how the system workslast verified 2026-09-24

how transgender left the mental-disorders chapter

the word “transsexual” was invented in 1949 by a doctor writing for a magazine, and he defined it as a mental illness in the same sentence. seventy years later the World Health Assembly voted to take gender incongruence out of the mental-disorders chapter of the international classification and file it under sexual health instead. between those two dates sits a short list of books, three editions of the DSM, one field study in Mexico City, and a Swedish registry whose findings point the other way. here is the record in order, with what each source can and cannot show.

the record, in order

1910

Magnus Hirschfeld publishes Die Transvestiten in Berlin, an investigation of “the erotic drive to cross-dress,” with case histories. it gave the phenomenon a name and a book of its own, apart from homosexuality.[1]

1949

David Cauldwell, an American doctor writing in the magazine Sexology, coins “psychopathia transexualis”: “a pathologic-morbid desire to be a full member of the opposite sex,” arising from “a poor hereditary background and a highly unfavourable childhood environment.” the word and the pathology were born together.[2]

1954 and 1966

the endocrinologist Harry Benjamin publishes “Transsexualism and transvestism as psychosomatic and somatopsychic syndromes” in a US clinical journal, then the first book, The Transsexual Phenomenon. the clinic now had a literature.[3][4]

1980

“transsexualism” appears in DSM-III, with a separate childhood diagnosis, gender identity disorder of childhood. ICD-10 later carries the same under “F64 Gender identity disorders,” in the mental and behavioural disorders chapter.[5][8]

1994

DSM-IV renames the adult diagnosis “gender identity disorder.” Beek and colleagues, tracing the editions, write that the changes “were not only based on research. Social and political factors contributed.”[5][6]

2012

the WHO working group revising ICD-11 publishes its reasoning: the question is “whether affected populations are best served by placement of these categories within the mental disorders section,” and the tension is between stigma on one side and “the need for diagnostic categories that facilitate access to healthcare” on the other.[7]

2013

DSM-5 replaces “gender identity disorder” with “gender dysphoria.” the APA’s own fact sheet: “gender nonconformity is not in itself a mental disorder. The critical element of gender dysphoria is the presence of clinically significant distress.” it also says why the diagnosis was kept at all: removing it “would jeopardize access to care.”[6]

2016

the ICD-11 proposal is published: gender identity disorders “reconceptualized as Gender incongruence” and moved to a new chapter on sexual health. the same year, the Mexico City field study of 250 transgender adults finds that distress and dysfunction were predicted by social rejection and violence, and by almost nothing about gender incongruence itself.[8][9]

May 2019

the 72nd World Health Assembly adopts ICD-11 (resolution WHA72.15). gender incongruence sits in “Conditions related to sexual health,” not in “Mental and behavioural disorders.” the WHO: this “reflects current knowledge that trans-related and gender diverse identities are not conditions of mental ill-health.”[10][11]

1 January 2022

ICD-11 comes into effect. the classification still contains a code for gender incongruence, deliberately: the WHO says its inclusion “should ensure transgender people’s access to gender-affirming health care, as well as adequate health insurance coverage.”[10][11]

five questions, answered from the sources

what was the earliest scientific documentation?[1][2][3][4]

Hirschfeld’s 1910 book is the first volume devoted to the subject; the modern word came later and from a worse place: “transsexual” was coined in a 1949 magazine article whose author defined it as being “mentally unhealthy.” Benjamin’s 1954 paper put it into a clinical journal, and his 1966 book made it a field.

how did it get into the DSM and the ICD?[5][6][8]

as “transsexualism,” in DSM-III in 1980, alongside a childhood diagnosis. ICD-10 filed it as “F64 Gender identity disorders” in the mental and behavioural disorders chapter. the labels then changed edition by edition, “gender identity disorder,” then “gender dysphoria” in 2013, and the people who wrote the history of those changes say they were driven by social and political factors as well as research.

why did the WHO move it out of mental disorders?[7][9][10]

three stated reasons. the working group’s: a mental-disorder label on top of being transgender is “doubly burdensome,” and the model behind it dated from “1940s conceptualizations of sexual deviance.” the evidence’s: in the Mexico City field study, distress and dysfunction were strongly predicted by rejection and violence (odds ratios 2.3 to 8.2 and 2.0 to 4.0) and barely at all by gender incongruence itself; a mental disorder is supposed to be defined by inherent distress or impairment, and this looked like neither. the WHO’s: classifying these identities as mental illness “can cause enormous stigma.”

why keep a code at all, then?[6][10]

access. both the APA in 2013 and the WHO in 2019 said the same thing in their own words: the diagnosis was kept because removing it “would jeopardize access to care,” and inclusion in ICD-11 “should ensure transgender people’s access to gender-affirming health care, as well as adequate health insurance coverage.” the code moved chapters so that the care could still be billed without the person being called mentally ill.

what does the evidence say about outcomes after treatment?[12][13][14]

it is mixed, and this page does not resolve it. the Swedish cohort of all 324 people who had reassignment surgery between 1973 and 2003 had 2.8 times the mortality of matched controls, 19 times the suicide mortality, and 2.8 times the rate of psychiatric inpatient care; the authors concluded surgery “may not suffice as treatment.” a 2020 total-population study of 2,679 people with the diagnosis found them about six times as likely to have a mood or anxiety visit and more than six times as likely to be hospitalised after a suicide attempt, and reported that each year since surgery went with an 8 percent lower odds of mental-health treatment; that surgery finding was formally corrected by the journal in the same issue. nothing on this page is a recommendation about any of it.

the move, and what it was not

the ICD-11 change is often summarised as “the WHO says being trans is not a mental illness,” and that is what the WHO’s own page says.[10] what it was not is a removal. the code survived the move on purpose, and the reasoning is the same on both sides of the Atlantic: the APA kept a diagnosis in 2013 because its work group feared that dropping it “would jeopardize access to care,” and the WHO kept one in 2019 so that care and insurance coverage would follow it.[6][10] the people who wrote the ICD-11 proposal named the trade-off in print in 2012, stigma against access, and chose to change the chapter rather than delete the entry.[7] it is the same shape as the 1973 homosexuality decision, which also replaced a diagnosis rather than deleting it, and took fourteen years to finish.

the other direction

the strongest evidence for the reclassification is the Mexico City study, and its authors are clear about what it is: a purposive sample of 250 adults already attending one specialist clinic, interviewed retrospectively about their adolescence.[9] people who reach a clinic and stay in it are not everyone, and memory of distress a decade on is not a measurement of it. the Swedish registry work runs the other way from the reclassification’s optimism: after surgery, mortality, suicide and psychiatric admission stayed far above the population for thirty years of cases, and the authors said plainly that surgery “may not suffice.”[12] that study has no untreated comparison, so it cannot say what those numbers would have been without treatment, but it cannot be read as reassurance either. the 2020 total-population paper that reported lower mental-health treatment with each year since surgery was corrected by its own journal in the same issue after letters challenged the analysis; the correction is paywalled, and this page does not pretend to know what it says beyond that it exists.[13][14] the field is one where the classification moved faster than the outcome data, and both the WHO and the Swedish authors would, on their own words, agree with that sentence.

what this page does not say

it does not say what gender identity is or where it comes from; none of the sources here claim to. it does not reproduce anything from the Hirschfeld, Benjamin or Cauldwell texts beyond what the source list says was read, and it treats a 1949 magazine article as the origin of a word, not as evidence of anything. it does not compare treatments, recommend any, or advise against any. the federal numbers on transgender mental health, with every construct and every discontinued survey named, are on the LGBTQ+ data page.

questions people ask

When did the WHO stop classifying being transgender as a mental disorder?

The World Health Assembly adopted ICD-11 in May 2019 (resolution WHA72.15), and it came into effect on 1 January 2022. In ICD-11, gender incongruence is in the chapter “Conditions related to sexual health,” not “Mental and behavioural disorders.” The WHO states this “reflects current knowledge that trans-related and gender diverse identities are not conditions of mental ill-health.”

Is gender dysphoria still in the DSM?

Yes. DSM-5 (2013) replaced DSM-IV’s “gender identity disorder” with “gender dysphoria.” The American Psychiatric Association’s fact sheet states that “gender nonconformity is not in itself a mental disorder” and that the diagnosis requires clinically significant distress; it also says the work group kept a diagnosis because removing it “would jeopardize access to care.”

Who coined the word transsexual?

The American physician David O. Cauldwell, in a 1949 article titled “Psychopathia transexualis” in the magazine Sexology, where he defined it as “a pathologic-morbid desire to be a full member of the opposite sex.” Harry Benjamin brought the term into the clinical literature in 1954 and published The Transsexual Phenomenon in 1966. Magnus Hirschfeld’s Die Transvestiten (1910) is the earliest book on the subject.

What did the Swedish follow-up study find?

Dhejne and colleagues (PLoS ONE 2011) followed all 324 people who had sex reassignment surgery in Sweden from 1973 to 2003 against matched population controls. Adjusted mortality was 2.8 times higher, suicide mortality 19.1 times higher, suicide attempts 4.9 times higher and psychiatric inpatient care 2.8 times higher. The authors wrote that surgery “may not suffice as treatment” and called for improved psychiatric and somatic care after it. The study has no untreated comparison group, so it cannot say what outcomes would have been without surgery.

Does this page give medical advice?

No. It is a history of how gender identity has been classified, sourced to the original texts, the journals, the APA and the WHO, with the limits of each source stated. It does not recommend or advise against any treatment.

sources

  1. Hirschfeld M. Die Transvestiten: eine Untersuchung über den erotischen Verkleidungstrieb mit umfangreichem casuistischen und historischen Material [The transvestites: an investigation of the erotic drive to cross-dress, with extensive case and historical material]. Berlin, 1910. Digitised original on the Internet Archive. Not read for this page beyond the title page; the book’s significance here is that it gave the phenomenon its own name and its own volume, separate from homosexuality. https://archive.org/details/hirschfeld-1910
  2. Cauldwell DO. Psychopathia transexualis. Sexology 1949;16:274-280. Read in the journal reprint (International Journal of Transgenderism 2001;5(2), archived copy). Verbatim: “One of the most unusual sexual deviations is PSYCHOPATHIA TRANSEXUALIS – a pathologic-morbid desire to be a full member of the opposite sex”; “This means, simply, that one is mentally unhealthy and because of this the person desires to live as a member of the opposite sex”; “Their condition usually arises from a poor hereditary background and a highly unfavourable childhood environment.” Sexology was a popular magazine, not a peer-reviewed journal; it is cited here as the documented origin of the word. https://web.archive.org/web/2007/http://www.symposion.com/ijt/cauldwell/cauldwell_02.htm
  3. Benjamin H. Transsexualism and transvestism as psychosomatic and somatopsychic syndromes. American Journal of Psychotherapy 1954;8(2):219-230. PMID 13148376. An early paper on the subject in a US clinical journal. No abstract on PubMed; not read for this page beyond the record. https://doi.org/10.1176/appi.psychotherapy.1954.8.2.219
  4. Benjamin H. The Transsexual Phenomenon. New York: Julian Press, 1966. Digitised copy on the Internet Archive (lending). Not read for this page; cited as the first book-length clinical treatment in English. https://archive.org/details/transsexualpheno0000harr
  5. Beek TF, Cohen-Kettenis PT, Kreukels BPC. Gender incongruence/gender dysphoria and its classification history. International Review of Psychiatry 2016;28(1):5-12. PMID 26782319. Abstract: “A diagnosis of ‘transsexualism’ appeared first in DSM-III in 1980. This version also included a childhood diagnosis: gender identity disorder of childhood”; “Changes in various aspects of the diagnosis, however, were not only based on research. Social and political factors contributed to the conceptualization of gender incongruence/gender dysphoria as well.” https://doi.org/10.3109/09540261.2015.1091293
  6. American Psychiatric Association. Gender Dysphoria (DSM-5 fact sheet), 2013. Verbatim: “This diagnosis is a revision of DSM-IV’s criteria for gender identity disorder”; “It replaces the diagnostic name ‘gender identity disorder’ with ‘gender dysphoria’”; “It is important to note that gender nonconformity is not in itself a mental disorder. The critical element of gender dysphoria is the presence of clinically significant distress associated with the condition”; “The Sexual and Gender Identity Disorders Work Group was concerned that removing the condition as a psychiatric diagnosis—as some had suggested—would jeopardize access to care.” https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM-5-Gender-Dysphoria.pdf
  7. Drescher J, Cohen-Kettenis P, Winter S. Minding the body: situating gender identity diagnoses in the ICD-11. International Review of Psychiatry 2012;24(6):568-577. PMID 23244612. Abstract: “one challenge has been to find a balance between concerns related to the stigmatization of mental disorders and the need for diagnostic categories that facilitate access to healthcare”; “The combined stigmatization of being transgender and of having a mental disorder diagnosis creates a doubly burdensome situation”; the working group “believes it is now appropriate to abandon a psychopathological model of transgender people based on 1940s conceptualizations of sexual deviance.” https://doi.org/10.3109/09540261.2012.741575
  8. Reed GM, Drescher J, Krueger RB, et al. Disorders related to sexuality and gender identity in the ICD-11: revising the ICD-10 classification based on current scientific evidence, best clinical practices, and human rights considerations. World Psychiatry 2016;15(3):205-221. PMID 27717275. Abstract: the ICD-10 grouping was “F64 Gender identity disorders”; “Gender identity disorders in ICD-10 have been reconceptualized as Gender incongruence, and also proposed to be moved to the new chapter on sexual health.” https://doi.org/10.1002/wps.20354
  9. Robles R, Fresán A, Vega-Ramírez H, et al. Removing transgender identity from the classification of mental disorders: a Mexican field study for ICD-11. Lancet Psychiatry 2016;3(9):850-859. PMID 27474250. “a purposive sample of transgender adults… receiving health-care services at the Condesa Specialised Clinic in Mexico City”; 250 enrolled; “During adolescence, distress related to gender identity was very common, but not universal (n=208 [83%])”; “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)”; “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).” Retrospective interview design. https://doi.org/10.1016/S2215-0366(16)30165-1
  10. World Health Organization. Gender incongruence and transgender health in the ICD (FAQ). Verbatim: “Gender incongruence has been moved out of the ‘Mental and behavioural disorders’ chapter and into the new ‘Conditions related to sexual health’ chapter. This reflects current knowledge that trans-related and gender diverse identities are not conditions of mental ill-health, and that classifying them as such can cause enormous stigma”; replacing “ICD-10’s ‘transsexualism’ and ‘gender identity disorder of children’”; “Inclusion of gender incongruence in the ICD-11 should ensure transgender people’s access to gender-affirming health care, as well as adequate health insurance coverage for such services.” https://www.who.int/standards/classifications/frequently-asked-questions/gender-incongruence-and-transgender-health-in-the-icd
  11. World Health Organization. International Statistical Classification of Diseases and Related Health Problems (ICD). ICD-11 “adopted May 2019 (WHA72.15)”, “into effect 1 Jan 2022.” https://www.who.int/standards/classifications/classification-of-diseases
  12. Dhejne C, Lichtenstein P, Boman M, Johansson ALV, Långström N, Landén M. Long-term follow-up of transsexual persons undergoing sex reassignment surgery: cohort study in Sweden. PLoS ONE 2011;6(2):e16885. PMID 21364939. “All 324 sex-reassigned persons (191 male-to-females, 133 female-to-males) in Sweden, 1973-2003,” with 10:1 population controls. “The overall mortality for sex-reassigned persons was higher during follow-up (aHR 2.8; 95% CI 1.8-4.3) than for controls of the same birth sex, particularly death from suicide (aHR 19.1; 95% CI 5.8-62.9). Sex-reassigned persons also had an increased risk for suicide attempts (aHR 4.9; 95% CI 2.9-8.5) and psychiatric inpatient care (aHR 2.8; 95% CI 2.0-3.9)”; “Our findings suggest that sex reassignment, although alleviating gender dysphoria, may not suffice as treatment for transsexualism, and should inspire improved psychiatric and somatic care after sex reassignment.” https://doi.org/10.1371/journal.pone.0016885
  13. Bränström R, Pachankis JE. Reduction in mental health treatment utilization among transgender individuals after gender-affirming surgeries: a total population study. American Journal of Psychiatry 2020;177(8):727-734. PMID 31581798. Swedish Total Population Register, N=9,747,324; 2,679 people diagnosed with gender incongruence 2005-2015. “individuals with a gender incongruence diagnosis were about six times as likely to have had a mood and anxiety disorder health care visit, more than three times as likely to have received prescriptions for antidepressants and anxiolytics, and more than six times as likely to have been hospitalized after a suicide attempt”; years since hormone treatment “not significantly related” (aOR 1.01, 0.98-1.03); time since last surgery “associated with reduced mental health treatment (adjusted odds ratio=0.92, 95% CI=0.87, 0.98).” https://doi.org/10.1176/appi.ajp.2019.19010080
  14. Correction to Bränström and Pachankis. American Journal of Psychiatry 2020;177(8):734. PMID 32741280. Published in the same issue as the paper, after letters to the editor; the authors’ response (PMID 32741272) appears at pp. 769-772. The correction’s text is paywalled and was not read for this page, so its wording is not reproduced; what this page can say is that the surgery finding above was formally corrected by the journal, and a reader should read the correction beside the abstract. https://doi.org/10.1176/appi.ajp.2020.1778correction

related: how homosexuality left the DSM · LGBTQ+ mental health in the data · the DSM

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