The term "transgender" describes individuals whose gender identity and/or expression differs from their assigned sex at birth. While many people have identified as transgender for centuries, it was only recently that there was any formal recognition of this identity in Western culture. In the past, being transgender was often seen as a mental disorder and was treated harshly. This history of pathologization has had lasting effects on transgender people's access to healthcare and legal recognition.
The World Health Organization (WHO) classified being transgender as a mental illness until 2019. The International Classification of Diseases (ICD) listed "gender incongruence" as a disease under "disorders of sexual development." This classification meant that doctors could deny treatment to transgender patients who wanted to transition because they believed that their condition needed to be cured rather than accommodated. It also justified discrimination against transgender people in employment, housing, and other areas of life.
Transgender people faced significant challenges in accessing medical care during this time. Many doctors were unfamiliar with treating transgender patients and refused to provide hormone therapy or surgeries related to transitioning. Even when they did treat transgender patients, it was often with stigma and disrespect.
Some doctors would require psychological evaluations or approval letters before beginning hormone therapy. These barriers made it difficult for transgender people to live authentically and fully express themselves.
The WHO removed gender incongruence from its list of diseases, but the legacy of pathologizing transgender identities continues to shape healthcare today. Some insurance companies still refuse to cover gender-affirming procedures such as hormone therapy and surgery. Others charge higher fees or impose stricter requirements for coverage. Some doctors still view transgender identity as a choice rather than an innate characteristic, which can lead to poor quality care or even rejection of patients.
The legacy of pathologizing transgender identities has also affected legal recognition. In many countries, the only way to change one's legal gender is through sex reassignment surgery (SRS). This requirement can pose financial, physical, and emotional burdens on transgender individuals who may not want or need surgery.
Some laws have required proof of "genuine" intent to undergo SRS to change one's gender marker, which can be difficult to prove without having completed surgery.
The impact of pathologization goes beyond access to healthcare and legal recognition. It has contributed to high rates of violence and discrimination against transgender people. Transphobia is rooted in the idea that being transgender is abnormal or wrong, making it easier to justify violence or marginalize transgender people in other ways. This stigma persists despite efforts to increase awareness and acceptance of transgender identities.
Despite these challenges, there are positive signs of progress. More doctors are trained in treating transgender patients and more insurance companies offer coverage for transition-related care. Several countries have removed the surgical requirement for changing one's gender marker or eliminated it altogether.
Much work remains to be done to ensure that all transgender people have equal access to healthcare and legal recognition.
How does the legacy of pathologizing transgender identities continue to shape access to healthcare and legal recognition?
The continuing legacy of pathologizing transgender identities can be seen as a major obstacle for both access to adequate healthcare and legal recognition. This issue has been brought into stark relief by recent events such as the Trump administration's attempt to restrict military service for trans individuals on the basis that they are inherently "disqualified" due to their gender identity (Booth).