Transgender health, the WHO, and the purpose of diagnostic manuals

By Rebecca Oas, Ph.D. | July 28, 2016

As we discussed in a recent Friday Fax, the World Health Organization (WHO) is contemplating changes to its forthcoming updated diagnostic manual, including its handling of individuals who identify as transgender.

A recent article published in The Lancet continues that theme, based on a field study in Mexico. According to the authors, the study “provides additional support for classifying health-related categories related to transgender identity outside the classification of mental disorders” in the new manual.

To give a brief summary, the current movement in psychiatric diagnosis is to remove the classification of gender identity issues from the mental illness category and instead focus on the suffering such individuals endure from being in a body that does not correspond to their perceived gender (“gender dysphoria.”) However, the WHO is proposing to go one step further and move gender identity issues out of the “mental disorders” category altogether—no firm decision has yet been made as to where they should end up in the manual.

Transgender advocates argue that being diagnosed with any kind of mental disorder adds a further stigma to those already stigmatized for being transgender. However, diagnosis with a disorder, whether physical or mental, is often the starting point for prescribing treatment, and provides the justification for such treatment to be paid for by either a nationalized health service or the patient’s private insurer. There’s something a bit odd about telling a patient, “You’re perfectly healthy and normal, here are some hormones to alter your appearance, and we’ll schedule a date for your surgery soon.” While elective surgical treatments certainly do exist, they are still subject to certain regulations, and are often paid for out of pocket.

The Lancet article unsurprisingly supports the proposed change to WHO’s manual, but a few further points should be clarified: first, that the study was specifically undertaken to gather evidentiary support for the change, and second, that the sample population is not exactly random:

“This was a retrospective interview study of adult transgender people (aged ≥18 years old) who were receiving transgender-related health services at the Condesa Specialised Clinic in Mexico City. … The research assistant provided a full explanation of the study, including the focus of the interview.”

It’s understandable that due to the minute size of the transgender population, a random selection process would have to be massive to find enough eligible participants. However, it’s worth pointing out that there are people with gender identity issues not represented in this study due to the fact that they are not seeking “transgender-related health services” (e.g. hormone treatments or surgery) at all. Might different results be obtained if the authors based their sample on persons seeking mental health services for their gender identity issues instead?

Additionally, the participants were given a “full explanation” of the study prior to their involvement. It’s unclear whether that explanation included mention of the proposed WHO diagnostic change, but the potential for advocacy and targeted participant recruitment to influence the outcome of the study seems worthy of note. Ultimately, 250 participants did the whole interview, of which 81% were born male (or, if you prefer, “assigned a male sex at birth.”)

Perhaps the clearest evidence that ideology is running the show here is in a companion “comment” piece that also appeared in The Lancet. Its authors, Griet De Cuypere and Sam Winter, noted that while the diagnosis of “gender incongruence” will likely be removed from the chapter on “disorders,” its ultimate location is still under debate. It is provisionally slated for a new chapter on “Conditions Related to Sexual Health,” although De Cuypere and Winter express concern that while this might reduce stigma, placement in a “more medical chapter” might “serve to conflate concepts of gender and sex.”

“There was also controversy concerning the name “gender incongruence”. Some … find this name pathologising, as the term incongruence presumes normative thinking around appearance. Another argument against the name is that translation into other languages can be difficult and sometimes carry negative connotations.”

Based on this analysis, one would think that the primary purpose of any change to the diagnostic manual must be to affirm the notion that being transgender is absolutely normal, totally healthy, and not in any way the result of any disorder—at least not on the part of a transgender person. De Cuypere and Winter write:

A prominent UN advocate [the UN Secretary-General’s Special Envoy for AIDS in Asia and in the Pacific] has put it this way: “Transphobia is a health issue.”

Perhaps the next iteration of the WHO’s diagnostic manual will label it as a mental health disorder.