The ICD-11 is about to be voted in at the World Health Assembly, after being completed last year by the World Health Organization. After moving trans-related categories out of the Chapter on Mental Health, the next steps in the process include getting rid of the remaining pathologizing language and advancing towards legal depathologization and universal health coverage.

The following briefing provides in depth information and a Call to Action. For further details, please contact us at icd@transactivists.org.

Outcomes of the technical revision process

In 2018, the technical process on the ICD-11 (International Classification of Diseases – 11th Revision) was completed, and outcomes publicly announced.

1. The next step is for the World Health Assembly (WHA) to officially adopt it, which is expected to happen on Monday 27^th May during the 72nd WHA.
   
   1. Read the proposed ICD-related WHA resolutions: Report by the Director-General and Proposal for supplementary agenda item.
   2. Follow the WHA live streaming.
2. Trans-related categories have been removed from the Chapter on Mental and Behavioral Disorders, which means that trans identities are formally de-psycho-pathologized in the ICD-11.
3. New trans-related categories have been added to Chapter 17 on Conditions Related to Sexual Health, one of five new chapters in the ICD-11. Although placement in this chapter is an improvement, it is by no means perfect. For example, it is somewhat reductive to define trans health as related only to sexual health. We consider the ICD-11 to be a transitional version, acceptable only as a step towards depathologization (see 12. for requirements for full depathologization).
4. The new trans-related categories are:
   1. Gender incongruence of Adolescence and Adulthood; and
   2. Gender Incongruence of Childhood.

Ongoing issues to address

1. The term ‘gender incongruence’ has been strongly contested by trans and gender diverse activists involved in the ICD reform process, and collective submissions on alternative wording and criteria have been made.
2. The category Gender Incongruence of Adolescence and Adulthood has been accepted as a temporary and imperfect solution to the needs of those trans and gender diverse people who require access to specific healthcare (e.g. surgeries and hormones) under health systems that otherwise will exclude them. This decision was very difficult to make and ultimately was made based on international solidarity and a strong shared commitment to continue to make submissions to WHO on alternative wording and criteria.
3. The category Gender Incongruence of Childhood has been rejected by activists involved in the ICD reform process. Alternative codes to ensure access to support systems for trans and gender diverse children have been submitted to WHO.
4. The ICD-11 codes are used globally for various purposes, including legal gender recognition, access to specific healthcare (e.g. gender affirming procedures) and healthcare coverage. Some countries use other classificatory systems (i.e. DSM, Diagnostic and Statistical Manual of Mental Disorders) for the same purposes. The ICD-11 does not immediately affect the DSM-5.

Addressing these issues through the ICD-11 revision process

1. The reviewing and updating process for the ICD-11 will soon begin. Once the ICD-11 is adopted by the WHA and the new Chapter on Conditions Related to Sexual Health is firmly included in ICD-11, our activist efforts focus on:
   • Replacing the term ‘gender incongruence’ with a non-pathologizing and non-stigmatizing term;
   • Removing the category Gender Incongruence of Childhood completely; and
   • Ensuring access to support systems for trans and gender diverse children, and coverage of same.

Addressing these issues elsewhere

1. Once the ICD-11 is adopted by the WHA, UN Member States are responsible for national-level implementation. In some cases, this process can take years. It is vital to work closely with Ministries of Health and e-Health to push for full and rapid adoption and implementation of the new Chapter and its categories at the national level.
2. In a world of unequal access to healthcare and its coverage, it is unfortunately necessary to retain a reference to trans and gender diverse identities in the ICD in order to ensure access to healthcare. However, we aim to combat this inequity with two key political goals:
   • Advancing legal depathologization everywhere, to ensure that the human rights of all trans and gender diverse people are respected; and
   • Progressive expansion of public healthcare coverage, as established in the Universal Health Coverage framework.
3. Trans and gender diverse depathologization is a human rights issue, recognized as such by international mechanisms, e.g. the UN SOGI Mandate. It is essential to put an end to all forms of human rights violations in medical settings, including torture and ill treatment.
4. Full depathologization of trans and gender diverse people requires the complete removal of:
   • psycho-medical classifications;
   • legal and bioethical gatekeepers;
   • corporate-driven medical care & treatments;
   • normative gender stereotypes; and
   • all forms of socioeconomic injustice.
5. Public health systems must be defended and expanded, including a decisive increase in national budgetary allocations. It is imperative to organize against private insurance companies, to prevent them from holding decision-making power over our identities and bodies.

Call to Action

It has taken us a long time to get here. Until a few years ago, removing pathologizing categories affecting trans and gender diverse people from the ICD-10 list of mental disorders seemed impossible. Today, we know that full depathologization can be achieved and will be achieved in our lifetime.

Dealing with medical classifications can be personally and politically challenging. You are not alone. Share your doubts, concerns and frustrations with others, including those of us working on the ICD process. Let us support one other in overcoming the negative effects of pathologization while working together to dismantle it.

Although the ICD-11 process appears to have finished, in reality it is just starting. We have everything to gain from engaging in the ongoing review process.

The moment to join us is now.

Signatories

– Akahatá (Latin America)

– Asia-Pacific Transgender Network (Asia-Pacific)

– GATE (Global)

– ILGA World (Global)

– Iranti (Africa)

– RFSL (Sweden)

– STP, International Campaign Stop Trans Pathologization (Global)

– TGEU (Europe)

– ULTRANS (Latin America)

Joint Statement on ICD-11 process for trans & gender diverse people