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ICD-11 and gender variation
The ICD-11, the WHO's international disease classification, in 2022 moved gender variation out of the chapter on mental disorders into a new chapter on 'conditions related to sexual health'. The new term is 'gender incongruence'. This decision was welcomed by proponents as depathologisation. At the same time the decision does not rest on new biomedical evidence, but mainly on a normative premise: that the label 'mental disorder' was stigmatising.
A reclassification without an evidence base
The standard scientific route is that a condition is removed from or moved within a classification when new evidence shows the existing place to be wrong. With gender variation, that is not what happened. There is no biomedical discovery showing that gender incongruence has no psychiatric substrate. The reclassification was carried by advocacy organisations, activist clinicians and the WHO working group — not by a research breakthrough. Critics, including several psychiatrists who worked on the DSM and ICD, warn that here a normative judgement has been presented as a scientific conclusion.
De facto: a lower threshold for medical intervention
In the ICD-11 distress is no longer a required criterion. Anyone who does not sufficiently recognise themselves in their birth sex meets the definition in principle, even without clinically significant suffering. That is a substantial broadening of the target group for medical intervention — while that intervention (hormones, surgery) remains unchanged in scope and irreversibility. Moving it out of the psychiatric classification means in practice that psychological assessment becomes less self-evident, while this is precisely the place where comorbid problems (autism, trauma, depression, eating disorders) are recognised.
Stigma gone, due care gone?
The argument of 'depathologisation' sounds appealing, but has a flip side. By placing gender variation outside psychiatry, the protection that psychiatric diagnostics offers is also weakened: differential diagnostics, attention to underlying problems, and the awareness that a wish to alter the body can itself be a subject of clinical reflection. The risk is that more and more people — often young, often with multiple problems — gain direct access to heavy medical pathways without psychiatric screening being structurally embedded.
International reconsideration
The Cass Review (2024) and reviews in Sweden, Finland and Norway point in the opposite direction: more psychological assessment, restraint with medical intervention in young people, and recognition that gender dysphoria often goes together with other problems that warrant attention first. The ICD-11 reclassification and that clinical shift are in tension with each other.
Implementation in the Netherlands
The Netherlands is moving to the ICD-11 in stages. In practice many care providers still work with ICD-10 codes. How Dutch gender care relates to the normative premise of the ICD-11 versus the more restrained line of the Cass Review is still an open question.