“We Are Not Confused”


The U.N. headquarters with a pride flag flying atop it.

Photo illustration by Slate. Photos by Thinkstock.

This post is part of Outward, Slate’s home for coverage of LGBTQ life, thought, and culture. Read more here.

Trans identities will no longer be classified as a mental health issue, according to an announcement made in June by the World Health Organization, the United Nations’ international public health arm. In the organization’s latest International Classification of Diseases (ICD-11), the term gender incongruence will be in an umbrella chapter of sexual health and away from the mental health chapter.

“On the local level … the change is groundbreaking,” said Danielle Castro, project director at the Center of Excellence for Transgender Health at the University of California, San Francisco. “Being trans is not a mental health issue,” but it’s the issues people face due to transphobia that lead to various health concerns in the trans population.

“People are really misinformed about what being trans is,” she explained.

In reclassifying trans identities, the WHO hopes to change that and to end the stigma around being trans by removing the barriers trans people may face when seeking medical care. The organization underscored the absence of evidence transgender people must have some mental health illness. Listing “gender incongruence” under sexual health, it said, would still provide trans people access to needed health services without exposing them to transphobia. These services could include hormone therapy, psychological support, and gender-affirmation surgery, among other care depending on the person. It could also include simply going for a checkup.

“This change makes it more possible to envision a world in which trans and gender diverse people are recognized as people first,” Cianán Russell, Transgender Europe’s U.N. officer, told Slate. “When health care providers carry anti-trans bias and cissexism into their practice, this can lead to poor, inaccurate, or even withheld care for general medical issues, sometimes concluding with trans and gender diverse people dying from otherwise treatable conditions as a result.”

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The WHO has stripped the Trump administration its argument that trans people cannot serve in the armed forces because they’re mentally ill.

In 2019, countries will vote to officially adopt ICD-11. It will not go into effect until 2022 because, as the WHO explains, the early release will allow member states “to plan how to use the new version, prepare translations, and train health professionals.”

ICD-11 contains all of the WHO’s officially recognized diseases, illnesses, and disorders along with information related to them. It is also the basis for insurance companies around the world including the in the United States.

“Historically, the pathologisation of gender identity through ICD over the past decades has contributed to the enormous stigma, discrimination, harassment, criminalization, and abuse on the basis of gender identity and expression,” Transgender Europe said in a statement.

In Europe, 34 countries require trans people to receive a mental health diagnosis before allowing them to change legal documentation related to their gender identity. Fourteen countries on the continent still require the forced sterilization of trans people.

However, it’s difficult to fully know whether the change in the ICD-11 will change laws, says Russell.

“What is very likely is that the problems in the link between access to medical transitional care and to legal gender recognition will become better understood as the gatekeeping role of health care providers is removed and replaced with a more appropriate role based on knowledge,” Russell explained.

In the United States, the Trump administration has used the WHO’s classification of “transsexualism” as a mental health disorder to support its ban on open transgender military service. Its reclassification in the new ICD will strip the administration of a key component of its argument that trans people cannot serve due to concern over their mental health. The administration has also rolled back protections for trans people in education, housing, and health care. The new ICD may provide legal fodder for opponents of these policies as they challenge them in court.

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About 0.7 percent of people in the U.S. identify as trans in some way. A Lambda Legal study found that 70 percent of transgender Americans said they have been discriminated against while receiving medical care. The organization defined discrimination as anything from being refused needed medical attention, to having medical professionals refuse to touch trans people, to being openly abusive toward trans patients.

“The change in classification in trans care puts it where it belongs with other medical care and removes it from being forced to sit with mental healthcare,” said Joshua Safer, the executive director of the Mount Sinai Center for Transgender Medicine and Surgery in New York. He added that the reclassification could also spur more insurance companies to potentially offer a broader range of transition-related treatments.

The next step, Safer explained, is to ensure that transgender care is as routine as any other type of medical treatment. Eventually, most medical professionals should be sufficiently educated to provide trans individuals with appropriate care. For now, specialists like Safer are cheering the WHO’s decision.

“We are not confused,” he said, “and neither are our patients.”



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