President's Note - June 2018

As many of you know, the ICD-11 has recently been released and I wanted to take this opportunity to let you know how WPATH has been involved in this process.

At the outset, two WPATH members Drs. Sam Winter and Peggy Cohen- Kettenis, were participants in the WHO Working Group on the Classification of Sexual Disorders and Sexual Health.

WPATH was asked to provide input on several occasions with respect to the diagnoses related to gender identity and sexual orientation. In fact, we had been working on this since 2011 and have gone through three phases of this project. The first was to gather a group of senior psychiatrists from WPATH to make the initial recommendations to the WHO. This group recommended that all of the diagnoses related to sexual orientation (F66) be removed. The recommendation with respect to Fetishistic Transvestism was two-fold, with no preferences expressed. Either keep it as paraphilia (with the reference to transsexualism removed) or remove it. They also recommended that the diagnosis of transsexualism and all other gender identity disorder diagnoses be removed and a diagnosis of gender dysphoria be placed outside of mental disorders chapter. They did not reach a consensus on the child diagnosis other than to delete Gender Identity Disorder of Childhood and add a Gender Dysphoria of Childhood diagnosis outside of mental disorders. It is important to put these recommendations into context as we were just releasing the Standards of Care Version 7 and the DSM 5 had yet to be released.

In 2012, the WHO approached WPATH, requesting a more definitive proposal from WPATH concerning its recommended disposition of the diagnoses related to Transsexualism and the other diagnoses in the Gender Identity Disorders section including feedback on the new proposed structure and content for these conditions. WPATH reconvened its original ICD-11 committee of 11 health care professionals who had reviewed and commented on the ICD-10 content in 2011, the WPATH Board of Directors, and invited additional participants from the global south, as well as non-clinical experts in transgender health with medical systems expertise, and additional experts and clinicians, particularly specialized in treating children. This group of thirty participants met in February 2013.

In summary, the consensus points were:

• All F66 diagnoses should be removed.
• F65.1, Fetishistic Transvestism, should be removed, but provision for clinical management should be retained under some other diagnostic category that is less stigmatizing.
• Gender Incongruence of Adolescence and Adulthood, should be removed from the Mental Health Chapter.
• Gender/Body Divergence nomenclature was preferred over Gender Incongruence.

The group was evenly divided over whether Gender Incongruence in Childhood should be removed or retained, but all agreed that children with Gender/Body Divergence, or Gender Incongruence, or Gender Dysphoria, and their families, need support.

Subsequent to this, WPATH members participated in the field trials in the following countries: the Netherlands, Belgium, and the United Kingdom in a  collaboration between the Amsterdam Center of Expertise on Gender Dysphoria, the Ghent Center for Sexology and Gender, and the Nottingham Centre for Transgender Health. Most participants were in favor of the proposed diagnostic term of `Gender Incongruence' and thought that this was an improvement on the ICD-10 diagnostic term of `Transsexualism'. Placement in a separate chapter dealing with Sexual- and Gender-related Health or as a Z-code was preferred by many, and only a small number of participants stated that this diagnosis should be excluded from the ICD-11.

In 2014, WPATH conducted a follow-up survey with the membership about the inclusion of the child diagnosis in the ICD-11. The results again were split however some countries were more strongly in favour of the removal than others.

In addition, the WPATH Board posted formal comments on the ICD-11 Beta Version portal from 2015 to 2017, and encouraged our membership to do so as well.

In July 2017, WPATH and the World Association for Sexual Health (WAS) issued a joint statement calling on the WHO “to consider further the proposed Gender Incongruence of Childhood diagnosis, including through comprehensive consultation with the transgender community.”

With the release of ICD-11, we see the following:

• All F66 diagnoses removed;
• F65.1, Fetishistic Transvestism removed;
• Gender Incongruence of Adolescence and Adulthood not appearing in the Mental Health Chapter and found in a new chapter – Conditions Related to Sexual Health; and
• Gender Incongruence of Childhood not appearing in the Mental Health Chapter and found in the same new chapter, Conditions Related to Sexual Health.

While many may find the inclusion Gender Incongruence of Childhood very disappointing, the majority of our recommendations do appear in the ICD-11.

As a Board, our next step is to write a letter to the American Psychiatric Association requesting the removal of Gender Dysphoria from the DSM-5.

In closing I would like to thank the WPATH Presidents, Drs. Bockting, Fraser, and Green, the Board of Directors from 2011-2018, as well as our valued WPATH members for their continued efforts in this process. And finally, I would like to thank my friend and fellow WPATH Board member, Dr. Griet DeCuypere, for being my conscientious and brilliant WPATH ICD-11 Consensus Committee Co-Chair throughout this journey.

Sincerely,

Gail Knudson, MD, MEd, FRCPC

WPATH President

WPATH ICD-11 Consensus Committee Co-Chair