Winters, K. (2013) “From Gender Madness to Gender Wellness in the ICD-11,” National Transgender Health Summit, Oakland, CA, May. A presentation to the 2013 National Transgender Health Summit, on gender diversity diagnostic policy issues in the ICD-11, to be published by World Health Organization (WHO). It summarizes a proposal Global Action for Trans* Equality (GATE) Civil Society Expert Working Group, Buenos Aires, April 2013.

1. From Gender Madness to GenderFrom 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

2. 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

3. The Challenge: Gender Diversity nomenclature
in the DSM and ICD has historically emphasized
enforcement of birth-assigned gender roles

4. “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

5. 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)

6. Photo by Kelley Winters Images Photography
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

7. 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)

8. 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

9. 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

10. 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.

11. 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

12. 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
Photo by Kelley Winters Images Photography

13. 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.

14. 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.’

15. 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.

16. 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.

17. GATE Discussion: Coding Approach Affirming
the 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

18. 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.

19. 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