Classifying difference

The Lancet Psychiatry has released results of what is being called the first field study on the topic of transgender mental health: Removing transgender identity from the classification of mental disorders: a Mexican field study for ICD-11

The conceptualisation of transgender identity as a mental disorder has contributed to precarious legal status, human rights violations, and barriers to appropriate health care among transgender people. The proposed reconceptualisation of categories related to transgender identity in WHO's forthcoming International Classification of Diseases (ICD)-11 removes categories related to transgender identity from the classification of mental disorders, in part based on the idea that these conditions do not satisfy the definitional requirements of mental disorders. We aimed to determine whether distress and impairment, considered essential characteristics of mental disorders, could be explained by experiences of social rejection and violence rather than being inherent features of transgender identity, and to examine the applicability of other elements of the proposed ICD-11 diagnostic guidelines.

In some places, the study’s authors note, viewing transgender people as having a mental illness might force them to get psychiatric care rather than the physical care they seek, or be used by governments to deny “decision-making authority to transgender people in matters ranging from changing legal documents to child custody and reproduction.”

The researchers interviewed 250 transgender people for the study. They found that the majority reported social rejection related to their gender identity as well as being the victim of violence.

The researchers conclude that “distress and dysfunction were more strongly predicted by” going through those experiences compared to “gender incongruence itself.”

Having grown up as a child and an adult who experienced gender incongruence, I’m personally very clear it’s not a mental disorder. There is stress that’s created as a result of having it reflected back to you that there’s something wrong with you.

--Jamison Green, president of the World Professional Association for Transgender Health and a transgender man

The authors of the study argue that being transgender might be better classified as a condition related to sexual health (rather than a mental disorder), in the next edition of the World Health Organization's International Classification of Diseases. They also note that this is the first field study on the topic, which was led by Mexico’s National Institute of Psychiatry Ramón de le Fuente Muñiz, and that it is being replicated in several other countries such as Brazil and India.

80% of the participants were transgender women.

The participants reported becoming aware they were transgender at a mean age of five years old. More than three-quarters of participants (76%) reported experiencing social rejection related to their feelings about gender, most commonly by family members. And nearly two-thirds (63%) said they had been a victim of violence related to their gender identity.

A 2012 study found that 47% of transgender youth who did not have supportive parents attempted suicide during the precious year, while just 4% of transgender youth with "very supportive parents" had done so.

Stigma associated with both mental disorder and transgender identity has contributed to the precarious legal status, human rights violations and barriers to appropriate care among transgender people.

--lead author Geoffrey Reed, National Autonomous University of Mexico

The WHO is struggling with how to treat the condition.

The intention is to reduce barriers to care.

--Dr. Reed

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. One of the benefits of moving it out of the mental disorder section is trying to reduce stigma.

--Dr. Michael First, Columbia University, chief technical consultant for ICD-11

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?

Karl Surkan, professor of women's studies, MIT and Temple, 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."

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. If it’s possible to have it more separately, it would be better.

--Dr. Griet De Cuypere, Center of Sexology and Gender, University Hospital, Ghent, Belgium

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.

In English it sounds kind of neutral — my association is with geometry. But in Spanish it sounds very bad, it sounds kind of psychotic.

So, in Spanish, the proposal is “gender discordance." in English that sounds really bad.

--Dr. Reed

The terminology is difficult because nobody likes anything. 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.

--Reed

Many (of the participants in the Mexican study) 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.

--DeCuypere

In France, they said, ‘Just leave us alone, we don’t need your stinking classification,’ But they live in a society where access to health care is conceptualized as a right.

--Dr. Reed

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