[AGTRT-BF83] WHO does not have a sharp definition of transgender, and creates ambiguity with term “experienced gender”

Jan Bergstra & Laurens Buijs
Amsterdam Gender Theory Research Team

On WHO’s FAQ page we read this, among other things:

“What is transgender and what are the main health concerns of transgender people?

Transgender people share many of the same health needs as the general population, but may have other specialist health-care needs, such as gender-affirming hormone therapy and surgery. However, evidence suggests that transgender people often experience a disproportionately high burden of disease, including in the domains of mental, sexual and reproductive health. Some transgender people seek medical or surgical transition, others do not.”

Surely it is remarkable that such a text, despite its title, does not make the slightest attempt to answer the question the headline formulates: what is transgender? But that does not speak for itself.

Another text from the same WHO site concerns gender incongruence. There is a similar text on Gender incongruence of childhood.

“ What is Gender Incongruence?

Gender Incongruence of Adolescence and Adulthood is characterized by a marked and persistent incongruence between an individual´s experienced gender and the assigned sex, which often leads to a desire to “transition,” in order to live and be accepted as a person of the experienced gender, through hormonal treatment, surgery or other health care services to make the individual´s body align, as much as desired and to the extent possible, with the experienced gender. The diagnosis cannot be assigned prior the onset of puberty. Gender variant behavior and preferences alone are not a basis for assigning the diagnosis.“

Here we notice that not “gender identity” is used but “experienced gender.” We were unable to find a description of gender experience in the literature, and the meaning of this term is by no means self-explanatory.

We arrive at the following description of this below: the gender experience of person P is the degree to which this person experiences his or her own body as fitting his or her own gender identity. In addition, person P’s experienced gender is that gender which (in P’s experience) best describes the person’s own experience of bodily gender.

Here, P’s gender identity is the gender (to be chosen from male, female and neutral) that the person “deeply” believes he or she has, with opinions regarding this concept (about which we have already written quite a bit, see among others AGTRT-BF62 and AGTRT-BF69) are divided on the following aspects of gender identity:

• Whether a person is always aware of their own gender identity.
• Whether a person already has gender identity at birth or whether gender identity develops over the years. And at what age the existence (and awareness) of gender identity may be assumed.
• Whether a person is able to determine their own gender identity based on “first person authority.”
• Opinions are also divided on whether, and if so to what extent, gender identity is a derivative of physical gender, and on whether each person has a gender identity.

Read more about our search for a theory of gender identity:
In search of a theory of gender identity

With this meaning of gender experience in mind, the WHO definition of gender incongruence is not well understood. Indeed, it is unclear what “assigned sex” has to do with it. Is it meant here that by treating the body with hormones and possibly surgeries that make it more like the experienced gender , also can change the assigned sex so that the incongruity disappears?

If by assigned sex is meant sex assigned at birth (SAAB) then obviously a change in it can never occur. If assigned sex involves a subsequently assigned sex then that should be mentioned. (As far as we know, legal transition involves assigning a different gender, not a different sex, but that aside.) Apparently assigned sex is not the cause of the incongruity because the solution may be medical, and assigning a different sex is precisely not medical but administrative.

We suspect that something else is meant: the friction (the incongruity is felt) between experienced gender and gender identity. A person born a woman (female SAAB, unknown at the time of gender identity assignment, or still absent), for example, may have a male gender identity, and thus feel male inside, even though a female gender experience is gained through the body, so that the experienced gender is also female. And after the medical procedures, the experienced gender changed (to male) and, if all went according to plan, became closer to (more congruent with) gender identity.

Now it is also possible that what is meant is that because of the medical procedures the gender identity has changed and, on the contrary, the experienced gender remains unchanged. But that is remarkable then because it is usually an important premise that not even trying to modify a person’s gender identity is unethical, just as it is unethical to even try to change someone’s sexual orientation.

The WHO text reverses the issue, and it is precisely by not using the term gender identity that the description becomes incomprehensible. Since this is a medical problem and it is the International Classification for Diseases (ICD) that lists and names medical issues, it is even less clear what the sex assigned at birth (SAAB) could have to do with it.

In most people, experienced gender is consistent with physical gender and also with assigned gender (= SAAB). From that perspective, it might seem that people with incongruent gender identity have a mismatch between assigned gender and gender identity, but that is superficial. On reflection, the mismatch is between gender identity and experienced gender, where this is then a subjective experience of bodily gender that differs from gender identity. It is the experienced gender that can be changed by interventions. When these interventions are successful, it is not unusual to subsequently find that with them the formal gender has also changed and on that basis to adjust the legal gender accordingly.

To our knowledge, the term experienced gender does not yet appear in theoretical work on gender theory. Apparently that is a relevant concept, though. The experienced gender is a characteristic of a medical condition, how one experiences one’s own body (for example, as different from how one would like to experience it or how one “deeply” thinks one should experience it).

From FGT’s point of view, none of this speaks for itself. Experienced gender is not “another kind of gender” in addition to bodily gender, etc. Gender experience is an awkwardly chosen expression; a clearer choice would be “bodily gender experience” here. The bodily gender experience is the degree to which you feel physically good (in terms of gender) in terms of matching your gender identity (which you have already assigned to yourself prior to any medical procedures).

In the “ordinary case,” the simplest gender transition one performs because of gender incongruence, for example, person P’s SAAB is male. But after some time, P observes that he has a female gender identity. Now there appears to be an insufficiently positive bodily gender experience(bodily gender experience) of P with respect to the female gender identity that P attributes to herself. Medical interventions can then reduce this deficit. So the mismatch is precisely not with the (male) SAAB but with its female counterpart.

At the risk of boring the reader: if we read experienced gender as the subjective experience of one’s own bodily gender then the problem is not the mismatch of the experienced gender with the SAAB but rather the match between the two. P (as above) feels (to his own chagrin) physically male and was also “assigned male at birth.” But that “doesn’t feel right” to P. The male experienced gender produces a negative gender experience (for P with now female gender identity). In the best case, P has a female experienced gender after the medical transition, but it is also already nice when P has a more positive gender experience.

Here, by the way, we see very well why primary gender identity plays such an important role in co-essentialism. WHO does not get around it (even though it seems to). Therefore, the problem of co-essentialism is not so much the primary role of gender identity in it but the difficulty of perceiving and operationalizing it. The dogma that everyone has a gender identity is also unconvincing. But WHO doesn’t need that in this description of gender incongruence, either.

Based on the above, we arrive at the following proposal for amending the WHO definition of gender incongruence:

“ What is Gender Incongruence?

Gender Incongruence of Adolescence and Adulthood is characterized by a marked and persistent incongruence between an individual´s gender experience and their gender identity, which often leads to a desire to “transition” (usually from the gender assigned at birth to the opposite gender or to neutral gender, as indicated by their gender identity), in order to live and be accepted as a person of the gender corresponding to the individual´s gender identity, through hormonal treatment, surgery or other health care services to make the individual´s body (and the gender experience thus aligned), as much as desired and to the extent possible, in correspondence with the individual´s gender identity. The diagnosis cannot be assigned prior the onset of puberty. Gender variant behavior and preferences alone are not a basis for assigning the diagnosis.“

Conclusion
One conclusion that we draw from this adaptation of the description is that determining the gender identity of the person concerned is inevitably part of the intended diagnosis. That gender identity may differ from the gender assigned at birth is explicitly not considered a psychological problem. However, any associated symptoms of gender incongruence may warrant medical intervention. As a matter of principle then, medical intervention is not aimed at changing gender identity because gender identity, like a person’s sexual orientation, is a respectable part of personal integrity.

Our description of co-essentialism implicitly assumes that a person is best able to determine his or her own gender identity on the basis of “first person authority” (i.e., that self-identification is sufficient to establish gender identity). When that premise is abandoned, formal gender becomes the same as gender identity, and co-essentialism becomes simply the negation of essentialism. The role and place of self-identification (and its justification in terms of first person authority) is paramount in this matter.