Published in the New York Times, July 22, 2016
The World Health Organization is moving toward declassifying transgender identity as a mental disorder in its global list of medical conditions, with a new study lending additional support to a proposal that would delete the decades-old designation.
The change, which has so far been approved by each committee that has considered it, is under review for the next edition of the W.H.O. codebook, which classifies diseases and influences the treatment of patients worldwide.
“The intention is to reduce barriers to care,” said Geoffrey Reed, a psychologist who is coordinating the mental health and behavior disorders section in the upcoming edition of the codebook, called the International Classification of Diseases, or I.C.D.
Dr. Reed, a professor at the National Autonomous University of Mexico and an author of the new study, said the proposal to remove transgender from the mental disorder category was “not getting opposition from W.H.O.,” suggesting that it appears likely to be included in the new edition. The revised volume would be the first in more than 25 years, and is scheduled to be approved in May 2018.
Removing the mental health label from transgender identity would be a powerful signifier of acceptance, advocates and mental health professionals say.
“It’s sending a very strong message that the rest of the world is no longer considering it a mental disorder,” said Dr. Michael First, a professor of clinical psychiatry at Columbia University and the chief technical consultant to the new edition of the codebook, which is known by its initials and the edition number I.C.D.-11. “One of the benefits of moving it out of the mental disorder section is trying to reduce stigma.”
Other parts of the proposed change are stirring debate, however. The proposal would not take transgender out of the codebook altogether, but would move it into a newly created category: “Conditions related to sexual health.”
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Many, but not all, advocates favor the idea of keeping transgender in the codebook in some form because the designations are widely used for billing and insurance coverage of medical services and for conducting research on diseases and treatments. But where should it go?
“I think there is a bit of a problem with the idea of putting it in a chapter on sexual health because it has nothing to do with sex,” said Dr. Griet De Cuypere, a psychiatrist at the Center of Sexology and Gender at University Hospital in Ghent, Belgium, and a board member of the World Professional Association for Transgender Health. “If it’s possible to have it more separately, it would be better.”
Others have concerns about a proposal to change the name from “transsexualism” to “gender incongruence,” a name chosen to try to express “a discrepancy between a person’s experienced gender identity and their body,” said Dr. Reed, who was part of the working group that recommended the changes to W.H.O.
One problem is that “incongruence” resonates differently in different languages. “In English it sounds kind of neutral — my association is with geometry,” Dr. Reed said. “But in Spanish it sounds very bad, it sounds kind of psychotic.”
So, in Spanish, the proposal is “gender discordance,” which, he said, “in English sounds really bad.”
Language differences are only part of the issue. “The terminology is difficult because nobody likes anything,” Dr. Reed said. “People have made suggestions that have been all over the map. One of the people at one of the meetings said we could call this happy unicorns dancing by the edge of the stream and there’d be an objection to it.”
The issue is reminiscent of the change in the way homosexuality was treated in the American bible of psychiatric diagnoses, the Diagnostic and Statistical Manual of Mental Disorders, known as the D.S.M. In 1973, the book, published by the American Psychiatric Association, changed the diagnosis of “homosexuality” to “sexual orientation disturbance,” and later to “ego-dystonic homosexuality” before dropping it altogether in 1987.
Transgender identity has changed in the D.S.M. too, classified under “sexual deviations” in 1968, “psychosexual disorders” in 1980 and “sexual and gender identity disorders” in 1994. In the fifth and most recent edition, D.S.M.-5 in 2013, the designation was changed to “gender dysphoria,” and was defined to apply to only those transgender people who are experiencing distress or dysfunction, said Dr. Jack Drescher, a psychiatrist and psychoanalyst at New York Medical College, who serves on the W.H.O. working group and served on a similar working group for the D.S.M.-5.
Dr. Drescher said he supported removing the diagnosis from the D.S.M. entirely, but he noted that the I.C.D. was different because it has categories for every disease and condition, not just psychiatric ones, and retaining some code for transgender identity might be the only way for some to receive medical care. Inmates, including Chelsea Manning, have received access to hormone treatments partly based on the fact that transgender identity belongs to a medical category, Dr. Drescher said.
Dr. First said he once received a call from the Internal Revenue Service asking him, as an expert, to support the agency’s intention to challenge a tax deduction that a transgender woman claimed for gender reassignment surgery. He declined, and said cases like that would be more likely without a diagnostic category.
Karl Surkan, a professor of women’s studies at M.I.T. and Temple University, who is transitioning from female to male, agreed. He said some trans people “say homosexuality was declassified, so now this is part of our civil rights movement, without understanding that it’s wildly different.”
Mr. Surkan said gays, lesbians and bisexuals were “not sort of reliant on medical treatment in the same way that the transgender population often is. You need a code to get an insurance company to pay for something.”
In a study published Tuesday in Lancet Psychiatry, Dr. Reed and co-authors interviewed 250 patients at a clinic that provides transgender health services in Mexico City. They found that while most had felt distress related to their gender identity during adolescence, almost a fifth of them had not. And among those who felt distress or experienced dysfunction at work, home or school, most was attributed to how they were treated — being rejected or violently attacked — rather than to their gender identity itself, the authors reported.
Many had physical health problems, likely a result of living on the margins of society, because their lives followed a “slope leading from stigma to sickness,” said Dr. De Cuypere, who is the co-writer of a commentary about the study.
Similar studies are being conducted in Brazil, India, Lebanon, South Africa and France.
“I would expect to see this kind of stigmatization and violence in all the other countries,” said Dr. Reed, although he said that in France, the researchers received a slightly more laissez-faire reception.
“In France, they said, ‘Just leave us alone, we don’t need your stinking classification,’ ” Dr. Reed said. “But they live in a society where access to health care is conceptualized as a right.”
