It has recently been announced that the World Health Organisation is proposing – finally – to remove transgender identity and gender dysphoria from its list of mental health disorders.
The list, known as the ICD-10, describes gender dysphoria as “the urge to belong to the opposite sex that may include surgical procedures to modify the sex organs in order to appear as the opposite sex”.
Calls for the WHO to revisit this have increased in recent years and most recently since new research has confirmed that transgender and non-binary people experience disproportionately high rates of social rejection and are more likely to be victims of violence. One such study, published in the medical periodical The Lancet, argued that “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 psychiatrists behind the study recommended removing “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…[after considering] 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” they concluded that there was a need to declassify gender dysphoria and transgender identity as mental disorders and to instead seek ways to “increase access to appropriate services and reduce the victimisation of transgender people.”
The human cost of conflating identity with disorder
Professor Geoffrey Reed, the study’s senior author, said: ““The definition of transgender identity as a mental disorder has been misused to justify denial of health care and contributed to the perception that transgender people must be treated by psychiatric specialists, creating barriers to health care services.
“The definition has even been misused by some governments to deny self-determination and decision-making authority to transgender people in matters ranging from changing legal documents to child custody and reproduction.”
Dr Rebeca Robles, the study’s lead investigator, added: “Rates of experiences related to social rejection and violence were extremely high in this study, and the frequency with which this occurred within participants own families is particularly disturbing.”
The WHO is reportedly considering declassification when it next reviews its list of mental and behavioural disorders in two years’ time. Work on this – which will be known as the ICD-11, has taken some time and the list has not been updated since the 1980s. There have so far been no objections from within the WHO to the calls to change the classification of transgender identity. There appears to be recognition that the existing classification reinforces stigma while doing nothing to alleviate the problems of rejection and distress many transgender and non-binary people experience. All this is naturally positive.
“A diagnosis – but not a mental health diagnosis”
Perhaps less positive is the suggestion that ICD-11 will declassify transgender identity will as a mental disorder but will list it in a different part of the document, potentially under conditions related to sexual health. New York psychiatrist Dr Jack Drescher, a member of the ICD-11 working group, explains: “So they’ll be diagnoses, but they won’t be mental disorder diagnoses.” Glad that’s been cleared up.
It is proposed that the new ICD-11 will refer to “gender incongruence” as “characterized by a marked and persistent incongruence between an individual´s experienced gender and the assigned sex, which often leads to a desire to ‘transition’, in order to live and be accepted as a person of the experienced gender, through hormonal treatment, surgery or other health care services to make the individual´s body align, as much as desired and to the extent possible, with the experienced gender. The diagnosis cannot be assigned prior the onset of puberty.” So while it’s been declassified as a mental health condition, it is still likely to remain a clinical diagnosis.
While declassification will be welcome, not to mention overdue, it will represent the beginning of a process rather than signify an end in itself. There can be little doubting that being rendered mentally disordered will always be stigmatising and dehumanising; however, it’s not only the ICD-11 categorisations that need to be challenged but also the culture of medicalisation behind it. It’s not enough to declassify the “mental disorder” element in a well-meaning but misguided attempt to strip away stigma that speaks volumes about the way mental health continues to be treated, when the same identity issue is continued to be perceived as something that is in some way “wrong”. We need to move away from the language of “disorder” altogether.
This is vitally important, especially as many transgender and non-binary people receive deficient treatment in the NHS. If we’re serious about tackling discrimination, we need a change of language – and a corresponding change in culture.
Medicalisation – part of the problem?
There is also a tendency in our scientific world to over-medicalise everything, and consequently there will be those who feel that transgender people are actually best served through a system that provides them with psychological care and institutional support. One such voice, American psychiatrist Paul McHugh, goes so far as to suggest transgender people’s real difficulty is “underlying psycho-social troubles”, which constitute “a mental disorder that deserves understanding, treatment and prevention”. He is not alone.
These voices may be arguing against a growing consensus, but they underline the reality that the arguments must move away from medical. After all, it wasn’t long ago that homosexual people were seen as being mentally disordered and it wasn’t the intellectual medical arguments that brought about greater social acceptance for our gay and lesbian brothers and sisters. Yes, declassifying transgender people as mentally disordered will, at a stroke, cease to mark them in the way they have for decades. It will also mean governments who have used the WHO’s inadvertent support for their denial of rights and protections to transgender and non-binary people may have to reconsider their actions.
The medical arguments label, analyse, consider data and seek to offer scientific explanations. All that can be helpful. But what they’re less good at is recognising that transgender experiences are incredibly varied, as are the “treatments” transgender people want. They don’t generally treat individuals as individuals, but as some kind of homogenous group with a shared identity. Ultimately, why should it be up to the medical profession to decide who has a valid gender identity and who doesn’t?
And that’s the real issue – who has the right to determine who is and who isn’t a particular gender? Who has the right to deny people the right to identify with any gender or none? While declassifying gender dysphoria as a mental health condition represents a powerful statement and an overdue step forward, the real solution lies in improving social awareness, with education rooted in the experiences of transgender and non-binary people.
Lesley has often been asked when she knew she first felt like a girl, a woman, and she can’t answer the question. She explains: “I have never felt like a girl or a woman; I simply was a girl, and, later, a woman. Nor can I explain how a child, albeit a very bright child, can get their head around the way I was and live comfortably with the dichotomy of being a girl while living as a boy.
“I had problems enough as a child and this wasn’t one of them. My father had a problem with my problem, and he had a drink problem, and the toxic mixture would bubble into regular physical violence, intimidation, and humiliation for me. I was clever too, I knew it, I wasn’t shy about it and that was a problem; I liked “snob music” and that was a problem. I was a problem. I would “end up a bloody pervert, like that one on the telly”, and I have no idea which pervert I was destined to be like. I never worried myself about that. My mother exploited my strange malady in another more sinister and sickening way, and that remains a problem for me.
“For a long time, my biggest issue was that I lived contentedly in a boys’ world while something in my manner seemed “girlish” to my parents, but I WAS a tomboy. I lived my boys’ life fully in character. I climbed trees better than any other child my age; I was up for every mad, crazy adventure going. I hung about the fringes of my older brother’s delinquent gang. I stole. I lied. I cheated. The police dragged me home from time to time, and I was charged with petty offences.
“The discovery that my conduct and my dilemma might be explained by my being a tomboy was a great relief. So I am a girl! That’s great!”
When Lesley first heard this expression, and discovered its meaning, a great weight was lifted from her shoulders. Puberty was hell, but she did all she could to survive, and be a girl in a boys’ life – not a boys’ body, or mans’ body. It annoys her still to hear to hear the phrase “a woman trapped in a man’s body”. She says: “I was a girl, a woman, and my body was my own. Don’t get me wrong; my body was pretty well screwed up, but it was mine, and my body and my psyche lived in joyous confusion together for most of my life. We still do. I don’t have a female body. Nor can I ever have one. My breast and genital surgeries were deeply moving experiences for me, but I don’t have a new body. I have my body, the same body I always had – altered but still me, still a woman, still the same woman I always was. I had to put my hand up to a ‘mental health disorder’ to be allowed certain treatment, but I was never convinced of the correctness of this.”
Andrew, who is non-binary, admits they’ve “never felt particularly male…from as young as I can remember I always wanted to do ‘girly’ things and struggled to adapt to societal gender roles. In my teens, things happened to my body physically that don’t really happen to boys. So while I didn’t have a woman’s body I certainly didn’t have a typically male one either. For all the arguments about gender being a psycho-social expression of identity or a social construct, in my case there was an undoubtedly a biological basis.
“The picture was complicated further by my sexual orientation (Andrew is bisexual) and the fact that in the Hebrides during the 1990s there were few opportunities to openly and positively discuss my gender identity. Seeing a doctor about this was difficult to say the least – I was also concerned about anything I said being connected to my mental health problem (Andrew experienced depression at this time). So I hid it, tried to make sense of it alone, sometimes even ashamed of who I was. Later, working in mental health, I became more aware of non-binary and transgender identities but also discovered the stigma behind them…there’s no doubt that revisiting the ICD and reclassifying gender dysphoria can help tackle this. But it isn’t enough by itself.”
The new ICD-11 is expected to change the status of transwomen like Lesley. She says: “I will no longer be seen to suffer from ‘gender dysphoria’ – a very vague mental health condition. It would seem that I have had it exchanged for a ‘condition related to sexual health’ – namely ‘gender incongruence’ . . . Hm! At least I’m not crazy! I still have ‘a condition’ and I am still suitable for treatment.
“When I first engaged in gender politics and activism, I met women like me who hated the term transsexual. It was the use of “sexual” that was a problem. We didn’t have a “sexual problem”; we had a “gender issue” and I remain conflicted about that. Transgender is a dreary term, and I have never liked it. Is it an umbrella term? Am I trangender(ed)? My feeling is that I am transsexual. My body, my own woman’s body, clearly bore the evidence of male sexual characteristics. I lived my life as a man. I have children to whom I am a father. My gender, my certainty that I am a woman, has never changed.
“I emerged from hiding. I nailed my colours to the mast. I am the woman I always was. I have never changed gender. My body is my own, it is a woman’s body; it always was.
“Not in this respect.”