The psycho-medical case against a gender incongruence of childhood diagnosis

Jack Drescher and colleagues (March, 2016)¹ highlight two controversies surrounding gender incongruent children below puberty. One controversy concerns how one helps these children. A study by Olson and colleagues² published in this month’s Pediatrics offers strong support for a gender affirmative approach. They report good mental health in pre-pubertal children allowed to transition socially at home and school. Their findings feed the second controversy; whether there is a case for a diagnosis.

The gender incongruence of childhood diagnosis for ICD-11 was not unanimous in the WHO Working Group that originally proposed it. There was concern that this pathologising diagnosis would stigmatise the experiences of young children who are simply exploring their identity, and are learning to become comfortable being and expressing who they are—children whose diversity would hardly raise an eyebrow in a number of cultures worldwide.

These children have no need for puberty suppression, cross-sex hormones, or surgery. Olson and colleagues confirm what many clinicians and researchers have observed; these children just need space and support to explore and to become comfortable with their identities.^{3, 4, 5}

The WHO Working Group considered the case for reform across many other sexual health diagnoses, including some that pathologise young people exploring and learning to embrace and express their sexual orientation. Thankfully, the group agreed to recommend that these diagnoses be removed.⁶ It is perplexing that the same approach was not taken with pre-pubertal children exploring and learning to embrace their gender identity.

Drescher and colleagues’ arguments for the gender incongruence of childhood diagnosis—for example that it will provide a foundation for research and training—appear flawed. Research needs should never dictate diagnostic categories. In any case, research into same-sex attraction and relationships has thrived since the homosexuality diagnosis was removed from the diagnostic manuals decades ago. So has our knowledge about ways of meeting the health-care needs of gay and lesbian youth.

Key trans rights organisations worldwide have spoken out against this proposal; among them Global Action for Trans* Equality, Stop Trans Pathologisation, and Transgender Europe. Importantly, the European Parliament in Sept, 2015, called on the European Commission to “intensify efforts to prevent gender variance in childhood from becoming a new ICD diagnosis”. A recent study by the World Professional Association for Transgender Health found that a small majority of participants were opposed to the proposed diagnosis, with this majority much greater outside the USA.

The gender incongruence of childhood proposal is the most controversial proposal from this Working Group. We urge WHO to abandon the proposal for GIC, and instead employ non-pathologising Z Codes to facilitate and document health care for gender-diverse children. This approach, proposed in a Global Action for Trans* Equality document in 2013, would be entirely consistent with WHO’s proposals for young people exploring, and learning to embrace and express, their sexual orientation. We see no reason why young gender incongruent children should be treated differently.

SW was a member of, and GDC was an external reviewer for, the WHO Working Group on the Classification of Sexual Disorders and Sexual Rights. SW and GDC were co-researchers on a survey of WPATH members’ attitudes towards the GIC proposal. SW was a member of the GATE Civil Society Experts Group. All authors are members of the No-GIC web-discussion group. DT is author of a book entitled The Conscious Parent’s Guide to Gender Identity (in press). DE is author of a book entitled Gender Born Gender Made (2011) and The Gender Creative Child (in press). SP-T has received funding to attend meetings to discuss the GIC proposal. We declare no competing interests.