Why and how to support depsychiatrisation of adult transidentity in ICD-11: A French study

Abstract

Background:For the 11th version of the International Classification of Diseases, the WHO recommended to rename transgender transidentity as “gender incongruence”, to remove it from the chapter of mental and behavioral disorders, and to put it in a new category titled “Conditions related to sexual health”. This should contribute to reduce stigmatisation while maintaining access to medical care. One argument in favor of depsychiatrisation is to demonstrate that essential features of gender identity disorders, namely psychological distress and functional impairment, are not necessarily reported by every transgender person, and may result from social rejection and violence rather than dysphoria itself. Initially confirmed in Mexico, these hypotheses were tested in a specific French medical context, where access to care does not require any prior mental health evaluation or diagnosis.Method:In 2017, 72 transgender persons completed retrospective interviews which focused on the period when they became aware that they might be transgender and perhaps would need to do something about it.Results:Results showed that psychological distress and functional impairment were not reported by every participant, that they may result from rejection and violence, and especially from rejection and violence coming from coworkers and schoolmates. Additional data showed that the use of health services for body transformation did not depend on distress and dysfunction. Finally, participants preferred ICD 11 to employ “transgender” or “transidentity” rather than “gender incongruence”.Conclusion:Results support depsychiatrisation. They are discussed in terms of medical, ethical, legal, and social, added values and implications of depsychiatrisation.

The expectations of transgender people in the face of their health-care access difficulties and how they can be overcome. A qualitative study in France

“…By way of their particular characteristics (comprehensive approach, accessibility), GPs enable a reduction in the levels of morbidity and mortality among transgender people (Reisner et al, 2016;Wylie et al, 2016;Aitken, 2017). In many health-care systems, GPs are the primary prescribers of hormone treatments (Sansfaçon et al, 2018;Askevis-Leherpeux et al, 2019).…”

“…The person can also access to care via a primary care pathway, with the support of a mixed network of health-care providers and local trans associations, in a way close to the WPATH standards of care (Coleman et al, 2012;Askevis-Leherpeux et al, 2019; Reseau sante trans, 2020). The mixed network can give support to the health-care providers, with opportunities for exchange on practices and improvement of their medical skills.…”

“…The person makes an appointment with the GP, and a reactive, personalized evaluation is conducted. Transgender people are considered by GPs like any other people with a medical request (Askevis-Leherpeux et al, 2019). In this trajectory, to our knowledge, access to care seems easier, without a systematic psychiatric evaluation, and without long waiting lists.…”

“…They wanted psychiatric follow-up to be adapted to the needs and requests of the persons concerned. One of the first arguments in favor of depsychiatrization is that the main characteristics of mental disorders among transgender people result more from social rejection and violence than from transgender-identity per se (Robles et al, 2016;Campbell et al, 2018;Askevis-Leherpeux et al, 2019). In addition, this systematic psychiatrization of the health pathway contributes to precariousness in access to rights and the creation of barriers to accessing appropriate health-care (Robles et al, 2016).…”

Transgender identity and mental health in adolescence: a scoping review

“…(48) The 2019 update of the classification (ICD-11) sees gender identity-related health now categorized with conditions related to sexual health, in acknowledgement of evidence from several regions indicating that gender diverse identity is not in itself a mental health issue and that, furthermore, classifying it as such leads to barriers to health care access and stigmatization of TGDNB people. (48-50) This research, undertaken among transgender adults to inform policy, underscored that most transgender individuals became aware of their gender identity in childhood or adolescence, that dysphoria related to gender identity was not a universal experience and that experience of stigma had the strongest impact on their mental health and other outcomes. Given the 2018 Lancet Commission’s imperative to adopt a life-course perspective on mental health, (1) it is important to consider the chronic nature of gender minority individuals’ experience of social adversity and stigma.…”