After the publication last year of the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in North America, advocates, supportive policymakers, and affirming providers for trans and transsexual people have shifted attention to the global medical diagnostic manual published by the World Health Organization (WHO), the International Statistical Classification of Diseases and Related Health Problems (ICD).
The current ICD-10 was released in 1992 and will be replaced by the ICD-11, scheduled for 2017. The diagnostic classification of young children who are trans and gender-nonconforming is drawing growing global controversy to the WHO and the ICD-11.
Contrary to misleading media headlines, gender diversity or the need for medical transition care were not declassified as mental illness in the DSM-5. There was some forward progress on longstanding shortcomings of gender diagnoses, however.
The old defamatory label of “gender identity disorder, implying “disordered” identities, was renamed “gender dysphoria” (from a Greek root for “distress”). This revised diagnosis was removed from the chapter of “sexual disorders” to reduce false stereotyping and clarify medical necessity of hormonal and/or surgical transition care for those who need it. Children could no longer be diagnosed with a gender “disorder” strictly on the basis of nonconforming behavior or dress.
Nevertheless, the fundamental contradiction of a mental disorder diagnosis to facilitate physical medical transition treatment remained in the DSM-5. For children, nonconformity to stereotypes of assigned birth sex was still described as symptomatic of mental illness. Moreover, a second gender diagnosis of “transvestic disorder” was actually worsened in the DSM-5, serving to stigmatize nonconforming gender expression and dress as sexual deviance and “paraphilia” for both trans women and trans men.
Hope for meaningful diagnostic reform now rests with the World Health Organization and the ICD-11. Their latest proposal is to remove the current gender identity disorder and transsexualism classifications from the ICD mental disorder chapter entirely, and replace them with new non-psychiatric codings in a new chapter on sexual health. The proposed “gender incongruence of adults and adolescents” (GIAA) coding could facilitate access to blockers, hormonal treatments, and surgical treatments for those adults and adolescents who need medical transition care. It could effectively render the flawed coding of gender dysphoria in the DSM-5 obsolete.
The WHO has also proposed to remove all “transvestic” and victimless paraphilia codings from the ICD-11 entirely. These changes in international diagnostic policy represent unprecedented forward progress, beyond the still-archaic gender diagnoses in the American DSM-5.
However, a proposed diagnosis of “gender incongruence of childhood” (GIC), for prepubescent children too young for medical transition care, has drawn intense controversy. Many trans* community members, advocates, parents, experts, and providers around the world have questioned the medical utility and possible harm of diagnosing children’s gender nonconformity in a manual of “diseases” — even if that diagnosis is no longer a mental disorder coding.
They warn that the ICD-11 proposal does not go far enough in destigmatizing trans and gender-different/non-conforming children and their supportive families. For trans and gender-nonconforming children, the question for the ICD-11 has shifted from depsychopathologization to comprehensive depathologization.
Removing the gender incongruence of childhood coding from the ICD-11 entirely would send a powerful message from the world’s largest medical authority that gender diversity in childhood is simply a part of human diversity. Removal would eliminate an ambiguity that could be misused to promote harmful gender-conversion or gender-reparative therapies to shame these children into the closets of their birth sex.
For children who need accommodation at school or medical or mental health services, the Civil Society Expert Working Group of Global Action for Trans* Equality (GATE) has proposed that existing ICD codes could be clarified and augmented by non-pathologizing Z-Codes to fill this need — without labeling their gender identities or expression as sickness.
Adults and adolescents who need access to medically necessary endocrine blocker, hormonal, or surgical transition care may require some kind of diagnostic coding in many global healthcare systems. However, young pre-pubescent children are another matter. They and their families might need information, support, and, in some cases, counseling — not medical care that requires a gender-related diagnosis.
Were I to identify any singular thing that would dramatically improve the lives of all gender-expansive children, it would that be that each and every one of them needs to know that there is nothing wrong with them… There is truly nothing wrong with these children.
I urge the WHO Working Group on Sexual Disorders and Sexual Health to eliminate the proposed “gender incongruence of childhood” category from the ICD-11 and to revise the appropriate Z-Codes to include gender identity and gender expression.