Apart from these main principles, the international trans depathologization activism expressed several demands and developed proposals and suggestions responding to recent developments.
Removal of the diagnostic classification as mental disorder and state-funded coverage of trans health care
One of the main demands of the international trans depathologization activism is the removal of the diagnostic classification of gender transition as a mental disorder from DSM and ICD [26,26,27,28,29,30,31,32,34, 46, 47, 54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74, 80, 82]. Trans people from different world regions expressed their concerns regarding a loss of access and state-funded coverage of trans health care, or an increased difficulty for achieving it, in the case of a complete removal of trans-related diagnostic codes. As another fear, they mentioned the loss of opportunities for legal gender recognition in those countries in which gender identity laws require diagnosis [111, 112].
Responding to these concerns, the international trans depathologization activism developed different strategies, contributing (1) an argumentation framework based in the right to health, the right to health care, and the right to legal personality as established in international human rights treaties, as well as in the Yogyakarta Principles; (2) the consideration of contextually specific priorities, taking into account the variety of health care systems and legal frameworks in force worldwide; and (3) the recommendation of strategies in the short term (health care access and legal gender recognition) and long term (in-depth change of the health care systems and legal frameworks) [28,28,29,30, 32, 33, 63, 66, 68,68,69,70, 72,73,74, 80]. Furthermore, STP added the demand of state-funded coverage of trans health care to its main demands [113], and an international expert group coordinated by GATE, Global Action for Trans Equality elaborated reports with suggestions for the ICD revision process taking into account the relevance of health care access [114, 115].
Regarding DSM, trans depathologization activism maintained the demand of a complete removal of trans-related diagnostic categories [26,27,28, 30, 31,32,33, 80]. In relation to ICD, taking into account its character as a classification not only of mental disorders or illnesses, but of all types of health processes that might require health care, the international trans depathologization activism proposed the removal of trans-related codes from the chapter “Mental and behavioural disorders.” At the same time, the inclusion of a non-pathologizing code in a different ICD chapter was suggested, as a health care process not related with disorders or illnesses [26, 28, 30, 33].
In 2013, the APA (American Psychiatric Association) published the DSM-5, in which the diagnostic category “Gender Identity Disorder” was substituted by “Gender Dysphoria”, and the category of “Fetishistic transvestism” by “Transvestic disorder” [35]. The international trans depathologization activism criticized the continued diagnostic classification of transexuality as a mental disorder, as well as the expansion of the category ‘Transvestic disorder’ by means of the ‘autogynophilia’ concept [28, 30, 31, 33, 80].
In the ICD revision process, all diagnostic codes related to gender expression/identity and sexual orientation were removed from the chapter “Mental and behavioural disorders” in ICD-11 [38]. A code “Gender incongruence” was included in the new chapter “Conditions related to sexual health,” with two subcodes “Gender incongruence in adolescence and adulthood” and “Gender incongruence of childhood” [38].
Trans depathologization activism considered this change as an important advancement [80, 82]. At the same time, international and regional trans depathologization networks questioned the continued diagnostic classification of gender diversity in childhood [1, 2, 26,27,28, 30, 33, 54,55,56,57,58,59,60,62, 80, 82] and criticized the psychopathologizing connotations of the term “Gender incongruence,” proposing alternative terminologies, such as “Health care related to gender transition” [30].
The demand of a removal of the diagnostic classification as a mental disorder can be related to the Yogyakarta Principles, especially Principle 2—The Rights to Equality and Non-Discrimination and Principle 18—Protection from Medical Abuses [93]. The demand of state-funded trans health care of the highest attainable quality can be related to Principle 13—The Right to Social Security and Other Social Protection Measures and Principle 17—The Right to the Highest Attainable Standard of Health [93]. These principles are also relevant aspects for the HRPC framework: “A particularly important (though not exclusive) source of international human rights law relevant to patient care is the right to the highest attainable standard of health found in Article 12 of the ICESCR” (p. 10) [93], opening a shared ground for advocacy on the right to health care.
Trans health care models
In parallel to the DSM and ICD revision process, international trans depathologization activism [26,27,28, 30, 33, 69,70,71,72, 80] focused over the last years on a third document, the SOC, Standards of Care for Gender Identity Disorders, elaborated by HBIGDA, Henry Benjamin International Gender Dysphoria Association, now WPATH, World Professional Association for Transgender Health [116, 117]. From 1979 on, HBIDGA/WPATH has been publishing periodically new versions of the SOC, developed initially from and for the US context, and applied in different world regions [116, 117].
Regarding the SOC-6, published in 2001 [116], trans depathologization activism and scholarship [30, 69,70,71,72] criticized the psychiatric assessment regulating the access to trans-related hormonal treatments and surgeries, the application of the diagnostic codes established in DSM and ICD, the assumption of a binary transition process and heterosexual orientation of trans people, and the requirement of the “real-life experience,” i.e., the requirement of living full time in the desired gender and contributing proofs of this process. Furthermore, they questioned the presupposition that all trans people wish to follow a “triadic therapy,” including real-life experience, hormone therapy, and surgery. As another critical aspect, they highlighted the exclusion of intersex people from trans health care. From different world regions, trans depathologization activist groups contributed proposals for a model of trans health care based on information, counseling, accompaniment, and informed decision making [26, 30].
In 2012, WPATH published the SOC-7, Standards of Care for the Health of Transsexual, Transgender and Gender Nonconforming People [117]. Trans depathologization activism [26, 30, 80] valued positively the recognition of gender transition processes as not pathological, the acknowledgment of a wide diversity of gender expressions, trajectories, and identities and differentiated situations regarding trans health care according to the cultural and geopolitical context, the intention of using a non-discriminatory language, and the explicit condemnation of so-called reparative therapies. At the same time, they questioned the continuation of a psychiatric assessment model, the requirement of a “12-month experience of living in an identity-congruent gender role” (p. 60) [117], as well as the use of pathologizing approach and language in the section on trans health care for intersex people.
Recently, changes in the trans health care models can be observed in some world regions, with informed decision-making models implemented in some countries and regions, among them in Community Trans Health Care Centers in the US [118, 119], as well as in the Public Health Systems of Argentina [120] and some Spanish regions [26, 27].
The demand for a trans health care model based on information, counseling, and informed decision making can be related to the Yogyakarta Principles, specifically Principle 18—Protection from Medical Abuses [93] and Principle—32, The Right to Bodily and Mental Integrity [94]. As mentioned before, the right to information, right to counseling, right to consent, right to free choice, and right to personalized treatment are also relevant for the HRPC framework [75, 76].
Legal gender recognition
Legal gender recognition without medical requirements is another relevant demand for international trans depathologization activism [5, 7, 26,26,27,28,29,30,31,32,33,34, 39,40,41, 63,64,65,66,67,68,69,70, 72,73,74, 80].
Recent studies identify a lack of gender recognition laws in many countries worldwide [1,2,3,4,5, 7, 10, 30, 39,40,41]. In those countries that count on Gender Identity Laws, they note a frequent presence of medical requirements, among them diagnosis, hormone treatment, genital surgery, and sterilization. Furthermore, requirements related to civil status (single status or divorce) are observed, as well as restrictions regarding age (limitation to people over 18) or nationality (exclusion of residents from other nationalities) [1,2,3,4,5, 7, 10, 30, 39,40,41].
Trans depathologization activism demands legal gender recognition without medical requirements or those related to civil status, age or nationality, and trans activist groups from different world regions work on the introduction or modification of gender identity laws without pathologizing requirements in their specific contexts [7, 26,27,28, 30, 33, 39,40,41, 63, 64, 66,67,68,69,70, 72,73,74]. This demand has been supported by European human rights bodies [83,84,85,86,87,88,89,90,91,92]. As a future demand, the abolition of gender markers from birth certificates, identity cards, and passports is claimed [30].
Over the last few years, the international trans depathologization movement celebrated advancements regarding legal gender recognition [7, 26,27,28, 30, 33, 39,40,41, 63, 64, 66,67,68,69,70, 72,73,74].
In 2012, the Argentinian Gender Identity Law (Ley 26.743) was passed [120], allowing legal gender recognition without medical requirements, including children and adolescents, under specific protection measures, with reference to the Convention on the Rights of the Child [121]. Taking the Argentinian Gender Identity Law as a reference point, over the last few years, gender recognition laws without medical requirements have been approved in several countries, among them 2014 in Denmark, 2015 in Mexico City, Colombia, Ireland, and Malta, 2016 in Bolivia, France and Norway, and 2018 in Portugal, Costa Rica, Chile, and Uruguay [26,27,28, 30, 33, 39,40,41]. In other countries, gender identity laws in force have been modified [30]. Nevertheless, in some of the named countries the law requires a court procedure for the sex markers change or maintains the requirement of clinical assessment for children and adolescents, limiting thus full gender self-determination [26].
The Yogyakarta Principle 3 establishes the right to recognition before the law [93], and Principle 31 of the Yogyakarta Principles plus 10 refers to the right to legal recognition [94]. The HRPC framework does not mention explicitly this right [75, 76]. Nevertheless, when applied to trans health care, these rights achieve relevance, due to the tight relationship between diagnosis and legal recognition still established in many gender identity laws, and the health impact of a lack of legal and social gender recognition.
Depathologization of gender diversity in childhood and adolescence
Over the last few years, the demand of depathologizing gender diversity in childhood and adolescence has achieved an increased relevance in trans depathologization activism [1, 2, 28, 30, 33, 54,55,56,57,58,59,60,61,62, 122,123,124,125], including the following demands: (1) removal of the diagnostic classification of gender diversity in childhood from DSM and ICD; (2) support to gender diversity in childhood and adolescence in the family, social, school, and health care context; and (3) legal gender recognition for children and adolescents.
Regarding the diagnostic classification of gender diversity in childhood, various international and regional activist networks published declarations demanding the removal of the diagnostic code “Gender incongruence of childhood” from ICD, and trans authors and allies contributed critical theoretical reflections on the diagnostic classification of gender diversity in childhood in the DSM and ICD [1, 2, 28, 30, 33, 54,55,56,57,58,59,60,61], preceded by critical reflections elaborated over the last decades [20, 21]. This demand also received the support of clinicians and researchers [62] and European bodies [90, 91].
Among the main arguments in favor of removing the diagnostic code, trans authors and allies highlight the lack of clinical utility, the Western character of a conceptualization of gender diversity in childhood as a problem that requires health care, the potential stigmatizing effect, and a contradiction between a removal of diagnostic codes related to sexual orientation and the maintenance of the Gender Incongruence of Childhood code [1, 2, 20, 21, 28, 30, 33, 54,55,56,57,58,59,60,61,62]. Furthermore, the critical discourses counter reasons contributed by the defenders of the diagnosis [126, 127], arguing that a specific diagnosis for gender diverse children is not necessary for covering psychological support, justifying access to puberty blockers, or promoting research and training [1, 2, 20, 21, 28, 30, 33, 54,55,56,57,58,59,60,61,62].
Trans depathologization activists and allied professionals defend the right of children and adolescents to free gender expression, including non-binary or fluid options [30, 56, 122,123,124,125]. They stress the need of supporting children and adolescents to express their gender in the family, social, educational, and health care context, by facilitating safe spaces for the exploration of different gender expressions and identities and protecting them from discriminatory and transphobic attitudes, without forcing them into a binary transition. In the health care context, they recommend the provision of support and accompaniment, avoiding a medicalization of gender diversity in pre-adolescent children [30, 56, 122,123,124,125]. Trans authors and allies also refer to the right of adolescents to access hormone blockers [30, 56]. At the same time, they express concerns about potential health and social risks [30, 56]. They recommend health professionals to facilitate gender diverse children, adolescents and their parents contacts with family associations that support gender diversity and gender diverse / trans youth groups [30, 56].
Regarding legal gender recognition, trans depathologization activist networks and authors stress the right of children and adolescents to change their gender markers [26, 30, 56]. They value positively the possibility of not inscribing the sex assignment at birth, as established in the Gender Identity, Gender Expression and Sex Characteristics Act, passed 2015 in Malta, as well as the option of several changes, as regulated in the Norwegian Gender Identity Law [26].
The Preamble of the Yogyakarta Principles [93] states that “in all actions concerning children the best interests of the child shall be a primary consideration and a child who is capable of forming personal views has the right to express those views freely, such views being given due weight in accordance with the age and maturity of the child” (9). Several principles established in the Yogyakarta Principles [93] and Yogyakarta Principles plus 10 [94] include a specific reference to children, such as the Principle 13—The Right to Social Security and to other Social Protection Measures; Principle 15—The Right to Adequate Housing; Principle 16—The Right to Education; Principle 18—Protection from Medical Abuses; Principle 24—The Right to Found a Family; and Principle 32—The Right to Bodily and Mental Integrity.
Depathologization of research practices
Trans authors and allies review critically dynamics of pathologization and discrimination present in clinical and social research [13,14,15,16, 23, 30, 42,43,44,45,46,47,48,49,50,51,52,53]. Questioning an external pathologizing gaze, they demand a recognition of trans authors with a double academic-activist background and contribute suggestions for non-pathologizing research practices.
Responding to the observation of a frequent pathologizing language use at conferences, WPATH and EPATH, European Professional Association for Transgender Health established working groups to develop ethical principles for guaranteeing a non-pathologizing and non-discriminatory use of conceptualizations, terminologies and visual representations, and avoiding a promotion of clinical practices contrary to human rights standards at the WPATH and EPATH conferences [45].
Furthermore, trans authors and allies contributed ethical reflections for studies on trans issues [13, 14, 30, 42,42,43,44,45,46,47,48,49,50,51,52,53], proposals for reducing cisgenderism in research practices [50, 52], recommendations for including gender diversity beyond the binary in quantitative methodologies [128], and for using a non-pathologizing language in the media [129].
Several of the principles established in the Yogyakarta Principles [93] and Yogyakarta Principles plus 10 [94] can be applied to the research field, such as Principle 2—The Rights to Equality and Non-Discrimination; Principle 6—The Right to Privacy; Principle 18—Protection from Medical Abuses; Principle 19—The Right to Freedom of Opinion and Expression; Principle 21—The Right to Freedom of Thought, Conscience and Religion; Principle 25—The Right to Participate in Public Life; Principle 26—The Right to Participate in Cultural Life; Principle 27—The Right to Promote Human Rights; Principle 30—The Right to State Protection; Principle 32—The Right to Bodily and Mental Integrity; Principle 36—The Right to the Enjoyment of Human Rights in Relation to Information and Communication Technologies; and Principle 37—The Right to Truth.
The critical gaze on pathologizing and discriminatory language also includes a critical review of the term “patient” [26]. From a trans depathologization perspective, the term “health care user” is given preference [26], proposing a non-pathologizing language use [26, 30, 45, 50, 52] that could inform the HRPC framework, especially when applied to trans health care.