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By María Sanz, from Asunción

Alejandra Grange, a trans woman, community psychologist, and member of Transitar , an organization that brings together trans and non-binary individuals in Paraguay, views with skepticism the World Health Organization's (WHO) decision to reclassify transsexuality in its International Classification of Diseases (ICD), removing it from the list of mental disorders. "I don't think it's actually progress, because there's still no education on the subject," she explained in an interview with Presentes.

In some countries, transvestites and transgender people need a diagnosis of a disorder such as gender dysphoria to change their name or sex on official documents. It may also be a requirement to access hormone therapy or gender reassignment surgery.

Alejandra points out that Paraguay lacks gender identity laws, and these therapies are not offered in the health system either, so she believes that the scope of the WHO reclassification will be even more limited in this country, where access to health for transvestites and trans people faces many barriers.

[READ ALSO: Two trans activists fight in court for the right to their names]

Alejandra is 28 years old and has just finished her degree in community psychology. She graduated with a thesis on the psychosocial effects of sex work for transvestites and trans people. But at university, she had to face being considered ill, or referred to with masculine pronouns, from textbooks to professors and many classmates, without being accepted as transfeminine, and even less so as a transvestite, which she claims as a form of dissent from binary gender norms.

“In medical discourse, a transvestite is a man who dresses as a woman as a fetish. But let's understand where this also comes from. It arises in the Latin American context, and for our demands, for our struggles, transvestite is a way of saying that I am neither a man nor a woman: I am a transvestite, I am this person, this is the construction of my identity. I don't have to undergo surgery to fit back into this binary model. I don't have to pass as a woman so that I'm accepted, and so that my fulfillment and happy ending are simply to go unnoticed. Society needs us to go unnoticed too, because otherwise we'll be out there demanding and trying to destabilize its structures,” says the activist.

What the WHO says

On June 18, the WHO announced a new version of this classification (ICD-11), in which transsexuality is removed from the list of mental disorders. However, the category of “gender incongruence” appears, defined as “a marked and persistent incongruence between an individual’s experienced gender and their assigned sex.”

The WHO classifies this “gender incongruence” as a “condition related to sexual health”, and considers that it manifests itself in traits such as “a deep disgust or discomfort with primary or secondary sexual characteristics”, a “strong desire to be free” from some of these characteristics, and a “strong desire to have the primary or secondary sexual characteristics of the experienced sex”.

[READ ALSO: For the WHO, being trans is no longer a mental illness]

The organization now acknowledges that “there is clear evidence that transsexuality is not a mental disorder” and that “classifying it as such can cause enormous stigma for transgender people.” However, it justifies the decision to keep transsexuality on the list of diseases because “significant healthcare needs remain that can be better met if this condition is coded in the ICD.” The body also states that, although “it is crucial to listen to the voices of people affected by gender incongruence,” the decision to move transsexuality to the sexual health section was based on scientific evidence.

Alejandra, along with her colleagues from Transitar, is cautiously observing the WHO's stance. She believes that, although it is a decision made by a body composed mostly of cisgender people in positions of academic power and disconnected from the reality of gender diversity, it is also the result of decades of struggle by trans and travesti activism.

Between secrecy, ignorance, and stigma

“In Paraguay, healthcare for trans women is clandestine,” says Alejandra. She explains how, if a trans woman wants to start hormone therapy, she has to find a pharmacy that will administer contraceptive injections, or learn to inject them herself. And, of course, she has to cover all the costs of the treatment. There is no medical oversight or follow-up, no Gender Identity Units in hospitals, and no specialists in this type of therapy in Paraguay.

Some organizations have promoted trans and travesti-friendly public health services. But, generally, when they go to a health center, they are met with stigma and pathologization. “Health services here don't treat you like you're mentally ill, but they stigmatize trans and travesti people. If you go to a health center, it's because you have HIV, and they immediately tell you you have AIDS. Once, I wanted to go for a consultation, and they sent me to where they did HIV testing. Another time, I went to the dentist, and when I went in, the dentist told me she was afraid and didn't know how she was going to be able to treat me. She apologized and said they weren't going to see me. You have to put up with private care because if you pay, they'll treat you, but not in the public system,” Alejandra recalls.

[READ ALSO: More than 20,000 LGBT youth will be subjected to sexual conversion therapy in the United States]

If the consultation is in the mental health field, with psychologists or psychiatrists, Alejandra says that there is only one discourse regarding trans and transvestite people. “They have a pathologizing view. They immediately tell you: ‘ You’re sick and we have the cure, we have the way to deal with it ,’ and they already give you medication. Or, in the worst case, you might run into a psychologist or psychiatrist who is involved in a religion, and they give you these conversion therapies, these supposed changes,” she explains.

Despite debates and reclassifications, paragraph 18 of the Yogyakarta Principles, which aim to guide international human rights law regarding sexual orientation and gender identity, states that “regardless of any classification to the contrary, a person’s sexual orientation and gender identity are not, in themselves, medical conditions and should not be treated, cured, or suppressed.” However, these principles are not legally binding on states.