On the 28^th November, an Australian state review into trans youth healthcare, called the Vine Review, was published. It was commissioned in response to political fear-mongering about trans youth healthcare, including from the UK’s Cass Review. It was commissioned specifically for the state of Queensland, who have brought in a politically motivated state bans on provision of puberty blockers through the public health service.

The Vine Review is 532 pages long and I am reading it through in stages. Here I’m going to focus on just one paragraph, on one page, page 27. On the topic of diagnosis and psychiatric control.  

Diagnosis.

The Vine review recognises that two diagnoses are available for trans healthcare. There is the 2013 psychiatric diagnosis of gender dysphoria from the DSM-V (Diagnostic and Statistical Manual for Mental Health Disorders). An explicitly pathologising diagnosis that explicitly defines trans people as having a mental health disorder.

And alternatively there is the 2019 ICD-11 diagnosis of gender incongruence, a diagnosis explicitly moved out of mental health, recognising the stigma (and psychiatric control) associated with defining trans people accessing trans healthcare as treatment for a mental health disorder.

Naturally, our past health systems have relied on DSM-V – the ICD diagnosis is newer (though now 7 years old) – and health systems evolve slowly. If we insist on past pathologising practices defining our current and future possibilities, we will never move away from harmful pathologising attachment to psychiatry.

A shift to an ICD-11 diagnosis needs to be on the table in shaping the options for trans healthcare in the present. You would have thought.

Not so according to the Vine review.

Use of ICD-11 is outright dismissed (p. 27). Here is their statement in full:

“The Panel acknowledges that both DSM-5-TR gender dysphoria and ICD-11 gender incongruence are relevant in the treatment and care of TGD children and adolescents. However, given the limited evidence base, we agree with the current practice of only providing PB and/or GAHT to young people who meet the diagnostic criteria for gender dysphoria under the DSM-5-TR. The ICD-11 criteria remain important, but do not accord with requirements to be met to support initiation of PB and/or GAHT in young people.”

The Vine review here takes an ideological position that trans healthcare MUST be tied to psychiatric diagnosis. An ideological position that runs in the face of the work of the World Health Organisation, that stated very clearly in 2019 that trans health should not be delivered as treatment for a mental health disorder.

The ideological nature of this decision to stick with psychiatry and a 2013 psychiatric diagnosis over a 2019 World Health Organisation diagnosis is not recognised. Instead, this highly impactful position is veiled under the explanation that ‘that is how things have been done historically’. Yes, Vine Review, we know things have been pathologised for trans people historically, this was the very reason for the WHO’s 2019 shift in ICD-11. This is not an explanation for centring a psychiatric diagnosis in 2026, nor is it a justification. Instead, this ideological decision is taken without any justification.

On paper, there isn’t even very much difference between ICD and DSM – one might question why they are making this effort to impose a dated and harmful psychiatric diagnosis on a marginalised population when the diagnoses are so similar.

WHOs’ ICD-11 Diagnosis for adolescence or adulthood

Any trans person who wishes to do any form of medical transition can be diagnosed as having ‘gender incongruence’ as per the World Health Organisation’s ICD-11. The first part of the ‘Gender Incongruence’ diagnosis requires a “marked and persistent incongruence between an individual’s experienced gender and the assigned sex”, which is just a description of being trans. The second component is “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”. This criteria captures a desire to medically transition.

DSM-V diagnosis for adolescence or adulthood

A diagnosis of ‘Gender Dysphoria’ for adults and adolescents is based on 6 assessment criteria. Criteria 1-3 relate to a trans person’s body, whether they have ‘a strong desire’ to change ‘primary or secondary sex characteristics’. Criteria 4-6 attempt to define transness, though in a way that feels very clumsy and written by a cis person, diagnosing ‘a strong desire’ to ‘be the other gender’, or ‘to be treated as the other gender’. Criteria 6 is particularly out-dated and cringe, ‘a strong conviction that one has typical feelings and reactions of the other gender’. 

Differences between the diagnoses: The diagnoses are near identical, covering trans people who want to do some form of medical transition. They cover the same population.

There are two important differences between these two diagnoses though. The DSM-V diagnosis adds an extra requirement – it has to be accompanied by significant mental health distress. And it is classified as a psychiatric diagnosis, requiring the judgement of a mental health professional.

CIS-SUPREMACY in 2026 – MISPREPRESENTING THE WORLD HEALTH ORGANISATION

Reasonable sounding anti-trans folks, especially those in healthcare, are proactively playing one particular game, a component of an anti-trans playbook, a game that I am here calling ‘Misrepresenting the World Health Organisation’. It is important to recognise this game, because they are playing it a lot, and are having significant success at it.

Step one: Praise the WHO for depathologising trans people.

The game starts by praising the World Health Organisation for depathologisation – recognising that trans people are NOT mentally ill, that they, in fact, have healthy levels of respect for trans people. They do this to distinguish themselves from ‘transphobic’ people.

Step two: Misrepresenting the WHO

The game moves on to a clear misrepresentation of the WHO ICD diagnosis.

When the WHO introduced their ICD-11 diagnosis, it was intended to be a replacement for trans healthcare diagnoses centred in mental health. Not an addition. Trans people receiving healthcare were supposed to be diagnosed and treated as a minority population group, similar to the treatment provided to pregnant people or to those seeking reproductive healthcare. Neither pregnancy nor need for reproductive health services is defined and treated in terms of mental health, and nor should trans health.

Anti-trans folks actively misrepresent how the ICD-11 is meant to work.

They present the ICD-11 diagnosis as only useful in recognition that trans people are not inherently mentally ill on the whole. They say ‘of course trans people on the whole are not mentally ill, see ICD-11’.

They follow this statement up with ‘but some trans people, are ALSO very sad and distressed, and those people, impacted by poor mental health, need some form of TREATMENT, that must be provided as a treatment for their mental health distress, and must, it follows, be treated and diagnosed under DMS-V.

This approach denies the possibility of providing all trans healthcare under an ICD-11 diagnosis, outside of mental health, outside of psychiatry.

It misrepresents the WHO in claiming that healthcare provision MUST be provided under DSM-V.

Step 3: Ant-trans folks double down with a claim that, whilst trans people are not inherently mentally unwell (see ICD-11), medical treatment should only be provided to those trans people who are suffering from mental health distress, necessitating use of DSM-V for all trans people who want to medically transition.

By this sleight of hand, even the possibility of trans healthcare provision outside of mental health, as intended by the World Health Organisation, is magically disappeared.

Instead it is as though 2019 never happened, and here we are in 2026, doubling down on the need for trans healthcare being governed by the Diagnostic and Statistical Manual of Mental Health Disorders.

This playbook has already been played in the UK’s NHS. Across all recent publications from the NHS the position is laid out that ICD-11 somehow applies to trans people NOT accessing healthcare, and that DSM-V is a requirement for any area of trans healthcare.

WHY DO ANTI-TRANS FOLKS WANT THE DSM?

The reason why those opposed to rights-based healthcare for trans people NEED to keep to the DSM, is linked to the way in which a psychiatric diagnosis removes patient autonomy, de-centring what trans individuals want for their own bodies and lives.

Under a psychiatric diagnosis model of care, trans healthcare (PBs and HRT) are provided to TREAT mental health distress. This mental health distress needs to be measured by a mental health professional. It needs to be evaluated and accredited as sufficiently distressed by a mental health professional. The mental health professional can say ‘no you are not distressed enough’. The mental health professional can say ‘no you are not yet distressed enough, let’s watch your mental health drop’. The mental health professional can be duty bound to explore other factors that may have caused your mental health to be low. They can explore other treatments for your mental health problems, including counselling or anti-depressants. They can evaluate whether other treatments are more or less effective in treating your mental health problem. They can ask whether other treatments (other than PBs or HRT) have a higher quality evidence base. Whether other treatments (other than PBs or HRT) are less controversial. Whether other treatment (other than PBs or HRT) have fewer side effects in terms of impact on fertility. Centring treatment of mental health distress quickly moves us away from individual autonomy, informed healthcare decision making, respect for trans rights, respect for trans life pathways, and back into psychiatric control of trans communities.

How does this one ideological decision impact the wider review?

The decision, made swiftly and with no debate, on page 26, to centre a DSM-diagnosis as the only way to provide trans healthcare, brings with it considerable implications.

I’ve only read the start of the review, but even from those first pages I can see direct implications. The Vine Review weighed up different options, including a ban on puberty blockers, or additional safeguards. In considering the ‘not a full ban’ option, one page 12 they provide a table of recommendations for how to deliver trans youth healthcare if it is not fully banned: (abridged with my emphasis added):

• a DSM-5-TR diagnosis of gender dysphoria is a requirement to indicate the use of PB and/or GAHT (p.12)
• PB should only be initiated within a specialist setting with multidisciplinary staff after comprehensive assessment and family engagement;
• PB should only be commenced at Tanner stage 2 or later, when there has been a thorough biopsychosocial assessment of the person and where co-occurring problems that may be contributing to distress have been addressed
• [On biopsychosocial assessment – please see my earlier blog of reflections from AUSPATH]
• initiation of GAHT should only occur after a comprehensive assessment involving multidisciplinary staff and holistic care planning that considers the prioritisation of interventions such that any other potential causes of distress are comprehensively addressed;
• in all cases, psychological and social support should be offered,
• QCGS can only function as intended with sufficient capacity, and sustainable workforce across psychiatry, paediatrics (endocrinology), psychology, speech pathology, nursing, social work and sexual health/general practice.

All of the above implications stem from the ideological decision, listed very briefly and without debate on page 26, to REQUIRE use of a psychiatric diagnosis for trans youth healthcare.

Requiring a psychiatric diagnosis for trans adolescents accessing medical intervention, also eases the route to also requiring psychiatric diagnosis and treatment for pre-adolescent trans children. Easing the route to requiring a parallel DSM diagnosis for pre-adolescent children, even perhaps, centring mental health distress in justifying the need for social transition. Even perhaps, centring mental health outcomes in justifying the evidence for or against social transition. Opening the doors wide to psychiatric oversight over all areas of trans children’s lives.

Of course, in practice, all of the above was a mute point, because the Government in Queensland instead implemented a full ban on provision of puberty blockers through the public health service.

RIGGING THE GAME

All of this needs to be understood in terms of rigging the game.

The outcome that is wanted by anti-trans actors is a full ban on trans healthcare, as seen in Queenland, the UK and elsewhere.

But they are also working to ensure that trans healthcare, where it is not banned, is as abusive and controversial as possible.

Requiring a DSM-V diagnosis is one important pillar of this strategy.

If health services shift to ICD-11, they might consider removing the power held by psychiatry and psychology.

They might consider the healthcare rights of a marginalised community

They might centre informed healthcare decision making, with patient autonomy centred.

They might find it harder to deny healthcare based, not on evidence of harm, but on having poor quality evidence of impact on mental health.

They might find it harder to place psychiatrists and psychologists in positions of medical power over trans people.

They might find it harder to impose ‘other treatments’ for resolving mental health distress, including conversion therapy.

They might actually focus on supporting trans children and adolescents.

Having got 26 pages into a 536 page report, I will have to consider whether to return to it. TBC