Maximizing Sexual Health & Rights of Transgender Populations: The Changing Role of the International Classification of Diseases

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Thanks to all who attended the USC Law & Global Health collaboration event on October 11, 2016. See below for a summary of the day’s proceedings.

Doe Mayer welcomed all in attendance and introduced Sofia Gruskin, Professor in the Keck School of Medicine and Gould School of Law, and Director of the Program on Global Health and Human Rights. This event continued the USC Law and Global Health Collaboration’s 2016-2017 topical focus on transgender rights and health. Professor Gruskin used the law and global health mix to help start a discussion about the critical role that the International Classification of Diseases (ICD) plays in the health, rights, and lives of trans populations.

The ICD is relevant to every country in the world. It is the global standard diagnostic tool for epidemiology, health management, and clinical diagnoses. It plays a critical role in medical records, public health surveillance, access to services, and ultimately allocation of resources in numerous ways. It was last updated in 1990, and the next iteration is slated for review and endorsement at the World Health Assembly in 2018, making the discussion is timely. As a technical document whose contents are nonetheless voted on by countries, politics are central and important to its development.

The ICD currently conceptualizes trans phenomena (1) as transsexualism located within the mental and behavioral disorders chapter, (2) using binary, oppositional language of the opposite sex and treating gender as static male or static female.

ICD classifications are intended to be used by healthcare providers, but also engage complex legal and regulatory issues. In Russia, for example, the trans diagnosis under the current ICD can restrict driving, as a result of a 2014 legal decree that limits driving for those diagnosed with “mental and behavioral disorders” as defined in the ICD. The ways in which the ICD definition is used by lawmakers within countries poses important challenges, as it can be used ultimately to violate or promote the human rights of transgender populations.

Of relevance here, globally, trans women are 49 times more likely to be living with HIV than adult males or females who are not trans. Additionally, there have been more than 2000 reported killings of trans and gender diverse people between 1 January 2008 and 30 April 2016, and this is likely the tip of the iceberg, as these are only killings that have been correctly reported as motivated because this person was trans. Thus, data limitations, related to and affecting ICD processes, have huge implications.

Health concerns relevant to the ICD discussion are many and include stigma, as well as treating trans populations as if they are invisible. All of this leads to a lack of supportive health services as well as limited systematically collected evidence on health and rights concerns for this population—including political data, financial data, safety data, and health data. Without adequate data, resource allocation and health service availability suffers.

Given this background, Professor Gruskin posed two questions: (1) Should transgender phenomena be included in the ICD-11 or better to be removed entirely? (2) What does this mean for law and global health? On the first question, trans advocacy groups and health practitioners have come to an overwhelming consensus that yes, trans phenomena needs to be in the ICD. Reasons include identifying vulnerable/at risk populations; defining the obligations of WHO Member States to provide free or subsidized health care including silicone and hormones; facilitating access to appropriate health care services; ensuring the ICD can act as a basis for guidelines for care and standards of practice. This means a non-pathologizing reclassification that facilitates appropriate access to non-coerced health care (hormones, silicone etc.); is scientifically defensible and grounded in evidence; broadly defined; helps to protect human rights; and will be acceptable to transgender people, health care professionals, researchers, and Member States.

The group then discussed potential definitions currently under consideration, and addressed the second question, including a discussion of the importance of assessing legal and policy environments as they relate to trans people’s health and well-being. Language was a key focus of the discussion, including the importance of terminology, and the group explored stimulating questions as to languages in which there are binary, gendered nouns and pronouns (e.g. Spanish) and the impact this may have for trans populations. The group also explored the implications of a medical code vs. a rights-based definition; the ICD is the former, but clearly has implications that affect rights. Finally, the group touched on the issue of ICD classification and its impact on trans refugees and asylum-seekers, which was an excellent preview for the event next month.

Many thanks to Doe Mayer and Sofia Gruskin leading such an insightful event, and our gratitude as well to the full room of people who make up the Law and Global Health Collaboration. The next event will be held on 22 November in Room 130 at the Law School, from 12:00-1:00pm, and is entitled Legal and Other Barriers to Protection for Transgender Asylum-Seekers in the United States. Please join us at our next event!


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