Diagnostic categories change as evidence, clinical practice and social understanding develop. The history of gender-related diagnoses shows how this process works and what it may mean for Body Integrity Dysphoria.
A psychiatric diagnosis can appear permanent once it receives a name, a code and a place in a diagnostic manual. Clinicians use it, researchers organise studies around it, health systems record it, and patients encounter their experiences through its language.
The stability is often temporary. Categories are renamed, divided, merged, relocated and removed. Their criteria change as research develops and clinicians reconsider the boundaries between distress, impairment, difference and disorder.
Many psychiatric categories—and I will go as far as saying that all psychiatric categories—do not correspond to sharply bounded biological entities. They are clinical classifications built from observed patterns of symptoms, research findings, professional judgement and practical utility. Their construction involves decisions about which experiences require medical attention, where the source of suffering lies, and what role medicine should assume.
DSM-5 acknowledges these limitations openly. It describes psychiatric classification as a historically determined framework applied to clinical and scientific information. It also recognises that many diagnostic boundaries remain porous and that future evidence may change the position and contours of individual disorders.
The history of gender-related diagnoses provides a useful example. Across several revisions, the diagnostic name changed, the focus of the diagnosis shifted, and the condition moved to a different part of the international classification system.
Body Integrity Dysphoria is much earlier in this process. Its inclusion in ICD-11 provides formal recognition and a common clinical language. Questions about its causes, boundaries and treatment remain unsettled.
What DSM-5 changed
Before 2013, DSM-IV and DSM-IV-TR used the diagnosis Gender Identity Disorder. The category appeared within the chapter titled Sexual and Gender Identity Disorders.
Its criteria placed considerable emphasis on cross-gender identification and discomfort with one’s assigned sex. This allowed the person’s identity to become the central object of psychiatric assessment.
DSM-5 replaced Gender Identity Disorder with Gender Dysphoria and gave the diagnosis its own chapter, separate from Sexual Dysfunctions and Paraphilic Disorders. The revision placed greater emphasis on gender incongruence and on the distress or functional impairment associated with it.
The current DSM-5-TR retains this basic structure. A transgender or gender-diverse identity alone does not meet the criteria for Gender Dysphoria. Diagnosis requires a marked incongruence between experienced or expressed gender and assigned gender, together with clinically significant distress or impairment in social, occupational or other important areas of functioning.
Some transgender people experience gender dysphoria and seek clinical support. Others experience little or no dysphoria and receive no psychiatric diagnosis.
The revision changed the clinical focus. The person’s distress, functioning and individual circumstances became central. DSM provides diagnostic criteria and leaves treatment recommendations to separate clinical guidelines and professional judgement. Care may include psychological support, changes in social presentation, hormonal treatment, surgery, or a combination suited to the person’s age, circumstances and goals.
Gender Dysphoria remained a psychiatric diagnosis. Its continued presence can support access to treatment and insurance reimbursement in systems where healthcare depends on diagnostic coding. The revised language also reduces the extent to which gender identity itself is framed as pathology.
The category stayed in the manual while its clinical object changed.
What ICD-11 changed
The World Health Organization made a broader classificatory change.
ICD-10 included Transsexualism and Gender Identity Disorder of Childhood within the chapter on mental and behavioural disorders. These diagnoses were separate from the paraphilic disorders, despite occasional confusion on this point.
ICD-11 replaced them with Gender Incongruence of Adolescence and Adulthood and Gender Incongruence of Childhood. It placed both categories in the chapter titled Conditions Related to Sexual Health.
The relocation changed the institutional meaning of the diagnosis. The World Health Organization states that transgender and gender-diverse identities are not conditions of mental ill health. Classification within the mental disorders chapter had contributed to stigma and did not reflect the available evidence.
Gender Incongruence remained within the ICD because many people require access to specialist healthcare. Diagnostic recognition allows health systems to record treatment, organise services and provide reimbursement where applicable.
ICD-11 therefore preserved a route to care while removing Gender Incongruence from the classification of mental disorders.
The chronology is also important. The World Health Organization released ICD-11 in 2018. The World Health Assembly adopted it in May 2019, and it came into effect on 1 January 2022. Individual countries continue to adopt and implement it at different rates.
Diagnostic revision proceeds through evidence reviews, expert committees, public consultation, institutional approval and national implementation. A conceptual change may take years before it alters ordinary clinical practice.
How depathologisation happens
The removal of homosexuality from the DSM remains the best-known example of psychiatric depathologisation.
American psychiatry classified homosexuality as a mental disorder during much of the twentieth century. That position came under increasing pressure as research failed to support the assumption that homosexuality inherently involved psychological dysfunction.
Clinical experience also exposed the role of the surrounding social environment. Many gay patients suffered from rejection, discrimination, criminalisation and pressure to change. Gay psychiatrists and activists challenged the authority through which their sexual orientation had been classified as disease.
In December 1973, the American Psychiatric Association’s Board of Trustees voted to remove homosexuality from DSM-II. Opponents demanded a referendum of the wider APA membership. The membership upheld the decision in 1974.
The institutional decision emerged from empirical research, clinical experience, conceptual criticism, professional advocacy and organised political pressure. Each contributed to the revision.
Residual categories remained. DSM-II retained Sexual Orientation Disturbance for people distressed by their homosexuality. DSM-III later introduced Ego-dystonic Homosexuality. DSM-III-R removed that named diagnosis in 1987, although a broader residual category could still cover persistent distress about sexual orientation.
Depathologisation developed across several revisions. Each stage narrowed the range of experiences psychiatry classified as disordered.
Gender-related diagnoses followed their own path several decades later. Research accumulated, patients described the effects of existing categories, clinicians examined the relationship between identity and distress, and professional organisations reconsidered the location of the diagnosis.
These histories show that diagnostic revision depends on several forms of knowledge. Empirical evidence is essential. Clinical experience reveals how categories work in practice. Conceptual analysis clarifies the meaning of distress and impairment. Patient testimony shows how a diagnosis affects the people it describes. Health systems also consider access to services, recording practices and insurance coverage.
Psychiatric classification takes shape through the interaction of these elements.
What a diagnosis does
A diagnosis performs several functions.
It gives clinicians a shared vocabulary. It establishes criteria for research. It allows health systems to collect data and organise services. It may provide access to treatment, reimbursement and legal recognition.
It also directs interpretation. Once an experience enters a psychiatric category, researchers tend to study symptoms, risk factors, impairment and treatment. Clinicians approach the person through the assumptions contained in the diagnostic description. Patients may adopt the language of the diagnosis when explaining themselves to families, employers and institutions.
Names carry implications. Disorder, dysphoria and incongruence direct attention towards different features of an experience. Placement within a manual also matters. A condition listed under mental disorders carries a different institutional meaning from one listed under sexual health, neurological disease or factors influencing contact with health services.
Removal can reduce stigma and may also disrupt access to care. Retention can protect services while preserving a framing that some patients consider inaccurate. Renaming and relocation are attempts to manage this tension.
A diagnostic label identifies a clinical pattern. Aetiology, prognosis and treatment require additional evidence. DSM itself warns that a diagnosis carries no necessary conclusion about the cause of a condition or the degree of control a person has over associated behaviour.
The limits of the comparison
Gender Incongruence and Body Integrity Dysphoria are distinct conditions.
They have different clinical presentations, research histories, risk profiles and treatment questions. Gender-related care concerns sex characteristics and social gender. BID commonly concerns the desire for limb amputation, paralysis, blindness or another significant impairment. The ethical questions surrounding irreversible disability create additional considerations.
Similar language about identity, incongruence or bodily discomfort cannot establish a shared cause. It also cannot determine that the two conditions should receive the same treatment or classification.
The value of the comparison lies in the institutional process. The history of gender-related diagnoses shows how psychiatry can change the name of a category, alter its diagnostic threshold, relocate the source of distress and move the condition to another chapter.
BID may follow a different course. Its first placement still represents an opening position within an evolving classification.
Where BID currently stands
Body Integrity Dysphoria entered ICD-11 under code 6C21. It is located within Disorders of Bodily Distress or Bodily Experience.
ICD-11 describes BID as an intense and persistent desire to acquire a significant physical disability (I already voiced my discontent with the word disability here, since disability also refers to the social restrictions imposed on people with bodily or functional differences. I better word is impairment). The desired state commonly involves major limb amputation, paralysis or blindness. The person also experiences persistent discomfort or a strong sense that the current non-disabled bodily configuration is inappropriate.
The pattern usually begins by early adolescence. The desired bodily state is often highly specific and remains stable over long periods. Some people simulate the desired impairment through pretending behaviours, such as immobilising a limb, using crutches or using a wheelchair. Others have attempted to injure themselves or have placed their lives at risk while trying to obtain the desired condition.
Diagnosis requires clinically significant consequences, including distress, impairment in important areas of functioning, or substantial danger arising from attempts to acquire the disability.
Formal recognition gives clinicians and researchers a shared category. Earlier literature used several terms, including apotemnophilia, xenomelia and Body Integrity Identity Disorder. Each carried different assumptions about sexuality, neurology and identity. ICD-11 provides a common point of reference.
The evidence base remains small. Prevalence is unknown. Most studies involve limited and self-selected samples. Neurological, psychological and social explanations each account for aspects of the condition, and no single aetiological model has achieved consensus.
There is also no established evidence-based treatment pathway. Psychotherapy and medication have not been shown reliably to eliminate the desire. Amputation has been followed by substantial relief in selected published cases, although the evidence comes mainly from case reports and small observational samples. These findings cannot establish a general treatment standard.
The current classification reflects the evidence and professional judgement available during the development of ICD-11. Future revisions may preserve it, adjust its criteria, identify subtypes or place it elsewhere.
Who shapes the next revision?
Researchers and professional committees retain formal control over diagnostic classification. They review studies, assess clinical utility and submit recommendations to the organisations responsible for the manuals.
Patients increasingly contribute to this process. Their accounts can reveal how a category affects clinical encounters, relationships, employment, stigma and self-understanding. They may also identify differences between the official description and the experience it is intended to capture.
Patient testimony cannot substitute for systematic research. It supplies evidence that imaging studies, questionnaires and case reports may overlook.
Public advocacy around BID is emerging and remains limited in scale and visibility. Many people conceal the condition because they anticipate ridicule, disbelief or rejection. This makes organised participation difficult and leaves the public description of BID largely in the hands of clinicians, researchers and media outlets.
Greater patient involvement would improve the information available to future classification committees. It would not guarantee removal, relocation or acceptance of any particular treatment.
The beginning of BID’s diagnostic history
Psychiatric manuals record the current state of professional classification. Their categories organise care and research while knowledge continues to develop.
The history of homosexuality and gender-related diagnoses shows how classifications change when earlier assumptions become difficult to sustain. Research, clinical experience, patient testimony and institutional debate gradually alter the official language.
BID has only recently acquired formal recognition. Code 6C21 gives the condition a name, a definition and a position within ICD-11. It supports more consistent research and allows clinicians to identify an experience that was previously neglected or misunderstood.
The present placement remains open to revision. Future evidence may confirm it, alter the criteria, divide the condition into subtypes or support relocation elsewhere in the classification.
BID has entered its diagnostic history. The next stage will depend on the quality of the research, the development of clinical practice and the participation of the people whose lives the category describes.
Essay adapted from my book Body Integrity Dysphoria and the Ethical Dilemma of On-Demand Amputation. Redefining Wholeness: Identity, Autonomy, and the Moral Boundaries of the Human Body
More writing at leandroloriga.com