New evidence supports removing the diagnosis of transgender from the WHO International Classification of Diseases (ICD), according to a study published in The Lancet Psychiatry.
“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,” said senior author Professor Geoffrey Reed, Universidad Nacional Autónoma de México Center for Global Mental Health Research, in a statement to the press.
“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,” Dr. Reed said. “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.”
Transgender Identity Is Currently Classified as a Mental Disorder
Transgender identity is currently classified as a mental disorder in both the WHO’s ICD-10 and the American Psychiatric Association’s DSM-5. A major component of the definition of mental disorders is that they are associated with distress and impairment in functioning. A WHO Working Group has recommended that transgender identity should no longer be classified as a mental disorder in ICD-11, but should instead come under a new chapter on conditions related to sexual health.
The researchers interviewed 250 transgender people (aged 18 to 65 years) who were receiving care at the Condesa Specialized Clinic in Mexico City. Most participants were transgender women who were assigned male sex at birth (80%), and used health interventions for body transformation (74%).
Psychological Distress in Transgender People Linked to Social Rejection and Violence
Most participants experienced psychological distress related to gender incongruence during their adolescence (83%), with depressive symptoms being the most common. Nearly all participants (90%) reported family, social, or work or academic dysfunction during adolescence relating to gender identity.
More than three-quarters of participants (76%) reported experiencing social rejection related to gender incongruence, most commonly by family members, followed by schoolmates/co-workers and friends. A majority of participants (63%) had been a victim of violence related to their gender identity, which was perpetuated by a family member in nearly half of these cases. Psychological and physical violence were the most commonly reported, and some people experiencing sexual violence.
Multivariate logistic regression models showed that distress and dysfunction were more strongly predicted by experiences of social rejection and violence than by gender incongruence itself. In fact, none of the gender incongruence variables predicted psychological distress or dysfunction, except that asking to be treated as a different gender predicted school/work dysfunction (odds ratio [OR], 1.82). On the other hand, distress and all types of dysfunction were strongly predicted by social rejection (OR, 2.29-8.15) and violence (OR, 1.99-3.99). In addition, current male gender identity also was a predictor of distress (3.90).
“Our findings support the idea that distress and dysfunction may be the result of stigmatization and maltreatment, rather than integral aspects of transgender identity,” said lead investigator Rebeca Robles, PhD, a researcher from the Mexican National Institute of Psychiatry, in a statement to the press. “The next step is to confirm this in further studies in different countries, ahead of the approval of the WHO revision to ICD in 2018.”
“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. Unfortunately, the level of maltreatment experienced in this sample is consistent with other studies from around the world. This study highlights the need for policies and programs to reduce stigmatization and victimization of this population. The removal of transgender diagnoses from the classification of mental disorders can be a useful part of those efforts,” Dr. Robles said.
Slope Leads From Stigma to Sickness For Transgender People
“This study prompts primary caregivers and psychiatrists to be aware of a ‘slope leading from stigma to sickness’ for transgender individuals, and to contribute to their mental health by a gender-affirmative approach,” commented Griet De Cuypere, MD, PhD, University Hospital, Ghent, Belgium, and Sam Winter, MEd, PhD, Associate Professor at the Curtin University School of Public Health in Perth, WA, Australia, in an accompanying editorial. Although the study provides evidence to support moving health-related categories related to transgender identity out of the classification of mental disorders in ICD-11, it does not address the most appropriate place for the diagnosis in the ICD, what name and diagnostic guidelines should be used, and the need for a diagnosis for children.
The study is the first of several field trials and is currently being replicated in Brazil, France, India, Lebanon and South Africa.
August 2, 2016
Robles R, Fresán A, Vega-Ramírez H, et al. Removing transgender identity from the classification of mental disorders: a Mexican field study for ICD-11. Lancet Psychiatry. 2016 Jul 26. pii: S2215-0366(16)30165-1. doi: 10.1016/S2215-0366(16)30165-1. [Epub ahead of print]
The Lancet. The Lancet Psychiatry: First field trial supports removing transgender diagnosis from mental disorders chapter within WHO classification. Available at: http://www.eurekalert.org/pub_releases/2016-07/tl-tlp072516.php. Accessed August 2, 2016.