Transgender treatment and NHS

[FlightyEmu]

This is something that I’ve been wondering about for a while. We hear about both children and adults getting puberty blockers, hormone treatment, and indeed gender-changing surgery on the NHS. But on what grounds does the NHS fund this? I can’t work it out.

We’re repeatedly told that being transgender isn’t a mental illness. And yet the only [supposedly] negative consequences of not ‘transitioning’ seem to be depression and anxiety - which are symptoms of mental illness. There is zero physical health risk to not transitioning, absolutely zero, because it’s not a physical illness. But transitioning actually causes physical issues.

So if gender dysphoria is not a mental illness, nor a physical one, isn’t treatment effectively cosmetic?

On what grounds is the NHS justifying any treatment other than psychological treatment to help with the concurrent depression and anxiety?

God question actually. It sounds as though its preventative.
I wonder what the people who have had this surgery have been diagnosed with. Can't be gender gysphoria.

I don't know. But menopause is not an illness, either, yet I get HRT. HRT prevents many problems which could ultimately cost the NHS and society a lot more. I expect that the cost of HRT is vastly less than the cost of fixing osteoporotic broken hips. If there's there a parallel, I struggle to find one.

Yes, good question. I'm sure there's a very reasonable and logical explanation.

The NHS funds a lot of stuff that isn’t illness treatment. IVF. Immunisations. Cosmetic procedures. Pain killers. Pregnancy and birth related issues. It’s supposed to be a comprehensive health service I suppose.

Menopause is a very good suggestion actually.

You are trying to find logic within the illogical.

Interesting how most of society is trying to de-stigmatise mental health problems, but TRAs are adamant that gender dysphoria is not a mental health issue - how rude!

TWAW despite gender dysphoria being the acknowledgment that you are not the sex you wish to be.

Ok, I’m seeing that ‘physical illness’ was the wrong phrase to use. ‘Physical condition’ would have probably been better.

I don’t think menopause is a good parallel, because menopause is a physical condition - it physically affects the body, and HRT is a physical treatment for that. Being transgender does not physically affect the body.

And even if the NHS is a comprehensive health service (although good luck getting anything considered cosmetic on it), we’re told that being transgender in itself isn’t a health issue. So what has the NHS got to do with it?

the parallel might be the treatment or lack of it for female hirsutism particularly associated with pcos.
It is seen as cosmetic afaik, despite causing psychological issues

Friends with PCOS tell me that electrolysis is not available to them on the NHS as it is classed as cosmetic.

WHO ICD-11 and "Transgender Health": PART 1 of 2

The World Health Organisation (WHO) has shuffled the deck and done a bit of relabelling in ICD-11 (current version April 2019) in order to provide a rationale for continuing health service provision for physical "transgender treatments".

ICD = International Classification of Diseases

"ICD purpose and uses

ICD is the foundation for the identification of health trends and statistics globally, and the international standard for reporting diseases and health conditions. It is the diagnostic classification standard for all clinical and research purposes. ICD defines the universe of diseases, disorders, injuries and other related health conditions, listed in a comprehensive, hierarchical fashion that allows for:

• easy storage, retrieval and analysis of health information for - evidenced-based decision-making;

• sharing and comparing health information between hospitals, regions, settings and countries; and

• data comparisons in the same location across different time periods.

Uses include monitoring of the incidence and prevalence of diseases, observing reimbursements and resource allocation trends, and keeping track of safety and quality guidelines. They also include the counting of deaths as well as diseases, injuries, symptoms, reasons for encounter, factors that influence health status, and external causes of disease."

continued at: www.who.int/classifications/icd/en/

• - - - -

"Gender Incongruence" is still included in ICD-11 as a "health condition".

It has been shifted to a new category called "Conditions related to sexual health" (Category 17):
icd.who.int/browse11/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f411470068

("Parent(s)" and "ancestors" below refer to the classification structure, not mums, dads, etc.)

Gender incongruence

Parent category:

17 - Conditions related to sexual health

Description

Gender incongruence is characterized by a marked and persistent incongruence between an individual’s experienced gender and the assigned sex. Gender variant behaviour and preferences alone are not a basis for assigning the diagnoses in this group.

Exclusions

Paraphilic disorders (6D30-6D3Z)

ICD-11 divides "Gender Incongruence" into two diagnostic age groups, "Adult and Adolescent" and "Childhood".

HA60 Gender incongruence of adolescence or adulthood
icd.who.int/browse11/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f90875286

All ancestors up to top
17 Conditions related to sexual health

Gender incongruence

HA60 Gender incongruence of adolescence or adulthood

Description

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.

Exclusions

Paraphilic disorders (6D30-6D3Z)

HA61 Gender incongruence of childhood
icd.who.int/browse11/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f344733949

All ancestors up to top
17 Conditions related to sexual health

Gender incongruence

HA61 Gender incongruence of childhood

Description

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. Gender variant behaviour and preferences alone are not a basis for assigning the diagnosis.

Exclusions

Paraphilic disorders (6D30-6D3Z)

• - - - -

ICD-11 Paraphilic Disorders

To clarify, given the repeated mention that "Paraphilic Disorders" are excluded from the above definitions:

Although Paraphilic Disorders are still included in ICD-11 (under "06 Mental, behavioural or neurodevelopmental disorders"), "Transvestism" has been removed from the list of paraphilias recognised in ICD-11.

(ALL references to "fetish" have been removed from ICD-11, which is why "Fetish" is now part of "Pride" events. Fetish, BDSM and Transvestism have been considered normal variants of human sexuality by WHO since 2018.
See "FETISH RIGHTS ARE HUMAN RIGHTS:" revisef65.net/2018/06/20/who/ )

ICD-11 Definition of "Paraphilic disorders"
<a class="break-all" href="https://icd.who.int/browse11/l-m/en#/id.who.int/icd/entity/2110604642" rel="nofollow" target="_blank">icd.who.int/browse11/l-m/en#/id.who.int/icd/entity/2110604642

"Paraphilic disorders are characterized by persistent and intense patterns of atypical sexual arousal, manifested by sexual thoughts, fantasies, urges, or behaviours, the focus of which involves others whose age or status renders them unwilling or unable to consent and on which the person has acted or by which he or she is markedly distressed. Paraphilic disorders may include arousal patterns involving solitary behaviours or consenting individuals only when these are associated with marked distress that is not simply a result of rejection or feared rejection of the arousal pattern by others or with significant risk of injury or death."

Paraphilic Disorders listed in ICD-11

6D30 Exhibitionistic disorder
icd.who.int/browse11/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f141881468

Exhibitionistic disorder is characterized by a sustained, focused and intense pattern of sexual arousal—as manifested by persistent sexual thoughts, fantasies, urges, or behaviors—that involves exposing one’s genitals to an unsuspecting individual in public places, usually without inviting or intending closer contact. In addition, in order for Exhibitionistic Disorder to be diagnosed, the individual must have acted on these thoughts, fantasies or urges or be markedly distressed by them. Exhibitionistic Disorder specifically excludes consensual exhibitionistic behaviours that occur with the consent of the person or persons involved as well as socially sanctioned forms of exhibitionism.

6D31 Voyeuristic disorder
icd.who.int/browse11/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f1832861162

Voyeuristic disorder is characterized by a sustained, focused and intense pattern of sexual arousal—as manifested by persistent sexual thoughts, fantasies, urges, or behaviours—that involves observing an unsuspecting individual who is naked, in the process of disrobing, or engaging in sexual activity. In addition, in order for Voyeuristic Disorder to be diagnosed, the individual must have acted on these thoughts, fantasies or urges or be markedly distressed by them. Voyeuristic Disorder specifically excludes consensual voyeuristic behaviours that occur with the consent of the person or persons being observed.

6D32 Pedophilic disorder
icd.who.int/browse11/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f517058174

Pedophilic disorder is characterized by a sustained, focused, and intense pattern of sexual arousal—as manifested by persistent sexual thoughts, fantasies, urges, or behaviours—involving pre-pubertal children. In addition, in order for Pedophilic Disorder to be diagnosed, the individual must have acted on these thoughts, fantasies or urges or be markedly distressed by them. This diagnosis does not apply to sexual behaviours among pre- or post-pubertal children with peers who are close in age.

6D33 Coercive sexual sadism disorder
icd.who.int/browse11/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f1890228613

Coercive sexual sadism disorder is characterized by a sustained, focused and intense pattern of sexual arousal—as manifested by persistent sexual thoughts, fantasies, urges or behaviours—that involves the infliction of physical or psychological suffering on a non-consenting person. In addition, in order for Coercive Sexual Sadism Disorder to be diagnosed, the individual must have acted on these thoughts, fantasies or urges or be markedly distressed by them. Coercive Sexual Sadism Disorder specifically excludes consensual sexual sadism and masochism.

6D34 Frotteuristic disorder
icd.who.int/browse11/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f1580013387

Frotteuristic disorder is characterized by a sustained, focused and intense pattern of sexual arousal— as manifested by persistent sexual thoughts, fantasies, urges, or behaviours— that involves touching or rubbing against a non-consenting person in crowded public places. In addition, in order for Frotteuristic Disorder to be diagnosed, the individual must have acted on these thoughts, fantasies or urges or be markedly distressed by them. Frotteuristic Disorder specifically excludes consensual touching or rubbing that occur with the consent of the person or persons involved.

6D35 Other paraphilic disorder involving non-consenting individuals
icd.who.int/browse11/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f1582257458

Other paraphilic disorder involving non-consenting individuals is characterized by a persistent and intense pattern of atypical sexual arousal— manifested by sexual thoughts, fantasies, urges, or behaviours— in which the focus of the arousal pattern involves others who are unwilling or unable to consent but that is not specifically described in any of the other named Paraphilic Disorders categories (e.g., arousal patterns involving corpses or animals). The individual must have acted on these thoughts, fantasies or urges or be markedly distressed by them. The disorder specifically excludes sexual behaviours that occur with the consent of the person or persons involved, provided that they are considered able to provide such consent.

6D36 Paraphilic disorder involving solitary behaviour or consenting individuals
icd.who.int/browse11/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f2055403635

Paraphilic disorder involving solitary behaviour or consenting individuals is characterized by a persistent and intense pattern of atypical sexual arousal— manifested by sexual thoughts, fantasies, urges, or behaviours— that involves consenting adults or solitary behaviours. One of the following two elements must be present: 1) the person is markedly distressed by the nature of the arousal pattern and the distress is not simply a consequence of rejection or feared rejection of the arousal pattern by others; or 2) the nature of the paraphilic behaviour involves significant risk of injury or death either to the individual or to the partner (e.g., asphyxophilia).

(continued below)

WHO ICD-11 and "Transgender Health": PART 2 of 2

ICD-10 (previous version) separated "Gender Identity Disorders" (Code F64) from "Disorders of Sexual Preference" (Code F65).

F65 Codes in ICD-10 "Disorders of Sexual Preference" (including "Paraphilias")
icd.who.int/browse10/2016/en#/F65

F65.0 Fetishistic transvestism

The wearing of clothes of the opposite sex principally to obtain sexual excitement and to create the appearance of a person of the opposite sex. Fetishistic transvestism is distinguished from transsexual transvestism by its clear association with sexual arousal and the strong desire to remove the clothing once orgasm occurs and sexual arousal declines. It can occur as an earlier phase in the development of transsexualism.

(Removed from ICD-11 as WHO considers this to be normal behaviour.WHO does not recognise the possibility that others might be involved in this activity without their consent, eg. that sexual arousal might be related to or heightened by the presence of women and girls whilst cross-dressing. Objections due to "lack of consent" are therefore understood as arising from irrational fear, hostility or prejudice - "transphobia".)

This does not mean that "Transvestism" has been magicked out of existence. It means that "Transvestism" it is no longer recognised and available as a diagnostic category, ie. as a "health condition", by the WHO.

In countries like the UK where ICD-11 is used to code health treatments for provision of services, the only option now for a person who distressed about cross-dressing is to submit to treatment for "Gender Incongruence" (see above).

The USA still uses a classification system called the "Diagnostic and Statistical Manual of Mental Disorders" (DSM). The current version, DSM-5, reflects ICD-10 and there is intensive lobbying in the USA for this to be updated to reflect ICD-11.

• - - - - - -

ICD-10, ICD-11 and the GRA2004

---------

When the GRA2004 came in, "Transsexuality" was in the ICD-10 "Mental Disorders" category. It was alongside and could be distinguished by medical "differential diagnosis" from the sexual paraphilias. You would expect the psychiatric assessment to distinguish between adult men with a variety of disorders to do with "cross dressing".

That protection has been removed and the only "cross dressing" category in ICD-11 is "Gender Incongruence". (ICD-11 was formally adopted by member states in May 2019 although is not officially in force until 2022.)

ICD-11

This is the wording of the Adult and Adolescent Category of ICD-11 under "17 Conditions related to sexual health"

17 Conditions related to sexual health

HA60 Gender incongruence of adolescence or adulthood

Description

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.

--------

V Mental and behavioural disorders

F60-F69 Disorders of adult personality and behaviour
> F64 Gender identity disorders
> F64.0 Transsexualism

ICD-10

These are relevant diagnoses that were available under ICD-10 for adults and adolescents that have been removed in ICD-11:

F64 Gender identity disorders (ICD-10)

F64.0 Transsexualism
A desire to live and be accepted as a member of the opposite sex, usually accompanied by a sense of discomfort with, or inappropriateness of, one's anatomic sex, and a wish to have surgery and hormonal treatment to make one's body as congruent as possible with one's preferred sex.

F64.1 Dual-role transvestism
The wearing of clothes of the opposite sex for part of the individual's existence in order to enjoy the temporary experience of membership of the opposite sex, but without any desire for a more permanent sex change or associated surgical reassignment, and without sexual excitement accompanying the cross-dressing.

Gender identity disorder of adolescence or adulthood, nontranssexual type

F65 Disorders of sexual preference (ICD-10)
Incl.:
paraphilias

F65.1 Fetishistic transvestism

The wearing of clothes of the opposite sex principally to obtain sexual excitement and to create the appearance of a person of the opposite sex. Fetishistic transvestism is distinguished from transsexual transvestism by its clear association with sexual arousal and the strong desire to remove the clothing once orgasm occurs and sexual arousal declines. It can occur as an earlier phase in the development of transsexualism.

--------

None of the ICD-10 "transvestic disorder" diagnoses appear anywhere in ICD-11.

Therefore, there is no longer any protection from them being excluded as positive diagnoses when there is application for a GRC. The only "gatekeeping" possible is excluding people who do not have a positive diagnosis of "gender dysphoria". However, as we know, there are plenty of tips about what information to give in order to obtain a diagnosis of "gender dysphoria".

Men with the "transvestic disorders" as described under ICD-10 have protection under the GRA.

----

Further reading:

Disorders related to sexuality and gender identity in the ICD‐11: revising the ICD‐10 classification based on current scientific evidence, best clinical practices, and human rights considerations
www.ncbi.nlm.nih.gov/pmc/articles/PMC5032510/#wps20354-sec-0004title

Proposals for Paraphilic Disorders in the International Classification of Diseases and Related Health Problems, Eleventh Revision (ICD-11)
www.ncbi.nlm.nih.gov/pmc/articles/PMC5487931/

The Elephant in the Room*
"Or, Is the “Third Type” of MTF Transgender Simply Mentally Ill ??"
sillyolme.wordpress.com/2017/11/09/the-elephant-in-the-room/

(Apologies for some duplication of content in these two posts - copying and pasting from previous posts).

ICD-11 was formally adopted by member states in May 2019 although is not officially in force until 2022

So am I correct in thinking that the NHS is currently still using ICD-10 codes but reviewing treatment protocols to be ready for ICD-11?

Correction to last paragraph of PART 2.

"Men with the "transvestic disorders" as described under ICD-10 have protection under the GRA."

Should read:

"People with the "transvestic disorders" as described under ICD-10 would be able to apply for a GRC using "Self-Declaration" under the proposed reforms to the GRA. They would then have protection under the Equality Act 2010 under the "protected characteristic" of "Gender reassignment". What they lose under ICD-11 is the "health budget coding" for provision of services other than "gender identity services". This would apply to Health Insurance as well as the NHS if they were to use ICD-11 to define "health conditions."

Thingybob that is a good question. I don't know the answer - I would have to check

NHS Digital - Snowmed codes and ICD-11

ICD-11 and the new Procedure Based Classification (PBC)
digital.nhs.uk/about-nhs-digital/our-work/nhs-digital-data-and-technology-standards/clinical-information-standards#icd-11-and-the-new-procedure-based-classification-pbc-

(Last edited: 21 January 2019 10:43 am)

Extract:

"In England, ICD-10 is used in secondary care, and each NHS organisation must dedicate resources to review relevant clinical notes and patient histories and assign the appropriate ICD-10 codes. NHS Digital will provide guidance and business rules to support appropriate allocation of patient episodes to the appropriate codes which are subsequently used for remuneration under the Payment by Results (PbR) mechanism.

In planning for ICD-11, we need to recognise that ICD-10 code derivation from clinical notes and patient histories is a significant investment for many providers. In addition, uptake of SNOMED CT will add additional burden to upskill clinical coders, who will also then need to upgrade their knowledge of ICD-10 to ICD-11. We expect that this would represent a very expensive exercise, as it would require significant investment in training, upskilling, and also a significantly increased workload for clinical coders initially."

There is probably an update on progress somewhere but it is not included on that page Thingybob

I've asked this question before, and sorry I haven't got time to read that long post above right now which may have the answer (I will read it later).

My thoughts are, the argument is, that it's not a mental health condition. And as this is promoted by big lobby groups which are endorsed by the NHS, then the implication must be that it is a physical health condition being treated. I.e. literally the wrong brain, wrong body argument. I don't know... I think the whole thing is just kind of fluffed over and we are supposed to ignore the big logic holes.

BlueHarry - "I think the whole thing is just kind of fluffed over and we are supposed to ignore the big logic holes."

Correct. WHO were clear that the reclassification was "to reduce stigma", ie. of being classified as a "mental disorder".

On that basis, it is arguable that everything still classified by WHO as a "mental disorder" should be reclassified as something else to "reduce stigma".

Presumable that would reduce the need for "Mental Health Services" too?

WHO were clear that the reclassification was "to reduce stigma", ie. of being classified as a "mental disorder".

On that basis, it is arguable that everything still classified by WHO as a "mental disorder" should be reclassified as something else to "reduce stigma".

Instead, for sufferers of other conditions which are classified as mental disorders, WHO are trying to remove the stigma associated with having a mental health condition.

www.euro.who.int/en/health-topics/noncommunicable-diseases/mental-health/priority-areas/stigma-and-discrimination

On 10 October 20014, World Mental Health Day, WHO addressed the stigma and misconceptions surrounding schizophrenia and suggested the actions needed to ensure that people with schizophrenia can live a dignified and healthy life.

WHO strongly believes that every person with a mental health problem, whatever the mental health problem, has a right to the same opportunities as everyone else in every aspect of their life.

Correct. WHO were clear that the reclassification was "to reduce stigma", ie. of being classified as a "mental disorder".

On top of being illogically inconsistent, I find that pretty bloody insulting on behalf of everyone with a mental health condition, including myself. There's also stigma surrounding the severely disabled. The answer isn't to pretend they're able-bodied. We should work to reduce the stigma, not skirt around it or pretend it doesn't exist.

Although, I suppose it is a similar thought process to the one that tells us the problem is with our brains/our bodies, and not with the system that imposes gender stereotypes. So there is some consistency there... The illogicality is consistent.

Logically inconsistent that should say**

Thank you Mole for all your posts. I will look at them carefully when I have more time.

The thing that confuses me from a quick look through (sorry if I misread) is why ‘sexual health’ has anything to do with this?
Sexual (often also called ‘...and reproductive...’) health, usually covers sexually transmitted disease treatment and prevention, provision of contraception including the long lasting and permanent types, abortion referral and provision and so on.

What’s any of that got to do with people’s purely psychological feeling that they must be born ‘in the wrong body’? Totally different set of (mental) health issues and totally different professional skill set required to actually help anyone, surely?

Also: if the ‘gender incongruence in children‘ section says that the child should have demonstrated two previous years of then, how on earth are the UK press reporting that NHS GIDS are seeing children as young as three as patients?

This smacks of politics not actual evidence based health care. Who writes these definitions and decides the categories they fit into? Do they, for example have expertise in child mental health?

I've just found the service agreement for GIDS which will soon be reviewed.

www.england.nhs.uk/wp-content/uploads/2017/04/gender-development-service-children-adolescents.pdf

It states,

3.2.2 Referring professionals will be encouraged to discuss the referral with the family/ carer and seek their agreement. The Service will only accept referrals for children and adolescents with features of GD which are consistent with the current diagnostic criteria as defined in DSM-5.

So GIDS (I haven't checked if it's the same in adult services) are not using ICD-10 or ICD-11 but DSM-5. Therefore they are currently treating a defined mental health condition. It will be interesting to see if that changes after the review

It just seems too obvious that something is very wrong with all of this. If we could go back to working on breaking down sex stereotypes, letting people be themselves, and if we are lucky, achieve geuinine equality. Then perhaps we'd be left with a very, small number of people who felt genuine and severe dysphoria over their sexed body parts, and I don't understand why we wouldn't treat such people the same way we would treat any other person who feels intense distress over, say their leg. They have a fine and normal and functional leg but they have a psychological disorder that makes them hate it with a passion and we help them, by treating their mind and helping change their thought pattern. We don't cut off their leg (well I know there are some dodgy surgeons who do/would, but it's frowned upon). We don't give the anorexic, liposuction and affirm her believe that she's overweight. I can't even understand how we ever originally started doing SRS... Why it was ever treated any differently to any other form of bodily dysphoria.

Bumping this to add a twitter thread by a woman who attended a UCL event called The Trans Experience of Surgery.

It's quite a read.

mobile.twitter.com/sarahstuartxx/status/1230564400555159553