The proposals to declassify transgender identity as a mental disorder have been approved by each committee that has considered it so far. A study published Tuesday in the journal Lancet Psychiatry, offers up new evidence supporting the change.
A condition is designated as a mental illness when the very fact that you have it causes distress and dysfunction, said Geoffrey Reed, a professor of psychology at the National Autonomous University of Mexico, a consultant on ICD-11 and co-author of the study. The study argues that this is not the case with transgender identity.
In 2014, from April to August, Reed and his team interviewed 250 transgender adults who were receiving transgender-related health services at the Condesa Specialized Clinic in Mexico City. They asked them about their childhoods, when they knew they were transgender, and what kinds of reactions they had gotten from work, school or family.
Reed found that many of the people he interviewed experienced a lot of distress in their lives. Later, using mathematical modeling, he found a good way to predict who was suffering — but the most important determining factor was not being transgender, it was something else.
"We found distress and dysfunction were very powerfully predicted by the experiences of social rejection or violence that people had," he said. "But they were not actually predicted by gender incongruence itself."
This finding contradicts the basic classification of a mental illness, which is that "distress or dysfunction are essential elements of the condition," the paper said.
Reed hopes his work shows that being transgender does not have to equate to suffering. It's actually the external factors, Reed said, that cause the suffering: the societal stigma, the violence and the prejudices. Remove them, and all that remains is the feeling of "gender incongruence," the label proposed in ICD-11 in a new chapter called "Conditions Related to Sexual Health," which will be medically and biologically oriented.
This issue echoes past controversies. The Diagnostic and Statistical Manual of Mental Disorders (DSM), the psychiatric disorder guidebook, once included homosexuality as a mental illness. In 1973, the diagnosis became "sexual orientation disturbance," and then disappeared completely in 1987, largely because of gay rights advocates.
Hysteria, an affliction often attributed to women, was in the DSM until 1980. The DSM called transgender identity "sexual deviations" in 1968. In 1980 it was "psychosexual disorders," and in 1994 it was "sexual and gender identity disorders." The DSM-5 changed the listing of transgender to "gender dysphoria," in 2013 (though it remains classified as a mental illness today).
There has been progress, but as long as mental illness continues to be widely stigmatized, Reed said, it's going to affect transgender people in a negative way. In most cases in the United States, to undergo a sex reassignment surgery, a person must first get a diagnosis from a doctor. That means readily accepting a mental illness diagnosis, even though the patient may not feel they have one, to go through with that part of transitioning.
After that, "stigma associated with both transgender status and mental disorders has contributed to precarious legal status, human rights violations, and barriers to appropriate health care among transgender people," the paper says.
"The fact that people have a mental disorder has sometimes been misused to say, that means that they're not competent to make their own decisions," Reed said. "They're not competent to decide if they want to be a different gender, they're not competent to decide if they want to change their identity documents, they're not competent to have custody of their own children, they're not competent to manage their own reproductive rights."
So why not remove the classification altogether, as was done with homosexuality? Because one of the primary goals of the reclassification is to also improve transgender people's access to health care. There are often insurance-coverage differences between mental and physical illness, and one of the incentives for the authors of the study would be to close that gap.
"The risk would be if we took conditions related to gender identity out of the classification altogether, it would undermine the access to health services that transgender people have," Reed said. "They wouldn't have a diagnostic code that conveyed eligibility."
Jack Drescher, a psychiatrist and psychoanalyst at New York Medical College who serves on the WHO working group, told the New York Times that inmates, such as Chelsea Manning, are able to receive hormone treatments in part because transgender identity belongs to a medical category.
Transgender activist groups have been working toward this for years, said Mauro Cabral, one of the program directors of the Global Action for Trans Equality.
Jamison Green, former president of the World Professional Association for Transgender Health, said the change would be a tremendous relief to any person who is gender variant or gender nonconforming. The association has been publishing Standards of Care since 1979, guidelines for health professionals to assist transgender and gender-nonconforming people.
"If we could stop society from judging people's gender expression as a kind of craziness if it doesn't fit what someone else thinks their gender identity ought to be," he said. "That's going to be a long process, it'll be more than just changing the diagnosis. But that would be a step in the right direction."
The study also reveals how much a toll societal stigma can have on a young person. A 2012 study showed that teenagers who grew up with unsupportive families had a 57 percent suicide rate, compared to a 4 suicide rate for those who had supportive families. Some studies show that transgender people can develop post-traumatic stress disorder just from being transgender.
Because of this, for some trans activists, such as Alok Vaid-Menon, changing the language of the ICD-11 is a small battle won, but the war is still being waged for trans rights.
"For me, I don't see it as necessarily a victory to differentiate ourselves from mental illness," Vaid-Menon said in an interview Wednesday night. "The true victory would be to de-stigmatize diversity and difference itself."
Even the fact that mental illness is stigmatized so much, to the point that trans people don't want to be associated with it, is a cause for concern, Vaid-Menon said. The issue is not the labeling, but how people can damage each other through their actions.
"I think the bigger question that we need to ask is: Why do we stigmatize difference?" Vaid-Menon said.
Vaid-Menon is part of a trans South Asian performance art duo called Dark Matter, along with Janani Balasubramanian. This year, the New Yorker magazine said they "offer a cheeky radical-queer critique of the gay-rights movement." They perform poems related to transgender rights and transphobia all over the country and are heavily involved in trans activism.
Even before this new study, to Vaid-Menon, it's been painfully obvious that any distress related to being transgender comes from the outside world.
"We literally are traumatized doing really basic actions, like going outside, walking, doing our laundry, eating, where we have people say and do horrendous and horrible things to us," Vaid-Menon said. "The only representation we see of ourselves in the media is violence and in the case of black and Latina trans women, often incredible murder. I think that it's really really irresponsible, rude, and humiliating to say that it's trans people's internal fault that we are dysphoric. That makes no sense to me."
Vaid-Menon is proud of the ICD-11 change, but said there are still bigger problems trans people face than a semantic definition. The real issues are violence, poverty, homelessness and housing discrimination. Reed acknowledged this in his paper, saying that "ample documentation from existing studies shows that transgender people experience high rates of harassment and violence, including sexual violence, not only from strangers but also from their own families and communities."
"Young people who grow up in supportive environments" are not particularly distressed, Reed said. "They are receiving adequate social support, they come from families that are not treating them with stigmatization and violence, and they expect that there will be services available to them. So there's no reason for them to be distressed. They still have the anatomical incongruence, where they experience themselves to be a different gender than what their body may be developing into. But they don't have to have hallmarks of distress and dysfunction."