How are transgender people treated in Germany

Gender diversity - trans *

Udo Rauchfleisch

Prof. Dr. Udo Rauchfleisch is a specialist psychologist, psychoanalyst, emer. professor at the University of Basel for clinical psychology as well as visiting professor at various domestic and foreign universities and technical schools. Rauchfleisch's main research interests include transsexuality - trans identity and homosexuality.

Trans * people have experienced a very changeable fate over time. Even if everything is far from perfect today, there have been a number of advances in the past 50 years.

View through the window of the trans * clinic "Tangerine" in Bangkok, Thailand. The hospital opened in 2015 and is the first trans * clinic in Asia. (& copy picture-alliance / dpa)

The path of medical diagnosis of trans * led from an unquestioned pathologization - an assessment as pathological - in the middle of the 20th century to the view, more or less accepted in specialist circles today, that trans * identity is a Norm variants and has nothing to do with mental health or illness.

From her own experience, Annette Güldenring, a specialist in psychiatry and psychotherapy, describes this situation as a life on the fringes of society, in a legal no man's land, since it was mostly impossible for trans people in the 50s and 60s of the last century to find a civil position . [1] Even medical aids such as hormone treatments and operations were only available to a few trans * people during this time, and only very few specialists in psychiatry and psychology were willing and competent to work with trans * people. The result was a life in hiding, in the constant fear of being discovered and of becoming the victim of massive exclusion and violence.

The rejection of the trans * experience and of trans * forms of life is mainly due to the idea of ​​binary genders - an idea that strongly shapes the thinking in our society and that is almost relentlessly adhered to. [2]

The tension and suffering that result from the discrepancy between a person's gender identity and their biological body lead many trans * people to seek physical assimilation to the desired gender. This condition has a disease value (see below diagnosis "Gender Dysphoria", DSM-5) and harbors the risk of serious psychosocial impairments. For this reason, the costs for hormonal and surgical adjustment to the desired gender are covered by the health insurance companies.

Medical classification of trans * people

The International Classification of Diseases (ICD):

The International Classification of Diseases (ICD) is an international diagnostic classification system that has been published by the World Health Organization (WHO) since 1948. Since then, the ICD has been revised several times.

The diagnosis "transsexuality" (302.5) appeared for the first time in ICD-9 (1975). Transsexuality was assigned to the "sexual behavior deviations and disorders". The ICD-10, which was revised in 1990 and valid until January 1, 2022, describes transsexualism (F64.0) as "gender identity disorders" (F64) and generally assigns it to personality and behavioral disorders (F 60 - F69).


The ICD-10 differentiates between a total of five forms of "gender identity disorders":

  • Transsexualism (F 64.0)
  • Transvestism while maintaining both gender roles (F 64.1)
  • Gender identity disorder in childhood (F 64.2)
  • Other gender identity disorders (F 64.8)
  • Unspecified gender identity disorders (F 64.9)

The diagnosis of "transsexualism" is described in the ICD-10 as "the desire to live and be recognized as a member of the opposite sex. This is usually associated with discomfort or the feeling of not belonging to one's own anatomical gender. The wish exists after surgical and hormonal treatment in order to adapt one's own body to the preferred gender as much as possible. ”This form of identity is pathologized by assigning“ transsexualism ”to“ disorders of gender identity ”.

In the course of the revision of the ICD, the responsible working group (Working Group on Sexual Disorders and Sexual Health) recommended that the category transsexualism (F64.0) be classified as gender incongruence, i. H. as a mismatch of gender identity with the gender characteristics of the body, to be redesigned in adolescence and adulthood. The category Disorder of Gender Identity in Childhood (F64.2) should also be renamed Gender Incongruence in Childhood. In addition, the working group has advocated no longer assigning gender incongruence to personality and behavioral disorders, but instead locating it in a new chapter "Problems / conditions in the area of ​​sexual health". On June 18, 2018, the final version of the new International Classification of Diseases, the ICD-11, was presented. In the coming year, the World Health Assembly will vote on this new ICD-11, which will then come into force on January 1, 2022.

In the ICD-11, the diagnosis "gender incongruence" has been assigned to the newly created chapter "conditions related to sexual health". This is an essential step in the direction of depathologization. This is of great importance insofar as the previous diagnosis of "transsexualism" falls under the heading of personality and behavioral disorders and has thus contributed significantly to the stigmatization and social marginalization of trans * people. In addition, the diagnosis of gender incongruence does not refer to a two-gender model and in this respect also represents a step forward compared to the earlier diagnosis of "transsexualism".

In addition to the "gender incongruence of adolescence or adulthood", the diagnosis for children has also been changed in the ICD-11. It is now "Gender incongruence of childhood".

The revision of the diagnoses in the ICD-11 was generally received very positively by the trans * organizations. However, it was critically noted that the gender incongruence diagnosis was also formulated for children. This is countered by the fact that no such diagnosis is required for children before puberty, as they are not treated medically and should therefore not be burdened by a diagnostic process.

Diagnostic and Statistical Manual of Mental Disorders (DSM):
The Diagnostic and Statistical Manual of Mental Disorder (DMS) is the American diagnostic classification system for mental disorders that has been published by the American Psychiatric Association since 1952.

The term "transsexualism" was first introduced in DSM III (1980) and assigned to the category "psychosexual disorders". In the DSM-IV (1994) the term "transsexualism" was replaced by the term "gender identity disorders". But it remained with a clear pathologization. Only the DSM-5, published in 2013, went a step further and dropped the term disruption. The diagnosis is now called "gender dysphoria". This signals that it is not the identity that is pathological, but rather that there is discomfort ("dysphoria") with one's own gender when identifying the opposite sex. This is at least a step in the direction of depathologization, even if this goal is not yet fully achieved. Because the "gender dysphoria" still figures among the mental illnesses. When the ICD-11 comes into force on January 1, 2022 with the diagnosis "Gender Incongruence" in the chapter "Problems / Conditions in the Area of ​​Sexual Health", the depathologization has been more clearly carried out than with the DSM-5 diagnosis " Gender dysphoria ".

Further steps on the way of depathologizing the trans * identity

The Yogyakarta Principles on the Application of International Human Rights Law in Relation to Sexual Orientation and Gender Identity (YP) (2006) played an important role in the depathologization process. Although these guidelines, formulated by international human rights experts, are not legally binding, they are of great political and legal relevance and have had a positive effect on dealing with trans people. This applies, for example, to the requirement that trans * people themselves be given greater decision-making authority and the so-called "everyday test" - the obligation to assume the desired gender role 24 hours a day, seven days a week for a year before hormonal treatment and any operations live - not to be made compulsory.

It is similar with the World Professional Association for Transgender Health (WPATH), which published the 7th version of the Standards of Care (SoC7) in 2011. Here, important guidelines for the treatment of trans * people have been formulated, which, like the Yogyakarta Principles, advocate that the clients should be given significantly greater powers of self-decision, e.g. B. to be able to decide freely whether they want to do an "everyday test" or not.

In Germany, the standards for the treatment and assessment of transsexuals (Becker et al. 1997), which originated in 1997 and are still valid today, serve as the basis for dealing with trans * people. However, these guidelines are considered out of date, as they assume a pathology of trans * identity and determine the steps of transition - the transition to the desired gender - without taking into account the individual situation of the trans * people concerned. Since 2012, the working group "Gender dysphoria: diagnostics, counseling and treatment", in which representatives from various German specialist societies under the direction of the German Society for Sexual Research (DGfS) are involved, has been working on developing new, contemporary guidelines. These are intended to help increase medical decision-making security and protection against arbitrary treatment, as well as flexibility in the treatment process. They are also intended to create trust between those seeking treatment and those involved in health care. The completion of the guidelines is planned for autumn 2018.

In Switzerland, a working group entitled From Transsexuality to Gender Dysphoria has developed and published new advice and treatment recommendations for trans * people. [3] These recommendations advocate depathologizing gender identity concepts and call for an individually designed transition, which means that old fixed treatment guidelines (e.g. everyday test, 2-year rule, etc.) are dropped. These recommendations are not binding, but are observed by the centers for the assessment and treatment of trans * people in Basel and Zurich as well as by specialists who treat and support trans * people.

In Austria, new "Recommendations for the treatment process for gender dysphoria or transsexualism according to the classification in the currently valid DSM or ICD version" have been available in Austria since the beginning of 2015. These were worked out by an interdisciplinary group of experts from the Advisory Board for Mental Health. It had revised the "Recommendations for the Treatment of Transsexuals", which had existed since 1997, and adapted them to current scientific knowledge. Despite clear improvements compared to the previously usual procedure (e.g. no more compulsory psychotherapy), a number of "consensual statements" from the specialists are still necessary so that the trans * person can take the path of transition. Another group of experts is currently working on "Recommendations for the treatment process for gender dysphoria in children and adolescents according to the classification in the currently valid DSM or ICD version".

What do trans * people need? What will be needed in the future?

The described depathologizations and the formulation of new treatment and counseling guidelines are only the first steps in the right direction. In order for trans * people to be freed from the untenable situation of extreme heteronomy, the following changes are necessary from my perspective [4]:
  • Trans * identity should be viewed by experts in the various disciplines as a variant of the norm that has nothing to do with mental health or illness.
  • The professionals with whom trans * people have to deal in the course of their transition (endocrinology, plastic surgery, psychiatry, psychology, social work, law, etc.) should make their specialist knowledge available to the trans * people so that they can make independent decisions about the be able to make the transition steps they want.
  • The determination of the goals and the procedure for the transition should lie solely with the trans * people themselves.
  • The consequence of this should be that there are no reviews or other professional statements (e.g. for hormonal and operative interventions or for changing first names and civil status) and no other requirements (e.g. "everyday test" or obligation to an accompanying one Psychotherapy) gives more.
  • Every trans * person should be given the recommendation and the opportunity to receive psychotherapeutic and social support, but not be obliged to do so. The type and scope of such an offer are to be determined by the trans * person.
  • The public should be informed comprehensively and without prejudice about trans * people. [5]
  • Society as a whole should face the challenge that trans * people pose for them by questioning the dichotomous notions of binary genders and perceiving the diversity of identity designs and lifestyles as an enrichment.