The Fenway Institute/Dartmouth-Hitchcock Paper calls for new psychiatric practices that affirm transgender and gender-diverse patients without pathologizing diagnoses

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The requirement by many third-party payers for a diagnosis code for health care reimbursement is currently driving the requirement for psychiatric assessment before any gender-affirming care can be delivered.

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"In our own practice and research, we find that a more affirming approach to care reduces stigma."

An editorial published in The British Journal of Psychiatry calls for the development of alternative psychiatric care frameworks that affirm transgender and gender-diverse (TGD) people without pathologizing them through clinical diagnoses. The editorial was authored by researchers at The Fenway Institute and Dartmouth-Hitchcock Medical Center and adds to a growing body of literature demonstrating the need to uncouple gender diversity from the stigma of diagnostic classification.

“In our own practice and research, we find that a more affirming approach to care reduces stigma,” said editorial co-author Alex Keuroghlian, MD, MPH, Director of Education and Training Programs at The Fenway Institute. “Our field has a duty to validate diverse gender identities without assuming pathology.”

The editorial asserts that the field should be asking critical questions as it creates alternative psychiatric care frameworks that affirm TGD people. These include the following:

  • Why is a specific diagnosis needed for a child struggling with questions related to their gender identity, but not their sexual orientation?
  • What is the value in assigning a diagnosis to a patient with no immediate medical needs when description of a specific service code such as “gender-affirming” counseling would suffice?
  • How can psychiatry deliver gender-affirming care for TGD people who do not endorse gender-related dysphoria?
  • Can psychiatry understand experiences of gender diversity without an assumption of distress or pathology?

The editorial notes that the requirement by many third-party payers for a diagnosis code for health care reimbursement is currently driving the requirement for psychiatric assessment before any gender-affirming care can be delivered, and that formal diagnoses often protect patients against denials of coverage. It also notes that the requirement for psychiatric evaluation prior to gender-affirming surgical care is widely misunderstood as a threshold test to determine whether a patient is sufficiently gender dysphoric to warrant surgical intervention. Instead, psychiatric evaluation is needed before gender-affirming surgical care to ensure that patients are connected to wellness services during a potentially stressful period of personal change.

“The inclusion, revision, and subsequent removal of homosexuality in successive editions of the DSM is illustrative of how our conceptions of gender identity may evolve,” added Keuroghlian. “Sexual minority people with major depressive disorder and substance use disorders are treated for these problems without need for a sexual minority-specific diagnostic code. At this point, we think psychiatry needs to look critically at the central role now played by the DSM in understanding TGD people.”

Read the full editorial here.

Since 1971, Fenway Health has been working to make life healthier for the people in our neighborhoods, the LGBTQ community, people living with HIV/AIDS and the broader population. The Fenway Institute at Fenway Health is an interdisciplinary center for research, training, education and policy development focusing on national and international health issues.

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Christopher A Viveiros
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