June 19, 2018

The WHO ICD-11 health manual removes transvestic fetishism. Being trans is no longer a mental illness.

Yesterday the World Health Organization released the new version of its International Classification of Diseases, the ICD-11. The new edition brings some very good news to transgender people.
Being transgender is no longer considered a mental illness by the international medical community (Photo: Wavebreakmedia)
"Transvestic fetishism" is no longer included

First of all, the diagnoses of "transvestic fetishism" and "dual-role transvestism" are no longer included.

Several countries, including the Nordic ones, have already removed the transvestic fetishims of the list of "paraphilias" from their national versions of the ICD-10 , arguing that crossdressing is just an unharmful expression of gender variance, and that including it in the manual causes needless stigmatization and suffering.

According to the WHO crossdressing and crossdreaming are no longer considered  mental illnesses.

Being transsexual is no longer a mental illness

Furthermore, being transsexual (in the sense of suffering from a mismatch between your biological sex and/or expected gender role and your experienced identity) is no longer classified as a mental illness, either.

This reflects a new view of gender identity. Members of the relevant working group put it this way back in 2012: 
The ICD-11 Working Group on the Classification of Sexual Disorders and Sexual Health believes it is now appropriate to abandon a psychopathological model of transgender people based on 1940s conceptualizations of sexual deviance and to move towards a model that is (1) more reflective of current scientific evidence and best practices; (2) more responsive to the needs, experience, and human rights of this vulnerable population; and (3) more supportive of the provision of accessible and high-quality healthcare services.
The ICD-11 now uses the term gender incongruence to describe this kind of mismatch and has included it under the headline of "Conditions related to sexual health".

The new definition is:
"Gender incongruence is characterized by a marked and persistent incongruence between an individual’s experienced gender and the assigned sex. Gender variant behaviour and preferences alone are not a basis for assigning the diagnoses in this group."
The manual does not go into the causes of gender incongruence. The personal experience is what counts.

As far as I see it, excluding gender variant behavior and preferences as a sufficient basis for a gender incongruence diagnosis makes sense. The transgender spectrum is broad, and not all suffer from the kind of gender mismatch that causes the suffering of gender dysphoria (to use the DSM-5 term). Transgender people who are able to express and experience gender variance without transitioning need not be included in a health manual like this one.

The paraphilia exclusion

There is a cause for some concern, however, as the the gender incongruence entry contains an "exclusion" referring to Paraphilic disorders (6D30-6D3Z). Transvestic fetishism has been removed, and unlike in  the DSM-5, the American psychiatric manual, "autogynephilia" is not listed. But there is still a category called "paraphilias" (meaning "sexual perversions").

It is not easy to understand what an "exclusion"  in ICD-11 terminology is. The manual explains that "Exclusion terms help users eliminate entities that should be assigned to a different ICD category because of differences in meaning or terminology," which is – to me at least – a pretty meaningless definition. Does it refers to differences in meaning or to completely different diagnoses, conditions or causes?

In any case, I suspect transphobic doctors and activists may try to use this "exclusion" to label transgender people who experience erotic crossdreaming as "paraphiliacs", arguing that these are completely different and unrelated conditions.

We know better. Erotic crossdreaming fantasies are very often an expression of an underlying gender dysphoria or gender incongurence. The DSM-5 was very much aware of the problem and included a paragraph under gender dysphopria that explicitly said that crossdreaming could be an expression of gender dysphoria: 
"In many cases of late-onset gender dysphoria in gynephilic natal males, transvestic behavior with sexual excitement is a precursor."
The WHO teams have not included a similar explanation in the ICD-11. That being said, the manual does in no way say that crossdreaming or erotic crossdressing invalidates a transgender identity. As noted, the definition of gender incongruence simply says that someone who experience a marked and persistent incongruence between experienced gender and assigned sex should be included.

Moreover, the definition of paraphilia is pretty restrictive, arguing that such arousal is to be accompanied by fantasies or behaviors where the person is forcing someone to have sex with them or where the fantasies causes them distress.

It is the distress part that may be used to invalidate transgender identities. Some gender dysphoric transgender persons feel distress from having  cross-gender erotic fantasies, even if such fantasies are simply an expression if their dysphoria. So the diabolically inclined might argue that crossdreamers who feel distress from their crossdreaming are "paraphiliacs" and not transsexual.

I find no support from such an interpretation. If  distress is caused by fear of rejection only, it is not to be classified as a paraphilia, the manual says. And it is exactly the fear of invalidation and marginalization that causes such distress among transgender people.

This is the  definition of paraphilia:
Paraphilic disorders are characterized by persistent and intense patterns of atypical sexual arousal, manifested by sexual thoughts, fantasies, urges, or behaviours, the focus of which involves others whose age or status renders them unwilling or unable to consent and on which the person has acted or by which he or she is markedly distressed. Paraphilic disorders may include arousal patterns involving solitary behaviours or consenting individuals only when these are associated with marked distress that is not simply a result of rejection or feared rejection of the arousal pattern by others or with significant risk of injury or death.
In other words: The paraphilia exclusion under the gender incongruence diagnosis cannot be used to exclude  transgender and non-binary people who experience  erotic  cross-gender fantasies before transitioning.

Gender stereotypes still matter

The gender incongruence of childhood diagnosis is problematic, but for other reasons:
Gender incongruence of childhood is characterized by a marked incongruence between an individual’s experienced/expressed gender and the assigned sex in pre-pubertal children. It includes a strong desire to be a different gender than the assigned sex; a strong dislike on the child’s part of his or her sexual anatomy or anticipated secondary sex characteristics and/or a strong desire for the primary and/or anticipated secondary sex characteristics that match the experienced gender; and make-believe or fantasy play, toys, games, or activities and playmates that are typical of the experienced gender rather than the assigned sex. The incongruence must have persisted for about 2 years. Gender variant behaviour and preferences alone are not a basis for assigning the diagnosis.
The definition does, as the one for adults, distinguish between gender variant behavior and a clear transgender identity, which is fine with me. Much of the current attacks on transgender kids are based on misleading statistics that conflates gender variant behavior in general with a clear transgender identity, and this definition will make sure that researchers and doctors do not make that mistake in the future.

The problem lies in the idea that transsexual kids (i.e. kids who identify with "the opposite gender" relative to the assigned one) have to play with toys or playmates that are typical of the experienced gender.

If we accept the idea of "gender variant behavior" among non-transgender kids, we also have to accept it among transgender children. I know of  feminine transgender men, as well as male to female tomboys.

Moreover, given the kind of social and cultural repression most transgender kids experience, a seeming lack of interest in gender typical toys may simply be caused by fear of rejection.

To conclude

Trans-exclusionary "radical feminists" and right-wing religious fanatics will no longer be able to refer to science or the medical profession to invalidate transgender people as mentally ill perverts. If they try, do refer to the new edition of the WHO ICD-manual.

Dr Lale Say, Coordinator, Adolescents and at-Risk Populations Team at the World Health Organization discusses changes in the classification of gender incongruence (transgender) in the new ICD-11. 

 See also:
The DSM-5 and ICD-11 on Transgender, Gender Dysphoria and Transsexualism
"Transvestism" is on its way out of the WHO health manual, but its makers leave a loophole for further invalidation of transgender people
What the DSM-5 says about terms like transgender, transsexual and gender dysphoria
Kelley Winters: GID Reform in the DSM-5 and ICD-11: a Status Update
WHO Removes Transgender Classification From List of Mental Disorders (Transgender Universe)


  1. A truely great change and a blow to all those who would try and use science and medicine as a weapon against transgender people!

  2. time to break out the champagne...

  3. My Name is SilenceJune 19, 2018 at 10:45 PM

    Ohhh, "exclusion." If it's anything like ICD-9 and 10's exclusions, it means paraphilia will be listed right next to gender incongruence in one of the lists used to code. For example, you look up depression (F32-). Bipolar disorder is an exclusion. So, if the patient's current "problem"/diagnosis of depression is because of bipolar disorder, you do not use that depression code. It directs you to a different code (F31-).

    So. The exclusion DOES mean that they're separate. But, if you go and try to code for gender incongruence, oops, are you sure you didn't mean paraphilia? IDK. Again, good they're separate now - a bit disappointing that they're still linked like this.

  4. @My Name is Silence. Thank you for clarifying this. I am worried about this too, even if they have clearly – although a bit clumsily – tried to address this in the definition of "paraphilia".

  5. Such an informative article. My understanding of gender incongruity is growing with rapidly. This has enabled me to reflect on my lifend and experience. As a child is was ridiculed for and seriously discouraged from wanting to play with "girls toys" and things like paying attention to babies. "Do you want people to think of you as a sissy?" was a question that stung me. I have strived to be recognised as a man and have been very successful in this. Everyone is have opened up to is shocked that I am transgender. Reading this has given me comfort, greater confidence and faith in me. Thank you.


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