Validity of Categories Related to Gender Identity in ICD-11 and DSM-5 Among Transgender Individuals who Seek Gender-Affirming Medical Procedures

Abstract

Background/Objective The most recent versions of the two main mental disorders classifications—the World Health Organization's ICD-11 and the American Psychiatric Association's DSM–5—differ substantially in their diagnostic categories related to transgender identity. ICD-11 gender incongruence (GI), in contrast to DSM-5 gender dysphoria (GD), is explicitly not a mental disorder; neither distress nor dysfunction is a required feature. The objective was compared ICD-11 and DSM-5 diagnostic requirements in terms of their sensitivity, specificity, discriminability and ability to predict the use of gender-affirming medical procedures. Method A total of 649 of transgender adults in six countries completed a retrospective structured interview. Results Using ROC analysis, sensitivity of the diagnostic requirements was equivalent for both systems, but ICD-11 showed greater specificity than DSM-5. Regression analyses indicated that history of hormones and/or surgery was predicted by variables that are an intrinsic aspect of GI/GD more than by distress and dysfunction. IRT analyses showed that the ICD-11 diagnostic formulation was more parsimonious and contained more information about caseness than the DSM-5 model. Conclusions This study supports the ICD-11 position that GI/GD is not a mental disorder; additional diagnostic requirements of distress and/or dysfunction in DSM-5 reduce the predictive power of the diagnostic model.

Impact of Depsychopathologization of Transgender and Gender Diverse Individuals in ICD-11 on Care Delivery: Looking at Trans Expertise through a Trans Lens

“…The shift in care delivery models is partly based on the depsychopathologization of TGD persons in the eleventh revision of the International Classification of Diseases (ICD-11) [ 5 ]. ICD-11 brought along epistemic transformations characterized by a politicization of classificatory considerations [ 6 , 7 ] while maintaining an appearance of neutrality focused on classification comparisons [ 6 , 8 , 9 ]. Debate between diagnoses of Gender Dysphoria and Gender Incongruence focused on whether suffering at the Index Period was necessary as a diagnostic criterion [ 9 ].…”

“…ICD-11 brought along epistemic transformations characterized by a politicization of classificatory considerations [ 6 , 7 ] while maintaining an appearance of neutrality focused on classification comparisons [ 6 , 8 , 9 ]. Debate between diagnoses of Gender Dysphoria and Gender Incongruence focused on whether suffering at the Index Period was necessary as a diagnostic criterion [ 9 ]. Index Period was defined as “a period of time […] during which gender incongruence, distress and dysfunction may have been particularly prominent” [ 10 ].…”

“…Index Period was defined as “a period of time […] during which gender incongruence, distress and dysfunction may have been particularly prominent” [ 10 ]. ICD-11 outperformed, both practically [ 9 ] and conceptually, as field studies conducted with the World Health Organization (WHO) highlighted that psychological distress was not systematic and primarily arose from widespread transphobia [ 9 , 10 , 11 ], interpreted as minority stress [ 10 , 12 ]. The non-necessity and external origin of psychological distress supported the WHO process of depsychopathologization [ 10 ].…”

“…In this context, depsychopathologization is best understood as part of a paradigm shift, rather than a natural evolution of medical epistemologies [ 8 ]. Thus, it appeared both as a violation of basic human rights [ 7 ] and as an unnecessary burden on the lives of TGD individuals and clinical practice [ 4 , 5 , 9 ].…”

“…Out of the six field studies conducted for ICD-11 [ 9 ], one was carried out in France in a multidisciplinary primary healthcare provider (Maison Dispersée de Santé, now MDS), based on risk-reduction and the free and informed consent model [ 4 ], and working closely with local TGD organizations [ 5 , 10 ]. This study drew on a participatory aspect.…”