Q: When you see a transgender patient and prescribe hormone therapy, what do you tell that person's insurance company you're treating them for? What is the diagnosis?
As a doctor, I'm always amazed how much emotion is involved in giving a diagnosis to a patient. When things are organized and categorized, they feel more manageable, more approachable. Giving a diagnosis is essentially giving a problem a name, and it can relieve a lot of stress for patients.
Words matter, though, and unfortunately some labels do more harm than good. One example of this has been the terms associated with gender identity issues.
Almost all mental health professionals, such as psychiatrists and psychologists, use a diagnostic manual called the Diagnostic & Statistical Manual ( DSM ), published by the American Psychiatric Association. It is basically a list of mental health disorders and their symptoms. It's sometimes called the "Bible of Psychiatry," and helps all professionals use the same terms and approaches when taking care of patients. Earlier this year, the 5th edition of this book came out. This update came with big changes for the diagnosis of gender identity issues.
For decades, providers treating transgender patients have diagnosed them with "gender identity disorder." The problem with this diagnosis is it implies that being transgender itself is a disorder. This term has finally been laid to rest, and replaced with a new diagnosis: "gender dysphoria." Dysphoria is Latin for "a state of unease"—so basically the new disorder is unease about your gender. This new term emphasizes that the distress caused by being transgender is the problem, not being transgender itself. The new definition is having "a marked incongruence between one's experienced/expressed gender and assigned gender." Another big change: this condition used to be grouped in the chapter for sexual dysfunction disorders, and it has now been separated out in its own chapter, to emphasize that this is an issue of identity and not behavior. The major change is that gender dysphoria does not apply to transgender people that are well adapted and feel no distress about their gender identity.
These may seem like subtle semantics to some, but this change has been hotly debated for years, both in the APA and among the transgender community. Some activists have advocated for dropping the diagnosis altogether. As most LGBT people are aware, the 1st through 3rd edition of the DSM manual classified "homosexuality" as a disorder, and it was famously dropped in 1974, based on the argument that homosexuality is not a mental illness. A similar approach for transgender patient would be groundbreaking. But, in an interesting paradox, that change may actually harm patients more than help. Having a specific diagnosis on your chart is often the key to getting insurance coverage and access to certain services, like hormone therapy or sex-reassignment surgery. If patients are not labeled with any diagnosis, insurance companies find it easier to deny these services. Healthcare for gay patients is often only indirectly related to their sexual orientation, but transgender patients often seek out services directly related to their gender identity.
This new language hopefully will change the focus of those dealing with patients with gender-identity issues. This is a topic in transition, and most likely will continue to evolve as we learn more about transgender patients, and as society becomes more aware of gender-identity issues. Many providers avoid this issue altogether, and instead use diagnoses such as "endocrine disorder" or "problems related to social environment" when billing for services and medication. This may in the end be the best approach of all. For now, though, these labeling changes seem to be a step in the right direction.
Dr. Cory Brown is a med/peds specialist, and practices at Howard Brown Health Center, a community clinic that focuses on quality care for LGBT people.
