Revisiting “being trans is a mental disorder”: Map and territory in ICD-11

The last time I addressed the faulty argument of “being trans is a mental disorder – it’s in the DSM” – a belief still held by more than 20% of Americans – I noted that such a labeling does not actually imply that gender dysphoria should be treated any differently than the current standard of care. The same organization responsible for placing gender dysphoria in the DSM has also gone to great pains to explain that gender affirmation and medical transition are known to be the most effective and successful treatments, and that its presence in the DSM is meant to facilitate access to this care rather than hinder it. Whether or not gender dysphoria is termed a “mental disorder” does nothing to alter the substantial body of research and clinical experience showing that the affirming approach produces the best known outcomes – a goal that is more important than whatever is being accomplished (stigma, exclusion, and invalidation) by ignorantly accusing trans people of being “mentally ill”.

At the time, I pointed out that the World Health Organization was in the process of considering whether the next version of the International Classification of Diseases should move gender dysphoria out of “mental and behavioural disorders”. That day has now come: the ICD-11, unveiled this month, renames the previous gender identity disorders to “gender incongruence” and places this in the category of “conditions related to sexual health”.

This is a moment to stop and observe how labels, and the actual content they refer to, interact in real time. With this recategorization, did the clinical approach to gender dysphoria suddenly shift radically, with this choice of words and categories now validating physical medical interventions that were previously unjustifiable in treating this “mental disorder”? No – those underlying clinical realities have not changed.

What has changed is that the terminology of “mental disorder” is now recognized as inaccurate and unhelpful in describing gender dysphoria. Professor Sam Winter, a member of the WHO Working Group on Sexual Disorders and Sexual Health, observes that the “mental disorder”was “a classification that was a historical artifact, had little basis in science, and had massive consequences for the lives of trans people.” The WHO has explicitly stated that “evidence is now clear that it is not a mental disorder, and indeed classifying it in this can cause enormous stigma for people who are transgender”.

This is a process that does not flow in the direction that many transphobes seem to believe it does, with the reshuffling of labels and categories somehow restructuring the underlying reality to which they refer. Instead, this process recognizes the distinction between a map of the territory and the territory itself, with terminology being deliberately revised over time to reflect our evolving understanding of the world. As psychiatrist Jack Drescher, who served on the American Psychiatric Association’s DSM-5 Workgroup on Sexual and Gender Identity Disorders, pointed out in 2016:

The ICD and DSM are expert consensus documents, and neither should be thought of as a “bible.” They are more like a user’s manual. As psychiatric diagnoses have changed over time, they presumably will change again based on new knowledge from research and clinical experience.

It is a satisfying irony that the bad-faith argument leveraging mental health stigma against trans people would ultimately become one of the strongest motivations for global health authorities to pull the rug out from under it. ■