In 250 transgender adults in Mexico City, distress tracked rejection and violence, not gender incongruence itself
The ICD-11 field study: distress and dysfunction "were strongly predicted by experiences of social rejection (odds ratios [ORs] 2.29-8.15) and violence (1.99-3.99)". Of the incongruence indicators, only one predicted anything.
Suggestive but preliminary. Not settled. how we score evidence
Caveat on this rating: Retrospective interviews in a purposive sample from one specialist clinic; adults recalling adolescence. No comparison group. Designed to inform the ICD-11 decision and co-authored by a working group member, so it is evidence gathered by the people proposing the change.
A mental disorder is supposed to involve distress or impairment that comes from the condition itself. This study asked whether, for transgender adults, the distress came from the identity or from how they were treated.
Significant findings
Between April and August 2014, "260 transgender adults were approached and 250 were enrolled in the study and completed the interview" at the Condesa Specialised Clinic in Mexico City. Most, "n=202 [81%]", had been assigned male at birth. Participants "reported first awareness of transgender identity at a mean age of 5.6 years", and "184 (74%) had used health interventions for body transformation, most commonly hormones (182 [73%])". Of those who used hormones, "84 (46%)" had started "without medical supervision".
Distress in adolescence "was very common, but not universal (n=208 [83%])", and high where present, "79.9 on a scale of 0 [none at all] to 100 [extreme]". Dysfunction was common too, "n=226 [90%]", but "typically moderate".
The finding the classification rests on: "distress and all types of dysfunction were strongly predicted by experiences of social rejection (odds ratios [ORs] 2.29-8.15) and violence (1.99-3.99)." A current male gender identity also predicted distress (OR 3.90). "Of the indicators of gender incongruence, only asking to be treated as a different gender was a significant predictor, and only of work or scholastic dysfunction (OR 1.82)."
The authors' reading: the study "provides additional support for classifying health-related categories related to transgender identity outside the classification of mental disorders in the ICD-11."
The other direction
The design limits are in the abstract. It is "a retrospective interview design in a purposive sample" of adults already receiving care at one specialist clinic. People who reach a clinic and stay are not everyone, and adults recalling adolescent distress a decade or more on are reporting memory, not measurement. Eighty three percent did report distress; the argument is about its source, not its absence. A study designed to inform a classification decision, funded by a national psychiatric institute and co-authored by a WHO working group member, is a study with a stake in the answer, and readers should weigh it as such.
What this does not show
It does not compare treatments and does not recommend any. It does not measure outcomes after care. It cannot show what distress would look like in a population that had never been rejected, because no such population was available.
Worth asking
If distress follows rejection and violence more than identity, what would reduce the distress: changing the person, or changing what happens to them?
Source
Removing transgender identity from the classification of mental disorders: a Mexican field study for ICD-11 — Robles R, Fresán A, Vega-Ramírez H, Cruz-Islas J, Rodríguez-Pérez V, Domínguez-Martínez T, Reed GM (2016)
Top-tier peer-reviewed journal
Read the source: https://doi.org/10.1016/S2215-0366(16)30165-1
DOI: 10.1016/S2215-0366(16)30165-1
How this was scored
- Study design
- Cross-sectional study / survey
- Funding
- Independently funded
- Published in
- Top-tier peer-reviewed journal
- Sample size
- 250
- Preregistered
- not recorded
- Conflicts disclosed
- not recorded
- Independent of proponent
- No
- Retracted
- No
Read the full scoring rubric, including what it can't tell you.
Published September 29, 2026.
Questions
How strong is the evidence behind this?
veisund rates this source "early signal". Suggestive but preliminary. Not settled. It scores 51 out of 100 on our published rubric. One caveat travels with that badge: Retrospective interviews in a purposive sample from one specialist clinic; adults recalling adolescence. No comparison group. Designed to inform the ICD-11 decision and co-authored by a working group member, so it is evidence gathered by the people proposing the change. The score is calculated from recorded facts about the source — study design, funding, publication venue, sample size, preregistration — not typed in by an editor.
What is the source for this?
Removing transgender identity from the classification of mental disorders: a Mexican field study for ICD-11 — Robles R, Fresán A, Vega-Ramírez H, Cruz-Islas J, Rodríguez-Pérez V, Domínguez-Martínez T, Reed GM (2016). Published in: Top-tier peer-reviewed journal. DOI: 10.1016/S2215-0366(16)30165-1. The full source is linked on this page so you can read it yourself.
Who paid for this research, and does that matter?
Study design: Cross-sectional study / survey. Funding: Independently funded. The researchers were not independent of whoever benefits from the result. Industry sponsorship is one of the most reliably measured biases in medicine, which is why funding carries real weight in the score rather than sitting in a footnote.
Is this medical advice?
This is information to bring to your prescriber, not medical advice and not a reason to change anything on your own. Nothing here is an instruction to stop or reduce a medication. If you are in crisis, call or text 988.
This is information to bring to your prescriber, not medical advice and not a reason to change anything on your own. Nothing here is an instruction to stop or reduce a medication. If you are in crisis, call or text 988.