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.

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.

"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:

What happens to crossdressing and crossdreaming in the ICD-11 manual?

As noted in my previous post, the recent edition of the Amercian psychiatric manual, the DSM-5, has gone a long way towards depathologizing some transgender conditions. Gender dysphoria, for instance, is no longer considered a mental illness.

Peggy Cohen-Kettenis

Note that DSM subworking-group members Peggy T. Cohen-Kettenis and Jack Drescher are also members of the World Health Organization’s Working Group on the Classification of Sexual Disorders and Sexual Health.

This group will address sex and gender diagnoses in WHO's forthcoming revisions of the International Classification of Diseases (ICD-11).  That manual is expected to be published in 2017. The WHO most often follow up changes made in the DSM.

The current manual has two different sections on crossdressing,  one clearly referring to what I call crossdreaming, and one referring to the mythical mirage of the asexual crossdresser. It is all pretty bizarre, if you ask me. (More about this here!)

Some countries have already made changes to the current ICD-10 edition, removing the sections on "transvestism".

In a recent paper the ICD-11 Working Group on the Classification of Sexual Disorders and Sexual Health, states that it "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."

Before the a preliminary WPATH consensus meeting the working group had proposed the term "transsexualism" to "gender incongruence", moving gender incongruence out of the chapter on mental and behavioral disorders, and deleting the categories "dual role transvestism" and "fetishistic transvestism".

In other words: Not only is the ICD-11 process moving in the same positive direction as the DSM; it is taking this process further, suggesting that one removes crossdressing and crossdreaming altogether.

If the ICD-11 takes crossdressing and crossdreaming out of its manual, it will be very hard for the Americans to keep the "transvestic disorder" in the  DSM.

Campaign against pathologization of transgender in medical manuals

The Coordination Team of STP 2012, the International Stop Trans Pathologization Campaign, has published a document called  “Reflections on the ICD Revision Process from a Depathologization and Human Rights Perspective”.

The document includes a good discussion on the way the American manual for mental diseases (DSM-5) and the UN/WHO International Classification of Diseases (ICD) cover transgender issues.

The team argues that both the gender identity disorders and the transvestic fetishism categories ought to be removed from the manuals.

The group is also initiating an International Day of Action for Trans Depathologization, which  will take place on Saturday, October 20th, 2012.

Gender and sexuality diversity is not a disease!

Imagine there was no social stigma attached to crossdreaming, crossdressing or being transgender.

Imagine you were allowed to talk about it without risking your job, you family and your circle of friends.

Imagine you could find friends with the same interest as yourself, not only online, but in the physical world. Imagine you could find a lover who, based on is or her own life experience, gets who you are.

As long as conditions like these are considered paraphilias and mental illnesses, that is going to be hard. As long as the medical authorities, the priesthood of the Church of Science, label you as a pervert, there will always be doubts.

For the gay movement, the removal of homosexuality from medical manuals in the 1970s was an important step towards social acceptance.

I am perfectly aware of the homophobia found in parts of the Western world (cp. the American Tea Party movement), but the fact that a majority of Amercians now support gay marriage tells me that the decisive battle has been won. It is clear to most sensible persons that the psychological suffering of gays and lesbians are not caused by their homosexuality, but by the way the surrounding society has treated them.

While I have -- partly for personal reasons -- focused on the gender dysphoria of crossdreaming and crossdressing, others have focused on the fact that such interests may just as well be harmless expressions of the diversity of natural sexuality.

Take away the stigma and "paraphiliacs", and crossdressers and crossdreamers are no more likely to be maladjusted, unhappy or mentally ill than other people. If society could accept, and maybe even embrace this diversity, there would be no mental illness of this sort.

In Europe these insights have led to the establishment of an alliance between homosexuals, BDSM enthusiasts and crossdressers aiming at the removal of "fetishes" from the WHO manual.

Among the leaders we find Svein Skeid, the leader of Revise F65, who has been working with gay and BDSM human rights for 30 years.  Another influential activist is  Odd Reiersøl, a well known psychologist in my country, from the University of Oslo and the Solverv Psychotherapy Institute. 

I must admit I cringe a little at their use of the word "fetish". I am still not convinced that the term may be salvaged from the stigmatizing use of the medical community. The term is also  often used to belittle those that suffer from a clear sex identity misalignment, and it is -- in may opinion -- hard to categorize non-crossdressing crossdreamers as fetishists. 

Still, their main message makes perfect sense to me:

"The fetish/BDSM group is an equal contributor to the society and scores on the level with most people on psychosocial features and democratic values such as self control, empathy, responsibility, love, equality, and non-discrimination. Because the ICD fetish and SM diagnoses are superfluous, outdated, non scientific and stigmatizing to the fetish/BDSM minority, these diagnoses have been removed in nearly all of the Nordic countries. The diagnoses are so seldom in use, that neither care, statistics, nor research are affected by their abolition."

Revise F65 has now presented a report to the Word Health Organisation where they explain why the diagnoses as mental illnesses have to go.

What is the difference between fetishistic and non-fetishistic crossdressing? (The ICD and beyond)

The WHO medical manual says that only crossdreaming crossdressers can become trans women, not the ones that do not get aroused by the idea of being a woman. How did sexual arousal become such a sin?

I have spent some time looking at the American DSM manual here at Crossdreamers. The American psychiatric manual say a lot about how some psychiatrist try to draw the line between different types of cross-gender identification.

There is another manual that is just as interesting, namely the WHO ICD  manual  (International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Version for 2007)

Under "Mental and behavioural disorders" there is a category called "Disorders of adult personality and behaviour", where you will find both transsexualism and crossdressing/crossdreaming categorized as mental illnesses. 

On the difference between transsexuals, crossdreaming crossdressers and non-crossdreaming crossdressers

I am not going to repeat my objection to transsexuals and crossdreamers being classified as ill here. Instead I am going to draw your attention to the fact that this manual classifies crossdreamers (people who get aroused by the idea of being the other sex) as completely separate from other crossdressers. In this manual the crossdreamers are actually overlapping with the transsexuals!

There are three categories of interest to my readers:

• F64.0 Transsexualism
• F64.1 Dual-role transvestism
• F65.1 Fetishistic transvestism

What I find so utterly bizarre is the fact that "fetishistic transvestism", which includes -- I surmise -- crossdressing crossdreamers, is categorized as "a fetish", while the other crossdressers are given "a gender identity disorder". 

The Finns remove crossdressing from their medical manual

As my regular readers will have noted, I have been seriously annoyed by the inclusion of crossdressing and crossdreaming in the American Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

As far as I can see, crossdressing and crossdreaming are not mental disorders per se, but the psyche's way of coping with some kind of gender misalignment. In other words: transgender conditions like these are expressions of natural diversity, not perversions or "paraphilias".

I am afraid the American psychiatrists will probably hold on to their "transvestic disorder".  Here in Scandinavia, however, the trend goes in the opposite direction.

The Finns no longer consider crossdressing a disease

The Finish newspaper Helsingin Sanomat recently reported  that crossdressing (transvestism) is no longer considered a disease in Finland:

"Certain diagnoses relating to sexual behaviour will be removed from the Finnish version of the International Statistical Classification of Diseases and Related Health Problems (ICD) next year. The number of categories to be removed from the ICD is five, including transvestism, sexual fetishism, sadomasochism, and diverse sexual target disorders."

The newspaper notes that  harm has been inflicted on people who have felt that they have been labelled by such diagnoses.

"The major problem is that when examining himself or herself, a transvestite may have noticed that he or she has a mental disorder, thereafter starting to regard himself or herself ill", Minna-Maaria Lax, the chair of a Finnish crossdresser association says.

The paper points out that in conflict situations, for example during a divorce, the classification may have given a weapon to the other party.

The Swedes changed the manual in 2009

The ICD codes F64.1 (Dual-role transvestism), F64.2 (Gender identity disorder of childhood), F65.0 (Fetishism), F65.1 (Fetishistic transvestism), F65.5 (Sadomasochism), F65.6 (Multiple disorders of sexual preference) have not been used in Sweden since January 1 2009.