In the National Health Service (NHS), clinical decision-making relies heavily on the International Classification of Diseases (ICD). A significant aspect of the ICD-11’s approach to “gender incongruence” is its inclusion of a desire for medical treatment as a critical part of the diagnostic criteria. This blog post will explore this framework and the implications it has for adolescents and adults seeking gender-affirming care.
The Role of ICD-11 in “Gender Incongruence”
According to ICD-11, a defining feature of “gender incongruence of adolescence and adulthood” is the desire to transition through medical means, such as hormonal treatment, surgery, or other healthcare services. This desire is said to arise from a persistent incongruence between an individual’s experienced gender and their “assigned sex”.
Lack of Diagnostic Requirements and Questions of Diagnostic Integrity
Interestingly, unlike many other diagnostic codes, the ICD-11 does not provide specific “Diagnostic Requirements” to aid clinicians in diagnosing gender incongruence. In the absence of other indicators of an incongruent “experienced gender”, and with “gender variant behaviour and preferences alone” deemed insufficient, the diagnosis may hinge primarily on the patient’s expressed desire to medically transition.
The ICD-11 does not consider the possibility that a desire for medical interventions might stem from factors unrelated to gender incongruence. This raises concerns about the integrity of the diagnostic process. If “gender variant behavior and preferences” alone are deemed insufficient for diagnosis, how do we differentiate between genuine gender incongruence and other motivations for seeking medical treatment?
The Circularity of NHS Service Specifications
The NHS service specification for adult gender services reinforces this diagnostic framework. It states that individuals who meet the criteria for gender dysphoria related to gender incongruence are accepted onto the NHS care pathway, and an individualized treatment plan is established. Since gender incongruence often coexists with gender dysphoria, a desire for medical treatment may inadvertently serve as a sign that one meets the diagnostic criteria for accessing the care they seek.
This creates a troubling circularity: the desire for treatment becomes an indicator of the very condition it aims to address. It raises significant concerns about how clinicians can ensure accurate differential diagnoses when the criteria may perpetuate a self-fulfilling prophecy.
The Impact on Young Patients
Bayswater families often report the immense faith that children and young people place in the diagnostic labels assigned to them. Given the serious implications of these diagnoses, it is crucial to maintain transparency about the uncertainties inherent in the diagnostic process. This honesty is essential to ensure that consent is genuinely informed, regardless of the patient’s age.