The "Gender Incongruence of Childhood" diagnosis revisited: A statement from clinicians and researchers

This is an open letter to the World Health Organization (WHO), an agency of the United Nations, from researchers and clinicians working in trans health and rights regarding proposed revisions to the International Statistical Classification of Diseases and Related Health Problems, Version 11 (ICD-11) that relate to healthcare for trans adults and adolescents, as well as gender diverse (GD) children.

We commend WHO for proposed revisions that would move diagnostic categories related to gender transition processes (currently ICD-10’s “F64 Gender identity disorders”) from the chapter of Mental and Behavioural Disorders to a new chapter on Conditions Related to Sexual Health. We also welcome the proposal to eliminate “F65.1. Fetishistic transvestism” and “F66. Psychological and behavioural disorders associated with sexual development and orientation” from the ICD-11 altogether. However, we are concerned about the proposed Gender Incongruence of Childhood (GIC) diagnosis and call on the WHO to reconsider its inclusion. Instead, we urge consideration of less stigmatizing proposals by the GATE Civil Society Expert Working Group and other global experts to facilitate access to psychological support for gender diverse children.

To add your name and voice to this letter, please fill out the form at the bottom. You will be able to view other signatories, after you sign. [Erratum 20150516. Should read, "You will be prompted to view other signatories after you submit your response, or follow the link in the signature section."] For questions about this open letter, please write Sam Winter <sjwinter@hku.hk>. For questions about this web form, contact Kelley Winters <kelley@wintersgap.net>.

For signing the letter please go to: www.gicrevisited.org

General comments on ICD proposals related to gender expression and identity

  1. We follow with interest the progress of the ICD revision process. We look forward to seeing the publication of ICD-11, which we are confident will remain, like ICD-10 (http://goo.gl/MlUnk8), the major diagnostic manual used worldwide.
     
  2. From the ICD-11 Beta Draft (http://goo.gl/tOhj9R) current at time of writing we note a number of revisions relevant to the provision of healthcare for transgender people, defined here as those individuals who identify in a gender other than the one that matches their sex assigned at birth.
     
  3. We support the proposal to abandon the diagnoses of fetishistic transvestism (F65.1) and all diagnoses in the block entitled disorders of sexual preference (Block F66). [Erratum 20150516. Should read, “Psychological and behavioural disorders associated with sexual development and orientation (Block F66).”] We agree that these diagnoses are problematic, in that they have no clinical utility, serve no credible public health need, reinforce defamatory stereotypes, and are potentially harmful to the health and wellbeing of those diagnosed.
     
  4. We support the proposal to remove from the Mental and Behavioural Disorders chapter the diagnoses most commonly used to facilitate gender affirming healthcare for transgender people, and to locate them instead in a chapter called Conditions Related to Sexual Health.
  5. We believe the proposal for a new chapter placement is in line with contemporary clinical understanding, affirmed by professional associations such as WPATH (the World Professional Association for Transgender Health,http://goo.gl/89zAwa), that the gender identities of transgender people are not properly viewed as psychopathological. We note that the psychopathologising perspective does not match (and has in fact sometimes undermined) the provision of effective gender affirming healthcare approaches used in contemporary times to support transgender people who have healthcare needs. Indeed it has contributed to potentially harmful approaches aimed at modifying their gender identities. The WPATH Standards of Care Version 7 (http://goo.gl/rven2O) note that such approaches are unethical. We believe too that the psychopathologising perspective has needlessly increased the stigma faced by transgender people, undermining the right to legal gender recognition.
  6. We support the abandonment of the term gender identity disorder, currently used as an overarching name for the block of diagnoses (F64) most commonly used to facilitate gender affirming healthcare for transgender people. We see the proposed replacement term, gender incongruence, as an attempt to reduce the overly pathologising language inherent in the term gender identity disorder. We note however that the term gender incongruence is not universally supported within transgender communities. See recent press releases by STP (International Campaign Stop Trans Pathologization, http://goo.gl/0GRvA6), and GATE (Global Action for Trans* Equality, http://goo.gl/GHpzog), the latter in association with STP.
  7. We note that there are currently two proposed gender incongruence diagnoses, one for adolescents/ adults, and one for children under the age of puberty. We note with approval language in the descriptions of these diagnoses which avoids binary thinking, and is more inclusive of the diversity in people’s gender identities.
  8. We note that other aspects of the wording of the diagnostic descriptions have attracted criticism. However we focus in the following sections on the proposal for a gender incongruence of childhood (GIC) diagnosis.

Specific concerns about the proposed gender incongruence of childhood diagnosis

  1. First, we note with concern that, regardless of where in ICD-11 the proposed GIC diagnosis is placed, it pathologises the experiences of young children below the age of puberty who are either exploring their identity, or are incorporating their gender identity into a broader sense of who they are, becoming comfortable expressing that identity, and managing any adverse reactions from others. We note that in a number of cultures worldwide these experiences, which we call here gender diversity, would not be regarded as pathology.

  2. We also note that many children who express pronounced and unwavering convictions regarding gender identity, and who have supportive families, do not display any level of distress. Rather, distress occurs when the child feels that their genitals ought to dictate their identity and behaviour.

  3. We note too that, unlike transgender adolescents and adults, gender diverse children below the age of puberty have no need of somatic gender affirming healthcare. These children do not need puberty suppressants, masculinising or feminising hormones, surgery, or indeed medical intervention of any type. They simply need the opportunity and freedom to explore, incorporate and express their gender identity; they need the support and information that enables them to do these things, as well as manage any adverse reactions of others. In our opinion these developmental challenges do not warrant a diagnosis. Furthermore, a diagnosis wrongly signals to the child and their family that there is something wrong or improper with the child.

  4. We note that the WHO Working Group generating the GIC proposal (http://goo.gl/8JiJi2), and the WHO secretariat, have taken a very different diagnostic approach to persons experiencing developmental processes linked to their sexual orientation. There are currently several diagnoses in ICD-10’s Block F66 (for example sexual maturation disorder and egodystonic sexual orientation) that have the effect of pathologising young people exploring same-sex sexual orientation, incorporating their sexual orientation into their sense of self, learning to express their sexual orientation and dealing with adverse reactions from others. To its credit, the Working Group took the view that developmental processes of this sort – exploration, incorporating, expression and reaction-management in regard to sexual orientation – should not be pathologised. The Group recommended that these diagnoses be removed. The ICD-11 beta draft reflects these recommendations. We are perplexed that the Working Group, and WHO secretariat in preparing the ICD-11 beta draft, have not taken the same approach with young gender diverse children, who engage in similar developmental processes, but linked to gender identity.

  5. We note that the Working Group has recommended that healthcare helping young people who experience discrimination on grounds of their sexual orientation can be provided by way of non-pathologising codes in Chapter 21 of ICD-10 entitled Factors Influencing Health Status and Contact with Health Services. These are the so-called Z Codes in Chapter 21 of ICD-10 (currently Q Codes in the ICD-11 Beta Draft, and placed in Chapter 24). Certain Z Codes may be useful in cases where a person is seeking healthcare for reasons associated with stigma and prejudice. We believe a similar Z Code approach should be taken with gender diverse children below the age of puberty (and their caregivers) who require support from the healthcare system.

An alternative proposal and call to WHO

  1. We note the proposals that arose out of the Civil Society Expert Working Group (https://goo.gl/O1NrbJ) that met in Buenos Aires in April 2013. The meeting was convened by GATE, an international organization focused on promoting trans people’s human rights, including to health. The proposals (GATE, 2013) [Erratum 20160516. Should read, “(https://goo.gl/wuPMkI)”] are for facilitating healthcare for gender diverse children below the age of puberty through the use of Z Codes – in most cases minor amendments of already existing Z Codes. Such Z codes would detail the nature of the support being offered to these children and to the adults responsible for caring for them. These codes could facilitate children’s (and caregivers’) access to supportive counselling and information services, as well as to medical examinations linked to approaching puberty. These codes could also be used to facilitate children’s access to school in authentic (gender affirmative) roles. Finally, in those few cases in which young gender diverse children experience distress of an extent and nature demanding clinical mental health care, these Z Codes could be used as markers, attached to generic diagnoses such as depression or anxiety, signaling that the child’s mental health issues are linked to experiences of discrimination on grounds of their gender diversity (with implications for the sort of care needed).

  2. We take the view that arguments for the GIC diagnosis – for example that it will provide a foundation for research and training – appear flawed. We do not believe that research or training in relation to childhood gender diversity would suffer if there were no GIC diagnosis in ICD-11. We note that research into same sex attraction and relationships has thrived since homosexuality diagnosis was removed from the diagnostic manuals decades ago. We believe too that knowledge about the healthcare needs of gay and lesbian youth is better now than it was when homosexuality was a diagnosis.

  3. We note too that key transgender health and rights organisations worldwide other than GATE have spoken out against this proposal. They include ILGA (International Lesbian, Gay, Bisexual, Trans and Intersex association), ILGA-Europe, STP (Stop Trans Pathologization) and TGEU (Transgender Europe). We note also statements arising out of two international meetings examining transgender health, one in Cape Town, South Africa, and the other in Taipei, Taiwan. Finally, we note that the European Parliament in the so called Ferrara Report published in July 2015 called on the European Commission to “intensify efforts to prevent gender variance in childhood from becoming a new ICD diagnosis”. This call was reaffirmed in a European Parliament Resolution passed in September 2015. We are aware of a recent member survey by WPATH that found that a majority of participants were opposed to the proposed diagnosis, with this majority much greater among members outside the USA.

– GATE (https://goo.gl/wuPMkI)
– ILGA (http://ilga.org/)
– ILGA-Europe (http://goo.gl/Z1k636)
– STP (http://goo.gl/oERkcm)
– TGEU (Transgender Europe, http://goo.gl/KRJLlI)
– Cape Town, South Africa (http://goo.gl/vIMwYH)
– Taipei, Taiwan (http://goo.gl/cW4Jxf)
– European Parliament Resolution (http://goo.gl/rBAJRA)
– Member survey by WPATH (http://goo.gl/mAVmgu)

Taking into account all the above, we the undersigned, a group of scholars, researchers and clinicians working in transgender health and rights, call on WHO to abandon the proposed GIC diagnosis and incorporate the use of Z Codes as a means of facilitating and guiding support for gender diverse children below the age of puberty. We commend to WHO the GATE Civil Society Expert Working Group proposal (https://goo.gl/NfdDmg).

Original Signatories

Sam Winter, BSc, PGDE, M.Ed., PhD
Associate Professor, School of Public Health, Curtin University, Perth, Australia.
Discipline: Psychologist.
Years working in field of transgender health and rights: 16.
Clinical services offered for transgender people: Yes
Years doing this sort of work: 14 years.
Clinical services for gender diverse children: Yes.

Elizabeth Riley BSc, GDCouns, MA(Couns), PhD
Counsellor, Clinical & PhD Supervisor, Trainer, Sydney, Australia
Disciplines: Health Sciences & Counselling
Years working in field of transgender health and rights: 18
Clinical services offered for transgender people: Yes
Years doing this sort of work: 20 years.
Clinical services for gender diverse children: Yes

Simon Pickstone-Taylor, MBChB
Honorary Senior Lecturer, Gender Identity Development Service, Division of Child & Adolescent Psychiatry, University of Cape Town, South Africa.
Discipline: Child & Adolescent Psychiatrist and General Adult Psychiatrist.
Years working in field of transgender health and rights: 13.
Clinical services offered for transgender people: Yes
Years doing this sort of work: 13 years.
Clinical services for gender diverse children: Yes.

Amets Suess, PhD, MA, BA
Researcher, Area of International Health, Andalusian School of Public Health, Granada, Spain
Discipline: Sociology, Social Anthropology, Art Therapy, Bioethics
Years working in field of transgender health and rights: 14

Kelley Winters, Ph.D.
Gender Diversity Medical Policy Analyst; author, Gender Madness in American Psychiatry: Essays from the Struggle for Dignity (2008)
Discipline: Interdisciplinary scholarship.
Years working in field of transgender health and rights: 21.

Lisa Griffin, Ph.D.
Virginia Commonwealth University, Richmond, Virginia, United States.
Discipline: Psychologist.
Years working in field of transgender health and rights: 21.
Clinical services offered for transgender people: Yes
Years doing this sort of work: 21.
Clinical services for gender diverse children: Yes.

Diane Ehrensaft, PhD
Associate Professor, Department of Pediatrics, University of California San Francisco
Discipline: Developmental and Clinical Psychologist
Years working in field of transgender health and rights: 25
Clinical services offered for transgender people: Yes
Years doing this sort of work: 30 years.
Clinical services for gender diverse children: Yes.

Darlene Tando, LCSW
Gender Therapist, Private Practice
San Diego, California
United States
Discipline: Licensed Clinical Social Worker
Years working in field of transgender health and rights: 10
Clinical services offered for transgender people: Yes
Years doing this sort of work: 10
Clinical services for gender diverse children: Yes.

Hershel Russell M.Ed, (Couns. Psych)
Registered Psychotherapist,Counsellor, Clinical Supervisor, Trainer, Toronto, Canada
Discipline: Psychotherapist.
Years working in field of transgender health and rights: 15.
Clinical services offered for transgender people: Yes
Years doing this sort of work: 20 years.

Brenda R. Alegre,PhD.
Registered Psychologist and Psychometrician
Assistant Lecturer Faculty of Arts, University of Hong Kong SAR, China
Discipline: Clinical Psychology
Years working in the field of transgender health and rights: 10+ years
Clinical Services offered for transgender people: Yes
Years doing this sort of work: 10+ years
Clinical services for gender diverse children: yes

Griet De Cuypere, M.D. Ph.D.
Former Head of the Gender Team Gent, Belgium
Discipline: Psychiatrist – psychotherapist.
Years working in field of transgender health and rights: 30.
Clinical services offered for transgender people: Yes
Years doing this sort of work: 30 years.

Sign the Letter:

For signing the letter please go to: www.gicrevisited.org
To view current signatories in spreadsheet form, see https://goo.gl/yqta4Q