ICD-11 and the depathologisation of the transgender condition

The World Health Organisation (WHO), as a specialised United Nations organisation, has the mission to achieve maximum levels of health for all individuals – understanding health to be complete wellbeing, physical, social and mental. The objectives set out in the WHO's International Statistical Classification of Diseases and Related Health Problems, currently in its tenth edition (ICD-10), include controlling epidemics and threats to public health, identifying populations at risk for specific problems, defining obligations of its member states in relation to the provision of healthcare, facilitating access to appropriate healthcare services, guiding routine clinical practice and assisting research into effective treatments.¹ Consequently, the classifications need to be revised from time to time to bring them up to date in the light of scientific evidence, world-wide health conditions and available attention-giving services.

The ICD-10 review process in preparation for the eleventh edition of the Classification (ICD-11) is now in its final stage. In fact, all the diagnostic categories and definitions intended to be included have already been published for external consultation (http://apps.who.int/classifications/icd11/browse/f/en). In addition, the World Health Assembly (made up of the ministers of health from the member states of the WHO) is expected to approve this edition and order the work for its implementation to be started around the middle of 2019.

The ICD-10 was approved in 1990, which means that the longest period in history to perform a major revision of the classification has taken place. During the decades that have gone by, understanding of sexual disorders and sexual health has increased substantially, as has recognition of the sexual rights of individuals with diverse gender identities. This is most certainly not reflected in the current edition of the classification (ICD-10), which includes the transgender condition in its Chapter 5, under “Mental and Behavioural Disorders.” The fact that this condition is considered to be a mental disorder undoubtedly increases the stigma and the painful consequences towards this already-discriminated sexual minority. And this makes the questioning of – and scientific evaluation of – whether it is really a mental health problem even more relevant.

Reviewing the ICD-10 has turned out to be a very good opportunity to do so. The fact is, to carry out the revision of ICD-10 Chapter 5 (“Mental and Behavioural Disorders”), the Department of Mental Health and Substance Abuse of the WHO set up an International Advisory Group focused on outlining the strategies to follow to give the ICD-11 greater clinical usefulness and a better response to the needs, experience and human rights of the populations involved. The structure of Work Groups for specific areas of the classification was then established, each group in charge of developing well-founded proposals for changes.²

The Work Group for the Classification of Sexual Disorders and Sexual Health was set up with 11 experts from different related disciplines, representatives of the various regions in the WHO member states. Their proposals for modifying the classification of the transgender condition were based on the review and assessment of the scientific literature available, as well as on the clinical information and public policies in force, on clinical usefulness and experience with the pertinent ICD-10 diagnostic categories in various scenarios and healthcare systems, and on consultation with different international bodies, including the French government, the European Consulate and Parliament, and civil organisations such as the World Professional Association for Transgender Health (WPATH), the Global Action for Trans* Equality (GATE), the Agnodice Foundation in Switzerland, AktionTranssexualität und Menschenrecht in Germany, the American Psychological Association, the national LGBT organisation in Denmark, the Revise F65 group in Norway and the Société Française d’Etudes et de prise en Charge du Transsexualisme in France.

Proposals for modifying the classification of the transgender condition in the ICD-11

The Work Group of experts in this material had two main goals: (1) depathologise and destigmatise the individuals called “transgender” and (2) facilitate accessible, quality healthcare treatment and services for individuals needing them. To reconcile both goals, the Work Group proposed, in the first place, removing the transgender categories from Chapter 5 of Mental and Behavioural Disorders and positioning them in another chapter.³ The option that has had the most support throughout the review process is that of creating a new chapter covering conditions related to sexuality, of which these transgender categories would be a part.

In second place, the Group suggested changing the name of and reconceptualising these categories, including the following points: (1) modifying the ICD-10 category F64.0 Transsexualism to “Gender Incongruence of Adolescence and Adulthood”, characterising this condition as “a pronounced, persistent incongruence between the individual's experience of gender and the sex assigned” during adult life and (2) modifying the ICD-10 category F64.2 Gender Identity Disorder of Childhood to “Gender Incongruence of Childhood”, characterising it as “a pronounced, persistent incongruence between the experience/expression of individual gender and the sex assigned in prepubertal children.” The objective behind changing the terms (from “Identity” to “Incongruence”) was to reduce the stigma associated, focusing less on the mental state implied. However, the literal translation of “Incongruence” to “Incongruencia” in Spanish might not be the most appropriate for this purpose. Consequently, the term “Discordancia” (discordance/discrepancy) has been proposed for use in Spanish.

In addition, a pair of diagnostic clarifications were proposed: (1) adding that in both categories (for children and for adolescents and adults), the condition may or may not be accompanied by significant distress or functional deterioration, particularly in social environments with strong disapproval of the condition and (2) modifying the time needed to establish the diagnosis: in the case of Gender Incongruence of Adolescence and Adulthood, the proposal is to reduce the wait to several months instead of 2 years, thereby opening the opportunity to access healthcare services quickly and reducing the risks involved in non-specialised attention; in the case of Gender Incongruence of Childhood, the opposite is proposed, increasing the time required to establish the diagnosis from 6 months to at least 2 years, so as to avoid any false positives created by including children that display behaviours or interests of gender variability.

Finally, eliminating both the category “Fetishistic Transvestism” from the ICD-10 group of “Sexual Inclination or Paraphilic Disorders” and the ICD-10 diagnosis F64.1 “Dual Role Transvestism” is recommended.

Based on the pair review process and the comments received from groups of professionals and from civil society, it seems that one of the main questions concerning the proposals for reclassifying the transgender condition revolves around the need for a “Gender Incongruence of Childhood” category. There are apparently 2 different, valid perspectives concerning the matter, and the decision cannot be based exclusively on later social and academic discussions. Along this line, both the clinical usefulness of the category and the potential consequences of using it were subjects of special importance in the field studies that followed in the process of developing the ICD-11.

ICD-11 studies on the classification of the transgender condition

The field studies to assess these proposals included: (1) an opinion poll for mental health professionals related to the categories that should be eliminated from the classifications (and the reasons for doing so)⁴; (2) a series of studies in different countries aimed at determining if the transgender condition covers or not the essential criteria for being considered a mental disorder⁵; and (3) the evaluation of the acceptability and clinical usefulness of the ICD-11 proposal for classifying the transgender condition in childhood.⁶

The opinion poll was conducted as part of the “natural taxonomy” study by Reed et al.⁷ It included a sample of mental health professionals from 8 countries (Brazil, China, India, Japan, Mexico, Nigeria, Spain and the United States) who had at least 2 years of experience after their clinical training, and who provided mental health services for at least 10 hours a week. Of the 505 professionals participating, 60.4% indicated that one or more of the 60 diagnoses of mental disorders included in the study should be removed from the classifications in force (ICD-10 and the Diagnostic and Statistical Manual of Mental Disorders, 4th edition [DSM-IV], at that time). The categories most often recommended for elimination were as follows: gender identity disorder, sexual dysfunction and paraphilia; this was generally due to the fact that the clinicians considered that the categories were based more on stigmatising a way of being or behaving.⁴

For its part, the evaluation of the validity of the proposal to not consider the transgender condition as a mental health problem any longer was guided by the premise that, by definition, a mental disorder causes significant discomfort or distress and/or dysfunction or incapacity in and of itself and not due to the stigma or social rejection of the condition. In an initial study in Mexico, which was later replicated in another 5 countries (Brazil, France, India, Lebanon and South Africa), exactly the opposite was shown: in the logistic regression models, the predictors of distress and of all types of dysfunction were the experiences of rejection (odds ratio [OR]: 2.29–8.15) and violence (1.99–3.99), instead of variables related to pronounced gender discordance or dysphoria (essential criteria for the transgender condition).⁸

Finally, in relation to the ICD-11 category Gender Incongruence of Childhood, a qualitative study was conducted to determine 2 points, using in-depth interviews with transgender individuals who had experienced some type of diagnosis of this condition during childhood: (1) if such a diagnosis had been an inherently damaging and unnecessary experience and (2) whether the ICD-11 proposal for the classification of gender incongruence in childhood, including its new position, name and definition, was appropriate and potentially useful. None of the participants received an official diagnosis of their condition (ICD- or DSM-based), but rather a non-specific diagnosis implying mental disease. In all the cases, it was perceived negatively and was used to justify potentially damaging “curative” interventions. At any rate, when the participants reviewed the ICD-11 proposal for classifying the transgender condition in childhood, the entire sample coincided that the category was necessary and that it might lead to personal, family and social benefits. The participants all agreed to its position in a new chapter entitled Conditions Related to SexualHealth, as well as its new name (translation to Spanish) and the corresponding definition.

Accordingly, there is already a lot of scientific evidence in favour of the proposed modifications to the classification of the transgender condition in the ICD-11, perhaps having a certain heuristic value for the World Health Assembly of the WHO in approving them. This will, without a doubt, help to reduce the stigma towards this population, while at the same time ensuring the quality attention for safe corporal transformation under medical supervision that might be required.

Funding

The World Health Organisation, through the Ramón de la Fuente Muñiz National Institute of Psychiatry (Pan American Health Organization [PAHO]/WHO Collaborating Centre). Countries: Switzerland and Mexico, respectively. Scholarship IDs: WHO Registry: 2013/328671-0; Project: consultation for and coordination of “Field Testing of ICD-11 Proposals for Sexual Disorders and Sexual Health in Mexico.”