the APA is pretty scary, IMO. I hope WPATH will say something about this in the not-too-distant future.

Dear all.

That WPATH board of Directors' Statement!!!

For me personally the statement is important for (at least) four reasons. First, it calls for de-psychopatholgisation of gender identity variance and gender variance -- an end to the naming of people as croazy because of who they feel they are or how they act gender-wise. And that for me clearly includes 'transvestic fetishism'.

Second, it correctly situates psychopathologisation of gender identity and gender variance at one end of a chain leading through stigma, prejudice and discrimination, marginalisation and exclusion, and finally (for far too many transpeople) to
ill-health and death.

Third, it cites psychopathologisation as a force which can create stigma, not simply reinforce stigma that is
already present.

Fourth reason has to do with the WPATH
Standards of Care. SOC appear to rest on an assumption that transgender people (being 'mentally disordered'!) cannot be trusted to make their own informed decisions about their own health care. It seems to me that the way is now open for WPATH, which is committed to revising its SOC in the next few years, to start thinking about a more patient-centred informed consent model.

Sam Winter in Hong Kong

HenryHall | May 29, 2010 11:09 AM

It is important that WPATH has called for de-psychopathologisation of gender identity variance and gender variance. Contrast with STP2012 that is still committed to de-pathologisation.
Thus STP2012 sees the WPATH call as a useful first step, but only that.

To illustrate the difference, top surgery (mastectomy) would be justified with a diagnosis of Gender Incongruence mental illness under Zucker's DSM. With a diagnosis of gynecomastia (somatic disorder) under WPATH. And without diagnosis (cosmetic) or a yet-to-be-created diagnosis (like pregnancy) under STP2012. And not at all for the 90% or so of the world's population that has no access to such medicine.

However, 100% of transfolk will benefit from stigma reduction.