Abstract

Histories of transgender medicine in mainland China can look like a sequence of labels: older clinical terms such as yixingzheng (易性症) appear to give way to “transgender,” “gender dysphoria,” or the ICD-11 category “gender incongruence.” The documentary record shows a more intricate institutional rhythm. The third edition of the Chinese Classification of Mental Disorders (CCMD-3), completed around 2001, emerged from a long process of local psychiatric classification and international harmonization. Surveys of Chinese psychiatrists in 2008 and 2014 show CCMD-3 and ICD-10 circulating side by side in professional practice. The World Health Organization later reconceptualized trans-related categories in ICD-11 as gender incongruence and placed them in the chapter on Conditions related to sexual health. Mainland Chinese medical-technology rules, hospital clinics, diagnostic certificates, hormone pathways, and surgical referrals have meanwhile followed their own interface schedules (Chen 2002; Zou et al. 2008; Dai et al. 2014; WHO 2019, 2022).

This entry interprets that history through multiple clocks of diagnostic classification. The first is an international-classification clock, marking ICD releases, adoption, effect, and maintenance. The second is a domestic-professional clock, marking the development of Chinese psychiatric classifications and clinicians’ actual use of them. The third is a clinical-interface clock, marking clinic names, assessment, certificates, referrals, and treatment pathways. The fourth is a regulatory clock, marking national medical-technology rules that connect diagnosis, institutional qualification, and surgical documentation. At any given moment, the four clocks can display different terms and institutional states.

The article also proposes a reusable diagnostic-migration ledger. Each item records classification_system, category_term, issuing_authority, publication_time, implementation_time, clinical_interface, administrative_link, self_identification_status, and source_version. The ledger turns the observation that “a term appeared” into a series of answerable historical questions: Which authority issued a classification? Which professionals used it? Which medical action did it organize? How did it connect to administrative evidence? Where did self-identification sit in relation to the clinical category? This approach reconstructs transgender diagnostic history in mainland China as a history of translation among classification, care, and regulation.

Keywords: transgender; mainland China; medical history; yixingzheng; gender incongruence; CCMD-3; ICD-10; ICD-11; diagnostic classification; depathologization

1. Research question: why do several diagnostic languages coexist in the same decade?

Diagnostic classification is institutional infrastructure. It gives clinicians a shared vocabulary for cases, helps hospitals organize referrals, and enters medical education, research inclusion criteria, health statistics, and some administrative procedures. The World Health Organization describes the ICD as a common language for recording, reporting, and comparing health information. Chinese psychiatry also developed the CCMD series, which interacted increasingly with ICD and DSM systems during the late twentieth and early twenty-first centuries (WHO 2026; Chen 2002; Lee 2001). Transgender medicine sits directly at the crossing of these classification systems, clinical services, and identity language.

A 2018 Peking University Third Hospital page was titled “Yixingzheng Comprehensive Treatment Clinic” and connected psychological or psychiatric assessment with multidisciplinary care, endocrinology, and surgery (Peking University Third Hospital 2018). During the same period, national surveys, UNDP reports, and academic studies routinely used “transgender” as a population and identity umbrella (UNDP 2016, 2018; Zhang et al. 2016). A 2022 national framework used “gender reassignment technology” as the name of a restricted medical technology. ICD-11, in turn, uses “gender incongruence” within the chapter on Conditions related to sexual health (National Health Commission 2022; WHO 2022). These sources belong to the same historical period and to distinct institutional layers.

The guiding question is therefore: How has transgender diagnostic classification migrated in mainland China since the early 2000s, and why do international classification, domestic professional practice, hospital services, and administrative regulation move at different speeds? The central answer treats the historical unit as a classification entering an institutional interface. Manual revision, clinicians’ everyday usage, hospital service design, and national technical regulation each have their own cycle. Their asynchronous movement is a substantive historical finding.

This focus complements GenderLibs’ earlier vocabulary-stratigraphy study. That project compared naming regimes across media, administration, clinics, and communities. The present entry narrows the lens to classification authority and execution interfaces. A word in a newspaper can describe a public figure; a similar word in a psychiatric classification can designate a diagnostic category; a related term in a surgical rule can organize required documentation. The article centers evidence where classification meets a concrete medical action.

2. Materials and method: from a term to authority, interface, and time

The first source group covers the history of psychiatric classification in China. Chen’s account of CCMD-3 gives unusually direct evidence about its production. From 1996 through 2000, prospective field trials involved 114 psychiatrists at 41 mental-health centers and psychiatric hospitals. Descriptive definitions drew on the ICD-10 clinical descriptions and diagnostic guidelines, while criteria also referred to ICD-10 research criteria and DSM-IV. The Chinese Psychiatric Association then published CCMD-3 as diagnostic guidance for psychiatrists across the country (Chen 2002). Lee’s work on CCMD-2-R and CCMD-3 places these changes in a longer relationship between international harmonization and locally meaningful psychiatric classification (Lee 1997, 2001).

The second group measures professional use. A 2008 Beijing survey yielded 181 analyzable questionnaires: 63.8 percent reported CCMD-III as their most commonly used system, 28.5 percent ICD-10, and 7.7 percent DSM-IV (Zou et al. 2008). A later study published in 2014 found that 91 percent of Chinese respondents regularly used a formal classification system; among those reported systems, 48.8 percent used ICD-10, 39.3 percent CCMD-3, and 11.4 percent DSM-IV (Dai et al. 2014). The samples, locations, and dates differ, so each percentage represents a bounded institutional snapshot. Together they document a period of plural use and increasing international convergence.

The third group consists of WHO sources on ICD-11 and the research surrounding the revision. WHO released ICD-11 in 2018, the World Health Assembly adopted it in 2019, and the revision entered a new international reporting phase from 2022. Trans-related categories were reconceptualized as Gender incongruence and placed in the chapter Conditions related to sexual health (WHO 2018, 2019, 2022, 2026). Work by Reed, Drescher, Robles, and colleagues records the scientific, clinical, and human-rights reasoning behind that reorganization (Reed et al. 2016; Robles et al. 2016; Drescher et al. 2016).

The fourth group comes from mainland Chinese medical and administrative interfaces: the 2009 Ministry of Health technical rule for sex-reassignment surgery, the 2022 national restricted-medical-technology framework, Peking University Third Hospital’s 2018 clinic page, the publicly available reproduction of its 2023 clinical and nursing guide, and materials on legal gender recognition, trans health, and community surveys (Ministry of Health 2009; Peking University Third Hospital 2018; National Health Commission 2022; PUH3 Plastic Surgery 2024; UNDP 2018). These sources show what a category actually connects to.

The diagnostic-migration ledger compares all four groups through nine fields:

  1. classification_system: CCMD, ICD, a hospital service vocabulary, or a medical-technology regime;
  2. category_term: the category or procedural term used in the source;
  3. issuing_authority: professional association, WHO, health authority, hospital, or research team;
  4. publication_time: the public release or version date;
  5. implementation_time: a supported date of use, effect, or adoption;
  6. clinical_interface: registration, assessment, diagnostic certificate, hormones, surgery, or referral;
  7. administrative_link: connections to technology approval, household registration, or documentary requirements;
  8. self_identification_status: professional category, research population, community self-label, or an overlap among them;
  9. source_version: original edition, revision, hospital page, reproduction, or retrospective account.

The ledger preserves the scope of each source. A WHO release establishes an international classification event. A survey of psychiatrists establishes bounded evidence about professional use. A hospital page establishes the public language of a particular service. A national technical rule establishes a regulatory requirement. The pieces become more informative when linked while retaining their separate evidentiary jobs.

3. Clock one: CCMD-3 and the domestic history of psychiatric classification

A major theme in post-reform Chinese psychiatric classification is the growing connection between domestic nosology and international standards. Lee’s analysis of CCMD-2-R describes a classification that combined international structure with categories and distinctions understood as locally useful. By CCMD-3, harmonization had advanced substantially (Lee 1997, 2001). Chen’s production history makes the institutional process concrete: a multi-year field-trial program preceded publication, and the task force compared the new edition with CCMD-2R, ICD-10, and DSM-IV (Chen 2002).

That background matters for transgender history because yixingzheng belonged to a wider psychiatric classificatory environment. Publicly accessible medical teaching material reproduces the term in relation to CCMD-3 and can serve as a locator for historical professional language; edition histories and professional surveys supply stronger evidence about authority and breadth of use (Tianshan Medical College 2013; Chen 2002). Historical reconstruction therefore needs more than a category name. It also needs the publishing body, version, professional uptake, and relationship to other systems.

The 2008 survey makes “use” visible. CCMD-III occupied the largest share in that Beijing sample while ICD-10 and DSM-IV were also present (Zou et al. 2008). The 2014 study found a different distribution, with ICD-10 more frequent than CCMD-3 among Chinese respondents (Dai et al. 2014). Read together, the two snapshots illustrate the distance between a manual’s publication date and the migration of everyday professional practice.

CCMD-3 can therefore be represented as a sequence: domestic classification work → multicenter field trials → comparison with ICD and DSM → professional publication → clinician use → deeper convergence with international classification. Transgender diagnostic terminology sat inside this larger knowledge infrastructure. When historians encounter a medical record, hospital webpage, or policy text from the 2000s, identifying its classificatory background helps clarify the category’s institutional function.

4. Clock two: ICD-11 changes category, chapter, and health-system function

The ICD-11 change relevant to transgender health operates on three levels. First, WHO uses “Gender incongruence of adolescence and adulthood” and “Gender incongruence of childhood” in place of the relevant older ICD-10 categories. Second, the categories sit in the chapter on Conditions related to sexual health. Third, WHO links continued classification to access to gender-affirming health care and to health-system coverage (WHO 2019, 2026).

The change followed a long revision process. Reed and colleagues described the proposed restructuring in 2016 and connected it to scientific evidence, clinical practice, and human-rights considerations (Reed et al. 2016). Robles and colleagues’ Mexico City field study separately measured distress, impairment, social rejection, and violence in support of the ICD-11 revision process (Robles et al. 2016). Research on the childhood category also documents how transgender stakeholders and health professionals weighed terminology, placement, clinical utility, and access to reimbursed care (Drescher et al. 2016; Cohen-Kettenis et al. 2017).

The 2019 World Health Assembly adoption and the 2022 international reporting transition belong to the international-classification clock. WHO’s own implementation material explains that national migration depends on existing information systems, coding infrastructure, and implementation preparation (WHO 2022). The 2022 date thus marks a global ICD phase. Adoption in a particular mainland Chinese hospital, psychiatric service, health-information system, or medical record requires domestic evidence specific to that interface.

This distinction prevents several dates from collapsing into one. A historian can record the 2019 World Health Assembly action as a change in international classification authority, a later Chinese hospital’s use of “gender incongruence” as a change in a clinical interface, and a national medical-technology revision as a change in regulatory language. Each event receives its own line in the ledger.

5. Clock three: a hospital clinic translates classification into a care pathway

Hospitals are among the most concrete public interfaces of diagnostic classification. Peking University Third Hospital’s 2018 “Yixingzheng Comprehensive Treatment Clinic” page connected gender-related assessment with psychological or psychiatric consultation, multidisciplinary treatment, endocrinology, and surgery (Peking University Third Hospital 2018). For a patient, a category at this point functions as navigation: it can point to a registration desk, an evaluator, a next treatment step, and a medical certificate.

The publicly available reproduction of the 2023 Clinical Diagnosis, Treatment, and Basic Nursing Guide for Yixingzheng reveals an especially clear layer of coexistence. The guide retains yixingzheng in its title and description of the service population, while listing terms that can appear in an assessment such as yixingzheng, gender incongruence, gender dysphoria, and gender identity disorder. It also presents a depathologizing explanation of transgender identity and organizes psychological support, endocrine treatment, and gender-reassignment surgery as elements within a care pathway (PUH3 Plastic Surgery 2024). One document therefore preserves older professional terminology, newer international language, and service-process language at once.

The clinical-interface clock captures this pattern. A clinic title has organizational history. A diagnostic certificate can reflect training traditions and documentary compatibility. Endocrine and surgical pathways operate under their own specialty rules. Terminological change can therefore have several dates inside a single institution. A webpage revision date can also differ from the date when clinicians changed practice, making web time and clinical time separate fields.

Zhou’s research on transgender care in China connects global norms, local adaptation, and family involvement. Shao’s work on trans medicine similarly emphasizes kinship, care, and institutional recalibration (Zhou 2024; Shao 2026). These studies show why classification in Chinese clinical settings interacts with family relations, service availability, hospital level, city resources, and multidisciplinary organization. Classification opens a pathway; the pathway itself is produced through a wider care ecology.

6. Clock four: medical-technology regulation keeps its own vocabulary and documentary logic

The Ministry of Health’s 2009 technical specification for sex-reassignment surgery organized institutional qualification, surgeon qualification, age, marital status, diagnosis, and preoperative documentation within a medical-technology framework (Ministry of Health 2009). Its central regulatory object was the clinical application of a high-risk technology. Diagnostic evidence therefore had a specific function within the surgical pathway.

In 2022, the national restricted-medical-technology system used “gender reassignment technology” and placed it in the national restricted-technology list (National Health Commission 2022; Chongqing Municipal Health Commission 2022). The naming shift documents an update in administrative medical language while the regulatory framework remains organized around institutional capacity, personnel, case management, and clinical conditions. Shanghai’s later public filing interface also lists gender reassignment technology among national restricted technologies, showing the term at a local government-service interface (Shanghai Municipal Government 2024).

The regulatory clock has a distinct object from the diagnostic clock. ICD provides health classification and coding infrastructure. Restricted-medical-technology rules govern the clinical use of specified procedures. Household-registration rules operate in another administrative system. A 2002 public-security reply on changing the sex item in household registration after surgery connected hospital evidence, the household-registration field, and a newly assigned identity number (Ministry of Public Security Third Bureau 2002). Diagnostic and surgical documents therefore become bridges among systems with different issuing authorities and revision cycles.

The social history of a classification change can consequently be traced through a document chain: category → hospital assessment → treatment referral → surgical documentation → surgical certificate → downstream administrative use. Different institutions control each arrow. Recording only the classification at the top loses the institutional work that makes it consequential; recording only the identity document at the bottom loses the medical authority assembled earlier in the chain.

7. Research and community language provide a fifth reference system

From the 2010s onward, “transgender” became a central population term in mainland Chinese research, surveys, and service projects. The 2016 national LGBTI survey placed gender identity and gender expression within a broad study of social attitudes. A trans-health blueprint organized knowledge explicitly around trans people and health services. The 2017 national transgender population survey then treated transgender and gender-nonconforming people as a dedicated research population (UNDP 2016; UNDP China 2016/2018; Beijing LGBT Center et al. 2017).

Health research similarly uses identity and study inclusion criteria. Zhang and colleagues studied transgender sexual health through a national online survey. Chen and colleagues separately analyzed demand for hormones and surgery and suicidality. Klemmer and colleagues studied violence, depression, anxiety, and suicidal ideation among transgender and gender-diverse adolescents in the People’s Republic of China (Zhang et al. 2016; Chen et al. 2019, 2020; Klemmer et al. 2019). In these studies, “transgender” primarily organizes population identification, sample inclusion, and analysis of health conditions and disparities.

Identity classification and diagnostic classification can occur in the same person’s medical trajectory. A participant can identify as a transgender woman in research, receive an assessment recorded with yixingzheng or gender incongruence in a clinic, and encounter “gender reassignment technology” in a regulatory document. The three labels belong to population research, clinical classification, and technical regulation. Recording them as an interface mapping preserves both self-identification and the documentary categories that structure services.

Community-service materials make the difference still clearer. A national transgender hotline, the Kuar Psychological Support Group, and community digital archives use terms such as “transgender” and kuar to organize access to resources, support, and historical materials (China Development Brief 2018; Kuar Psychological Support Group 2022; Trans and Gender-Diverse Archive 2026). Their primary task is discoverability and mutual aid. For diagnostic history, they provide an essential comparison layer: community identity vocabulary deserves its own record alongside medical classification.

8. Original synthesis: four clocks and a diagnostic-migration ledger

The evidence supports four concurrent clocks.

International-classification clock: ICD revision, release, World Health Assembly adoption, entry into effect, implementation support, and version maintenance.

Domestic-professional clock: CCMD drafting, field trials, professional publication, psychiatrists’ use, and the expanding role of ICD within Chinese psychiatric practice.

Clinical-interface clock: clinic names, psychological or psychiatric assessment, diagnostic certificates, hormone and surgical referral, medical records, and care guides.

Regulatory clock: national restricted-medical-technology rules, local filing systems, surgical documentation, and household-registration evidentiary requirements.

Together they form an asynchronous systems map. CCMD-3’s publication belongs to the domestic-professional clock. The 2008 and 2014 surveys measure changes in professional use. The 2018 PUH3 page documents a clinical interface. The World Health Assembly’s 2019 ICD-11 adoption belongs to the international clock. The 2022 “gender reassignment technology” framework belongs to the regulatory clock. The 2023 clinical guide places several diagnostic expressions inside one care pathway. Every node has a source type appropriate to its claim.

The diagnostic-migration ledger makes this map maintainable. An ICD-11 entry can record classification_system=ICD-11, category_term=Gender incongruence, issuing_authority=WHO/WHA, publication_time=2018, adoption_time=2019, international_reporting_start=2022, and a clinical_interface field awaiting institution-specific evidence. A PUH3 entry can record classification_system=clinic/service interface, a set of locally used diagnostic expressions, issuing_authority=hospital clinical team, a page or guide publication date, and clinical_interface=assessment → support → endocrinology → surgery. The records link while retaining their separate authority.

The same method can absorb future evidence. A new national guideline, hospital page, medical-record coding manual, or medical textbook receives a new row with version and interface fields. Researchers can then observe which clock moved. Revision becomes additive and traceable: a new source updates a node while the surrounding chronology keeps its provenance.

9. Competing explanations and evidence boundaries

The strongest available evidence concerns classification versions, public regulations, public hospital pages, and published surveys. These sources establish issuing authorities, dates, professional-use snapshots, service descriptions, and regulatory vocabulary. They provide a verifiable institutional skeleton.

The detailed implementation history requires denser local records. Cities, hospitals, and specialties can maintain distinct training traditions and documentary habits, while webpages follow editorial cycles. The connections among medical-record coding, psychiatric certificates, endocrine referral, and surgical preoperative documentation call for hospital rules, sequential versions of clinical guidance, anonymized forms, professional teaching material, and oral histories. Current evidence strongly supports the multiple-clock model and leaves substantial room for local histories.

International and domestic timelines also require version-level precision. WHO’s 2019 adoption event and the 2022 international reporting transition precisely locate the global ICD clock. Adoption across mainland Chinese information systems, hospital coding, and clinical diagnosis belongs to a separate implementation record built from domestic sources. Keeping those records distinct lets future implementation evidence enter the ledger directly.

Professional continuity offers another explanation for overlapping terminology. A hospital’s continued use of yixingzheng can reflect clinic history, patient search habits, compatibility with diagnostic certificates, and teaching traditions. The 2023 care guide’s side-by-side presentation of yixingzheng, gender incongruence, gender dysphoria, and gender identity disorder illustrates a practical translation function (PUH3 Plastic Surgery 2024). This pattern is best modeled as multiversion interoperability: a service translates among vocabularies that carry different histories and institutional uses.

10. How to use this entry: fill nine fields when reading a medical-history source

When researchers encounter a source in transgender medical history, they can begin by copying the source’s original category term and preserving its period language. Next, identify the issuing actor: WHO, a professional association, a health authority, a hospital, a research team, or a community organization. Then record both the document’s publication date and the date of the event it describes. The fourth step identifies the action attached to the term: registration, assessment, certificate, endocrine treatment, surgery, coding, insurance, household registration, or research inclusion. A fifth step records the corresponding vocabulary used by other systems in the same period.

The self_identification_status field comes next. In a hospital source, labels such as “patient” or yixingzheng population belong to the clinical interface. In a national survey, “transgender” can combine a research category with participant self-selection. In a community hotline, kuar primarily functions as relational and resource-navigation language. Separating these roles lets historical writing preserve individual identity language alongside the original terminology of institutional documents.

Finally, record source_version. Original manuals, official regulations, and contemporaneous hospital pages have the strongest version-locating value. Later institutional retrospectives, news reproductions, and digital archives restore context and accessibility. Academic work compares institutions and interprets change. The three source functions together transform a history of words into a history of classifications entering institutions and producing practical consequences.

Conclusion: diagnostic history is a history of migrating institutional interfaces

From the early 2000s through the 2020s, transgender diagnostic classification in mainland China has developed through several processes at once: international harmonization of Chinese psychiatric classification, global ICD revision, growth of multidisciplinary hospital services, and updates to medical-technology regulation. CCMD-3 documents the domestic psychiatric background of localization and international convergence. The 2008 and 2014 psychiatrist surveys show plural use and movement among classification systems. ICD-11 places gender incongruence in the sexual-health chapter. PUH3 materials show several diagnostic expressions operating in one clinical service chain. The 2022 national framework organizes restricted medical technology through the term “gender reassignment technology” (Chen 2002; Zou et al. 2008; Dai et al. 2014; WHO 2019; National Health Commission 2022; PUH3 Plastic Surgery 2024).

The most explanatory historical unit is therefore the combination of classification, interface, and time. International standards create shared classification language. Domestic professional systems shape training and diagnosis. Hospitals determine what patients encounter in concrete care pathways. Administrative rules determine which documents enter technical and identity procedures. The four clocks explain why several terms can remain active in one period.

The diagnostic-migration ledger offers an extensible archival format for future research. As local hospital histories, medical textbooks, coding guides, professional-conference materials, community oral histories, and new policy versions enter public archives, researchers can add authority, version, time, and interface data line by line. Transgender medical history in mainland China then appears as a calibratable map of institutional migration, with each change anchored to evidence and each clock preserved on its own scale.

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