Both the psycho-medical health care providers and groups of trans people themselves use “transsexual” as the only valid group within the transgender category. I argue here that this is problematic because it delegitimises the existence of others. And I consider it not wise to adopt an alien identity that comes with a whole power structure behind it, as genuine.
The idea of transsexual historically comes from doctors and psychiatrists who were confronted with trans* people who sought relief from their stress of being confronted daily with a world that denies their feelings, their wishes. From the 1950s there were increasing possibilities to use medicine to change the body more towards ones’s own perception. With the arrival of synthetic sex hormones it became feasible to feminize or masculinize the body. Robert Stoller tells in his Sex and Gender (1968) the story of Agnes who presented as intersex (hermaphrodite) but actually was a trans woman who used her mothers/sisters Stilbestrol to feminize her body. Trans as we know it thus has a strong link with the development of the biochemical industry, something that Paul B. Preciado writes about extensively in Testo Junkie.
From the 1980s something like a transition trajectory got created in the Western world through adoption of gender identity in DSM-9 and through the first Standards of Care of the Harry Benjamin International Gender Dysphoria Association (HBIGDA, now WPATH, World Professional Association for Transgender Health.) The website trans-health.com mentions that the first SOC of HBIGDA (1979) were very strict with their requirement of six months (real life test) before surgery. Later this has grown to a year and a half or a year.
Where does “transsexual” come from? What does it describe?
While the appearance of the term comes from a complex interplay and power struggle between endocrinology, pharmaceutical industry and psychiatry, it is mostly thanks to Harry Benjamin (the father of WPATH) that it got into mainstream. Benjamin’s “The Transsexual Phenomenon” became the Bible for trans* people seeking access to medical procedures. Who presents as straight and decent enough feminine often got accepted thanks to the heterosexual bias of the providers. In a setting of scarcity in access this is of course important.
This need for a psychiatric diagnosis, specifically of transsexualism, is problematic for several reasons. First of all is assumes a stable identity called transsexual with the defined criteria for that. But this becomes a circular reasoning: Transsexual is defines as A and to become transsexual one must identify as, comply with the reasons for A. One is transsexual by definition.
A complicating factor is that many legal procedures – if there are legal procedures in place – require this diagnosis (or a relevant psychiatric diagnosis) regardless of how one feels or identifies and that produces people who (for the record) identify as such. So often there is no free will in play anyway.
Only a handful of countries up to now have done away with this criterion: Argentina (2012), Ireland (21014), Malta (2015), Norway (2106), Denmark (2014 and 2017), Colombia (2014) and only Argentina and Malta are really ‘clean’. While other countries also declassified trans people from having a mental disorder – France already did that in 2009, though in a very cranky way, replacing it with placement with chronic diseases – real depathologization still is far away often. And some countries are worse than any standard: Belarus requires a six weeks stay in psychiatric ward, with tests nobody understands the usefulness of. Plus the whole (unfriendly) medical procedure, before a legal change might be possible.
The fact that gender identity disorder, with the specification transsexuality, entered classifications at the time most of homosexuality left, is an indication the providers were mostly interested in gender norm deviation. The change for ICD-11 (the only really globally authoritative classification, scientifically sound is not sure yet, nor sufficient if accepted.
That people started naming themselves transsexual is understandable, given the conditions mentioned above. However slowly, with transgender really in vogue as alternative umbrella term, it is time to liberate ourselves as much as possible from this diagnosis that ascribes us all kinds of issues.
The sexual orientation group of SOGIE has emancipated hugely after their removal from the DSM and ICD, it is time trans* people start doing he same. It is not about the need to adapt our body, but that this need comes largely from minority stress: we feel different for not being accepted and that gets us stress; when we adapt our body to sex and gender norms, we are better accepted. We gain more acceptance. But multiple groups of trans* people who do not want or cannot enter such a process, are not accepted for legal change.
Another reason to stop using “transsexual” in classifications is its regional Western origin. While these classifications pretend to have a global working and tell global truths. Global truths that do not exist automatically, but instead are the product of colonial effects and history. Aniruddha Dutta and Raina Roy describe in their “Decolonizing transgender in India: some reflections” (Transgender Studies Quarterly 1:3, p.320-337) how transgender as a reference has become the term of preference when working with higher level funders or NGOs (f.i. UNDP, UNAIDS) and that an effect of this is the elision of local identities like kothi (a complex identity, that is comparable as a partial overlap between gay and trans in the Western world). South Asian discourses of gender/sexual variance may blur cis-trans or homo-trans distinction and community formations may also be built on calls/caste position rather than just the singular axis of gender identity, they say (P.321) Again: things are more complex.
Medical classifications take up issues and identities without investigating the cultural and conceptual baggage that comes from it, such as the false homo-trans or cis-trans binaries, that are definitely not global. The idea that people are either trans or homo is still pretty much alive, as incorrect as it is. Someone who starts out feeling homosexual and then moves on towards trans does not always leave their homosexuality behind, these are no discrete binaries. Nor is cis-trans a discrete binary: where to leave intersex people whose sex characteristics and identification may put them at odds with both categories. Using only one axis for identification leaves out several factors of importance.
With “transsexual” several elements from different disciplines are joined together under a disciplinary regime. Heteronormativity (why else get rid of reproductive organs that may still have a function for the trans person) as perfectly described under the old regime by Ines Orobio de Castro in her dissertation.
A good way out would be to first of all declassify gender identity issues out of the psychiatric classification categories and change it towards something along the lines of “medical assistance with (somatic) gender transition”. In technical terms it would end somewhere in what are now in ICD-10 the Z categories. As the campaign “Stop Trans Pathologization” suggests:
We identified Chapter XXI “Factors influencing health status and contact with health services” as the least pathologizing section for introducing a new “Trans Health Care” block in the ICD. In the process of elaborating a new trans health care block we consider it important to take into account the following aspects:
- The inclusion of an explication at the beginning of the new block / code stating that“trans health care” comprehends a health care that recognizes and affirms the chosen gender of the persons, independently of their birth-assigned gender.
- The inclusion of a description not based on etiological hypothesis or diagnostic criteria, but on a reference of procedures that are relevant for trans health care.
- We definitely need a human rights approach because everything is connected with rights, that we can ‘cash in’ or not. There is a right to health that should be applicable to everyone, including trans* people. There is right to be free of unnecessary and unwanted treatment. This is why the intersex movement says: keep your hands off our bodies! Just that bodies do not conform to societal standards does not mean they are to be cut open and rearranged. As we have a right to bodily autonomy it is up to the person concerned to indicate what they need.
And as we fight for our rights to self define our feelings and identities, expressions, we should leave the definition of transsexual out. An alien definition that promotes – with the relative entitlements – hierarchies under trans* people.
In this article I present two cases of trans* women in the Netherlands with their story that indicates thoroughly the transphobia and preoccupation with a mental health model of Dutch trans* health care professionals in the Amsterdam gender clinic.
Amsterdam Free University Medical Centre (VUmc) Knowledge and Care Centre for Gender Dysphoria (KZcG) is the biggest in the country with over 200 clients a year. That they have to bear the brunt of complaints is only logical in a restrictive transition supporting health care model. Some 80% of clients are seen at the VUmc KZcG, 10 to 15 at the northern UMCG and the remainder at private practices of mental health care providers; only a tiny percentage finds their way into medical assistance outside of VUmc and UMCG. This has to do with health care providers realising not having the cultural to medical competence to help health care users, plus the clinics discouraging providers to get educated in the field and demanding the client to go to their facilities in Amsterdam or Groningen.
The societal, medical and psychiatric tendency is to view transgender persons as having an identity issue or even identity disorder. This way trans* people entered psychiatric classifications (1978 and 1980) and have since never left. The general audience thinks trans* people to be freaks of nature that through medical treatment can be helped, involving genital surgery. With genitals being a topic of interest for people in general and for the cis supremacy, the SRS trope lives on even in progressive press. General practitioners or other (para)medical personnel generally do not have any cultural competence in dealing with trans* people. No official training apart from on the job when working explicitly with trans* people, is given.
International development through human rights interventions has led to the development that in all probability the next edition of the authoritative International Classification of Diseases of the World Health Organisation (WHO) will no longer list gender identity as a mental health issue, an identity disorder. All changes have been pushed for by the trans movement and taken up by among others the EU and the Council of Europe. Analogous to the struggle of homosexuals for their rights and for depathologisation, the trans movements have taken this up with considerate success.
The clinics however are only dimly aware of this and up to now arguing with human rights and patients rights does not have the success it should have, neither with the ministry of Health, health authorities and insurance companies (that play a strong role in the Dutch system) nor within the medical sector.
First do no harm
I contend that lack of consideration for a patient who indicates severe emotional/physical problems strongly related to her gender transition/gender identity, or not securely checking on a patient who indicates health issues with the medication, amount to cisgenderism. To a relative blindness for what lies outside of the expected realities, outside of ramifications of what might reasonably happen. In fact these two people and most probably several or even many others are withheld access to appropriate health care. Protocols and expectations count over individual lives while the decisions and lack thereof could have led to suicide or even death by medical neglect.
A doctor who puts protocol before patient and values strict enforcement of the treatment procedure over the wellbeing of their health care users, might need to think twice if they are in the right place. It is seriously debatable if such a situation is compliant with primum non nocere, first do no harm. Patient B had to go to her GP for the first instance of allergy and ended up at the Emergency Care for acute issues with the second anti-androgen. Due to hitherto unknown medical condition she showed lupus like reactions to medication and strong immunodeficiency reactions.
As other healthcare users report in interviews and talk among each other, and as the Principle 17 report shows, there is large discomfort with the care providers who are experienced as culturally incompetent.
Health care users regularly debate the medical stance that co-existing issues must be fixed before medical transition can start. In their experience it is exactly the “gender dysphoria” that causes or stimulates those other problems. Starting their medical transition causes a significant relief and makes several of the problems go into remission. Providers are advised strongly to listen more closely to the needs of their clients.
Person A called upon the Amsterdam gender team some nine years ago for needing medical assistance to align her body with her felt female gender identity. During the process she reported an ever increasing dysphoria with her body and feeling excruciating pains whenever she passed a cisgender woman in the streets. She reports this was related with on the one hand the endocrinologist not willing to accept her for diabetes that did not all interfere with her gender affirming treatment (not even to him) and on the other the psychologist who did not advance. She developed strong depression related problems around the rejection, the waiting times, the insecurity with a second opinion that might have had grave consequences.
Person B is as a young trans woman and had initially no problems. Shortly after going on anti-androgens she reported severe allergic reactions to them2. Long time she had all kinds of complaints, and never was taken seriously by the doctors or the psychologists. Then, as she decided to search a non-clinic plastic surgeon, she got a letter by the hospital threatening to stop her transition health care there and leaving her thus in limbo. Just for exercising her freedom of choice for a medical provider now that was a realistic option (contrary to changing transition providing centre). This issue is reported more frequently though it does not surface explicitly in the most recent Dutch research. Only after filing a formal complaint things got better. Now her transition is finished but due to non-gender related medical problems she is a very frequent visitor of clinic for treatment and for some finishing surgeries. Most doctors now treat her as an ordinary medical patient with not so ordinary medical issues. Apart from one surgeon at the gender department of VUmc, who behaves as arrogantly to her as probably to all other gender patients.
In my eyes this not only points to reproachable behaviour and questionable estimates, but also of an inherent transphobia. It is very questionable if a cis person would not have been believed. This is even more questionable for an academic hospital.
Gender dysphoria and being transgender is not considered an issue that may require medical assistance to relieve a societal problem, but in the core it still considered a mental health issue: there is something essentially weird/wrong with trans people. Gender dysphoria is still considered a psychiatric issue, as it is listed in the DSM-5.
Both examples serve to indicate a inherent transphobic and psychiatric attitude with the involved clinic. This patient is being read more and more as female and her self confidence has grown so she hardly perceives any transphobia anymore in the hospital (being read as the correct gender works miracles) except for this gender team surgeon who approaches her with arrogance and medical authority.
Both persons got no mental health care at the clinic, while person A actually just needed a less presumptuous MD and no psychologist; or a psychologist that really helped. Person B has her own therapist and in the clinic even had an extra psychologist who insisted in making clear that to her person B had not finished her transition and thus was not ready for surgery.
In a reaction to the Principle 17 report on the state of trans health care in the Netherlands from December 2016 that measured 43% complaints in the interviewed population, the director of the gender team suggested it was all word of mouth and an over representation of complaints. In the meantime the report and a petition will be handed to the Parliamentary Committee on Public Health, together with over a thousand supporting signatures gathered in four days time. It is election time now and that offers interesting opportunities to see what we can get.
De discussie over een betere transzorg lijdt onder onzekerheid over hoe een niet-pathologiserende zorg er dan uitziet. Dit stuk legt uit waar we vandaan komen en werpt een blik in de toekomst door een paar alternatieve scenario’s te schetsen.
De gendertransitiezorg (kortweg transzorg) in Nederland heeft een sterk poortwachterselement in zich. Wie de ‘keuringspsycholoog’ niet kan overtuigen is praktisch uitgesloten van deze zorg. En dan moet je hormoonvervangende therapie goedkeuring hebben van het hele team (consensus) en voor chirurgie is weer een deskundigenbrief nodig of teamovereenstemming. Dit model wordt nationaal en internationaal zwaar gekritiseerd en en er wordt flink aan de poten ervan gezaagd. Dat leidt tot onrust in verschillende betrokken geledingen. Bij psychiaters, psychologen en medici die bij de transzorg betrokken zijn. En ook bij transactivisten die het (nog weer) anders willen, en bij de transgender zorgvragers die zich afvragen of en hoe hun zorg toekomstig gefinancierd gaat worden. Dat vraagt om uitleg, en vooral om een visioen hoe het eruit kan komen te zien. Continue reading