At the dawn of 2017 the Danish parliament struck a blow for transgender rights and became the first country to remove trans people’s classification as “mentally ill.” In this New Year’s Day move the government took official action to destigmatize transgender individuals, separating them from any association with words such as “problem,” “disorder” or dysphoria.
Words matter, says Linda Thor Pedersen of rights organization LGBT Denmark. “It was very important,” she says, “that terms like “incongruence,” “disturbance” and “problem” were left out of the code title used by the country’s medical community to track care. The change, she says, “makes it a code instead of a diagnosis.” The old system made indirect discrimination possible, she explains; job applications were sometimes rejected because of a “diagnosis.”
The change, although currently limited to Denmark, represents a new phase in the evolution of views on being transgender. An earlier change occurred in 2013, when “gender identity disorder” was dropped from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), U.S. psychiatry’s bible for diagnosing mental illness. A new condition called “gender dysphoria” was added to diagnose and treat those transgender individuals who felt distress at the mismatch between their identities and their bodies. The new diagnosis recognized that a mismatch between one’s birth gender and identity was not necessarily pathological, notes pediatric endocrinologist Norman Spack, a founder of the gender clinic at Boston Children’s Hospital. It shifted the emphasis in treatment from fixing a disorder to resolving distress over the mismatch.*
Spack compares the DSM-5’s new definition as similar in effect to its 1973 declassification of homosexuality as a mental illness. University of San Francisco human rights scholar Richard Johnson agrees. Although gay people certainly knew they were not sick, he says, the move did have an effect. “It has allowed the gay population in the U.S. an opportunity to pursue life on their own terms,” he says. “This will also be the same situation for the transgender population living in Denmark.”
As the brand-new measure takes effect, experts are speculating about its political, medical and financial ramifications in Denmark and around the world. Danish politicians had announced last year that they hoped to spur the World Health Organization (WHO) to remove transgender from a category of mental illnesses in its globally used International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10), whose codes are used to mark health records, track epidemiological trends and inform insurance reimbursement. If WHO did not act by January 1, 2017, Denmark had promised to act unilaterally.
As of January 5, WHO had made no comment on the Danish move. In the past the organization had told questioners the transgender redefinition will be part of the ICD-11, an immense and time-consuming project that is expected to be released this year or next.
The Danish action clearly aims to destigmatize being transgender. Removing any association with a problem or syndrome, however, has some experts wondering how it will be possible to label the person’s distress and guide treatment when trans people seek medical interventions such as hormone treatment or sex-change surgery.
Psychologist Laura Edwards-Leeper of Pacific University in Oregon notes Denmark will still require that psychological evaluation be conducted before any medical intervention. “I’m wondering if Denmark plans to make the diagnosis a medical one,” she says. “Perhaps they are approaching it similarly to what I recommend, which is to involve health care providers in offering support through the process and with readiness assessments, much like we do for patients seeking other life-changing, body-altering surgeries, such as bariatric surgery or organ transplants.”
“We expect,” LBGT Denmark’s Pedersen says, “that transgender health care will move more toward informed consent instead of psychiatric evaluations. In Denmark it can take from a couple of years to more than a decade to get permission for genital reassignment surgery.”
A major difference between Denmark and the U.S. is in how medical treatment is financed. What conditions are called can affect that process. “The difference [between the U.S. and Denmark],” Spack says, “is only [that] they have a national health system, and they wanted to make a statement that could not be made here by those who insure the care of transgender people. Because it’s conceivable, pending litigation, that insurance companies could persist in not covering the medical and surgical care needed because they don’t buy into the necessity of these treatments. But that is all changing,” he says, “more bit by bit because we are a hodgepodge of care providers and insurers. Different states have different policies.”
Whatever the practical effect of Denmark’s move, Edwards-Leeper says, “it is sending the message that an increasing number of people across the globe do not perceive transgender people as ‘crazy,’ but as valuable members of society worthy of respect and human rights like everyone else.”