Sexual Health Sexual Health Society
Publishing on sexual health from the widest perspective
REVIEW

Gender trouble: The World Health Organization, the International Statistical Classification of Diseases and Related Health Problems (ICD)-11 and the trans kids

Sam Winter
+ Author Affiliations
- Author Affiliations

A School of Public Health, Curtin University, Kent Street, Perth, WA 6102, Australia.

B Corresponding author. Email: sam.winter@curtin.edu.au

Sexual Health 14(5) 423-430 https://doi.org/10.1071/SH17086
Submitted: 24 April 2017  Accepted: 7 August 2017   Published: 13 October 2017

Abstract

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.

Additional keywords: children, ICD, transgender, WHO.


References

[1]  Reed GM, Correa J, Esparza J, Saxena S, Maj M. The WPA-WHO global survey of psychiatrists’ attitudes towards mental disorders classification. World Psychiatry 2011; 10 118–31.
The WPA-WHO global survey of psychiatrists’ attitudes towards mental disorders classification.CrossRef |

[2]  Reed GM, Drescher J, Krueger RB, Atalla E, Cochran SD, First MB, Cohen-Kettenis PT, Arango-de Montis I, Parish SJ, Cottler S, Briken P, Saxena S. Disorders related to sexuality and gender identity in the ICD-11: revising the ICD-10 classification based on current scientific evidence, best clinical practices, and human rights considerations. World Psychiatry 2016; 15 205–21.
Disorders related to sexuality and gender identity in the ICD-11: revising the ICD-10 classification based on current scientific evidence, best clinical practices, and human rights considerations.CrossRef |

[3]  Chou D, Cottler S, Khosla R, Reed G, Say L. Sexual health in the International Classification of Diseases (ICD): implications for measurement and beyond. Reprod Health Matters 2015; 23 185–92.
Sexual health in the International Classification of Diseases (ICD): implications for measurement and beyond.CrossRef |

[4]  Cochran SD, Drescher J, Kismodi E, Giami A, Garcia-Moreno C, Atalla E, Marais A, Vieira EM, Reed GM. 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; 92 672–9.
Proposed declassification of disease categories related to sexual orientation in the International Statistical Classification of Diseases and Related Health Problems (ICD- 11).CrossRef |

[5]  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.
Minding the body: situating gender identity diagnoses in the ICD-11.CrossRef |

[6]  Winter S, Diamond M, Green J, Karasic D, Reed T, Whittle S, Wylie K. Transgender people: health at the margins of society. Lancet 2016; 388 390–400.
Transgender people: health at the margins of society.CrossRef |

[7]  Winter S, Chalungsooth P, Teh YK, Rojanalert N, Maneerat K, Wong YW, Beaumont A, Ho LMW, Gomez FC, Macapagal RA. Transpeople, transprejudice and pathologization: a seven-country factor analytic study. Int J Sex Health 2009; 21 96–118.
Transpeople, transprejudice and pathologization: a seven-country factor analytic study.CrossRef |

[8]  World Health Organization. ICD-11 Beta Draft [Internet]. Geneva: World Health Organisation; 2015. Available online at: http://apps.who.int/classifications/icd11/browse/l-m/en [verified 22 April 2017].

[9]  Robles R, Fresán A, Vega-Ramírez H, Cruz-Islas J, Rodríguez-Pérez V, Domínguez-Martínez T, Reed GM. Removing transgender identity from the classification of mental disorders: a Mexican field study for ICD-11. Lancet Psychiatry 2016; 3 850–9.
Removing transgender identity from the classification of mental disorders: a Mexican field study for ICD-11.CrossRef |

[10]  Beek TF, Cohen-Kettenis PT, Bouman WP, de Vries ALC, Steensma TD, Witcomb GL, Arcelus J, Richard C, Elaut E, Kreukels BPC. Gender incongruence of adolescence and adulthood: acceptability and clinical utility of the World Health Organization’s proposed ICD-11 criteria. PLoS ONE 2016; 11 e0160066
Gender incongruence of adolescence and adulthood: acceptability and clinical utility of the World Health Organization’s proposed ICD-11 criteria.CrossRef |

[11]  Beek TF, Cohen-Kettenis PT, Bouman WP, de Vries ALC, Steensma TD, Witcomb GL, Arcelus J, Richard C, De Cuypere G, Kreukels BPC. Gender incongruence of childhood: clinical utility and stakeholder agreement with the World Health Organization’s proposed ICD-11 criteria. PLoS ONE 2017; 12 e0168522
Gender incongruence of childhood: clinical utility and stakeholder agreement with the World Health Organization’s proposed ICD-11 criteria.CrossRef |

[12]  Costa L, Matzner A. Male bodies, women’s souls: personal narratives of Thailand’s transgendered youth. Philadelphia: Haworth; 2007.

[13]  Besnier N, Alexeyeff K, editors. Gender on the edge: transgender, gay and other Pacific Islanders. Hong Kong: Hong Kong University Press; 2014.

[14]  Olson KR, Durwood L, DeMeules M, McLaughlin KA. Mental health of transgender children who are supported in their identities. Pediatrics 2016; 137 e20153223
Mental health of transgender children who are supported in their identities.CrossRef |

[15]  Ehrensaft D. Gender born: gender made. Raising healthy gender-nonconforming children. New York: Workman Publishing; 2011.

[16]  Ehrensaft D. The gender creative child: pathways for nurturing and supporting children who live outside gender boxes. New York: The Experiment; 2016.

[17]  Ehrensaft D. Gender nonconforming youth: current perspectives. Adolesc Health Med Ther 2017; 8 57–67.
Gender nonconforming youth: current perspectives.CrossRef |

[18]  Pepper R, Brill S. The transgender child: a handbook for families and professionals. San Francisco: Cleis Press; 2008.

[19]  Global Action for Trans* Equality (GATE). Critique and alternative proposal to the “gender incongruence of childhood” category in ICD-11: report of the Civil Society Expert Working Group. Buenos Aires: Global Action for Trans* Equality; 2013. Available online at: https://globaltransaction.files.wordpress.com/2012/03/critique-and-alternative-proposal-to-the-_gender-incongruence-of-childhood_-category-in-icd-11.pdf [verified 22 April 2017].

[20]  Drescher J. Queer diagnoses revisited: the past and future of homosexuality and gender diagnoses in DSM and ICD. Int Rev Psychiatry 2015; 27 386–95.
Queer diagnoses revisited: the past and future of homosexuality and gender diagnoses in DSM and ICD.CrossRef |

[21]  Drescher J, Cohen-Kettenis P, Reed G. Gender incongruence of childhood in the ICD-11: controversies, proposal, and rationale. Lancet Psychiatry 2016; 3 297–304.
Gender incongruence of childhood in the ICD-11: controversies, proposal, and rationale.CrossRef |

[22]  Jokić-Begić N, Altabas V, Antičević V, Arbanas G, Begic D, Budi S, Dumić M, Grubić M, Grujić J, Jakušić N, Stipančić G, Šarić D, Žegura I. Croatia needs a gender incongruence diagnosis for prepubertal children. Arch Sex Behav 2016;
Croatia needs a gender incongruence diagnosis for prepubertal children.CrossRef |

[23]  Lobato MIR, Saadeh A, Cordeiro DM, Gagliotti DAM, Brandelli ÂC, Fontanari AMV, Filho CB, de Garcia CCG, da Silva DC, Salvador J, Schwarz K, Schneider MA, Brambila MI, Giardin A, Monteiro LM, Soll BMB, Real AG. Gender incongruence of childhood diagnosis and its impact on Brazilian healthcare access. Arch Sex Behav 2016;
Gender incongruence of childhood diagnosis and its impact on Brazilian healthcare access.CrossRef |

[24]  Khorashad BS, Talaei A, Bordbar MRF, Modares-Gharavi M, Vakili R, Razavizadeh RT, Koohestani L, Afkhamizadeh M. Iranian gender-nonconforming children will not benefit from the omission of gender incongruence in children diagnosis. Arch Sex Behav 2016;
Iranian gender-nonconforming children will not benefit from the omission of gender incongruence in children diagnosis.CrossRef |

[25]  International Lesbian, Gay, Bisexual, Trans and Intersex Association (ILGA). Statement on gender incongruence of childhood. [Internet]. Geneva: International Lesbian, Gay, Bisexual, Trans and Intersex Association; 2016. Available online at: http://ilga.org/what-we-do/gender-identity-and-gender-expression-program/gender-incongruence-childhood/ [verified 22 April 2017].

[26]  International Campaign Stop Trans Pathologisation. Reflections from STP regarding the ICD revision process and publication of the DSM-5. Granada: International Campaign Stop Trans Pathologisation.2013. Available online at: http://www.stp2012.info/STP_Communique_August2013.pdf [1 August 2013].

[27]  Transgender Europe TGEU calls upon WHO to support gender variant children, not label them as “sick”. Berlin: Transgender Europe; 2015. Available online at: http://tgeu.org/support-gender-variant-children/ [verified 22 April 2017].

[28]  Asia Pacific Transgender Network (APTN). Understanding the ICD: its history, organisation, and engaging Asia and the Pacific in the revision process. Bangkok: Asia-Pacific Transgender Network; 2016 Available online at: https://static1.squarespace.com/static/53cf9459e4b0a5929855f337/t/ [verified 22 April 2017].

[29]  Mokoena N, Ramphele L, Pickstone-Taylor S, Nathanson R, de Villiers A, Dickinson D, Mogapi S, Deyi B, Mabuza X, Ncongwane N, Musikanth C, Moodley T, Moodley M, Toker B, Addinall R, Klopper T, Kheswa S, Kirsten L, Engelbrecht C, De Larch G, Roberson C, Theron L, Thomas E, Kokome L, Bowey G, McLachlan C, Gonyela V, Nel K, West T, Kgositau TR, Petersen A. Cape Town Declaration: Gender incongruence in childhood. Cape Town: declaration of the 2nd Trans* Health, Research and Advocacy Conference; May-June 2014. Available online at: http://www.genderdynamix.org.za [verified 22 April 2017].

[30]  International Lesbian, Gay, Bisexual, Trans and Intersex Association (ILGA). Statement by the ILGA Asia trans* pre-conference (Taipei) on gender incongruence in childhood. Geneva: International Lesbian, Gay, Bisexual, Trans and Intersex Association; 2015. Available online at: http://ilga.org/the-ilga-asia-trans-pre-conference-statement-on-gender-incongruence-in-childhood/ [cited 22 April 2017].

[31]  European Parliament. Annual report on human rights and democracy in the world 2013 and the European Union’s policy on the matter. Strasbourg: European Parliament; 2015. Available online at: http://www.europarl.europa.eu/sides/getDoc.do?type=REPORT&mode=XML&reference=A8-2015-0023&language=EN [verified 22 April 2017].

[32]  European Parliament. European Parliament resolution of 8 September 2015 on the situation of fundamental rights in the European Union (2013–2014) (2014/2254(INI)). Strasbourg: European Parliament; 2015. Available online at: http://www.europarl.europa.eu/sides/getDoc.do?pubRef=-//EP//NONSGML+TA+P8-TA-2015-0286+0+DOC+PDF+V0//EN [verified 22 April 2017].

[33]  Cabral M, Suess A, Ehrt J, Seehole J, Wong J. Removal of gender incongruence of childhood diagnostic category: a human rights perspective. Lancet Psychiatry 2016; 3 405–6.
Removal of gender incongruence of childhood diagnostic category: a human rights perspective.CrossRef |

[34]  Winter S, Ehrensaft D, Pickstone-Taylor S, DeCuypere G, Tando D. The psycho-medical case against a gender incongruence of childhood diagnosis. Lancet Psychiatry 2016; 3 404–5.
The psycho-medical case against a gender incongruence of childhood diagnosis.CrossRef |

[35]  Winter S, De Cuypere G, Green J, Kane R, Knudsen G. The proposed ICD-11 gender incongruence of childhood diagnosis: a World Professional Association for Transgender Health survey. Arch Sex Behav 2016; 45 1605–14.
The proposed ICD-11 gender incongruence of childhood diagnosis: a World Professional Association for Transgender Health survey.CrossRef |

[36]  Riley E. Being human. Arch Sex Behav 2017;
Being human.CrossRef |

[37]  Suess-Schwend A. Gender diversity in childhood: a human right. Arch Sex Behav 2017;
Gender diversity in childhood: a human right.CrossRef |

[38]  Cabral MC. Right answers. Arch Sex Behav 2017;
Right answers.CrossRef |

[39]  Winter S, Riley E, Pickstone-Taylor S, Suess A, Winters K, Griffin L, Ehrensaft D, Tando D, Russell H, Alegre BR, De Cuypere G. The “gender incongruence of childhood” diagnosis revisited: a statement from clinicians and researchers. 2016. Available online at: https://docs.google.com/forms/d/1aSlSKqyZi6zC3-gWm320dFRYawDEwlkM8KerkyN3pg4/viewform [verified 22 April 2017].

[40]  World Professional Association for Transgender Health. Forthcoming ICD-11 proposed draft may contain hope for transgender health 2017 [cited 2017 July 30]. Available online at: http://www.wpath.org/site_page.cfm?pk_association_webpage_menu=1351&pk_association_webpage=3928 [verified 14 September 2017].


Full Text PDF (151 KB) Export Citation Cited By (1)