Abstract The World Health Organization (WHO) is currently updating the tenth version of their diagnostic tool, the International Classification of Diseases (ICD, WHO, 1992). Changes have been proposed for the diagnosis of Transsexualism (ICD-10) with regard to terminology, placement and content. The aim of this study was to gather the opinions of transgender individuals (and their relatives/partners) and clinicians in the Netherlands, Flanders (Belgium) and the United Kingdom regarding the proposed changes and the clinical applicability and utility of the ICD-11 criteria of ‘Gender Incongruence of Adolescence and Adulthood’ (GIAA). A total of 628 participants were included in the study: 284 from the Netherlands (45.2%), 8 from Flanders (Belgium) (1.3%), and 336 (53.5%) from the UK. Most participants were transgender people (or their partners/relatives) (n = 522), 89 participants were healthcare providers (HCPs) and 17 were both healthcare providers and (partners/relatives of) transgender people. Participants completed an online survey developed for this study. Most participants were in favor of the proposed diagnostic term of ‘Gender Incongruence’ and thought that this was an improvement on the ICD-10 diagnostic term of ‘Transsexualism’. Placement in a separate chapter dealing with Sexual- and Gender-related Health or as a Z-code was preferred by many and only a small number of participants stated that this diagnosis should be excluded from the ICD-11. In the UK, most transgender participants thought there should be a diagnosis related to being trans. However, if it were to be removed from the chapter on “psychiatric disorders”, many transgender respondents indicated that they would prefer it to be removed from the ICD in its entirety. There were no large differences between the responses of the transgender participants (or their partners and relatives) and HCPs. HCPs were generally positive about the GIAA diagnosis; most thought the diagnosis was clearly defined and easy to use in their practice or work. The duration of gender incongruence (several months) was seen by many as too short and required a clearer definition. If the new diagnostic term of GIAA is retained, it should not be stigmatizing to individuals. Moving this diagnosis away from the mental and behavioral chapter was generally supported. Access to healthcare was one area where retaining a diagnosis seemed to be of benefit.

Citation: Beek TF, Cohen-Kettenis PT, Bouman WP, de Vries ALC, Steensma TD, Witcomb GL, et al. (2016) Gender Incongruence of Adolescence and Adulthood: Acceptability and Clinical Utility of the World Health Organization’s Proposed ICD-11 Criteria. PLoS ONE 11(10): e0160066. https://doi.org/10.1371/journal.pone.0160066 Editor: Paula Braitstein, University of Toronto Dalla Lana School of Public Health, CANADA Received: January 11, 2016; Accepted: July 13, 2016; Published: October 24, 2016 Copyright: © 2016 Beek et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability: Regarding the availability of the data: as specified in our original submission, due to the sample size of specific subgroups (participants were transgender individuals and/or clinicians specialized in transgender health care), the privacy of the participants may be violated. Therefore data will not be placed in a public repository. However, data will be available upon request from the data manager of the Centre of Expertise on Gender Dysphoria, Mieke Staphorsius, who can be contacted at: data-kzcg@vumc.nl. In the dataset that will be provided, any personal information that might compromise the privacy of the participants has been removed. Funding: The work was supported by the following: the Netherlands - Ministerie Buitenlandse Zaken (Foreign Affairs), Ministerie van Onderwijs, Cultuur en Wetenschap (Education, Culture and Science), Ministerie van Volksgezondheid, Welzijn en Sport (Health, Welfare and Sport) (no grant numbers available); United Kingdom - Nottinghamshire Healthcare NHS Foundation Trust (no grant numbers available). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing interests: I have read the journal's policy and the authors of this manuscript have the following competing interests: Professor Peggy Cohen-Kettenis is a member of the Working Group on the Classification of Sexual Disorders and Sexual Health (WGSDSH) of the World Health Organization. The WGSDSH has developed the diagnostic criteria for Gender Incongruence and advised regarding its placement in the ICD-11. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Introduction The World Health Organization (WHO) is currently updating the tenth edition of their diagnostic tool; the International Classification of Diseases (ICD [1]). The ICD is used as a diagnostic tool for epidemiology, health management and clinical purposes and aids the monitoring of the incidence and prevalence of diseases and other health problems in different countries and populations. The ICD-11 is scheduled to be released in 2018 [2], making the 26 year period between both editions without a revision the longest in the ICD’s history. As part of the development of the new edition of the ICD the diagnostic category of “Gender Identity Disorders” (F64), which includes Transsexualism (F64.0); Dual-role Transvestism (F64.1); Gender Identity Disorder of Childhood (F64.2); Other Gender Identity Disorders (F64.3); and Gender Identity Disorder, Unspecified (F64.4) is being reviewed. WHO’s Working Group on the Classification of Sexual Disorders and Sexual Health (WGSDSH) was given the task of “reviewing and evaluating clinical and research data informing gender identity diagnoses since the publication of the ICD-10 in 1992” [3]. Based on their review, the WGSDSH wrote: “…it is now appropriate to abandon the 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”[3]. The revision of the diagnosis related to gender identity was expected to spark debates, as has been the case when developing the new diagnosis of Gender Dysphoria as part of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) from the American Psychiatric Association (APA) (e.g. [3–7]). The WHO has received many proposals calling for de-pathologization of a diagnosis of gender identity disorder and its removal from the mental disorders section of the classification (e.g. from Global Action for Trans* Equality–GATE [8] and the International Campaign Stop Trans Pathologisation [9]). Furthermore, the European Parliament called on the Commission and the World Health Organization to withdraw gender identity disorders from the mental and behavioral disorders chapter, and to ensure a non-pathologising reclassification in the negotiations on the ICD-11 [10]. The desire to destigmatize gender incongruence and the importance of securing access to care has been described as the central dilemma in both the DSM-5 and ICD-11 revision processes [3]. The WGSDSH has proposed to change the name of the diagnosis from Transsexualism/Gender Identity Disorder to Gender Incongruence and to remove it from the chapter of Mental and Behavioral Disorders to a new chapter (Conditions Related to Sexual and Gender Health) [3]. Currently, four diagnoses have been proposed within the diagnostic category of Gender Incongruence, namely Gender Incongruence of adolescence and adulthood (5A30); Gender Incongruence of Childhood (5A31); Other Specified Gender Incongruence (5A3Y) and Gender Incongruence, Unspecified (5A3Z). See [11]. Some of the suggested changes are: Distress or impairment of functioning not to be required for the diagnosis. Gender Incongruence to be present for a shorter period of time: several months as opposed to two years as per the ICD-10. The wording used to be less binary and therefore the diagnosis to be applicable to a larger group of individuals. The term “experienced gender” to be used as opposed to “opposite sex” or “preferred sex” as currently used in the ICD-10. (See S1 Text for the final draft criteria of ‘Gender Incongruence of Adolescence and Adulthood’ of the WGSDSH criteria used in this study). In the proposed diagnosis, the person will not be required to experience serious distress or functional impairment (e.g. inability to function properly in their job or social life) as a consequence of their gender incongruence in order to fulfill the diagnostic criteria. Formerly, people would only be eligible for the diagnosis, and therefore treatment [3,4], if they experienced serious distress from their gender incongruence or were unable to function properly because of it. Since most health insurance systems use a classification code as a requirement to offer healthcare, it is only when a person has a diagnosis that treatment can be provided. The proposed change entails that people who experience discomfort with their birth assigned gender but who do not experience significant distress or impaired ability to live a functional life (work, socialize, etc.) will now meet the diagnostic criteria and as result, be entitled to access to treatment in many countries. As a result of these broadened criteria, the diagnosis will be applicable to a more diverse group of individuals. Although this may result in increased accessibility to healthcare for transgender people wanting treatment, it may also pathologise individuals who might not have any problems with their gender incongruence nor desire any treatment. Fulfilling criteria for a diagnosis may be experienced by some as stigmatizing although the WGSDSH felt, that by removing it from the mental disorder chapter stigmatization should be reduced [3]. The WHO encouraged the public to provide feedback on the proposed ICD-11 and made the proposed criteria available online [11]. Further input is expected through the results of several field trials in lower and middle-income countries, funded by the WHO. As a part of this process and considering that the proposed changes have a number of advantages and disadvantages, the aim of our study was to gather the views of transgender individuals (and their relatives/partners) and clinicians in the Netherlands, Flanders (Belgium) and the United Kingdom regarding the proposed changes and the applicability and utility of the diagnostic criteria of Gender Incongruence of Adolescence and Adulthood for clinicians. The opinions regarding the GIC diagnosis will be reported elsewhere, see [12]. These countries were selected for a number of reasons. First, the Netherlands, Belgium, and the United Kingdom have established and well developed gender identity clinic services which broadly follow similar standards of care [13,14]. Secondly, they have a different healthcare system as The Netherlands and Flanders (Belgium) have a health insurance system whereas the United Kingdom has not. The study also aims to compare the responses between both countries.

Method and Materials Method Participants & procedure in the Netherlands and Flanders (Belgium). Participants in this study consisted of healthcare providers as well as service users of transgender healthcare and other stakeholders (i.e., parents of trans children, and siblings or partners of trans people). Only people over the age of 16 years were included. The following procedure was followed for the recruitment of healthcare providers: Mental health professionals working in the field of gender incongruence were recruited from the VU University Medical Center Amsterdam Center of Expertise on Gender Dysphoria (VUmc-CEGD); the Gender Team of the University Medical Center Groningen and Transvisie zorg (an organization that provides information, counselling and psychological care for transgender people and their social environment) in The Netherlands; and the Center of Sexology and Gender of the University Hospital in Ghent, Belgium. Specialized healthcare providers were sent a link to an online survey to complete. Healthcare providers who were not specialized in transgender care (e.g., healthcare psychologists, psychiatrists, general practitioners, general practitioners trainees, social workers) were contacted via e-mail through the researchers’ networks and were–after agreeing to participate—invited via e-mail to the online survey. Furthermore, general psychiatrists and psychiatric trainees were invited to participate in the survey following a research session organized by the Dutch researchers. Some people completed the online version, while others completed a pen and paper version of the survey. For the recruitment of service users, transgender adults who came to the VUmc- CEGD for an appointment were invited to participate in the study. If they were interested in participating, their e-mail address was passed to the researcher and a link to the survey was sent. Reasons as to why transgender adults refused to participate were also collected. Parents of children with gender dysphoria were approached using a mailing list from Dutch a support group for parents of transgender children. Parents attending the CEGD at the VUmc were also invited to participate. A total of 758 people were invited to participate in the Dutch survey (from the Netherlands and Belgium). Of this group, 36 people refused participation for various reasons (multiple response options were possible): They did not feel like participating (n = 16); they did not have time (n = 11); it did not matter to them whether or not the diagnosis (terminology and criteria) was changed (n = 8); and other reasons (n = 5). Therefore, 722 agreed to participate and received a link to the survey via e-mail. Despite several reminders, 383 people (53.0%) failed to open the link to start the survey. At the start of the survey, participants first received information about the study and were then asked to give written consent by selecting “yes” in response to the question: “Do you agree to participate in this study?”. Forty-one people gave consent but did not answer any questions so they were removed from the data set. Another 6 participants were excluded as they answered fewer than 5 questions. A total of 292 Dutch-speaking participants (284 from the Netherlands, 8 from Belgium) started the survey and answered at least 5 questions (40.4% of those who received a link to the survey and 38.5% of all participants who were approached). All participants from Belgium were specialized Healthcare providers. The survey was not presented to transgender people/or their partners or relatives in Belgium. The survey was completed by 223 people (76.4% of included Dutch participants). Participants & procedure in the United Kingdom. Information about the study (including the service user recruitment procedure) and information sheets were sent by the research team at the Nottingham Centre for Gender Dysphoria (NCGD) to every Gender Identity Clinic Service in the UK (n = 8) and the four main surgical centers specialized in trans surgery. Healthcare professionals working in these clinics were invited to participate, and if they agreed a link to the online survey was sent. Information regarding reasons for not participating were recorded. Service users were recruited from the nine Gender Identity Clinic Services, including the NCGD. Clinicians provided a brief explanation of the study to the service users and invited them to participate in the study by providing them with a very brief information sheet where a link to the survey could be found. Further information about the study and a consent form were hosted online. A paper copy was offered to potential participants who were not computer literate, had no access to online facilities, or preferred paper and pen. Only three individuals requested a paper copy and these were mailed out with a consent form, information sheet, and return stamped and addressed envelope; however none were returned. A snowballing method was used in order to increase recruitment, with service users sharing the online link with friends and family, and clinicians with their gender and non-gender specialist colleagues. Due to the snowballing methods used the number of invitations sent is unknown. Overall, 552 UK participants entered the survey. Five people opted to answer the questionnaire regarding non-participation. The reasons given were: no opinion of whether the diagnosis changes (n = 1); technical issues (n = 1); not feeling knowledgeable enough (n = 1); adverse to the concept of diagnosis (n = 1); and concerns regarding online surveys (n = 1). In total, 387 completed the survey (70%) and only their responses were saved by the survey software. Seven participants did not progress past the information page, but all others continued to give consent. Participants then dropped out at various stages, the greatest number of drop-outs (n = 71) occurred for questions regarding the positioning of the diagnosis. Of the 387 participants who completed the survey, 50 were not from the United Kingdom and were excluded. One other person was excluded because they were under the age of 16. This resulted in a final UK sample of 336 participants. Participants overall. A total of 628 participants were included in data analysis: 284 from the Netherlands (45.2%); 8 from Flanders (Belgium) (1.3%); and 336 (53.5%) from the UK (see Table 1 below). PPT PowerPoint slide

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larger image TIFF original image Download: Table 1. Frequency Table of Gender Assigned at Birth, Gender Identity, and Level of Education (and Percentages for each Column). https://doi.org/10.1371/journal.pone.0160066.t001 Materials The research team from the CEGD in Amsterdam developed a questionnaire with the input of transgender health care professionals and other stakeholders. This questionnaire covered questions regarding both the Gender Incongruence of Childhood classification (GIC) and the Gender Incongruence of Adolescence and Adulthood (GIAA The opinions regarding the GIC diagnosis will be reported elsewhere, see [12]. The final survey consisted of two parts (see S2 Text for the complete survey). The first part focused on the view of the service users and clinicians with regard to the various changes proposed in the new edition of the ICD (as compared to the ICD-10). The second part was only for healthcare providers and aimed to examine the clinical utility and the clinical implications of the proposed criteria. A special effort was made to explain concepts that some participants may have been unfamiliar with through the use of pop-up information windows that appeared when participants placed their mouse on the blue-colored, bold and underlined words. For example, explanations were provided on the concept of a Z-code (this concerns “factors that affect health and also influence contacts with the healthcare system” but does not concern diseases or disorders) and Disorders/Differences of Sex Development (DSD; when sex development is not completely in the typical male or female direction). The Dutch survey went live on June 2nd 2014 and was open for 10.5 months. The Dutch version of the questionnaire was translated into English by a Dutch translation company and then further amendments to the language were made by the research team in the UK (GW, WB & CR) to ensure appropriateness and ease of use by lay people. Following this, the questionnaire was sent to the lead clinicians at all Gender Identity Clinic services in the United Kingdom, as well as the main providers of gender-related surgery. A meeting took place where stakeholders could comment on the questionnaire and no major amendments were suggested, but the length of the questionnaire was questioned by various stakeholders. However, changes to this could not be made for reasons of consistency with the original Dutch version. During the same period, representatives from the major trans stakeholder groups in the United Kingdom were invited to meet and discuss the questionnaire in detail. The overarching remit given to this group was to remain as closely as possible to the original Dutch version of the questionnaire. Amendments were made to some of the language used, the order of questions, response options, and a small number of new questions was added. The final version was then translated back into Dutch by another Dutch translation company and shared with the team in the Netherlands. The online questionnaire went live in the UK on October 1st 2014 and was open for 7.5 months. The survey began with a series of demographic questions that asked about age, geographical location, gender identity (identification and description), birth assigned gender, education, employment status, and respondent category (i.e., trans, relative, healthcare provider). It then went on to ask about general opinions towards diagnosis and whether the respondent was receiving or had received treatment (if applicable). All questions were fixed-choice options, with spaces provided to answer “other” and add more information if required. The answer options going through the survey were a mixture of one-option responses or multi-option responses, depending upon the question. Options were provided to cover all eventualities, including neutral/no opinion; always with the addition of “other, please specify” or “please explain your answer” to allow for additional comments. For example, questions that asked for level of agreement would give seven main options: “Strongly agree, Agree, agree a little, Neutral; neither agree nor disagree, Disagree a little, Disagree, and Strongly disagree”, plus “please explain your answer”. Questions that asked about opinions (e.g., “Do you think….”) would give four main options: “Yes, No, No opinion, Don’t know” plus “please explain your answer”. The Dutch study was granted full ethical approval (inclusion of Belgian participants and the consent method for participants under the age of 18 was covered) by the Commissie Wetenschappelijk Onderzoek [Committee of Scientific Research] of the EMGO Institute for Health and Care Research (EMGO+) with project ID WC2014-09 and the UK study was granted full Ethics Approval (the consent method for participants under the age of 18 was covered) by the UK National Research Ethics Service Committee East Midlands—Nottingham 1 with IRAS project ID 152591. Data analysis Participants who were healthcare provider as well as a transgender person were included in both the Transgender group (TG) and the Healthcare providers (HCP) group. Differences between participants from the United Kingdom (UK) and participants from the Netherlands/Flanders (NL) were explored with a t-test for continuous data (age), Chi-square tests or Fisher’s Exact test (for the HCP only questions were the sample was smaller and Chi-square assumptions were violated) for categorical data and Mann-Whitney U tests for ordinal data or when t-test assumptions were violated. As participants who were both HCP and TG persons were included in both groups, the TG and HCP group were not independent. Therefore, no statistical differences between these groups were explored. The results of the HCP group are described after the TG group.

Discussion The main aim of this study was to collect the views of service users of transgender healthcare and other stakeholders (i.e., parents of trans children, and siblings or partners of trans people) and healthcare providers regarding the proposed terminology and diagnostic criteria for Gender Incongruence of adolescents and adults in the new edition of the ICD (ICD-11). The study found that overall the proposed changes in the ICD-11 diagnosis of Gender Incongruence of Adolescence and Adulthood were considered an improvement on the ICD-10 diagnosis of Transsexualism. Though a variety of diagnostic terms were mentioned, UK respondents most often chose gender incongruence as the preferred diagnostic term. The two most preferred positions of the GIAA diagnosis in ICD-11 were for it to be placed in a separate chapter dealing with Sexual- and Gender-related Health, or as a Z-code. It should be noted that the name of the new chapter was slightly different in the survey than in the original proposal of the WGSDSH, whose first preference was for placement in a separate chapter focused on gender incongruence only [3]. Their second preference was for the GIAA to be placed in a new chapter focusing on sexual and gender health [3]. In the current ICD beta version, the focus on gender is lost and reads: Conditions related to Sexual Health, see [11]. The preference for placement differed by country; with the first option being preferred by the Dutch and Flemish participants and the latter by the UK participants. This difference may be explained by several factors. First, in the UK, the National Healthcare System (NHS) is funded through central taxation and provides a comprehensive range of health services—the vast majority of which are free at the point of use for people legally resident in the United Kingdom. It is not an insurance-based system and although ICD diagnoses are collected, the funding is not depended upon them; therefore diagnoses which are part of Z-code may still be funded. In contrast, in the Netherlands treatments based on Z-codes are not reimbursed by insurance companies which would make this a less desirable option in terms of service provision. Gender Incongruence as a Z-code might compromise access to care for transgender people, and therefore this placement option may be a less popular choice in the Netherlands than in the UK, where access to care would be unaffected by this change in placement. Second, in the UK, transgender participants more often report experiencing discrimination than in the Netherlands. Also, compared to Dutch participants, more UK participants think a GI diagnosis has a stigmatizing effect. Therefore, the need for destigmatization (in this case through less stigmatizing Z-codes) might be more relevant and stronger in the UK than in NL. When the ICD-11 proposal was made available—and the survey created—this was based on the assumption that a GIAA diagnosis was retained in ICD-11 and removal of the diagnosis was not recommended because this “would undoubtedly prove to be a significant impediment for transgender people seeking access to medical treatment” (p. 575, [3]). Therefore, questions regarding the possibility of excluding the GIAA diagnosis in its entirety from ICD-11 were not extensively explored in the survey. When asked in which chapter the GIAA diagnosis should be placed in ICD-11, only a small number of participants stated that the GI diagnosis should not be in the ICD at all. This response option was the eighth option out of nine and the question does not necessarily imply that there would be a response option for not being in the ICD; so some people might have chosen a category that they found acceptable and might not have finished reading all the options. In other words, their responses might have been based on the idea that if the diagnosis is retained, where should it be placed. The number of people that favored removing the GI diagnosis thus might be higher than the percentage of respondents that picked “It should not be in the ICD at all”. The UK survey included more questions regarding exclusion of the GIAA diagnosis. The findings on this issue, however, seem to contradict responses to other questions: on the one hand, most UK transgender respondents thought there should be a diagnosis related to being trans and thought there were benefits towards a diagnosis; on the other hand almost half of the transgender respondents indicated they wanted to remove the diagnoses from the ICD in its entirety if it were removed from the chapter on “psychiatric disorders” (healthcare providers were split on this question; some wanted to retain the diagnosis, others preferred removal). Also, when asked about the preferred chapter, only a small number of participants thought the diagnosis should not be in the ICD at all. As described above, the desire to destigmatize gender incongruence and the importance of securing access to care has been described as the central dilemma in both the DSM-5 and ICD-11 revision processes [3]. This dilemma is clearly reflected in the results of this study. While many participants thought a GI diagnosis has a stigmatizing effect, many also see benefits in having an ICD-11 GIAA diagnosis. The contradicting findings in the UK survey regarding the preference of retaining or removing the GIAA diagnosis (see above) reflects this dilemma. Therefore, at one point in the survey the desire of a respondent to reduce stigma might have been more salient, whereas at other times the benefits of including a diagnosis (e.g., securing access to reimbursed healthcare) may have been more so. It is worth noting that the survey was somewhat lengthy and so shifts in saliency of competing issues and/or desires are likely. There were no large differences between the responses of the transgender participants and the healthcare providers. Their responses reflected the same dilemmas as the responses of the entire group. Healthcare providers were generally positive about the GIAA diagnosis and most thought the diagnosis was clearly defined and easy to use in their practice/work. The main point of critique of HCPs was aimed towards the duration requirement of “several months”. Almost half of the HCPs thought the duration of “several months” was too short and difficult to determine. Including more practical suggestions by the WHO in the ICD-11 on this matter would be advisable. One such advice could be that a clinician should judge if the gender incongruence is stable enough to permit treatment without mentioning a specific time-frame. Though this may be sufficiently practical for experienced practitioners, it may pose problems for less experienced practitioners. Some limitations were present in this study. First, the recruitment of the transgender participants started with individuals who intended to receive, are receiving, or have received gender identity care (see Table A in S3 Text). Although this allows comparison between both countries, as it is a relatively homogenous group, it does not allow for the views of non-treatment seeking trans people to be collected. Transgender people who do not want or need medical or psychological care [15] may have a different perspective on the GI diagnosis in the ICD-11; and particularly in the matter of widening the scope of the diagnosis as they will then fulfill diagnostic criteria under the new ICD. Transgender people who do not need/want treatment, but do fulfill the diagnostic criteria, might be more opposed to including any GI diagnosis in the ICD-11 than the group included in this study. For the latter, reimbursed medical treatment is only possible in the NL through a diagnostic code other than a Z-code and in the UK some diagnosis must be made for treatment. Therefore, people who need medical care clearly benefit from the presence of a diagnosis as it makes them eligible for reimbursed healthcare. As a result, they might be more positive and less worried about the possible stigmatizing effect of including a GI diagnosis in ICD-11. A second limitation was the fact that the survey was long and involved some complex concepts. As a result, the sample may have been biased towards participants with a higher level of education, and those who may have difficulties understanding the survey may have given up. In addition, only those with strong opinions may have been motivated to complete the survey to the end. This opens up the possibility that the numbers of potentially more ambivalent people are not accounted for. In addition, no paper surveys were completed which also indicated that only those participants with access to the internet took part, which may exclude certain demographics. In conclusion, it seems that respondents were overall in favor of the proposed changes regarding the terminology and diagnostic category of Gender Incongruence of Adolescence and Adulthood (GIAA), albeit with some caveats–especially that clear advice as to the duration of the gender incongruence from the WHO is required. If a GIAA diagnosis is retained, it is important that it is not-stigmatizing, and moving it away from the mental and behavioral chapter will likely help with this. Those who oppose removing (or want to retain) a GIAA diagnosis in ICD-11 seem to have a practical view that in some current health care systems, a diagnosis is needed in order to access healthcare that is reimbursed—and so available to a wide variety of people who require treatment.

Acknowledgments We would like to thank all participants of this survey for sharing their views; all other gender identity clinic and surgical centre services for disseminating the survey; all members of the stakeholder groups for their time and valuable input.

Author Contributions Conceived and designed the experiments: TFB PTCK ALCV TDS WPB GLW JA CR BPCK. Performed the experiments: TFB ALCV TDS GLW BPCK. Analyzed the data: TFB GLW JA BPCK. Contributed reagents/materials/analysis tools: TFB PTCK ALCV TDS WPB GLW JA CR BPCK. Wrote the paper: TFB PTCK ALCV TDS WPB GLW JA CR EE BPCK. Interpretation of data: TFB PTCK ALCV TDS WPB GLW JA CR EE BPCK.