Being transgender is not a mental illness, and the WHO should acknowledge this

The World Health Organisation (WHO) has announced it may no longer classify being transgender as a disorder in the revised version of its International Classification of Diseases (ICD), due for release in 2018.

The ICD is a diagnostic tool used across much of the world to diagnose health issues, including mental illness.

A study published this week in the Lancet medical journal has lent support to this move. Echoing previous research, the study found poor mental health among transgender people is primarily the product of social stigma and violence. This counters the view that being transgender is itself pathological.

History of diagnostic criteria

Historically, it has been assumed that the sex we are assigned at birth determines our gender. Primarily on the basis of visual inspection of genitalia, people are considered male if they have a penis and female if they have a vagina. Respectively, people are expected to experience themselves as such.

For transgender people, these assumptive classifications are incorrect. Yet the belief that sex determines gender has remained, despite evidence to the contrary.

This is evident in the treatment of transgender people as disordered, as in the case of the ICD. This designation is a product of social values and norms, not of any evidence that transgender people are inherently disordered.

Calls to remove being transgender from the ICD reflect growing recognition of the rights of transgender people. In 2013, this was recognised in changes to the American Psychiatric Association’s fifth edition of the Diagnostic and Statistical Manual (DSM).

The previous edition of the DSM included the diagnosis of gender identity disorder, which treated being transgender as a disorder. The DSM5 classifies being transgender under the diagnosis of gender dysphoria. The ICD’s proposed revised terms include gender incongruence or gender discordance.

Those involved in introducing new terminology to the DSM suggested the focus on dysphoria reflects the impact of social norms on transgender people, rather than being indicative of a disorder. As such, the diagnosis is limited to the time in which the person is experiencing distress about their gender.

Arguments for and against

The DSM5 (and likely the ICD) retain mention of transgender people due to the apparent necessity of a diagnosis when accessing services covered by medical insurance or public health funds. Insurers, it is suggested, are unlikely to pay if there is not a diagnosed issue requiring treatment.

But the Standards of Care of the World Professional Association for Transgender Health recognise that some transgender people do not experience significant distress and should not need to do so in order to access services.

Transgender people have long opposed diagnoses being applied to their lives, even if to warrant access to services. Many have argued these pathologise transgender people’s lives, allow for gatekeeping of access to services and place unnecessary barriers to accessing them.

In terms of pathologisation, it has been argued that retaining diagnostic categories, even if not framed in terms of a disorder, may be used negatively by those opposing rights of transgender people.

In terms of gatekeeping, focusing on a particular description of what counts as transgender may encourage some to present a scripted account of their experiences in order to justify support. This could mean actual mental health issues requiring attention are overlooked or minimised.

And in terms of barriers, services for transgender people are relatively limited in most countries – certainly so in Australia. Requiring a diagnosis means that before accessing specialist services such as endocrinologists or surgeons, transgender people must first attend appointments with mental health professionals.

Given the demand for mental health professionals, wait times can be long. Research suggests that people can be particularly vulnerable during the period between first disclosure of being transgender and accessing services. Long wait times extend this unnecessarily.

Alternative approaches

Some transgender people may certainly experience mental health concerns, as may any person. GP referral to a mental health professional currently provides a clear pathway to services.

Transgender people who do not require support for mental health, but who wish to access support for hormones or surgery, could be referred directly to specialists rather than via a mental health professional assessment.

This would require upskilling GPs so they are able to provide appropriate referral and initial support. Some transgender people may of course wish to access support from a mental health professional, but this would be at their discretion, not as a requirement for a diagnosis.

As when a person is pregnant, the pregnancy is not a diagnosis but a confirmation of fact, and services are provided accordingly. While the ICD includes a code for professionals who supervise a pregnancy, this is not per se a diagnosis.

A person who has received no care throughout their pregnancy can still walk into a hospital when in labour and receive services covered by health insurers or public funds.

Similarly, and as an informed consent model would advocate, transgender people are well versed in the facts of their lives and should be able to present for specialist services with a GP referral.

This would not prohibit transgender people also accessing mental health services. Treating mental health assessment (when needed) as separate from referrals for specialist services would help reduce gatekeeping and wait times.

Changes to the ICD, like the DSM, would be welcomed, as is research that continues to demonstrate the impact of social stigma. However, transgender people have long made these points, and we must acknowledge their rights to self-determination and timely access to services.