title: Gender Incongruence of Childhood: Clinical Utility and Stakeholder Agreement with the World Health Organization's Proposed ICD-11 Criteria.
abstract: The World Health Organization (WHO) is revising the tenth version of the International Classification of Diseases and Related Health Problems (ICD-10). This includes a reconceptualization of the definition and positioning of Gender Incongruence of Childhood (GIC). This study aimed to: 1) collect the views of transgender individuals and professionals regarding the retention of the diagnosis; 2) see if the proposed GIC criteria were acceptable to transgender individuals and health care providers; 3) compare results between two countries with two different healthcare systems to see if these differences influence opinions regarding the GIC diagnosis; and 4) determine whether healthcare providers from high-income countries feel that the proposed criteria are clinically useful and easy to use. A total of 628 participants were included in the study: 284 from the Netherlands (NL; 45.2%), 8 from Flanders (Belgium; 1.3%), and 336 (53.5%) from the United Kingdom (UK). Most participants were transgender people (or their partners/relatives; TG) (n = 522), 89 participants were healthcare providers (HCPs) and 17 were both HCP and TG individuals. Participants completed an online survey developed for this study. Overall, the majority response from transgender participants (42.9%) was that if the diagnosis would be removed from the mental health chapter it should also be removed from the ICD-11 completely, while 33.6% thought it should remain in the ICD-11. Participants were generally satisfied with other aspects of the proposed ICD-11 GIC diagnosis: most TG participants (58.4%) thought the term Gender Identity Disorder should change, and most thought Gender Incongruence was an improvement (63.0%). Furthermore, most participants (76.1%) did not consider GIC to be a psychiatric disorder and placement in a separate chapter dealing with Gender and Sexual Health (the majority response in the NL and selected by 37.5% of the TG participants overall) or as a Z-code (the majority response in the UK and selected by 26.7% of the TG participants overall) would be preferable. In the UK, the majority response (35.8%) was that narrowing the GIC diagnosis was an improvement, while the NL majority response (49.5%) was that this was not an improvement. Although generally the results from HCPs were in line with the results from TG participants some differences were found. This study suggests that, although in an ideal world a diagnosis is not welcomed, several participants felt the diagnosis should not be removed. This is likely due to concerns about restricting access to reimbursed healthcare. The choice for positioning of a diagnosis of GIC within the ICD-11 was as a separate chapter dealing with symptoms and/or disorders regarding sexual and gender health. This was the overall first choice for NL participants and second choice for UK participants, after the use of a Z-code. The difference reflects that in the UK, Z-codes carry no negative implications for reimbursement of treatment costs. These findings highlight the challenges faced by the WHO in their attempt to integrate research findings from different countries, with different cultures and healthcare systems in their quest to create a manual that is globally applicable.
authors.affiliation: Center of Expertise on Gender Dysphoria, VU University Medical Center, Amsterdam, The Netherlands.|Department of Medical Psychology, VU University Medical Center, Amsterdam, The Netherlands.
authors.forename: Titia F
authors.initials: TF
authors.lastname: Beek
authors.affiliation: Center of Expertise on Gender Dysphoria, VU University Medical Center, Amsterdam, The Netherlands.|Department of Medical Psychology, VU University Medical Center, Amsterdam, The Netherlands.
authors.forename: Peggy T
authors.initials: PT
authors.lastname: Cohen-Kettenis
authors.affiliation: Nottingham Centre for Gender Dysphoria, Nottingham, United Kingdom.
authors.forename: Walter P
authors.initials: WP
authors.lastname: Bouman
authors.affiliation: Center of Expertise on Gender Dysphoria, VU University Medical Center, Amsterdam, The Netherlands.|Department of Child and Adolescent Psychiatry, VU University Medical Center, Amsterdam, The Netherlands.
authors.forename: Annelou L C
authors.initials: AL
authors.lastname: de Vries
authors.affiliation: Center of Expertise on Gender Dysphoria, VU University Medical Center, Amsterdam, The Netherlands.|Department of Medical Psychology, VU University Medical Center, Amsterdam, The Netherlands.
authors.forename: Thomas D
authors.initials: TD
authors.lastname: Steensma
authors.affiliation: School of Sport, Exercise, and Health Sciences, Loughborough University, Loughborough, United Kingdom.
authors.forename: Gemma L
authors.initials: GL
authors.lastname: Witcomb
authors.affiliation: Nottingham Centre for Gender Dysphoria, Nottingham, United Kingdom.|Division of Psychiatry and Applied Psychology, Faculty of Medicine & Health Sciences, University of Nottingham, Nottingham, United Kingdom.
authors.forename: Jon
authors.initials: J
authors.lastname: Arcelus
authors.affiliation: Nottingham Centre for Gender Dysphoria, Nottingham, United Kingdom.
authors.forename: Christina
authors.initials: C
authors.lastname: Richards
authors.affiliation: Center for Sexology and Gender, Ghent University Hospital, Ghent, Belgium.
authors.forename: Griet
authors.initials: G
authors.lastname: De Cuypere
authors.affiliation: Center of Expertise on Gender Dysphoria, VU University Medical Center, Amsterdam, The Netherlands.|Department of Medical Psychology, VU University Medical Center, Amsterdam, The Netherlands.
authors.forename: Baudewijntje P C
authors.initials: BP
authors.lastname: Kreukels
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D005260:Female; D005783:Gender Identity; D006801:Humans; D007223:Infant; D008297:Male; D057829:Gender-Affirming Procedures; D012735:Sexual Dysfunction, Physiological / Q000145:classification* / Q000175:diagnosis* / Q000503:physiopathology / Q000628:therapy; D063106:Transgender Persons; D014944:World Health Organization