Diagnoses and Their Effect on Care
In the United States, the medical establishment follows the APA definition as set out in the DSM for diagnosis and care of transgender people. In the fourth edition, text revision, of the DSM (DSM-IV-TR), diagnostic criteria for GID included strong and persistent crossgender identification, persistent discomfort with the current sex, or sense of inappropriateness in the gender role of that sex. More importantly, the discomfort must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. In the DSM-5, GID has been replaced with the term gender dysphoria. The new classification emphasizes gender incongruence rather than cross-gender identification in an effort to reflect the individual's felt sense of incongruence with natal gender, as opposed to pathologizing gender-atypical behavior. (Despite the APA's stated intention, the new criteria seem to retain diagnosis based on gender nonconformity and fail to differentiate between distress caused by societal prejudice and that caused by a mental disorder.) Additionally, gender dysphoria is now separated from the chapters on sexual dysfunctions and paraphilias. In contrast to the dichotomized DSM-IV-TR GID diagnosis, the type and severity of gender dysphoria can be inferred from the number and type of indicators and from the severity measures.
At the outset, I must state that the inclusion of gender identity and transgender-related matters in the DSM reflects an inherent problem. Although diagnostic coding is necessary to facilitate access to medical and surgical transition care, the pathologizing and stigmatizing suggested by its designation as a mental disorder is not. Such designation gives rise to an inherent contradiction in terms: what is presented as a mental condition has recognized medical and surgical treatment:
Gender Dysphoria is a unique condition in that it is a diagnosis made by mental health care providers, although a large proportion of the treatment is endocrinological and surgical.
These treatments are aimed not at affecting or changing mental state but rather at addressing the physical components that lead to the dysphoria. Such logic makes GID or gender dysphoria a unique case of surgically treatable mental illness, which is an oxymoron.
When the category of gender dysphoria was proposed, several LGBT and transgender organizations, including Lambda Legal, urged the APA to prioritize coverage of transitional treatment of transgender people as a medical necessity for a recognized condition over demedicalizing and depathologizing transgender people. The current changes reflect an effort to strike a balance between stigmatization and the need to maintain access to care.
Future deliberations as to how to enable coverage of transgender-related care without designating a mental condition might consider an approach similar to that taken toward pregnancy and preventive care. Pregnancy is a condition that is recognized clinically and coded under the World Health Organization's International Classification of Diseases. It is treated, billed, and covered accordingly (with various policy options related to coverage of what is medically deemed necessary) without being pathologized. Similarly, preventive care is offered and routinely covered and is often considered necessary, independent of any diagnosis. So, too, I would suggest, can need for SRS be covered for transgender people without necessitating a DSM diagnosis.