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Tecelli Domnguez-Martnez
Geoffrey M. Reed
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Articles
Summary
Background The conceptualisation of transgender identity as a mental disorder has contributed to precarious legal
status, human rights violations, and barriers to appropriate health care among transgender people. The proposed
reconceptualisation of categories related to transgender identity in WHOs forthcoming International Classication
of Diseases (ICD)-11 removes categories related to transgender identity from the classication of mental disorders, in
part based on the idea that these conditions do not satisfy the denitional requirements of mental disorders. We aimed
to determine whether distress and impairment, considered essential characteristics of mental disorders, could be
explained by experiences of social rejection and violence rather than being inherent features of transgender identity,
and to examine the applicability of other elements of the proposed ICD-11 diagnostic guidelines.
Methods This eld study used a retrospective interview design in a purposive sample of transgender adults
(aged >18 years or older) receiving health-care services at the Condesa Specialised Clinic in Mexico City, Mexico.
Participants completed a detailed structured interview focusing on sociodemographic characteristics, medical history
related to gender identity, and, during a specic period of adolescence, key concepts related to gender identity
diagnoses as proposed for ICD-11 and from DSM-5 and ICD-10, psychological distress, functional impairment, social
rejection, and violence. Data were analysed with descriptive statistics and univariate comparisons and multivariate
logistic regression models predicting distress and dysfunction.
Findings Between April 1, 2014, and Aug 17, 2014, 260 transgender adults were approached and 250 were enrolled in the
study and completed the interview. Most (n=202 [81%]) had been assigned a male sex at birth. Participants reported rst
awareness of transgender identity at a mean age of 56 years (SD 25, range 217), and 184 (74%) had used health
interventions for body transformation, most commonly hormones (182 [73%)], with the rst such intervention at a mean
age of 250 years (SD 91, range 1054). 84 (46%) of those who had used hormones did so initially without medical
supervision. During adolescence, distress related to gender identity was very common, but not universal (n=208 [83%]),
and average level of distress was quite high among those who reported it (799 on a scale of 0 [none at all] to 100
[extreme], SD 207, range 20100). Most participants (n=226 [90%] reported experiencing family, social, or work or
scholastic dysfunction related to their gender identity, but this was typically moderate (on a scale of 0 [not at all disrupted]
to 10 [extremely disrupted], family dysfunction mean 53 [SD 39, range 010]; social dysfunction mean 50 [SD 38,
range 010]; work or scholastic dysfunction mean 48 [SD 36, range 010]). Multivariate logistic regression models
indicated that distress and all types of dysfunction were strongly predicted by experiences of social rejection (odds ratios
[ORs] 229815) and violence (199399). A current male gender identity also predicted distress (OR 390). Of the
indicators of gender incongruence, only asking to be treated as a dierent gender was a signicant predictor, and only of
work or scholastic dysfunction (OR 182).
Interpretation This study provides additional support for classifying health-related categories related to transgender
identity outside the classication of mental disorders in the ICD-11. The reconceptualisation and related
reclassication of transgender-related health conditions in the ICD-11 could serve as a useful instrument in the
discussion of public health policies aimed at increasing access to appropriate services and reducing the victimisation
of transgender people.
Funding National Institute of Psychiatry Ramn de la Fuente Muiz, Mexico.
Introduction
The WHO is currently revising the International
Classication of Diseases (ICD)-10,1 and ICD-11 is
expected to be approved in May, 2018. WHOs
194 Member States use the ICD as the international
standard for the collection and reporting of health
information, and in many countries it is used as a part of
the framework for dening governments obligations to
provide free or subsidised health services to their
Articles
Research in context
Evidence before this study
Current classication systems of mental disorders, including
WHOs International Classication of Diseases (ICD)-10 and the
American Psychiatric Associations DSM-5, include categories
related to transgender identity. These classications are
important in part because in many countries they determine
access to health services, but the view of transgender people as
having a mental disorder has been increasingly controversial,
with calls from many parties, including the European
Parliament, to facilitate access to health services for this
population in some other way. A WHO Working Group on
Sexual Disorders and Sexual Health, comprising experts from all
WHO regions, recommended renaming these categories as
gender incongruence and moving them to a new proposed
ICD-11 chapter on Conditions Related to Sexual Health, which is
conceptualised as a more medical chapter. DSM-5 has managed
these categories dierently, renaming them as gender
dysphoria and continuing to classify them as mental disorders,
partly based on the rationale that distress or dysfunction are
essential elements of the condition. Whether distress and
dysfunction in this population should be more appropriately
viewed as the result of social rejection, stigmatisation, and
violence toward individuals with gender variant appearance and
behaviour has provoked substantial questions.
We searched PubMed for all publications in English and Spanish,
including meta-analyses and reviews, from January, 1996, to
December, 2015, using the terms transgender, trans,
transsexual, transsexualism, gender dysphoria, gender
incongruence, or gender identity along with the terms violence,
stigmatisation, social impairment, or distress. Ample
documentation from existing studies shows that transgender
people experience high rates of harassment and violence,
including sexual violence, not only from strangers but also from
their own families and communities. Existing research has
provided evidence of associations between experiences of
discrimination, social exclusion, and violence and psychological
Articles
Methods
Study design and participants
This was a retrospective interview study of adult
transgender people (aged 18 years old) who were
receiving transgender-related health services at the
Condesa Specialised Clinic in Mexico City. The
transgender community receiving services at the clinic
were informed about the study through an information
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Procedures
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Results
Between April 1, 2014, and Aug 17, 2014, 260 transgender
people indicated that they were willing to consider
participating. Of these, ve declined to participate after
the study was explained by the research assistant, and
ve did not provide sucient information during the
interview for analysis. Of these ten people, nine were
trans women (ie, assigned a male gender at birth). The
present analysis is based on the sample of 250 participants
who completed the interview.
Most participants had been assigned a male sex at birth
(n=202 [81%]) and currently identied as women or trans
women (n=199 [80%]). The mean age of the sample was
308 years (SD 102, range 1865). Most were unmarried
(n=207 [83%]), more than half lived with their family of
origin (parents or siblings; n=143 [57%]), and 72% (n=179)
had remunerated employment. Demographic characteristics by current gender identity are shown in table 1.
As shown in table 1, participants reported that they
had rst become aware of their transgender identity and
Statistical analysis
Means (SDs) and ranges were calculated for continuous
variables. Contingency table tests were used to test
dierences among groups for categorical variables and
independent samples t tests were used for continuous
variables. The Bonferroni correction for multiple familywise comparisons was applied for continuous variables
and the Holm correction was applied for categorical
variables. Multivariate logistic regression analyses were
done to determine whether distress and dysfunction
were predicted by variables related to the experience of
gender incongruence, violence, and social rejection.
The Akaike Information Criterion (AIC) was used
to determine which of the candidate models best
approximated the data. The model with the lower AIC
value is considered to be superior, although there are no
dened thresholds associated with this measure. Data
Total sample
(n=250)
Women/trans
women (n=199)
Men/trans men
(n=46)
Genderqueer
(n=4)
Intersex
(n=1)
Age (years)
21
Years of education
13
179 (72%)
146 (73%)
31 (67%)
2 (50%)
Unmarried
207 (83%)
160 (80%)
42 (91%)
4 (100%)
1 (100%)
184 (74%)
159 (80%)
24 (52%)
1 (25%)
Hormonal treatment
182 (73%)
158 (79%)
23 (50%)
1 (25%)
36 (14%)
32 (16%)
4 (9%)
Surgeries
Age of rst awareness of transgender identity and
maybe needing to do something about it
Age of rst awareness of secondary sex
characteristics (interview index period)
..
56 (25, 217)
57 (25, 217)
54 (26, 317)
52 (32, 310)
14
32
..
..
..
..
Type of surgery
Breast implants
15 (42%)
15 (47%)
..
..
Nose
14 (39%)
14 (44%)
..
..
..
Sexual reassignment
7 (19%)
5 (16%)
..
..
Orchiectomy
4 (11%)
4 (13%)
..
..
..
Liposuction
3 (8%)
4 (13%)
..
..
..
Chin
3 (8%)
3 (9%)
..
..
..
Mastectomy
2 (6%)
..
Cheekbones
2 (6%)
2 (6%)
Buttock implants
2 (6%)
2 (6%)
Hysterectomy
1 (3%)
..
Phalloplasty
1 (3%)
1 (3%)
2 (50%)
2 (50%)
..
..
..
..
..
..
..
..
..
..
..
..
1 (25%)
..
Table 1: Demographic characteristics, ages related to trans identity and body transformation, and health services used for body tranformation, by
current gender identity
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Male sex
assigned at
birth (n=202)
Female sex
assigned at birth
(n=46)
171 (68%)
134 (66%)
36 (78%)
Voice
113 (45%)
87 (43%)
26 (57%)
Pubic hair
93 (37%)
84 (42%)
9 (20%)
Hips
118 (47%)
88 (44%)
30 (65%)
Chest
123 (49%)
80 (40%)
42 (91%)
Back
94 (38%)
89 (44%)
5 (11%)
..
145 (72%)
..
..
123 (61%)
..
..
..
40 (87%)
Behavioural changes done during interview index period to be more like the desired gender
Attempting to change physical appearance
206 (82%)
167 (83%)
38 (83%)
Dressing dierently
204 (82%)
163 (81%)
39 (85%)
143 (57%)
111 (55%)
32 (70%)
79 (32%)
67 (33%)
11 (24%)
107 (43%)
85 (42%)
20 (44%)
*Total sample includes males at birth, females at birth, and two participants who reported being identied as intersex
at birth.
Table 2: Discomfort with body aspects and behavioural changes performed during interview index
period to be more like the desired gender, by assigned sex at birth
No distress
reported (n=42)
Reported distress
(n=208)
Statistics*
38 (91%)
164 (79%)
=56, df 2, p=006
38 (91%)
161 (77%)
=46, df 3, p=020
33 (79%)
174 (84%)
=06, df 1, p=042
31 (74%)
148 (71%)
=01, df 1, p=072
34 (100%)
148 (99%)
=04, df 1, p=049
6 (18%)
30 (20%)
=009, df 1, p=075
=49, df 1, p=002
20 (48%)
137 (66%)
23 (55%)
168 (81%)
Age (years)
Years of education
=131, df 1, p<0001
Family dysfunction
24 (37, 010)
59 (36, 010)
Social dysfunction
23 (33, 010)
55 (37, 010)
23 (31, 010)
53 (35, 010)
Data are n (%) or mean (SD, range). *The pattern of signicant and non-signicant results reported in this table
remains the same using the Bonferroni correction for multiple family-wise comparisons for continuous variables and
the Holm correction for categorical variables. Dierences between distressed and non-distressed participants for
categorical variables (ie, frequencies) were also examined using Fishers exact test. The pattern of results for categorical
variables was the same, with the only signicant dierences being for experienced violence (p=003) and experienced
rejection (p=0001). n=182 (see table 1). n=36 (see table 1). Based on adaptation of the Sheehan Disability Scale.
Table 3: Dierences between study participants by reporting and not reporting distress during interview
index period
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572 (2741191)
<00001
390 (1111374)
003
Family rejection
815 (4441497)
<00001
Sexual violence
399 (1491068)
0006
229 (130404)
0004
Physical violence
241 (130445)
0005
337 (182624)
Psychological violence
199 (103383)
<00001
003
182 (102325)
004
Table 4: Multivariate logistic regression models for dysfunction and distress among study participants
(n=250)
Discussion
The reports collected by this large retrospective study of
transgender peoples own experiences support the ICD-11
reconceptualisation of gender incongruence and its
removal from the classication of mental disorders in
several ways. This is dierent from the DSM-5
conceptualisation of gender dysphoria, which requires
distress or dysfunction for the diagnosis. These aspects
of the DSM-5 diagnostic criteria are key because without
them gender dysphoria would not full the requirements
of DSM-5s own denition of a mental disorder. By
contrast, the proposed diagnostic guidelines for ICD-11
indicate that distress and dysfunction can occur in
disapproving social environments and that individuals
with gender incongruence are at increased risk for
psychological distress, psychiatric symptoms, social
isolation, school dropout, loss of employment, home-
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