Under many healthcare services, access to gender-affirming treatment may require a formal diagnosis of gender dysphoria (or gender incongruence). Usually, a mental health professional is involved in the diagnostic assessment, which raises the question of whether gender dysphoria is a mental illness or disorder. This post addresses the problems with framing gender incongruence as a disorder and also the benefits of the recent initiative to depathologise gender incongruence.

Historical Background

There is a long history of trans identities being pathologised. For example, in 1966, the sexologist Harry Benjamin considered “transsexualism” to be a disorder that could be treated with gender-affirming medical and surgical treatment.1 Subsequently, gender incongruence has often been classified in diagnostic manuals as a mental disorder. The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) included “transsexualism” in its third edition and “gender identity disorder” in its fourth edition, while the tenth revision of the World Health Organization’s International Classification of Diseases (ICD) included “gender identity disorder”.2–4

Implications of Labelling Gender Incongruence as a Disorder

Whether a condition is a disorder has implications. Usually, to label something a disorder is to suggest that it has a claim to healthcare resources. Hence, part of the motivation for considering gender incongruence a disorder was to recognise it as a legitimate health condition that warrants the provision of gender-affirming medical treatment.

However, labelling something a mental disorder is also associated with significant harms. These include connotations of being defective, undesirable, or irrational. And so, framing gender incongruence as a disorder potentially contributes to the stigmatisation of and prejudice against trans people.5–7 Furthermore, by bringing gender incongruence within the purview of mental healthcare, trans people are not granted due power over their own identities.

Accordingly, there has been an international initiative to depathologise gender incongruence and to recognise it as a part of healthy diversity. In 2019, the World Health Organization removed “gender identity disorder” from the ICD-11 and instead clarified that gender incongruence is not a mental disorder or illness.8

The Concept of Disorder: Is Gender Incongruence a Mental Disorder or Illness?

The DSM-5 defines a mental disorder as a “clinically significant disturbance in an individual’s cognition, emotion regulation, or behaviour that reflects a dysfunction in the psychological, biological, or development processes underlying mental functioning”.9 However, this definition relies on several unqualified terms that warrant further analysis. For example, it does not specify the norms for judging what is “clinically significant”, what is a “disturbance”, and what is acceptable “mental functioning”.

Hence, the question of whether a condition is a disorder is not a straightforward matter of fact, but is a philosophical question that is informed by various values and considerations. Different philosophers have proposed different definitions of disorder based on considerations such as biological features, statistical atypicality, harmfulness, undesirability, and unacceptability.10–14

More recently, some philosophers have proposed that there may not be a single adequate definition of disorder, but rather different accounts that serve different institutional purposes.15, 16 Such a view suggests that whether or not gender dysphoria is deemed a disorder or illness should be informed by the ethical, political, and pragmatic implications of pathologising or depathologising it.

Depathologising Gender Incongruence

The depathologisation of gender incongruence has numerous ethical, political, and pragmatic benefits. Acknowledging that gender incongruence is not a disorder or illness but a part of healthy diversity could contribute to reducing the stigmatisation of trans people that is associated with pathologisation.17

Acknowledging that gender incongruence is not a disorder or illness also gives trans people more power over their own identities. By removing gender incongruence from the purview of mental healthcare, mental health professionals would no longer be the arbiters of people’s gendered identities and experiences. This lends support to an informed consent model of care, where the focus is not on the diagnosis of a disorder, but is on respect for the person’s autonomy.18, 19

Still, the depathologisation perspective does not deny the distress and suffering that can be associated with gender dysphoria. Indeed, trans people do suffer from higher rates of depression and anxiety than the cis population. However, many of these associated mental health problems in the trans population are understood as being due to factors such as social inequality, family rejection, stigmatisation, and exclusion, rather than inevitable outcome of gender incongruence.20, 21 Mental ill health is not an intrinsic feature of being trans.22

The Future

There is increasing recognition that gender incongruence is not a mental disorder, but is a part of healthy diversity. In theory, this depathologisation perspective could contribute to decreasing the stigmatisation of trans people and to developing fairer practices that give trans people more power over their own identities. However, political will is needed to implement these practices, both at the level of healthcare services and at the wider level of law and policy. As well as freeing gender-affirming healthcare from current gatekeeping practices, there is a need to free legal gender recognition from the purview of medicine.

 

References

  1. Benjamin, H. (1966). The Transsexual Phenomenon. New York: The Julian Press.
  2. American Psychiatric Association (1980). Diagnostic and Statistical Manual of Mental Disorders, 3rd edition. Washington, DC: American Psychiatric Association.
  3. American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders, 4th edition. Washington, DC: American Psychiatric Association.
  4. World Health Organization (1992). International Classification of Diseases, 10th revision. Geneva: World Health Organization.
  5. Ashley, F. (2021). “The Misuse of Gender Dysphoria: Toward Greater Conceptual Clarity in Transgender Health”. Perspectives on Psychological Science, 16: 1159–1162.
  6. Davy, Z. (2015). “The DSM-5 and the Politics of Diagnosing Transpeople”. Archives of Sexual Behavior, 44: 1165–1176.
  7. Suess Schwend, A., Espineira, K., and Walters, P. C. (2014). “Depathologization”. Transgender Studies Quarterly, 1: 73–77.
  8. World Health Organization (2019). International Classification of Diseases, 11th revision. Geneva: World Health Organization.
  9. American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th edition. Washington, DC: American Psychiatric Association.
  10. Boorse, C. (1977). “Health as a Theoretical Concept”. Philosophy of Science, 44: 542–573.
  11. Wakefield, J. C. (1992). “On the Concept of Mental Disorder: On the Boundary between Biological Facts and Social Values”. American Psychologist, 47: 373–388.
  12. Cooper, R. (2002). “Disease”. Studies in History and Philosophy of Biological and Biomedical Sciences, 33: 263-282.
  13. Nordenfelt, L. (2007). “The Concepts of Health and Illness Revisited”. Medicine, Health Care, and Philosophy, 10: 5–10.
  14. Bolton, D. (2008). What is Mental Disorder? An essay in Philosophy, Science, and Values. Oxford: Oxford University Press.
  15. Maung, H. H. (2019). “Is Infertility a Disease and Does it Matter?” Bioethics, 33: 43–53.
  16. Kukla, Q. (2024). “What Counts as a Disease, and Why Does It Matter?” Journal of Philosophy of Disability, https://doi.org/10.5840/jpd20226613.
  17. Suess Schwend, A. (2020). “Trans Health Care from a Depathologization and Human Rights Perspective”. Public Health Reviews, 41: 3.
  18. Davy, Z., Sørlie, A., and Suess Schwend, A. (2018). “Democratising Diagnoses? The Role of the Depathologisation Perspective in Constructing Corporeal Trans Citizenship”. Critical Social Policy, 38: 13–34.
  19. Schulz, S. L. (2018). “The Informed Consent Model of Transgender Care: An Alternative to the Diagnosis of Gender Dysphoria”. Journal of Humanistic Psychology, 58: 72–92.
  20. Klein, A., and Golub, S. A. (2016). “Family Rejection as a Predictor of Suicide Attempts and Substance Misuse Among Transgender and Gender Nonconforming Adults”. LGBT Health, 3: 193–199.
  21. Zwickl, S., Wong, A. F. Q., Dowers, E., Leemaqz, S. Y., Bretherton, I., Cook, T., Zajac, J. D., Yip, P. S. F., and Cheung, A. S. (2021). “Factors Associated With Suicide Attempts Among Australian Transgender Adults”. BMC Psychiatry, 21: 81.
  22. Horton, C. (2023). “‘Euphoria’: Trans Children and Experiences of Prepubertal Social Transition”. Family Relations, 72: 1890–1907.