Researchers found mental health issues among transgender individuals are rarely down to transgender identity itself, but are more a result of stigma.
Senior author Prof. Geoffrey Reed, of the National Autonomous University of Mexico, and colleagues recently reported their findings in The Lancet Psychiatry.
The American Psychological Association define transgender as an umbrella term used to describe a person "whose gender identity, gender expression or behavior does not conform to that typically associated with the sex to which they were assigned at birth."
A mental disorder, however, is considered a condition that causes significant stress or impairment. Since many transgender individuals do not experience such problems, the classification of transgender as a mental disorder has attracted much criticism.
"The definition of transgender identity as a mental disorder has been misused to justify denial of healthcare and contributed to the perception that transgender people must be treated by psychiatric specialists, creating barriers to healthcare services," says Prof. Reed.
"The definition has even been misused by some governments to deny self-determination and decision-making authority to transgender people in matters ranging from changing legal documents to child custody and reproduction," he adds.
With ICD-11 - the updated diagnostic manual for the WHO - due to come into play in May 2018, Prof. Reed and colleagues decided to embark on the first ever field trial to assess the feasibility of reclassifying transgender identity.
The scope of gender incongruence, social rejection, and violence
For their study, the team interviewed 250 transgender individuals aged 18-65, the majority of whom were transgender women who had been assigned male sex at birth.
"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," the authors explain.
As part of the study, subjects were asked about their experience of gender incongruence - that is, whether they had ever felt any discomfort with secondary sex characteristics, whether they had felt discomfort with any changes they underwent to become more like their desired gender, or whether they had experienced discomfort when requesting to be referred to as their desired gender.
They were also asked to recall any experiences of psychological distress, functional impairment, social rejection, and violence.
All participants reported becoming aware of their transgender identities between the ages of 2-17.
A total of 208 subjects (83 percent) reported experiencing psychological distress - primarily depression - associated with gender incongruence during adolescence, while 226 participants (90 percent) reported experiencing family, social, or work or academic problems relating to gender identity.
Social rejection associated with gender incongruence was reported by 191 subjects (76 percent); such rejection most commonly occurred with family members, the team found, followed by schoolmates, co-workers, and friends.
A total of 157 participants (63 percent) reported that they had been a victim of violence due to their gender identity; the most commonly reported forms of violence were psychological and physical violence, and subjects reported experiencing sexual violence.
Gender incongruence could not predict psychologic distress
Next, the researchers used statistical models to assess whether psychological distress and functional impairment were associated with gender incongruence or experience of social rejection and violence.
While social rejection and violence were found to be strong predictors of distress and all forms of dysfunction, no variables of gender incongruence could predict psychological distress, while only one variable could predict a single form of dysfunction; requests to be referred to as the desired gender were a predictor of dysfunction at work or school.
According to the authors, their findings highlight the stigma many transgender individuals continue to face.
"Rates of experiences related to social rejection and violence were extremely high in this study, and the frequency with which this occurred within participants' own families is particularly disturbing," says lead investigator Dr. Rebeca Robles, of the Mexican National Institute of Psychiatry.
"Unfortunately, the level of maltreatment experienced in this sample is consistent with other studies from around the world."
Additionally, the results show that mental disorder characteristics among transgender individuals are largely fueled by such stigma, rather than transgender identity itself. As such, the team calls for transgender to no longer be classified as a mental disorder.
"This study highlights the need for policies and programs to reduce stigmatization and victimization of this population. The removal of transgender diagnoses from the classification of mental disorders can be a useful part of those efforts."
Dr. Rebeca Robles
There are some limitations to the study, such as the small number of transgender individuals involved, though the authors state that the sample is large relative to many other studies.
Additionally, they note that because the participants were volunteers, their reports of gender incongruence, social rejection, and violence may not be representative of the transgender population.
In a linked editorial, Drs. Griet De Cuypere, of Ghent University Hospital, Belgium, and Sam Winter, of Curtin University, Australia, say the study "prompts primary caregivers and psychiatrists to be aware of a 'slope leading from stigma to sickness' for transgender individuals, and to contribute to their mental health by a gender-affirmative approach."
However, they state that while the results offer evidence to suggest transgender identity should not be classified as a mental disorder, they do not offer an alternative classification for consideration in the next ICD manual.
"Many questions remain, such as the case for a diagnostic category, the name and diagnostic guidelines that should be used, the place the diagnosis should occupy in the manual, and, above all, the need for a diagnosis for children, for which other field studies are needed," they add.