A/HRC/35/36 C. Legal recognition of gender identity 57. In many countries, transgender persons are not able to have their self-identified gender recognized by the State, even with gender reassignment surgery, and have to endure lifelong abuses and discrimination. Non-recognition is interlinked with the environment that leads to violence and discrimination. In some situations, they are forced to undergo gender reassignment surgery, other medical procedures, such as psychological assessment, conversion therapy, sterilization and also divorce, with or without legal recognition of their self-identified gender. Other impediments include bureaucratic hurdles and difficulties in accessing medical care, such as hormone treatment, as well as in accessing the wherewithal of life, such as education, housing, a decent standard of living and employment opportunities. Yet, a number of countries, such as Argentina, Australia, Malta, and Scandinavian countries, are now leading the way by enabling people to have their selfidentified gender recognized under national law without the need for surgery and related medical procedures, unless they opt for the latter on a non-coerced basis, and by reducing the bureaucratic hurdles along the way. On a related front, the issue of forced surgery (from a young age) also pertains to intersex persons; this is interrelated with violence and discrimination, whereby such persons are prevented from enjoying the element of choice concerning their sexual orientation and gender identity, which is an intrinsic part of the diversity of human life. There is thus a need to move towards legal recognition of selfdefined gender identity without coerced methods. D. Destigmatization linked with depathologization 58. Stigma based on sexual orientation and gender identity, and, concomitantly, violence and discrimination, may arise in a variety of situations, including in the medical and related sectors, and this is linked with the issue of pathologization. Before 1990, even at the international level, homosexuals were classified as mentally ill; this exemplified a pathologizing approach towards sexual and gender identity (looking as lesbian, gay, bisexual and transgender persons as suffering from some form of illness, mental disorder, dysphoria or incongruence), which is now increasingly being questioned. Even though the pathologization facing homosexuals/gays is now no longer the case internationally, at the national and local levels, the situation is still opaque. There are also some parts of the world where gays and lesbians are still being forced into conversion therapy in the distorted belief that this will change their sexual orientation and gender identity. In regard to transgender and intersex persons, the situation is difficult internationally, as they still fall under the International Classification of Diseases, which is now in the process of being adjusted to reduce stigma.31 There is a further consideration as regards how to ensure sustained access to medical care and services, such as access to hormones and related treatment. The preferred approach should be to ensure access to comprehensive health care for all, without resorting to labels that give rise to stigma. The invitation to destigmatize and depathologize opens the door to more cooperation with the medical, scientific and ethics sectors, to promote shared understanding that sexual orientation and gender identity are part of the natural state of being human, and correlatively, to ensure respect for all persons without distinction. E. Sociocultural inclusion 59. Regrettably, lesbian, gay, bisexual and transgender persons are excluded from society in many countries: the marginalization and peripheralization are part of a vicious cycle that gives rise to a host of other problems. The atmosphere that excludes people from the sociocultural environment inevitably lends itself to violence and discrimination. The case of transgender persons illustrates this: in many countries, they are often bullied at 31 Doris Chouand others, “Sexual health in the International Classification of Diseases (ICD): implications for measurement and beyond”, Reproductive Health Matters, vol. 23, No. 46 (2015), pp. 185-192. 17