ICD-11 and Gender Variance

In 2022, the ICD-11, the WHO’s international classification of diseases, moved gender variance from the chapter on mental disorders to a new chapter on "conditions related to sexual health". The new term is "gender incongruence". Supporters welcomed this decision as de-pathologization. At the same time, the decision is not based on new biomedical evidence, but primarily on a normative premise: that the label "mental disorder" would be stigmatizing.

Related topics can be found in WHO and the ICD-11 revision.

A reclassification without an evidence base

The usual scientific approach is to remove or relocate a condition in a classification when new evidence shows that the existing categorization is incorrect. That is not what happened with gender variance. There has been no biomedical discovery showing that gender incongruence has no psychiatric substrate. The reclassification was driven by advocacy organizations, activist clinicians, and the WHO working group—not by a breakthrough in research. Critics, including several psychiatrists who have worked on the DSM and ICD, warn that a normative judgment has been presented as a scientific conclusion.

In practice: a lower threshold for medical intervention

In the ICD-11, psychological distress is no longer a mandatory criterion. In principle, anyone who does not sufficiently identify with their sex at birth meets the definition, even without clinically significant distress. This substantially broadens the target group for medical intervention—while the nature and irreversibility of those interventions (hormones, surgery) remain unchanged. In practice, moving gender variance out of the psychiatric classification means that psychological assessment becomes less routine, even though it is precisely where comorbid issues (autism, trauma, depression, eating disorders) are identified. The distinction between autism and gender dysphoria is discussed at genderautisme.nl.

Stigma removed, caution removed?

The argument for "de-pathologization" sounds appealing, but it has a downside. By placing gender variance outside psychiatry, the safeguards provided by psychiatric assessment are also weakened: differential diagnosis, attention to underlying problems, and recognition that a desire to change the body can itself be a subject of clinical reflection. The risk is that more and more people—often young and often facing multiple issues—will gain direct access to intensive medical pathways without systematic psychiatric screening being secured.

International reconsideration

The Cass Review (2024) and revisions in Sweden, Finland, and Norway point in the opposite direction: more psychological assessment, greater caution regarding medical intervention for young people, and recognition that gender dysphoria often co-occurs with other issues that deserve attention first. The ICD-11 reclassification and this clinical shift are at odds with each other.

Implementation in the Netherlands

The Netherlands is gradually transitioning to the ICD-11. In practice, many healthcare providers still use ICD-10 codes. How Dutch gender care will relate to the ICD-11’s normative premise, as opposed to the more cautious approach of the Cass Review, remains to be seen.