Proposal of the BVSM to revise the ICD10-GM-2004

Proposal:

Deletion of the diagnostic codes under section F65 ('disturbances of sexual prefernece') without replacement,
especially deletion of F65.0 ('Fetischism'), F65.1 ('Fetishistic Transvestism') and F65.5 ('Sadmasochism') without replacement.

Background:

Section F65 of ICD –10 – GM 2004 should, in the interest of Physicians, Health Insurers and Patients be deleted without replacement. According to the latest scientific position paraphilias are no valid diagnoses. An outdated diagnostic code promotes erroneous diagnoses and treatments. Data on the sexual interests of patients were not required for reimbursement from health insurance carriers in psychotherapy and other areas. Through the issuing and dissemination of relevant diagnoses to the health insurance carriers through physicians a significant damage to the relationship of trust and confidentiality between the physician and the patient has arisen, producing as a result, unnecessary costs for the carriers.

The diagnoses arising under section F 65 are clearly farther reaching than those which are listed as illnesses under the corresponding codes in the portions of DSM-IV-TR relevant for the psychiatric treatment. They lack of the B-criterion in the DSM-IV-TR that, in addition to the existence of the corresponding sexual preference, is necessary if a mental disorder of the patient may be diagnosed. According to the terms of the DSM-IV-TR a disorder is only present if both critera are met.

Even the stronger diagnostic problem specifications in theDSM-IV-TR concerning paraphilias are disputed among experts since they describe a pure behavior like formerly homosexuality. This is a practice usually donsidered sceptically. Particular behaviors are normally consideres as symptom of a particular disorder at the utmost, but never as disorder in itself. But with paraphilis the sexual behavior itself not fitting to the norm is considered as disturbance. The fact that particular forms of sexual behavior are socially inacceptable or illegal is irrelevant to the process of diagnosis. If one considers that it is impossible to define a healthy sexual behavior with the actual standard of knowledge, the diagnosis of a behavior, that departs therefrom, can be only subjectively and not be generally valid, as the history of homosexuality teaches us. Holding on to the still farther reaching criteria of paraphilias in ICD-10-GM2004, for which a suffering of the patient is irrelevant, is truly problematically.

For both medical care and it’s reimbursement disturbances should be the focus of interest. Further preferences, behaviors or practices of the patient are irrelevant for the physician’s treatment and even more so for his payment. At the moment there’s no efffecftive treatment for paraphilias themselves, similar to the absence of an effective treatment for homosexuality. If there are patients with paraphilias in psychiatric treatment, then usually because of additionally present mental disturbances without direct relation to their sexuality like depressions, posttraumatic stress syndrome, borderline syndrome, or self-destructive behavior, to name only a few. These disturbances are being treated in the same manner, no matter if the patients are paraphiliacs or not. Of course there are psychological problems with relation to the patient’s sexual life. In the reality of today’s situation that the definition of healthy sexual behavior is not possible, there is no reason that these problems should receive a different diagnosis or must be treated differently in patients with paraphilas in general.

Though for the patient informing his physician about possible paraphilias is advantageful for the talks between patient and physician and for the treatment itself, these informations effect the form of treatment in the fewest cases. For reimbursement of the health insurance carrier paraphilias are irrelevant even in cases of psychological treatment. They don’t affect the resulting costs. Patients in psychological treatment with diagnosed paraphilias are confronted quickly with the historical situation of homosexuals. Therapists assume that the patient’s problems are caused or engraved by his individual sexual interests, though there’s no direct relation in most cases. An outdated diagnostic code inhibits therapists’ disposition for further education in that sector. Reducing costs caused by initially erroneos approaches of therapy is also in the interest of health insurance carriers.

Recording data that don’t describe illness is neither in the interest of patients nor physicians or health insurance companies. In contrast recording and distributing of patient’s data concerning more than the information about the illness to treat can damage the trustful relationship between physician and patient sustainably. If patient feel that they can’t trust the legal requirement concerning confidential medical communication any more, they will avoid giving their physician more than the information absolutely necessary, even if it could simplify and accelerate diagnosis and treatment. The fact that since the first of january 2004 every ICD-10-GM-2004 diagnosis issued by the physician will be distributed to the health insurance carrier causes addicional distrust of the patient.

Not only at sectors the presence of a paraphilia is relevant to the treatment the danger of maldiagnosing and –treatment is growing, but also everywhere, where patients aren’s sure if they can trust their physician. Regarding psychological illness, but also paraphilias this is problematically for two reasons. First a correct disgnosis of psychological processes is a very complex and difficult task psycologists and psychiatrics have attended a longyeared training. If by the actual state of the law ordinary physicians are put into the position to distribute notices or self diagnosis of patients that could indicate psycological illness to the health insurance carrier in form of the diagnosis code describing that illness, this is increasing the chance of maltreatment, too. In cases of doubt improperly diagnosed mentally healthy patients can feel stigmatised by a paraphilia diagnosis.

On the other hand the fear of a relevant diagnosis and the resulting shrinkin trust towards physicians on the side of patients could lead to patients refraining from consulting physicians for information about medically wise behavior concerning their sexuality, caring for genital piercings or about medically riskful practices and endangered body regions. Especially groups of patients belonging to a sexual minority often do have problems in finding medically correct information about these themes, thus the danger of avoidable wounds or infections will increase if not created. Forthermore these patients will tend to delay treatment of diseases or avoid consulting a physician out of fear he could notice the patient being a paraphiliac. This is preventing prophylaxis, early diagnosis and treatment which will increase costs for health insurance carriers on long term.

Recapitulating: Paraphilias are no indicator for any diagnosis and thus irrelevant to the reimbursement of health insurance carriers. For the treatment of psychological problems with relation to the patient’s sexual life the existing diagnosis codes without F65 are sufficient.

The further transmission of patient data interferes strongly against the sense of informational self determination of the patient and should therefore be reduced to a minimum. The strongly damaged sense of trust of the patient leads to the withholding of information important for the treatment, to the delay of consultions of the physician and a fear of the gathering information serving prophylaxis. The sdeletion of section F65 without replacement thusly assures the professional medical care and, finally, avoids unnecessary costs.

 

 

Literature:

Davis, D.L. (1996). Cultural sensitivity and the sexual disorders of the DSM-IV: Review and assessment. In J.E. Mezzich, A. Kleinman, H. Fabrega, & D. L. Parron (Eds.) Culture and psychiatric diagnosis: A DSM-IV perspective (pp. 191-208). Washington, DC: American Psychiatric Press.

Moser/Kleinplatz: The DSM & the paraphilias http://home.netcom.com/~docx2/mk.html

McConaghy, N. (1999). Unresolved issues in scientific sexology. Archives of Sexual Behavior, 28, 285-302.

Rubin, G. (1992). Thinking sex: Notes for a radical theory of the politics of sexuality. In C. S. Vance (Ed.), Pleasure and danger: Exploring female sexuality (pp.267-319). London, U.K.: Pandora Press.

Silverstein, C. (1984). The ethical and moral implications of Sexual Classification: A Commentary. Journal of Homosexuality, 9 (4), 29 -37.

Suppe, F. (1984). Classifying sexual disorders: The Diagnostic and Statistical Manual of the American Psychiatric Association. Journal of Homosexuality, 9 (4), 9-28.

Sadomasochismus - Szenen und Rituale Wetzstein, Steinmetz u.a.; 1993 Rowohlt Taschenbuch Verlag ISBN 3-499-19632-8