Updated on: March 16, 2016

Medical Response to Gender Identity Dysphoria Enters Spotlight in Wake of Transgender Teen’s Suicide

Original story posted on: January 19, 2015

Monica Greene remembers with perfect clarity the response one friend had when she broke the news to him a little more than 20 years ago: she was a woman trapped in a man’s body.

“Couldn’t you just lie for the rest of your life?” Greene recalled the friend saying – “and take it like a man?”


Much has changed during the last two decades, but transgender people still face an uphill battle as it pertains to gaining societal acceptance and securing effective medical and psychiatric attention. In the wake of the recent high-profile suicide death of transgender Ohio teenager Leelah Alcorn, gender identity dysphoria was an ideal topic to broach during the most recent edition of Talk Ten Tuesdays, the weekly Internet broadcast hosted by ICD10monitor.com.

Greene, a prominent Dallas-area restauranteur and transgender advocate, and two respected medical professionals participated in the broadcast and shared some invaluable advice and perspective.

“One wonders whether Leelah Alcorn, who took her life by walking in front of a tractor-trailer, suffered from suicidal ideations that were not documented in her medical record – and if proper treatment could have averted this tragedy,” Philadelphia-based physician Wilbur Lo, M.D. said.

Lo noted that gender identity dysphoria affects a relatively low number of people – 1 in 7,000 adult males and 1 in 33,000 adult females – but despite its rarity, the nation’s medical community is slowly familiarizing itself with the condition. In fact, last May, Lo said, Medicare announced that it will no longer deny coverage for sex reassignment surgery, reversing a policy that had been in place since 1981.

“This mirrors the decisions of a small but growing number of university health plans and large companies like Shell Oil and Campbell Soup who cover gender transition medical services,” Lo said.

Lo also said that, for patients with gender identity dysphoria, it is vital that underlying conditions be documented in medical records.

“As a physician and educator who specializes in clinical documentation improvement, I’d like our audience – specifically, my fellow physicians – to understand the importance of documenting conditions in ICD-10 that may be associated with gender dysphoria,” he said. “Potentially life-threatening conditions such as depression, suicidal ideations, mood disorders, and schizophrenia must receive immediate attention. Other conditions associated with gender dysphoria include anxiety, eating, personality, and substance use disorders, as well as autism spectrum disorders and disorders of sex development.”

“Capturing a correct ICD-10 code for the patient’s principal, or primary, diagnosis is like outlining the contours of a patient’s portrait with a pencil. It creates a silhouette. It’s only when you add the detail of the underlying conditions, comorbidities, and complications that the true picture of that specific individual comes into focus,” Lo added. “That’s why I want our listeners to understand that proper clinical documentation practices, whether in ICD-9 or ICD-10, are the cornerstone for optimal patient care, appropriate reimbursement, and accurate physician profiling.”

For transgender patients, finding a healthcare provider suited to their specific needs can be tricky, but several providers in particular have emerged as national leaders in the field. Prominent psychiatrist and author Steven Moffic, M.D., who worked with Pathways Counseling Center, a Milwaukee-based office that specializes in addressing gender identity dysphoria, said he has spoken with hundreds of patients during a career spanning decades.

“What we did, with support of psychotherapy, was to help these people ranging in age from children to the elderly to make the social and physical changes each desired – and that were medically possible to fit their individual internal gender identity,” Moffic explained. “Often encountering some degree of family and societal rejection along the way, along with less-than-desired physical changes, they fortunately almost always came out relieved, happier, and better able to reach their potential and contribute to society. Suicide disappeared as an option, and associated depression and anxiety disorders also seemed to disappear or dissipate.”

Moffic strongly advised against ever giving the kind of advice Greene received from her friend.

“What never works to help them, just like with homosexuality, is any conversion therapy that tries to convince or force a person not to transition,” he said. “That won’t work because we are beginning to understand that our gender identity reflects hardwired brain changes caused by genetic and hormonal differences.”

It wasn’t until the 1950s that medical and surgical techniques became advanced enough that sex reassignment surgery was even possible, Moffic noted. And it has only been in recent years that gender identity dysphoria went from being labeled a “disease” or a “disorder” to its current term (“dysphoria” meaning “dissatisfaction”).

For Moffic, the topic recently became personal, as he discussed publicly for the first time on Talk-Ten-Tuesday.

“I have a 5-and-a-half-year-old grandchild who now tells us, quote, ‘I have a girl brain and a boy body,’” Moffic said. “This grandchild has entered kindergarten identified and dressed as a girl.”

“If my grandchild (one day has sex reassignment surgery), my hope is that normal variations (in gender identity) will continue to be better accepted in our society,” he added. “I will do everything possible to make that happen for him, and you can help too. Let’s all make a New Year’s resolution to do so.”  

Greene said she too knew as a child that the image she saw in the mirror didn’t match what was going on in her heart and head. She moved from Mexico to Texas in the 1970s, arriving as Eduardo, a 17-year-old teen, but it wasn’t until her late 30s – after getting married, having two children, and launching her successful career in the restaurant industry – that she reached a breaking point.

“I realized after the … surgical procedure that I had not changed. Nothing had changed within me. I was the same person,” she said Tuesday. “Yes, I finally brought that physical reality in line with that mental reality, but nevertheless with the same brain, the same cravings, the same bad driving habits. And I still hated rice pudding.”

On a serious note, though, Greene said she hopes that seeking acceptance becomes an easier endeavor for transgender people, going forward.

“Being a transsexual is not something that can be ignored or suppressed forever … and it’s a matter of life and death for many of us,” she said. “I am not naïve. I understand that when an individual identifies with a gender inconsistent or not associated with their assigned sex, unintentionally we can challenge people’s beliefs. We can also challenge their integrity as good humans. We challenge their religion. We also challenge their compassion toward others. All of that by just being ourselves.”



Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.
Mark Spivey

Mark Spivey is a national correspondent for ICDmonitor.com who has been writing on numerous topics facing the nation’s healthcare system (and federal oversight of it) for five years.