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Transgender People Aren’t Sick – They Are Failed By An Inadequate Classification System

July 27, 2016

Yesterday, Pam Belluck of the New York Times reported that the World Health Organization is working toward removing transgender identity from the list of mental health disorders in its International Classification of Diseases.

Removing it from the list of mental health disorders is apparently not controversial. The question Belluck spotlights in her piece is the question of what to do with it outside of that list. The WHO is likely to determine that transgender identity represents an illness related to sexual health, instead of one related to mental health. The answer matters if transgender people are still going to want any related medical care to be covered by insurance policies or health plans.

When the American Psychiatric Association demedicalized homosexuality in 1973, the issue was different. By saying that homosexuality was itself not an illness they were not saying that gay people would not, like anyone else, suffer from psychiatric problems. They were simply saying that no one  needed to be treated for homosexuality itself. The kinds of treatments required to help a person whose gender identity and sex assignment don’t match are directly related to that discrepancy, and so a diagnosis recognizing that would still be important.

Calling transgender identity a sexual health issue doesn’t fit many people’s experience, since the issue is one of gender more than sexuality. In addition, finding a name that reduces stigma is also a challenge. “Gender incongruence,” appears to be leading the list of likely new names but as Belluck points out, words have very different connotations in different languages, so something that seems benign in one language is stigmatizing in another. She quotes psychologist Geoffrey Reed, who notes that “In English it sounds kind of neutral … but in Spanish it sounds very bad, it sounds kind of psychotic.”

I have a suggestion. Why not remove the burden of illness from the transgender individual altogether, and call this phenomenon something like “gender misassignment,” thus putting the burden on the system that does the assigning rather than on the individual, whose identity is not a sign of illness.

There are good reasons to do it this way. Gender assignment is a process that happens without consultation of the individual being assigned. In most nations, it is a process that happens at or before birth based on a very brief inspection of genital organs. If the fetus on the ultrasound image or the baby in the delivery room appears to have a penis, it is assigned male and expected to be raised as a boy and develop a boy identity that transitions into “man” over time. If it doesn’t appear to have a penis, it is assigned female and we expect it will be raised as a girl, will develop a “girl” identity that transitions into “woman” over time. This simply doesn’t happen for all of us. The problem is not with the individual, but with the original diagnosis of sex/gender.

If the WHO, and as a result national health organizations, could conceive of transgender people as people who were failed by a system that only had two options for gender when more were needed, or who were misdiagnosed by a system based on an at-birth inspection genitals when there are many more factors involved in shaping how our identities develop over time, then the required care could be provided without considering the transgender person to be sick in the first place. This approach would also facilitate dialogue within national and international health care about gender diversity and the need for a different way of classifying humans by sex and gender from the start. In fact, imagine if by starting this process at the level of the WHO, we could move toward the kind of world that Lois Gould imagined back in 1978 when she published “X: A Fabulous Child’s Story,” where sex/gender isn’t relevant when a child is small. Maybe we’d even end up with societies where reproductive capacities are no longer associated with abilities, interests and positions in society.


Trans & GNC


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