Insight, Policy Matters, Oct '16
Debjyoti Ghosh on the World Health Organisation’s plans to delist transgender identity as a mental disorder
“All people, including lesbian, gay, bisexual and transgender people, are entitled to enjoy the protections provided for by international human rights law, including in respect of rights to life, security of person and privacy, the right to be free from torture, arbitrary arrest and detention, the right to be free from discrimination and the right to freedom of expression, association and peaceful assembly” – United Nations High Commissioner for Human Rights in Discriminatory Laws and Practices and Acts of Violence against Individuals Based on their Sexual Orientation and Gender Identity, a report published by the United Nations in 2011. The ‘trans body’ has been the site of many battles – battles of how to demarcate it, diagnose it, control it, and many times in history, not even acknowledge it (and if possible, remove it from its rightful place in human history). I use the word ‘trans’ for the sake of brevity but it as an umbrella term, and stands for several supposedly non-normative gender identities – trans woman, trans man, genderqueer and gender fluid to mention a few – that have not received the respect due to them.
European colonizers needed to control the new, ‘discovered’ and conquered populations, including non-normative, ‘deviant’ humans, or even ‘sub-human’ and ‘savage’ in their rhetoric. To fit the small identity boxes of binaries brought in by them was crucial. This carried on in the post-colonial period, and it took many embattled years for people of colour, people with different sexualities, and people of different gender definitions to get on an equal footing with everyone else.
For people with non-normative genders though, the battles still carry on, primarily because this type of difference from the norm is even now considered to be a ‘mental disorder’, which, once diagnosed, can be ‘fixed’ by hormones and surgery, thus, once again, placing such persons in either side of the gender binary.
Throughout medical history, disorders were ordained so in specific social, temporal and power settings. What was considered to be possession by the devil in the Middle Ages was relegated to the annals of psychiatric disorders later. Visions of gods and angels were diagnosed as hallucinations. Bodily possession by the devil or by ghosts was diagnosed as different types of fits.
In the same way, the ‘unknown’ body of the trans person has traversed through many different paradigms before landing in the type of conflicts we see today. From being a monster, a curse, the subject of mysticism, reverence and fear, and to finally being put in the terms of a mental disorder, trans identities have come under fire since a long time.
The way gender is perceived by society has undergone massive changes in the last 100 years or so. From the absolutely unchangeable to the transient, different perceptions about it have been used to control women, people of colour and trans people the world over.
The medical field is no exception to these perceptions – many misconceptions, lack of knowledge and high levels of controversy have all gone into perceiving non-normative gender identities as mental disorders. The easiest way to deal with them is to push them into the corner of mental disorders (along with the likes of kleptomania and others) and then treat them in a clinical manner, never mind if this only dehumanizes the individual. This also means that mental health experts hold the keys to the gateway of access to procedures like hormone replacement therapy and gender or sexual reassignment surgeries.
The ICD10 has been in force since 1990, after being drafted and finalized over the preceding years. Since then, several changes in perception about the trans body and trans identities have taken place in the world, both in scientific advancements as well as social movements. Several countries have seen quite a surge in trans rights movements, both jointly and separately from gay and lesbian movements.
Section F64 of the ICD10 classifies trans people as suffering from a mental disorder called the gender identity disorder. This has led to further stigmatization of an entire section of society, above and beyond the social stigma they already face for not fitting into normative gender frameworks. In many places in the world where trans people have legal rights as equal citizens, they are often required to necessarily ‘fit’ into either the (trans) man or (trans) woman categories, unlike India and some other countries that have a third gender category.
In law and medicine, the term ‘disorder’ strikes a reader as being something outside the normative. Terminology often makes all the difference in society – it helps create positive and negative narratives, and acts as the basis for different types of significations. A change in terminology not only influences health care providers, but also the primary stakeholders themselves. Being considered ‘disordered’ has a stigmatizing affect on the stakeholders, not just from the medical perspective but also the social perspective.
When the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM5) was published, and ‘gender identity disorder’ was replaced by ‘gender dysphoria’ , which means a state of discomfort to be in the body one is born in, it brought about a breakthrough in the way many behavioural health experts looked at trans people. This was a culmination of years of activism as well as the support of several mental health experts in USA. The DSM code influences the medical practices of several other countries as well. Now the ICD code is set to follow suit. The ICD11 has had its delays. It was supposed to have its technical components completed in 2014, with the World Health Organisation (WHO) passing it in 2015. However, given its enormity and complexity, and the several important changes being brought about, it is still in the making, and there is a High-Level Revision Meeting with Member States taking place in Tokyo in October 2016, with the field testing in 2017 and the publishing of its final form in 2018.
Replacing ‘disorder’ with ‘dysphoria’ in the 11th edition of the ICD will give people who identify outside the so called gender norms a reprieve from being viewed only through the medicalised gaze. It will decrease the burden of having the dual stigma of being considered the ‘diseased other’, while trying to navigate societal identities.
This change has been years in coming, and it is high time that it is brought about. This move shifts the paradigm from the 1940s’ conception of sexual deviance framed in the 6th edition of the ICD, and trans identities as being seen as psycho-pathological models under it, and updates it to reveal the changes around the world.
While many people are seeing this as a welcome change, at the end of the day, this is at a policy level. At the field level, the fact remains that several countries till date do not have a domestic medical protocol for helping people with gender dysphoria access medical services. In such situations, though, having a change in the ICD can help push forward a new agenda in creating new domestic protocols, though it might take time for such a change to happen.
Also, while some critics state that having gender dysphoria as a diagnosis in the ICD still stigmatizes people with non-normative gender identities, the world of health care often works on the basis of such codes. After all, having a code in the ICD aids access to certain kinds of health care for trans people, and this is something many trans people don’t want to do away with.
Whether the WHO’s move will pan out in favour of people with trans identities or not in a world still heavily divided along gender binary lines remains to be seen. But, for now, it does seem to be a step in the right direction.
Click here for good practices guide on gender reassignment and gender affirmative care for transgender people developed by Sappho for Equality, Kolkata – Editor. The year 2018 is going to be pivotal for the depathologisation of gender non-conforming people. After getting feedback from the world over, the ICD11 is finally being released. There is one major change – the ICD10 had ‘gender incongruence’ under Mental, Behavioural or Neurodevelopmental Disorders. The ICD11 has broken new ground by putting 'gender incongruence' under Conditions Related to Sexual Health. This is a culmination of years of advocacy for removing the medicalised gaze from gender non-conforming identities. However, while this battle has been won, the war for socio-legal recognition is far from over. For the latest version of ICD, click here – Update courtesy author.
About the main photo: A scene from the 'Kolkata Rainbow Pride Walk 2014'. Photo credit: Pawan Dhall.