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ICD-11 and gender incongruence of childhood: a rethink is needed

Authors:
Sam Winter Phd at The University of Hong Kong
Sam Winter Phd
Diane Ehrensaft at University of California, San Francisco
Diane Ehrensaft
Michelle Telfer at The Royal Children's Hospital
Michelle Telfer
Guy T'Sjoen at Ghent University
Guy T'Sjoen
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www.thelancet.com/child-adolescent Published online August 19, 2019 http://dx.doi.org/10.1016/PII
1
The 11th edition of WHO’s International Classification
of Diseases (ICD-11), approved by the World Health
Assembly in May, 2019, incorporates a number of
changes relevant to children and adolescents, including
those in regard to their sexual and gender development.
Endorsed in 1990, ICD-10 contained several
psychological and behavioural disorders associated
with sexual development and orientation. Some
disorders appeared to target youth who are attracted to
individuals of the same sex and were out of step with
our contemporary understanding of young people’s
sexuality. Examples of these diagnoses included
egodystonic sexual orientation for individuals distressed
about their sexual orientation, and sexual maturation
disorder for individuals distressed about being uncertain
regarding their sexual orientation. It has been argued by
Cochran and colleagues1 that these diagnoses, which had
long survived the removal of homosexuality from ICD
in the early 1990s, effectively pathologised same-sex
attraction. The criticism seems fair. All things considered,
it is improbable in the heteronormative world where
we live that many people would be distressed by the
knowledge, or indeed the possibility, that they might
be heterosexual. Rather, it would be those experiencing
feelings of same-sex attraction who might be distressed.
ICD-11 finally consigns these diagnoses to history. Few
people regret their passing.
WHO’s decision to relocate gender incongruence of
adolescence or adulthood (ie, after puberty onset)—
transsexualism diagnosis in ICD-10, previously classified
as a mental disorder—to a new chapter on sexual
health has been widely welcomed by health providers
in the field, as well as the communities they serve. The
relocation is evidence of substantial progress made in
the past decades in our understanding of transgender
people’s identity and experiences.2
However, gender incongruence of childhood, the ICD-11
diagnosis used with gender-diverse children who have not
yet reached puberty, has proved far more controversial.
A wide range of health-care providers, researchers, and
representatives of the transgender community and their
organisations have voiced misgivings about the diagnosis,
through academic papers,3,4 position statements, a
civil society expert group report, and an international
petition (the Berlin Statement). This statement was
signed, in 2016, by over 200 clinicians and scholars who
collectively have more than 2000 years of experience
in transgender health. Overall, opinions of health-care
professionals working in transgender health are divided
on the diagnosis, as shown by a membership survey
of the World Professional Association for Transgender
Health, published in 2016.5 Meanwhile, the European
Parliament in 2015 expressed its clear opposition to the
gender incongruence of childhood. The concern that the
diagnosis is inappropriate, unnecessary, and harmful,
and that it should be removed from ICD-11 altogether
is evident. As ICD-11 enters its implementation phase,
we highlight some of the arguments for the removal of
gender incongruence of childhood from the manual.
The diagnosis pathologises the experiences of young
children who are merely exploring their experience
of gender, incorporating a gender identity into a
broader sense of who they are, learning to express that
identity, and managing any associated stigma. These
young children do not need puberty suppressants,
masculinising or feminising hormones, or surgery.
Rather, they need a safe emotional space with the
freedom to explore, embrace, and express their gender
identity.6,7 For some children, this process requires
social transition; a child-led change in their expressed
gender identity through adoption of a preferred
name and pronouns, as well as clothing and hairstyle,
consistent with their gender identity. Ensuring that
families, caregivers, and educational providers both
understand and support the child’s gender experience
is paramount in facilitating transition and minimising
negative experiences (such as bullying or social
exclusion). Research and clinical experience show that
social transition in affirming, supportive home and
school environments leads to positive outcomes, with
no signs of clinical pathology.6,7 Not all young children
will be so fortunate as to have the support they need.
However, we suggest that the application of a clinical
diagnosis would only add to their gender-minority
stress and parental or social rejection, signalling to the
social environment the misconception that something
ICD-11 and gender incongruence of childhood: a rethink is
needed
Lancet Child Adolesc Health 2019
Published Online
August 19, 2019
http://dx.doi.org/10.1016/PII
For more on the joint statement
on ICD-11 process for trans and
gender-diverse people see
https://transactivists.org/icd-11-
trans-process/
For more on the civil society
expert group report on ICD-11
see https://transactivists.org/
critique-and-alternative-
proposal-to-the-gender-
incongruence-of-childhood-
category-in-icd-11/
For more on the Berlin
Statement see https://
transpolicyreform.wordpress.
com/2019/07/22/the-2016-
berlin-statement-on-childhood-
gender-incongruence-diagnosis-
an-archive-copy/?fbclid=IwAR2k
SrG12hOzOJRAUphILPtjmT3tyn
FMaqavwGapHBErNYdUpLS1Rb
A7Oa0
For more on the European
Parliament position see http://
www.europarl.europa.eu/doceo/
document/A-8–2015–0230_
EN.html
iStock/Ridofranz
Doctopic: Analysis and Interpretation
THELANCETCHILDADOL-D-19-00381
[PII_REPLACE]
Embargo: August 19, 2019—23:30 (BST)
Comment
2
www.thelancet.com/child-adolescent Published online August 19, 2019 http://dx.doi.org/10.1016/PII
is wrong with them.8,9
There is an inconsistency in the different diagnostic
approaches WHO has taken in regard to young people’s
sexual orientation compared with young children’s gender
diversity. The ICD-10 diagnoses of sexual maturation
disorder and egodystonic sexual orientation pathologised
individuals exploring a same-sex attraction, who are
learning to embrace and express a same-sex attracted
identity, as well as coping with associated stigma. To its
credit, WHO took the view that such diagnoses should
be removed entirely from the diagnostic manual, with
counselling support provided (when sought on the
basis of sexual orientation) through non-pathologising
codes in ICD-11 chapter 24, Factors influencing health
status or contact with health services.10 Many such non-
pathologising codes exist. Among the more relevant
would be codes for people experiencing social rejection
and exclusion, or discrimination. Non-pathologising
codes could also be used to document services for gender-
diverse children who have not yet reached puberty. Sadly,
WHO chose not to take this approach, opting instead to
pathologise these children’s diversity.
A call to action published in The Lancet in 2016 urged
WHO to reconsider what was then its proposal for
gender incongruence of childhood.11 As professionals
working in transgender health, in various settings, and
from each continent, we write to express our most
sincere hope—shared by many health-care providers,
researchers, and community organisations globally—
that in the coming months and years, as ICD-11 content
is reviewed, WHO does indeed revisit this deeply
problematic diagnosis.
*Sam Winter, Diane Ehrensaft, Michelle Telfer, Guy T’Sjoen,
Jun Koh, Simon Pickstone-Taylor, Alicia Kruger, Lisa Griffin,
Maya Foigel, Griet De Cuypere, Dan Karasic
School of Public Health, Curtin University, Perth, WA 6102,
Australia (SW); Child and Adolescent Gender Center (DE),
Department of Pediatrics (DE), and Department of Psychiatry
(DK), University of California San Francisco, San Francisco, CA,
USA; Department of Adolescent Medicine, The Royal Children’s
Hospital Melbourne, Melbourne, VIC, Australia (MT); Center for
Sexology and Gender, and Department of Endocrinology, Ghent
University Hospital, Ghent, Belgium (GT’S); Department of
Neuropsychiatry, Osaka Medical College, Osaka, Japan ( JK);
Division of Child & Adolescent Psychiatry, University of Cape
Town, South Africa (SP-T); Department of Sexually Transmitted
Infections, HIV/AIDS and Viral Hepatitis, Brazil Ministry of Health,
São Paulo, Brazil (AK); Brazilian Professional Association for
Transgender Health, São Paulo, Brazil (AK); Pride Inside,
Richmond, VA, USA (LG); US Professional Association for
Transgender Health, East Dundee, IL, USA (LG); Psychology
Institute, University of São Paulo, São Paulo, Brazil (MF); and
Gender Team Ghent, University of Ghent, Belgium (GDC)
sam.winter@curtin.edu.au
SW was a member of the WHO Working Group on Sexual Disorders and Sexual
Health, has received travel and accommodation expenses as a speaker or
participant at meetings on ICD reform, and is a former member of the Board
of the World Professional Association for Transgender Health (WPATH). GT’S
is President of the European Professional Association for Transgender Health
(EPATH), is a co-editor for the International Journal of Transgenderism and the
Journal of Sexual Medicine, is on an Advisory Board for Ferring and Novartis,
and has received grants from Bayer, Ipsen, and Sandoz. GDC is a former
member of the Board of the WPATH and is a member of the Board of the
EPATH. All other authors declare no competing interests.
1 Cochran S, Drescher J, Kismödi E, et al. Proposed declassification of disease
categories related to sexual orientation in the International Statistical
Classification of Diseases and Related Health Problems (ICD-11).
Bull World Health Organ 2014; 92: 672–79.
2 Drescher J, Cohen-Kettenis P, Winter S. Minding the body: situating gender
identity diagnoses in the ICD-11. Int Rev Psychiatry 2012; 24: 568–77.
3 Winter S, Ehrensaft D, Pickstone-Taylor S, De Cuypere G, Tando D.
The psycho-medical case against a gender incongruence of childhood
diagnosis. Lancet Psychiatry 2016; 3: 404–05.
4 Cabral M, Suess A, Ehrt J, Sehoole T, Wong J. Removal of gender
incongruence of childhood diagnostic category: a human rights
perspective. Lancet Psychiatry 2016; 3: 405–06.
5 Winter S, De Cuypere G, Green J, Kane R, Knudson G. The proposed ICD-11
gender incongruence of childhood diagnosis: a World Professional
Association for Transgender Health membership survey. Arch Sex Behav
2016; 45: 1605–14.
6 Olson KR, Durwood L, Demeules M, McLaughlin KA. Mental health of
transgender children who are supported in their identities. Pediatrics 2016;
137: 1–8.
7 Ehrensaft D, Giammattei S, Storck K, Tishelman A, Keo-Meier C. Prepubertal
social gender transitions: what we know; what we can learn—a view from a
gender affirmative lens. Int J Transgend 2018; 19: 251–68.
8 Cabral M, Suess A, Ehrt J, Seehole TJ, Wong J. Removal of a gender
incongruence of childhood diagnostic category: a human rights
perspective. Lancet Psychiatry 2016; 3: 405–06.
9 Suess Schwend A, Winter S, Chiam Z, Smiley A, Cabral M. Depathologising
gender diversity in childhood in the process of ICD revision and reform.
Glob Public Health 2018; 13: 1585–98.
10 Winter S. Gender trouble: the World Health Organization, the International
Statistical Classification of Diseases and Related Health Problems (ICD)-11
and the trans kids. Sex Health 2017; 14: 423–30.
11 Winter S, Settle E, Wylie K, et al. Synergies in health and human rights:
a call to action to improve transgender health. Lancet 2016; 388: 318–21.
... Over the last few years, the demand of depathologizing gender diversity in childhood and adolescence has achieved an increased relevance in trans depathologization activism [1,2,28,30,33,[54][55][56][57][58][59][60][61][62][122][123][124][125], including the following demands: (1) removal of the diagnostic classification of gender diversity in childhood from DSM and ICD; (2) support to gender diversity in childhood and adolescence in the family, social, school, and health care context; and (3) legal gender recognition for children and adolescents. ...
... Regarding the diagnostic classification of gender diversity in childhood, various international and regional activist networks published declarations demanding the removal of the diagnostic code "Gender incongruence of childhood" from ICD, and trans authors and allies contributed critical theoretical reflections on the diagnostic classification of gender diversity in childhood in the DSM and ICD [1,2,28,30,33,[54][55][56][57][58][59][60][61], preceded by critical reflections elaborated over the last decades [20,21]. This demand also received the support of clinicians and researchers [62] and European bodies [90,91]. ...
... Among the main arguments in favor of removing the diagnostic code, trans authors and allies highlight the lack of clinical utility, the Western character of a conceptualization of gender diversity in childhood as a problem that requires health care, the potential stigmatizing effect, and a contradiction between a removal of diagnostic codes related to sexual orientation and the maintenance of the Gender Incongruence of Childhood code [1,2,20,21,28,30,33,[54][55][56][57][58][59][60][61][62]. Furthermore, the critical discourses counter reasons contributed by the defenders of the diagnosis [126,127], arguing that a specific diagnosis for gender diverse children is not necessary for covering psychological support, justifying access to puberty blockers, or promoting research and training [1,2,20,21,28,30,33,[54][55][56][57][58][59][60][61][62]. ...
Trans health care from a depathologization and human rights perspective
Article
Full-text available
  • Feb 2020
Abstract Trans people are exposed to multiple human right violations in clinical practice and research. From 1975 on, gender transition processes have been classified as a mental disorder in diagnostic classification manuals, a classification that was removed recently from ICD, International Classification of Diseases, and continues in DSM, Diagnostic and Statistical Manual of Mental Disorders. Trans people in different world regions are forced to accept psychiatric diagnoses and assessment in order to get access to trans health care, subject to reparative therapies and exposed to transphobic institutional and social discrimination and violence. In many countries, gender identity laws include medical requirements, such as psychiatric diagnosis, hormone treatment, genital surgery, or sterilization. In the scientific literature, a frequent pathologization of trans experiences can be identified, by means of pathologizing conceptualizations, terminologies, visual representations, and practices, as well as ethnocentric biases. Trans activism and scholarship have questioned widely the pathologization of trans people in clinical practice and research. Over the last decade, an international trans depathologization movement emerged, demanding, among other claims, the removal of the diagnostic classification of transexuality as a mental disorder, as well as changes in the health care and legal context. International and regional bodies built up a human rights framework related to sexual, gender and bodily diversity that constitute a relevant reference point for trans depathologization activism. The Yogyakarta Principles, published in 2007 and extended in 2017 by means of the Yogyakarta Principles plus 10, establish an application of international human rights law in relation to sexual orientation, gender expression, gender identity, and sex characteristics. International and regional human rights bodies included demands related to depathologization in their agenda. More recently, advancements towards trans depathologization can be observed in the diagnostic classifications, as well as in the health care and legal context. At the same time, trans people continue being exposed to pathologization and transphobic violence. The Human Rights in Patient Care (HRPC) framework offers a human right-based approach on health care practices. The paper aims at analyzing the shared human rights focus and potential alliances between the trans depathologization perspective and the HRPC framework.
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... La crítica a la posibilidad de que se incluya la "discordancia de género en la infancia" en la CIE-11 ya se expresó durante la fase de redacción del documento y se ha hecho eco de ella desde su publicación. Son varias las motivaciones de quienes expresan su preocupación por una clasificación que se considera "inapropiada, innecesaria y perjudicial" (Winter et al. 2019). La principal crítica a la decisión de la OMS de mantener la incongruencia de género en la infancia dentro de la CIE-11 es que, de este modo, sigue patologizando la experiencia de la infancia que simplemente está explorando su identidad social, familiarizándose con los significados del género y aprendiendo a hacer frente a las reacciones de otros miembros del grupo social al que pertenecen (Winter et al. 2016(Winter et al. , 2019. ...
... Son varias las motivaciones de quienes expresan su preocupación por una clasificación que se considera "inapropiada, innecesaria y perjudicial" (Winter et al. 2019). La principal crítica a la decisión de la OMS de mantener la incongruencia de género en la infancia dentro de la CIE-11 es que, de este modo, sigue patologizando la experiencia de la infancia que simplemente está explorando su identidad social, familiarizándose con los significados del género y aprendiendo a hacer frente a las reacciones de otros miembros del grupo social al que pertenecen (Winter et al. 2016(Winter et al. , 2019. También se pone de manifiesto el riesgo de que seguir definiendo la experiencia trans en la infancia como una enfermedad aumente el estigma sobre las criaturas que se incluyen en el diagnóstico y contribuya a generar tanto en estas como en sus progenitores la sensación de que existe un problema, despertando un sentimiento permanente de inseguridad y vergüenza (Horowicz 2021;Suess Schwend 2017). ...
Infancia trans*: etnografía de una crianza situada Tesis Doctoral por Michela Mariotto Barcelona
Thesis
Full-text available
  • Feb 2022
Until recently, talking about transgender children was only accepted and described in medical terms as a pathology to be prevented and treated. Although this interpretative framework still prevails today, we are witnessing an important epistemological change that fosters the recognition of this experience as an expression of human diversity to be claimed first and foremost by families. From the sociological point of view, we are dealing with a new phenomenon. This is the first generation of parents who choose to support and accompany their transgender not just at home but in public, thus facing unexplored paths and heading to unknown destinations. This thesis aims to describe how parenting a transgender child takes shape from the voices of those directly involved: the families. My research takes place in the Catalan and the Italian contexts, which are very close in cultural, historical, and economic terms, but show remarkable differences when it comes to the object of this study. The world of associations, the current medical model, and the legislative instruments designed to protect young gender variant people are organized differently in Catalonia and in Italy and can deeply affect the way families attribute meaning to their children's experience and the way they accompany them. Ethnography is the method chosen to develop this work because it gives researchers closer access to the reality they want to describe and the opportunity to show the reality based on the meanings, language, and relationships of the social actors that constitute the subject of study. The analysis of the interviews, which is the central part of the thesis, highlights such elements as the emotions felt by the parents, their ethical reflections when confronted with the breaking of the gender norm by their children, the social meanings attributed to them by the available discourses and the practical strategies activated to create legitimate and socially recognized possibilities of existence. Hasta hace unos años, hablar de infancia trans* era concebible únicamente dentro de un marco médico, que consideraba este tipo de experiencias una patología que había que prevenir y tratar. Aunque este sigue siendo hoy el principal campo de conocimiento desde el que se desarrolla el discurso sobre lo trans* en la infancia, estamos asistiendo a un importante cambio epistemológico que lleva a reconocer estas experiencias como una mera expresión de la diversidad humana que debe ser afirmada, ante todo, por las familias. Desde el punto de vista sociológico, estamos ante un fenómeno nuevo. Se trata de la primera generación de progenitores que opta por apoyar y acompañar a sus hijes trans* y que lo hace de forma pública, navegando por caminos hasta ahora inexplorados y de destinos inciertos. Esta tesis pretende describir cómo toma forma la crianza de criaturas trans* a partir de las voces de las personas directamente implicadas, las familias. He situado la investigación en dos contextos, el catalán y el italiano, muy próximos entre sí en cuanto a cultura, historia y economía, pero que presentan importantes diferencias por lo que se refiere al objeto de estudio de esta tesis. El mundo asociativo, el modelo médico actual y los instrumentos legislativos destinados a proteger a las pequeñas personas trans* se organizan de forma diferente en Catalunya y en Italia, y contribuyen a determinar el modo en que las familias atribuyen un significado a la experiencia de su prole, así como el modo en que la acompañan. La etnografía es el método elegido para desarrollar este trabajo por su capacidad de acercar a la persona investigadora a la realidad que desea describir, permitiéndole emerger a través de los significados, el lenguaje y las relaciones de los actores sociales que conforman el objeto de estudio. El análisis de las entrevistas, que constituye la parte principal de esta tesis, pone de relieve las emociones que sienten madres y padres, las reflexiones éticas que surgen cuando se enfrentan a la ruptura de la norma de género por parte de sus criaturas, los significados sociales que los discursos disponibles les atribuyen y las estrategias prácticas.
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... Como fruto dessas reinvindicações uma grande mudança ocorreu a partir da décima primeira edição da Classificação Internacional de Doenças (CID-11), o que era encontrado nas edições anteriores nos capítulos de "Transtornos Mentais", a partir dessa edição passou a constar no capítulo de "Condições Relacionadas à Saúde Sexual" como diagnóstico de incongruência de gênero (Winter, 2019). No Brasil, o Sistema Único de Saúde (SUS), através da portaria de Nº 1.707 em 2008, instituiu o processo transexualizador, sendo ainda redefinida pela portaria Nº 2.803 em 2013, que acrescentou o direito ao acesso a terapia de hormonização e intervenções cirúrgicas. ...
O panorama da rede assistencial do processo transexualizador no Brasil de 2008-2022
Article
Full-text available
  • Jun 2024
Introdução: O processo transexualizador, que sempre existiu ao longo da história da humanidade, é atualmente oferecido através do Sistema Único de Saúde (SUS) no Brasil, a todos os cidadãos de forma gratuita. Isto se dá pelo entendimento de que tal procedimento é uma medida essencial para saúde pública dessa parcela da população. Para além de procedimentos cirúrgicos, hormonais ou ambulatoriais, trata-se da saúde mental e integridade de uma parcela da população brasileira. Objetivo: Quantificar o número de procedimentos e atendimentos ambulatoriais prestados pelo Sistema Único de Saúde (SUS), bem como a prevalência destes ao longo dos anos – desde quando começou a ser ofertado em 2008 até 2022, e comparar os resultados de acordo com as macrorregiões do país. Metodologia: Trata-se de um estudo ecológico misto, realizado por meio da consulta aos dados do Sistema de Informações Ambulatoriais do Departamento de Informática do Sistema Único de Saúde do Brasil (DATASUS). A população de estudo foi composta por todos os procedimentos e atendimentos ambulatoriais prestados a pessoas transexuais de acordo com a temporalidade e as macrorregiões. Resultados: Durante o período de 2008 a 2022, foram observados no Brasil 85.889 procedimentos envolvendo a população supracitada. As regiões Sul e Sudeste notificaram um maior número de atendimentos e procedimentos ambulatoriais, contrapondo-se a região Norte, que não apresentou nenhum dado durante o período analisado. Conclusão: Faz-se necessário mais produções científicas sobre esse assunto, a fim de aumentar a visibilidade e interesse dos profissionais da área da saúde sobre esse tema.
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... Despite this important change, a wide range of healthcare providers, researchers and trans community organisations have voiced misgivings about the diagnosis "gender incongruence of childhood" (WHO 2018), the ICD-11 diagnosis currently uses for gender-diverse children who have not yet reached puberty(Winter et al. 2019;Cabral Grinspan et al. 2016). Clinical researchers and trans activists argue that the diagnosis pathologises the experiences of children who are merely exploring, embracing, and expressing gender diversity(Ehrensaft et al. 2018). ...
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... 3 However, this condition, which was considered "transsexualism" in the International Classification of Diseases, 10th Revision (ICD-10), is evaluated in a different category as "Gender Incongruence" in ICD-11, and removed from the chapters where psychiatric disorders were listed. 4 Globally, applications for clinical assistance for GD have increased. Recent studies indicate that GD is more prevalent than it was previously estimated to be in the population. 1 The current medical management of GD aims to assist individuals to acquire and express the physical characteristics, gender expression of the gender they identify with, and existence and perception they desire in social domains. ...
Gender Dysphoria and Perceived Social Support: A Matched Case-Control Study
Article
Full-text available
  • Feb 2021
Background In people diagnosed with Gender Dysphoria (GD), low perceived social support from their families and society has been suggested to be associated with poor quality of life and mental well-being. Aim To compare the perceived social support in individuals with GD with that in individuals without GD matched for age and gender. Methods The study group (n = 50) consisted of individuals diagnosed with GD via psychiatric evaluation. A control group (n = 50) was created by matching volunteers without GD by age and gender. Sociodemographic data form, Structured Clinical Interview Form for DSM-IV TR Axis I Disorders (SCID-I), and Multidimensional Scale of Perceived Social Support (MSPSS) were used to gather data from participants. Outcomes comparing the perceived social support, the total and subscale MSPSS scores of groups were calculated. Results The presence of at least 1 psychiatric disorder was significantly higher in the GD group than in the control group, either lifetime or during evaluation (P < .001 and P = .025, respectively). The total MSPSS and family support subscale scores were found to be significantly lower in the GD group than in the control group (P = .001 and P ≤ .001, respectively). When the groups formed on the basis of gender identity (32 trans men vs 32 cis men and 18 trans women vs 18 cis women) were compared, only the family support subscale score was found to be lower in trans men than cis men (P = .005). In addition, comparisons within the groups formed based on sex assigned-at-birth revealed lower total, friend, and family support in those assigned female-at-birth and lower total and family support in those assigned male-at-birth in the GD group. A multiple linear regression analysis revealed that the presence of GD was significantly associated with total and family support MSPSS subscale scores. Clinical Implications The findings show that perceived social support in people diagnosed with GD is lower, even when the presence of psychiatric disorders is included in the analysis. Strengths and Limitations The matched case-control design was the major study strength, whereas the sample size was the major limitation. Conclusion Clinical care of people diagnosed with GD should include the evaluation of diverse sources of social support, efforts to strengthen family and friend support, maintenance of interpersonal relationships, and support of mental well-being. Kaptan S, Cesur E, Başar K, et al. Gender Dysphoria and Perceived Social Support: A Matched Case-Control Study. J Sex Med 2021;XX:XXX–XXX.
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... Many leading trans-affirmative clinicians working with gender diverse youth are against the inclusion of this diagnosis in the ICD (e.g. Winter et al., 2019). They argue that there is no need for a psychomedical framework to be applied to pre-pubescent children who are exploring their gender: 'These young children do not need puberty suppressants, masculinising or feminising hormones, or surgery. ...
Support for parents/carers of primary school aged gender diverse children in England, UK: a mixed-method analysis of experiences with health services
Article
  • Dec 2020
This paper presents findings from a UK mixed-method study that aimed to understand parents/carers' views and experiences of support received from health services for primary school age (4–11) gender diverse children and their families. Data was collected via an e-survey including 10 open-ended questions with 75 parents/carers addressing experiences with (i) primary health services, including general practice (GP) clinics and child and adolescent mental health services (CAMHS) (ii) specialist gender identity development services (GIDS) (iii) non-health related support including transgender groups and online resources. Findings are organised into four themes: ‘journey to health service provision', ‘view on health services used', ‘waiting' and ‘isolation’. Discourses about gender diversity, childhood and the validity of trans healthcare shape parental experiences, including their desire for better information, more certainty in healthcare pathways and more expedient access to support services to reduce anxiety, distress and isolation. The emotional costs of waiting are compounded by the material costs of accessing the limited number of specialist services. Experiences could be improved through ensuring GPs and CAMHS are better prepared, expanding access to trans-specific support groups for those caring for children and young people, and exploring the provision of school-based support for gender diverse primary-age children.
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Das Unbehagen am eigenen Geschlecht – Geschlechtsinkongruenz in der ICD-11
Article
Full-text available
  • Nov 2024
  • PRAX KINDERPSYCHOL K
Sexual Self in Disquiet - Gender Incongruence in ICD-11 The ICD-11 represents a shift in the clinical conceptualization and diagnostic assessment of variant gender identity developments. The revised approach to describing individuals whose gender identity does not align with their natal sex is reflected in the departure from the previous pathogenetic understanding and is demonstrated by the introduction of the diagnosis of "gender incongruence" as a "condition related to sexual health". In this article, the diagnostic and theoretical revisions in the ICD-11 are discussed in the context of previous and ongoing debates about the appropriate classification of this phenomenon in children and adolescents. The practical implications for the treatment of minors are then examined, with a particular focus on adolescents after the onset of puberty. At this age, requests for body-modifying procedures are frequently expressed and present significant clinical and ethical challenges in treatment practice. The diagnostic revisions in the ICD-11 are recognized as a pivotal advance in the de-stigmatization of variant gender identity developments. At the same time, this article argues for the necessity of a clinically oriented approach, which includes careful differential diagnosis and psychotherapeutic exploration, to address the complex needs of adolescent patients, particularly those who seek irreversible body-modifying interventions and often experience significant psychological distress.
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Sexual Orientation and Gender Identity/Expression in Adolescent Research: Two Decades in Review
Article
There is a long history of research among adolescents who are minoritized and marginalized for their sexual orientation and gender identity/expression (SOGIE). However, it remains unclear how we can best conceptualize and assess SOGIE in adolescence, resulting in different subpopulations and findings across studies. Addressing this issue, we present a narrative literature review of the conceptualization and assessment of SOGIE, and provide recommendations for conceptualizing and operationalizing these concepts. Our review indicated that most research with adolescent populations still almost exclusively assesses isolated dimensions of sexuality and gender (e.g., attraction but not identity). We argue that to make research inclusive and equitable, scholars are required to make clear substantiated decisions and be transparent about the SOGIE dimensions and, thus, subpopulations they represent.
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Gender ‘dysphoria’ and ‘variability’: notes on the biomedical management of gender nonconformity in childhood and adolescence
Article
  • Feb 2021
The article discusses modalities of understanding and management provided by the biomedical knowledge for the health care of transgender/gender- nonconforming children and adolescents. Taking as its object the norms, guidelines and resolutions that establish and regulate health practices for the group in question, such as the DSM-V, the World Professional Association for Transgender Health (WPATH)’s Standards of Care (SOC) and the American Society of Endocrinology’s guidelines, it analyzes the diagnostic categories, their criteria and the orientations for the management of clinical interventions. Throughout the three sections of this article, the paper discusses the existing relationship between the biomedical and certain values and social concepts of gender present in these documents. The analysis suggests that despite the supposedly technical character they update some socio-cultural expectations as expressed both in the definitions of the diagnostic categories and in the orientations for hormonal interventions.
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The Notion of Gender in Psychiatry: a Focus on DSM-5 maria Cristina amoretti*
Article
  • Oct 2020
In this paper I review how the notion of gender is understood in psychiatry, specifically in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). First, I examine the contraposition between sex and gender, and argue that it is still retained by DSM-5, even though with some caveats. Second, I claim that, even if genderqueer people are not pathologized and gender pluralism is the background assumption, some diagnostic criteria still conceal a residue of gender dualism and essentialism. Third, I consider gender dysphoria, which is characterized by an incongruence between one's experienced or expressed gender and one's assigned gender; since this condition pertains to distress and disability, not to the incongruence per se, it does not pathologize transgender people. Still, I contend that it should be removed from DSM-5 for theoretical reasons.
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Prepubertal social gender transitions: What we know; what we can learn—A view from a gender affirmative lens
Article
Full-text available
  • Mar 2018
Background: This article provides a review and commentary on social transition of gender-expansive prepubertal youth, analyzing risks, and benefits based on a synthesis of research and clinical observation, highlighting controversies, and setting forth recommendations, including the importance of continued clinical research. Methods: This article involved: (1) a review and critique of the WPATH Standards of Care 7th edition guidelines on social transition; (2) a review and synthesis of empirical research on social transition in prepubertal children; (3) a discussion of clinical practice observations; (4) a discussion of continuing controversies and complexities involving early social transition; (5) a discussion of risks and benefits of social transition; and (6) conclusions and recommendations based upon the above. Results: Results suggest that at this point research is limited and that some of the earliest research on young gender-expansive youth is methodologically questionable and has not been replicated. Newer research suggests that socially transitioned prepubertal children are often well adjusted, a finding consistent with clinical practice observations. Analysis of both emerging research and clinical reports reveal evidence of a stable transgender identity surfacing in early childhood. Discussion: The authors make recommendations to support social transitions in prepubertal gender-expansive children, when appropriate, as a facilitator of gender health, defined as a child's opportunity to live in the gender that feels most authentic, acknowledging that there are limitations to our knowledge, and ongoing research is essential.
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Depathologising gender diversity in childhood in the process of ICD revision and reform
Article
Full-text available
  • Jan 2018
From 2007 on, the World Health Organisation (WHO) has been revising its diagnostic manual, the International Statistical Classification of Diseases and Related Health Problems (ICD), with approval of ICD-11 due in 2018. The ICD revision has prompted debates on diagnostic classifications related to gender diversity and gender development processes, and specifically on the ‘Gender incongruence of childhood’ (GIC) code. These debates have taken place at a time an emergent trans depathologisation movement is becoming increasingly international, and regional and international human rights bodies are recognising gender identity as a source of discrimination. With reference to the history of diagnostic classification of gender diversity in childhood, this paper conducts a literature review of academic, activist and institutional documents related to the current discussion on the merits of retaining or abandoning the GIC code. Within this broader discussion, the paper reviews in more detail recent publications arguing for the abandonment of this diagnostic code drawing upon clinical, bioethical and human rights perspectives. The review indicates that gender diverse children engaged in exploring their gender identity and expression do not benefit from diagnosis. Instead they benefit from support from their families, their schools and from society more broadly.
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Gender trouble: The World Health Organization, the International Statistical Classification of Diseases and Related Health Problems (ICD)-11 and the trans kids
Article
Full-text available
  • Oct 2017
The World Health Organization (WHO) is revising its diagnostic manual, the International Statistical Classification of Diseases and Related Health Problems (ICD). At the time of writing, and based on recommendations from its ICD Working Group on Sexual Disorders and Sexual Health, WHO is proposing a new ICD chapter titled Conditions Related to Sexual Health, and that the gender incongruence diagnoses (replacements for the gender identity disorder diagnoses used in ICD-10) should be placed in that chapter. WHO is proposing that there should be a Gender incongruence of childhood (GIC) diagnosis for children below the age of puberty. This last proposal has come under fire. Trans community groups, as well as many healthcare professionals and others working for transgender health and wellbeing, have criticised the proposal on the grounds that the pathologisation of gender diversity at such a young age is inappropriate, unnecessary, harmful and inconsistent with WHO's approach in regard to other aspects of development in childhood and youth. Counter proposals have been offered that do not pathologise gender diversity and instead make use of Z codes to frame and document any contacts that young gender diverse children may have with health services. The author draws on his involvement in the ICD revision process, both as a member of the aforementioned WHO Working Group and as one of its critics, to put the case against the GIC proposal, and to recommend an alternative approach for ICD in addressing the needs of gender diverse children.
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The Proposed ICD-11 Gender Incongruence of Childhood Diagnosis: A World Professional Association for Transgender Health Membership Survey
Article
Full-text available
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).
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Proposed declassification of disease categories related to sexual orientation in the International Statistical Classification of Diseases and Related Health Problems (ICD-11)
Article
Full-text available
  • Sep 2014
  • B WORLD HEALTH ORGAN
The World Health Organization is developing the 11th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-11), planned for publication in 2017. The Working Group on the Classification of Sexual Disorders and Sexual Health was charged with reviewing and making recommendations on disease categories related to sexuality in the chapter on mental and behavioural disorders in the 10th revision (ICD-10), published in 1990. This chapter includes categories for diagnoses based primarily on sexual orientation even though ICD-10 states that sexual orientation alone is not a disorder. This article reviews the scientific evidence and clinical rationale for continuing to include these categories in the ICD. A review of the evidence published since 1990 found little scientific interest in these categories. In addition, the Working Group found no evidence that they are clinically useful: they neither contribute to health service delivery or treatment selection nor provide essential information for public health surveillance. Moreover, use of these categories may create unnecessary harm by delaying accurate diagnosis and treatment. The Working Group recommends that these categories be deleted entirely from ICD-11. Health concerns related to sexual orientation can be better addressed using other ICD categories.
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Minding the body: Situating gender identity diagnoses in the ICD-11
Article
Full-text available
  • Dec 2012
  • INT REV PSYCHIATR
Abstract The World Health Organization (WHO) is in the process of revising the International Statistical Classification of Diseases and Related Health Problems (ICD) and ICD-11 has an anticipated publication date of 2015. The Working Group on the Classification of Sexual Disorders and Sexual Health (WGSDSH) is charged with evaluating clinical and research data to inform the revision of diagnostic categories related to sexuality and gender identity that are currently included in the mental and behavioural disorders chapter of ICD-10, and making initial recommendations regarding whether and how these categories should be represented in the ICD-11. The diagnostic classification of disorders related to (trans)gender identity is an area long characterized by lack of knowledge, misconceptions and controversy. The placement of these categories has shifted over time within both the ICD and the American Psychiatric Association's Diagnostic and Statistical Manual (DSM), reflecting developing views about what to call these diagnoses, what they mean and where to place them. This article reviews several controversies generated by gender identity diagnoses in recent years. In both the ICD-11 and DSM-5 development processes, one challenge has been to find a balance between concerns related to the stigmatization of mental disorders and the need for diagnostic categories that facilitate access to healthcare. In this connection, this article discusses several human rights issues related to gender identity diagnoses, and explores the question of whether affected populations are best served by placement of these categories within the mental disorders section of the classification. The combined stigmatization of being transgender and of having a mental disorder diagnosis creates a doubly burdensome situation for this group, which may contribute adversely to health status and to the attainment and enjoyment of human rights. 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.
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Mental Health of Transgender Children Who Are Supported in Their Identities
Article
  • Feb 2016
  • Pediatrics
Objective: Transgender children who have socially transitioned, that is, who identify as the gender "opposite" their natal sex and are supported to live openly as that gender, are increasingly visible in society, yet we know nothing about their mental health. Previous work with children with gender identity disorder (GID; now termed gender dysphoria) has found remarkably high rates of anxiety and depression in these children. Here we examine, for the first time, mental health in a sample of socially transitioned transgender children. Methods: A community-based national sample of transgender, prepubescent children (n = 73, aged 3-12 years), along with control groups of nontransgender children in the same age range (n = 73 age- and gender-matched community controls; n = 49 sibling of transgender participants), were recruited as part of the TransYouth Project. Parents completed anxiety and depression measures. Results: Transgender children showed no elevations in depression and slightly elevated anxiety relative to population averages. They did not differ from the control groups on depression symptoms and had only marginally higher anxiety symptoms. Conclusions: Socially transitioned transgender children who are supported in their gender identity have developmentally normative levels of depression and only minimal elevations in anxiety, suggesting that psychopathology is not inevitable within this group. Especially striking is the comparison with reports of children with GID; socially transitioned transgender children have notably lower rates of internalizing psychopathology than previously reported among children with GID living as their natal sex.
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