The first field trial to evaluate a proposed change to remove the diagnosis of transgender from its current classification as a mental disorder within the WHO International Classification of Diseases has been conducted.
The research involved interviewing 250 transgender people, and found that distress and dysfunction were more strongly predicted by experiences of social rejection and violence than by gender incongruence itself.
The study is the first of several field trials and is currently being replicated in Brazil, France, India, Lebanon and South Africa.
"Stigma associated with both mental disorder and transgender identity has contributed to the precarious legal status, human rights violations and barriers to appropriate care among transgender people," says senior researcher Professor Geoffrey Reed, National Autonomous University of Mexico.
"The definition of transgender identity as a mental disorder has been misused to justify denial of health care and contributed to the perception that transgender people must be treated by psychiatric specialists, creating barriers to health care services." Reed said.
Reed says the definition has been misused by some governments to deny self-determination and decision-making authority to transgender people in matters ranging from changing legal documents to child custody and reproduction.
"Our findings support the idea that distress and dysfunction may be the result of stigmatisation and maltreatment, rather than integral aspects of transgender identity," says lead investigator Dr Rebeca Robles, Mexican National Institute of Psychiatry.
"The next step is to confirm this in further studies in different countries, ahead of the approval of the WHO revision to International Classification of Diseases in 2018."
Transgender identity is currently classified as a mental disorder in both of the world's main diagnostic manuals, the WHO's ICD-10 and the American Psychiatric Association's DSM-5. A major component of the definition of mental disorders is that they are associated with distress and impairment in functioning.
The classification of transgender identity as a mental disorder is increasingly controversial and a WHO Working Group has recommended that transgender identity should no longer be classified as a mental disorder in ICD-11, but should instead come under a new chapter on conditions related to sexual health.
Of those who took part in the study, aged between 18 and 65, 80 per cent were transgender women, assigned male sex at birth.
Participants reported first becoming aware of their transgender identity during childhood or adolescence (ages 2-17). During the study, they completed a detailed interview about their experience of gender incongruence in adolescence (e.g, discomfort with secondary sex characteristics, changes performed to be more similar to the desired gender, and asking to be referred to as the desired gender), and recalled related experiences of psychological distress, functional impairment, social rejection and violence.
83 per cent experienced psychological distress related to gender incongruence during their adolescence, with depressive symptoms being the most common. Family, social, or work or academic dysfunction during adolescence related to their gender identity was reported by 90 per cent.
More than three-quarters of participants (76 per cent) reported experiencing social rejection related to gender incongruence, most commonly by family members, followed by schoolmates/co-workers and friends. A majority of participants (63 per cent) had been a victim of violence related to their gender identity — in nearly half of these cases, violence was perpetrated by a family member. Psychological and physical violence were the most commonly reported, and some experienced sexual violence.
The researchers then used statistical models to examine whether distress was related to gender incongruence per se or if it was related to experiences of social rejection and violence. They found that none of the gender incongruence variables predicted psychological distress or dysfunction, except in one case where asking to be referred to as the desired gender predicted school/work dysfunction. On the other hand, social rejection and violence were strong predictors of distress and all types of dysfunction.
"Rates of experiences related to social rejection and violence were extremely high in this study, and the frequency with which this occurred within participants own families is particularly disturbing," Dr Robles says.
"Unfortunately, the level of maltreatment experienced in this sample is consistent with other studies from around the world. This study highlights the need for policies and programs to reduce stigmatisation and victimisation of this population. The removal of transgender diagnoses from the classification of mental disorders can be a useful part of those efforts."
"A prominent UN advocate has put it this way: 'Transphobia is a health issue'," says Dr Sam Winter from Curtin University in Western Australia "This study prompts primary caregivers and psychiatrists to be aware of a 'slope leading from stigma to sickness' for transgender individuals, and to contribute to their mental health by a gender-affirmative approach."