April 17, 2018

"Transvestism" is on its way out of the WHO health manual, but its makers leave a loophole for further invalidation of transgender people

It seems the WHO health manual, the ICD-11, will remove the "fetishistic transvestism" diagnosis from the chapter on paraphilias. This is good new for the transgender community, as is the fact that being transgender is no longer considered a mental disorder. Unfortunately the current text proposal may still be used to reduce a transgender identity to a paraphilia.
The new medical manual from WHO removes the "fetishistic transvestism" diagnosis, which is great. Unfortunately, its makers still seem to think there is a clear divide between crossdressers and those suffering from what it calls gender incongruence. (Photo: Creatista)

Transvestism is out

As I have reported before, it is now pretty certain that "Fetishistic Transvestism" will to be removed from the paraphilia chapter of the international WHO health manual, the ICD-11 (International Statistical Classification of Diseases and Related Health Problems, 11th Revision).

Richard Krueger, Geoffrey M. Reed, Michael B. First and Peer Briken, members of the ICD The Working Group on the Classification of Sexual Disorders and Sexual Health (WGCSDSH), put it this way:

The WGSDSH recommended that the grouping, Disorders of sexual preference, be renamed to Paraphilic Disorders and be limited to disorders that involve sexual arousal patterns that focus on non-consenting others or are associated with substantial distress or direct risk of injury or death. Consistent with this framework, the WGSDSH also recommended that the ICD-10 categories of Fetishism, Fetishistic Transvestism, and Sadomasochism be removed from the classification and new categories of Coercive Sexual Sadism Disorder, Frotteuristic Disorder, Other Paraphilic Disorder Involving Non-Consenting Individuals, and Other Paraphilic Disorder Involving Solitary Behaviour or Consenting Individuals be added.

This means that as far as the World Health Organization is concerned, the term "paraphilia" no longer refers to some fundamental error in the sexual wiring of a particular person. Instead "paraphilia" refers to sexual behavior that may cause some kind of harm or distress to the person in question and people he or she is interacting with.

Note that this does not mean that the doctors and researchers involved may not believe that there is something wrong with the sexuality of crossdreamers and other transgender people. What this means is that in the context of the WHO manual, that is irrelevant to the diagnosis given.

WGCSDSH says this about why they want to remove "fetishistic transvestism" and "sadomasochism" from the manual:

The WGSDSH has recommended the removal of the three of the named diagnostic categories currently included in ICD-10 Disorders of sexual preference (F65) from the ICD-11: Fetishism, Fetishistic Transvestism and Sadomasochism. These conditions involved consensual or solitary sexual activity that do not involve inherent harm to self or others and are not necessarily distressing to the individual or associated with functional impairment. Therefore, the WGSDSH did not consider these arousal patterns per se to represent mental disorders or to be an appropriate focus of public health surveillance and reporting, but more accurately as variants in sexual arousal. The inclusion of these diagnoses can therefore be seen as inconsistent with human rights principles endorsed by the UN and the WHO (Drew et al., 2011) by stigmatizing those individuals practicing such behavior without clinical or public health benefit.

The Devil is the Other

One might think that these arguments would be solid enough to stop transphobes from arguing that crossdressers and other transgender people who report cross-gender arousal or erotic crossdreaming are "paraphiliacs". 

Still, the devil is in the detail. There continues to be a more generic category of paraphilias that can be used for those who truly suffer from their crossdreaming:

According to current ICD-11 proposals (see sections below), cases in which these arousal patterns are associated with marked distress or significant risk of  injury or death could be accommodated under other categories in the ICD-11.
Indeed, the paper goes on to say exactly that:

DSM-5 includes Sexual Masochism Disorder, Fetishistic Disorder, and Transvestic Disorder as mental disorders categories, but these are not proposed as specific, named categories in ICD-11. In ICD-11, these phenomena may be diagnosed under the category Other Paraphilic Disorder Involving Solitary Behaviour or Consenting Individuals if they are associated with significant distress or significant risk of injury or death.
This means that a closeted, non-transitioned, transgender woman who suffer from severe gender dysphoria may still be diagnosed with an "Other Paraphilic Disorder" if she tells the doctor about her erotic cross-gender fantasies. She is, after all, suffering from "substantial distress". If the doctor belongs to the tribe that believes that trans people should not get turned on by the idea of being their target gender, she will end up in the paraphilia category.
WHO logo.

The gender incongruence chapter is of no help

The chapter on gender dysphoria (called gender incongruence in ICD-11) will therefore be of great importance to such women.

In the American psychiatric manual, the DSM-5, the chapter on gender dysphoria explicitly says that what I have called erotic crossdreaming does not stop someone from being a transsexual:

An individual with transvestic disorder who also has clinically significant gender dysphoria can be given both diagnoses. In many cases of late-onset gender dysphoria in gynephilic natal males, transvestic behavior with sexual excitement is a precursor.

The beta version of the relevant chapter of the ICD-11 has a pretty restrictive idea about what gender incongruence is and should be. Unlike the DSM-5, it does not refer to the fact that crossdreaming may be a natural expression of a transgender person's sexuality. Moreover, it adds "paraphilic disorders" as an "exclusion".

ICD-10 : F64.9

Gender Incongruence of Adolescence and Adulthood is 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. Gender variant behaviour and preferences alone are not a basis for assigning the diagnosis.

Paraphilic disorders (6D30-6D3Z)

Exactly what "Exclusions" mean in this context is not perfectly clear to me.  Many  exclusions in the ICD-11 are conditions that might be thought to be subcategories of a given condition, but – because they occur elsewhere in the classification–  must be excluded from a particular part of the manual. Others are codes representing possible cooccurring conditions that should be distinguished from the condition listed.

Worst case scenario: Readers will interpret the "exclusion" to mean that any client who confesses to cross-gender arousal is suffering from a paraphilia or is "only a transvestite".  Which brings us back to thinking of the 1940s.

There is no clear cut line between crossdresser and transsexual

I do not think the people working on the relevant parts of the ICD-11 want this. The discussions leading up to the current version of the text tells me that the experts involved do see that it often is the social and cultural context of transgender lives that leads to much of the suffering, and not necessarily being transgender in itself.

But the discussions also show me that many of them are trapped in the old dichotomy crossdresser ("fetishistic transvestite" to use their old fashioned term) vs. transsexual.

The reason they do this is, I believe, that they consciously or unconsciously turn paraphilias into "things" (reifying them, to follow Andrea James' argument against "autogynephilia"). In this view of the world crossdressing/crossdreaming is a substantially different "thing" compared to being transsexual (i.e. suffering from gender incongruence). The main clue is found in whether someone get turned on by something or not.

So, if a male to female crossdresser suffers from his "transvestism" it has to be because he  is turned on by women's clothing and not because she has a female sexuality. The idea that feminine clothing can become a turn-on because dressing up like a woman is a confirmation of this trans person's fundamental being is lost.

Crossdressing is not a condition

The following points  have to be repeated over and over again:

1. Crossdressing is not a "condition". It is an act that is used to express something or experience something. Before they transition the great majority of transgender people crossdress, because they want to feel more aligned with their target gender, and because they want to express that side of themselves. It is not because they are crossdressers.

2. Neither gender nor sexual orientation are completely binary. We are looking at spectrums and variation in intensity. This is why many gender variant and non-binary people may crossdress while still identifying as their assigned gender.

Gender dysphoria and gender incongruence are also continuums. In our survey of crossdreamers we found  that 59 percent reported gender dysphoria. Among those that did experience gender dysphoria 30 percent reported high levels of distress associated with this dysphoria (4 or 5  on a scale of 5).

Gender dysphoria and gender incongruence are useful terms that tell us something about how much distress a transgender person feels from any misalignment between the gender role they are asked to play and their sense of self, as well as the dissonance between mind and body. But we should not be misled into believing that gender dysphoria is an either/or phenomenon.

3. Crossdreaming or cross-gender arousal (some of which is referred to as female/male embodiment fantasies by Julia Serano) are not symptoms of a disease. They are most likely expressions of some kind of gender variance, i.e. the psyche's way of expressing a side of what it truly is. This does not mean that all  crossdreamers are transsexuals suffering from severe gender incongruence, but some are.

4. Not all crossdreamers crossdress. The term "transvestite" is not only old fashioned and offensive; it is also misleading. Some experience cross-gender arousal, not from dressing up as their target gender, but by imagining themselves being their target gender.

5. Being transgender is a journey. Cultural and social oppression and a lack of words and role models mean that trans people need time to find and understand themselves. Some find that their crossdressing is just a way of expressing another side of themselves. They remind committed to their assigned gender. Others find that their crossdressing is an expression of their true gender. If a doctor puts a transgender woman or man into the paraphilia box, she or he may never get out of it again.

The transgender community must be aware of the fact that this battle is not over.

See also:
Does the WHO ICD-11 Manual Erase Transgender and Non-binary Identities?
The WHO ICD-11 health manual removes transvestic fetishism. Being trans is no longer a mental illness.

Richard Krueger et. al.: Proposals for Paraphilic Disorders in the International Classification of Diseases and Related Health Problems, Eleventh Revision (ICD-11) Archives of Sexual Behavior 46(5), 2017

Geoffrey M. Reed et. al.: Disorders related to sexuality and gender identity in the ICD‐11: revising the ICD‐10 classification based on current scientific evidence, best clinical practices, and human rights considerationsWorld Psychiatry, Volume15, Issue3 2016

ICD-11 Beta Draft

Charles Moser: Paraphilias and the ICD-11: Progress but Still Logically InconsistentArchives of Sexual Behavior 47(4)  2018


  1. stupendous Jack! thanks for this great assembly of information. Sadly although many transgender people now understand these nuances very well those who are bent on marginalizing us at any price will twist whatever wording they desire to do their handiwork.
    What I take away from this however is that over the decades we are making societal progress in our sensitivity to transgender people and their needs and that arousal patterns in transsexuals do not in any way invalidate their identities. Hence progress is still progress in my book.
    I like how Moser seeds doubt in his paper by the way about the subjectivity of the choices made.

  2. Thank you for your kind words, Joanna.

    You are right: The main message from the work on the new edition of the ICD-11 is that these experts are doing their best to respect and help transgender people.

  3. Xora makes a very interesting argument regarding self-acceptance among trans people in a debate over at CDL:

    “I mean, if a part of you, for whatever reason, religion, parenting, or simple embarrassment, fundamentally rejects the very idea that you might be trans, or it just wasn’t even a concept that you were even aware of, I can see that as the basis for your carefully constructing your self-identity omitting that one vital piece of information, until one day the nagging cognitive dissonance you experience with your body and in every social interaction grows too great, and you reach a point where you can no longer ignore it, which might well take until you are 30ish, and that is what presents as so-called ‘late onset’, at least to the clinicians.

    “Then you go back and try to reconstruct a narrative of your existence and experiences including that piece of information you had previously omitted, and find that it all makes so much more sense to you what was actually going on at the time, but you then get accused by the clinicians and the separatists of engaging in rationalisation in the opposite direction.

    Instead of coming up with true information to support your new-found and sincerely believed ‘born this way’ case, you are accused of spinning a false and flawed self-narrative to support your late developing but overpowering sexual perversion.”


  4. Very well written, Jack. I’m always impressed with how much effort you put into your posts and this one is particularly good and helpful.


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