Japan’s Society of Psychiatry and Neurology (JSPN) finalized the 5th edition of their treatment guidelines for gender incongruence (formerly gender identity disorder) on August 21 and released them the following week on the Society’s website as well as on that of the newly renamed Japanese Society of Gender Incongruence (JSGI, formerly the Japanese Society for Gender Identity Disorder or JDGID) [1, 2].
The new guidelines are in many ways similar to the previous 4th edition, first released in 2011 and updated several times through 2018. This should come as no surprise, as both the 4th and 5th editions are based on the 7th edition of the WPATH Standards of Care (SOC)[3], although the 5th edition also utilized the guidelines produced by the Endocrine Society and the University of Amsterdam [4, 5]. The WPATH SOC 8 [6], while released in 2022, is only mentioned in the introductory chapters. Regardless, there have been a number of important changes to the Japanese guidelines. While some of these were likely influenced by possible upcoming changes to legal transition, several other new realities also needed addressing.
The first and perhaps largest issue is the removal of gender identity disorder (GID) from both the DSM V [7] and the ICD 11 [8] in favor of gender dysphoria and gender incongruence respectively. Japanese diagnostic criteria up until this latest revision relied primarily on the now obsolete GID diagnosis criteria found in the DSM IV and ICD 10. Current Japanese law also specifies a GID diagnosis as a requirement to receive a court order for legal gender change. Going forward, diagnosis will be carried out under the ICD 11 specifications for gender incongruence, which is no longer categorized as a psychological disorder the way GID or transexualism was, but rather is placed under “Conditions related to sexual health”. The new diagnostic criteria primarily require clinicians to confirm that a patient feels an incongruence between their experienced gender and their AGAB. This also now includes non-binary individuals, and marks what appears to be the first time Japanese guidelines specifically mention non-binary identities. Also worthy of note is that there is no specific need for someone to experience dysphoria to receive diagnosis or treatment.
The second is that, as consultations are said to be on the rise within Japan, there was a need for clearer directives on trans youth care. This includes more specific guidance on evaluation of trans youth than was presented in the 4th edition, as well as including guidance on support for parents, kindergartens, daycares, schools, and other children’s facilities with trans children. They also provide more detailed guidance regarding physical interventions in trans youth (including puberty blockers, HRT, and surgery). In addition, they make special note that, even if there is a possibility that a young patient may eventually desist in a trans identity or have comorbidities, these should not be a barrier to evaluation and to helping them cope with the stress of dysphoria. Overall, the new guidelines recommend what could be called a patient-led affirming model for young patients.
Third, as should be expected, the Cass Review was discussed in the new guideline’s introduction, specifically in reference to trans youth care. Following a summation of the Review’s origins and findings, the Japanese guidelines note that “multiple relevant international organizations, including the Endocrine Society in the United States, have made statements to the effect that the issues pointed out by the Cass Review were already known, that puberty suppression treatment has been developed over many years, and that determinations on things such as the efficacy and safety of puberty suppression treatment should be made based on scientific findings.” (The statement from the Endocrine Society is available here and the WPATH statement is available here.) [9, 10] They also note that the “WPATH 8th edition SOC in regards to the effectiveness, limits, and side-effects [of puberty suppression treatment] is written based on a greater number of systematic reviews than the Cass Review.” In particular, the Japanese guidelines make note that it “is medically self-evident that bodily features of the undesired sex will become permanent if AMAB individuals who would require puberty suppression do not receive it” and that “even though performing research to provide high quality evidence for such cases is difficult, there are concerns about the negative impact on the individual’s psychological state after [irreversible pubertal changes occur].” They ask clinicians to file reports with the JSPN when treatment is started or stopped for the purposes of monitoring the state of treatment within the country, itself a continuation of guidance found in the 4th edition guidelines.
Fourth, given that the upcoming legislation proposed by Japan’s ruling coalition regarding legal gender change will likely demand more stringent requirements for diagnosing and treating physicians (reported by us here), clearer language on which doctors are to provide diagnosis for legal gender change purposes has been included. As the Asahi Shinbun also notes [11], letters of diagnosis for the purposes of legal gender change will now need to be written by two doctors recognized by the JGIS or with a similar standing. This is in contrast to a simple diagnosis, which only requires a single doctor who should ideally have either long-term relevant experience or an interest in trans care, or have attended workshops held by the JSPN or JGIS. In sum, while these changes may make getting the necessary letters of diagnosis for legal gender change somewhat more difficult, they shouldn’t affect the ability to get a basic initial diagnosis. However, we should note that physical interventions require further assessments beyond the initial diagnosis under the guidelines: namely, two letters of opinion written by medical health professionals, at least one of whom is explicitly required to be a JGIS approved psychiatrist. Previously, the doctor was required to be JSGID (currently the JGIS) approved “in principle”. How this change will affect access to things like HRT via the guidelines in the future is unclear.
As a matter of observation, one thing that puts the new Japanese guidelines somewhat in contrast to WPATH SOC 8 in particular is the lack of discussion of the informed consent model of care. As can be seen on Erin Reed’s informed consent clinic map, at least one clinic in Japan does offer this option, and others are known to exist. The main issue here, however, is that formal letters of diagnosis and recommendations for treatment, including those needed to carry out legal changes of name and sex under Japanese law, may not be obtainable unless a person receives them via the JSPN guidelines. For those in Japan seeking a clinic to begin consultation, it may be advisable to check with clinics to see what models of care they can provide. We would also like to note that Japanese laws on legal name and gender change are primarily written for those with Japanese citizenship. If you reside in Japan, be certain to consult with a legal professional for specific questions on your situation.
Finally, among other changes include listing recommended dosages for hormone regimens, including GnRH agonists (puberty blockers) for the first time within the guidelines. These recommendations, however, do not feature target hormone levels, as seen in Endocrine Society guidelines and WPATH SOC 8.
We have reached out by e-mail to the JSGI for further comment, but have not heard back at time of publication. This article will be updated should we receive a response.
References and citations:
- 日本精神神経学会 性同一性障害に関する委員会 『性同一性障害に関する診断と治療のガイドライン(第 4 版改) 』2018年1月
- 日本精神神経学会 性別不合に関する委員会、日本GI（性別不合）学会『性別不合に関する診断と治療のガイドライン （第 5 版）』 2024年８月
- The World Professional Association for Transgender Health, Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People, 7th Version, 2009
- Wylie C Hembree, Peggy T Cohen-Kettenis, Louis Gooren, Sabine E Hannema, Walter J Meyer, M Hassan Murad, Stephen M Rosenthal, Joshua D Safer, Vin Tangpricha, Guy G T’Sjoen, ‘Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline’, The Journal of Clinical Endocrinology & Metabolism, Volume 102, Issue 11, 1 November 2017, Pages 3869–3903, https://doi.org/10.1210/jc.2017-01658
- Kreukels BP, Cohen-Kettenis PT. Puberty suppression in gender identity disorder: the Amsterdam experience. Nature Reviews Endocrinology. 17 May 2011; 7(8):466-72. https://nature.com/articles/nrendo.2011.78
- Coleman, E., Radix, A. E., Bouman, W. P., Brown, G. R., de Vries, A. L. C., Deutsch, M. B., … Arcelus, J. (2022). Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. International Journal of Transgender Health, 23(sup1), S1–S259. https://doi.org/10.1080/26895269.2022.2100644
- American Psychiatric Association, “Gender Dysphoria Diagnosis”
- World Health Organization, “Gender incongruence and transgender health in the ICD”
- Endocrine Society, “Endocrine Society Statement in Support of Gender-Affirming Care”, 8 May 2024,
- WPATH, USPATH, “WPATH and USPATH Comment on the Cass Review”, 17 May 2024
- 「医師の適性、学会が明確化 性別変更に関わる診断 ガイドライン改訂」朝日新聞、30 August 2024
*All links last accessed at time of publication
