When being trans stopped being a mental disorder: ICD-11 explained

Being trans stopped being a mental disorder in the World Health Organization's classification on 1 January 2022, the day ICD-11 came into effect. Adopted by the World Health Assembly in May 2019, ICD-11 replaced the old diagnoses of transsexualism and gender identity disorder of children with gender incongruence, and moved it out of the mental disorders chapter into a new chapter on sexual health. The American psychiatric manual, the DSM, still lists gender dysphoria, so the story is not quite finished.

What the ICD and the DSM are

Two classifications shape how health conditions are named. The International Classification of Diseases, or ICD, is published by the WHO. It is used to record and report health conditions around the world, so that health data can be compared from one country to another. The Diagnostic and Statistical Manual of Mental Disorders, or DSM, is published by the American Psychiatric Association (APA), and clinicians and researchers use it to diagnose and classify mental disorders.

Where trans people sit in these books has never been a purely academic question. The APA's own fact sheet on DSM-5 puts the tension in one sentence: diagnostic terms make clinical care and insurance coverage possible, and they can also stigmatise. Both halves of that sentence run through everything below.

This article is history, not medical advice. For anything about your own care, talk to a clinician or a trans health service you trust.

How trans people entered the manuals

The first two editions of the DSM, published in 1952 and 1968, contained no diagnosis comparable to gender dysphoria. That changed in 1980 with DSM-III. It introduced gender identity disorder, at first only for children, under a heading of psychosexual disorders; adolescents and adults were diagnosed with transsexualism instead. The 1987 revision, DSM-III-R, added a further category for adolescents and adults who were not considered transsexual.

The timing has been argued over ever since, because the APA had removed homosexuality from the DSM in 1973 (some accounts say 1974) and the gender identity diagnoses arrived a few years later. Some writers have described their addition as a political manoeuvre to re-stigmatise homosexuality; other researchers have argued that it was included because it met the criteria the manual's authors generally used. By the fourth edition, DSM-IV, and its text revision, the diagnoses for children, adolescents and adults all sat under one name: gender identity disorder.

The WHO's list followed a parallel path. ICD-10, approved in 1990, placed a group called gender identity disorders (codes F64) in its chapter on mental and behavioural disorders, among the disorders of adult personality and behaviour. It included gender identity disorder of childhood and, for adults, transsexualism: a clinical term built on the older word transsexual, which some people still use about themselves and which is best left to them.

DSM-5: from disorder to dysphoria

In 2013 the APA published DSM-5 and replaced gender identity disorder with gender dysphoria. Its fact sheet explained the choice. Gender nonconformity, it said, is not in itself a mental disorder; what the diagnosis turns on is clinically significant distress. DSM-5 also gave gender dysphoria a chapter of its own, separate from sexual dysfunctions and paraphilic disorders.

The APA kept the diagnosis on purpose. Its working group was concerned that removing it, as some had suggested, would put access to care at risk, because insurance coverage for medical treatment generally requires a diagnosis. Swapping disorder for dysphoria was meant to remove the suggestion that the person was disordered, without closing the door to treatment.

A text revision, DSM-5-TR, followed in 2022, the first published revision since 2013. It updated the vocabulary: desired gender became experienced gender, natal male and natal female became individual assigned male or female at birth, and cross-sex treatment regimen became gender-affirming treatment regimen.

Today the APA's page for the public states that the term transgender is not a psychiatric diagnosis. Gender dysphoria still is one, and it still sits in a manual of mental disorders. That is where the American manual and the WHO's classification now part ways.

Why the WHO moved it

Pressure came from several directions. A 2016 paper in World Psychiatry, written by members of the WHO working group, records that civil society organisations, the governments of several member states and the European Parliament had all urged the WHO to take trans-related categories out of its classification of mental disorders.

Stigma on its own was not the argument that won. The same paper says the stigma attached to mental disorders would not, by itself, justify moving a category. What mattered was harm to health. The combined stigma of being trans and of carrying a mental disorder label, the authors wrote, had contributed to precarious legal status, human rights violations and barriers to appropriate care. Such a label also fed the idea that trans people must be seen by psychiatric specialists, which restricted services that other clinicians could reasonably provide, and insurers often excluded trans-related care anyway.

Field studies then tested the core question: is the distress part of being trans, or does it come from how trans people are treated? In Mexico City, researchers interviewed 250 trans adults at the Condesa Specialised Clinic in 2014. Distress about gender identity during adolescence was common but not universal, and both distress and difficulties at home, at work and socially were strongly predicted by experiences of social rejection and violence. A later field test with trans adults in Lebanon reached a similar conclusion: their distress was better explained by the social context they lived in than by their trans identity.

A few governments had moved before the WHO did. France announced in 2009 that it would no longer class transsexual identity as a psychiatric condition, although French trans organisations said little changed on the ground. Denmark made a similar announcement in 2016.

What ICD-11 changed

The WHO released ICD-11 on 18 June 2018. Member states adopted it at the 72nd World Health Assembly on 25 May 2019, and it came into effect on 1 January 2022. For trans people, the changes came in three parts:

• New names. Transsexualism became gender incongruence of adolescence and adulthood, and gender identity disorder of childhood became gender incongruence of childhood.
• A new chapter. Both left the chapter on mental and behavioural disorders for a new chapter 17, Conditions related to sexual health, which gathers conditions that used to be classified in other places.
• A clearer definition. The adult category is defined by a marked and persistent incongruence between a person's experienced gender and the sex they were assigned, and the WHO adds that gender variant behaviour and preferences alone are not a basis for the diagnosis.

That last point matters more than it looks. In plain terms, how someone dresses, plays or wears their hair is not, on its own, grounds for the label.

The WHO states its reason plainly in its questions and answers on the subject: the move reflects current knowledge that trans and gender diverse identities are not conditions of mental ill-health, and that classifying them as such "can cause enormous stigma".

Why gender incongruence is still in the ICD at all

If being trans is not an illness, why keep a code? The WHO's answer is access. Including gender incongruence in ICD-11, it says, should ensure trans people's access to gender-affirming health care, and adequate health insurance coverage for it.

The working group gave the practical version in 2016. In most countries, a health service can only be provided against a diagnosis related to it. Without any diagnosis to identify trans people seeking those services, the group wrote, they would likely become even less available than they already were.

So the category survives as a compromise between stigma and access. The APA reached the same conclusion for DSM-5 for the same reason. Trans organisations count the move out of mental disorders as progress, and keep pressing against the gatekeeping that any diagnosis can be used for: in 2025, TGEU and its partners called for trans healthcare built on informed consent, free from psychiatric gatekeeping.

What is still being argued about

The childhood category is the most disputed piece. In a 2016 article in The Lancet Psychiatry, members of the WHO working group set out the controversies and knowledge gaps around it, and argued for keeping gender incongruence of childhood as a basis for structuring clinical care and ensuring access to services. Trans organisations have kept asking for gender diversity in childhood to be depathologised, and it is one of the demands in the 2025 statement by TGEU, EATHAN and ILGA World.

Putting ICD-11 into practice is slow. It has been in effect since 2022, but the same 2025 statement says many countries in Europe and Central Asia have yet to align their healthcare and legal systems with it. Legal gender recognition in many places still demands medical procedures or proof of transition, which is exactly what the statement asks governments to drop.

The depathologisation movement still has its own date each October, the International Day of Action for Trans Depathologisation, and in Barcelona the whole month is known as Trans October. For more of the history behind dates like these, see our pieces on LGBTQ+ History Month and trans awareness days.