What is Gender Dysphoria? – Terms Defined for Accurate CodingSeptember 10, 2019
“Gender Identity Disorder,” “Transgender,” “Gender Incongruence, “Gender Dysphoria,” are terms used in the past and present to denote, as defined in the American Psychiatric Associations “Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), individuals who “…have a marked incongruence between the gender they have been assigned to (usually at birth, referred to as natal gender) and their experienced/expressed gender.”
“Transgender” is the term commonly used today in the media, in politics, and elsewhere. Transgender “________” (fill-in-the-blank) can generate controversy and will not be commented on in this blog. Our goal here, as always, is to provide the professional coder with information, using authoritative sources, focused on how to correctly assign and report ICD-10-CM/PCS codes for the topics we cover. In this blog, our authoritative source is the DSM-5, mainly because The American Psychiatric Association has worked in with the co-operating parties of ICD-10-CM and because the documentation coders see in patient records is usually based on DSM-5 diagnostic criteria and definitions.
ICD-10-CM classifies this diagnosis as “gender identity disorder.” DSM-5 refers to this as “gender dysphoria,” and the WHO, in ICD-11, classifies this diagnosis as “gender incongruence;” add in “transgender” and we have four different terms often referring to the same thing! But are these terms synonymous? The answer is “Yes” (mostly).
- Dysphoria – (from Greek: (dysphoros), difficult to bear) is a profound state of unease or dissatisfaction. “Dysphoria” is not limited to or synonymous with “gender dysphoria.” Code 6 Postpartum mood disturbance contains the inclusion term “postpartum dysphoria,” aka “postpartum blues” or “postpartum sadness.”
- Incongruence – inconsistent or incompatible, not the same. Carl Rogers, PhD (1902-1987), an American psychologist and among the founders of the humanistic approach to psychology, introduced the concept of incongruenceto psychology in the 1950s. Although general use of the word has come to mean inconsistent or incompatible, Rogers defined “congruence” as the matching of experience and awareness. Therefore, “incongruence,” is “lacking congruence, or having feelings not aligned with your actions.”
- Transgender – definitions vary, however “transgender” generally refers to a gender identity or gender expression that differs from an individual’s assigned sex, or natal gender.
- Of note: The term “Transgender” isn’t included in any of the ICD-10-CM code descriptors, and “Transgender” is not a term found in the Index
- Gender identity – defined in DSM-5 as “…a category of social identity and refers to an individual’s identification as male, female, or occasionally, some category other than male or female.” It cannot be assumed that these patients have a gender identity disorder/gender dysphoria. If documentation is not clear, the provider should be queried.
- Of note: “Gender identity” is not a disorder in and of itself, it is what gender a person identifies with. There is no ICD-10-CM code for “gender identity.” If it is documented that a male patient identifies as a female or even some other category, and that patient is not expressing any related concerns or complaints, is not experiencing any distress, social impairments or functioning, no code is assigned.This is consistent with the Official Guidelines for Coding and Reporting Section III. Reporting Additional Diagnoses GENERAL RULES FOR OTHER (ADDITIONAL) DIAGNOSES. For reporting purposes, the definition for “other diagnoses” is interpreted as additional conditions that affect patient care in terms of requiring: clinical evaluation; or therapeutic treatment; or diagnostic procedures; or extended length of hospital stay; or increased nursing care and/or monitoring. The UHDDS item #11-b defines Other Diagnoses as “all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay. Diagnoses that relate to an earlier episode which have no bearing on the current hospital stay are to be excluded.”
Terms having been defined, now let’s sort this out from a coding perspective.
Here are the codes as they appear in the Tabular for category F64 Gender Identity Disorders.
F64 Gender identity disorders
- Gender identity disorder in adolescence and adulthood
- Gender dysphoria in adolescents and adults
F64.1 Dual role transvestism
- Use additional code to identify sex reassignment status (Z87.890)
- Excludes1: gender identity disorder in childhood (F64.2)
- Excludes2: fetishistic transvestism (F65.1)
F64.2 Gender identity disorder of childhood
- Gender dysphoria in children
- Excludes1: gender identity disorder in adolescence and adulthood (F64.0)
- Excludes2: sexual maturation disorder (F66)
F64.8 Other gender identity disorders
- Other specified gender dysphoria
F64.9 Gender identity disorder, unspecified
- Gender dysphoria, unspecified
- Gender-role disorder NOS
More terms, as they appear in the codes, defined:
- F64.0 Transsexualism, or “transsexual” when referring to an individual, is defined in DSM-5 as denoting an individual “….who seeks, or has undergone, a social transition from male to female or female to male, which in many, but not all, cases also involves a somatic transition by cross-sex hormone treatment and genital surgery (sex reassignment surgery).” Inclusion terms are “gender identity disorder in adolescence and adulthood,” and “gender dysphoria in adolescents and adults.”
- F64.1 Dual role transvestism. The closest that DSM-5 comes to this term or diagnosis is “transvestic disorder.” It appears in the chapter “Paraphylic Disorders,” not the chapter “Gender Dysphoria.” Paraphilic disorders include voyeuristic disorder, exhibitionistic disorder, sexual masochism, pedophilia, and transvetic disorder. Transvestic disorder is defined as “engaging in sexually arousing cross-dressing.”
- “Dual role transvestism” appears in research review, and is essentially defined as an individual, usually male, who wears clothes of the opposite sex in order to experience temporary membership in the opposite sex, has no sexual motivation for the cross-dressing, and no desire for a permanent change to the opposite sex.
- Yet, code F64.1 includes the instruction note “Use additional code to identify sex reassignment status (Z87.890). Code F64.1 is the only code in code category F64 that includes this instruction note, but that does not prohibit reporting Z87.890 for any applicable cases.
F64.2 Gender identity disorder of childhood includes “gender dysphoria in children.”
Perhaps you are also wondering why, at least for consistency’s sake, the description for code F64.1 isn’t “Gender disorder of adolescence and adulthood.” That concern is eliminated with the World Health Organization (WHO) and ICD-11.
In ICD-11, Gender incongruence has been moved out of mental disorders in the ICD into a completely new chapter, Chapter 17 Conditions related to sexual health. The WHO states, “The rationale being that while evidence is now clear that it is not a mental disorder, and indeed classifying it in this can cause enormous stigma for people who are transgender, there remain significant health care needs that can best be met if the condition is coded under the ICD.” Here are the ICD-11 codes and definitions for gender incongruence of adolescence or adulthood and gender incongruence of childhood:
HA60 Gender incongruence of adolescence or adulthood
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,’ 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 behavior and preferences alone are not a basis for assigning the diagnosis.
- “Transsexual” and “trans-sexualism” are inclusion terms for code HA60. So, if we compare F64.0 with HA60, we see that the respective code descriptions are changed but the meanings are the same.
HA61 Gender incongruence of childhood
Gender incongruence of childhood is characterized by a marked incongruence between an individual’s experience/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 two years. Gender variant behavior and preferences alone are not a basis for assigning the diagnosis.
We see that ICD-11 seems more current and better defined than ICD-10-CM with regard to gender dysphoria/gender incongruence. However, at the time this blog was written, the transition from ICD-10-CM to ICD-11 is not expected to occur in the United States before the year 2024.
Back to ICD-10-CM
Now that our terms have been defined and we are aware of the inclusion terms that appear under all but one of the codes (F64.1) in category F64 Gender identity disorders, we see the potential for legitimate variations in documentation of diagnoses. These variations are not impediments to accurate coding. If the documentation is not clear, as always, query the physician.
Example 1, Diagnosis and Code: An adult patient diagnosed with “gender dysphoria” presents for male to female sex reassignment surgery. Code F64.0 Transsexualism.
Example 2, Diagnosis and Code: A male patient is treated for anxiety following several years of secretly dressing up in his girlfriend’s clothing and fear of being discovered. He undergoes counselling and is prescribed an anti-anxiety medication. Code F64.1 Dual role transvestism.
Example 3: A 10 year old girl is brought to see her pediatrician because she asked for a football for her birthday. The pediatrician documents that the girl only wants the football to play with her brothers, she is not experiencing any distress and has not expressed a desire to be a boy. Nothing is prescribed and no treatment or counselling is recommended for her. No code is assigned. Refer to the Official Guidelines for Coding and Reporting Section III. Reporting Additional Diagnoses GENERAL RULES FOR OTHER (ADDITIONAL) DIAGNOSES.
Example 4, Diagnosis and Code: An adult male patient is under tremendous stress because he strongly believes that he cannot conform to his family’s expectations of gender roles. Individual and family counselling is advised. At this initial stage of work-up and treatment, the physician documents “gender role disorder.” Code F64.9 Gender identity disorder, unspecified
Example 5: An individual was admitted for elective surgery. During the admission process, the individual was asked to state their gender. The individual refused, responding that they do not identify with being either male or female and in fact do not believe in the “concept of gender.” The provider documents that their gender identity is “unknown at this time” and nothing further is mentioned. No code is assigned. Refer to the Official Guidelines for Coding and Reporting Section III. Reporting Additional Diagnoses GENERAL RULES FOR OTHER (ADDITIONAL) DIAGNOSES.
There are four terms used for the same diagnosis, namely “Gender Identity Disorder,” “Transgender,” “Gender Incongruence, and “Gender Dysphoria.”
The American Psychiatric Associations “Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) defines “gender dysphoria” as individuals that “…have a marked incongruence between the gender they have been assigned to (usually at birth, referred to as natal gender) and their experienced/expressed gender.”
“Gender Identity” is not a disorder in and of itself, it is what gender a person identifies with. There is no ICD-10-CM code for “gender identity.”
If an individual expresses a gender identity that does not conform to their gender at birth, if they are not expressing any related concerns or complaints, and if they are not experiencing any distress, social impairments or functioning, no code is assigned. Refer to the Official Guidelines for Coding and Reporting Section III. Reporting Additional Diagnoses GENERAL RULES FOR OTHER (ADDITIONAL) DIAGNOSES.
Looking ahead, in ICD-11 the term “Gender incongruence” is used instead of “gender dysphoria.” Gender incongruence was moved out of the “mental health/disorders” chapter in ICD-11 and into a completely new chapter, Chapter 17 Conditions related to sexual health.
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