First field trial supports removing transgender diagnosis from mental disorders chapter within WHO classification

New evidence suggests that it would be appropriate to remove the diagnosis of transgender from its current classification as a mental disorder, according to a study conducted in Mexico City. The study is the first field trial to evaluate a proposed change to the place of the diagnosis within the WHO International Classification of Diseases (ICD).

The research, published in The Lancet Psychiatry journal today and led by the National Institute of Psychiatry Ramón de le Fuente Muñiz, involved interviewing 250 and found that distress and dysfunction were more strongly predicted by experiences of social rejection and violence than by gender incongruence itself. The study is the first of several field trials and is currently being replicated in Brazil, France, India, Lebanon and South Africa.

"Stigma associated with both mental disorder and transgender identity has contributed to the precarious legal status, and barriers to appropriate care among transgender people," says senior author Professor Geoffrey Reed, National Autonomous University of Mexico. "The definition of transgender identity as a mental disorder has been misused to justify denial of health care and contributed to the perception that transgender people must be treated by psychiatric specialists, creating barriers to . The definition has even been misused by some governments to deny self-determination and decision-making authority to transgender people in matters ranging from changing legal documents to child custody and reproduction."

"Our findings support the idea that distress and dysfunction may be the result of stigmatization and maltreatment, rather than integral aspects of transgender identity," says lead investigator Dr Rebeca Robles, Mexican National Institute of Psychiatry. "The next step is to confirm this in further studies in different countries, ahead of the approval of the WHO revision to International Classification of Diseases in 2018."

Transgender identity is currently classified as a mental disorder in both of the world's main diagnostic manuals, the WHO's ICD-10 and the American Psychiatric Association's DSM-5. A major component of the definition of mental disorders is that they are associated with distress and impairment in functioning. The classification of transgender identity as a mental disorder is increasingly controversial and a WHO Working Group has recommended that transgender identity should no longer be classified as a in ICD-11, but should instead come under a new chapter on conditions related to sexual health.

The study is the first field trial to evaluate the applicability of the proposed re-classification. It was conducted in collaboration with the Condesa Specialized Clinic, the only publicly funded specialized clinic providing transgender health care services in Mexico City. Researchers interviewed 250 transgender people aged 18-65 who were receiving health care services at the Condesa Clinic. Most participants were transgender women, assigned male sex at birth (199 participants, 80%).

Participants reported first becoming aware of their transgender identity during childhood or adolescence (ages 2-17) (table 1). During the study, they completed a detailed interview about their experience of gender incongruence in adolescence (e.g, discomfort with secondary sex characteristics, changes performed to be more similar to the desired gender, and asking to be referred to as the desired gender), and recalled related experiences of psychological distress, functional impairment, social rejection and violence.

Most participants experienced psychological distress related to gender incongruence during their adolescence (208, 83%), with depressive symptoms being the most common. Family, social, or work or academic dysfunction during adolescence related to their gender identity was reported by nearly all participants (226, 90%).

More than three-quarters of participants (191, 76%) reported experiencing social rejection related to gender incongruence, most commonly by family members, followed by schoolmates/co-workers and friends. A majority of participants (157, 63%) had been a victim of violence related to their gender identity (table 3) - in nearly half of these cases, violence was perpetrated by a family member. Psychological and physical violence were the most commonly reported, and some experienced sexual violence.

The researchers then used statistical models to examine whether distress was related to gender incongruence per se or if it was related to experiences of social rejection and violence. They found that none of the gender incongruence variables predicted psychological distress or dysfunction, except in one case where asking to be referred to as the desired gender predicted school/work dysfunction. On the other hand, social rejection and violence were strong predictors of distress and all types of dysfunction (table 4).

Although the study includes a relatively large sample of transgender people, the authors warn of some important limitations. For example, the study was a volunteer sample, so was not representative of the population and participants' experiences were based on their recollection of events, which can be subject to bias. However, the authors note that a similar study would be difficult to conduct prospectively as this would involve children.

"Rates of experiences related to social rejection and violence were extremely high in this study, and the frequency with which this occurred within participants own families is particularly disturbing. Unfortunately, the level of maltreatment experienced in this sample is consistent with other studies from around the world. This study highlights the need for policies and programs to reduce stigmatization and victimization of this population. The removal of transgender diagnoses from the classification of mental disorders can be a useful part of those efforts," says Dr Robles.

Writing in a linked Comment, Dr Griet De Cuypere, University Hospital, Ghent, Belgium and Dr Sam Winter, Curtin University, Perth, WA, Australia, say: "A prominent UN advocate has put it this way: 'Transphobia is a health issue'. This study prompts primary caregivers and psychiatrists to be aware of a 'slope leading from stigma to sickness' for transgender individuals, and to contribute to their mental health by a gender-affirmative approach." They also note that although the study provides evidence to support moving health-related categories related to transgender identity out of the classification of mental disorders in ICD-11, it does not address where in ICD would be the most appropriate place for the diagnosis, which should be a topic for future research.

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More information: Rebeca Robles et al, Removing transgender identity from the classification of mental disorders: a Mexican field study for ICD-11, The Lancet Psychiatry(2016). DOI: 10.1016/S2215-0366(16)30165-1
Provided by Lancet
Citation: First field trial supports removing transgender diagnosis from mental disorders chapter within WHO classification (2016, July 27) retrieved 15 September 2019 from
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Jul 27, 2016
I agree completely. When I started my transition back n 1984, the required psychological evaluations were my first exposure to psychologists, and it seemed silly at 30 and having known most of my life I wanted a sex change. I continued on in therapy though, even after surgery in 1986, because my life was then so stressed out that I needed support. It was always a matter of the outside's world reaction to me - mostly at the "street level" at that time- I didn't feel threatened by the power structure then- that drove me into anger and depression and panic attack. The Jerry Springer Show had a lot of negative impact on the perception of transgender people- probably more than most people realize without "being there". The latest round of public attack is depressing and disappointing and certainly no grounds for better mental health, as our critics hope to drive up suicide rates for further verbal ammunition to use against us.

Jul 27, 2016
How unfortunate, yet unsurprising, that psychology/psychiatry organizations in the United States are shifting their diagnostic analyses and parameters to match more closely the desires of the afflicted and the programmes of the "politically correct". Given the bureaucratic nature of organizations like the WHO, not to mention their dependence on countries like the United States to maintain a level of perceived legitimacy, their charge to follow suit is, similarly, of no particular newsworthiness.

Regardless of whether those afflicted with "gender dysphoria" (or whatever appellation is most favoured this week) feel the assessment of their dysfunction is "stigmatizing" or negatively affects them under the laws of any given country, the fact is their problem is not the scientific or social norm. Dismissing that fact by virtue of organizational proclamation only further diminishes the public perception of the field, not their perception of the disease.

Jul 27, 2016
And so some people- many hundreds of thousands of people, and for over SIX DECADES now- are doing something that makes them happy and feel more at ease with their own lives- but that YOU - and suddenly now an angry social media mob of mostly "States Rights" smaller Confederate governments- DON'T LIKE

But how then does that make us transgender people intrinsically mentally ill? Because you suddenly now say so? Because your political stance- after having to concede finally simple legal union rights to gay couples, and becoming mentally ill RABID yourselves, says so?

We are NOT mentally ill by default, simply because we follow our inner selves. And how then does this "diminish the public perception of the field" ? Because a bunch of lay people with no firsthand knowledge of Gender Dysphoria but only a mob-like internet ARGUMENT behind them says it's so? Poppycock!

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