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Sam Winter: Enhancing Lives by Depathologizing Trans

Sam Winters responds to fears around loss of access to funds for research if gender diversity in childhood is depathologized in the ICD-11.

  • Written by
  • Sam Winter
  • Published
  • 23 October 2015
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I started working on trans issues at the end of 1999. I had been researching and working with children, their families and schools for 25 years and had become increasingly concerned that much of the research out there did not get used in classrooms, and even less had an impact on children’s lives.

I wanted to work in an area in which I could make a contribution to enhancing lives. Many of the challenges in trans people’s lives – the hostility and bigotry – stem from other people’s ignorance. Research and advocacy can help trans communities reduce ignorance. For example, the idea that gender different children are sick is a very modern and Western one. There are cultures all over the world where gender difference has been (and is!) regarded as an aspect of diversity, not a sign of disorder. The idea of gender identity disorder and similar diagnoses is a peculiarly Western cultural export. And a peculiarly nasty export too. The idea of employing a pathologizing diagnosis for gender different children (exploring their gender identity, learning to become comfortable with who they are, learning to express freely who they are, and learning to deal with the hostility of others) should be anathema to us all. Would we regard sick other children in similar situations; for example ethnic minority children exploring their ethnic identity, learning to accept and express it, and learning how to deal with racism? There are analogies closer to home.

Ironically, WHO is proposing to remove from ICD a whole bunch of diagnoses that currently pathologize young people exploring and learning to accept and express their sexual orientation, as well as learning to deal with the hostility of others to that sexual orientation. Well done WHO. But why the inconsistency in regard to the exploration of gender identity?

Actually, some people are afraid of losing access to funds for research if gender diversity in childhood is depathologized, which doesn’t stand up to scrutiny at all. Homosexuality was removed from the various diagnostic manuals decades ago. Is there less research into same-sex attraction and behavior now than before? No! There is more. The difference is that the nature of the research has changed. Away from a medical and pathologizing perspective to a more humanities and social science perspective.

All parents seek to understand their children and to do the best for them. The parents of gender different children need to understand that their children are different, not disordered. They need to know that their children need space, support and information to help them explore, accept, and express who they are. They as parents need to help provide that space, support and information, And that means they, the parents, need support and information themselves. None of this merits a diagnosis that says ‘your child is sick’.Some supporters of the childhood diagnosis say that it will be the only way of getting access to hormonal blockers in puberty, but that’s certainly not the case!

There is a whole chapter in ICD (the so-called Z Codes of Chapter 21) that provides a rich and productive way of documenting access to health services and the factors that influence the seeking of those services. Z codes provide a perfectly acceptable way of documenting previous contacts with health services. Such documentation should also be sufficient where School Principals are being asked to make accommodations at school. It seems that much of the WPATH membership, most markedly outside the United States, is opposed to the GIC diagnosis and is in support of alternatives involving the use of Z Codes. A survey was conducted last December and January to tap members’ views on WHO proposals for the Gender Incongruence of Childhood diagnosis. Two hundred and forty-one members completed the survey. The survey indicated an even split among members regarding the GIC proposal (51.1% opposing and 47.7% supporting the proposal). However, non-US members were overall opposed to the proposal (63.9% opposing, 36.1% supporting). In the event of the proposed diagnosis entering ICD, members were in favor of the proposed name (51.0% versus 13.7% opposed) and the proposed location (41.1% versus 7.5% supporting the idea that it is classified as a mental disorder).

Among those expressing a view about Z Codes, there was substantial overall support for their use in healthcare provision for children with gender issues (35.7% of the sample supporting, versus 8.3% rejecting). Support was evident, not only among those who oppose the WHO GIC proposal but also among those who support it. The support was evident regardless of geographical location, time spent working in trans healthcare, or client age group. WPATH has undertaken to take account of the results of the membership survey in future communications with WHO on this matter.

Every month more voices join the chorus; most recently the European Parliament has spoken on this issue. We can win this!

Photo of Sam Winter seated, speaking into a microphone
  • About the author

Sam Winterhe/him

Clinician and Researcher Guest author

Sam Winter heads the sexology team at the School of Public Health at the Faculty of Health Science at Curtin University in Perth.