A transgender identity should no longer be diagnosed as a mental disorder, according to the first field study to evaluate a proposed change in the WHO International Classification of Diseases (ICD).



The mental distress experienced by many transgender people is primarily the result of social rejection and violence, the study found. Not, as has been assumed for decades, solely the result of being transgender.



The findings, published in the Lancet, show that viewing transgender people as having a mental illness might force them to get psychiatric care rather than the physical care they seek.

Authors of the “Removing transgender identity from the classification of mental disorders” study also warned that association with mental illness could be used by governments to deny decision-making authority to transgender people, in matters such as child custody and reproduction.

According to the first report by a UK parliamentary committee to tackle transgender issues, which was published earlier this year, as many as 650,000 people in the UK are gender incongruent to some degree. The transphobia they experience undermines their careers, incomes, living standards and mental and physical health, it found.

A third of transgender adults and half of “gender-variant” young people attempt suicide, and transgender people in the UK face high levels of transphobia on a daily basis, the Commons Women and Equalities Committee concluded. MPs urged ministers to draw up a new strategy to tackle discrimination in the NHS, prison service, police and schools.

Changing the classification in the ICD, the most influential medical bible, will have a significant impact on how transgender people are treated by the medical establishment, as well as how they are viewed by society.

“Stigma associated with both mental disorder and transgender identity has contributed to the precarious legal status, human rights violations and barriers to appropriate care among transgender people,” said senior author Professor Geoffrey Reed, of the National Autonomous University of Mexico.

“The definition of transgender identity as a mental disorder has been misused to justify denial of healthcare and contributed to the perception that transgender people must be treated by psychiatric specialists, creating barriers to healthcare services. The definition has even been misused by some governments to deny self-determination and decision-making authority to transgender people in matters ranging from changing legal documents to child custody and reproduction.”

The study’s authors interviewed 250 transgender people. It is the first of several field trials and is currently being replicated in Brazil, France, India, Lebanon and South Africa.

“Our findings support the idea that distress and dysfunction may be the result of stigmatisation and maltreatment, rather than integral aspects of transgender identity,” said lead investigator Dr Rebeca Robles, of the Mexican National Institute of Psychiatry. “The next step is to confirm this in further studies in different countries, ahead of the approval of the WHO revision to the International Classification of Diseases in 2018.”

The study found 83% of participants had experienced psychological distress related to gender incongruence during their adolescence. More than three-quarters had experience social rejection related to gender incongruence, most commonly by family members, followed by school and workmates, and then friends.

Over 60% of participants had been the victim of violence as a result of their gender identity: in nearly half of these cases the violence was perpetrated by a family member. Psychological and physical violence were the most commonly reported, while some experienced sexual violence.

A WHO working group has recommended that transgender identity should no longer be classified as a mental disorder. But it would not be removed from the codebook. Instead, transgender would be moved into a newly created category: conditions related to sexual health.

This, however, has stirred further controversy. “I think there is a bit of a problem with the idea of putting it in a chapter on sexual health because it has nothing to do with sex,” said Dr Griet De Cuypere, a psychiatrist at the Center of Sexology and Gender at University Hospital in Ghent, Belgium, and a board member of the World Professional Association for Transgender Health. “If it’s possible to have it more separately, it would be better.”