gender reassignment icd 10

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Billing and Coding: Gender Reassignment Services for Gender Dysphoria

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Title XVIII of the Social Security Act (SSA) §1833(e) prohibits Medicare payment for any claim lacking the necessary documentation to process the claim

Article Guidance

Gender Dysphoria (GD) is defined by the Diagnostic and Statistical Manual of Mental Disorders - Fifth Edition, DSM-5™ as a condition characterized by the "distress that may accompany the incongruence between one’s experienced or expressed gender and one’s assigned gender" also known as “natal gender”, which is the individual’s sex determined at birth. Individuals with gender dysphoria experience confusion in their biological gender during their childhood, adolescence or adulthood. These individuals demonstrate clinically significant distress or impairment in social, occupational, or other important areas of functioning. GD is characterized by the desire to have the anatomy of the other sex, and the desire to be regarded by others as a member of the other sex. Individuals with GD may develop social isolation, emotional distress, poor self-image, depression and anxiety. The diagnosis of GD is not made if the individual has a congruent physical intersex condition such as congenital adrenal hyperplasia. Gender Reassignment Therapy GD cannot be treated by psychotherapy or through medical intervention alone. Integrated therapeutic approaches are used to treat GD, including psychological interventions and gender reassignment therapy. Gender reassignment therapy, either as male-to-female transsexuals (transwomen) or as female-to-male transsexuals (transmen), consists of medical and surgical treatment that changes primary or secondary sex characteristics. Initially, the individual may go through the real-life experience in the desired role, followed by cross-sex hormone therapy and gender reassignment surgery to change the genitalia and other sex characteristics. The difference between cross-sex hormone therapy and gender reassignment surgery is that the surgery is considered an irreversible physical intervention. Gender reassignment surgical procedures are not without risk for complications; therefore, individuals should undergo an extensive evaluation to explore psychological, family, and social issues prior to and post-surgery. Additionally, certain surgeries may improve gender- appropriate appearance but provide no significant improvement in physiological function. These surgeries are considered cosmetic and are non-covered. NON-SURGICAL TREATMENT Initiation of cross-sex hormone therapy may be provided after a psychosocial assessment has been conducted and informed consent has been obtained by a health professional. The criteria for cross sex hormone therapy are as follows:

• Persistent, well-documented gender dysphoria;
• Capacity to make a fully informed decision and to consent for treatment;
• Member must be at least 18 years of age;
• If significant medical or mental health concerns are present, they must be reasonably well controlled.

The presence of co-existing mental health concerns does not necessarily preclude access to cross-sex hormones. These concerns should be managed prior to or concurrent with treatment of gender dysphoria. Cross-sex hormonal interventions are not without risk for complications, including irreversible physical changes. Medical records should indicate that an extensive evaluation was completed to explore psychological, family and social issues prior to and post treatment. Providers should also document that all information has been provided and understood regarding all aspects associated with the use of cross-sex hormone therapy, including both benefits and risks. READINESS FOR THE TREATMENT OF GENDER DYSPHORIA Readiness criteria for gender reassignment surgery includes the individual demonstrating progress in consolidating gender identity, and demonstrating progress in dealing with work, family, and interpersonal issues resulting in an improved state of mental health. In order to check the eligibility and readiness criteria for gender reassignment surgery, it is important for the individual to discuss the matter with a professional provider who is well-versed in the relevant medical and psychological aspects of GD. The mental health and medical professional providers responsible for the individual's treatment should work together in making a decision about the use of cross-sex hormones during the months before the gender reassignment surgery. Transsexual individuals should regularly participate in psychotherapy in order to have smooth transitions and adjustments to the new social and physical outcomes. TRANS-SPECIFIC CANCER SCREENINGS Professional organizations such as the American Cancer Society, American College of Obstetricians and Gynecologists and the US Preventive Services Task Force provide recommended cancer screening guidelines to facilitate clinical decision-making by professional providers. Some cancer screening protocols are sex/gender specific based on assumptions about the genitalia for a particular gender. There is little data on cancer risk specifically in transsexual individuals. There is difficulty in recommending sex/gender specific screenings (e.g., breast, cervix, ovaries, penis, prostate, testicles and uterus) for transsexual individuals because of their physiologic changes. For example, transmen who have not undergone a mastectomy have the same risks for breast cancer as natal women. In transwomen, the prostate typically is not removed as part of genital surgery, so individuals who do not take feminizing hormones may be at the same risk for prostate cancer as natal men. Therefore, cancer screenings (e.g., mammograms, prostate screenings) may be indicated based on the individual's original gender. Gender specific screenings may be medically necessary for transgender persons appropriate to their anatomy. Examples include:

• Breast cancer screening may be medically necessary for transmen who have not undergone a mastectomy.
• Prostate cancer screening may be medically necessary for transwomen who have retained their prostate.

Claims for gender reassignment surgery will be reviewed on a case-by-case basis. Surgical treatment of gender reassignment surgery for gender dysphoria may be eligible when medical necessity and documentation requirements outlined within this article are met. Surgical treatment for gender dysphoria may be considered medically necessary when ALL of the following criteria are met:

• The individual is at least 18 years of age.
• A gender reassignment treatment plan is created specific to an individual beneficiary
• The individual has a documented Diagnostic and Statistical Manual of Mental Disorders -Fifth Edition, DSM-5 ™ diagnosis of GD:

 A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested by at least two of the following:

• A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics.
• A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender.
• A strong desire for the primary and/or secondary sex characteristics of the other gender.
• A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender).
• A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender).
• A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender).

 B. The condition is associated with clinically significant distress or impairment in social, occupational or other important areas of functioning.

• That any co-morbid psychiatric or other medical conditions are stable and that the individual is prepared to undergo surgery.
• That the patient has had persistent and chronic gender dysphoria.
• That the patient has completed twelve months of continuous, full-time, real-life experience (i.e., the act of fully adopting a new or evolving gender role or gender presentation in everyday life) in the desired gender.
• The individual, if required by the mental health professional provider, has regularly participated in psychotherapy throughout the real-life experience at a frequency determined jointly by the individual and the mental health professional provider.
• Unless medically contraindicated (or the individual is otherwise unable to take cross-sex hormones), there is documentation that the individual has participated in twelve consecutive months of cross-sex hormone therapy of the desired gender continuously and responsibly (e.g., screenings and follow-ups with the professional provider).
• The individual has knowledge of all practical aspects (e.g., required lengths of hospitalizations, likely complications, and post-surgical rehabilitation) of the gender reassignment surgery.

 SURGICAL TREATMENTS FOR GENDER REASSIGNMENT When all of the above criteria are met for gender reassignment surgery, the following genital surgeries may be considered for transwomen (male to female):

• Orchiectomy - removal of testicles
• Penectomy - removal of penis
• Vaginoplasty - creation of vagina
• Clitoroplasty - creation of clitoris
• Labiaplasty - creation of labia
• Mammaplasty - breast augmentation
• Prostatectomy -removal of prostate
• Urethroplasty - creation of urethra

When all of the above criteria are met for gender reassignment surgery, the following genital/breast surgeries may be considered for transmen (female to male):

• Breast reconstruction (e.g., mastectomy) - removal of breast
• Hysterectomy - removal of uterus
• Salpingo-oophorectomy - removal of fallopian tubes and ovaries
• Vaginectomy - removal of vagina
• Vulvectomy - removal of vulva
• Metoidioplasty - creation of micro-penis, using clitoris
• Phalloplasty - creation of penis, with or without urethra
• Urethroplasty - creation of urethra within the penis
• Scrotoplasty - creation of scrotum
• Testicular prostheses - implantation of artificial testes

Services or procedures may not be covered when the criteria and documentation requirements outlined within this article are not met.

The determination of whether to cover gender reassignment surgery and related care for a particular individual is based on whether the item or service is reasonable and necessary to treat the beneficiary’s medical condition after considering the individual’s specific circumstances. These decisions are made after the individual has obtained the medical service and a claim has been submitted by the Medicare provider.   The individual's medical record must be submitted along with the claim and support the services billed. These medical records may include but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports. When reporting procedure code 55970 (Intersex surgery; male to female), the following staged procedures to remove portions of the male genitalia and form female external genitals are included:

• The penis is dissected, and portions are removed with care to preserve vital nerves and vessels in order to fashion a clitoris-like structure.
• The urethral opening is moved to a position similar to that of a female.
• A vagina is made by dissecting and opening the perineum. This opening is lined using pedicle or split- thickness grafts.
• Labia are created out of skin from the scrotum and adjacent tissue.
• A stent or obturator is usually left in place in the newly created vagina for three weeks or longer.

When reporting CPT ® code 55980 (Intersex surgery; female to male), the following staged procedures to form a penis and scrotum using pedicle flap grafts and free skin grafts are included:

• Portions of the clitoris are used, as well as the adjacent skin.
• Prostheses are often placed in the penis to create a sexually functional organ.
• Prosthetic testicles are implanted in the scrotum.
• The vagina is closed or removed.

Response To Comments

Coding information, bill type codes, revenue codes, cpt/hcpcs codes.

Transwoman procedures (male to female) *NOTE: For Part A services only, the provider should bill the appropriate procedure code(s) for inpatient services. The following CPT ® codes will be considered when applicable criteria have been met:

Transman procedures (female to male) *NOTE: For Part A services only, the provider should bill the appropriate procedure code(s) for inpatient services. The following CPT ® codes will be considered when applicable criteria have been met:

All unlisted procedure codes will suspend for medical review. The following CPT ® codes are considered cosmetic. When billed with any Covered ICD-10 Codes listed below, the service will not be covered (list may not be all-inclusive):

CPT/HCPCS Modifiers

Icd-10-cm codes that support medical necessity.

The following diagnosis codes are considered covered when applicable criteria have been met:

ICD-10-CM Codes that DO NOT Support Medical Necessity

All other diagnosis codes will be denied as non-covered.

ICD-10-PCS Codes

Additional icd-10 information.

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

Other Coding Information

Coding table information, revision history information, associated documents.

• Gender Reassignment
• Gender Dysphoria

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Page Help for Article - Billing and Coding: Gender Reassignment Services for Gender Dysphoria (A53793)

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• Introduction
• Conclusions
• Article Information

Error bars represent 95% CIs. GAS indicates gender-affirming surgery.

Percentages are based on the number of procedures divided by number of patients; thus, as some patients underwent multiple procedures the total may be greater than 100%. Error bars represent 95% CIs.

eTable.  ICD-10 and CPT Codes of Gender-Affirming Surgery

eFigure. Percentage of Patients With Codes for Gender Identity Disorder Who Underwent GAS

Data Sharing Statement

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Wright JD , Chen L , Suzuki Y , Matsuo K , Hershman DL. National Estimates of Gender-Affirming Surgery in the US. JAMA Netw Open. 2023;6(8):e2330348. doi:10.1001/jamanetworkopen.2023.30348

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National Estimates of Gender-Affirming Surgery in the US

• 1 Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, New York
• 2 Department of Obstetrics and Gynecology, University of Southern California, Los Angeles

Question   What are the temporal trends in gender-affirming surgery (GAS) in the US?

Findings   In this cohort study of 48 019 patients, GAS increased significantly, nearly tripling from 2016 to 2019. Breast and chest surgery was the most common class of procedures performed overall; genital reconstructive procedures were more common among older individuals.

Meaning   These findings suggest that there will be a greater need for clinicians knowledgeable in the care of transgender individuals with the requisite expertise to perform gender-affirming procedures.

Importance   While changes in federal and state laws mandating coverage of gender-affirming surgery (GAS) may have led to an increase in the number of annual cases, comprehensive data describing trends in both inpatient and outpatient procedures are limited.

Objective   To examine trends in inpatient and outpatient GAS procedures in the US and to explore the temporal trends in the types of GAS performed across age groups.

Design, Setting, and Participants   This cohort study includes data from 2016 to 2020 in the Nationwide Ambulatory Surgery Sample and the National Inpatient Sample. Patients with diagnosis codes for gender identity disorder, transsexualism, or a personal history of sex reassignment were identified, and the performance of GAS, including breast and chest procedures, genital reconstructive procedures, and other facial and cosmetic surgical procedures, were identified.

Main Outcome Measures   Weighted estimates of the annual number of inpatient and outpatient procedures performed and the distribution of each class of procedure overall and by age were analyzed.

Results   A total of 48 019 patients who underwent GAS were identified, including 25 099 (52.3%) who were aged 19 to 30 years. The most common procedures were breast and chest procedures, which occurred in 27 187 patients (56.6%), followed by genital reconstruction (16 872 [35.1%]) and other facial and cosmetic procedures (6669 [13.9%]). The absolute number of GAS procedures rose from 4552 in 2016 to a peak of 13 011 in 2019 and then declined slightly to 12 818 in 2020. Overall, 25 099 patients (52.3%) were aged 19 to 30 years, 10 476 (21.8%) were aged 31 to 40, and 3678 (7.7%) were aged12 to 18 years. When stratified by the type of procedure performed, breast and chest procedures made up a greater percentage of the surgical interventions in younger patients, while genital surgical procedures were greater in older patients.

Conclusions and Relevance   Performance of GAS has increased substantially in the US. Breast and chest surgery was the most common group of procedures performed. The number of genital surgical procedures performed increased with increasing age.

Gender dysphoria is characterized as an incongruence between an individual’s experienced or expressed gender and the gender that was assigned at birth. 1 Transgender individuals may pursue multiple treatments, including behavioral therapy, hormonal therapy, and gender-affirming surgery (GAS). 2 GAS encompasses a variety of procedures that align an individual patient’s gender identity with their physical appearance. 2 - 4

While numerous surgical interventions can be considered GAS, the procedures have been broadly classified as breast and chest surgical procedures, facial and cosmetic interventions, and genital reconstructive surgery. 2 , 4 Prior studies 2 - 7 have shown that GAS is associated with improved quality of life, high rates of satisfaction, and a reduction in gender dysphoria. Furthermore, some studies have reported that GAS is associated with decreased depression and anxiety. 8 Lastly, the procedures appear to be associated with acceptable morbidity and reasonable rates of perioperative complications. 2 , 4

Given the benefits of GAS, the performance of GAS in the US has increased over time. 9 The increase in GAS is likely due in part to federal and state laws requiring coverage of transition-related care, although actual insurance coverage of specific procedures is variable. 10 , 11 While prior work has shown that the use of inpatient GAS has increased, national estimates of inpatient and outpatient GAS are lacking. 9 This is important as many GAS procedures occur in ambulatory settings. We performed a population-based analysis to examine trends in GAS in the US and explored the temporal trends in the types of GAS performed across age groups.

To capture both inpatient and outpatient surgical procedures, we used data from the Nationwide Ambulatory Surgery Sample (NASS) and the National Inpatient Sample (NIS). NASS is an ambulatory surgery database and captures major ambulatory surgical procedures at nearly 2800 hospital-owned facilities from up to 35 states, approximating a 63% to 67% stratified sample of hospital-owned facilities. NIS comprehensively captures approximately 20% of inpatient hospital encounters from all community hospitals across 48 states participating in the Healthcare Cost and Utilization Project (HCUP), covering more than 97% of the US population. Both NIS and NASS contain weights that can be used to produce US population estimates. 12 , 13 Informed consent was waived because data sources contain deidentified data, and the study was deemed exempt by the Columbia University institutional review board. This cohort study followed the Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE ) reporting guideline.

We selected patients of all ages with an International Statistical Classification of Diseases and Related Health Problems, Tenth Revision ( ICD-10 ) diagnosis codes for gender identity disorder or transsexualism ( ICD-10 F64) or a personal history of sex reassignment ( ICD-10 Z87.890) from 2016 to 2020 (eTable in Supplement 1 ). We first examined all hospital (NIS) and ambulatory surgical (NASS) encounters for patients with these codes and then analyzed encounters for GAS within this cohort. GAS was identified using ICD-10 procedure codes and Common Procedural Terminology codes and classified as breast and chest procedures, genital reconstructive procedures, and other facial and cosmetic surgical procedures. 2 , 4 Breast and chest surgical procedures encompassed breast reconstruction, mammoplasty and mastopexy, or nipple reconstruction. Genital reconstructive procedures included any surgical intervention of the male or female genital tract. Other facial and cosmetic procedures included cosmetic facial procedures and other cosmetic procedures including hair removal or transplantation, liposuction, and collagen injections (eTable in Supplement 1 ). Patients might have undergone procedures from multiple different surgical groups. We measured the total number of procedures and the distribution of procedures within each procedural group.

Within the data sets, sex was based on patient self-report. The sex of patients in NIS who underwent inpatient surgery was classified as either male, female, missing, or inconsistent. The inconsistent classification denoted patients who underwent a procedure that was not consistent with the sex recorded on their medical record. Similar to prior analyses, patients in NIS with a sex variable not compatible with the procedure performed were classified as having undergone genital reconstructive surgery (GAS not otherwise specified). 9

Clinical variables in the analysis included patient clinical and demographic factors and hospital characteristics. Demographic characteristics included age at the time of surgery (12 to 18 years, 19 to 30 years, 31 to 40 years, 41 to 50 years, 51 to 60 years, 61 to 70 years, and older than 70 years), year of the procedure (2016-2020), and primary insurance coverage (private, Medicare, Medicaid, self-pay, and other). Race and ethnicity were only reported in NIS and were classified as White, Black, Hispanic and other. Race and ethnicity were considered in this study because prior studies have shown an association between race and GAS. The income status captured national quartiles of median household income based of a patient’s zip code and was recorded as less than 25% (low), 26% to 50% (medium-low), 51% to 75% (medium-high), and 76% or more (high). The Elixhauser Comorbidity Index was estimated for each patient based on the codes for common medical comorbidities and weighted for a final score. 14 Patients were classified as 0, 1, 2, or 3 or more. We separately reported coding for HIV and AIDS; substance abuse, including alcohol and drug abuse; and recorded mental health diagnoses, including depression and psychoses. Hospital characteristics included a composite of teaching status and location (rural, urban teaching, and urban nonteaching) and hospital region (Northeast, Midwest, South, and West). Hospital bed sizes were classified as small, medium, and large. The cutoffs were less than 100 (small), 100 to 299 (medium), and 300 or more (large) short-term acute care beds of the facilities from NASS and were varied based on region, urban-rural designation, and teaching status of the hospital from NIS. 8 Patients with missing data were classified as the unknown group and were included in the analysis.

National estimates of the number of GAS procedures among all hospital encounters for patients with gender identity disorder were derived using discharge or encounter weight provided by the databases. 15 The clinical and demographic characteristics of the patients undergoing GAS were reported descriptively. The number of encounters for gender identity disorder, the percentage of GAS procedures among those encounters, and the absolute number of each procedure performed over time were estimated. The difference by age group was examined and tested using Rao-Scott χ 2 test. All hypothesis tests were 2-sided, and P  < .05 was considered statistically significant. All analyses were conducted using SAS version 9.4 (SAS Institute Inc).

A total of 48 019 patients who underwent GAS were identified ( Table 1 ). Overall, 25 099 patients (52.3%) were aged 19 to 30 years, 10 476 (21.8%) were aged 31 to 40, and 3678 (7.7%) were aged 12 to 18 years. Private insurance coverage was most common in 29 064 patients (60.5%), while 12 127 (25.3%) were Medicaid recipients. Depression was reported in 7192 patients (15.0%). Most patients (42 467 [88.4%]) were treated at urban, teaching hospitals, and there was a disproportionate number of patients in the West (22 037 [45.9%]) and Northeast (12 396 [25.8%]). Within the cohort, 31 668 patients (65.9%) underwent 1 procedure while 13 415 (27.9%) underwent 2 procedures, and the remainder underwent multiple procedures concurrently ( Table 1 ).

The overall number of health system encounters for gender identity disorder rose from 13 855 in 2016 to 38 470 in 2020. Among encounters with a billing code for gender identity disorder, there was a consistent rise in the percentage that were for GAS from 4552 (32.9%) in 2016 to 13 011 (37.1%) in 2019, followed by a decline to 12 818 (33.3%) in 2020 ( Figure 1 and eFigure in Supplement 1 ). Among patients undergoing ambulatory surgical procedures, 37 394 (80.3%) of the surgical procedures included gender-affirming surgical procedures. For those with hospital admissions with gender identity disorder, 10 625 (11.8%) of admissions were for GAS.

Breast and chest procedures were most common and were performed for 27 187 patients (56.6%). Genital reconstruction was performed for 16 872 patients (35.1%), and other facial and cosmetic procedures for 6669 patients (13.9%) ( Table 2 ). The most common individual procedure was breast reconstruction in 21 244 (44.2%), while the most common genital reconstructive procedure was hysterectomy (4489 [9.3%]), followed by orchiectomy (3425 [7.1%]), and vaginoplasty (3381 [7.0%]). Among patients who underwent other facial and cosmetic procedures, liposuction (2945 [6.1%]) was most common, followed by rhinoplasty (2446 [5.1%]) and facial feminizing surgery and chin augmentation (1874 [3.9%]).

The absolute number of GAS procedures rose from 4552 in 2016 to a peak of 13 011 in 2019 and then declined slightly to 12 818 in 2020 ( Figure 1 ). Similar trends were noted for breast and chest surgical procedures as well as genital surgery, while the rate of other facial and cosmetic procedures increased consistently from 2016 to 2020. The distribution of the individual procedures performed in each class were largely similar across the years of analysis ( Table 3 ).

When stratified by age, patients 19 to 30 years had the greatest number of procedures, 25 099 ( Figure 2 ). There were 10 476 procedures performed in those aged 31 to 40 years and 4359 in those aged 41 to 50 years. Among patients younger than 19 years, 3678 GAS procedures were performed. GAS was less common in those cohorts older than 50 years. Overall, the greatest number of breast and chest surgical procedures, genital surgical procedures, and facial and other cosmetic surgical procedures were performed in patients aged 19 to 30 years.

When stratified by the type of procedure performed, breast and chest procedures made up the greatest percentage of the surgical interventions in younger patients while genital surgical procedures were greater in older patients ( Figure 2 ). Additionally, 3215 patients (87.4%) aged 12 to 18 years underwent GAS and had breast or chest procedures. This decreased to 16 067 patients (64.0%) in those aged 19 to 30 years, 4918 (46.9%) in those aged 31 to 40 years, and 1650 (37.9%) in patients aged 41 to 50 years ( P  < .001). In contrast, 405 patients (11.0%) aged 12 to 18 years underwent genital surgery. The percentage of patients who underwent genital surgery rose sequentially to 4423 (42.2%) in those aged 31 to 40 years, 1546 (52.3%) in those aged 51 to 60 years, and 742 (58.4%) in those aged 61 to 70 years ( P  < .001). The percentage of patients who underwent facial and other cosmetic surgical procedures rose with age from 9.5% in those aged 12 to 18 years to 20.6% in those aged 51 to 60 years, then gradually declined ( P  < .001). Figure 2 displays the absolute number of procedure classes performed by year stratified by age. The greatest magnitude of the decline in 2020 was in younger patients and for breast and chest procedures.

These findings suggest that the number of GAS procedures performed in the US has increased dramatically, nearly tripling from 2016 to 2019. Breast and chest surgery is the most common class of procedure performed while patients are most likely to undergo surgery between the ages of 19 and 30 years. The number of genital surgical procedures performed increased with increasing age.

Consistent with prior studies, we identified a remarkable increase in the number of GAS procedures performed over time. 9 , 16 A prior study examining national estimates of inpatient GAS procedures noted that the absolute number of procedures performed nearly doubled between 2000 to 2005 and from 2006 to 2011. In our analysis, the number of GAS procedures nearly tripled from 2016 to 2020. 9 , 17 Not unexpectedly, a large number of the procedures we captured were performed in the ambulatory setting, highlighting the need to capture both inpatient and outpatient procedures when analyzing data on trends. Like many prior studies, we noted a decrease in the number of procedures performed in 2020, likely reflective of the COVID-19 pandemic. 18 However, the decline in the number of procedures performed between 2019 and 2020 was relatively modest, particularly as these procedures are largely elective.

Analysis of procedure-specific trends by age revealed a number of important findings. First, GAS procedures were most common in patients aged 19 to 30 years. This is in line with prior work that demonstrated that most patients first experience gender dysphoria at a young age, with approximately three-quarters of patients reporting gender dysphoria by age 7 years. These patients subsequently lived for a mean of 23 years for transgender men and 27 years for transgender women before beginning gender transition treatments. 19 Our findings were also notable that GAS procedures were relatively uncommon in patients aged 18 years or younger. In our cohort, fewer than 1200 patients in this age group underwent GAS, even in the highest volume years. GAS in adolescents has been the focus of intense debate and led to legislative initiatives to limit access to these procedures in adolescents in several states. 20 , 21

Second, there was a marked difference in the distribution of procedures in the different age groups. Breast and chest procedures were more common in younger patients, while genital surgery was more frequent in older individuals. In our cohort of individuals aged 19 to 30 years, breast and chest procedures were twice as common as genital procedures. Genital surgery gradually increased with advancing age, and these procedures became the most common in patients older than 40 years. A prior study of patients with commercial insurance who underwent GAS noted that the mean age for mastectomy was 28 years, significantly lower than for hysterectomy at age 31 years, vaginoplasty at age 40 years, and orchiectomy at age 37 years. 16 These trends likely reflect the increased complexity of genital surgery compared with breast and chest surgery as well as the definitive nature of removal of the reproductive organs.

This study has limitations. First, there may be under-capture of both transgender individuals and GAS procedures. In both data sets analyzed, gender is based on self-report. NIS specifically makes notation of procedures that are considered inconsistent with a patient’s reported gender (eg, a male patient who underwent oophorectomy). Similar to prior work, we assumed that patients with a code for gender identity disorder or transsexualism along with a surgical procedure classified as inconsistent underwent GAS. 9 Second, we captured procedures commonly reported as GAS procedures; however, it is possible that some of these procedures were performed for other underlying indications or diseases rather than solely for gender affirmation. Third, our trends showed a significant increase in procedures through 2019, with a decline in 2020. The decline in services in 2020 is likely related to COVID-19 service alterations. Additionally, while we comprehensively captured inpatient and ambulatory surgical procedures in large, nationwide data sets, undoubtedly, a small number of procedures were performed in other settings; thus, our estimates may underrepresent the actual number of procedures performed each year in the US.

These data have important implications in providing an understanding of the use of services that can help inform care for transgender populations. The rapid rise in the performance of GAS suggests that there will be a greater need for clinicians knowledgeable in the care of transgender individuals and with the requisite expertise to perform GAS procedures. However, numerous reports have described the political considerations and challenges in the delivery of transgender care. 22 Despite many medical societies recognizing the necessity of gender-affirming care, several states have enacted legislation or policies that restrict gender-affirming care and services, particularly in adolescence. 20 , 21 These regulations are barriers for patients who seek gender-affirming care and provide legal and ethical challenges for clinicians. As the use of GAS increases, delivering equitable gender-affirming care in this complex landscape will remain a public health challenge.

Accepted for Publication: July 15, 2023.

Published: August 23, 2023. doi:10.1001/jamanetworkopen.2023.30348

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2023 Wright JD et al. JAMA Network Open .

Corresponding Author: Jason D. Wright, MD, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, 161 Fort Washington Ave, 4th Floor, New York, NY 10032 ( [email protected] ).

Author Contributions: Dr Wright had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Wright, Chen.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Wright.

Critical review of the manuscript for important intellectual content: All authors.

Statistical analysis: Wright, Chen.

Administrative, technical, or material support: Wright, Suzuki.

Conflict of Interest Disclosures: Dr Wright reported receiving grants from Merck and personal fees from UpToDate outside the submitted work. No other disclosures were reported.

Data Sharing Statement: See Supplement 2 .

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How gender dysphoria and incongruence became medical diagnoses – a historical review

Marc-antoine crocq.

Department of Child and Adolescent Psychiatry, Centre Hospitalier, Mulhouse, France

This article is a historical review of the medical and psychiatric diagnoses associated with transgender people across epochs. Ancient Greek and Roman writings already mention gender change. Before a diagnosis even existed, historical documents described the lives of numerous people whom we would consider transgender today. The development of medical classifications took off in the nineteenth century, driven by the blooming of natural sciences. In the nineteenth century, most authors conflated questions of sexual orientation and gender. For example, the psychiatrist Krafft-Ebing reported cases of transgender people but understood them as paranoia, or as the extreme degree of severity in a dimension of sexual inversion. In the early 1900s, doctors such as Magnus Hirschfeld first distinguished homosexual and transgender behaviour. The usual term for transgender people was transvestite, before Harry Benjamin generalised the term transsexual in the mid-20th century. The term transgender became common in the 1970s. This article details the evolution of diagnoses for transgender people from DSM-III and ICD-10 to DSM-5 and ICD-11.

Gender Dysphoria (GD) became a psychiatric diagnosis in the fifth edition of DSM (2013), and Gender Incongruence (GI) appeared in ICD-11, the WHO classification that was approved in 2019 and should be effective in 2022. GI was not included in the section on mental health but instead in a section on sexual health. The introduction of GD and GI in today’s medical nomenclatures was hailed as progress because it intended to facilitate the provision of hormonal therapy and surgical reassignment in the context of sexual transition. However, some critics argue that gender identity is a free choice that medical authorities should not sanction. In addition, a diagnostic category is a simplistic way of describing all the nuances of gender fluidity that have asserted themselves in recent decades.

This historical review shows that the usages and connotations of terms associated with sex and gender have evolved across places and historical periods. Therefore, we should be wary of making anachronisms by understanding historical terms with our current references.

Gender metamorphoses in Greco-Roman culture

The medical classifications that appeared in the Age of Enlightenment regarded themselves as heirs to the Greco-Roman models of antiquity. Non-binary gender and gender transformations were common themes in Greco-Roman mythology. In the Metamorphoses (the Greek μεταμορφώσεις means ‘Transformations’), the Roman poet Ovid (ca. 8 A.D.) relates how Tiresias was transformed into a woman, punished for disturbing two giant snakes mating. He lived as a woman for seven years before being turned into a man again. Once Jupiter, ‘expansive with wine and exchanging pleasantries with Juno,’ told her that women derive more sexual pleasure [voluptas] than men (Book III, 320). Juno denied it, and they agreed to ask Tiresias for his opinion since he had known sex from both perspectives. As the arbiter of the dispute, Tiresias. did confirm Jupiter’s words. Ovid further narrates (Book XII, 190) how Caenis (Καινις), a renowned beauty, was raped by Poseidon, the god of the sea. In response to Poseidon’s offer to realise a wish, she asked to be transformed into a man to prevent the repetition of such an assault. Thus, Caenis became as a man, Caeneus (Καινεύς), a famous warrior who received the additional faculty of having a skin that any weapon could not wound.

Transgender themes are not limited to mythology but are also associated with Roman emperors. According to Varner ( 2008 ), Roman imperial portraits could be quite gender fluid and even transgender, consciously hybridising elements of traditional male and female categorizations. In imperial portraits, the mixture of human and divine, male and female, intentionally blurred traditional taxonomic categories to assert the transcendence of imperial authority over prescribed gender roles. For example, museums contain busts, coins, gems showing the identification of emperor Domitian with the female goddess Minerva. These artefacts show Minerva’s recognisable female body or hairstyle mixed with Domitian’s facial features.

The Roman emperor Elagabalus (ca. 204–11 March 222), also called Heliogabalus, might be the first historical record of a famous person asking to be addressed femininely and requesting surgical sexual reassignment. According to Cassius Dio (c. 155–c. 235 AD) (Dio Cassius: Roman History 1955 ), Elagabalus once said: ‘call me not Lord (κύριος), for I am a Lady (κυρία).’ Also, he asked physicians to contrive a woman’s vagina in his body through an incision, promising them large sums for doing so. Elagabalus was just an adolescent when he became an emperor and hardly an adult when assassinated. Cassius Dio, a statesman and historian who wrote in Greek was a contemporary of Elagabalus. However, he was not a direct witness since he was in Pergamum and Smyrna during most of Elagabalus’ reign, which he generally depicted as a period of decline (Scott 2018 ).

Transgender behaviour existed before diagnostic classifications

Historical sources from the early modern period in Europe indicate that cases of persons living permanently with the clothes and roles of the other sex were not exceptional. History has highlighted the most adventurous biographies. Catalina de Erauso (Repubblica) ran away from her convent in Spain in the early seventeenth century as a young woman. She adopted a male identity and embarked to America, where she was active in business or the military in almost all the provinces of the Spanish Empire. She is said to have posed as a castrato – a legitimate social status at the time – to pursue love relationships with feminine partners. She achieved such fame that she gained audiences with the king of Spain, Philip IV, and the Pope, Urbano VIII, who granted her permission to wear male clothes. She died in Mexico under the name Antonio de Erauso. Another exceptional biography is the Chevalier d’Éon, who served the French King Louis XV as an envoy and spy in Russia and as an officer on the Seven Years’ War battlefields. He spent the last part of his life in England as Mademoiselle or Chevalière d’Éon, dressing as a woman. His birth sex remained a mystery and was the subject of speculation until his death. Only then did a surgeon attest in a post-mortem certificate that he had well-formed male genital organs.

Early medical characterisations. The conflation of homosexual and transgender

The current psychiatric classifications were initially developed by German-speaking authors in the nineteenth century. At that time, homosexuality, transvestism, or transgender behaviours were conceptualised as various degrees of a single dimension of ‘gender/sexual inversion.’ This conflation of homosexuality and gender contrasts with modern notions that homosexuality is independent of gender identity and related exclusively to sexual object choice.

The essential point in Karl Heinrich Ulrichs’ theory of homosexuality (1864) was the conviction that the male homosexual possesses a female soul enclosed in a male body (‘ anima muliebris in corpore virili inclusa ’). Ulrichs believed that both possibilities of sexual development remained possible in the embryo’s early stages when the sexual organs were not yet differentiated. He saw confirmation of this idea in the existence of hermaphrodites. He postulated that there must be a ‘germ’ [‘ Keim ’] that determined whether the sexual organs would develop male or female. To explain the discrepancy between the sexual organs and the sexual orientation, he postulated the existence of another ‘germ’ that determined the direction of the sex drive. We will see that this model prefigures modern biological conceptions. The term homosexuality was coined in 1869 by the Austro-Hungarian writer Karl Maria Kertbeny.

Krafft-Ebing (1840–1902), influenced by the theory of degeneracy, postulated a gradient of severity from effeminacy and homosexuality to complete transmutatio sexus [sex transmutation]. In the 7th edition of his textbook of sexology, Psychopathia sexualis , he gives a clinical description that would satisfy the DSM-5 criteria of GD. The person referred to as Case 99 (von Krafft-Ebing 1894 ; or Case 129 in the textbook’s 12 t h edition), a physician born as a male in Hungary in 1844, writes autobiographically:

at the age of twelve or thirteen, I had a definite feeling of preferring to be a young lady. A young lady’s form was more pleasing to me; her quiet manner, her deportment, but particularly her attire, attracted me. But I was careful not to allow this to be noticed. I am sure that I should not have shrunk from the castration-knife, could I have thus attained my desire. If asked why I preferred female attire, I could have said nothing more than that it attracted me powerfully… I remember, when fifteen, to have first expressed to a friend the wish to be a girl. In answer to his question, I could not give the reason why … when in high school I finally had once coitus; hoc modo sensi, me libentius sub puella concubuisse et penem meum cum cunno mutatum maluisse (litteraly: I would have preferred to lie under the girl and to have her sexual organs exchanged for my penis) … But, even on my marriage-night, I felt that I was only a woman in man’s form.

Krafft-Ebing diagnosed this case as ‘ Metamorphosis sexualis paranoiaca ’ indicating that he understood it as delusional.

Distinguishing transvestite, transsexual, and transgender

Before World War I in Berlin, Magnus Hirschfeld first distinguished between the questions of sexual orientation and those of gender identity, putting an end to the confusion between the fields of homosexuality and gender identity. However, Hirschfeld still used the word transvestite to refer to what we call transgender today. After the World Wars in the United States, Harry Benjamin clearly defined the difference between transvestite and transsexual. After the 1970s, the term transsexual gave way to transgender (Yarbrough 2018 ).

Magnus Hirschfeld (1868–1935) was a physician who practiced in the Charlottenburg district of Berlin. He founded two organisations committed to the support of homosexuals and sexual minorities, first the Wissenschaft-humanitäres Komitee (WhK) in 1897, and then the Institut für Sexualwissenschaft (1919) whose staff included transgender people (Bauer et al. 2017 ). Hirschfeld published an annual journal entitled ‘ Jahrbuch für sexuelle Zwischenstufen unter besonderer Berücksichtigung der Homosexualität ’ (Yearbook for sexual intermediaries with special reference to homosexuality), which aimed to spread scientific research to carry out advocacy on behalf of sexual minorities (Dobler, 2004 ). One of his objectives was the revision of paragraph 175 of the German criminal code, which criminalised homosexual acts between males. As recounted by Susan Stryker ( 2017 ), Hirschfeld had a central position in the history of the transgender movement. He collaborated with Eugen Steinach (1861–1944), the Austrian endocrinologist who worked on the anatomical and behavioural effects of sexual hormones (Steinach 1912 ). One of his young colleagues was Harry Benjamin, who settled in the United States. Two transgender women seen by Hirschfeld in the late 1920s et early 1930s belong to the first documented cases of sex reassignment surgeries: Dora [Dörchen] Richter (1931), and the Danish painter Lili Elbe whose life was fictionalised in the film The Danish Girl . As a Jew and homosexual, Magnus Hirschfeld had to leave Germany and died in exile in France.

According to Drescher ( 2014 ), Hirschfeld is credited with being first to distinguish the desires of homosexuality (to have partners of the same sex) from those of transsexualism (to live as the other sex), thus putting an end to the conflation of gender identity and sexual orientation. He used the term ‘transvestites’; he also coined the term ‘transsexual’ in 1923 but this word would only catch three decades later with H. Benjamin. Hirschfeld’s famous book-length publication on transvestites appeared in 1910 in the Jahrbuch (Hirschfeld 1910 ). A sequel publication illustrated with numerous drawings and photos of transvestites, historical or contemporary, was released in 1912 (Hirschfeld and Tilke 1912 ). According to Marhoefer ( 2015 ), Hirschfeld’s contemporaries disagreed over whether ‘transvestites’ denoted people who only wished to dress in the clothing of the other sex, or people whose actual sex was not their birth sex and who transitioned to their actual sex, or both of these groups. Three decades later, the former would be called ‘transvestites’ and the latter ‘transsexuals’. Mak ( 1998 ) remarks that Hirschfeld included only one woman in his transvestite case histories. In an article based on the cases of four women whom Hirschfeld knew while writing his book on transvestites, Maak hypothesises that Hirschfeld continued to regard the ‘masculinity’ of feminists as a hallmark of inverted sexual identity, an ancient model which had flourished in the nineteenth century.

Havelock Ellis (1859–1939), a British physician, also studied transgender phenomena as a question distinct from homosexuality. He disagreed with Hirschfeld’s term ‘transvestitism’ and proposed in 1913 the term sexo-aesthetic inversion instead (Ekins and King 2006 ). In the 1920s, he coined the word eonism , which he derived from the name of the historical figure Chevalier d’Éon.

Harry Benjamin visited the United States in 1913. As fate would have it, the First World War broke out shortly after that, and the Royal Navy blockade cut him off from the way back to Germany. He lived in the United States till the age of 101-½ (Green 2009 ). Guided by his interest in hormonal research, he became a disciple of Eugen Steinach, whom he visited in Vienna every summer through the twenties and early thirties. On these occasions, he also took frequent trips to Berlin, where he would meet Magnus Hirschfeld. He also knew Alfred C. Kinsey, who acquainted him in 1948 with a young patient, Barry. Born with male sex, Barry started dressing in girls’ clothes by age 3. He denied ever having an erection or even masturbating. Medical people were advising genital surgery, but conversion intervention was prevented by the Attorney General of Wisconsin and state laws interpreting such surgery as ‘mayhem’. Through Benjamin’s encouragement, Barry, now known as Sally, made three trips to Europe between 1953 and 1958 to complete the genital operations, which culminated in the construction of a vagina lined with skin from the thigh (Schaefer and Wheeler 1995 ).

Benjamin’s most famous patient, George Jorgensen, went to Denmark as a natal man and returned to the US in 1952 as trans woman Christine Jorgensen. When she died at 62 in 1989, a New York Times obituary retraced her biography. Growing up, she was frustrated by feelings that she was a woman trapped in a man’s body. She served as a clerk in the army and was honourably discharged. Her sexual conversion began with hormone injections in 1950 when she was 24 years old and was completed in 1952 with surgery in Copenhagen under the care of Christian Hamburger, a Danish specialist whose first name she adopted to form her own. Hamburger and his colleagues published a report in the Journal of the American Medical Association (Hamburger et al. 1953 ).

Such cases led to Benjamin’s interest in what he later described as transsexualism, realising that there was a different condition to that of transvestism, which was then the current diagnosis for adults who had such needs. Benjamin thought that

transvestitism is the desire of a certain group of men to dress as women, or of women to dress as men … It can be overwhelming, even to the point of wanting to belong to the other sex and correct nature's anatomical ‘error’ … For such cases the term transsexualism seems appropriate. True transsexuals have the feeling that they belong to the other sex; they want to be seen and function as members of the opposite sex and not only appear as such. Their sexual organs, primary (testicles) and secondary (penis and others), are disgusting deformities to be changed by the surgeon's scalpel. It is only because of the recent and great advances in endocrinology and surgical techniques that the picture has changed. (Benjamin 1953 )

Another historical pioneer is Michael Dillon (1915–1962). Born as a girl in London, he started self-administering testosterone tablets in 1939. He underwent his first operation for phalloplasty in 1945. He graduated from medical school at Trinity College in Dublin in 1951. He finished his life in India as a Buddhist monk under the name Lobzang Jivaka. His autobiography, Out of the Ordinary , was published posthumously in 2017. He has been called the first female to male ‘transsexual,’ although that term would become common only after his lifetime.

Today, expressions of gender variance or gender nonconformity are frequently subsumed by the popular term transgender, although this term does not appear in the DSM or ICD. ‘Transgender’ is a relatively recent word. According to the Oxford English Dictionary, ‘transgender’ was first used in the early 1970s to designate a person whose sense of personal identity and gender does not correspond to that person’s sex at birth or does not otherwise conform to conventional notions of sex and gender. It is also an umbrella term which includes any or all non-conventional gender identities.

Psychology, society, or biology?

A diagnostic category needs an aetiological hypothesis to enhance its validity. Authors have been searching in three main fields for influences that might make a person transgender: psychology, sociology, and biology. A proponent of the role of sociology and education was John Money, a New Zealand psychologist. He published theories in the 1950s that one’s sense of being male or female was acquired and determined by external, environmental factors. Based on cases of gender assignment in intersex children born with ambiguous genitalia, Money believed parental attitudes had a substantial effect on whether a child accepted the gender category that had been surgically and medically assigned.

Benjamin is quoted as having little regard for his era’s psychoanalysts and believing that transgender women had a brain that was probably ‘feminized’ in utero . This belief seemed to be confirmed by a milestone paper published in Nature in 1995 (Zhou et al. 1995 ) that studied the volume of the central subdivision of the bed nucleus of the stria terminalis (BSTc). The BSTc, a brain area essential for sexual behaviour, is more prominent in men than women. A female-sized BSTc was found in male-to-female transsexuals. The size of the BSTc was not influenced by sex hormones in adulthood and was independent of sexual orientation. According to the authors, this study was the first to show a female brain structure in genetically male transsexuals and supported the hypothesis that gender identity develops due to an interaction between the developing brain and sex hormones. Swaab ( 2014 ), the senior author, further elaborated that the differentiation of our sex organs occurs in the first months of pregnancy. In contrast, the sexual differentiation of the brain occurs in the second half of pregnancy. One might hypothesise that these two successive differentiations may occur in different directions in some transgender persons. This hypothesis is reminiscent of Ulrichs’ theory mentioned earlier (vide supra).

Recent articles suggest that the sexual differentiation of the human brain is more complex than initially thought. MRI analyses of approximately 1500 human brains showed extensive overlap between the distributions of females and males for all parameters assessed. Moreover, brains with features that are coherently at one end of the ‘maleness-femaleness’ continuum are rare. Instead, most brains comprise unique ‘mosaics’ of features, some more common in females compared with males, some more common in males compared with females, and some common in both females and males (Joel et al. 2015 ). However, recent studies comparing transgender and cisgender persons show differences in the cerebral networks involved in own body perception in the context of self (Manzouri and Savic 2019 ; Nota et al. 2017 ), and in the patterns of brain connectivity that might affect one’s sense of body congruence (Moody et al. 2021 ). If proven, a biological aetiology would destigmatize transgender behaviour.

DSM and ICD

Table 1 shows the diagnostic categories associated with transgender persons in the successive editions of DSM and ICD. Drescher has finely analysed the evolution of these diagnoses in DSM (Drescher 2020 ). The first two editions of the DSM placed a significant emphasis on psychoanalytic theories of normal and pathological mental functioning; the gender identity diagnoses or anything equivalent did not appear in either one (APA, 1952, 1968).

Gender as a diagnostic category in DSM and ICD.

DSM-III to DSM-IV-TR

Zucker and Spitzer ( 2005 ) summarised the mutations of the gender diagnoses from DSM-III through DSM-IV-TR. In the DSM-III (1980), there appeared for the first time two psychiatric diagnoses in children, adolescents, and adults: gender identity disorder of childhood (GIDC) and transsexualism, the latter concerning adolescents and adults. The decision to place transsexualism in the DSM was supported by the research and clinical contributions of John Money, Harry Benjamin, Robert Stoller, and Richard Green. A third diagnosis appeared in the DSM-III-R (APA, 1987): gender identity disorder of adolescence and adulthood, nontranssexual type (GIDAANT). However, GIDAANT was not kept in DSM-IV (APA, 1994, 2000a), and GIDC and transsexualism were collapsed into one overarching diagnosis, gender identity disorder (GID), with different criteria sets for children versus adolescents and adults.

The ICD-10, endorsed by the Forty-third World Health Assembly in 1990, followed the DSM-III’s lead and included the diagnoses of transsexualism and gender identity disorder of childhood. ICD-10 also created the diagnosis of dual-role transvestism (‘ Transvestisme bivalent ’ in French). In ICD-10, Transsexualism designated 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 hormonal and surgical treatment to make one’s body as congruent as possible with the preferred sex. To qualify for this diagnosis, the transsexual identity had to persist for at least two years. Dual-role transvestism designated the wearing of clothes of the opposite sex for part of the individual’s existence 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. No sexual excitement accompanied the cross-dressing, which distinguished the disorder from fetishistic transvestism.

In DSM-5, being transgender is not considered per se a psychiatric disorder; it is only the resultant dysphoria that justifies a diagnosis. While dysphoria was chosen for the diagnostic title, the word incongruence is used for the definition in criterion A. In DSM-IV-TR, criterion A requested ‘cross-gender identification.’ In DSM-5, this criterion was modified in order to avoid a male-female dichotomy, and the expressed gender can be female, male, in-between, or otherwise. The primary reason for creating separate diagnostic categories for GD in children on the one hand, and adolescents and adults on the other, is a difference in course. The longitudinal observation of children with GD shows that the persistence of GD into adolescence and adulthood is variable, ranging from 2% to 50% (Zucker et al. 2013 ). On the other hand, in adolescents and adults, there is considerable evidence of diagnostic stability.

In DSM-5, the term transvestic has nothing to do with gender. Transvestic Disorder is part of the section on paraphilias. The diagnosis of transvestic disorder applies to individuals whose cross-dressing or thoughts of cross-dressing are always or often accompanied by sexual excitement. The specification ‘with fetishism’ indicates that fabrics, materials, or garments sexually arouse the person. The specification ‘with autogynephilia’ indicates that thoughts or images of self as female provoke sexual arousal. According to Blanchard ( 2010 ), the presence of fetishism decreases the likelihood of GD in men with transvestic disorder, whereas autogynephilia increases the likelihood of GD in men with transvestic disorder. Individuals with transvestic disorder do not report an incongruence between their experienced gender and assigned gender or desire to be of the other gender. Individuals with a presentation that meets full criteria for transvestic disorder and GD should have both diagnoses.

The diagnosis of gender incongruence (GI) was included in the ICD-11 to preserve access to health services, but it was moved from the ICD-11 chapter on Mental and Behavioural Disorders to the chapter on Sexual Health. Following DSM-5, The ICD-11 abandoned ICD-10 terms such as ‘opposite sex’ and ‘anatomic sex,’ using more contemporary and less binary terms such as ‘experienced gender’ and ‘assigned sex.’ Unlike ICD-10, but like DSM-5, the proposed ICD-11 diagnostic guidelines do not implicitly presume that all individuals seek or desire complete transition to the ‘opposite’ gender. In ICD-11 (Reed et al. 2016 ), GI is characterised 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 GI diagnoses in this group, whether in adolescents, adults, or children.

The ICD-10 categories fetishistic transvestism and dual-role transvestism disappeared in ICD-11. These conditions involve consensual or solitary sexual activity, cause no inherent harm to self or others, and are not necessarily distressing to the individual or associated with functional impairment. Therefore, these arousal patterns were not considered per se as mental disorders but more accurately as variants in sexual arousal (Krueger et al. 2017 ).

DSM-5 emphasises distress and dysfunction related to gender identity through the category’s name and criteria. Distress and dysfunction are also the central rationales for classifying gender dysphoria as a mental disorder. In CIM-11, the diagnostic guidelines indicate that GI may be associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning, particularly in disapproving social environments and where protective laws and policies are absent, but that neither distress nor functional impairment is a diagnostic requirement.

From diagnosis to depathologization

The theme of gender change is frequent in ancient Greco-Roman sources. The reliable historical documents available in the premodern era produced numerous and continuous testimonies of people who led lives that would seem transgender today. The interest in medical diagnosis started in the mid-nineteenth century, thanks to expanding natural sciences. In the twentieth-century culture, giving a medical diagnosis is double-edged, allocating both help and pathological labelling to the person. The concern for depathologization guides the most recent classifications. The aetiology of transgender behaviours is unknown, but research suggests that they have a biological basis in the brain. If this is the case, transgender expression is not a matter of choice influenced by social fads. Nor is it a matter that must be subject to religious or political rules.

Disclosure statement

No potential conflict of interest was reported by the author(s).

• Bauer H, Blume S, Greenough P.. 2017. The Hirschfeld archives: violence, death, and modern queer culture . Philadelphia (PA): Temple University Press. Project MUSE. Accessible at https://muse.jhu.edu/book/64071 . [ Google Scholar ]
• Benjamin H. 1953. Transvestism and transsexualism . Int J Sexol . 7 :12–14. [ Google Scholar ]
• Blanchard R. 2010. The DSM diagnostic criteria for transvestic fetishism . Arch Sex Behav . 39 ( 2 ):363–372. [ PubMed ] [ Google Scholar ]
• Dio Cassius: Roman History. 1955. English translation by Earnest Cary, on the basis of the version of Herbert Baldwin Foster . Cambridge, MA, Harvard University Press, Vol. 9, Book 80, 16.4 and 16.7. [ Google Scholar ]
• Dobler J, editor. 2004. Prolegomena zu Magnus Hirschfelds Jahrbuch für sexuelle Zwischenstufen (1899 bis 1923). Hamburg, Bockel Verlag. ISBN 3-932696-53-0. 389. p. 8.
• Drescher J. 2014. Gender identity diagnoses: history and controversies. Chapter 7. In Kreukels BPC, Steensma TD, De Vries ALC, editors. Gender dysphoria and disorders of sex development. Progress in Care and Knowledge . New York: Springer Science. [ Google Scholar ]
• Drescher J. 2020. Queer diagnoses parallels and contrasts in the history of homosexuality, gender variance, and the Diagnostic and Statistical Manual (DSM) Review and Recommendations Prepared for the DSM-V Sexual and Gender Identity Disorders Work Group . Focus (Am Psychiatr Publ) . 18 ( 3 ):308–335. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Ekins R, King D.. 2006. The transgender phenomenon . London: SAGE Publications. ISBN 978-0761971634. [ Google Scholar ]
• Green R. 2009. The three kings: Harry Benjamin, John Money, Robert Stoller . Arch Sex Behav . 38 ( 4 ):610–613. [ PubMed ] [ Google Scholar ]
• Hamburger C, Sturup GK, Dahl-Iversen E.. 1953. Transvestism; hormonal, psychiatric, and surgical treatment . J Am Med Assoc . 152 ( 5 ):391–396. [ PubMed ] [ Google Scholar ]
• Hirschfeld M, Tilke M.. 1912. Der erotische Verkleidungstried (Die Tranvestiten). Illustrierter Teil . Berlin: Alfred Pulvermacher & Co. [ Google Scholar ]
• Hirschfeld M. 1910. Die Transvestiten. Eine Untersuchung über den erotischen Verkleidungstrieb . Berlin: Alfred Pulvermacher & Co. [ Google Scholar ]
• Joel D, Berman Z, Tavor I, Wexler N, Gaber O, Stein Y, Shefi N, Pool J, Urchs S, Margulies DS, et al.. 2015. Sex beyond the genitalia: the human brain mosaic . Proc Natl Acad Sci U S A . 112 ( 50 ):15468–15473. 15 [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Krueger RB, Reed GM, First MB, Marais A, Kismodi E, Briken P.. 2017. Proposals for paraphilic disorders in the International Classification of Diseases and related health problems, eleventh revision (ICD-11) . Arch Sex Behav . 46 ( 5 ):1529–1545. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Mak G. 1998. ‘ Passing Women’ im Sprechzimmer von Magnus Hirschfeld: Warum der Begriff ‘Transvestit’ nicht für Frauen in Männerkleidern eingeführt wurde . Österreichische Zeitschrift Für Geschichtswissenschaften . 9 ( 3 ):84–399. [ Google Scholar ]
• Manzouri A, Savic I.. 2019. Possible neurobiological underpinnings of homosexuality and gender dysphoria . Cereb Cortex . 29 ( 5 ):2084–2101. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Marhoefer L. 2015. Sex and the Weimar Republic . Toronto: University of Toronto Press. ISBN 978-1-4426-4915-6. p. 340. [ Google Scholar ]
• Moody TD, Feusner JD, Reggente N, Vanhoecke J, Holmberg M, Manzouri A, Sorouri Khorashad B, Savic I.. 2021. Predicting outcomes of cross-sex hormone therapy in transgender individuals with gender incongruence based on pre-therapy resting-state brain connectivity . Neuroimage Clin . 29 :102517. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Nota NM, Kreukels BPC, den Heijer M, Veltman DJ, Cohen-Kettenis PT, Burke SM, Bakker J.. 2017. Brain functional connectivity patterns in children and adolescents with gender dysphoria: sex-atypical or not? Psychoneuroendocrinology . 86 :187–195. [ PubMed ] [ Google Scholar ]
• Reed GM, Drescher J, Krueger RB, Atalla E, Cochran SD, First MB, Cohen-Kettenis PT, Arango-de Montis I, Parish SJ, Cottler S, et al.. 2016. 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 . World Psychiatry . 15 ( 3 ):205–221. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• La Repubblica . 2021. Catalina, the rebel, became a man [in Italian]. https://www.repubblica.it/robinson/2021/01/08/news/e_catalina_la_ribelle_si_fece_uomo-300848577/ .
• Schaefer LC, Wheeler CW.. 1995. Harry Benjamin’s first ten cases (1938-1953): a clinical historical note . Arch Sex Behav . 24 ( 1 ):73–93. [ PubMed ] [ Google Scholar ]
• Scott AG. 2018. Emperors and Usurpers. An historical commentary of Cassius Dio’s Roman History. Books 79-80 (A.D. 217-229). Society for Classical Studies. Vol. 58 . New York: Oxford University Press. [ Google Scholar ]
• Steinach E. 1912. Willkürliche Umwandlung von Säugetier-Männchen in Tiere mit ausgeprägt weiblichen Geschlechtscharakteren und weiblicher Psyche. (Arbitrary Transformation of Mammalian Males in Animals with Pronounced Female Sexual Characteristics and Female Psyche) . Pflüger’s Arch . 144 ( 3-4 ):71–108. [ Google Scholar ]
• Stryker S. 2017. Transgender history . 2nd ed. Berkeley: Seal Press. ISBN 978-1-580-05690 8. [ Google Scholar ]
• Swaab DF. 2014. We are our brains . New York: Spiegel & Grau. [ Google Scholar ]
• Varner ER. 2008. Transcending gender: assimilation, identity, and Roman imperial portraits . Memoirs of the American Academy in Rome. Supplementary volume. Ann Arbor (MI): University of Michigan Press 7 . p. 200–221. [ Google Scholar ]
• von Krafft-Ebing R. 1894. Psychopathia sexualis. Translation of the 7th German edition by Chaddock CG . Philadelphi: F. A. Davis publishers. Case 99, p. 203 sqq. [ Google Scholar ]
• Yarbrough E. 2018. Transgender mental health . Washington (DC): American Psychiatric Association Publishing. ISBN 978-1-61537-189-1. p. 339. [ Google Scholar ]
• Zhou JN, Hofman MA, Gooren LJ, Swaab DF.. 1995. A sex difference in the human brain and its relation to transsexuality . Nature . 378 ( 6552 ):68–70. [ PubMed ] [ Google Scholar ]
• Zucker KJ, Cohen-Kettenis PT, Drescher J, Meyer-Bahlburg HFL, Pfäfflin F, Womack WM.. 2013. Memo outlining evidence for change for gender identity disorder in the DSM-5 . Arch Sex Behav . 42 ( 5 ):901–914. [ PubMed ] [ Google Scholar ]
• Zucker KJ, Spitzer RL.. 2005. Was the gender identity disorder of childhood diagnosis introduced into DSM-III as a backdoor maneuver to replace homosexuality? A historical note . J Sex Marital Ther . 31 ( 1 ):31–42. [ PubMed ] [ Google Scholar ]

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WPATH Standards for Providing Gender Reassignment Care

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WPATH recommends that gender-affirming care for adolescents be provided in a safe and ethical manner, taking into account their physical, emotional, and cognitive development, as well as the potential reproductive effects of treatment.

The World Professional Association of Transgender Health (WPATH) recommends the following standards for providing gender-affirming medical or surgical treatments requested by an adolescent patient:

The adolescent meets the diagnostic criteria of gender incongruence as per the ICD-11 in situations where a diagnosis is necessary to access health care. In countries that have not implemented the latest ICD, other taxonomies may be used although efforts should be undertaken to utilize the latest ICD as soon as practicable.

The experience of gender diversity/incongruence must be marked and sustained over time.

The adolescent demonstrates the emotional and cognitive maturity required to provide informed consent/assent for the treatment.

The adolescent’s mental health concerns (if any) that may interfere with diagnostic clarity, capacity to consent, and gender-affirming medical treatments have been addressed.

The adolescent has been informed of the reproductive effects, including the potential loss of fertility and the available options to preserve fertility, and these have been discussed in the context of the adolescent’s stage of pubertal development.

The adolescent has reached Tanner stage 2 of puberty for pubertal suppression to be initiated. Stage 2 is defined as the beginning of puberty- related physical changes. ■

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Taking a Closer Look at the June ICD-10 Coding Challenge

July 20, 2015 / By Sue Belley, RHIA

CHALLENGE QUESTION

A 37-year old male with a long-standing history of the diagnosis of gender identity disorder is currently undergoing counseling and medical therapy in an effort to work toward physically modifying his body to better match his psychological gender identity. The patient is scheduled to undergo an orchiectomy penectomy and surgical construction of a vagina in the near future.

Assign the ICD-10-CM code for the diagnosis of gender identity disorder.

What ICD-10-PCS code will be used for the procedure of a surgical construction of a vagina using autologous tissue procedure for this patient? Diagnosis Code

F64.1 Gender identity disorder in adolescence and adulthood

Root Operation

BLOG RESPONSE:

The recent news coverage of a former Olympic gold medalist and media figure who transitioned from male to female provides the opportunity to understand how sex reassignment surgery is captured in ICD-10-PCS. The root operation, Creation, is assigned when a new genital structure that does not physically take the place of a body part is created.

This root operation is only used for sex change operations such as the creation of a vagina in a male or the creation of a penis in a female. In this scenario, the procedure code that would be assigned for the creation of a vagina in a male patient is 0W4M070. Some of you assigned code 0W4N071 which is incorrect; this code indicates that a penis is being created in a male patient. Use the 7th character qualifier for the codes in this table to help you assign the correct code for they identify the genital organ that was created during the surgery.

The diagnosis code for gender identify disorder is F64.1, Gender identity disorder in adolescence and adulthood. Some of you assigned an additional code – Z87.890, Personal history of sex reassignment. This code would not be assigned during the encounter when sex reassignment surgery was performed. This code would, however, be assigned for any subsequent encounters.

Sue Belley is a project manager with the consulting services business of 3M Health Information Systems.

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Susan Belley, M.Ed., RHIA, CPHQ, is the manager of clinical content development and the manager of outsource services within the consulting services business of 3M Health Information Systems. She is…

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