The movement of the World Health Organization (WHO) to declassify transgender identity as a mental disorder is simultaneously a step forward in affirming the personhood of gender minority individuals, and a step backward in diagnoses that adequately reflect their health needs. The solutions posited by the WHO reveal the systemic influence of health insurance policies in defining not only medical disorders, but also social categories.
Currently, in the United States and abroad, in order to qualify for health insurance coverage for gender affirming surgery or hormone replacement therapy (HRT), mentally healthy transgender individuals must receive a diagnosis indicating a gender-related mental disorder based on either the WHO classification or the "gender dysphoria" diagnostic category in the Diagnostic and Statistical Manual of Mental Disorders (DSM). In the hopes of fostering greater acceptance while still satisfying insurers, after 25 years, the WHO is considering a new diagnostic category: "Conditions related to sexual health."
According to Dr. Celia B. Fisher, Director of the Center for Ethics Education and Professor of Psychology at Fordham University, the new terminology, while well-intentioned, "runs the risk of perpetuating stereotypes that conflate gender identity and sexual orientation and lead to continued misclassification of transgender personhood as a sexual problem."
Fisher's research, sponsored by National Institute on Minority Health and Health Disparities (NIMHD), has demonstrated that regardless of whether transgender youth and young adults are receiving or desire to receive HRT in the future, "they do not necessarily see their bodies as creating sexual problems."
"Our data demonstrate that these young persons exhibit a wide range of sexual attractions and orientations, and in some cases are resistant to identifying with traditional sexual orientation categories. As a result, assigning transgender persons' health care needs to a sexual health condition may erroneously communicate to young people that they have some sort of sexual impairment," Fisher explained.
The WHO re-classification of transgender individuals is of particular importance to transgender persons in the U.S. as the Affordable Care Act has ushered in a gradual shift away from the DSM classifications in favor of using the WHO codebook, called the International Classification of Diseases (ICD) for health insurance diagnostic categories.
According to Fisher, the WHO's proposal to substitute the term "gender incongruence" for the current misnomer of "transsexualism," poses similar problems of pathologizing the health care needs of transgender persons. For example, Fisher's research indicates that many transgender youth and young adults on HRT who are able to express themselves through change of name or dress no longer feel their gender identity is incongruent with their bodies, but may need HRT to be able to continue their gender expression.
"The DSM 4 tried to reach a compromise," Fisher said. "Although the implication is that being transgender is not a condition in and of itself, in order to get medical treatment, there needs to be diagnostic label, so they settled for the term 'gender dysphoria.'"
The problem with this, Fisher argued, is that many people who successfully go on HRT or those who have selected to have gender affirming surgery are no longer unhappy or distressed--yet they require continuing medical care.
According to Fisher, who was also a member of the White House-commissioned expert panel on conversion therapy, "the only thing that would be distressful to them is taking away the continued medical care they need and the perpetuated bias among medical personnel and society at large."
"This move toward new sexual health classifications and gender incongruence labeling to satisfy insurance companies will not resolve, but in fact exacerbate that kind of problem," Fisher stated. "Even in the strides our country is making towards transgender civil rights, at this point, adopting the new WHO classifications could create another quarter century of further stigmatization that will perpetuate gender injustice and affect our social progress."
The Fordham University Center for Ethics Education operates a resource for LGBT youth -- please visit http://www.facebook.com/lgbtrelay for more information, or to "like" the page for updates. Please also visit our resource page for creating an LGBTQ-inclusive classroom.
This blog post was originally published on the Fordham University Center for Ethics Education Ethics & Society blog.