June 21, 2018

Does the WHO ICD-11 Manual Erase Transgender and Non-binary Identities?

In the new WHO ICD-11 manual the only condition described is gender incongruence. Does this mean that transgender people who are not suffering from this kind of misalignment between experienced and assigned gender will be denied the help they need?
The new edition of the health manual of the World Health Organization no longer considers being transgender a mental illness. Stigmatizing diagnoses like "transvestic fetishism" have been removed.

After my positive review of the treatment of gender incongruence in the new edition of the international WHO health manual, I got an email from one concerned non-binary reader who pointed out that since gender incongruence  – i.e. the experience of a deep mismatch between the experienced gender and assigned gender – is the only symptom of being transgender included in the manual, the medical profession may ignore the suffering experienced by other transgender and non-binary people.

They  argued that the medical gatekeepers may even use the manual to erase other parts of the transgender spectrum, leaving us with what was once called "the classic transsexual" (i.e. those that are able to live up to the "trapped in the wrong body" narrative) as the only "real" transgender people.

They also argued that given the gender stereotypes listed under the gender incongruence in childhood definition, this may even lead to continuation of a system that forces transgender people to live up to the stereotypes.

The threat of a binary backlash

You are not paranoid when they are out to get you, so do understand what this reader is getting at.

Transgender separatists ("HBS", "truscum" or "transmedicalists") may try to use this new edition to argue that they are the only real transgender, that there is no spectrum and that other transgender people should stop calling themselves transgender.

These groups have repeatedly tried to split the transgender community by arguing that you have to be gender dysphoric to call yourself transgender. The fact that the word transgender was adapted by the community to cover all types of gender variance does not bother them.

The separatists have made a big fuzz about transgender (in their narrow understanding of the word) being a medical condition that gives them the right to proper health care. In other words, they do not distinguish between the gender identity ("transgender") and the "disease" ("gender dysphoria").

Many of the "transmedicalists"  have argued that being transgender must be defined as an illness, as this is the only way the "disease" can be included in the manuals. This condition has to be included in the manuals, they argue, as this is the only way you may gain public support for hormone treatment and surgery, or – as in the USA – coverage from your private medical insurance. They therefore keep their distance from other transgender people, whose very existence – they believe – may threaten their status of suffering from some kind of intersex-like, physiological, disease.

There are doctors and health personell who agree with this two type model of gender variance, where "the fetishists" and the "non-binary " belong to a different species than "the real transgender people".

The ICD-11 does not use terms like transgender

The genius of the ICD-11 is that it does not try to define terms like "transgender," "transsexual" or gender variant. It does not use these terms, in the same way it does not use terms like "crossdresser", "transvestic fetishist", "dual-role fetishist", "drag queen", "non-binary", "autogynephile" or any other terms that have been used to define different categories of transgender people. Because of this the manual does not have to decide on what  a "proper" transgender person is.

Unlike the American Psychiatric Manual, the DSM-5, the ICD-11 does not try to diagnose the identities of gender variant people, because as far as the ICD-11 goes being transgender is not an illness or a condition, regardless of where you are on the spectrum. These identities are simply natural variations of the thing called life. They do not belong in a health manual, and most definitely not in a classification of mental diseases.

However, being transgender may cause mental and physical suffering, because of the way non-transgender people treat transgender people and/or because a body/mind mismatch makes it hard for them to live their lives as the gender they truly are.

The manual therefore limits itself to one diagnosis, gender incongruence, which is not an identity, but a term that refers to  a severe misalignment between mind and body.

Gender incongruence defined

Here is the full definition:
Gender incongruence of adolescence and adulthood is characterized by a marked and persistent incongruence between an individual's experienced gender and the assigned sex, as manifested by at least two of the following: 
1) a strong dislike or discomfort with the one’s primary or secondary sex characteristics (in adolescents, anticipated secondary sex characteristics) due to their incongruity with the experienced gender; 
2) a strong desire to be rid of some or all of one’s primary and/or secondary sex characteristics (in adolescents, anticipated 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. 
The individual experiences a strong desire to be treated (to live and be accepted) as a person of the experienced gender. 
The experienced gender incongruence must have been continuously present for at least several months. The diagnosis cannot be assigned prior the onset of puberty.  [There is a separate definition for gender incongruence in childhood.]
Gender variant behaviour and preferences alone are not a basis for assigning the diagnosis.
The definition tells us that you may think of the suffering that follows from gender incongruence as a "disease" that deserves medical treatment, but the gender identity of this patient would not be a disease, mental or otherwise.

This is also why the diagnosis is included under the top-category "Conditions related to sexual health", as gender incongruence – in a similar way as sexual dysfunctions, I suppose – stop you from having a satisfying sex life.

(To tell the truth, the relevant working group had a long discussion about where to put gender incongruence now that it was to be removed from the mental illness category, and "sexual health" was the choice that made most sense to them. I don't know...)

The ICD-11 gender incongruence diagnosis leaves room for a wide variety of identities and gender expressions, but the text is so dense and complicated that many readers will read it as another example of the gender binary. (Photo: Creatista)

The good side of gender incongruence

The gender incongruence diagnosis is made for transgender people who feel a strong dissonance between mind and body. They are the ones who are most likely to benefit from a treatment consisting of hormone replacement therapy and/or genital surgery.  Indeed, it seems to me that this is the main objective here: to ensure that this subcategory of transgender people does get the treatment they need.

The gender incongruence diagnosis will, if the political powers are willing, ensure that the relevant transgender persons get public support for their health care or reimbursements from their insurance companies.

Transgender people who are not alienated from their own bodies, and who primarily want to express their gender identity through behavior, clothes and other symbols, do not normally need medical treatment of this kind, and forcing them to have such surgery in order for them to be accepted as their experienced gender would be a crime.

The current trend in sane countries is to separate the legal aspect of gender identity from the medical treatment of gender incongruence. In my country, Norway, you yourself decide on your legal and public gender, without having to ask the medical gatekeepers for acceptance. Being transgender is not an illness, so there is no reason  to ask doctors to be  judges of your identity.

In this context the ICD-11 approach to gender variance makes sense.

The problems with gender incongruence

The main problem with the ICD-11 is this one: Since it only includes only one diagnosis that addresses possible effects of being transgender, other types of distress that follow from gender variance are not included.

Transgender people who are not troubled by their "primary or secondary sex characteristics" may still experience depression, alienation, obsessive-compulsive behavior, anxiety and insomnia – most often caused by harassment, violence and a general lack of social acceptance.

I guess some would argue that there are diagnoses for all of these challenges, and that the doctor may use them to treat this transgender person, thus ensuring that they get the necessary public support or insurance coverage.

This is true, but transgender people often need access to doctors and other medical personell who know something about gender variance, and who can look at these symptoms in a sex and gender context.

In many countries getting access to a publicly funded gender specialist or sexologist requires that the general practitioner give a diagnosis that is relevant for gender variance. If the only relevant diagnosis is gender incongruence, gender clinics may refuse patients who do not fit the ICD-11 definition.

In other words: The effectiveness and fairness of this new manual requires that the relevant doctors around the world are as open minded and liberal as the ones who wrote this part of the manual. The same applies to the policy makers who, in the coming years, are to adapt the ICD-11 manual nationally.

This progressive approach to sex and gender is not in any way given.  Even in Norway, a country which has one of the most liberal laws on gender identity in the world, the main clinic providing health services for transgender people is run by extremely conservative doctors, steeped in gender stereotypes, and allied with transgender separatists.

They have used the ICD-10 classification to keep those who do not live up to their narrow and binary definitions of gender out of the health system as a whole. There is no reason to believe that they will not try to do so under the ICD-11. (See my post What Transphobic Norwegian Doctors can Teach Us about the Diversity of Transgender People).

Medical personell steeped in the gender binary and the old model of sexually motivated "fetishists" vs. "real transsexuals" (who live up to the gender stereotypes as regards interests, abilities and sexual orientation) may try to use definition of gender incongruence to stop transgender people who struggle with other issues from getting the help they need.

It may also be used to keep out transgender people who are suffering from some kind gender incongruence, but who – because of social conditioning, personality or a different understanding of gender identity – do not fit the more narrow concepts of the traditionalist gatekeepers. There are those, for instance, who suffer severely from gender dysphoria, but who do not accept the "trapped in the wrong body" paradigm.

I am sure the transgender separatists will also see the potential in this part of the ICD-11. These days they argue that you have to suffer from gender dysphoria to call yourself transgender. I am sure they will soon start saying that you have to be gender incongruent instead.

Does the gender incongruence diagnosis reinforce the binary?

The current definition of gender incongruence does in some ways reflects the old way of thinking about transgender lives.

Dr. Charles Moser puts it this way:
Both the DSM-5 and the ICD-11 diagnostic criteria mostly ignore issues related to non-binary presentations of the gender dysphoria (e.g., those who identify as agender, both genders, a third gender).
The ICD-11 definition of gender incongruence has grown out of a model where someone assigned to one gender wants to live as the opposite, and where a transformation of the body is the solution.  However, it is also clear that the committee that has written this text, is aware of how limiting this view is.

A careful parsing of the text tells us that the definition is not limited to the traditional "classic transsexual", i.e. those who desire a complete body modification, including hormone replacement therapy and "bottom surgery".

Note that the diagnosis talks about "a strong dislike or discomfort with the one’s primary or secondary sex characteristics" and "a strong desire to be rid of some or all of one’s primary and/or secondary sex characteristics".

The "or" is important here, as it opens up for transgender people who could benefit from hormone treatment, hair removal and even facial surgery, but who do not feel the need for genital surgery. It also leaves room for transgender and non-binary people who would like to explore rooms outside the binary.

Note also that "a strong desire to have the primary and/or secondary sex characteristics of the experienced gender" is not a requirement for being diagnosed with gender incongruence.

"The opposite sex" is gone

Indeed, if you look at what the relevant committee members have written about this diagnosis in scientific papers it is clear that they have been aware of the problem:
The ICD‐11 abandons ICD‐10 terms such as “opposite sex” and “anatomic sex” in defining the condition, using more contemporary and less binary terms such as “experienced gender” and “assigned sex”. Unlike ICD‐10, the proposed ICD‐11 diagnostic guidelines do not implicitly presume that all individuals seek or desire full transition services to the “opposite” gender. 
The committee members also underline that a person may be diagnosed with gender incongruence even if they do not experience distress. This is important, because it opens the door to transgender clients who do wish to modify their bodies, but who do not feel that they suffer from gender dysphoria.
The proposed ICD‐11 diagnostic guidelines indicate that distress and dysfunction, although not necessary for a diagnosis of Gender incongruence, may occur in disapproving social environments and that individuals with gender incongruence are at increased risk for psychological distress, psychiatric symptoms, social isolation, school drop‐out, loss of employment, homelessness, disrupted interpersonal relationships, physical injuries, social rejection, stigmatization, victimization, and violence. At the same time, particularly in countries with progressive laws and policies, young transgender people living in supportive environments still seek health services, even in the absence of distress or impairment. The ICD‐11 approach provides for this.  
(Quotes from "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 considerations"
The devil is in the detail, and the ICD-11 text does not contain much in the way of context helping readers understand these nuances. Both medical experts and trans activists will have to be vigilant as doctors start using this manual around the world. A progressive and humane manual is of little use, if the doctors are so steeped in prejudices and traditionalist dogma that they are unable to understand what the text actually says.

But let me say this again: The new manual is a huge step forward as regards the treatment of transgender people in the health system. Being transgender does no longer mean that you are mentally ill. Stigmatizing and invalidating terms like "transvestic fetishism" and "autogynephilia" are not included. The Working Group on Sexual Disorders and Sexual Health has brought transgender health care into the 21st century, and for that they deserve much praise.

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  1. Jack you are very correct to point out here that we do need to separate the mental distress coming from societal prejudice from the discomfort of gender dysphoria which does seem to vary from person to person.
    There seem to be many people who are happy in their alternate forms of gender expression who would otherwise suffer no discomfort if they were not persecuted for their difference. This should be the next step in our quest to liberate people from rigid gender norms which encourage suppression of their natural tendencies.

    1. Does relieving people of gender norms require labels? If say a cis male wants to wear makeup than why doesn't he do just that? Does he feel less ashamed by claiming non-binary? Defying gender norms doesn't = transgender. It equals defying gender norms. Theirs is a social issue. There needs to be a marked difference in terminology.

  2. I agree. This is difficult, though. For each and every one of us it is hard to determine what part of our suffering is caused by social marginalization and what part is caused by a body/mind misalignment. I many cases both will be present.

  3. unfortunately this is true. Things are getting better though which is what counts...


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