WHO: Depathologising Gender Diversity

One of the jobs of the World Health Organization (WHO) is to classify and re-classify diseases and health trends on a global basis. This work is important not only for our understanding of health but also for our understanding of identities. How we categorise “diseases” and “disorders” has far-reaching consequences. It affects our human rights, the medical attention and care we receive and are entitled to, and the ways in which we are treated in our everyday lives.

(Re-)Classifying Identities

On the 18th June 2018, the WHO released an online version of the International Classification of Diseases (ICD-11), which is a classification tool that identifies health trends globally and provides a system of diagnostic codes for classifying diseases. In the ICD-11, an adjustment has been made in regard to gender. “Transsexualism” (which was considered a mental “disorder”) has been removed from the mental health chapter, renamed “gender incongruence” and transferred to the sexual health chapter. This decision has had mixed reviews. For many it is seen as a victory – a paving stone on a long road towards anti-discrimination of transgender people. For others, although the depathologisation of transgender identities is welcomed, there are several concerns with the rationale of the WHO’s decision.

One of the concerns that trans activists have highlighted is the rationale that removing “gender incongruence” from the mental health chapter should “reduce stigma”. The problem with this is that it reproduces the long history of stigmatisation associated with mental health issues in general. It does nothing to help with destigmatising mental health itself. In this respect, it is unhelpful to advocate one campaign of acceptance by devaluing another. It must be made clear that persistently identifying with a different gender to the sex that one was assigned at birth is not a mental illness. However, there needs to be sensitivity in our use of language concerning this issue so as not to devalue the campaign against the stigmatisation and discrimination of those with mental health issues. Transgender people face widespread discrimination across the globe in a variety of forms. Not only are they particularly vulnerable to abuse, bullying and violence, they also have difficulties in accessing work, housing and health services. There are numerous issues that we must turn our attention towards in order to fight discrimination against transgender and gender diverse people. What really needs to be tackled are people’s prejudices in relation to both gender and mental health, as well as the systems that uphold those prejudices.

Gender incongruence” is stated (for adolescents and adults) to be “characterized by a marked and persistent incongruence between an individual’s experienced gender and the assigned sex”. Experiences of this feeling must persist for at least several months and a person must experience at least two of the following:

  1. “1) a strong dislike or discomfort with one’s primary or secondary sex characteristics […] due to their incongruity with the experienced gender;
  2. 2) a strong desire to be rid of some or all of one’s primary and/or secondary sex characteristics […] due to their incongruity with the experienced gender; 3) a strong desire to have the primary and/or secondary sex characteristics of the experienced gender”.

Addressing Issues Alongside the ICD-11 Change

More must be done in advancing legal recognition of transgender people across the globe. Some progress has been made in this area. For example, Pakistan has recently passed a historic bill (Transgender Persons (Protection of Rights) Act 2018) which protects the rights of transgender citizens and recognises the identity of transgender people in accordance with their self-perceived gender. More must be done to make transgender people visible in data in order to develop research concerning health, economical, and everyday needs. Data collection (particularly concerning issues such as health) is currently structured around a rigid binary sex/gender system and must be adjusted and collected in a way that includes the needs of trans, intersex, and gender diverse people. Thus, the wording and language we use is an important area to tackle. The United Nations (UN), working alongside organisations such as the WHO, must not only speak of inclusion, equality and anti-discrimination, they must lead by example. It is important for the UN to include these issues in their agenda and promote solutions. Issues of legal recognition, data collection and language go hand in hand and must (continue to) be addressed alongside the changes made in the ICD-11.

Transforming Systems, Transforming Attitudes

In order to tackle discrimination and to provide access to health care and civil rights protection for all, people need to be seen amongst the term all. It is difficult to say what effect the re-classification of “gender incongruence” will have on discrimination against transgender people, including access to health care services, but it is certain that this alone is not enough to put into effect long-term change in relation to the issues mentioned. It is not until the 1st January 2022 that member states will start reporting using the ICD-11. And the implementation of the ICD-11 in many member states will take a lot longer than 2022. The US, for example, only began to use the ICD-10 in 2015 even though it was endorsed as long ago as May 1990. Nonetheless, the decision to bring “gender incongruence” to the fore through its re-classification in the ICD-11 as a sexual health matter rather than a mental health matter puts pressure on member states to re-consider and adjust their own laws, policies and attitudes towards the transgender community. Although it may be argued that the execution of this change is not perfect, it is, nonetheless, a long-awaited move which, many claim, will improve the relationship between transgender people and the health care system. This change opens up a dialogue on “gender incongruence” which will transform, amongst other things, education, funding, policies, laws, health care, and human rights on and for transgender people. Many psychiatrists use the ICD to help in their diagnoses of mental health issues. Thus, the changes made in the ICD will be felt by numerous people across the health care service. Furthermore, laws such as the outdated Transsexuellengesetz (Transsexuals Act 1980) in Germany are under further scrutiny to be either repealed and replaced with a new act or updated so that they align with more recent understandings of “gender incongruence” and the rights and needs that transgender people deserve and require.

However, the ICD-11 alone is unlikely to be enough to interrupt processes such as the one we see in the US, where, for example, the Trump administration reportedly plans to roll back the expansion of Section 1557 of the Affordable Care Act, which was expanded in 2016 to include prohibition of discrimination on the basis of gender. Therefore, we must continue to place pressure on political regimes that seek to undermine and ignore the human rights of those who do not conform to the current dominant social model. Although the re-classification of “gender incongruence” from the mental health chapter to the sexual health chapter may seem, at first, to be a victory of anti-discrimination, it is not a victory of anti-discrimination for all, particularly not for those with mental health issues. We must mind our step as we go whilst ensuring that one step forward does not result in two steps back.

Teri Shardlow