This is a proposal, including case examples, on future transgender health care outside the psychiatric classification. Support this proposal and tell WHO gender variation is not a mental disorder.
Dear World Health Organization,
thank you for the opportunity to provide feedback on the ICD revision process.
I am happy to share with you our vision for transgender care in the future building upon our consensus document downloadable at http://www.grevsen.dk/TS/SPGV.pdf
The document was developed spring 2011 during the second commenting period of the APA DSM5 revision process. It was distributed world wide to all organizations in the ILGA directories, to the TGEU member organizations, to the GID Reform Advocates and a number of other organizations and individuals in the field. In total more than three hundred organizations were allowed to submit feedback within a time frame of roughly two months. Currently 37 organizations have signed the document including such groups as Amnesty, the Danish Association of Sexologists, and International Medical Collaboration Committee Copenhagen.
For several reasons we believe gender variations should no longer exist as central diagnostic categories within ICD. Apart from the reasons already explained in the consensus document they are:
1. According to the Transgender Europe mappings available at http://www.transrespect-transphobia.org/en_US/mapping.htm ALL countries in the European maps allowing legal gender recognition of trans persons depend on a psychiatric diagnosis. Thereby a central gender diagnosis appears to be an obvious point of control, not only limiting access to care, but limiting the civil rights of transgender people as well. Many countries require similar evaluations prior to a simple name change.
This may well remain true even if a central somatic diagnosis was introduced.
2. As documented in the consensus document the number of people seeking a change of passport gender markers is expected to be approximately an order of magnitude higher in a country which do not require psychiatric evaluation prior to obtaining such documents compared to another country, which do so. It is quite possible that people in need don’t seek medical care just as they don’t seek recognition limiting their quality of life, because of the stigma associated with diagnosing gender variation as a mental disorder and the troublesome process. It may also make gender variant people view themselves in a negative light just for being who they are.
3. We note that human biology is diverse. A number of variations exists, where people develop unwanted hair growth, excessive breast tissue or even undeveloped genitals. We believe people in need of care for such variations deserve the same respect be the ethiology a known genetic variation or be it transgenderism. Since these diagnoses are not in essence restricted to specific conditions one group in need of such care should not be discriminated against and singled out as mentally ill.
It is perfectly possible and a lot more flexible to allow gender variant people access to care under the individual codes relating to their treatment needs.
A transgender woman approaches her doctor requesting hormonal treatment. The doctor examines her and offers her advice on possible treatments including counselling to determine her needs just as if she had been any other woman lacking natural estorgen production. Since she was born without ovaries, she receives the diagnosis Q50.0 Congenital absence of ovary and is refered for hormone replacement therapy.
While they are at it they also discuss her excessive hair growth and her voice. She is refered for hair removal under the diagnosis L68.0 Hirsutism and for speech therapy under the diagnosis R49.0 Dysphonia.
In line with the standards of care following one year of hormonal treatments the woman may approach her doctor for genital surgery if desired. Since she was born without a vagina, the surgery is provided under the diagnosis Q52.0 Congenital absence of vagina.
At no point during her treatment did she have to be singled out as a gender variant person or classified with a mental disorder.
A transgender man approaches his doctor requesting hormonal treatment. The doctor examines him and provides information on possible treatments including counselling to determine his needs just as if he had been any other man lacking natural testosterone production. Since he was born without testicles, he receives the diagnosis Q55.0 Absence and aplasia of testis and he is refered for hormone replacement therapy. He may also approach the doctor with discomfort about excessive breast growth, which can be treated under the diagnosis N62 Hypertrophy of breast.
In line with the standards of care following one year of hormonal treatments the man may approach the doctor for genital surgery if desired. Since he was born with an underdeveloped penis, the surgery is provided under the diagnosis Q55.5 Congenital absence and aplasia of penis. Testicular implants can be offered under the diagnosis Q55.0 Absence and aplasia of testis.
Again, at no point during his treatment did he have to be singled out as a gender variant person or classified with a mental disorder.
As with any other medical treatment, the provider may request the tests necessary to determine the appropriateness of the treatment. That is a fact, which does not depend on how the treatment is classified. When that is said, we do want to draw your attention to the report Discrimination on Grounds of Sexual Orientation and Gender Identity in Europe, by the Council of Europe, which recommends:
”Review any requirements of a diagnosis of mental disorder for accessing transgender health care in view of eliminating obstacles to the effective enjoyment, of transgender persons, of the right to self-determination and the highest attainable standard of health
Make gender reassignment procedures, such as hormone treatment, surgery and psychological support, accessible to transgender persons subject to informed consent and ensure that they are reimbursed by health insurance.”
(Hammarberg T. Discrimination on grounds of sexual orientation and gender identity in Europe. Council of Europe Publishing, june 2011 p. 110. URL: http://www.coe.int/t/Commissioner/Source/LGBT/LGBTStudy2011_en.pdf)
And we note that the Standards of Care expresses support for the informed consent model as well
”A number of community health centers in the United States have developed protocols for providing hormone therapy based on an approach that has become known as the Informed Consent Model. These protocols are consistent with the guidelines presented in the WPATH Standards of Care, Version 7. (…) The difference between the Informed Consent Model and SOC, Version 7 is that the SOC puts greater emphasis on the important role that mental health professionals can play in alleviating gender dysphoria and facilitating changes in gender role and psychosocial adjustment.” (WPATH. Standards of Care for the Health of Transsexual, Transgender and Gender Nonconforming People, Seventh version, 2011 p. 35. URL: http://www.wpath.org/documents/Standards%20of%20Care%20V7%20-%202011%20WPATH.pdf )
1. As shown, the diagnoses of gender variation are not necessary to provide transgender health care and we propose their removal from ICD.
2. To facilitate the use of Q5x diagnoses in transgender care we suggest renaming or merging the categories "Developmental anomalies of the female genital system" and "Developmental anomalies of the male genital system". This would also make better sense in case of intersex conditions, where persons may not identify or classify as one of the common sexes.
3. We suggest WHO issues a supporting statement facilitating the switch in classification of transgender health care among practitioners and insurance companies.
We note, that this proposal is in line with the main demand of the 270+ organization STP-2012 movement as well as a multitude of other movements around the world:
”The removal of 'Gender Dysphoria' / 'Gender Identity Disorders' categories from the international diagnosis manuals (their next versions DSM-5 and ICD-11).” (http://www.stp2012.info/old/en/objectives)
Finally we want to present to you a petition for removal of gender diagnoses from the classification of diseases signed by more than 10.000 persons in a country of only roughly 5.400.000 citizens!
Feel free to contact us in case of questions regarding this proposal or the consensus document downloadable at http://www.grevsen.dk/TS/SPGV.pdf