There is a rejuvenated movement to have trans diagnoses removed from mental health classification, under the belief that if transsexuality were no longer considered a mental illness (in the way that happened with homosexuality was in 1973), that it will lead to the level of acceptance that gay men and lesbians have attained.

This is something that has to happen. But if not done with care and consideration, it could become more chaotic than it needs to be, and burn more people than necessary in the process. Here’s why, and what can minimize this.

There is no doubt that there is a need for change.  Some of this is optics: as long as the public thinks of transsexuality as mental illness, it provides seeming justification for creating roadblocks, denying employment, denying housing, blocking access to services, blocking access to health care funding, and more. Throw a rock in the air, and you’re sure to hit any of thousands of right-wing commentaries that use mental health classification as reason to oppose even basic human rights inclusion for trans people.

But it’s not just optics. Pathologizing diagnoses are sometimes used to adversely affect custody of children, employment, access to support services, participation in the (US) military and more. There are many tangible instances where this classification becomes a roadblock.

Unlike when homosexuality was declassified from mental health arenas, transsexed people do have very specific medical needs (such as genital reassignment surgery, mastectomies and hysterectomies for trans men, tracheal shave, facial hair removal and breast augmentation for trans women). And if depathologization isn’t addressed with the greatest of care, the result on access to trans health care could be disastrous.

Before declassification can be done, an alternate medical model that does not depend on a mental health diagnosis needs to be developed and established, so that existing medical access for people in transition would not be compromised or lost.  Here are some things that are risked in simply removing classification:

• Funding. In most public and private health insurance structures, a medical code is required to justify the paying out of money for surgical and non-surgical health procedures and services. So public and private health funding of sex reassignment surgery (GRS/SRS) are vulnerable. Insurers see them as "cosmetic" procedures, and switching to an elective medical model will only reinforce that perception. Other trans-related procedures and treatments could conceivably be affected as well. Not all of these are funded in all areas, and in fact, some regions go to great lengths to deny funding for any or all of these things. But some do, and they could be compromised if GID / GD is simply declassified, with no contingency plan. Moreover, delisting would significantly hamper the potential to gain funding from insurers that don’t currently cover trans health.

Having a classification grounded in physical health treatment would help avert these risks, but doing so is a greater challenge than many believe.

Before a reclassification outside mental health can occur, a cause needs to be ascertained, and diagnosable criteria defined. Is transsexuality congenital? Would classification as "Congenital malformations, deformations and chromosomal abnormalities" (Q50-Q56) be just as stigmatizing and warrant yet another future change?

Recategorization is not yet feasible, although there have been many intriguing research avenues found in biological sciences which call for more study. Convincing the medical profession to move a categorization when they believe that the current model is workable in their eyes (even if not perfect) is difficult, especially if the alternatives are not yet conclusively proven or causes defined tangibly.

Something that helps but complicates the question at the same time is the fact that diagnosis is not treatment. While the two are connected, and affect each other, addressing a diagnosis does not necessarily change the existing treatment processes, other than to sometimes inject confusion into the equation.

If GID were listed tomorrow, there would still be people who seek counselling to deal with their sense of feeling out of place, and believing that changing their mind is easier than changing the body. There would also still be people coerced or forced into treatment, especially youth, who are often not given any personal agency of their own. And it would take time for medical professionals to become aware of this change, let alone warm to it.

One such concern is that if GID were dropped from medical classification while Transvestic Fetish (TF) remained, this would open up the possibility that for anyone who crosses paths with the mental health system (and possibly the health system overall), TF could become a diagnosis of choice. This classification puts an emphasis on the clothes one wears, and implies a sexual motivation (which are besides the point and inaccurate, respectively), but it doesn’t take a lot of imagination to see how those who are adverse to transitioning people would take advantage of the existence of a TF-style classification and its exclusive status... and weaponize it.  Rather than depathologize, the result could be a far more damaging pathology.

The discussion also says a lot about the way we think about mental health, and the idea that "mental illness" is anathema. The movement to depathologize is based on a shallow understanding of what a diagnosis means, let alone a mental health one. The assumption, of course, is that a mental health condition either automatically means insanity or else is a figment of a person’s imagination. The stigma trans people face is more rooted in the public belief about what constitutes "normal" than anything that’s actually in the diagnosis itself, and that societal obsession with normativity won’t change just by reclassifying or declassifying anything.

In a way, the underlying motive is an injustice to the many people who are diagnosed with depression, autism, bipolar or social anxiety conditions, addictions, ADD / ADHD and more, some of whom travel in trans communities as well. And it can easily translate to horizontal violence, if people choose to ignore this fact.

Change never comes easy. There appears to always be some turmoil, at which point, society has to adjust, and figure out how to deal with it. The question, then, is this: is society at a place where it’s ready to do so? Are we at a place yet where the benefits outweigh the price that will be paid? And have we adequately thought about ways to minimize the harm between points A and B?

I’m not satisfied that this is the case, especially when one looks at the question globally. In some parts of the world, even what we have now is a hard sell.

Problems are easy to point out. Solutions, usually not so much. There is a possible solution, here, albeit one that doesn’t neatly solve everything.

Most of the risks outlined above hinge upon the existence of a medical category. There is an apparent need for one, but that categorization does not have to be a mental health diagnosis.

If the focus were on asking the World Health Organization to actively and urgently investigate the development of an alternate category in a way that would make transition not dependent on a mental health diagnosis, this would be a very different article.

This solution doesn’t address the point about the way we think about mental health. That would take a changing of hearts and minds, starting with our own.  But it is a solution. And it could be do-able, in a way that is compatible with requests to delist while keeping medical services available in the same way as other medical procedures - pregnancy is the example mentioned in one petition.

Pregnancy is covered at length in Chapter XV of the ICD, in classifications O00-O99: "Pregnancy, childbirth and the puerperium." Just in case anyone was wondering.