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Japan’s top court strikes down required sterilization surgery to officially change gender

Lawyers of a claimant, Kazuyuki Minami, left, and Masafumi Yoshida, right, speak to media after the ruling of the Supreme Court Wednesday, Oct. 25, 2023, in Tokyo. Japan’s Supreme Court on Wednesday ruled that a law requiring transgender people to have sterilization surgery in order to officially change their gender is unconstitutional.(AP Photo/Eugene Hoshiko)

Lawyers of a claimant, Kazuyuki Minami, left, and Masafumi Yoshida, right, holds signs that read “Unconstitutional”, right, and “Back (to High Court)” during a press conference following the ruling of the Supreme Court Wednesday, Oct. 25, 2023, in Tokyo. Japan’s Supreme Court on Wednesday ruled that a law requiring transgender people to have sterilization surgery in order to officially change their gender is unconstitutional. The claimant is only identified as a resident in western Japan. (AP Photo/Mari Yamaguchi)

Japan’s Supreme Court is seen in this Sept. 4, 2023, in Tokyo. Japan’s Supreme Court will rule Wednesday, Oct 25, whether a law forcing transgender people to have their reproductive organs removed in order to officially change their gender is constitutional.(Kyodo News via AP)

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TOKYO (AP) — Japan’s Supreme Court on Wednesday ruled that a law requiring transgender people to undergo sterilization surgery in order to officially change their gender is unconstitutional, a landmark verdict welcomed by advocates as a sign of growing acceptance of LGBTQ+ rights.

The ruling by the top court’s 15-judge Grand Bench applies to the sterilization portion of the 2003 law only. It does not address the constitutionality of requiring gender-transition surgery in general to obtain a state-sanctioned gender change — a requirement also criticized by international rights and medical groups.

The law forces those who seek a gender change a “cruel choice between accepting the sterilization surgery that causes intense bodily invasion and giving up important legal benefits of being treated according to their gender identity,” the Supreme Court said.

The decision, which requires the government to reconsider the law, is a first step toward allowing transgender people to change their identity in official documents without getting sterilized. But it was not a full victory for the claimant because the Supreme Court sent her case back to the high court to further examine the requirement for gender-affirmation surgery.

The claimant in 2020 sought a gender change in her family registry — to female from assigned male at birth — but her request was turned down by lower courts.

The decision comes at a time of heightened awareness of issues surrounding LGBTQ+ people in Japan and is a partial victory for that community.

The judges unanimously ruled that the part of the law requiring sterilization for a gender change is unconstitutional, according to the court document. The claimant’s lawyers said the decision that did not find the gender-affirmation surgery requirement unconstitutional was regrettable because it delays the settlement of that issue.

The claimant, identified only as a transgender woman in her late 40s living in western Japan, said in a statement read by one of her lawyers Kazuyuki Minami that she was “surprised” by the decision and was “disappointed” that a decision on the gender-affirmation surgery requirement is delayed.

It causes her more ordeal and court sessions for “further scrutiny about the inside of her underpants,” Minami said.

Under the law, transgender people who want to have their gender assigned at birth changed on family registries and other official documents must be diagnosed as having gender dysmorphia and must undergo an operation to remove their sex organs.

Other requirements are that they are unmarried and do not have children under 18.

Kanae Doi, Japan director of Human Rights Watch said it was “great news” that the top court unanimously found the sterilization unconstitutional and that the government now must follow up. “The government is obliged to amend the law to remove the sterilization and gender-affirmation surgery requirements,” she said. “Any invasion of the body against one’s will is a human rights violation.”

LGBTQ+ activists in Japan have recently stepped up efforts to pass an anti-discrimination law since a former aide to Prime Minister Fumio Kishida said in February that he wouldn’t want to live next to LGBTQ+ people and that citizens would flee Japan if same-sex marriage were allowed.

But changes have come slowly and Japan remains the only Group of Seven member that does not allow same-sex marriage or legal protections, including an effective anti-discrimination law.

The claimant originally filed the request in 2020, saying the surgery requirement forces a huge economic and physical burden and that it violates the constitution’s equal rights protections.

Rights groups and the LGBTQ+ community in Japan have been hopeful for a change in the law after a local family court, in an unprecedented ruling earlier this month , accepted a request by a claimant for a gender change without the compulsory surgery, saying the rule is unconstitutional.

The special law that took effect in 2004 states that people who wish to register a gender change must have their original sex organs, including testes or ovaries, removed and have a body that “appears to have parts that resemble the genital organs” of the new gender they want to register with.

More than 10,000 Japanese have had their genders officially changed since then, according to court documents from the Oct. 11 ruling that accepted Gen Suzuki’s request for a gender change without the required surgery.

Surgery to remove sex organs is not required in most of the approximately 50 European and central Asian countries that have laws allowing people to change their gender on official documents, the Shizuoka ruling said. The practice of changing one’s gender in such a way has become mainstream in many places around the world, it noted.

In a country of conformity where the conservative government sticks to traditional paternalistic family values and is reluctant to accept sexual and family diversity, many LGBTQ+ people still hide their sexuality due to fear of discrimination at work and schools.

Some groups opposing more inclusivity for transgender people, especially to those changing from assigned male at birth to female, had submitted 20,000 petitions Tuesday to the Supreme Court, asking it to keep the surgery requirement in place to keep “women’s spaces safe.”

Hundreds of municipalities now issue partnership certificates for same-sex couples to ease hurdles in renting apartments and other areas, but they are not legally binding.

In 2019, the Supreme Court in another case filed by a transgender man seeking a gender registration change without the required sexual organ removal and sterilization surgery found the law constitutional.

In that ruling, the top court said the law was constitutional because it was meant to reduce confusion in families and society, though it acknowledged that it restricts freedom and could become out of step with changing social values and should be reviewed later.

Japan court approves a trans man’s request for legal recognition without needing surgery

TOKYO — A court in western Japan on Wednesday approved a transgender man’s request to have his gender changed in official records without undergoing sterilization surgery, the first known ruling of its kind since the country’s top court  struck down a surgery requirement  for such record changes.

The Okayama Family Court’s Tsuyama Branch said Tacaquito Usui, 50, could get the gender listed for him in his family registry updated to male. Usui original application for the revision was rejected five years ago.

“It’s like I’m standing at the start line of my new life,” he said during a televised news conference after Wednesday’s ruling came out. “I’m so excited.”

Japan’s Supreme Court ruled in October that a provision of a 20-year-old law that made the removal of reproductive organs a precondition for the legal recognition of gender changes was unconstitutional. The ruling, however, only applied to the sterilization provision and did not address the constitutionality of requiring other procedures.

The Okayama court found that the hormone therapy Usui received made him eligible for gender affirmation. Usui welcomed the recognition, saying he thinks the law in Japan might be evolving faster than the public awareness.

Many LGBTQ people in Japan still hide their sexual orientations and gender identities due to fear of discrimination at work and schools. The country remains the only Group of Seven member that does not allow same-sex marriages.

Activists have pressed for greater rights and protections. But change has come slowly in a country of conformity with a conservative government that sticks to traditional paternalistic values and is reluctant to accept gender, sexual and family diversity,

The law that the Supreme Court addressed in its ruling took effect in 2004. It stated that individuals who wanted to register a gender change needed to have reproductive organs, including testes or ovaries, removed. They also were required to have a body that “appears to have parts that resemble the genital organs” of their expressed gender.

More than 10,000 Japanese have since had their genders officially changed, according to court documents from  another court case . A court in central Japan noted in last year’s case that sterilization surgery was not required in most of the approximately 50 European and central Asian countries that have laws that allow gender changes on official documents.

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The Associated Press

Japan’s Top Court Strikes Down Required Sterilization Surgery to Officially Change Gender

Japan’s Supreme Court has ruled that a law requiring transgender people to undergo sterilization surgery in order to officially change their gender is unconstitutional

Eugene Hoshiko

Lawyers of a claimant, Kazuyuki Minami, left, and Masafumi Yoshida, right, speak to media after the ruling of the Supreme Court Wednesday, Oct. 25, 2023, in Tokyo. Japan’s Supreme Court on Wednesday ruled that a law requiring transgender people to have sterilization surgery in order to officially change their gender is unconstitutional.(AP Photo/Eugene Hoshiko)

TOKYO (AP) — Japan’s Supreme Court on Wednesday ruled that a law requiring transgender people to undergo sterilization surgery in order to officially change their gender is unconstitutional, a landmark verdict welcomed by advocates as a sign of growing acceptance of LGBTQ+ rights.

The ruling by the top court’s 15-judge Grand Bench applies to the sterilization portion of the 2003 law only. It does not address the constitutionality of requiring gender-transition surgery in general to obtain a state-sanctioned gender change — a requirement also criticized by international rights and medical groups.

The law forces those who seek a gender change a “cruel choice between accepting the sterilization surgery that causes intense bodily invasion and giving up important legal benefits of being treated according to their gender identity,” the Supreme Court said.

The decision, which requires the government to reconsider the law, is a first step toward allowing transgender people to change their identity in official documents without getting sterilized. But it was not a full victory for the claimant because the Supreme Court sent her case back to the high court to further examine the requirement for gender-affirmation surgery.

The claimant in 2020 sought a gender change in her family registry — to female from assigned male at birth — but her request was turned down by lower courts.

The decision comes at a time of heightened awareness of issues surrounding LGBTQ+ people in Japan and is a partial victory for that community.

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The judges unanimously ruled that the part of the law requiring sterilization for a gender change is unconstitutional, according to the court document. The claimant's lawyers said the decision that did not find the gender-affirmation surgery requirement unconstitutional was regrettable because it delays the settlement of that issue.

The claimant, identified only as a transgender woman in her late 40s living in western Japan, said in a statement read by one of her lawyers Kazuyuki Minami that she was “surprised” by the decision and was “disappointed” that a decision on the gender-affirmation surgery requirement is delayed.

It causes her more ordeal and court sessions for “further scrutiny about the inside of her underpants,” Minami said.

Under the law, transgender people who want to have their gender assigned at birth changed on family registries and other official documents must be diagnosed as having gender dysmorphia and must undergo an operation to remove their sex organs.

Other requirements are that they are unmarried and do not have children under 18.

Kanae Doi, Japan director of Human Rights Watch said it was “great news” that the top court unanimously found the sterilization unconstitutional and that the government now must follow up. “The government is obliged to amend the law to remove the sterilization and gender-affirmation surgery requirements," she said. “Any invasion of the body against one's will is a human rights violation.”

LGBTQ+ activists in Japan have recently stepped up efforts to pass an anti-discrimination law since a former aide to Prime Minister Fumio Kishida said in February that he wouldn’t want to live next to LGBTQ+ people and that citizens would flee Japan if same-sex marriage were allowed.

But changes have come slowly and Japan remains the only Group of Seven member that does not allow same-sex marriage or legal protections, including an effective anti-discrimination law.

The claimant originally filed the request in 2020, saying the surgery requirement forces a huge economic and physical burden and that it violates the constitution's equal rights protections.

Rights groups and the LGBTQ+ community in Japan have been hopeful for a change in the law after a local family court, in an unprecedented ruling earlier this month , accepted a request by a claimant for a gender change without the compulsory surgery, saying the rule is unconstitutional.

The special law that took effect in 2004 states that people who wish to register a gender change must have their original sex organs, including testes or ovaries, removed and have a body that “appears to have parts that resemble the genital organs” of the new gender they want to register with.

More than 10,000 Japanese have had their genders officially changed since then, according to court documents from the Oct. 11 ruling that accepted Gen Suzuki's request for a gender change without the required surgery.

Surgery to remove sex organs is not required in most of the approximately 50 European and central Asian countries that have laws allowing people to change their gender on official documents, the Shizuoka ruling said. The practice of changing one's gender in such a way has become mainstream in many places around the world, it noted.

In a country of conformity where the conservative government sticks to traditional paternalistic family values and is reluctant to accept sexual and family diversity, many LGBTQ+ people still hide their sexuality due to fear of discrimination at work and schools.

Some groups opposing more inclusivity for transgender people, especially to those changing from assigned male at birth to female, had submitted 20,000 petitions Tuesday to the Supreme Court, asking it to keep the surgery requirement in place to keep “women's spaces safe.”

Hundreds of municipalities now issue partnership certificates for same-sex couples to ease hurdles in renting apartments and other areas, but they are not legally binding.

In 2019, the Supreme Court in another case filed by a transgender man seeking a gender registration change without the required sexual organ removal and sterilization surgery found the law constitutional.

In that ruling, the top court said the law was constitutional because it was meant to reduce confusion in families and society, though it acknowledged that it restricts freedom and could become out of step with changing social values and should be reviewed later.

Copyright 2023 The  Associated Press . All rights reserved. This material may not be published, broadcast, rewritten or redistributed.

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Japan: Transgender rights progress as court rules surgery not required for legal gender change 

Responding to the Supreme Court of Japan’s ruling on Wednesday that a law requiring people who want to legally change gender to undergo reproductive surgery is unconstitutional, Amnesty International East Asia Researcher Boram Jang said:  

“This is a landmark decision for transgender rights in Japan, and the latest encouraging sign that countries in the region are reevaluating discriminatory practices or laws affecting LGBTI people. The court’s ruling is an important step forward, but the fight for LGBTI rights in Japan remains an uphill battle. 

“Amnesty International continues to call on the Japanese authorities to ensure legal gender recognition is not contingent on psychiatric diagnosis, medical treatment such as gender-affirming surgery or other abusive or discriminatory requirements such as being unmarried or not having children. It must be a quick, accessible and transparent administrative process based on an individual’s self-determination.” 

Background:  

The Supreme Court issued a ruling on 25 October in a family law case, declaring that the stipulation of the Special Law on Gender Identity Disorder, which mandates surgical sterilization as a prerequisite for gender reassignment, is unconstitutional in Japan. This decision was based on the determination that the sterilization requirement runs counter to Article 13 of the Constitution, which emphasizes the importance of respect for individual rights. 

The Special Law on Gender Identity Disorder stipulates the procedures for changing a person’s legal gender on the family register. If a person is diagnosed with gender identity disorder by doctors and files a petition with the Family Court, and meets all of the following five requirements: (1) 18 years of age or older, (2) not currently married, (3) no minor children, (4) no reproductive function, and (5) genitalia similar in appearance to those of the sex after the change, the change of legal gender will be approved. 

Japan court says requiring surgery for gender switch unconstitutional

A Japanese court has said that a law requiring surgery to switch genders on a family registry is unconstitutional in a ruling on a case involving a transgender man in central Japan, his lawyers said Thursday.

The Hamamatsu branch of the Shizuoka Family Court delivered the country's first judgment on a challenge to the rule after the man, Gen Suzuki, filed a request in 2021 seeking to change his gender without sex reassignment surgery, according to the lawyers.

The decision Wednesday by the central Japan court allows Suzuki, 48, to be listed as a man in his family registry without undergoing an operation to remove reproductive capacity.

Japanese law on gender identity disorder requires sex reassignment surgery as a condition for changing one's gender.

"(The ruling) could give hope to children who have also been denied their gender identities," Suzuki told Kyodo News.

Presiding Judge Takehiro Sekiguchi said that the impact of problems that might arise if a gender change is allowed without surgery would be "limited."

Ruling that the law violates Article 13 of the Constitution that stipulates all people shall be respected as individuals, he also said restricting the freedom of people with gender identity disorder to choose not to undergo physically invasive procedures against their will is "not rational."

Suzuki has undergone hormone therapy and surgically removed his breast tissue but believes a sex reassignment operation would have a serious impact on his physical and mental health.

He says he felt uncomfortable being treated as female from a young age and was diagnosed with gender identity disorder at age 40.

Family courts must give permission to make corrections to a family register, which records information about the identity of citizens such as gender as well as family relationships.

The Supreme Court is expected to deliver a ruling on the constitutionality of the law in a separate case involving another transgender individual seeking to switch gender without surgery.

In 2019, the top court ruled that the law was constitutional, but that it should be reviewed in accordance with changes in society.

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Download the full report in English

Download the appendix of the report in English

“A Really High Hurdle”

Japan’s Abusive Transgender Legal Recognition Process

Fumino Sugiyama, a transgender man, holds his Japanese ID card, which reads “female,” at his home in Tokyo. © 2019 Human Rights Watch

The procedure in Japan for changing an individual’s legal gender is regressive and harmful. It rests on an outdated and pejorative notion that a transgender identity is a mental health condition, and requires transgender people who want legal recognition to undergo lengthy, expensive, invasive, and irreversible medical procedures. The relevant legislation—known as the “Gender Identity Disorder Special Cases Act”—is contrary to international human rights law and international medical best practices. And while some trans people in Japan desire a diagnosis of “Gender Identity Disorder” (性同一性障害) (GID) and to undergo the medical procedures listed in the law, many do not—and should not be required to do so.

“Transgender” is an inclusive term for anyone whose sex assigned to them at birth does not conform to their lived or perceived gender. It refers to people for whom the designation as “female” or “male” on their birth certificate does not align with the gender that they are most comfortable expressing or would express, if given a choice.

Human Rights Watch interviewed transgender people in Japan who described their struggles to fit into rigid school systems designed around strict gender binaries, to seek and obtain employment, to engage healthcare providers, and to raise families in accordance with their basic rights. The existence of a law in Japan allowing transgender people to change their legal gender signals the government’s willingness to engage with and support transgender people. But Japan’s government needs urgently to address and fundamentally revise the legal recognition process that remains anchored to a diagnostic framework that fails to meet international standards and has been roundly criticized and discredited worldwide. The requirement that a transgender person not have underage children if they wish to secure legal recognition of their gender identity violates transgender people’s right to private and family life. Mandatory surgical interventions amount to coercion. And legal gender recognition is an essential element of other fundamental rights—including the right to privacy, the right to freedom of expression, rights related to employment, education, health, and the ability to move freely.

Those interviewed for this report also described how the GID Special Cases Act itself is a barrier to self-respect and acceptance by society. “It is definitely a system that is wrecking people’s dignity as a human being,” one said. Another transgender man said he believed the law was designed to exclude trans people “in order not to admit the exceptions and so as to keep homogeneity.”

Japan’s national government and courts, including the Supreme Court in 2019, have in recent years repeatedly used pejorative myths and stereotypes in their analysis of transgender peoples’ rights. For example, the government and Supreme Court have expressed concerns related to trans men becoming pregnant, saying they “ may cause confusion in society ” as justification to uphold the law’s sterilization requirement.

Japan’s GID Special Cases Act was drafted in 2003 and came into force in 2004. For that era, it is not unique. Other legal regimes around the world from that period contain similar discriminatory and abusive provisions. Legislatures, domestic courts, and regional human rights courts and bodies have in recent years found that such requirements violate human rights law. Medical expert bodies have, similarly, urged governments to remove medical requirements from legal gender recognition procedures. Most recently, the World Health Organization (WHO) published its new International Classification of Diseases, which removes “gender identity disorders” from the “mental disorders” section much like the American Psychological Association did with “Gender Identity Disorder” in 2012. This progress, as well as international human rights standards, gives Japan a roadmap for reforming its own law.

Achieving the right to legal gender recognition is crucial for transgender people to leave behind a life of marginalization and enjoy a life of social equality and dignity. A simple shift toward allowing people autonomy to determine how their gender is expressed and recorded is gaining momentum. The law should not force people to carry an identity marker that does not reflect who they are. It should also not force transgender people to undergo unwanted medical procedures to be recognized or achieve any of the other associated rights.

The Japanese government should urgently reexamine its law and revise it according to its international human rights obligations and medical best practices to allow transgender people a transparent and quick administrative procedure to change their legal gender.

Recommendations

The government of Japan should work urgently across ministries to realize the recommendation put forward by the United Nations independent expert on sexual orientation and gender identity during his 2018 address to the UN General Assembly. The independent expert called for the elimination of abusive requirements as prerequisites for change of legal sex or gender, including:

• Forced, coerced or otherwise involuntary sterilization;
• Medical procedures related to transition, including surgeries and hormonal therapies;
• Undergoing medical diagnosis, psychological appraisals or other medical or psychosocial procedures or treatment;
• Requirements relating to economic status, health, marital, family or parental status; and
• Any third-party opinion.

To the Ministry of Justice

• Revise Law 111 of 2003, the GID Special Cases Act, to bring it into accordance with international human rights standards and medical best practices so that individuals’ gender marker in the family registry can be changed without having to satisfy any medical conditions. In particular, abolish the current conditions of sex reassignment surgery and irreversible infertility, as well as the requirement that applicants have no underage children.
• Ensure that legal recognition of transgender people’s gender identity applies to all aspects of people’s lives.
• Recognize that it may be in the best interest of some transgender children and young adults to change their legal gender before the age of majority (currently age 20 and beginning April 1, 2022, age 18), and ensure that transgender children are not excluded from the possibility of applying for legal recognition of their gender identity. Procedures for the consideration of transgender children’s applications should include a mechanism for the transgender child to give their opinion on the need to change their legal gender. The child’s freely expressed opinion needs to be given due weight. In line with Japan’s obligation under the Convention on the Rights of the Child, the relevant procedures should be designed in such a way as to acknowledge that as children grow and acquire capacities, they are entitled to an increasing level of responsibility for the regulation of matters affecting them.
• Ensure that the revised legal gender recognition law does not require trans people to be single in order to be legally recognized according to their self-declared gender identity.

To the Ministry of Foreign Affairs

• Invite the UN independent expert on sexual orientation and gender identity to visit Japan and meet with transgender people, service providers, and government interlocutors.

To the Ministry of Health, Labor and Welfare

• As a matter of urgency, issue a public statement indicating that the ministry will adopt the World Health Organization’s new category of “gender incongruence” and work with the Ministry of Justice to ensure that the GID Special Cases Act is revised in accordance with the WHO’s International Classification of Diseases, version 11. 
• With the Ministry of Justice, launch a process of revising the GID Special Cases Act to institute a legal gender recognition procedure based on an administrative act of self-declaration of gender identity.
• Ensure that transgender people have access to the medical and psychological assistance and support they require, and that such support and assistance is available to transgender individuals within a reasonable time.
• In consultation with transgender people, ensure that all medical interventions related to gender transition for transgender people are covered by health insurance schemes.
• Ensure that training is available to health service professionals, including psychologists, psychiatrists and general practitioners, as well as social workers, with regard to the specific needs and rights of transgender persons and the requirement to respect their dignity.

Methodology

Human Rights Watch conducted the research for this report between August and December 2015 and additional research between July and November 2018 with individuals from 14 prefectures in Japan. During the time period that elapsed between the phases of research, Human Rights Watch engaged UN Special Procedures regarding Japan’s legal gender recognition procedure, eliciting a response from the government. The law and its implementation has not changed since 2015, when the initial interviews were conducted, so the facts presented remain relevant to analysis of the law today.

Researchers conducted interviews with 48 transgender people, as well as interviews with lawyers, health providers, and academics.

Human Rights Watch researchers obtained informed consent from all interview participants, and provided explanations in Japanese about the objectives of the research and that interviewees’ accounts would be used in a report and related materials. Interviewees were informed that they could stop the interview at any time or decline to answer any questions they did not feel comfortable answering.

No compensation was paid to either survey respondents or those who participated in face-to-face interviews. Human Rights Watch reimbursed public transportation fares for interviewees who traveled to meet researchers in safe, discreet locations. The interviews were conducted in Japanese, or with Japanese-English interpretation. All interviews were conducted privately, with participants interviewed alone.

In this report, pseudonyms are used for all transgender interviewees except those who expressed a strong preference that their real names be used.

Human Rights Watch engaged the United Nations Office of the High Commissioner for Human Rights Special Procedures branch and two UN experts wrote to the Japanese government following our submission. That correspondence, and the government’s response, is analyzed in this report.

Human Rights Watch wrote to Japan’s Ministry of Justice in October 2018 to share our research findings and preliminary recommendations for this report.

I. Gender Identity and Legal Recognition

Everyone has a gender identity. Most people identify as either female or male, in line with what they were assigned on their birth certificates. Some may identify as a gender that is different from the one they were assigned at birth, and some may identify as both, or neither. If someone is labeled “female” at birth but identifies as male, he is a transgender man (or transman). If someone is labeled “male” at birth but identifies as female, she is a transgender woman (or transwoman). In Japan, the identity term “x-gender” is used by some people. It roughly translates to “non-binary” or “genderqueer” in English, signifying a neutral gender identity that is neither male, nor female. The term “cisgender” (i.e., non-transgender) is used for someone who identifies with the same gender, male or female, as the sex they were assigned at birth.

Historically, many medical systems, including those supported by the World Health Organization (WHO), have categorized being transgender as a mental health condition. However, this has been gradually changing, and the WHO has updated its standards—as discussed later in this report.

There is widespread consensus among medical and psychological experts, consistent with the views of transgender communities around the world, that experiencing gender as different from that which was assigned at birth is not a disorder or a disease—but rather a natural variation of human experience. [1]

Transgender people, in Japan and elsewhere, experience mental health problems like everyone else. Research suggests that transgender populations experience higher rates of some mental health problems.  Transgender people incur mental health problems from stigma, discrimination, bullying, and harassment that are not inherent in gender non-conformity. These conditions may require diagnoses in order to receive treatment, but they are separate from the experience of gender identity as such.

Transgender people, as per the usage in this report, are not experiencing a form of mental health condition; rather, they experience a deep sense of identification with a gender different from the sex assigned to them at birth. They may or may not take steps to physically alter their bodies, such as undergoing hormone replacement therapy (HRT) or sex reassignment surgery (SRS). They may or may not seek mental health care related to their transition or associated anxieties.

Gender identity is not the same thing as sexual orientation. Like cisgender people, transgender people may identify as heterosexual, homosexual, bisexual, or asexual. Transgender people, like anyone else, can form relationships with people of all other genders.

While there have been some changes in national laws recognizing and protecting transgender people in recent years, [2] many countries, like Japan, still enforce outdated, discriminatory, and coercive policies. As this report details, legal gender recognition procedures such as Japan’s, which mandate medical procedures with irreversible consequences and construe gender identity as a “disorder,” run afoul of international human rights law. Requirements of a minimum age, parental status, and relationship status for undergoing processes to change legal gender are discriminatory.

Changing such laws to respect transgender people’s right to self-declared legal recognition is a human rights imperative. Due to upcoming changes in global diagnostic systems, as set by the WHO, it is also important for Japan to update its legal gender recognition system to come in line with modern medicine. As detailed below, a simple shift toward allowing people autonomy to determine how their gender is expressed and recorded is gaining momentum globally. The law should not force people to carry an identity marker that does not reflect who they are. It should also not force transgender people to undergo unwanted medical procedures to be recognized or achieve associated rights. And it should not construe gender identity as a medical condition in need of diagnosis.

Japan’s Legal Gender Recognition System

Legal gender recognition in Japan is regulated by Law No. 111 of 2003, the “Act on Special Cases in Handling Gender Status for Persons with Gender Identity Disorder”—or the GID Special Cases Act. The law came into effect on July 16, 2004. [3]

The law requires a diagnosis of “Gender Identity Disorder” (GID) before any transgender person can apply to secure legal recognition of their appropriate gender. “GID” is defined in the law as:

A person, despite his/her biological sex being clear, who continually maintains a psychological identity with an alternative gender, who holds the intention to physically and socially conform to an alternative gender. [4]

The process requires the person to receive “concurrent diagnoses on such identification with the opposite gender from two or more physicians equipped with the necessary knowledge and experience to give accurate diagnoses on this matter, based on generally accepted medical knowledge.” [5]

The legal gender recognition decision is made by the Family Court. In addition to providing a certificate attesting to the fact that the individual has been diagnosed with GID, an applicant to the court must meet the following qualifications:

• Be 20-years-old or older;
• Be presently unmarried;
• Not presently have any underage children;
• Not have gonads or permanently lack functioning gonads; and
• Have a physical form that is “endowed with genitalia that closely resemble the physical form of an alternative gender.” [6]

The GID Special Cases Act is the first legal gender recognition procedure Japan has ever had, and its adoption represented a pivotal moment in the Japanese government’s treatment of  sexual and gender minorities. [7] However, the procedure established under the law violates the rights of Japanese people  who wish to be legally recognized as having a different gender from the one they were assigned at birth.

In 1980, when the American Psychological Association published the third edition of the Diagnostic and Statistical Manual (DSM-III), psychiatrists in Japan embarked on translating it into Japanese. Karen Nakamura, an anthropologist, explained that there were “debates over what the proper Japanese term might be for the word ‘disorder’ which was used consistently through the DSM. The chief candidates were byô, shô , and shôgai .” [8] Shogai can be translated as “disorder” or disability” – an ambiguity that transgender advocates embraced in 1982 when the DSM-III Japanese version was published. According to Nakamura:

Part of the difficulty is that Japanese medical terminology does not always differentiate between impairment, injury, disorder, disturbance, pathology, and disability when translating these terms as shôgai. In any case, the obfuscation was a happy one for Japanese transsexuals as the DSM-III category of “gender-identity-disorder” became 性同一性障害, seidoitsusei-shogai . [9]

As the concept of GID entered Japanese medical practice and society, it provided an explanatory framework for transgender people to discuss and disclose their identity and access services. The GID diagnosis also became the basis for related legal developments, which culminated in the GID Special Cases Act. And while there was an emancipatory element in the law’s recognition of the experience of a gender identity that does not correspond with the sex one is assigned at birth, the law itself is inconsistent with international human rights law and medical best practices.

The GID Special Cases Act, while serving to acknowledge the existence of a population and allowing for their legal recognition, is a formidable barrier for transgender people in Japan. The requirement of a GID diagnosis is unscientific; the requirement of single marital status and not having minor children is discriminatory; and the requirement of surgeries that sterilize amounts to coerced sterilization. As legal scholar Hiroyuki Taniguchi noted in a 2013 article, “the Act reinforces gender binary not only in social contexts, but also at the physical level by requiring surgical intervention when it is not medically necessary.” [10]

Some transgender people may indeed want to undertake all or some of these actions as part of their transition. However, requiring all transgender people to do so is contrary to international law and a violation of transgender people’s basic rights. The law’s requirements are also regressive with regard to international medical and diagnostic standards. As analyzed later in this report, now that neither of the major international medical diagnostic systems acknowledge “GID” or “transsexualism” as a mental disorder, Japan legally mandating that transgender people obtain such a diagnosis amounts to coercion.

Such a shift may not be insignificant for individuals. As one transgender woman in Tokyo told Human Rights Watch:

I don’t think gender incongruency is a mental disease. However, many have their identity accepted by admitting they have some disorder. If gender incongruence no longer is a disorder, I think there are some who are afraid of losing the way to justify who they are. [11]

Dr. Jun Koh, a psychiatrist in Osaka who works with transgender patients, said:

In Japan, there is a background that social recognition advanced along with the spread of the medical model, in which treatments are carried out based on the diagnosis of a hospital or a clinic. If the medical model is denied, people think it’s about taste and preference – so then there is a chance of not being able to ensure the understanding of transgender being a diversity in gender seen everywhere in the world. [12]

However, while the framework may indeed provide a functional and preferred method for some transgender people to seek care and legal status, the requirements in the current law should not be applied to everyone.

In a 2016 report, the United Nations special rapporteur on torture said that the refusal of transgender people’s legal recognition in their appropriate gender “leads to grave consequences for the enjoyment of their human rights, including obstacles to accessing education, employment, health care and other essential services.” [13] The special rapporteur noted that,

In States that permit the modification of gender markers on identity documents abusive requirements can be imposed, such as forced or otherwise involuntary gender reassignment surgery, sterilization or other coercive medical procedures. [14]

The legal requirements for transgender people in Japan to obtain a GID diagnosis often involves unnecessary, arbitrary, and burdensome tests. The mandatory psychiatric evaluation and the law’s requirements that applicants be unmarried, sterile and lacking any minor children are inherently discriminatory. These conditions—and in particular the maltreatment many transgender people must accept in order to meet them— also amount to cruel and inhuman treatment and to a violation of transgender people’s right to health. The law forces all transgender people who want to secure legal recognition of their appropriate gender to secure diagnosis of a psychological disorder, to refrain from having children at any point during the two decades prior to securing recognition and to be unmarried. It forces many would-be applicants—including those who would not otherwise choose to take these steps— to undergo physically transformative surgical interventions, undergo sterilization, and contemplate the breakup of existing marriages.

Japan’s legal requirements are particularly harmful for transgender children. It sets a mandatory minimum age of 20 for achieving legal gender recognition. Legal recognition can only be given if the individual holds “the intention to physically and socially conform to an alternative gender,” [15] which sets children up to understand surgeries as inevitable and puts intense pressure on them to conform to gender stereotypes about what “male” and “female” bodies and behavior should look like.

These requirements cannot be squared with the principle that the best interests of children be a primary consideration in all administrative and legal decisions that impact them. [16] The GID Special Cases Act negatively impacts children’s rights to physical integrity, privacy, and autonomy. These problems are also reflected in how the government has interpreted the GID Special Cases Act with regard to gender non-conforming children in statements issued by the Ministry of Education [17] , and the guidance issued to psychiatrists on GID patients. [18]

Japan’s current legal gender recognition procedure violates the basic rights of transgender people. It treats the fact of being transgender as a disorder that does not exist—one that transgender people are required to certify that they suffer from as a prerequisite to securing legal recognition. It forecloses legal recognition to transgender people who are married, who have underage children or who have the capacity to reproduce. Not only is this discriminatory, but it forces many transgender people who want to secure legal recognition of their gender identity to contemplate invasive surgical procedures they may not want and, in some cases, requires the breakup of their families.

As one transgender man in Kanagawa Prefecture told Human Rights Watch: “It is definitely a system that is wrecking people’s dignity as a human being.” [19]

Mandatory Psychiatric Evaluation

The GID Special Cases Act requires transgender people in Japan who seek legal recognition of their gender identity to obtain a diagnosis of GID as a prerequisite. Some people in Japan consider their gender identity to be a mental health condition and seek services accordingly. [20] However, such a framework can also stigmatize transgender people. Many of the people whom Human Rights Watch interviewed, including psychiatrists who work with transgender people, discussed this stigma. Our research also found that the process associated with obtaining a medical certificate for GID was itself burdensome and abusive in some cases.

Transgender people Human Rights Watch interviewed reported a variety of experiences in obtaining the GID diagnosis. For example, one was able to obtain the diagnosis certificate on their first visit to a psychiatrist, [21] while in other instances clinic staff and psychiatrists forced applicants to undergo a lengthy and humiliating procedure.

The 4th edition of the Diagnosis and Treatment Guidelines for “Gender Identity Disorder,” published by the Japan Society for Psychiatry and Neurology and last revised in January 2018, recommend three tests for a GID diagnosis:

• A gender identity test, which is based on the testimony of the individual;
• A biological gender test, which can contain an examination of chromosomes, an examination of hormonal action, an inspection of internal and external genitals, and “other examinations that doctors find necessary”; and
• An exclusion of other diagnoses test to “confirm that the denial of gender identity/request for the surgery is not coming from schizophrenia nor other cultural, social, or occupational reasons.” [22]

The only test that contains a reference to the time it can take is test 1, which “may last until enough information will be collected.” [23] Our research found that for some applicants, the process can take an excessive amount of time.

Kiyoshi M., a 24-year-old transgender man in Tokyo, told Human Rights Watch of his year-long effort to obtain the GID diagnosis four years earlier, when he was 20-years-old. On his first visit to a gender clinic in Tokyo, the psychiatrist told him to write his personal history, then return a few weeks later with a series of photos of himself from when he was a toddler through to the present day. “At every session I had to fill out a 100-question questionnaire,” Kiyoshi M. said. According to him, the questions on the survey queried stereotypical understandings of gender-specific behaviors and appearances: 

“All of them were open ended questions about gender, such as ‘when I was little, people told me I was____’ or ‘if my parent died, I would react by ____.’”

Kiyoshi M. continued to visit that hospital for six months. “On my first time at the hospital, I told the doctor I wanted the diagnosis as soon as possible,” he said. “But the doctor said to come every two weeks, then even after six months they needed more time and said they couldn’t give [the diagnosis] to me so they told me to keep coming back.” After six months, he gave up and started going to a second hospital in Tokyo, where the psychiatrist at the gender clinic tested him through verbal therapy sessions and interviews for an additional six months before giving him the GID diagnosis. “Clinic staff constantly asked me at every step of the process, ‘Are you sure?’” he said. [24]

Yasuhiro D., a 30-year-old transgender man, traveled to a gender clinic 520 kilometers away from his home for six appointments over the course of two months, where he was subjected to psychiatric tests. “They showed me drawings and I had to talk to the therapist about them many times, it was extremely time consuming and repetitive,” Yasuhiro said. “The drawings were of several people and they asked me which ones looked like my family members.” Once he obtained the GID diagnosis certificate, he went to a clinic closer to Kyoto to request hormone therapy, but they told him he would have to redo all of the tests. “They said it was for a second opinion,” he said. “Then after that second opinion was affirmative, they sent me to an external psychiatrist for a third opinion.” [25]

Hanae T., a 29-year-old transgender woman living in the Ishikawa Prefecture, told Human Rights Watch that it took her nearly a year to get the diagnosis. “I saw the psychiatrist almost the whole year. I kept seeing the psychiatrist until right before the beginning of 2011. It was in December 2010 that I got the diagnosis of GID,” she said. [26]

Coerced Sterilization and Compulsory Surgery

The surgery requirement itself feels wrong. It feels a lot like a surgery to maintain order. Why do we have to put a scalpel through our healthy bodies just for sake of the country’s order? The requirements being incorporated like that into the system—that itself feels as though I am severely insulted or my human rights being neglected. It is humiliating. —Transgender man in Kanagawa Prefecture, September 2018

I don’t want to [have surgery], to be honest. However, I have to just because it is a requirement for marrying in Japan. I feel pressured to be operated on—so terrible. —Transgender man in Tokyo, August 2018

Legal requirements that transgender people undergo surgeries to alter the appearance and function of their bodies amount to coercion. That someone is forced to undergo surgical procedures to obtain legal recognition is itself coercive. And that someone is only afforded access to other rights, such as marriage, after having undergone surgery, is also coercive. Transgender people told Human Rights Watch they found Japan’s surgical requirement to be a substantial burden. Even those who wanted some of the procedures felt rushed onto the operating table by the law requiring them.

“Of course I want to change the gender on my official family register, and have relationships with my significant other,” explained a transgender woman in Tokyo. “But the walls that I have to overcome are just too big. Why do I have to go through so much struggles and challenges just by living?” [27] She said that once she considered the risks associated with the surgeries, she decided not to have them. “Once you start, there’s no going back. The surgery itself also has too many complications, and I would have to keep maintenance for life.”

For some, the surgery was the only gateway toward other rights—for example, the right to marry and enjoy the benefits that come with marriage. Takayuki G., a 24-year-old transgender man in Tokyo, explained: “When we get married, we can receive spousal [tax] deductions.” [28] He said that while he wanted to change his gender in the family register, he had not yet undergone the requisite surgeries because he did not want to. “I feel I am forced to be operated on to get a tax benefit. There are many advantages for marrieds, for example, tax deductions.” [29]

For many, the physical risks and impacts associated with the surgeries were a major barrier. “Another big thing is that I will become infertile if I get the procedure done,” said a 25-year-old transgender man in Tokyo who had not undergone any surgeries. “I am forced to choose between having kids and being lawfully recognized as the gender I associate myself with,” he said. “I am always wondering why this surgery must be part of the requirements. It’s not even like we live our everyday life exposing our genitals to the public.” [30]

A transgender man in Kanagawa Prefecture said he felt that his transition went smoothly because he had his family’s support and he knew what he wanted. However, he told Human Rights Watch, had it not been for the law requiring surgery in order for him to change his legal gender, he would have not undergone the operations. “It was a surgery that I underwent, questioning why I had to put a scalpel to my healthy body,” he said. “I was not able to accept my gender being female on the family register and with that being my top concern, I was inevitably forced to undergo surgery in order to change my gender marker.” [31]

He explained:

If there had not been the requirement of having to undergo surgery, I would have given more thought to it, collecting data and comparing. I would have made a decision when everything had really made sense to me. However, because it was a necessary requirement and because it was an urgent matter due to the fact that I was working, I wanted to change it as soon as possible. [32]

A transgender man in Fukuoka said:

I myself had decided to remove [my uterus] because I don’t want to get the female menstrual cycle. However, my friends around me, their parents are really against them having the surgery. Doing the surgery is a big matter. You could be risking your life. I want there to be an environment where it is possible for people to talk about wanting to change their gender on the family register, without having to do it. From our parents’ perspectives, it must be difficult to understand why we should have a scalpel put to our healthy bodies. [33]

Human Rights Watch interviewed transgender people in Japan who told us that they would not have chosen sterilization if they had had the option to have their gender legally recognized without doing so.

For example, Yasuhiro D., a 30-year-old transgender man in Osaka, said that the recent birth of his brother’s second daughter made him reflect on how his reproductive rights were compromised in his quest to be legally recognized as a man. “Since I had my ovaries when my first niece was born, I even thought about stopping the hormones to make my body able to have children,” Yasuhiro said. He explained:

I thought about this issue of having a child even as I sat waiting in the hospital for the SRS [sex reassignment surgery]. I didn’t have any doubt that I wanted to live as a man, but I also wanted to preserve my ability to have a baby. I had to choose between being legally recognized for who I am and keeping my body the way I wanted it.

He added, “I think a lot of transgender people want to have the surgery; however, having it as a prerequisite for LGR [legal gender recognition] means our reproductive rights are stripped away.” [34]

As Yasuhiro’s account illustrates, compulsory surgery requires transgender individuals who seek legal gender recognition to make an unacceptable choice between exercising their right to recognition as a person before the law and their right to bodily autonomy.

A transgender man who had undergone surgery that sterilized him said:

Back then, I was just really caught up with changing [the gender on] the family register that I could not think about that. But thinking about it now, if it was possible to leave the possibility of having children open, I would have. I really did not have the time to think everything through. [35]

Another transgender woman who has not undergone any surgeries said: “It’s my dream to have my own children. Of course, there are ways to get an adoption, but there’s still the significance of having your own genetic babies.” She explained that she had chosen to carry her documents marked “male,” which had resulted in hardship and discrimination, because she did not want to undergo the legally required surgeries to be recognized as female. “If I had to change my gender, then that would mean giving up all means of reproduction,” she said. “I’m a woman, but I’m not allowed to call myself the mother of my own children. To get the surgery or have children. This is a decision that none of us should be forced to take. It is a despair.” [36]

Others who were contemplating undergoing the law’s required procedures expressed a desire to change their gender, but trepidation about the procedures. For example, Tamaki I., a 27-year-old transgender woman in Osaka, said:

The hurdle is really high. I read that in America you don’t need to have surgery to change your gender; you can just change your gender on the family register. [37] If that becomes true in Japan, I would want to change my gender right now. I can’t understand why the government is asking for such high conditions. I do want to change my legal gender, but surgery has such a high risk, so I don’t know yet. [38]

Noriko R., 22, said: “I want to get my identification card changed. To change it on the family register, we have to get surgery. It’s really a lot of pressure for me.” She worried about the financial burdens: “It costs a lot, and I can’t rely on my parents for help. My transgender friends are waiting for surgery, but I can’t do that, so I feel like I’m becoming isolated, falling behind them.” Noriko said that everyone in her local transgender support group “has some level of pressure about the surgery. Everyone thinks we’ll have to undergo surgery in the future. That’s very tough for us.” [39]

Kiyoshi M., who obtained the GID diagnosis after he spent a year visiting two clinics, and was on hormones when Human Rights Watch interviewed him, but had not undergone surgery, said, “Ideally I would want to just change my legal gender right now. All of these procedures are putting a lot of strain on my body that I don’t want.” [40]

Others highlighted that the surgery requirement does not reflect the lived reality of trans people in Japan. A transgender woman in Tokyo said: “It’s not like getting the surgery will ensure that your life will be better. It’s also not like you show your crotch while you walk around everywhere, so it’s not that terrible.” [41]

Age Restrictions

The GID Special Cases Act bars all transgender people who are younger than 20, Japan’s age of majority (which will be 18 in April 2022), from securing legal recognition of their gender identity. People under 20 can obtain a diagnosis or in some cases a “preliminary diagnosis” of GID. Interviewees told Human Rights Watch they used their GID diagnosis certificates to successfully advocate for access to education according to their gender identity—including through restroom access and school uniforms according to their gender identity. 

People who have reached Japan’s age of majority can independently pursue legally required surgical procedures without parental consent. After obtaining a GID diagnosis, a process that varies in length, the subsequent requisite medical procedures can take years and carries considerable costs. As a result, legal gender recognition is sometimes not possible until people have reached their mid-20s even though they have expressed their gender identity and desire to legally transition more than a decade earlier.

But without eliminating the mandatory GID diagnosis and medical interventions, simply reducing the age at which applicants can pursue legal gender recognition will be inadequate. Gender non-conforming children lack access to legal recognition and suffer abuses as a result. In addition, the rigid medical requirements for legal recognition as an adult creates significant anxiety for young people, evident in the accounts of individuals whom Human Rights Watch interviewed.

Japan’s legal age limit is discriminatory and does not allow for the best interests of the child to be considered. This can have a harmful impact on children who are exploring and questioning their gender. A strict age limit can also violate the right to education for those transgender children who desire to attend school according to their gender identity. As discussed below, in its 2015 statement on gender recognition, the World Professional Association for Transgender Health (WPATH) stated that “appropriate legal gender recognition should be available to transgender youth.” [42]

In the context of Japan’s education system, the state’s failure to accord legal recognition of transgender children’s gender identity contributes to their discrimination and degrading treatment. Both the age restriction and the rigid medical criteria are harmful to young people who instead need information, support, and safe spaces to explore and express gender—all elements of inclusive and supportive schools. Furthermore, the current requirement of mandatory medical procedures can cause gender non-conforming children to feel intense pressure to pursue otherwise unwanted medical procedures at a young age.

Japan’s schools feature deeply engrained gender separation based on stereotypes. Nearly all junior high and high school students are required to wear gender-specific uniforms, and school activities are often gender-segregated. [43] For children exploring their gender identity or those who identify as transgender, such an environment can be harsh. Itsuki Dohi, a transgender high school teacher, said:

The Japanese school system is really strict with the gender system. It imprints on students where they belong and don’t belong.  In later years, when gender is firmly tracked, transgender kids really start suffering. They either have to conceal and lie or act like themselves and invite bullying and exclusion. [44]

Additionally, the GID Special Cases Act mandate of psychiatric and surgical intervention for transgender people who wish to secure legal recognition of their gender identity can cause anxiety for young people. Dozens of interviewees said that their negative experiences in school when they were forced to dress and present as their birth-assigned sex instead of their gender identity informed their anxieties about the future, including university life and employment. Transgender children as young as 14 looked to the future with trepidation. Some children explained that while they do not necessarily want to undergo the medical procedures required by the GID Special Cases Act, it is currently their only route to social recognition, and—they hope—an end to years of abuse, discrimination and exclusion.

In 2015, the Ministry of Education sent a directive to all school boards titled “Regarding the Careful Response to Students with Gender Identity Disorder.” [45] The Education Ministry directive sends a serious message from the ministry about schools’ responsibility to care for transgender children. However, the directive focusses on diagnoses and medical institutions as the primary source of information about gender and sexuality. For example, the directive states: “The diagnosis and advice from medical institutions is a very crucial opportunity for the school to get a professional knowledge.” This reflects the government’s continued reliance on the harmful, pathological model of understanding transgender people’s gender identity as enshrined in the GID Special Cases Act.

The 2015 Education Ministry directive is official advice, and so its examples of support for schools to follow are nonbinding recommendations. Human Rights Watch interviews with transgender children in Japan revealed that school officials issue varied responses to transgender students’ requests to use facilities according to their gender identity. Enshrining a right to legal recognition of gender based on their self-declared identity alone would substantially improve the situation for transgender children.

Japan should recognize that it may be in the best interest of many transgender children to change their legal gender before they reach age 20. The law should set no absolute minimum age for legal recognition of a transgender person’s gender identity. Instead, the individual circumstances of each child should be assessed by appropriate authorities to determine whether it is in that child’s best interest to change their legal gender. The government should also amend its school-based policies and directives for transgender children to clarify that no child should be required to provide a diagnosis of GID in order to wear uniforms, or access school facilities or activities according to their gender identity.

Relationship Status and Parental Status Discrimination

Japan’s requirement that all applicants for legal gender recognition are single implies mandatory divorce for married transgender people who wish to be recognized. This is because Japan does not recognize same-sex marriages, which a gender transition would create. Such a requirement is discriminatory, and has been condemned by major human rights bodies, including the United Nations Human Rights Council in 2011 and 2014 reports.

The requirement that a transgender person not have underage children (under 20) if they wish to secure legal recognition of their gender identity violates transgender people’s right to private and family life and the right to found a family, and discriminates on those grounds.

The revision of the GID Special Cases Act in 2008 to clarify that transgender people seeking legal gender recognition must not have any children under 20 (previously the law mandated no children whatsoever), demonstrated that the government is willing to consider changes to the law, but it was an insufficient step. [46]

II. Impact of Japan’s Legal Gender Recognition System

The GID Special Cases Act is the first legal gender recognition procedure Japan has ever had, and its adoption represented a pivotal moment in Japan’s public debate on sexual and gender minority issues. [47] And while some activist groups and individuals support the mandatory procedures featured in the law, these have caused significant problems for others.

The diagnostic label of “GID” helped, in some cases, to explain gender identity to families. For example, one transgender man told Human Rights Watch that he pursued a medical certificate for a “GID” diagnosis in an effort to legitimize his transition in the eyes of his parents:

I came out to my parents during New Year’s, but they greatly opposed me. Even if my parents are reluctant to give me approval, I felt as though the certificate to indicate my gender would become beneficial when trying to persuade them. I am still going to the clinic, and the process has prolonged this long, unable to get the certificate. I am very worried that I won’t receive it [soon]. [48]

However, for those who do not undergo the requisite diagnosis and procedures—or those who attempt to, but face barriers such as long delays, failures to obtain a diagnosis—operating in daily life with documents that do not match their identity and appearance causes significant hardship.

“I always try to hide this part of the paperwork whenever I hand it in,” said Aki T., a transgender woman in Tokyo. “Because there is a difference in my body and heart, many people around me get thrown. My heart sinks every time I have to submit any legal documentation, anywhere I go. [49]

Like in Aki’s experience, legal gender recognition is an essential element of other fundamental rights—including the right to privacy, the right to freedom of expression, rights related to employment, education, health, and the ability to move freely.

Access to Education

In 2016, Human Rights Watch published a report that documented bullying and exclusion of lesbian, gay, bisexual, and transgender students in Japanese schools. [50] The report noted significant barriers to accessing education experienced by transgender students, as well as several directives the Ministry of Education had issued in that regard in recent years. While the ministry’s attention to the issues facing transgender students is undoubtedly helping young people thrive, the policies and directives remain grounded in the current law—that is, they refer to trans students as “students with GID.”

In addition to this policy barrier, Japanese school culture, while undergoing important shifts in recent years, [51] remains rigid when it comes to gender norms. Most Japanese schools insist on conformity to strict gender norms as a matter of school policy with regard to uniforms, restroom access, information imparted in classrooms, and other mechanisms of gender norm enforcement.

Student activities are typically gender-segregated, though the degree to which schools enforce gender roles appears to vary. The anxieties this standard system causes transgender and gender-nonconforming students are intense. As one junior high student said, “Gender segregation is everywhere in school—roll call, uniforms, seating arrangement, and hair length are all dictated by gender.” [52] Peter Cave, an anthropologist who studies Japanese education, has documented how even in primary schools, gender differences in the treatment and social conditioning of students are apparent. [53]

Itsuki Dohi, a transgender high school teacher told Human Rights Watch:

The Japanese school system is really strict with the gender system. It imprints on students where they belong and don’t belong. In later years when gender is firmly tracked, transgender kids really start suffering. They either have to conceal and lie or act like themselves and invite bullying and exclusion. [54]

Kaoru M., a 19-year-old transgender woman in Setagaya, said that her school’s “firmly tracked” gender segregation left her isolated: “I expected in high school that there would be more mixing of boys and girls but there was complete social separation.” Kaoru was not allowed to wear a female uniform in high school but wore long hair and had what she described as a “feminized appearance.” She was able to join all-girls extracurricular activities but faced aggressive and scrutinizing questions and teasing from classmates. “I was isolated from both boys and girls,” she said. “There was nowhere to go for me.” [55]

A transgender woman in Tokyo said that the negative experiences she had in school impacted his life:

The disgrace I felt during school had discouraged me so much to the point where I wasn’t able to attend school any longer. In terms of education, I always believed that everything that adults say are always correct. But now, I know that whatever adults [like that] say is almost always incorrect. I had lived my life without hope. [56]

Some students told Human Rights Watch that their schools, to their credit, sought and followed guidance on ensuring transgender students’ rights. A lawyer in Tokyo said that several schools in the city had consulted with him on issues such as uniforms and restroom access when they became aware that they had transgender students, and as a result agreed that students would be able to wear uniforms and have access to lavatories and school activities according to their gender identity. [57] Such approaches by schools appear to be the exception rather than the norm.

School Uniforms

Most of Japan’s junior high and high schools require students to wear uniforms. The attire is gender-specific and the two options, male or female, are dispensed to students according to the sex they were assigned at birth. “The dress codes are usually very strict,” said Mameta Endo, a transgender man who has worked on issues facing LGBT youth in Japan. “The idea behind the uniform is that if you can’t wear it properly, you’re a bad student. It makes you an outcast.” [58]

In some instances that Human Rights Watch documented, students were able to request alterations to their uniforms; in a few cases, students were able to request a full switch of the uniform according to their gender identity. “Schools are really starting to be flexible,” a Tokyo-based lawyer said. [59]

Human Rights Watch, however, identified many agreements to alter uniform requirements that were not the result of consistently applied policies designed to respect students’ right to free expression of their gender identity, but rather due to the compassion of school officials, assiduous advocacy by parents, or in some cases the student’s presentation of their diagnosis with GID. For some transgender students and other children exploring gender identity, the strict uniform policy was an acute source of anxiety, leading to extended school absences and even dropouts. Said the Osaka-based psychiatrist Jun Koh:

Since middle schools and high schools typically require uniforms, this results in the coercion of transgender students, who have questions about their birth-assigned gender, to wear school uniforms that differ from their gender identity. Wearing uniforms result in the complete separation of genders, provoking feelings of gender denial. This leads kids thinking that their feelings are never respected, and it becomes difficult for them to have good self-esteem.  It is around this time [when transgender students start entering middle or high schools] that the number of transgender students seeking counselling increases. [60]

For example, Takeshi O. said that his anxieties about the female gender of his school uniform increased over time. “When I first started junior high school I didn’t question the uniform initially,” he said. “I progressively started to question it and by the third year I dreaded every school day because it meant I would have to put the skirt on.” [61]

All of these challenges facing transgender and gender non-conforming youth in Japan’s schools underscore the need to revise the GID Special Cases Act to accommodate and support transgender people regardless of their age.

University Education

In July 2018, news broke that some women’s universities in Japan were revising their admissions policies to admit transgender women. According to an article in the Nikkei Asian Review ,

A panel of experts under the Science Council of Japan's law committee pointed out last year that denying transgender students’ admission to girls' schools and women's universities constitutes "an encroachment on their rights to learn." The panel includes representatives from women's colleges. [62]

Human Rights Watch reached out to Ochanomizu University in Tokyo regarding their stated intent to admit trans women. We inquired about their planned criteria for determining gender identity among applicants. The public relations manager of the university, an all-women’s institution in Tokyo, replied explaining:

Regarding the admission of trans women, we have adopted the method of receiving requests prior to the entrance examination application period, and confirming the eligibility of requirement. Then, after explaining the measures that will be taken upon entering the student life and receiving consent, they will be eligible to take the entrance exam. For those who have made the request, they will be asked to submit their self-declaration of their own gender disparity and gender identity, and if they possess one, a document confirming their gender identity (certificate from a medical doctor, documents written by high school teachers or parents, etc.). Then, the eligibility of application will be considered. [63]

That the medical certificate appears to not be a requirement for admissions to Ochanomizu University is a promising step towards a rights-based self-declaration procedure for trans people to secure official recognition.

Implications for Health Care, Employment, and Travel

Absent identity documents that match their gender presentation, transgender people who seek health care may be subjected to invasive questioning and humiliation. For example, a 30-year-old trans man in Osaka told Human Rights Watch that before he had changed his legal gender, he avoided getting medical care:

Before, I hated going to the hospital because my insurance card was marked as female. So my health was at risk because of that fear. Once I had such bad pain in my stomach and my partner forced me to go to the hospital. I hesitated for several days, but she forced me to go. Otherwise I would have died. [64]

Transgender people in Japan who do not—or cannot—undergo the requisite procedures to change their legal gender risk harmful exposure when seeking employment or in the workplace. The legal regime can even impact how young people think about their future. For example, an 18-year-old trans man university student in Okinawa said:

I’m happy like this [without surgery]. But I think I might have to do more operations and fully transition before applying for a job because that’s what people expect of me – the full GID procedure. That’s the pressure on me right now. I’m happy, but the future feels horrible already. [65]

Others told Human Rights Watch that revealing their gender identity led to pejorative and discriminatory treatment. “Job hunting is a really big deal. I went to my college career center and came out to them,” a 22-year-old x-gender person in Tokyo said. “They told me ‘You’re the minority, you can’t expect all of these things to work out for you.’ Because of that I decided to take time off from college and see a psychiatrist.” [66]

Simply moving from one place to another can be a dangerous and humiliating experience for people whose documents do not match their expression. The stakes are high, particularly for international travel, and range from fraud accusations and exposure to intense scrutiny and humiliation. United Nations human rights experts have condemned such targeting of transgender people in security processes. [67]

“Being legally recognized is good because I have my documents and I no longer have to explain to anybody about myself,” a trans man in Osaka said. “I had always dreamed of living smoothly – like nothing was wrong and that’s what I have now. For work, travel, all administrative interactions.” [68]

III. Japan’s Legal System’s Treatment of Transgender People

In a 2004 legal volume written to help interpret the GID Special Cases Act, Nouno Chieko, the leader of the Members of Parliament group when the law was adopted in 2003 and who served as Japan’s justice minister from 2004-2005, wrote:

Having “to not have gonads or to permanently lack functioning gonads” as a requirement is due to the fact that it was decided that after the legal sex reassignment was admitted, it was not appropriate to remain having reproductive organs of the original sex, or for the gonads to be releasing hormones of the original sex. Thereby, if after legal sex reassignment is carried out, there happens to be a case in which an offspring is born from the remaining reproductive organs, it could cause various [kinds of] confusion and problems. In addition, the possibility of unfavorable effects is not deniable if hormones are released from the gonads of the original sex. [69]

This analysis is based on hypothetical fears of negative social outcomes if transgender people were to retain their reproductive capacity. It does not have a basis in science and runs contrary to human rights standards and medical best practice guidelines. Unfortunately, while this explanation of the law was written over a decade ago, the same ill-informed and discriminatory ideas about trans people remain at the root of the Japanese government’s analysis today.

In 2016, Human Rights Watch wrote to the United Nations special rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health and the UN special rapporteur on torture and other cruel, inhuman or degrading treatment or punishment regarding Japan’s legal gender recognition law. [70] The Special Rapporteurs exchanged letters with Japan’s Ministry of Health in Japan. [71]

The Special Rapporteurs critiqued several aspects of Japan’s legal gender recognition law as being in violation of international human rights law. They found that the sterilization requirement in Japan’s law especially abusive and discriminatory:

[S]ubjecting transgender persons to forced or otherwise involuntary gender reassignment surgery, sterilization or other coercive medical procedures is abusive, is rooted in discrimination, and violates the rights to physical integrity and self-determination of individuals and amount to ill-treatment or torture, and recommends that forced and coerced sterilization be outlawed in all circumstances, that special measures be adopted to protect individuals belonging to marginalized groups from such forced or coercive sterilization, that other abusive requirements for legal recognition of gender identity be abolished, and that transparent and accessible legal gender recognition procedures be adopted. [72]

While the government responded that the GID Special Cases Act is “exercised appropriately, taking into consideration international humanitarian [sic] laws and universal standards,” [73] the government’s defense of the GID Special Cases Act indicates several fundamental misunderstandings of gender identity as it is understood in international medical and legal standards.

Regarding the requirement of a diagnosis of “GID,” the government said: “The requirement also aims to prevent claims by persons claiming gender identity disorder for a change in gender status without having obtained a diagnosis.”

The government emphasized that,

In order to ensure that recognition of Gender Identity Disorder be made objectively and certainly, concurrent diagnoses from two or more physicians are required, and those diagnoses should be made “based on generally accepted medical knowledge.”

Generally accepted medical knowledge with regard to gender identity has changed substantially since the GID Special Cases Act was passed. As analyzed in the following section, it is not generally accepted medical knowledge that a diagnosis should be required for legal recognition; in fact, global transgender health expert bodies have called for the complete separation of medical and legal processes. [74] Furthermore, the diagnosis of “transsexualism” or “Gender Identity Disorder” is no longer recognized in either of the two major international diagnostic manuals, the Diagnostic and Statistical Manual (DSM) and the International Classifications of Diseases (ICD).

Regarding the criticism of the sterilization requirement as a human rights violation, the government responded:

When a person, after having had a change in legal gender status recognized, procreates using the reproductive function of the former gender, it may give rise to confusion and various problems.

This argument suggests that transgender men who wanted to provide eggs or get pregnant, or transgender women who wanted to provide sperm to conceive a child, should have their rights to do so curtailed in order to prevent “confusion.” While it is reasonable to expect that some people may be confused by a pregnant man, for example, such hypothetical social fears do not justify the coerced sterilization of a person.

Regarding the requirement that the applicant have no minor children, the government wrote:

The requirement that the person “currently has no child who is a minor” is stipulated, taking into consideration the arguments that this system could give rise to confusion within the family, including between parent and child, or influence the child’s welfare.

Chieko’s legal analysis mirrored this claim, arguing that a “child may get psychological confusion or anxiety, or it may affect the parent-child relationship.” [75] This assertion is based on pejorative and unfounded assumptions that transgender people cannot be good parents. In fact, research has shown that transgender people can be—and are—good parents, and their relationships with their children are good. [76]

Unfortunately, courts in Japan have followed similarly flawed logic in their judgments regarding transgender people’s rights.

Court Cases

Human Rights Watch is only aware of one case in which an individual directly challenged the sterilization requirement of Japan’s legal gender recognition law in court (a case in 2005 challenged the no-child requirement only). In February 2018, a High Court in Okayama ruled on the case of Takakito Usui, a 43-year-old transgender man who had brought a case to the court challenging the GID Special Cases Act on the grounds that the requirement of surgery violated Japan’s constitution.

In the case, the Hiroshima High Court ruled that the GID Special Cases Act existed to avoid confusion, contending: 

If there is an incidence where a child is born based on the reproductive capabilities of the previous gender after the parent undergoes a gender change under the procedure of the special case act, there are issues where the current legal system is unable to deal with, which may cause confusion in the legal order of personal status. [77]

The court further ruled that “it is not appropriate for an individual to maintain the reproductive capabilities of their previous gender.” [78] The court’s decision in this case runs counter to international human rights law, and serves to uphold a harmful, discriminatory, and outdated paradigm.

In January 2019, the Supreme Court issued its judgment in Usui’s case, upholding the GID Special Cases act as constitutional at this time, stating that there is a “need to avoid abrupt changes in a society where the distinction of men and women have long been based on biological gender.”

However, the four-judge bench noted that, “It cannot be denied that [this law] impinges on freedom from invasion of bodily [integrity].”

Two of the justices in a concurring opinion wrote of the urgency of Usui’s case, and the need to reform Japan’s law: “The suffering that [transgender people] face in terms of gender is also of concern to society that is supposed to embrace diversity in gender identity.” They noted that “because gender is treated as one of the attributes of an individual in social life and in personal relationships, it can be said that gender is inseparable from the existence as a person of an individual.” They concluded that for transgender people, being “able to receive rulings of changes in recognition of gender status…is an important, perhaps even urgent, legal benefit.” [79]

Other Japanese court decisions in recent years demonstrate the complexities of interpreting a law that recognizes a population of people—the transgender population—as people who have rights, but also construes them as suffering from an illness, “GID,” that does not in fact exist. Nevertheless, within this framework, transgender individuals have challenged instances of discrimination in courts and in many instances, won. The list of cases below is illustrative, not comprehensive, and some of the cases are still pending, so publicly available information about them is limited.

IV. International Law, Best Practices for Gender Recognition

International human rights standards are increasingly understood to require the separation of legal and medical processes of gender reassignment for transgender people. During the 2017-2018 cycle of Japan’s Universal Periodic Review at the United Nations Human Rights Council in Geneva, New Zealand issued a recommendation that Japan “[t]ake steps to address discrimination based on sexual orientation and gender identity, including revising the Gender Identity Disorder Law.” [87] The government of Japan responded “supporting” the recommendation, indicating its commitment to implement the recommendation before its next review, which will take place in 2022. [88]

In his report to the UN General Assembly in 2018, the independent expert on sexual orientation and gender identity, Victor Madrigal-Borloz, stated:

[L]ack of legal recognition negates the identity of the concerned persons to such an extent that it provokes what can be described as a fundamental rupture of State obligations. As expressed by one scholar, when States deny legal access to trans identities, what they are actually doing is messaging a sense of what is a proper citizen. [89]

Transgender people whom Human Rights Watch interviewed in Japan felt similarly. Asked what he thought of the justification for the surgical requirement in Japan’s legal gender recognition law, Takayuki G., a trans man in Tokyo, said:

Japan is cold to even slightly exceptional people, so this provision should be it. They use the word ‘not proper’ in order not to admit the exceptions and so as to keep homogeneity…The law is created in order not to give rise to exceptions and that’s why it’s ‘not proper’ that people who have male genitals marry men. [90]

The International Covenant on Civil and Political Rights (ICCPR) provides for equal civil and political rights for all (article 3), the right to recognition for everyone before the law (article 16), the right to one’s privacy and family (article 17), and the right of people of marriageable age to marry and to start a family (article 23(2)).

Governments are obligated under the ICCPR to ensure equality before the law and the equal protection of the law of all persons without discrimination on any ground, including sex (article 26). The UN Human Rights Committee, the international expert body that monitors state compliance with the ICCPR, has specifically recommended that government should guarantee the rights of transgender persons including the right to legal recognition of their gender, and that states should repeal abusive and disproportionate requirements for legal recognition of gender identity. [91]

Several countries have adopted best practices that reflect this. Sweden, the Netherlands, Ireland, Colombia, Malta, and Denmark in recent years changed their legal recognition procedures to remove invasive medical requirements; Denmark and Malta, along with Argentina, do not require a medical diagnosis for legal gender recognition. [92] Argentina and Malta are widely considered to set best standards in legal gender recognition procedures. [93] In some countries, legislatures have adopted these standards in laws and policies; in other countries, courts have required the application of these principles.

In 2013, the UN special rapporteur on torture stated that, “In many countries transgender persons are required to undergo often unwanted sterilization surgeries as a prerequisite to enjoy legal recognition of their preferred gender.” [94] The special rapporteur noted a trend of finding such compulsory sterilization a violation of human rights, including non-discrimination rights and physical integrity, and called upon governments “to outlaw forced or coerced sterilization in all circumstances and provide special protection to individuals belonging to marginalized groups.” [95]

A 2012 Office of the High Commissioner for Human Rights (OHCHR) report, prepared in response to a 2011 Human Rights Council resolution calling for an end to violence and discrimination on the basis of sexual orientation and gender identity, noted that “[r]egulations in countries that recognize changes in gender often require, implicitly or explicitly, that applicants undergo sterilization surgery as a condition of recognition. Some States also require that those seeking legal recognition of a change in gender be unmarried, implying mandatory divorce in cases where the individual is married.” [96]

In a 2014 joint statement, the WHO, OHCHR, UN Program on HIV/AIDS (UNAIDS), the UN Development Programme, UNICEF, and UNFPA said: “States parties’ obligation to respect the right to health requires that they abstain from imposing discriminatory practices. This includes an obligation to respect the rights of persons with disabilities and transgender and intersex persons, who also have the right to retain their fertility.” [97] The agencies called on governments to “[p]rovide legal guarantees for full, free and informed decision-making and the elimination of forced, coercive and otherwise involuntary sterilization, and review, amend and develop laws, regulations and policies in this regard.” [98] In 2017, the Board of Directors of the Japanese Society of Gender Identity Disorder, the first and the largest Japanese organization founded in 1999 for professionals working on GID, adopted a statement in support of this report, noting that “it can be assumed that if the requirements stated in Article 3 Section 1 of the Special Cases Act, especially the “surgery requirement,” did not exist, the situation would have been vastly different.” [99]

In a 2015 report, mandated by a 2014 Human Rights Council resolution on sexual orientation and gender identity, OHCHR recommended that states begin immediately “[i]ssuing legal identity documents, upon request, that reflect preferred gender, eliminating abusive preconditions, such as sterilization, forced treatment and divorce.” [100]

The 2015 Blueprint for the Provision of Comprehensive Care for Trans People in Asia and the Pacific , co-published by WHO, UNDP, USAID, PEPFAR, the Asia-Pacific Transgender Network, and the Health Policy Project, recommended that governments “[t]ake all necessary legislative, administrative, and other measures to fully recognize each person’s self-defined gender identity, with no medical requirements or discrimination on any grounds.” [101]

Similarly, principle 3 of the Yogyakarta Principles on the Application of International Human Rights Law in relation to Sexual Orientation and Gender Identity states that:

Everyone has the right to recognition everywhere as a person before the law. Persons of diverse sexual orientations and gender identities shall enjoy legal capacity in all aspects of life. Each person’s self-defined sexual orientation and gender identity is integral to their personality and is one of the most basic aspects of self-determination, dignity, and freedom. No one shall be forced to undergo medical procedures, including sex reassignment surgery, sterilization or hormonal therapy, as a requirement for legal recognition of their gender identity. No status, such as marriage or parenthood, may be invoked as such to prevent the legal recognition of a person’s gender identity. No one shall be subjected to pressure to conceal, suppress, or deny their sexual orientation or gender identity. [102]

Regional bodies have followed the logic of these principles.

In June 2013, the Parliamentary Assembly of the Council of Europe, a regional body comprised of 47 member states, passed Resolution 1945, calling for an end to coercive sterilization and castration. Transgender people are listed as one of the groups in the Council of Europe countries disproportionally affected by coercive sterilization. [103] Similarly, in January 2018 the Inter-American Court of Human Rights issued an advisory opinion which maintained that states are obligated under the American Convention to establish efficient, inexpensive, and straightforward legal gender recognition procedures based solely on the “the free and autonomous decision of each person” and that forcing transgender people to argue for a change in gender markers before a judge would constitute an “excessive limit” on their rights. [104]

International health expert bodies have in recent years strengthened their positions against medical models for legal gender recognition. The WPATH, an international multidisciplinary professional association aimed at promoting evidence-based care, education, research, advocacy, public policy, and respect in transgender health and comprised of over 700 members worldwide, called for removal of any sterilization requirements as part of legal gender recognition in a 2010 statement. [105] WPATH stated:

No person should have to undergo surgery or accept sterilization as a condition of identity recognition. If a sex marker is required on an identity document, that marker could recognize the person’s lived gender, regardless of reproductive capacity. The WPATH Board of Directors urges governments and other authoritative bodies to move to eliminate requirements for identity recognition that require surgical procedures. [106]

In 2015 the WPATH updated the statement, reiterating its condemnation of forced sterilization, and expanding its critique of arduous and medicalized procedures for legal gender recognition, saying: “No particular medical, surgical, or mental health treatment or diagnosis is an adequate marker for anyone’s gender identity, so these should not be requirements for legal gender change”; and, “Marital status and parental status should not affect legal recognition of gender change, and appropriate legal gender recognition should be available to transgender youth.” [107]

And in 2017, WPATH updated their position statement again, reiterating that:

WPATH further recognizes the right of all people to identity documents consistent with their gender identity, including those documents which confer legal gender status…. Transgender people, regardless of how they identify or appear, should enjoy the gender recognition all persons expect and deserve. Medical and other barriers to gender recognition for transgender individuals may harm physical and mental health. WPATH opposes all medical requirements that act as barriers to those wishing to change legal sex or gender markers on documents. [108]

Implementation around the World

The Science Council of Japan, an independent organization under the ministry of cabinet, representing Japanese scientists in social sciences, life sciences, natural sciences, and engineering, according to a report published in September 2017, recommends removing “GID” terminology, and suggests there have been conversations underway inside the Japan Society of Psychology and Medicine to adopt “gender incongruence” terminology instead. [109] The council also recommends removing the surgical, divorce, and no-children requirement from the law, saying:

Upon the establishment of the Special Cases Act, the law makers were aware that gender has a direct connection to personal identity, and therefore has issues to the 13th Article of the Constitution of Japan, is a persons’ right to pursue happiness and dignity. Taking into consideration the trends of the world, including the joint statement by the World Health Organization (2014), it is now the time to reconsider the requirements in order to secure the unalienable rights to pursue happiness and human dignity. [110]

To reach its conclusions, the council cited legal and medical changes that have taken place in recent years around the world, many of which are explored in this report. 

As the special rapporteur on torture noted in his 2013 report, national courts in several countries have begun to reflect these standards in their decisions as well. The special rapporteur’s report refers to the following domestic cases:

• In 2009, the Austrian Administrative High Court ruled that mandatory gender reassignment, as a condition for legal recognition of gender identity, was unlawful. [111]
• In 2011, the Constitutional Court in Germany found that the requirement of gender reassignment surgery violated the rights to physical integrity and self-determination. [112]
• In 2012, the Swedish Administrative Court of Appeals ruled that forced sterilization could not be seen as voluntary. [113]
• In September 2014 the Norwegian Equality Body ruled that the Ministry of Health had provided no justification for the sterilization requirement in its gender recognition law, and thus the sterilization requirement was deemed to contravene the Anti-Discrimination Act. [114]

Courts in some Asian countries have demonstrated a similar commitment to medical non-interference in legal gender recognition processes, including in the following cases:

• In a 2007 judgment, the Nepal Supreme Court’s definition of a third gender category situated it as a minority encompassing a broad range of identities for transgender and gender non-conforming people. [115] A 2014 study found that respondents wrote in 16 different terms for their gender identities. [116] The court made clear that the sole criterion for being legally recognized as third gender on documents and in government registers was an individual’s “self-feeling.” [117] The judgment cited the right to recognition before the law, guaranteed under article 16 of the ICCPR, as well as the Yogyakarta Principles.
• In 2013, India’s Supreme Court stated that undertaking medical procedures should not be a requirement for legal recognition of gender identity. The court said: “Few persons undertake surgical and other procedures to alter their bodies and physical appearance to acquire gender characteristics of the sex which conform to their perception of gender, leading to legal and social complications since official record of their gender at birth is found to be at variance with the assumed gender identity.” It continued: “Gender identity, therefore, refers to an individual’s self-identification as a man, woman, transgender or other identified category.” The court made it clear that mandatory sterilization was not acceptable: “no one shall be forced to undergo medical procedures, including SRS, sterilization or hormonal therapy, as a requirement for legal recognition of their gender identity.” [118]
• In 2015, the Delhi High Court reinforced that, “Everyone has a fundamental right to be recognized in their gender” and that “gender identity and sexual orientation are fundamental to the right of self-determination, dignity and freedom.” [119]

Rights of Trans Children

The right to recognition as a person before the law is articulated in the Universal Declaration of Human Rights and guaranteed in the ICCPR and the Convention on the Rights of the Child (CRC). [120] The right to preserve one’s identity is guaranteed by article 8 of the CRC, which specifies three aspects of identity—nationality, name, and family relations—but that list is not exhaustive. Together with the right to protection from arbitrary interference in privacy, such as ICCPR article 17, the right to preserve one’s identity extends to the way one’s identity is reflected on state-issued documents—including for children.

As the CRC makes clear, “In all actions concerning children, whether undertaken by public or private social welfare institutions, courts of law, administrative authorities or legislative bodies, the best interests of the child shall be a primary consideration.” [121] This includes decisions about legal recognition of the gender identity of transgender children.

Article 12 of the CRC provides that in determining the child’s best interest, the child itself should be heard and taken into account:

• Governments should assure to the child who is capable of forming their own views the right to express those views freely in all matters affecting the child, the views of the child being given due weight in accordance with the age and maturity of the child.
• For this purpose, the child shall in particular be provided the opportunity to be heard in any judicial and administrative proceedings affecting the child, either directly, or through a representative or an appropriate body, in a manner consistent with the procedural rules of national law. [122]

Diagnostic Shifts

Psychiatrists in Japan use both the International Classification of Diseases (ICD), which is published by the UN WHO, and the Diagnostic and Statistical Manual (, which is published by the American Psychiatric Association (APA). Both the DSM and the ICD have removed the diagnoses for “GID” and “transsexualism” from “mental disorders” sections altogether.

In 2012 the APA board’s changes to the latest DSM removed the term “Gender Identity Disorder.” APA instead added the term “Gender Dysphoria” with the specific definition that it refers to emotional distress over “a marked incongruence between one’s experienced/expressed gender and assigned gender.” The APA specifically clarified: “It is important to note that gender nonconformity is not in itself a mental disorder. The critical element of gender dysphoria is the presence of clinically significant distress associated with the condition.” [123]

The WHO published a revised version of the ICD in June 2018. [124] The new WHO guidelines reframe “gender identity disorders” as “gender incongruence,” and move the diagnostic codes from the chapter on mental disorders to one on sexual health—an important gain for transgender adolescents and adults, who may soon be able to seek medical care without being viewed as “mentally disordered.” The World Health Assembly, the governing body of the WHO, which features representatives from 194 member states, will likely approve ICD-11 in 2019. Governments will then have until 2022 to change their diagnostic coding systems. According to the WHO, “evidence is now clear that [gender identity] is not a mental disorder, and indeed classifying it in this can cause enormous stigma for people who are transgender.” [125] As one member of the ICD-11 working group that undertook the revisions process explained,

WHO, a United Nations agency, has a human rights mission, and there is substantial evidence that the stigma associated with the intersection of transgender status and mental disorders contributes to precarious legal status, human rights violations, and barriers to appropriate health care for this population. [126]

The SOGI Independent Expert noted that this change signaled clearly that “there is no reason to assign a diagnosis to trans people who do not seek gender-affirming medical treatment or some sort of bodily change.” [127]

Japan’s legal recognition procedure is out of step with that recommended model on multiple levels, including because it requires transgender people to undergo medical procedures to secure legal recognition of their gender identity. This has contradictory effects. To some extent the fact that gender-affirming medical procedures are available in Japan reflects advances in medical practices and the medical community’s embrace of care for transgender people. But it also reinforces a pathological model that contributes to stigmatization of transgender people.

Acknowledgments

Research for this report was conducted by Kyle Knight, researcher in the lesbian, gay, bisexual, and transgender rights program; Kanae Doi, Japan director; and Michael Garcia Bochenek, senior children’s rights counsel at Human Rights Watch.

We wish to thank Fumino Sugiyama, Itsuki Dohi, Yuko Higashi from Osaka Prefecture University for their expertise and support in conducting the research. Riyo Yoshioka, Japan Senior program officer, Teppei Kasai, Japan program officer, Emily Okabe, Kanako Nannichi, Kota Ono, Yuto Takeda, Ayako Ogo, and Kan Kikumoto, Tokyo office interns, offered outreach and desk research support. Naho Toivonen, an intern in Human Rights Watch’s London office in 2016, provided significant background research and analysis on some of the legal cases referenced in this report.

Graeme Reid, director of the LGBT rights program, Kanae Doi, and Michael Bochenek edited the report. James Ross, legal and policy director, and Danielle Haas, senior program editor, provided legal and programmatic review. Tetz Hakoda and Yuki Akimoto were the Japanese translators, and Hiroyuki Taniguchi was the specialist reviewer of the Japanese translation of this report. Production assistance was provided by MJ Movahedi, LGBT rights program coordinator, and Fitzroy Hepkins, administrative manager.

We wish to thank the trans people who shared their stories with us.

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People changing registered gender rising at record pace in Japan

A total of 948 people changed their officially registered gender in Japan in 2019, the highest number since a law was enforced more than a decade ago as part of efforts to protect the rights of transgender people, a judicial survey showed Sunday.

The number of people who altered their gender under the law increased from 868 in 2018 and 903 in 2017, according to data compiled by the Supreme Court.

It rose above 500 for the first time in 2010 after gradually increasing from the mere 97 marked in 2004 when the law took effect. The total over the 15 years through 2019 stands at 9,625.

But Japan Alliance for LGBT Legislation, a support group, expects a temporary decrease in the number of such registrations due to the coronavirus pandemic as well as strict legal requirements.

Some people have had to postpone their sex reassignment surgeries due to travel restrictions and financial difficulties caused by the pandemic, the group said.

Under the law, people diagnosed by at least two doctors as having gender identity disorder can apply to change their registration.

Applicants are also required to meet other conditions including being age 20 or above, unmarried, having no underage children, and no longer having functioning reproductive organs of their assigned gender as a result of undergoing sex reassignment surgeries.

If all the conditions are met, pending approval by a family court, a new registration can be created with a different sex entry.

In a time of both misinformation and too much information, quality journalism is more crucial than ever. By subscribing, you can help us get the story right.

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Editorial: Japan top court's ruling on gender change a major step forward for human rights

October 26, 2023 (Mainichi Japan)

Japanese version

The Japanese Supreme Court has ruled that a legal provision requiring surgery to remove an individual's reproductive function to change their gender in their family registry is "unconstitutional and null." It is a major leap toward a society where sexual minorities' dignity and rights are protected.

In the groundbreaking ruling, the top court pointed out that the provision under the gender identity disorder special law "forces an individual to make a harsh choice between accepting surgery or abandoning the benefit of being treated according to their gender identity." The court ruled that the provision seriously restricts an individual's freedom to not go through a surgical operation against their will and therefore violates Article 13 of the Japanese Constitution, which guarantees the right to be "respected as individuals."

The latest decision transforms the conventional way of thinking that to lead a social life as a person of the self-identified gender, they must change their biological sex. The judicial system is pushing for improvements in Japan's current situation surrounding sexual minorities, which is far behind its Western counterparts.

Judicial decision in step with the times

The special law came into force in 2004 for transgender people to change their registered sex in their family registry. One of the prerequisites for a gender change included "having no reproductive functions," meaning that surgery is necessary as a general rule. The supposed reasoning behind this was if the person has a child after their gender change, it could cause confusion to the parent-child dynamic and to society at large. But the top court denied the necessity of the surgery, stating that it's "extremely rare for problems to occur, and it's also medically unreasonable."

Japan's Supreme Court ruled the provision constitutional in 2019, but overturned its own precedent based on societal changes, such as growing awareness for sexual minorities among the public and the recent enactment of a law to promote understanding for LGBTQ+ people.

Surgical removal of testicles or ovaries poses a great burden on the body and there are risks of complications. The surgery is also expensive. Some can't go through the procedure due to health issues.

The World Health Organization and six other United Nations-related groups released a joint statement in 2014, saying that requiring unwanted sterilization for a legal gender change was a human rights violation. A growing number of countries mainly in Europe and South America are now not requiring sterilization surgeries to change one's gender.

Japan's special law also requires "having a physical appearance of genitals that resemble those the individual wishes to change to," which also necessitates surgery in some cases. The top court didn't rule on this provision in the latest decision. It sent the matter back to the lower court, claiming that it was not examined in the appeal trial.

That being said, three of the 15 justices provided supplementary comments that this provision is also "an excessive restriction on freedom" and "goes against the Constitution."

Under the special law, some 12,000 people had changed their registered gender by 2022, but there are people who can't do so with the surgery requirement being their obstacle. A person's gender on their family registry is used in legal procedures and public documents. Transgender people who haven't been able to change their registered gender can be subject to unfavorable treatment in various parts of social life, including employment.

Diet must revise the law at once

The Japanese government and Diet must swiftly revise the special law.

Before the latest Supreme Court ruling, a parliamentary group formed by the conservative camp of the ruling Liberal Democratic Party released a statement saying that an unconstitutional ruling would "cause a great deal of confusion," demanding that the surgical requirement be maintained.

The Supreme Court has the power to review whether a law violates the Constitution. Based on the philosophy of separation of the powers among the three branches of government, the Japanese government and Diet must respect the top court's decision.

There is widespread false discourse that "a man can enter a women's bath and restrooms just by claiming to be a woman" regarding transgender women. However, gender identity is not something that can be changed on one's own volition. Transgender people live their lives while balancing their self-identified gender with the public community. We must expand our understanding for the reality they live in and eradicate prejudice.

Legalizing same-sex marriage is also a pressing matter. A same-sex couple is not legally recognized as family, and they face disadvantages in many aspects, including inheritances, custody and social security.

According to various opinion polls, the majority of people in Japan support legalizing same-sex marriage. In five separate lawsuits filed by same-sex couples across Japan, four district courts have so far ruled the existing law that doesn't recognize same-sex marriage either "unconstitutional" or "in a state of unconstitutionality."

Japan must promptly build legal systems to protect people's rights so that they would not be subject to disadvantages based on their sexual orientation or gender identity. An anti-discrimination law is also essential. A society where sexual minorities feel hardships must be changed.

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• Are surgical requirements to change sex unconstitutional? Japan top court reviewing case
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Japan's top court strikes down gender change surgery law

A law requiring transgender people to have their sexual organs removed for official recognition is unconstitutional. LGBTQ rights in Japan have fallen behind other advanced economies.

Japan's Supreme Court ruled on Wednesday that a law requiring transgender people to undergo surgery to have their gender officially recognized was in violation of the constitution.

The 2003 law states that for people to have their gender recognized on family registries and other official documents must have their reproductive organs removed, thus rendering them sterile.

The 15 judges of the top court reportedly were unanimous in their decision that the law was unconstitutional, according to Japanese news agency Kyodo news.

What does Japan's gender reassignment law require?

The case came before the Supreme Court after a transgender woman who wanted to have her gender changed in her family registry was rejected by a lower court.

More than 10,000 people have changed their officially recognized genders since the law requiring surgery came into effect.

The law states that transgender people must be diagnosed with Gender Identity Disorder before having their testes or ovaries removed and given surgery so that their body "appears to have parts that resemble the genital organs" of the new gender they want to register with.

Japan has fallen behind other advanced economies in terms of LGBTQ rights . It is the only member of the Group of Seven industrialized nations that does not permit same-sex marriage or legal protections and is lacking an effective anti-discrimination law.

Japan's slow rate of progress

LGBTQ rights activists have increased their efforts to introduce an anti-discrimination law after a former aide to Prime Minister Fumio Kishida said in February that he would not want to live next door to LGBTQ people and that Japanese citizens would flee the country if same-sex marriage was legalized.

Hundreds of municipalities throughout Japan have also already introduced non-legally binding partnership certificates for same-sex couples that, while not amounting to marriage, make it easier for them to rent apartments, among other things.

The LGBTQ community also received a boost earlier this month when a lower court accepted a request for a transgender man to legally change his gender without undergoing surgery, stating that the law was unconstitutional.

A previous Supreme Court ruling in 2019, in the case of a transgender man seeking a gender registration change, the judges had ruled the surgery law constitutional but said that it should be reviewed later as social values change.

ab/lo (AP, Reuters)

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OKAYAMA UNIVERSITY HOSPITAL

• Gender Center (Department of Neuropsychiatry)

For Patient Visit

What is the gender center.

The Gender Center treats, researches, and provides education about gender associated diseases (GAD) including gender identity disorder (GID). Today, national insurance coverage for sex reassignment surgery has been approved. Therefore, this center plays an important role as a training institute to cultivate GID medical specialists. We developed the world’s first flap combination phalloplasty and introduced recto-sigmoid colon vaginoplasty using a laparoscope. We have researched sex organ transfer homosexually and heterosexually for the first time uterine transplantation. We have global partners that include Ghent Univ. in Belgium, Vrije Univ. in Amsterdam in the Netherlands, Dong-A Univ. in Korea, and Chulalongkorn Univ. in Thailand.  

Information on Mastectomy (FTM) and Sex Reassignment Surgery (SRS)

We offer the following physical treatments. ■Mastectomy ■Urethral lengthening ■Penile plasty ■Vulvar feminization ■Vaginoplasty

Precautions

Flow of medical examination, ■ obtaining an appointment for consultation.

・ First, please consult with your primary doctor about getting a referral letter and send a fax to our clinic for an appointment. ・The person in charge at our clinic will later inform you how to make an appointment for your first visit.

 ※For foreign patients who visit our hospital For overseas patients who want a consultation or treatment at our hospital, please check  this page  first. Overseas patients must contact us via medical coordinator companies or The National University Hospital Medical Cooperation Network , for safe and reliable medical care. Our physicians will determine on your acceptance as a patient, comprehensively,based on your prior medical information, imaging data interpretation, expected benefits of our services, and so on. Thank you in advance for your understanding and cooperation for smooth consultation and treatment. The patient also must cover the expenses for medical coordination.  

Surgery Costs (Expenses)

We require a deposit prior to surgery. Payment is due 30 days prior to the scheduled surgery date. Payment can be made at conveniences store or post office in Japan. If you wish to pay by credit or debit card, please pay at the counter.

"Deposit" does not equal "surgery fee". If complications arise, the hospital stay is longer than expected, or only expensive private rooms are available, additional fees may be added to the deposit. On the other hand, a portion of the deposit may be returned. Fees are subject to change without notice. ※Deposits for Surgery, click  here  (Only　Japanese).  

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Japan Offers National Health Insurance Coverage for Sex Reassignment Surgeries

The cost of staying true to yourself went down; yet many financial and ethical issues remain unsolved..

by Vladimir Zivanovic December 4, 2018, 11:15 pm 4.5k Views

In an attempt to revive the economy of Japan, Prime Minister Shinzo Abe made a major step by trying to boost the economy by fostering the fruitful environment for women employees. Still, gender issues continue drastically affecting the economy by maintaining the disbalance in the education and employment opportunities for women and elderly people . Another topic that raises a lot of discussions is the LGBTQ community in Japan.

There are many people diagnosed with gender dysphoria in the country. The Government of Japan has established a health insurance coverage for these people. The health insurance covers the majority of expenses associated with the gender reassignment surgery and recovery period.

What factors and coverage amount are in question?

Surgery payments will be covered in the same way the other treatments falling under the terms and conditions of the national health insurance: the patient has to pay up to 30% of the total cost. The final sum for a sex reassignment surgery may differ depending on the direction of a transition and the type of surgery performed.

For men, the price can range from 400,000 yen to 2 million yen, while for women, it is from 300,000 yen to 1.2 million yen. As of 2015, Japan has 22,435 people officially diagnosed with gender dysphoria. It might seem that the Government of Japan now has to allocate a significant sum to cover for thousands of operations, yet it is not so easy to get the treatment.

The Law 111 regulating the issue got a wave of criticism for human rights violation as one of the requirements for a patient is to undergo sterilization. It gets trickier as Japan only recognizes marriages between two different sexes, meaning that if one of the spouses is to undergo a transition, first the couple has to divorce. The number of people that are willing to make a choice in between the possibility to have a sex reassignment surgery or maintain their fertility will definitely decrease the total sums covered by the national health insurance. Other issues involve difficulties with registration, public services, job hunting, etc.

In the meantime, there has been a lot of positive development regarding the sex transition issue in Japan. Let’s take a closer look at some amazing doctors helping to change people’s lives for the better. A brand new clinic specializing in therapy for transgender people has started working in Nagoya. It will provide counseling services and hormonal therapy to transgender people.

Hisaya Clinic

The price ranges from 400,000 yen to 2 million yen, while for women, it is from 300,000 yen to 1.2 million yen.

Procedures that save lives

An Aichi Prefecture resident was a patient at Hisaya Clinic. She decided to visit Dr. Muto’s clinic in her 30s because all she ever wanted was to be identified as a female. According to her, many clinics turned her down and didn’t want to treat her because she was very clear about being attracted to women. She found herself lost in this situation, wondering why she is not attracted to men when she is clearly identifying herself as a woman. Fortunately, she stumbled upon some information about Dr. Muto’s clinic online. Soon after she visited the clinic, the first thing that she recalls are the questions she was asked by the medical staff and the answers she had given.

One of those questions was about her childhood memories. She replied that she was under the impression that her genitalia would disappear once she grew up. She added that she clearly remembers enjoying herself while playing house with girls. She also mentioned that her mother kept asking her why she didn’t want to play with the boys. Talking about her childhood she also mentioned that she always loved keeping her hair long and that she remembers being the victim of bullies. The boys she was growing up with have bullied her because she clearly behaved more like a girl. She remembers wearing a skirt over her pants, to mask her true intentions, hoping that it would be interpreted as a fashion choice. One counseling session was more than enough to clarify her transgender situation. Dr. Muto helped her understand the circumstances better and explained that people who identify themselves as women don’t necessarily have to be attracted to men but can also like women.

Gender identity in grown-ups

Muto also explained that transgender people usually become aware of their gender identity only after they grow up, but this doesn’t erase their childhood memories. At this point, they usually realize that they have been acting differently than the rest of their peers in the same sex group. And they know that this was because of their true sexual identity. Later on, Muto explained that the patient’s earliest discomforts with the assigned sex were more than enough for her to diagnose the patient as transgender. She added that kindergartens where kids end up divided into groups by gender usually cause transgender people to behave differently from others. The patient in question is currently undergoing hormone therapy. The counseling helped her relieve all that stress that had accumulated over the past years. The results of hormone therapy will soon follow because it takes time before it can produce changes in the body.

Muto said that the patient is responding to the entire treatment really well. The clear sign is her leaving her house happy with her hat raised, while in the past she kept her eyes constantly covered with the same hat. The first gender reassignment surgery in Japan took place in 1998, just a year after the Japanese Society of Psychiatry and Neurology created the first guideline for treating and diagnosing dysphoria. Over the years, the availability of treatments has improved but the entire practice is still not on the required level, according to Dr. Muto. Dr. Muto’s primary concern is the hormone therapy, which has become the first step of treatment in many clinics. She expressed her worries by explaining that the hormone treatment should only follow a thorough examination and that it should be prescribed only if the patient is really determined to change their sex. This is simply because the hormone therapy has several irreversible effects which people should be aware of. Some of these are very serious, such as becoming sterile, increased risk of thrombosis, and severe nausea. At the same time, hormonal treatment remains unchecked by the authorities because it’s not covered by health insurance. This leads to too many problems being overlooked or swept under the rug.

Affordable treatment: from confident and happy individuals to happier and more productive employees with equal opportunities to a better economy.

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Transgender inclusion? World's major religions take varying stances on policies toward trans people

The Vatican has issued a new document rejecting the concept of changing one’s biological sex – a setback for transgender people who had hoped Pope Francis might be setting the stage for a more welcoming approach from the Catholic Church.

Around the world, major religions have diverse approaches to gender identity, and the inclusion or exclusion of transgender people. Some examples:

Christianity

The Catholic Church’s disapproving stance toward gender transition is shared by some other denominations. For example, the Southern Baptist Convention – the largest Protestant denomination in the United States – adopted a resolution in 2014 stating that “God’s design was the creation of two distinct and complementary sexes, male and female.” It asserts that gender identity “is determined by biological sex, not by one’s self-perception”

However, numerous mainline Protestant denominations welcome trans people as members and as clergy. The Evangelical Lutheran Church in America elected an openly transgender man as a bishop in 2021.

In Islam, there isn’t a single central religious authority and policies can vary in different regions.

Abbas Shouman, secretary-general of Al-Azhar’s Council of Senior Scholars in Cairo, said that “for us, ... sex conversion is completely rejected.”

“It is God who has determined the ... sex of the fetus and intervening to change that is a change of God’s creation, which is completely rejected,” Shouman added.

In Iran, the Shiite theocracy’s founder, Ayatollah Ruhollah Khomeini, issued a religious decree, or fatwa, decades ago, opening the way for official support for gender transition surgery.

In Hindu society in South Asia, while traditional roles were and are still prescribed for men and women, people of non-binary gender expression have been recognized for millennia and played important roles in holy texts. Third gender people have been revered throughout South Asian history with many rising to significant positions of power under Hindu and Muslim rulers. One survey in 2014 estimated that around 3 million third gender people live in India alone.

Sanskrit, the ancient language of Hindu scriptures, has the vocabulary to describe three genders – masculine, feminine and gender-neutral.

The most common group of third gender people in India are known as the “hijras.” While some choose to undergo gender reassignment surgery, others are born intersex. Most consider themselves neither male or female.

Some Hindus believe third gender people have special powers and the ability to bless or curse, which has led to stereotyping causing the community to be feared and marginalized. Many live in poverty without proper access to healthcare, housing and employment.

In 2014, India, Nepal and Bangladesh, which is a Muslim-majority country, officially recognized third gender people as citizens deserving of equal rights. The Supreme Court of India stated that “it is the right of every human being to choose their gender,” and that recognition of the group “is not a social or medical issue, but a human rights issue.”

Buddhism has traditionally adhered to binary gender roles, particularly in its monastic traditions where men and women are segregated and assigned specific roles.

These beliefs remain strong in the Theravada tradition, as seen in the attempt of the Thai Sangha Council, the governing Buddhist body in Thailand, to ban ordinations of transgender people. More recently, the Theravada tradition has somewhat eased restrictions against gender nonconforming people by ordaining them in their sex recorded at birth.

However, the Mahayana, and Vajrayana schools of Buddhism have allowed more exceptions while the Jodo Shinshu sect has been even more inclusive in ordaining transgender monks both in Japan and North America. In Tibetan Buddhism, Tashi Choedup, an openly queer monk, was ordained after their teacher refrained from asking about their gender identity as prescribed by Buddhist doctrine. Many Buddhist denominations, particularly in the West, are intentionally inclusive of transgender people in their sanghas or gatherings.

Reform Judaism is accepting of transgender people and allows for the ordination of trans rabbis. According to David J. Meyer, who served for many years as a rabbi in Marblehead, Massachusetts, Jewish traditional wisdom allowed possibilities of gender identity and expression that differed from those typically associated with the sex assigned at birth.

“Our mystical texts, the Kabbalah, address the notion of transitioning from one gender to another,” he wrote on a Reform-affiliated website.

It’s different, for the most part, in Orthodox Judaism. “Most transgender people will find Orthodox communities extremely difficult to navigate,” says the Human Rights Campaign, a major U.S. LGBTQ-rights advocacy group.

“Transgender people are further constrained by Orthodox Judaism’s emphasis on binary gender and strict separation between men and women,” the HRC says. “For example, a transgender person who has not medically transitioned poses a challenge for a rabbi who must decide whether that person will sit with men or women during worship.”

Rabbi Avi Shafran, spokesman for the Orthodox Jewish organization Agudath Israel of America, wrote a blog post last year after appearing on an Israeli television panel to discuss transgender-related issues.

“There can be no denying that there are people who are deeply conflicted about their gender identities. They deserve to be safe from harm and, facing challenges the rest of us don’t, deserve empathy and compassion,” Shafran wrote. “But the Torah and its extension, halacha, or Jewish religious law, are unequivocal about the fact that being born in a male body requires living the life of a man, and being born female entails living as a woman.”

“In Judaism, each gender has its particular life-role to play,” he added. “The bodies God gave us are indications of what we are and what we are not, and of how He wants us to live our lives.”

Associated Press religion coverage receives support through the AP’s collaboration with The Conversation US, with funding from Lilly Endowment Inc. The AP is solely responsible for this content.

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Vatican calls gender fluidity and surrogacy threats to human dignity

Infinite Dignity declaration reaffirms church’s position on gender reassignment, abortion and euthanasia

The Vatican has described the belief in gender fluidity as “a concession to the age-old temptation to make oneself God”, as it released an updated declaration of what the Catholic church regards as threats to human dignity.

The new Dignitas infinita (Infinite Dignity) declaration released by the Vatican’s doctrinal office on Monday after five years in the making reiterates Pope Francis’s previous criticism of what he has called an “ugly ideology of our time”.

“Desiring a personal self-determination, as gender theory prescribes, apart from this fundamental truth that human life is a gift, amounts to a concession to the age-old temptation to make oneself God, entering into competition with the true God of love revealed to us in the gospel,” the 20-page document says.

Reiterating opposition to gender reassignment surgery, it adds: “It follows that any sex-change intervention, as a rule, risks threatening the unique dignity the person has received from the moment of conception.”

The Holy See distinguished between these sorts of surgeries and procedures to resolve “genital abnormalities” that are present at birth or develop later. It said those abnormalities could be treated with the help of healthcare professionals.

The Vatican said Pope Francis had approved the document, which also reaffirms its condemnation of surrogacy, saying the practice represents “a grave violation of the dignity of the woman and the child”.

“A child is always a gift and never the basis of a commercial contract,” the document says. “Every human life, beginning with that of the unborn child in its mother’s womb, cannot be suppressed, nor become an object of commodity.”

The chief cardinal, Victor Manuel Fernández, said on Monday that the pope had asked for the Vatican’s doctrinal office (DDF) to include “poverty, the situation of migrants, violence against women, human trafficking, war and other themes” in its updated assessment of threats to human dignity.

The document says gay people should be respected and denounces the fact that “in some places not a few people are imprisoned, tortured, and even deprived of the good of life solely because of their sexual orientation”.

Fernández, a liberal theologian who was appointed to the DDF role – one of the Vatican’s most powerful positions – by Francis last year, said punishing homosexuality was “a big problem” and that it was “painful” to see some Catholics support anti-homosexuality laws.

The declaration also reaffirms the church’s position on abortion and euthanasia while strongly condemning femicide. “Violence against women is a global scandal, which is increasingly being recognised,” it says.

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Guest Essay

The Problem With Saying ‘Sex Assigned at Birth’

By Alex Byrne and Carole K. Hooven

Mr. Byrne is a philosopher and the author of “Trouble With Gender: Sex Facts, Gender Fictions.” Ms. Hooven is an evolutionary biologist and the author of “T: The Story of Testosterone, the Hormone That Dominates and Divides Us.”

As you may have noticed, “sex” is out, and “sex assigned at birth” is in. Instead of asking for a person’s sex, some medical and camp forms these days ask for “sex assigned at birth” or “assigned sex” (often in addition to gender identity). The American Medical Association and the American Psychological Association endorse this terminology; its use has also exploded in academic articles. The Cleveland Clinic’s online glossary of diseases and conditions tells us that the “inability to achieve or maintain an erection” is a symptom of sexual dysfunction, not in “males,” but in “people assigned male at birth.”

This trend began around a decade ago, part of an increasing emphasis in society on emotional comfort and insulation from offense — what some have called “ safetyism .” “Sex” is now often seen as a biased or insensitive word because it may fail to reflect how people identify themselves. One reason for the adoption of “assigned sex,” therefore, is that it supplies respectful euphemisms, softening what to some nonbinary and transgender people, among others, can feel like a harsh biological reality. Saying that someone was “assigned female at birth” is taken to be an indirect and more polite way of communicating that the person is biologically female. The terminology can also function to signal solidarity with trans and nonbinary people, as well as convey the radical idea that our traditional understanding of sex is outdated.

The shift to “sex assigned at birth” may be well intentioned, but it is not progress. We are not against politeness or expressions of solidarity, but “sex assigned at birth” can confuse people and creates doubt about a biological fact when there shouldn’t be any. Nor is the phrase called for because our traditional understanding of sex needs correcting — it doesn’t.

This matters because sex matters. Sex is a fundamental biological feature with significant consequences for our species, so there are costs to encouraging misconceptions about it.

Sex matters for health, safety and social policy and interacts in complicated ways with culture. Women are nearly twice as likely as men to experience harmful side effects from drugs, a problem that may be ameliorated by reducing drug doses for females. Males, meanwhile, are more likely to die from Covid-19 and cancer, and commit the vast majority of homicides and sexual assaults . We aren’t suggesting that “assigned sex” will increase the death toll. However, terminology about important matters should be as clear as possible.

More generally, the interaction between sex and human culture is crucial to understanding psychological and physical differences between boys and girls, men and women. We cannot have such understanding unless we know what sex is, which means having the linguistic tools necessary to discuss it. The Associated Press cautions journalists that describing women as “female” may be objectionable because “it can be seen as emphasizing biology,” but sometimes biology is highly relevant. The heated debate about transgender women participating in female sports is an example ; whatever view one takes on the matter, biologically driven athletic differences between the sexes are real.

When influential organizations and individuals promote “sex assigned at birth,” they are encouraging a culture in which citizens can be shamed for using words like “sex,” “male” and “female” that are familiar to everyone in society, as well as necessary to discuss the implications of sex. This is not the usual kind of censoriousness, which discourages the public endorsement of certain opinions. It is more subtle, repressing the very vocabulary needed to discuss the opinions in the first place.

A proponent of the new language may object, arguing that sex is not being avoided, but merely addressed and described with greater empathy. The introduction of euphemisms to ease uncomfortable associations with old words happens all the time — for instance “plus sized” as a replacement for “overweight.” Admittedly, the effects may be short-lived , because euphemisms themselves often become offensive, and indeed “larger-bodied” is now often preferred to “plus sized.” But what’s the harm? No one gets confused, and the euphemisms allow us to express extra sensitivity. Some see “sex assigned at birth” in the same positive light: It’s a way of talking about sex that is gender-affirming and inclusive .

The problem is that “sex assigned at birth”— unlike “larger-bodied”— is very misleading. Saying that someone was “assigned female at birth” suggests that the person’s sex is at best a matter of educated guesswork. “Assigned” can connote arbitrariness — as in “assigned classroom seating” — and so “sex assigned at birth” can also suggest that there is no objective reality behind “male” and “female,” no biological categories to which the words refer.

Contrary to what we might assume, avoiding “sex” doesn’t serve the cause of inclusivity: not speaking plainly about males and females is patronizing. We sometimes sugarcoat the biological facts for children, but competent adults deserve straight talk. Nor are circumlocutions needed to secure personal protections and rights, including transgender rights. In the Supreme Court’s Bostock v. Clayton County decision in 2020, which outlawed workplace discrimination against gay and transgender people, Justice Neil Gorsuch used “sex,” not “sex assigned at birth.”

A more radical proponent of “assigned sex” will object that the very idea of sex as a biological fact is suspect. According to this view — associated with the French philosopher Michel Foucault and, more recently, the American philosopher Judith Butler — sex is somehow a cultural production, the result of labeling babies male or female. “Sex assigned at birth” should therefore be preferred over “sex,” not because it is more polite, but because it is more accurate.

This position tacitly assumes that humans are exempt from the natural order. If only! Alas, we are animals. Sexed organisms were present on Earth at least a billion years ago, and males and females would have been around even if humans had never evolved. Sex is not in any sense the result of linguistic ceremonies in the delivery room or other cultural practices. Lonesome George, the long-lived Galápagos giant tortoise , was male. He was not assigned male at birth — or rather, in George’s case, at hatching. A baby abandoned at birth may not have been assigned male or female by anyone, yet the baby still has a sex. Despite the confusion sown by some scholars, we can be confident that the sex binary is not a human invention.

Another downside of “assigned sex” is that it biases the conversation away from established biological facts and infuses it with a sociopolitical agenda, which only serves to intensify social and political divisions. We need shared language that can help us clearly state opinions and develop the best policies on medical, social and legal issues. That shared language is the starting point for mutual understanding and democratic deliberation, even if strong disagreement remains.

What can be done? The ascendance of “sex assigned at birth” is not an example of unhurried and organic linguistic change. As recently as 2012 The New York Times reported on the new fashion for gender-reveal parties, “during which expectant parents share the moment they discover their baby’s sex.” In the intervening decade, sex has gone from being “discovered” to “assigned” because so many authorities insisted on the new usage. In the face of organic change, resistance is usually futile. Fortunately, a trend that is imposed top-down is often easier to reverse.

Admittedly, no one individual, or even a small group, can turn the lumbering ship of English around. But if professional organizations change their style guides and glossaries, we can expect that their members will largely follow suit. And organizations in turn respond to lobbying from their members. Journalists, medical professionals, academics and others have the collective power to restore language that more faithfully reflects reality. We will have to wait for them to do that.

Meanwhile, we can each apply Strunk and White’s famous advice in “The Elements of Style” to “sex assigned at birth”: omit needless words.

Alex Byrne is a professor of philosophy at M.I.T. and the author of “Trouble With Gender: Sex Facts, Gender Fictions.” Carole K. Hooven is an evolutionary biologist, a nonresident senior fellow at the American Enterprise Institute, an associate in the Harvard psychology department, and the author of “T: The Story of Testosterone, the Hormone That Dominates and Divides Us.”

The Times is committed to publishing a diversity of letters to the editor. We’d like to hear what you think about this or any of our articles. Here are some tips . And here’s our email: [email protected] .

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Vatican says sex reassignment surgery, surrogacy and gender theory threaten human 'dignity'

The Vatican has declared gender confirmation operations and surrogacy as grave threats to human "dignity", putting them on par with abortion and euthanasia as practices that violate God's plan for human life.

The Vatican's doctrine office on Monday published a 20-page declaration titled Infinite Dignity that was in the works for the past five years.

It was approved for publication by Pope Francis on March 25 after substantial revision in recent months.

In its most eagerly anticipated section, the Vatican reiterated its rejection of "gender theory" or the idea that one's gender can be "a self-determination".

It said God created man and woman as biologically different, separate beings, and said they must not tinker with that plan or try to "make oneself God".

"It follows that any sex-change intervention, as a rule, risks threatening the unique dignity the person has received from the moment of conception," the document said.

It distinguished between transitioning surgeries, which it rejected, and "genital abnormalities" that are present at birth or that develop later. Those abnormalities can be "resolved" with the help of health care professionals, it said.

The document's existence, rumoured since 2019, was confirmed in recent weeks by the new prefect of the Dicastery for the Doctrine of the Faith, Argentine Cardinal Víctor Manuel Fernández, a close confidante of Pope Francis.

He had cast it as something of a nod to conservatives after he authored a more explosive document approving blessings for same-sex couples that sparked criticism from conservative bishops around the world, especially in Africa.

While the new document rejected gender theory, it took pointed aim at countries — including many in Africa — that criminalise homosexuality.

It echoed Pope Francis's assertion in a 2023 interview that "being homosexual is not a crime", making the assertion now part of the Vatican's doctrinal teaching.

It denounced "as contrary to human dignity the fact that, in some places, not a few people are imprisoned, tortured, and even deprived of the good of life solely because of their sexual orientation".

The document restated well-known Catholic doctrine opposing abortion and euthanasia.

It also added to the list some of Pope Francis's main concerns as pope: the threats to human dignity posed by poverty, war, human trafficking and forced migration.

A child's right to 'a fully human origin'

In a newly articulated position, the declaration said surrogacy violated both the dignity of the surrogate mother and the child.

While much attention on surrogacy has focused on possible exploitation of poor women as surrogates, the Vatican document focuses more on the resulting child.

"The child has the right to have a fully human (and not artificially induced) origin and to receive the gift of a life that manifests both the dignity of the giver and that of the receiver," the document said.

"Considering this, the legitimate desire to have a child cannot be transformed into a 'right to a child' that fails to respect the dignity of that child as the recipient of the gift of life."

The Vatican published its most articulated position on gender in 2019, when the Congregation for Catholic Education rejected the idea that people can choose or change their genders.

It insisted on the complementary nature of biologically male and female sex organs to create new life.

Gender fluidity was described as a symptom of the "confused concept of freedom" and "momentary desires" that characterise post-modern culture.

The new document from the more authoritative Dicastery for the Doctrine of the Faith quoted from that 2019 education document but tempered the tone.

Significantly, it did not repurpose the 1986 language of a previous doctrinal document saying that homosexual people deserve to be treated with dignity and respect but that homosexual actions are "intrinsically disordered".

Francis has made reaching out to LGBTQ+ people a hallmark of his papacy, ministering to trans Catholics and insisting that the Catholic Church must welcome all children of God.

But he has also denounced "gender theory" as the "worst danger" facing humanity today, describing it as an "ugly ideology" that threatens to cancel out God-given differences between man and woman.

"It needs to be emphasised that biological sex and the sociocultural role of sex (gender) can be distinguished but not separated," the new document said.

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The Vatican says surrogacy and gender theory are 'grave threats' to human dignity

Jason DeRose

The crowd looks in direction of the window of the apostolic palace overlooking St. Peter's square during Pope Francis' prayer on April 1 in The Vatican. TizianaI Fabi/AFP via Getty Images hide caption

The crowd looks in direction of the window of the apostolic palace overlooking St. Peter's square during Pope Francis' prayer on April 1 in The Vatican.

The Vatican has released a new document calling poverty, war and the plight of migrants "threats to human dignity." But it also calls abortion, surrogacy and gender theory "grave threats" facing humanity today.

The document, titled " Infinite Dignity " says that each person's dignity comes from the love of the creator "who has imprinted the indelible features of his image on every person." This language is familiar to Christians accustomed to hearing that humans are all made in God's image.

The document goes on to say that this dignity is inalienable, beyond any circumstance or situation the person might encounter. Simply put, because a person exists, a human has intrinsic dignity.

"Infinite Dignity" details a long list of what it calls grave threats to that dignity, some of which might be expected given other Catholic teachings. It talks about the drama of poverty and how the unequal distribution of wealth denies humans their God-given dignity. It also describes war, the abuse of migrants, sexual abuse, violence against women, the marginalizing of people with disabilities, assisted suicide and abortion all as affronts to human dignity.

But then the document turns to other issues that have become more highly politicized in recent years: surrogacy, gender theory, and what it calls "sex change."

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The document's framework holds that if a person is made in God's image, gender theory and gender reassignment surgery call into question why God would create a person with the wrong gender.

It says that the understanding of humanity as divided into two sexes — male and female — is biblical and deeply meaningful, especially in terms of procreation. Gender theory argues that a person's gender can be different from the sex that person was assigned at birth.

"Infinite Dignity" says the concept of human dignity can be misused to justify what it calls an "arbitrary proliferation of new rights," describing those, rather, as "individual preference" or "desire." That language is very similar to how conservatives often talk about being transgender as a choice, which is something major medical and psychological groups dispute.

The document makes a clear distinction between the issue of sexual orientation (whether a person is gay, lesbian or bisexual) and the issue of gender identity (whether a person's sex assigned at birth matches what that person understands his or her gender to be).

The document will be seen by some more conservative Catholic as a win after years of feeling embattled during Pope Francis's leadership. Just last year, the Vatican said priests could baptize transgender Catholics and allowed for priests to bless people in same-sex relationships .

Catholic Church works to explain what same-sex blessings are and are not

But many transgender Catholics and their families as well as more progressive Catholics are displeased with "Infinite Dignity."

Executive director of the LGBTQ Catholic group New Ways Ministry, Francis DeBernardo says of the document, "When it gets to the section on people who are transgender or non-binary, it doesn't apply the principles of human dignity to them."

New Ways Ministry's mission is, in part, to help pastors and religious teachers better understand gender identity and sexuality. It also fosters, "holiness and wholeness within the Catholic LGBTQ+ community."

DeBernardo argues "Infinite Dignity" does not live up to its own name. "In a sense, it's not infinite dignity," he says. "It's a very limited dignity that the church is offering."

He fears this document will be used to further persecute transgender people, and he thinks it will cause transgender Catholics and their families to leave the church.

The Vatican says priests can baptize transgender people

DeBernardo also worries the sections on gender theory and what it calls "sex change" will eclipse what he describes as the very good parts of the document on war, poverty and migrants.

The group Catholics for Choice, is also disappointed and calls into question how the document was created. "Yet again," said the group's president Jamie Manson in a written statement, "a group of all-male, celibate clergymen are telling women and gender-expansive people that their lived experiences are not real or valid."

Catholics for Choice advocates within the church on a variety of issues regarding sexual and reproductive health, including abortion rights. The group holds – and argues that Catholic teaching supports – people's individual consciences should be their guide in such decisions.

"It is clear to me that the women and trans people who continue to identify as Catholic — despite documents like this completely disregarding our experiences — only do so because of a deep love for our faith and its traditions," continues Manson in her statement. "It is devastating that our leaders do not offer the same respect and love in return."

• gender confirmation surgery

Vatican rejects gender-affirming surgery and surrogacy in new document

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'GENDER THEORY'

Abortion, euthanasia, death penalty.

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Reporting by Alvise Armellini; Editing by Kevin Liffey and Lisa Shumaker

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