The study, published in The Lancet Psychiatry journal this week, found that the distress and dysfunction experienced by transgender people were more strongly related to the social rejection and violence they experienced than by gender incongruence.
The study, the first field trial to evaluate a proposed change to the place of the diagnosis within the WHO International Classification of Diseases (ICD), was published in The Lancet Psychiatry journal this week.
Led by the Mexican National Institute of Psychiatry, the study interviewed 250 transgender people aged 18 to 65. Most participants were transgender women, assigned male sex at birth (199 participants, 80%).
All were receiving health care services at the Condesa Clinic, the only publicly funded specialized clinic providing transgender health care services in Mexico City.
“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,” said author Professor Geoffrey Reed from the 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,” he added.
“The definition has even 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.”
Distress and dysfunction
Lead investigator Dr Rebeca Robles, Mexican National Institute of Psychiatry, said: “Our findings support the idea that distress and dysfunction may be the result of stigmatization and maltreatment, rather than integral aspects of transgender identity. 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.
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. The study is the first field trial to evaluate the proposed re-classification.
Participants reported first becoming aware of their transgender identity during childhood or adolescence (from ages 2 to 17). During the study, they completed a detailed interview about their experience of gender incongruence in adolescence and recalled related experiences of psychological distress, functional impairment, social rejection and violence.
Violence by family members
Most participants experienced psychological distress related to gender incongruence during their adolescence (208, 83%), with depression being the most common. Family, social, or work or academic dysfunction during adolescence related to their gender identity was reported by nearly all participants (226, 90%).
More than three-quarters of participants (191, 76%) reported experiencing social rejection related to gender incongruence, most commonly by family members, followed by schoolmates or co-workers and friends.
Almost two-thirds of participants (157, 63%) had been a victim of violence related to their gender identity, and in nearly half of these cases, the violence was perpetrated by a family member.
The researchers 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 or 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. 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 stigmatization and victimization of this population. The removal of transgender diagnoses from the classification of mental disorders can be a useful part of those efforts,” says Dr Robles.
The study is the first of several field trials ,which are also taking place in Brazil, France, India, Lebanon and South Africa.