1. Mauro Cabral Global Action for Trans* Equality (GATE) TRANS* ISSUES IN THE PROCESS OF REVISION AND REFORM OF THE INTERNATIONAL CLASSIFICATION OF DISEASES

2. PathologizationDepathologization What it is? Why? By whom? How? When? Pros & ConsPros & Cons?

3. What does it mean to re-classify diagnostic categories? Better definition Updated language Narrower criteria Focus on medical necessity ÷  Improve clinical utility  Improve differential diagnoses ÷ Improve access to healthcare Improve access to treatment

4. What reclassification does not mean Getting “cured”. Loosing access to healthcare. Changing your gender identity, gender expression and/or sexual orientation, Not being able to consult with your regular physician, Not getting access to mental health support.

5. ICD DSM Produced by an UN agency : WHO Produced by a national association: AºA Free and open resourceProvides revenue to APA For countries and health providers For countries and psychiatrists International developmentUS dominated development Approved by World Health Assembly Approved by Board of Trustees Ongoing : ICD-11Done : DSM V

6. ICDDSM Covers all health conditions Covers only mental health conditions

7. ICD Revision and Reform Process World Health AssemblyMandated by World Health Assembly (Health Ministers of all WHO Member Countries) ICD-10 completed in 1990ICD-10 completed in 1990; longest time without revision in history of ICD all areasCovers all areas of diseases, disorders, and injuries, and health conditions; diagnostic standard for medicine and health systems process involvesICD revision process involves WHO-appointed expert Topic Advisory Groups, plus any international professional associations, scientific societies, disease-based groups; and civil society organizations Technical work to be completed 2017 2018WHA approval expected 2018

8. Revision Steering Group World Health Assembly Mental Health Advisory Group (Chapters F, Z) Sexual Disorders and Sexual Health Working Group G-U & Rep Med Advisory Group (Chapter N) Internal Medicine Advisory Group (Chapter E) Endocrinology Working Group. ICD Revision Political Structure for Sexual Disorders and Sexual Health

9. Chapter V. Mental and behavioural disorders F00-F09 Organic, including symptomatic, mental disorders F10-F19 Mental and behavioural disorders due to psychoactive substance us F20-F29 Schizophrenia, schizotypal and delusional disorders F30-F39 Mood [affective] disorders F40-F48 Neurotic, stress-related and somatoform disorders F50-F59 Behavioural syndromes associated with physiological disturbances and physical factors F60-F69 Disorders of adult personality and behaviour F70-F79 Mental retardation F80-F89 Disorders of psychological development F90-F98 Behavioural and emotional disorders with onset usually occurring in childhood and adolescence F99-F99 Unspecified mental disorder

10. F60-F69 Disorders of adult personality and behaviour F60 Specific personality disorders F61 Mixed and other personality disorders F62 Enduring personality changes, not attributable to brain damage and disease F63 Habit and impulse disorders F64 Gender identity disorders F65 Disorders of sexual preference F66 Psychological and behavioural disorders associated with sexual development and orientation F68 Other disorders of adult personality and behaviour F69 Unspecified disorder of adult personality and behaviour

11. Trans-related categories in ICD-10 F64. Gender identity disorders F64.0 Transsexualism F64.1 Dual-role transvestism F64.2 Gender identity disorder of childhood F65. Disorders of sexual preference F65.1 Fetishistic transvestism F66 Pyschological and behavioural disorders associated with sexual development and orientation F66.0 Sexual maturation disorder F66.1 Egodystonic sexual orientation F66.2 Sexual relationship disorder

12. What it’s the problem with GID? It’s insensitive to clinically relevant experiences (i.e., suffering vs happiness) It pathologizes what people are (instead of diagnosing a problem that people *have*) It has not exit clause It’s culturally specific It restricts access to healthcare and access to legal gender recognition It’s definition reproduces and reinforce gender, expressive and bodily binaries. It promotes forced institutionalization and conversion therapy (human rights violations) It diminishes trans people’s autonomy and self determination

13. WHO Proposal (2012) 1. Delete F64, F65 and F66 codes 2. Introduce Gender incongruence -Gender incongruence of childhood -Gender incongruence in adolescence and adulthood 3. Move GI out of mental and behavioural disorders chapter (V, F codes) to a different chapter Options: -Chapter IV on Endocrine Diseases (E Codes) -Chapter XIV on Genitourinary Diseases (N Codes) -Stand alone chapter -Chapter on Sexual Health

14. Gender identity Disorder DSM & ICD Gender Dysphoria DSM V Gender Incongruence ICD-11

15. ICD 11 Beta Chapter 05. Conditions related to sexual health -Sexual Dysfunctions -Gender Incongruence 5A30 Gender incongruence of adolescence and adulthood 5A31 Gender incongruence of childhood -Changes in female genital anatomy -Changes in male genital anatomy

16. Gender Incongruence Gender incongruence is characterized by a marked and persistent incongruence between an individual’s experienced gender and the assigned sex.

17. GIAA Gender Incongruence of Adolescence and Adulthood Gender Incongruence of Adolescence and Adulthood is characterized by a marked and persistent incongruence between an individual’s experienced gender and the assigned sex. The diagnosis cannot be assigned prior to the onset of puberty. Gender Incongruence of Adolescence and Adulthood often leads to a desire to ‘transition’, in order to live and be accepted as a person of the experienced gender. Establishing congruence may include hormonal treatment, surgery or other health care services to make the individual’s body align, as much as desired and to the extent possible, with the experienced gender.

18. GIC Gender Incongruence of Childhood Gender Incongruence of Childhood is characterized by a marked incongruence between an individual’s experienced/expressed gender and the assigned sex in pre-pubertal children.

19. Challenges Paradigmatic challenges: sexual difference Definitional challenges: gender incongruence & the pathologization of gender expression / bodily diversity (to feel vs. to be perceived). Cisexist challenge: idealized congruence = health -> ‘compulsory’ transition / stigma, discrimination and violence Political challenges: chapter on sexual issues & LG(T)B(I) Pathologization-related challenges: gender incongruence of childhood Coverage challenges: ICD vs. DSM

20. Strategies International networking ( i.e., STP, GATE, TGEU) Technical input (i.e., ICD 11 Beta on line; submissions) Visible Advocacy (i.e., International Day of Action for Trans Depathologization). Training and communications Inter-movements alliances Alliances with health providers / researches Expert papers (i.e, published on peer review journals) Research (i.e., on national versions and uses of ICD; on bibliography). Official Statements on Depathologization (i.e., Council of Europe, OAS). Legal Depathologization: Argentina, Malta, Denmakr, Participation in regional and international meetings (i.e., WPATH, EPATH) Actively Monitoring the process (i.e., field tests).

21. Strategies Disaggregate the ICD revision and reform process from other forms of LGTB activism (i.e., at the UN Human Rights Council) to avoid backlash at WHO.