On 17 May, International Day against Homophobia, Transphobia and Biphobia commemorates the day in 1990 when the World Health Assembly stopped classifying homosexuality as a mental disorder.
At the time, the classification was changed in the International Statistical Classification of Diseases and Related Health Problems (ICD), a standard guide used the world over as the basis for health statistics with implications for funding for health services and health insurance.
Now, a new edition of the ICD, known as ICD-11, has made changes to reflect a modern understanding of sexual health and gender identity – notably, by replacing “transsexualism” with a new concept of “gender incongruence”, defined as a condition relating to sexual health rather than a mental and behavioural disorder.
What’s in a name?
How a condition or disease is classified in the ICD can make a significant difference to the way health systems and communities comprehend and respond to it. The previous classification of trans-related and gender-diverse identity issues created stigma and potential barriers to care. For example, individuals had to be diagnosed as mentally ill in order to access gender-affirming health care supported by health insurance coverage.
ICD-11 now acknowledges links that frequently occur between gender identity, sexual behaviour, exposure to violence and sexually transmitted infections.
For Anzhelika Volkonskaya, a trained nurse and transgender activist from Belarus, ICD-11 is a welcome change that she believes will ultimately lead to transgender people receiving better care within health systems.
“If a doctor sees a transgender patient in a state of depression, then they should be offered treatment like anyone else,” she says. “Transgender people need to access specialized medical care. We are often faced with the side effects of hormone therapies and this has to be taken into consideration. In order to survive, it’s not uncommon for transgender people to be engaged in commercial sex work and a person in that situation needs regular testing for sexually transmitted infections and HIV.”
Medical, psychological and social needs
Transgender is an umbrella term for a diverse group of people. While Anzhelika emphasizes that she can only speak from her own experience with the health system, she says she has had generally positive experiences. However, she says, “Other transgender people have often told me they were faced with ridicule and a dismissive tone.”
It is important to break down existing barriers to accessing health services for transgender people, who often have diverse needs. “The main thing for me, like many other transgender people, is consulting an endocrinologist who specializes in transgender issues,” says Anzhelika.
“Transgender people find it hard to get work and it’s difficult for them to survive. Some simply end up below the poverty line and need basic social assistance. Many people live in internal discomfort and depression, which in some cases leads to suicide. The needs of transgender people are medical, psychological and social.”
“This revision of the ICD is a game changer,” says Dr Masoud Dara, Acting Director of Communicable Diseases at WHO/Europe. “It is crucially important that transgender individuals have equal access to health services, including HIV prevention and care, and this requires health systems to be responsive to their needs. The adoption of ICD-11 by more and more countries is a vital first step towards removing legal barriers to care. That will help stop stigma and discrimination and accelerate progress towards true universal health coverage.”
Failure to uphold the human rights of lesbian, gay, bisexual, transsexual and intersex people against abuses such as violence and discriminatory laws and practices constitutes a serious violation of international human rights law. It has a far-reaching impact on society and contributes to increased vulnerability to ill health, including HIV infection.