As European countries grapple with how best to serve the health needs of transgender and gender-diverse people, fresh momentum is on the horizon. In the coming months, the World Health Organization (WHO) is set to release a new guideline on the health of trans and gender-diverse adults — potentially setting a new benchmark for care, policy, and legal recognition worldwide.

Against this backdrop, Europe’s progress on gender-affirming care remains uneven. While some countries have pioneered reforms that recognize self-determined gender identity by adults and reduce psychiatric gatekeeping, others continue to require psychiatric diagnoses and retain significant barriers to care.

The forthcoming WHO guideline — expected to address access to gender-affirming care, health worker training, the provision of healthcare to those who have suffered interpersonal violence, the institution of supportive policies, and the establishment of legal recognition for self-determined gender identity — could be instrumental in shaping more inclusive health systems and setting minimum standards for countries across the region.

Removing the Psychiatrist as Gatekeeper

The WHO’s International Classification of Diseases (ICD) has provided a foundation for disease classification and statistical tracking for over a century. The system underpins decisions that help policymakers align health strategies and support data-driven improvements within and across countries.

Recent progress for transgender health came with ICD-11, adopted in 2019 and implemented from January 2022. This edition eliminated the diagnosis of “transsexualism” as a mental disorder, instead introducing “gender incongruence” in a chapter on sexual health, a move intended to support depathologizing trans-specific healthcare and reduce stigma. 

For Cianán Russell, PhD, senior policy officer at International Lesbian, Gay, Bisexual, Trans, and Intersex Association-Europe, an organization working for lesbian, gay, bisexual, transgender, and intersex people’s safety, equality, and freedom across Europe and Central Asia, the removal of transsexualism from the mental health disorders chapter was pivotal. It marked an important shift away from the gatekeeping role long played by mental health professionals towards a more supportive role through a primary care health pathway.

“The use of the word transsexualism as a diagnosis implies being trans is a mental illness. There’s historic stigma associated with this terminology,” Russell explained to Medscape Medical News. They added, “The psychiatrist owning trans health was part of the problem — they [transgender people] don’t need their point of access to be psychiatric care. The change creates opportunity for a general practitioner to be the point of contact for diagnosis and access to first-line care — whether that’s for a referral to a psychologist if needed or supporting access to hormone therapy.”

Uneven Implementation

Implementation of these new definitions, however, rests with individual Member States. Deekshitha Ganesan, LLM, policy and advocacy manager at Trans Europe and Central Asia, noted that the organization’s research shows 12 countries in the European Union still use a formal diagnosis of transsexualism and that, currently, Malta, Denmark, and parts of Spain are the only countries in the region that don’t require a psychiatric diagnosis to access healthcare.

“The problem with still using a psychiatric diagnosis is that it sees trans identities as a disorder and opens up the door to all types of indignities in terms of accessing healthcare,” Ganesan told Medscape Medical News. “It allows gender identity to be seen as a mental health issue when it’s not necessarily one, and it also ties up a lot of resources on mental health, which we know is already difficult to access.”

She added, “Our biggest ask is the implementation of ICD-11 at the national level and to also prioritize an informed consent model and make sure the wishes and needs of an individual are prioritized and met. This requires adopting a more holistic model of care: Recognizing that trans people accessing healthcare around their identity has an impact on almost every aspect of their lives because of the minority stress and very concrete realities they face, such as what does it means to access reproductive care.” Still, she said, “This is not to say there can never be a need for a psychiatrist, but I think the main need is for better psychosocial support rather than seeing a psychiatrist.”

Russell said they are not surprised by the slow rollout of ICD-11, observing that implementation is a very long and expensive process that can take many years. But implementation is not the only path to change, they said, stressing that ICD-11 is a data collection system, not a diagnostic guide or a guide on treatment.

Even where countries have not implemented ICD-11, individual practitioners are using the guidance to decide how they provide services. “We particularly see this in countries that have community-led clinics, such as the Netherlands, Belgium, and Germany, and among individual practitioners across certain countries that are using informed consent models.” 

Russell explained that a practitioner’s job is to make sure the person understands their treatment options and the likely effects and ultimately lets the individual decide. Being trans is for the person to define — not for doctors or psychiatrists.

Optimism for Change

Denmark offers an example of what change can look like. Dorte Glintborg, MD, PhD, professor of gender-affirming hormone treatment at the University of Southern Denmark, Odense, Denmark, described the country’s transition away from psychiatric gatekeeping in 2017, making it the first globally to declassify transgender identity as a mental illness.

Now, three multidisciplinary public centers provide care, with costs covered by the national health service. Psychological support remains central but is offered as part of a broader continuum rather than a mandatory hurdle. Ideally, Glintborg said, they would like to offer even more support to transgender people who don’t wish to pursue hormone therapy. And, while efforts had been made to shorten wait times, Glintborg acknowledged that capacity is still limited in the public system.

Ganesan highlighted the significance of the upcoming WHO guideline, stating, “We have Member States releasing their own guidelines at the national level — some good, others not so good. The upcoming WHO guideline will provide an aspirational standard that Member States can slowly implement.” She added, “It’s also expected to answer two important issues: the provision of hormones and trauma-informed provision of care.”

Russell is one of 21 members of the WHO’s guideline development group. Although they could not share specifics or a timeline, they said the guideline will reiterate that “when trans people exist, they should have access to care.” Russell hopes the guideline will encourage more countries to make care accessible and integrated in insurance coverage and create mechanisms for funding clinics and increasing large-scale research on trans healthcare.

Russell, Ganesan, and Glintborg reported having no relevant financial relationships. 

Sophie Cousins, MIPH, is a global health journalist who has reported from more than 20 countries.