ICD 11 Draft Verbesserungsvorschläge

ICD-11_update_Empfehlung zur Verbesserung__v1.01Update 2017-06-05 9pm/6am (pic commentary)

Es wird empfohlen, die Einteilung und einige Punkte im aktuellen Entwurf der ICD 11 Beta Draft noch weiter an zupassen.
Dieses betrifft den Abschnitt „Gender incongruence“. Nachfolgend die entsprechende Erläuterung dazu (english).

HA20 Gender incongruence of adolescence or adulthood
HA21 Gender incongruence of childhood,

Es geht hier bei nicht um den Gesetzentwurf im Deutschen Bundestag.

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[Warning: Long post about some ongoing changes to the ICD, which is like the DSM for the WHO. Either this is your sort of thing or it isn’t.]

Here are a few notes on the current draft ICD-11 as it pertains to trans issues. The new draft can be found here:

http://apps.who.int/classifications/icd11/browse/l-m/en

Summary:

The old F64 (gender identity disorders) is being folded into Section 17 (conditions related to sexual health): HA20 (Gender incongruence of adolescence or adulthood) and HA21 (Gender incongruence of childhood). This has led to some improvements and some problems.

Highlights:

1. The new ICD still files gender-related diagnoses under sexual health, which sexualizes people who must interact with such diagnoses (hereafter „transitioners“). To avoid sexualizing transitioners, it would be better if the relevant material formed its own free-standing section.

2. The new formulation, „gender incongruence“, is a major improvement over the old F64 „gender identity disorders“, because the new formulation is less pathologizing. However, this formulation still can be read as saying that the medical problem faced by transitioners is with their genders, while in reality, the medical problem faced by transitioners is with their bodily configurations.

Instead, I would prefer a formulation, „gender-body incongruence“ or the wordier but more accurate „bodily incongruence in relation to gender“. This formulation would also survive a translation into the German word „Geschlecht“, which would avoid many flame wars.

3. The ICD-11 narrows its old F65 „disorders of sexual preference“ section (now moved to Section 6, Mental, behavioural or neurodevelopmental disorders, Chapter C, Paraphilic disorders) to remove „Fetishistic transvestism“ and other non-harmful, natural forms of sexual and gender variation. This is a clear improvement, though I am not the right person to comment on whether this is good enough.

4. The ICD-11 maintains a distinction between HA20 (Gender incongruence of adolescence or adulthood) and HA21 (Gender incongruence of childhood). This distinction has a few problems.

4a. The content of HA20 reads somewhat unproblematically, „Gender Incongruence of Adolescence and Adulthood is characterized by a marked and persistent incongruence between an individual´s experienced gender and the assigned sex, which often leads to a desire to ‘transition’, in order to live and be accepted as a person of the experienced gender, through hormonal treatment, surgery or other health care services to make the individual´s body align, as much as desired and to the extent possible, with the experienced gender. The diagnosis cannot be assigned prior the onset of puberty. Gender variant behaviour and preferences alone are not a basis for assigning the diagnosis.“

I would quibble with the part about „living and being accepted as a person of the experienced gender“ in relation to health care, since this convolutes social acceptance („passing“) with the goal of feeling right in one’s body, but I can see why others who care about „passing“ would want this in.

To reconcile these points, a better formulation would be, „Gender Incongruence of Adolescence and Adulthood is characterized by a marked and persistent incongruence between an individual´s experienced gender and the assigned sex, which often leads to a desire to physically ‘transition’ through hormonal treatment, surgery, or other health care services. This is done to make the individual´s body align, as much as desired and to the extent possible, with the experienced gender, and/or in order to live and be accepted as a person of the experienced gender. The diagnosis cannot be assigned prior the onset of puberty. Gender variant behaviour and preferences alone are not a basis for assigning the diagnosis.“

4b. The content of HA21, meanwhile, reads, „Gender incongruence of childhood is characterized by a marked incongruence between an individual’s experienced/expressed gender and the assigned sex in pre-pubertal children. It includes a strong desire to be a different gender than the assigned sex; a strong dislike on the child’s part of his or her sexual anatomy or anticipated secondary sex characteristics and/or a strong desire for the primary and/or anticipated secondary sex characteristics that match the experienced gender; and make-believe or fantasy play, toys, games, or activities and playmates that are typical of the experienced gender rather than the assigned sex. The incongruence must have persisted for about 2 years, and cannot be diagnosed before age 5. Gender variant behaviour and preferences alone are not a basis for assigning the diagnosis.“

While HA20 reasonably limits itself with the need to align one’s body with one’s inner sense of identity (or self), HA21 mixes together elements of HA20, while placing additional conditions on particular types of dysphoria and on gender expression („typical of the experienced gender“ in the eyes of some authority figure). This set of formulations misses the true distinction between HA20 and HA21–HA20 is meant to expedite (rather than hinder) physical transition, while HA21 unduly pathologizes children, who (usually) do not physically transition until they reach adolescence, at the earliest.

At a minimum, HA21 would have to be rewritten in a way to depathologize children and to clarify what the medical reason would be for such a diagnosis. Otherwise, I would prefer HA20 to be rewritten to include children, with some provision for the special issues that they face (limited consent, a „wait and see“ approach to medical treatment, and increased vulnerability).

Conclusion: The new ICD is less pathologizing, but it could still do a better job at reclassifying gender-related medical care, cleaning up some language, and at depathologizing children.

Claire

HA20 commentary
b2017-06-05_2132

HA21commentary
b2017-06-05_2133

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ICD-11_update_Empfehlung zur Verbesserung__v1.01

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