What does WHO's proposal to remove transgender identity from mental disorders list mean for India?

When 41-year-old Abhina Aher went for counselling before undergoing a sex reassignment surgery to help her transition to living as a woman, she did not anticipate a barrage of insensitive questions from a trained professional.

“The psychiatrist asked me whether or not I masturbate, or if I want to have sex with a woman,” said Aher. “How does that fit into what I am telling you [the psychiatrist]? I am telling you I am a woman. Please ask questions based on that. Ask me if I am prepared for social change.”

Aher, who now works for India HIV/AIDS Alliance in Delhi, a non-profit that works with communities vulnerable to HIV/AIDS, including transgender people and men having sex with men, said that many psychiatrists do not understand the nuances of what transgender people go through and treat them like “a mental patient”.

But this isn’t the case in India alone. The World Health Organisation classifies the discomfort with the sex one was born with and the desire to be accepted as a member of the opposite sex as a mental disorder.

However, in a victory for transgender rights activists the world over, the WHO has said that it is considering removing the transgender identity from the classification of mental disorders in its International Classification of Diseases – considered a Bible for healthcare service providers and doctors. The list is due to be revised in May 2018.

This decision was based on the findings of a study in Mexico, published on July 26 in the medical journal Lancet Psychiatry, which said that this classification has contributed to human rights violations, creating barriers to healthcare access and the precarious legal position that the transgender community faces.

This is comparable to the success of the queer rights movement when homosexuality was removed from the Diagnostic and Statistical Manual of Mental Disorders, known as the DSM, in 1987. This manual is a diagnostic tool used by mental health care providers all over the world and vetted by the American Psychiatric Association.

Landmark shift

As part of the study in Mexico, 250 transgender people were interviewed over three-and-a-half months in 2014 about their gender identity, body transformation and the social stigma and violence they may have faced, among other things.

The study found out that individuals with gender incongruence are at an increased risk of psychological distress, psychiatric symptoms, social isolation, dropping out of school, loss of employment, homelessness, disrupted interpersonal relationships, physical injuries, social rejection, stigmatisation, victimisation and violence.

However, the key finding of the study was that the psychological distress and dysfunction stemmed from violence and social rejection and not the fact of gender incongruence itself – strengthening the argument for its declassification as a mental disorder.

“I am glad they [WHO] have done this finally,” said Anjali Gopalan, from the Naz Foundation in Delhi that works on HIV/AIDS and sexual health. “If you do not consider homosexuality a disease, why consider transgender identity one? It [the study] also clearly states that the problem is from external sources, and not from within.”

In India, the transgender community has existed at the fringes of society for more than a century, struggling for acceptance and victims of ridicule, stigma and violence. However, in recent years, there has been growing political intent towards recognising transgender identity. In 2014, the Supreme Court recognised them as the third gender and directed the government to provide them social protection. Last month, the Union Cabinet cleared a bill to protected the rights of transgender people. The bill was modelled on a private member’s bill passed in the Rajya Sabha last year.

However, the attitudes of people, including those in the medical community, could take a while to change. “Despite the removal of homosexuality from the DSM so many years ago, some doctors are still trying to cure it,” said Gopalan. “But, still this move [the probable change in classification by the WHO] is a start.”

The DSM-5 in 2013 had also retained its classification of gender dysphoria as a mental disorder.

The International Classification of Disorders, in its 11th edition, proposes a new category, gender incongruence, which emphasises an individual’s subjective experience of incongruence between his or her experienced gender and the assigned sex. The WHO wants to place gender incongruence under a new chapter in the manual called Conditions Related to Sexual Health, placing it more firmly in the medical realm.

This could possibly improve the transgender community’s access to healthcare. The study noted that since transgender identity was seen as a mental disorder, the classification was used to justify denial of coverage by governments and has contributed to the perception that transgender people must be treated by psychiatric specialists.

The study will be replicated in India, at All India Institute of Medical Sciences, Delhi, with only the hijra population (and not women who identify with the male gender).

A long wait to change bodies

For hormonal or surgical procedures to change one’s gender, the protocol followed globally are the Standards of Care for the Health of Transsexual, Transgender, and Gender Noncomforming People, formed by Harry Benjamin International Gender Dysphoria Association in the US, called. The document was first drafted in 1979 and last updated in 2001.

These guidelines, Aher said, are redundant and are not country-specific.

The Lancet paper said that in most countries where transgender people can access gender transition services, there is an unreasonable two-year wait, ostensibly to ensure that the transgender person is certain about his or her decision.

The reclassification by the WHO could possibly help make reduce the number of rigid pre-surgery requirements, thereby making the process smoother and faster. This will also prevent transgender people from undergoing transformation without medical supervision.

This is of particular concern to India, where many transgender people, especially those belonging to the hijra community, undergo castration under the knife of quacks, or pop hormone pills freely available in the medical stores. The high costs of such surgeries are an additional hurdle for hijras, many of whom don’t have a steady source of income.

“These are extremely desperate measures taken to change their bodies,” said Aher. “They are not going to wait two years for that. And the psychiatrists and counsellors are not giving them the support they need.”

The counselling is required before sex reassignment surgeries and at every step of the process to ensure the person is sure of undergoing such a change, has given it due consideration and is also aware of the physical changes caused due to hormones, and the psychosocial impact.

Also, as most public hospitals do not conduct such surgeries and rates at private hospitals are exorbitant. Even a simple laser shot for hair removal costs nearly Rs 1,500, while vaginoplasty – plastic surgery on the vagina, also done to create one in the case of sex reassignment surgeries – costs about Rs 2.5 lakhs and breast augmentation could cost Rs 1 lakh.

“Going to quacks leads to many complications,” said Aher. “There is no hospital stay, counselling or post-operative care. Sometimes the urethra closes and sometimes people die of excessive bleeding.”

For India, therefore, where the stigma against transgender people is compounded by the lack of access to public healthcare, the reclassification by the WHO could give a shot in the arm to the transgender rights movement.