The Proposed ICD-11 Gender Incongruence of Childhood Diagnosis: A World Professional Association for Transgender Health Membership Survey

Abstract

ICD-11 (the eleventh edition of the World Health Organization International Statistical Classification of Diseases and Related Health Problems) is due for approval in 2018. For transgender health care, the most important proposals for ICD-11 are as follows: (1) the five ICD-10 diagnoses (most notably Transsexualism and Gender Identity Disorder of Childhood) currently in Chapter 5 (Mental and Behavioural Disorders) will be replaced by two Gender Incongruence diagnoses, one of Adolescence and Adulthood and the other of Childhood (GIC), and (2) these two diagnoses will be located in a new chapter provisionally named Conditions Related to Sexual Health. Debate on the GIC proposal has focused on whether there should be a diagnosis for young children exploring their identity and has drawn on a number of arguments for and against the proposal. The World Professional Association for Transgender Health conducted a survey to examine members’ views concerning the GIC proposal, as well as an alternative framework employing non-pathologizing Z Codes. The survey was completed by 241 (32.6 %) out of 740 members. Findings indicated an even split among members regarding the GIC proposal (51.0 % [n = 123] opposing and 47.7 % [n = 115] supporting the proposal). However, non-US members were overall opposed to the proposal (63.9 % [n = 46] opposing, 36.1 % [n = 26] supporting). Across the sample as a whole, and among those expressing a view about Z Codes, there was substantial support for their use in healthcare provision for children with gender issues (35.7 % [n = 86] of the sample supporting vs. 8.3 % [n = 20] rejecting).

Full text

INVITED PAPER
The Proposed ICD-11 Gender Incongruence of Childhood
Diagnosis: A World Professional Association for Transgender
Health Membership Survey
Sam Winter
1
•Griet De Cuypere
2
•Jamison Green
3
•Robert Kane
4
•
Gail Knudson
5
Received: 6 August 2015 / Revised: 25 April 2016 / Accepted: 8 July 2016
Springer Science+Business Media New York 2016
Abstract ICD-11 (the eleventh edition of the World Health
Organization International Statistical Classification of Diseases
and Related Health Problems) is due for approval in 2018. For
transgender health care, the most important proposals for ICD-
11 are as follows: (1) the five ICD-10 diagnoses (most notably
Transsexualism and Gender Identity Disorder of Childhood)
currentlyin Chapter 5 (Mentaland BehaviouralDisorders) will
be replaced by two Gender Incongruence diagnoses, one of
Adolescence and Adulthood and the other of Childhood (GIC),
and (2) these two diagnoses will be located in a new chapter
provisionally named Conditions Related to Sexual Health. Debate
on the GIC proposal has focused on whether there should be a diag-
nosis for young children exploring their identity and has drawn on a
number of arguments for and against the proposal. The World
Professional Association for Transgender Health conducted a sur-
vey to examine members’ views concerning the GIC proposal, as
well as an alternative framework employing non-pathologizing Z
Codes. The survey was completed by 241 (32.6 %) out of 740
members. Findings indicated an even split among members regard-
ing the GIC proposal (51.0 % [n=123] opposing and 47.7 %
[n=115] supporting the proposal). However, non-US members
were overall opposed to the proposal (63.9 % [n=46] opposing,
36.1 % [n=26] supporting). Across the sample as a whole, and
among those expressing a view about Z Codes, there was sub-
stantial support for their use in healthcare provision for children
with gender issues (35.7 % [n=86] of the sample supporting vs.
8.3 % [n=20] rejecting).
Keywords ICD-11 Gender Incongruence of Childhood 
Gender dysphoria World Professional Association for
Transgender Health WHO
Introduction
The World Health Organization (WHO) is responsible for devel-
oping and disseminating the International Statistical Classifi-
cation of Diseases and Related Health Problems (ICD) (World
HealthOrganization, 1990).In the areaof mental health,ICD is
the most widely used diagnostic manual, with a recent study
across 44 countries reporting that 70% of psychiatrists seeing
patients useit more commonlythan any otherclassification sys-
tem in their day-to-day clinical work (64% when weighted by
country) (Reed, Mendonc¸a Correia, Esparza, Saxena, & Maj,
2011). Worldwide, there is a variation. For example, the figure is
80 % across Europe (weighted 81 %), with some countries yield-
ing particularly high figures (UK, 86 %; Germany, 96%). By
contrast, the corresponding figure in the USA (home o f DSM-5)
is 1 %, a figure matched nowhere else in the study (and surpassing
only Kenya).
ICD (currently in version 10) contains a number of diag-
noses related to transsexual, transgender, and gender-variant
&Griet De Cuypere
decuypere.griet@telenet.be
1
Faculty of Health Science, School of Public Health, Curtin
University, Bentley, Perth, WA 6102, Australia
2
Center of Sexology and Gender, University Hospital, De
Pintelaan 185, 9000 Ghent, Belgium
3
Human Sexuality PhD Program, California Institute of Integral
Studies, 1453 Mission Street, San Francisco, CA 94103, USA
4
Faculty of Health Science, School of Psychology and Speech
Pathology, Curtin University, Bentley, Perth, WA 6102,
Australia
5
Faculty of Medicine, University of British Columbia,
#201 – 1770 Fort Street, Victoria, BC V8R 1J5, Canada
123
Arch Sex Behav
DOI 10.1007/s10508-016-0811-6

people. They appear in the Mental and Behavioural Disorders
chapter, in a section called Disorders of Adult Personality and
Behaviour, and in a subsection called Gender Identity Disor-
ders. There are a number of disease diagnostic codes in this
section. The main ones are Transsexualism (used with adoles-
cents and adults) and Gender Identity Disorder of Childhood
(used with children below the age of puberty). Others are
Dual-role Transvestism, Other Gender Identity Disorders,
and Gender Identity Disorders, Unspecified (World Health
Organization, 1990).
WHO is reviewing the current edition. It is expected that
ICD-11 will be approved by the World Health Assembly in
2018. Because of ICD’s influence on global health policy and
the structure and functioning of healthcare systems through-
out the world, it is important to ensure that the categories and
descriptions of conditions in the new edition are as fit for use
as possible. Clinical utility and access to care are important
issues, in the area of mental health as elsewhere (Reed, 2010).
With this in mind, WHO has researched the views of psychi-
atrists worldwide on diagnostic issues (Reed et al., 2011).
However, WHO has also needed to bear in mind the other uses
to which ICD is put, beyond clinical practice, including research,
teaching and training, health statistics, and decisions on public
health (International Advisory Group for the Revision of ICD-
10 Mental and Behavioural Disorders, 2011). WHO has also
borne in mind human rights considerations (Kismo
¨di, 2015). As
part of therevision process,WHO convened in2012 a Working
Group on Sexual Disorders and Sexual Health (WGSDSH),
which the following year made recommendations for diagnos-
tic reform in a number of areas in sexuality and gender currently
covered by ICD-10 (including in areas relevant to trans people
and their healthcare providers).
The two most important WGSDSH proposals relevant to
trans health care are as follows. Firstly, it is proposed that the
current ICD-10 diagnoses will be replaced by two others, named
Gender Incongruence of Adolescence and Adulthood (GIAA)
and, for children below the age of puberty, Gender Incongruence
of Childhood (GIC). For the clinical description of the proposed
GIC diagnosis at time of writing, see‘‘Appendix’’. S e c o n d l y , i t i s
proposed that these two diagnoses will be removed from Chap-
ter 5 (the Mental and Behavioural Disorders chapter) and placed
elsewhere (Drescher, Cohen-Kettenis, & Winter, 2012). The
WGSDSH preference was for a separate chapter focused entirely
on gender incongruence. A second preference (less ideal but still
avoiding the double stigma that arises out of a mental disorder
classification) was for placement in a new chapter focused on
conditions related to sexual and gender health. Current WHO
thinking, evident on the Web-based ICD-11 beta draft, is that
these diagnoses should be located in a new chapter entitled
Conditions Related to Sexual Health (World Health Organi-
zation, under continuing revision). We note that, while place-
ment in this chapter is preferable to placement in the chap-
ter on mental disorders, the title of this proposed chapter runs
the risk of encouraging perceptions among healthcare pro-
viders that gender incongruence is about sex and not gender.
As indicated earlier, the WGSDSH has made a number of
other proposals related to sexuality and gender. For example,
there is currently a section in ICD-10’s Chapter 5 headed Psy-
chological and Behavioural Disorders Associated with Sex-
ual Development and Orientation (Code F66). This section
currentlycontains a number ofdiagnoses that may be usedwith
people facing challenges related to their sexual orientation or
gender identity. These diagnoses include Ego-dystonic Sexual
Orientation (for those who are distressed by an awareness of
their sexual orientation or gender identity) and Sexual Matura-
tion Disorder (for those whose distressarises out of uncertainty
about their sexual orientation or gender identity). WHO is propos-
ing to remove this block entirely. A key argument is that these are
residual diagnoses for homosexuality (Cochran et al., 2014). The
WGSDSH has also proposed that a range of solitary or con-
sensual sexual patterns in ICD-10 (e.g., Fetishistic Transvestism
[F65.1]) should be removed (World Health Organization, under
continuing revision).
The World Professional Association for Transgender Health
(WPATH) is a nonprofit, multi-disciplinary organization work-
ing for transgender health worldwide. It publishes the influential
Standards of Care, currently version 7, providing guidelines for
the provision of health care for transsexual, transgender, and
gender nonconforming people (WPATH, 2011). In February
2013, WPATH, in response to a request from the WHO for its
views on the ICD proposals, convened a consensus meeting in
San Francisco at which invited clinicians and others (including
WHO staff and trans community members) were able to discuss
the proposals (which at that time had not yet been made fully
public). While there was broad consensus agreement with the
bulk of the WHOproposals related totrans health, there wasno
consensusin regard to the GIC proposal.A final voteby private
ballot on whether there should be a GIC diagnosis was tied, with
14 for and 14 against (De Cuypere, Knudson, & Green, 2013).
Arguments for a GIC diagnosis included that it facilitated
access to care, to reimbursement, and to professional training
and that it made possible a‘‘protected status’’(de Vries, 2014;
Menvielle& de Vries, 2013). Other arguments made reference
to the syndromic nature of gender incongruence and noted the
evidence indicating the discriminant and predictive validity of
diagnoses in the area of childhood gender incongruence. It is
also arguedthat a diagnosis providesan opportunity forparents
to make choices about what is in the best interest of theirchild
(Zucker, 2015). Arguments against the diagnosis ranged from
anthropological (in a number of cultures, the children who would
be pathologized by this diagnosis are not usually seen as sick at
all) to clinical (prepubertal children do not need substantial
medicalsupport, but instead needthe psychological space,sup-
port, and information to explore who they are, become com-
fortablewith their gender identity and its expression, andlearn
how to handle hostility in others). There is also a political
Arch Sex Behav
123

argument that notes WHO’s inconsistency in proposing a
GIC diagnosis while simultaneously proposing the removal of
pathologizing F66 diagnoses used with youth exploring and
learning to accept and handle responses to their sexual orien-
tation (Ehrensaft, 2011,2012,2013; Winter, 2013,2014,2015).
It is also argued that there are alternative approaches to facili-
tate research, funding, and access to health care for children with
gender issues, just as there were when the pathological diagnosis
of homosexuality was removed from ICD and DSM (Pickstone-
Taylor, 2003).
Since February 2013, the GIC debate has perhaps become
even more vigorous. In May 2013, GATE (Global Action for
Trans* Equality), an international organization promoting trans
people’s rights,convened itsown experts’ meeting on thistopic
in Buenos Aires. The meeting incorporated input from 26 trans
community activists, researchers and academics, clinicians,
lawyers, sociologists, and others and proposed, on health and
rights grounds, abandonmentof the GIC proposal. Instead, the
GATE Expert Group proposed thatsuch health care as may be
needed by prepubertal gender-incongruent children (and their
caregivers) should be primarily provided by way of Z Codes.
(GATE Civil Society Expert Working Group, 2013). Z Codes
are non-pathologizing, non-disease categories currently loca-
ted in a chapter called Factors Influencing Health Status and
Contact with Health Services andare used‘‘when a person who
may or may not be sick encounters the healthservices for some
specific purpose, such as …to discuss a problem which is in
itself not a disease or injury’’or‘‘when some circumstance or
problem is present which influences the person’s health status
but is not in itself a currentillness or injury’’(WHO, 1990,Web
version, 2015). The GATE group noted that Z Codes already
exist that can, with minor modifications and additions, do the
job of documentingcontacts between gender-incongruentchil-
dren and health services (e.g., in the Z70 block: Counseling
related to sexual attitude, behavior, and orientation). It also noted
that, where any young children are experiencing clinically sig-
nificant depression and anxiety linked to their gender issues
and merit a depression oranxiety diagnosis, Z Codes could be
appended to those diagnoses to indicate the nature of the issues
experienced by the child (GATE, op.cit.)
The proposed use of Z Codes in this area is somewhat
controversial. On the one hand, Z Codes are very commonly
employed to guide and document provision of health care. On
the other hand, they can in some parts of the world sometimes
present reimbursement challenges for healthcare providers.
Reimbursement issues do not appear to have prevented WHO
from incorporating into its ICD-11 beta draft a WGSDSH pro-
posal to use Z Codes in place of the F66 diagnoses mentioned
earlier (Cochran et al., 2014).
Other voices questioning the GIC proposal include: Trans-
gender Europe (TGEU) (Transgender Europe, 2014), the Inter-
national Campaign Stop Trans Pathologization (International
Campaign Stop Trans Pathologization, 2013), and the Interna-
tional Lesbian, Gay, Bisexual, Trans and Intersex Association
(International Lesbian, Gay, Bisexual, Trans and Intersex Asso-
ciation, 2016). In Cape Town in May 2014, a group of over 30
healthcare providers, lawyers, trans community leaders, and par-
ents attending a regional conference on trans health issued a state -
ment opposing the proposed diagnosis (the‘‘Cape Town Dec-
laration,’’Mokoena et al., 2014).In October 2015,a group of 37
trans activists, advocates, clinicians, and researchers issued a sim-
ilarly worded declaration(the‘‘Taipei Declaration,’’Lama et al.,
2015) at the ILGA Asia Conference. More recently, an onlin e
statement signed by clinicians and researchers in the field (the
‘‘Berlin Statement’’) has attracted, at the time of writing, almost
200 signatures from professionalsin31countriesacrosssix
continents. They represent almost 2500 years of work in trans-
gender health and rights, and almost 1500 years of clinical expe-
rience (Winter et al., 2016). Finally, in an unusual concern with
diagnostic procedures, a report of a European Parliament com-
mittee (the so-called Ferrara Report published in July 2015)
called on the European Commission to ‘‘intensify efforts to
prevent gender variance in childhood from becoming a new
ICD diagnosis’’ (European Parliament Committee on Civil Lib-
erties, Justice and Home Affairs, 2015). This call was reaffirmed
in a European Parliament Resolution passed in September 2015
(European Parliament, 2015).
Meanwhile, there has been a degree of unease among some
WPATH members about the absence of consensus on the GIC
proposalevident at the 2013 San Francisco consensus meeting.
It was feltthat WPATH, the largest association ofprofessionals
in transgender health, in which perhaps an increasing number
of members are working with children, should take a second
more comprehensive look at the GIC proposal. WPATH lead-
ership (Board of Directors and Executive Committee) decided
to do so by way of a Web survey concerning the proposed diag-
nosis. It was intended that the survey would provide a more
definitive WPATH view for consideration by WHO.
Method
Participants
All WPATH members (740 at the time of the survey) were
sent an e-mail inviting them to participate in a survey on the
GIC proposal, accessed through a link on the WPATH Web
site: www.wpath.org. The survey was constructed using Survey
Monkey. Participants were provided with background infor-
mation on theproposal, similar to whathas been provided here.
Participants were able to complete the survey between December
15, 2014, and January 15, 2015.
Arch Sex Behav
123

Procedure and Measures
The first section of the survey involved demographics, includ-
ing: the region in which the participant works or worked (11
categoriesprovided), category of membership (full, associate,
or student);whether he or she works (or has in the past worked)
in transgender health care, and for how long (1–5 years, 5–10
years, and more than 10 years), in what capacity (8 categories
provided—several responses were possible), client group served
(three categories provided: adults, adolescents, children below
the age of puberty—morethan one response waspossible), and
whether he or she prescribes/has prescribed puberty blockers.
The second (main) section of the survey presented questions
about the WHO GIC proposal and an alternative approach to
facilitating and recording health care involving Z Codes (i.e.,
along the lines of the GATE proposal). The third section
focused on views regarding the name Gender Incongruence of
Childhood and invited additional comments. The questi onn aire
was developed by the first two authors and went through
several drafts. It was also reviewed and was endorsedby senior
members of the WPATH leadership and two internationally
known commentators on the GIC proposal: one a recognized
advocate of the proposal and the other an opponent.
Key questions (in the second and third section) were as
follows:
1. Do you think a disease diagnosis Gender Incongruence of
Childhood should be included in ICD-11? Response options:
yes or no. Participants then indicated their reason for their
answer. Six categories of reason were provided for those
opposing the proposal which were: the diagnosis is pathol-
ogizing, stigmatizing/discriminating, has limited utility,
has limited validity, Z codes provide a more appropriate
method of enabling and documenting health care, and other.
Five were provided for those supporting the proposal which
were that the diagnosis: enables access to care, enables reim-
bursement, facilitates professional training and research,
provides the child protected status, and other. Participants
were able to choose more than one option.
2. If there is no disease diagnosis at all in ICD-11, what is
your view on the use of non-disease Z Codes (either existing,
new, or amended) as the primary means of documenting the
gender-related issues of these children? Response options
were: support, neutral, or reject.
3. If there is a GIC disease diagnosis, what is your view on
which chapter it should be placed in? Response options
were: support the WHO proposal for placement in a new
chapter on Conditions Related to Sexual Health, neutral,
support remaining in the Mental and Behavioural Disor-
ders chapter, and other suggested locations.
4. What are your views on the proposed name Gender Incon-
gruence of Childhood (instead of the current name Gender
Identity Disorder of Childhood)? Response options were
agree, neutral, disagree, or other suggested names.
There was a final item that invited other comments to pass
on to WHO. By completing the survey, the members indi-
cated their agreement to participate, and their understanding
that WPATH might communicate the results with WHO and
other entities with a valid interest in WPATH’s opinion on this
topic. No personal participant information would be revealed.
Statistical Analysis
Only a few participants (n=3) omitted to answer the question
‘‘Do you think a disease diagnosis GIC should be included in
ICD-11?’’ They were excluded from the GIC analysis. The per-
centages of responses supporting and opposing the GIC pro-
posal weretherefore computedas a proportionof the total num-
ber of supporting and opposing responses. The analysis of
responses to the Z Code issue also focused on comparing the
percentages of supportingand opposingresponses.A large pro-
portion of participants were undecided on the question of Z
Codes. In order to avoid bias when comparing percentages of
supporting and opposing responses, these percentages were
computed as a proportion of the total number of supporting,
opposing, and neutral responses.
For the GIC data, a one-sample ttest between percentages
was conducted comparing the percentages of responses sup-
porting and opposing the GIC proposal. Additional analyses
were conducted in which the binaryresponse variable was ana-
lyzed as a function of four categorical independent variables
(IVs): geographical region (Australia and Oceania, Canada,
USA, Western Europe, other), region in which participant works
and lives (USA, non-USA), number of years working in trans-
gender health care (1–5, 6–10, more than 10), and the age group
served (children and adolescents only, adults only). Each inde-
pendent variable was crossed with the binary response variable,
and the resulting contingency table was subjected to a v
2
test of
independence. The v
2
test was deemed appropriate because all
expected cell frequencies were greater than five, and the per-
centages of responses supporting and opposing the GIC pro-
posal summed to 100.Following a significant v
2
, a one-sample
ttest was conducted at each level of the IV comparing the
proportions of supporting and opposing responses. Following
a nonsignifi cant v
2
, a one-samplettest was conducted compar-
ing the marginal proportions of supporting and opposing respon-
ses. For the Z Codes data, one-sample ttests were used to com-
pare the proportions of participants supporting and rejecting the
use of Z Codes. v
2
tests were not used for these comparisons
because the percentages of supporting and opposing responses
summed to less than 100. In all analyses, the per-test alpha
level was .05, in keeping with the exploratory nature of this
study.
Arch Sex Behav
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Results
Demographics
Of the 740 WPATH members at the time of the survey (the
end of 2014), a total of 253 responded to the survey. Of these,
there were 241 valid completed surveys, representing 32.6 %
of the membership. Our response rate compared favorably
with the mean of 33 % reported for e-mail surveys in a recent
review of research using this methodology (Shih & Fan,
2009). Indeed, it compared well with the 34 % response rate
reported for WHO’s recent international survey of psychia-
trists’ views concerning the ICD mental disorders chapter (Reed
et al., 2011, cited earlier). It also substantially exceeded the
12.4 % response rate reported in Vance et al.’s (2010)inter-
national survey on the views of organizations working with
trans people toward DSM diagnostic reform regarding the
gender identity disorder diagnosis.
Table 1showsthe regionin which participantswere located,
along withthose for the entireWPATH membershipat the time
of the survey. Sample proportions appeared similar to that of
the entire membership in all categories. The majority of partic-
ipants (137 or 56.8 %) were identified exclusively as mental
health professionals, in line with their proportion as 48.8 % of
WPATH members. Fifty-six (23.2 %) were identified as physi-
cians (27identifyingas physicianswho prescribe hormones,18
as primary care physicians, 9 as surgeons, and 2 as other spe-
cialisms). Fifteen participants were identified as human rights
activists, with another 8 identifying as lawyers, and 27 as others.
Sample proportions for all other areas of involvement in
transgender health were in line with proporti ons for the mem-
bership as a whole. Among other sample characteristics of inter-
est, a totalof 215 (89.2 %) out of 241participants indicated they
were currently providing health care or related services to trans-
gender clients/patients (or had done so in the past). A total of 138
(57.3 %) participants had worked more than 10 years in trans-
gender healthcare, while 42 (17.4. %) had workedfive years or
less in the field. Eighty-seven (36.1 %) worked with children.
The group of participants was representative for the total
WPATH membership concerning geographical location as
well as profession.
Overall Support for the GIC Proposal
For the question: ‘‘Do you think a disease diagnosis Gender
Incongruence of Childhood should be included in ICD-11?’’a
total of 115 (47.7 %) participants answered ‘‘yes’’ and 123
(51.0 %) answered ‘‘no.’’Three (1.2 %) participants abstained.
The difference in proportions of‘‘yes’’and‘‘no’’ responses was
not significant, t(237)\1.
Support for the GIC Proposal According to
Geographical Region
The 5 (geographical region) 92 (support vs. oppose) contin-
gency table is shown in Table 2.Thev
2
test of independence
was significant, v
2
(4) =10.35, p=.035, indicating that the
difference between the proportions of participants supporting
and opposing GIC varied across the five regions. Australia and
Oceania was the only region for which there was a significant
difference between percentages supporting and opposing the
proposal. For the other four regions, there was no significant
difference. As noted earlier, 70 % of psychiatrists worldwide
appear to use ICD more commonly than any other manual
(Reed et al., 2011). Within the USA, home of DSM-5, this fig-
ure drops to 1 %. Given the number of US participants in this
study, and the likelihood that they might have less acquain-
tance with ICD and ICD Reform, we decided to compare the
responses of US participants with those of participants else-
where. The 2 (US vs. non-US) 92 (support vs. oppose) contin-
gency table is reported in Table 3.Thev
2
test of independence
was significant, v
2
(1) =5.48, p=.019, indicating that the dif-
ference between the proportions of participants supporting and
opposing GIC varied across the two groups. Among non-US
participants (n=72), there were significantly more participants
opposed to the GICproposal than there were supporting it, 63.9
versus 36.1 %, t(71) =2.46, p=.017. For US participants (n=
166), the difference between the proportions of participants
supporting (53.6 %) and opposing GIC (46.4 %) was not sig-
nificant, t(165)\1.
Support for the GIC Proposal According to the
Number of Years Working with Trans people
The 3 (number of years) 92 (support vs. oppose) contingency
table is shown in Table 4.Thev
2
test of independence was non-
significant, v
2
(2)\1, indicating that the difference between
the proportions of participants supporting and opposing GIC
was invariant across the three groups.
Support for the GIC Proposal According to the Age
Group with Which Participants Work
The 2 (age groupserved) 92 (support vs. oppose)contingency
table is shown in Table 5.Thev
2
test of independence was non-
significant, v
2
(1)\1, indicating that the difference between
Arch Sex Behav
123

the proportions of participants supporting and opposing GIC
was invariant across the two groups.
Arguments For and Against the GIC Proposal
The most commonly endorsed arguments to support the GIC
diagnosis were that a diagnosis would: enable access to care
(79.1 % of the participants supporting the GIC proposal); give
‘‘protected status’’(54.5 %); facilitate reimbursement (54.7 %);
and facilitate training and research (49.5 %). The most com-
monly endorsed arguments to abandon the proposal were that
the GIC diagnosis would be: pathologizing (53.6 % of those
opposing the proposal); stigmatizing/discriminating (50.4 %);
of limited utility (39.0 %); and of limited validity (34.1 %).
Support for the Use of Z Codes
For the question‘‘If there is no disease diagnosis at all in ICD-
11, please tell us what is your view on the use of non-disease
‘‘Z’’Codes (either existing, new or amended) as the primary
means of documenting the gender-related issues of these chil-
dren?’’ it was evident from participants’ responses that, where
a view was expressed, Z Codes drew substantial support. Over-
all, 86 (35.7 %) participants supported the use of Z Codes com-
pared with 20 (8.3 %) rejecting them and 135 (56.0 %) either
neutral orleavingtheir responseblank.A one-sample ttest com-
paring the proportions supporting and rejecting the use of Z
Codes wassignificant, t(240) =7.04, p\.001, indicatingthat a
significantly greater proportion of participants supported the
use of Z Codes. Support was evident both within and outside
the USA. It was also evident regardless of how long participants
had worked in trans health care and with which client age group
they worked. The results of the one-sample ttests are shown in
Table 6.
It can be seen in Table 7that support for Z Codes was par-
ticularly strong among those who were opposed to GIC. Among
them, 48.8 % supported Z Codes, as compared to 4.1 % oppos-
ing. The difference in proportions was highly significant
Table 1 Geographical location of participants
Participants %
b
WPATH membership
n=241 %
a
n=740 %
Australia and Oceania 8 3.3 34.8 23 3.1
North America: Canada 21 8.7 38.2 55 7.4
North America: USA 169 70.1 30.9 546 73.8
Western Europe 29 12.0 30.2 96 12.9
Other 14 5.8 26.4 53 7.1
Other: Africa, Asia, Caribbean & Central America, Eastern Europe, Middle East, South America, Worldwide
%
a
Participants as percentage of overall sample
%
b
Participants as percentage of WPATH members located in that region
Table 2 Distribution of the members supporting or opposing the GIC proposal, according to their geographical region
Support GIC Oppose GIC pvalue
n=115 % n=123 %
Australia and Oceania 1 11.1 8 88.9 .006
North America: Canada 7 33.3 14 66.7 .120
North America: USA 89 53.6 77 46.4 .352
Western Europe 14 48.3 15 51.7 .856
Other
a
4 30.8 9 69.2 .16
a
Other: Africa, Asia, Caribbean and Central America, Eastern Europe, Middle East, South America
Table 3 Distribution of respondents supporting and opposing the GIC proposal according to the region in which they work and live
Support GIC Oppose GIC pvalue
n=115 % n=123 %
US members 89 53.6 77 46.4 .352
Non-US members 26 36.1 46 63.9 .017
Arch Sex Behav
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(p\.001). However, there was also substantial support for Z
Codes even among those who supported the GIC diagnosis:
22.6 % supporting,as compared to 12.2 % rejecting (p=.057).
A large number of others (65.2 %) expressed a neutral view or
did not express a view.
Placement of the Proposed GIC Diagnosis
In response to the question about where the proposed GIC
diagnosis, if approved, should be located in ICD-11, 41.1 % (n=
99) of participants supported the WHO proposal for placing it
(presumably alongside GIAA) in a new chapter with the puta-
tive title Conditions Related to Sexual Health. Only 7.5 % (n=
18) had the view that it should be placed in the Mental and
Behavioural Disorders chapter (the current location for the
various gender identity disorder diagnoses). Another 19.5 %
(n=47) of participants remained neutral, while 10.4 % (n=
25) made other suggestions and 21.5 % (n=52) did not respond .
The support for the Chapter Conditions Related to Sexual Health
was significantly above that for its retention in the Mental and
Behavioural Disorders chapter, t(240) =8.54, p\.001.
The Proposed Name for GIC
In response to the question about the suggested name ‘‘Gender
Incongruence of Childhood’’for the proposed diagnosis, 51.0 %
(n=123) agreed with the choice of name, while only 13.7 %
(n=33) were opposed. Another 17.8 % (n=43) were neutral,
while 8.3 % (n=20) suggested other options, and another 9.1 %
(n=22) did not respond. The number supporting the proposed
name was significantly greater than the number opposing it,
t[240] =8.12, p\.001.
Discussion
WHO can take reassurance from WPATH members’ support
for the proposal to place the Gender Incongruence of Child-
hood diagnosis in a chapter on sexual health, as well as on the
choice of name for any such diagnosis. But beyond that, there
is an even division of opinion as to whether there should be a
GIC diagnosis in ICD-11 at all. Around half said yes, the most
common argument being that it enables access to care, pro-
vides‘‘protected status’’ to the child, and facilitates reimburse-
ment. The other half said no, commonly arguing that it would
result in pathologization, stigma, and discrimination. The split
in opinion echoed WPATH’s ICD Consensus meeting in San
Francisco in 2013 (De Cuypere et al., 2013). Elsewhere there
are strong voices of opposition to the GIC proposal. GATE
(GATE Civil Society Expert Working Group, 2013), Inter-
national Campaign Stop Trans Pathologization (2013), Trans-
gender Europe (2014), and the International Lesbian, Gay,
Bisexual, Trans and Intersex Organisation (ILGA, 2016)have
issued statements opposing the proposal. Groups at two con-
ferences (Lama et al., 2015; Mokoena et al., 2014)andalarge
number of researchers andclinicians (Winter et al.,2016)have
also issuedstatements. A keyEuropean Parliament Committee
(European Parliament Committee on CivilLiberties, Justice
and Home Affairs, 2015) and the European Parliament itself
(European Parliament, 2015)haveeachcalledupontheEuro-
pean Commission to oppose WHO’s GIC proposal. Together
Table 4 Distribution of respondents supporting and opposing the GIC proposal according to the number of years working with trans people
Support GIC Oppose GIC pvalue
n=113 % n=112 %
1–5 years 22 53.7 19 46.3 –
5–10 years 25 52.1 23 47.9 –
More than 10 years 66 48.5 70 51.5 –
Marginal proportions 113 50.2 112 49.8 .952
Table 5 Distribution of respondents supporting and opposing the GIC proposal according to the age group with which they work
Support GIC Oppose GIC pvalue
n=111 % n=113 %
Adults and adolescents only 71 51.8 66 48.2 –
Children only 40 46.0 47 54.0 –
Marginal proportions 111 49.6 113 50.4 .905
Arch Sex Behav
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these voices come from an internationally wide range of stake-
holders in transgender health and rights.
It is apparent from our analysis that US respondent views
on the GIC proposal are overall finely balanced, but that, viewed
as a whole, respondents elsewhere are overall opposed to the pro-
posal and that, furthermore, where they express a view, they are
(viewed as a whole) particularly likely to support a Z code
approach, along the lines of GATE’s proposal. In some places
(e.g., Canada and Australia/Oceania), there are indications
(though significant only in the latter case) that opposition to
the GIC proposal is particularly strong, although the data are
small and further research on thisis indicated. It is possiblethat
the geographical divergence is related to the very different
health systems in which participants in this study work, with
those in at least some socialized health systems less dependent
on the use of pathologizing codes than those, such as in the USA,
workinginhealthsystemsinwhichtheneedforinsurance
company reimbursements predominates in healthcare policy.
The Z Code results in this study seem particularly interesting. A
large number of participants appeared undecided on the ques-
tionofZ Codes. This may, ofcourse,reflecta lack of familiarity
with the GATE proposal or Z Codes more generally. Unfamil-
iarity with these codes may have been particularly relevant in
the USA, where a high percentage of participants (60.3 %) were
neutral or left this item blank. Overall across our sample, 81.1 %
of those who expressed a view on Z Codes supported them and
only 18.9 % rejected them (a ratio of 4:1 in favor of Z Codes).
As one might expect, there was a significant link between
support for Z Codes and opposition to the GIC proposal. US-
based respondents, the source of greatest support for the GIC
proposal, were least in favor of Z Codes. Yet, even in the USA,
30 % supportedthe use of Z Codes. Indeed,support for Z Codes
was strikingly consistent, with support outweighing rejection
regardless of whether participants worked in the USA or out-
side, regardless of how long they had been working with trans
people, and regardless of the age group worked with.
The opinions, here expressed, are the opinions of an appar-
ently representative part of the WPATH membership, all pro-
fessionals working in the transgender field. It would be inter-
esting toknow what opinions mentalhealth professionals more
generally (not just specialists in the field) have on this issue, as
well as parents of children covered by this proposed diagnosis.
It would also be usefulto know what arguments theseviews are
based on. It is evident that the USA (and US institutions) tends
to dominate in international discussions on trans health care.
DSM-5 (like DSM-IV before it) is influential far beyond the
clinics in which it is used. Within WPATH, the peak profes-
sional organization in the field, a majority of members are US-
based. But WHO, like WPATH itself, is an international orga-
nization committed to a global perspective on health care. The
challenge for WHO in making decisions on the GIC proposal
(and indeedon the use of Z Codes)will be to maintainthat inter-
national perspective. The challenge for WPATH in inputting
into WHO’s decision making will be to do the same thing: to
Table 6 Distribution of respondents rejecting or supporting the use of non-disease Z Codes as primary means of documenting the gender-related issues
of children according to their location, the number of years working in trans health care, and the age group with which they work
Reject Z codes Support Z codes Neutral/Blank pvalue
a
n=20 % n=86 % n=135 %
US members 16 9.5 51 30.2 102 60.3 \.001
Non-US members 4 5.6 35 48.6 33 45.8 \.001
1–5 years 1 2.4 13 31.0 28 66.7 \.001
5–10 years 3 6.3 18 37.5 27 56.2 \.001
More than 10 years 15 10.9 50 36.2 73 52.9 \.001
Adults/adolescents only 11 7.9 42 30.0 87 62.1 \.001
Children 9 10.3 36 41.4 42 48.3 \.001
a
One-sample ttest comparing proportion supporting against proportion rejecting
Table 7 Distribution of the respondents’ views on Z Codes, according to their views on a GIC diagnosis
Support Z codes Reject Z codes Neutral and Blank pvalue
a
n%n%n%
Support GIC 26 22.6 14 12.2 75 65.2 .057
Oppose GIC 60 48.8 5 4.1 58 47.1 \.001
a
One-sample ttest comparing proportion supporting against proportion rejecting
Arch Sex Behav
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incorporate into its representations voices from trans healthcare
providers and users worldwide.
Acknowledgments Gail Knudson is President of WPATH (2016–2018),
Jamison Green is Past-President of WPATH (2014–2016). Thanks to
Annelou de Vries, Simon Pickstone-Taylor, Andrea Martin, and Bean
Robinson for their help in reviewing and developing the survey. Sam
Winter and Griet De Cuypere have contributed equally to this article
and are both Board Members of WPATH.
Compliance with ethical standards
Conflict of interest One of the authors of this paper, Sam Winter, was a
member of the WHO Working Group on Sexual Disorders and Sexual
Health generating the GIC proposal, as well as a group producing a counter-
proposal incorporating the use of Z Codes (GATE Civil Society Experts
Working Group, 2013).
Appendix: The Clinical Description of the Proposed
GIC Diagnosis (World Health Organisation, 2015)
Gender Incongruence of Childhood is characterized by a marked
incongruence between an individual’s experienced/expressed
gender and the assigned sex in prepubertal 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 activitiesand playmates that are typical of
the experienced genderrather than theassigned sex. The incon-
gruence must have persisted for about 2 years and cannot be
diagnosed before age 5. Gender-variant behavior and prefer-
ences alone are not sufficient for making the diagnosis.
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