The WHO is currently revising the International Classification of Diseases (ICD)-10,1 and ICD-11 is expected to be approved in May, 2018. WHO's 194 Member States use the ICD as the international standard for the collection and reporting of health information, and in many countries it is used as a part of the framework for defining governments' obligations to provide free or subsidised health services to their populations; other public and private insurers also use ICD health conditions as a basis for defining eligibility and covered services.2
The classification of conditions related to transgender identity has been controversial.3, 4, 5 This controversy must be understood in the context of serious health disparities, poor access to health services, and experiences of systematic discrimination and violence among transgender people around the world.6, 7 WHO's recent report on “Sexual health, human rights, and the law”8 described how poor access to accurate information and appropriate health services can have serious behavioural and mental health consequences for transgender people, including increased HIV-related risk behaviour, anxiety, depression, substance abuse, and suicide.9, 10 Public and private insurers in many countries often do not provide coverage for transgender-related health services.7, 8, 11
Research in context
Evidence before this study
Current classification systems of mental disorders, including WHO's International Classification of Diseases (ICD)-10 and the American Psychiatric Association's DSM-5, include categories related to transgender identity. These classifications are important in part because in many countries they determine access to health services, but the view of transgender people as having a mental disorder has been increasingly controversial, with calls from many parties, including the European Parliament, to facilitate access to health services for this population in some other way. A WHO Working Group on Sexual Disorders and Sexual Health, comprising experts from all WHO regions, recommended renaming these categories as gender incongruence and moving them to a new proposed ICD-11 chapter on Conditions Related to Sexual Health, which is conceptualised as a more medical chapter. DSM-5 has managed these categories differently, renaming them as gender dysphoria and continuing to classify them as mental disorders, partly based on the rationale that distress or dysfunction are essential elements of the condition. Whether distress and dysfunction in this population should be more appropriately viewed as the result of social rejection, stigmatisation, and violence toward individuals with gender variant appearance and behaviour has provoked substantial questions.
We searched PubMed for all publications in English and Spanish, including meta-analyses and reviews, from January, 1996, to December, 2015, using the terms transgender, trans, transsexual, transsexualism, gender dysphoria, gender incongruence, or gender identity along with the terms violence, stigmatisation, social impairment, or distress. Ample documentation from existing studies shows that transgender people experience high rates of harassment and violence, including sexual violence, not only from strangers but also from their own families and communities. Existing research has provided evidence of associations between experiences of discrimination, social exclusion, and violence and psychological distress, depression, suicide attempts, and elevated risk for HIV infection, with some findings supporting the minority stress model. Other studies have provided evidence of discrimination, stigma, and mistreatment faced by transgender people within the health-care system.
Added value of this study
This results of this first field test of the Working Group's proposals in a relevant health-care setting in a large, middle-income country support the major elements of the ICD-11 proposal. During adolescence, distress was very common among this transgender population, although not universal, and average level of distress was high. Family, social, and work or scholastic dysfunction were also common and typically moderate. However, consistent with previous research on the minority stress model, distress and all types of dysfunction were more strongly predicted by experiences of social rejection and violence than by gender incongruence per se.
Implications of all the available evidence
This study supports the removal of categories related to gender identity from the ICD classification of mental disorders given that distress and dysfunction, considered to be defining features of mental disorders, were not universal and were found to be more strongly related to experiences of stigmatisation and violence than to gender incongruence. Very high observed rates of social rejection and violence experienced by the transgender individuals participating in this study suggest a continuing need for legal protections, social policies, and family interventions to reduce these experiences. This study is being replicated in other countries. The reconceptualisation and related reclassification of transgender-related health conditions in the ICD-11 could serve as a useful instrument in the discussion of public health policies aimed at increasing access to appropriate services and reducing the victimisation of transgender people.
Because of the ICD's important role in defining health conditions and in determining access to health services, retaining health conditions in the ICD-11 related to transgender identity has been widely, although not universally, viewed as necessary in the current global health context.3, 4 In ICD-10, approved in 1990, these categories are called gender identity disorders and are included in the chapter on Mental and Behavioural Disorders.12, 13 However, stigma associated with both transgender status and mental disorders has contributed to precarious legal status, human rights violations, and barriers to appropriate health care among transgender people.6, 7, 8 The definition of conditions related to transgender identity as mental disorders has been used to justify denial of coverage for these conditions by governments and private health plans and has contributed to the perception that transgender people must be treated by psychiatric specialists, further restricting access to services that could be provided at other levels of care. The fact that transgender people have been considered to have a mental disorder has also been misused by some governments to deny self-determination and decision-making authority to transgender people in matters ranging from changing of legal documents to child custody to reproduction.3, 4, 6, 7, 8 In 2011, in a unanimous resolution, the European Parliament called on WHO “to withdraw gender identity disorders from the list of mental and behavioural disorders, and to ensure a non-pathologising reclassification” as a part of the development of ICD-11.14
Categories related to transgender status have been retained in the most recent classification of mental disorders of the American Psychiatric Association, DSM-5.15 DSM-5 renamed gender identity disorder as gender dysphoria, defined by “marked incongruence between one's experienced/expressed gender and assigned gender of at least 6 months' duration” and “clinically significant distress or impairment in social, school, or other important areas of functioning” (p 452). Both the name of the DSM-5 condition—dysphoria—and the diagnostic criteria therefore emphasise distress and dysfunction as integral aspects of the condition and a central rationale for classifying the category as a mental disorder. A challenge to this conceptualisation is the question of whether distress and dysfunction related to the social consequences of gender variance (eg, stigmatisation, violence) can be distinguished from distress related to transgender identity.16, 17
By contrast, the proposal for WHO's ICD-11 is to remove categories related to transgender identity from the Mental and Behavioural Disorders chapter and place them in a new ICD-11 chapter called Conditions Related to Sexual Health,18 which is conceptualised as a more medically oriented chapter. The ICD-11 proposal names the category gender incongruence and emphasises the individual's subjective experience of incongruence between the individual's experienced gender and the assigned sex.3 The proposed diagnostic guidelines note that gender incongruence can be associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning, particularly in disapproving social environments, but neither distress nor functional impairment is a diagnostic requirement.
Mexico, like several other Latin American countries, has some federal protections against discrimination related to gender identity through a general national programme for equality and non-discrimination. Much stronger local protections are in place in Mexico City, where behaviours related to physical or psychological abuse of transgender people and any limitation or restricted access to public spaces, employment, or schools on the basis of gender identity or gender expression are explicitly prohibited. Nevertheless, many transgender people in Mexico City have reported rejection, exclusion, discrimination, and conditions of vulnerability and marginalisation. In one sample of 500 transgender women in Mexico City, 60% had supported themselves through sex work, at least 11% had lived on the street, 25% had been in prison, and a high proportion were HIV positive.19 This study was particularly likely to include marginalised individuals with few economic resources owing to its sampling method, but nonetheless provides an indication of the scope of the challenges faced by this group. Accurate population-based data for the number of transgender people in Mexico City are not available, but a conservative estimate20, 21 would suggest that there are at least 26 700 transgender people among Mexico City's population of 8·9 million and at least 63 600 among the greater metropolitan area's population of about 21·2 million.
Publicly funded health services available to transgender people in Mexico City are scarce. The Condesa Specialised Clinic is the only specialised clinic in the public health-care system in the greater Mexico City area that provides comprehensive services for transgender adults, including hormonal treatment and related medical supervision, psychotherapeutic support, and prevention and treatment of sexually transmitted infections and HIV/AIDS, as appropriate. Individuals are eligible to receive services at Condesa Specialised Clinic only if they have no form of employer-based or private health insurance, so that the clinic mainly serves individuals with few economic resources and many of those who work do so as part of the informal sector. As of the end of 2015, the Condesa Clinic was providing health services to 1395 transgender people. Of these, 1144 (82%) identified as transgender women (trans women) and 16% (n=223) as transgender men (trans men), with the rest identifying in some other way. HIV prevalence among the Condesa population was 40% among trans women and 0% among trans men.22
The aim of this study was to compare the proposed diagnostic elements of ICD-11 gender incongruence, DSM-5 gender dysphoria, and the ICD-10 category transsexualism to transgender people's own self-reported experience of gender incongruence, distress, and dysfunction. Moreover, the study sought to examine whether experiences of distress or dysfunction were universally reported by transgender people in association with their experience of gender incongruence, as would be implied by the conceptualisation of transgender identity as a mental disorder, and whether there was evidence that distress and dysfunction could be attributed to experiences of social exclusion, prejudice, stigmatisation, and violence. This study was done among a sample of transgender people receiving health-care services at the Condesa Specialised Clinic in Mexico City, Mexico, and was the first field test of the ICD-11 proposals for gender incongruence in a relevant health-care setting in a large, middle-income country.
