Is the ICD-11 (International Classification of Diseases) redefinition of “Gender incongruence” a progressive change to the medical treatment of trans people? Almost too progressive. Trans people are accustomed to seeing psychiatrists. What will we do when we can’t?
Gender incongruence, in the proposed new ICD, to be considered in May 2019, is not a mental illness. Desire for physical alteration is the diagnostic criterion. To be diagnosed with gender incongruence, you need to want rid of your primary and secondary sexual characteristics, or to want those of the opposite sex to your birth gender.
This is the definition: 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. 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. Gender variant behaviour and preferences alone are not a basis for assigning the diagnosis.
So thinking you are a woman, though you have a penis, would not fit this definition. The desire to be accepted socially as a woman is not enough, even though most people only show off their genitals to sex partners. There is a separate diagnosis for childhood, but it too requires dislike of ones own sex characteristics and desire for the target gender’s. We will have to just accept ourselves, without long agonising sessions with counsellors and psychiatrists!
Gender Incongruence comes under ICD-11 17, conditions related to sexual health, which includes physical illnesses but also paraphilic disorders. It uses “desire” as a diagnostic criterion. That desire will be assessed by a psychiatrist. Might there be a similar desire which was a mental illness, such as a psychotic delusion? I can’t find the appropriate treatment in ICD 11: it does not exclude an attempt to reconcile the person to their physical characteristics.
For me, the role, expressing myself as a woman, was more important than the physical changes. It liberated me to be myself. I now believe my passionate desire for the physical changes came from social pressure, the idea that the “true transsexual” wanted these changes, and only “true transsexuals” should transition. I regret my physical alterations, probably in part because the operation was not as successful as it was in others I have talked to. I have had a significant loss of sensitivity.
The Guardian correctly reported that GI no longer comes under “mental, behavioural and neurodevelopmental disorders”, and quoted Lale Say, co-ordinator of the WHO department of reproductive health and research, who said, “We think it will reduce stigma so it may help better social acceptance for these individuals”. I am glad not to be called mentally ill. That is a relief. I am concerned that there might be greater pressure to have surgery and hormones. I am not convinced they are necessary, or that they would improve our happiness if we were not told they were necessary.
There should be two rigorously separated approaches to gender incongruence. One is the medical approach: really, those of us who want to present in the other sex without surgery or hormones should not need to see a doctor, so that reasonably concerns itself with medical treatment, but some might like reassurance from a psychiatrist without any assumption that they will have hormones. The other is the legal/social approach: those of us who transition, intending to live life long in the acquired gender, should be treated like others of that gender. Those who intend to transition or manifest as non-binary should not suffer discrimination because of it. As long as the legal definition does not require medical diagnosis, people may not be pressured into unnecessary medical treatment. We might benefit from support, even though we are not ill: transition is difficult. Hair removal and voice training might be available.
It is necessary to define a medical condition to say what a health service or health insurance should pay for, and what doctors should do. The desire to alter your body in this way is not a mental illness. The health problem, for those who desire the changes, is that the changes are necessary.
The desire to transition may involve mental distress- can I manage it? How will work, family, community react? Am I deluded in wanting this? Psychotherapists could be part of helping a trans person resolve these issues. Gender dysphoria- that distress- exists and is mentally debilitating. Mental health services have a role in helping with it. The mental illness is not a deluded belief that you are part of the true gender. The mental illness is the difficulty you feel realising that, given the social pressure you suffer to conform to the assigned gender. Gender dysphoria, discomfort with gender role, exists and is debilitating, and one cure is transition. Internalised transphobia could be a medical condition.
The document will be sent to WHO member states, and will take effect from 1 January 2022 if adopted.