TRANS HEALTH CARE IN THE NETHERLANDS LEAVES A LOT TO BE DESIRED

Life for trans people is often complicated. The huge amount of gender stress stemming from cis normativity complicates the full development of a trans individual’s sense of self. Changing one’s identity documents to male or female – the only genders recognised in the Netherlands – is relatively straight forward. But in order to get trans specific health care, trans people have to wait for over a year and, once accessed, that health care is often not fit for purpose. This practice costs lives.

Defining trans

It is useful to have a common understanding of what we are talking about when we use the term ‘trans’. This term refers to anyone who feels that their body doesn’t fit comfortably with their gender assigned at birth and wants to make changes, sometimes social, sometimes medical, to alter that discomfort. When taking into consideration the entire trans and gender diverse population, including children and other people who haven’t come forward yet, to seniors who go back into the closet, we estimate that there are about one million people in the Netherlands (1 in 17). Only a small percentage opt for trans-specific health care, but almost all make some change to address the discomfort with their gender. By changing their voice, their hair, wearing makeup (or not), wearing jewellery … many use gender expression to feel more comfortable in themselves. Only a small minority require any form of medical support. Due to discomfort with the norms governing the body, hormones, psychological support and/or surgeries can be used to adapt their body to their needs and thus greatly decrease their gender distress. This distress may never go away fully, as the outside world keeps projecting opinions onto us about our identities and our bodies. This consistently reinforces gender distress upon us, even after accessing trans-specific health care.

Trans inclusivity

There exist good practices of how to design trans inclusive legislation, e.g. Malta in 2014, and the first good practice law, in Argentina in 2012. The same is true for trans health care. This does not mean that the social situation is also trans-inclusive, which is, at best, a couple percent better than in other places. In Argentina, travesticidios (murder of travestis, a regional trans identity) regularly take place, and trans-inclusive health care advances in fits and starts. For Argentina, it took several years after the was law passed to develop the current health care protocol, and Malta is currently in this process. Trans health care in Denmark is better. To start with, being trans is not an illness anymore, and their non-pathologising approach to trans-specific health care is better developed. In general, trans wellbeing is reliant on the following: the more you belong to the demographic ‘mainstream’, i.e. the better your class position, the less issues you face.

A report by TransUnited Amsterdam earlier this year showed that trans-specific health care for trans people of colour is not culturally appropriate. Health care providers often have too little insight into the, often, complicated situation of non-white bi-cultural trans people. This report is focused on Amsterdam, but it is unlikely that other places in the Netherlands are any better.

Lack of respect for trans people in general health care is even more of an issue. Several trans people with in-patient experience in psychiatry state they were not the only trans person in the clinic and that the consistent experience is one of lack of respect, with health care providers assuming that their transness is part of the overall clinical picture, with privacy always being grossly absent. Knowing this, one can only imagine how it is for a non-binary (not male or female identifying) trans person. Furthermore, when that trans person is also a person of colour, all cultural competence of staff disappears completely. In general health care, the “transgender broken arm” syndrome is still prevalent. This term was coined to refers to doctors that refuse to fix your broken arm (for example) because you are trans, so you have to go to the gender clinic (in Amsterdam or Groningen) to have it fixed. This practice is ridiculous, of course, and highlights lack of knowledge and cultural competency. There are still stories of trans people being treated incorrectly by their GPs or by nursing staff. This stems from pure transphobia.

Inadequate health care leads to health care avoidance, something which I do, myself. I have no interest in being patronised by uneducated medical professionals. The last time I went to see an endocrinologist at the VUmc Amsterdam gender team, he hadn’t read my file, misgendered me and assumed I was new, thus ignoring my 20+ years history of attending that clinic (which was clearly demonstrated in my file). Taking into account all the stories and research about trans-specific healthcare that I have accumulated over the years, I went to my GP with this knowledge to ask them to manage my hormone requirements. If I don’t get proper care from those who are supposed to take care of it, I will arrange it myself.

Social rejection

Trans people also experience problems due to poverty. This affects bi-cultural trans people disproportionately. Problems at home, in school, being homeless: all these situations impact upon your health. Trans people, generally, also have a higher likelihood of substance use, caused by stress placed upon them every single day. Multiple research reports indicate a relationship between stress in minority groups and high substance use. This heightened vulnerability often forces them into psychiatric care or sex work. However, sex work is not the most sustainable job in these times of increasingly restrictive regulations.

Having to wait for health care (currently 60 weeks wait in the Netherlands for trans-specific health care), poverty and lack of acceptance are factors that influence the prevalence of suicide ideation as a last resort. Among trans people, suicide attempts are at least five times higher than among the general population, and suicide ideation is seven times higher. These figures come from the suicide hotline 113Online. In general, statistics are higher again for young people across all social groups. Adult trans women who are not read as cis (a term that refers to people who are not trans), i.e. who do not ‘pass’ enough as cis, have increasingly more problems with gaining mainstream acceptance. This probably coincides with the existence of trans people becoming more well known by mainstream society, leading to greater visibility with an unequal progression in social insight and acceptance of trans communities.

Transphobic health care providers

When we shift our gaze to the population of trans youth, we see that they are realising that they are different earlier than ever and want to start their social transition earlier in life. It is at this that time they face social and legal issues. Social, because a dominant group in society does not care about the rights of the child to be themselves, to be happy (as required by the UN Convention on the Rights of the Child) and because there are no supports in place. Legally one can only change their gender marker at age sixteen, despite the fact that one can be sure of their gender identity at age six. Of course, medical gender transition support is only available from puberty onwards, before which it is not required. From a transphobic viewpoint, trans kids often are seen as gay or autistic, except for those that fit easily into the binary trajectory. A “real” trans person pursues medical transition with hormone treatment and genital surgery (among trans youth, this percentage is worryingly higher, at 95%, far more than trans adults). That a large segment could be gender diverse, rather than strictly binary, is not something these health care providers consider. The Amsterdam team is personally and professionally closely connected to anti-trans pioneer and reparative therapist, former chief of CAMH Toronto, Kenneth J. Zucker (see here at Transavocate [link] or shorter here at Queerty [link]). Such good pals that one starts to wonder how transphobic our great ‘helpers’ really are.

Given the assumptions upon which the Amsterdam team works, the focus on ‘carefulness’ and the cis heteronormativity, I see enough reason to call their working practices structurally transphobic, even when they do good work. For a solution, I would counsel the team to descend from their throne and start taking interest in the humbler social scientific approach. Looking at the attitude of doctors and the Amsterdam gender team especially, we still see an attitude of othering, of seeing trans people as different and unequal. An explicit example of this is dissected in a scientific article by J. R. Latham. These experts continue to argue for a cautious approach, insisting that a psychiatric diagnosis is necessary. This, however is not for our benefit, but for their protection. Informed consent works, that is why it has been introduced into other areas of health care. This is a human rights issue. Up to now, a trans person has never been employed in the gender team.

Needs/Wishes

The trans community has several needs regarding access to health care and the quality thereof. Of course, the needs may differ depending on the specific community, but on the whole we demand, at a minimum: quick, transparent, accessible gender recognition; an end to violence and discrimination; trans-friendly shelters; decent jobs; and adequate trans-specific health care where the health care user is taken seriously. We also demand an end to societal transphobia and the imposition of cisgender norms upon our bodies and our identities.

All of this has a strong connection to health and health care, because those with a decent job get more social respect and are consequently less isolated and lonely. Accessible gender recognition leads to less problems with job applications and with institutions. Working to end societal transphobia by weakening cisgender norms means creating space for everyone who experiences their gender in a different way that of a cisgender, heteronormative ‘man’ or ‘woman,’ or within a different embodiment than expected. All this results in less need for health care as a consequence.

Looking more directly at the health care process itself, diversification of health care provision is required, including provision of more locations where one can access trans-specific health care. Waiting times have reverted to previous lengths of over a year. Many trans people who are currently transitioning know of someone who ended their life because they could not manage any longer. Still, many people hope that the feelings of hopelessness and gender dysphoria will pass when they get married, or work extra hard in a typically ‘masculine’ or ‘feminine’ job. These individuals only report back to the clinic when they really cannot cope anymore. There should be better research on all of this, but there is not. Psychiatrists say that they want to keep the diagnosis in order to encourage research. However, homosexuality was removed from the psychiatric health classification system in the 1990s and research is still booming. Declassification is good for research, as Sam Winter, Ph.D., has demonstrated (research results forthcoming).

Is nothing good, then, in Dutch) trans-specific health care? The default programme (half a year of psychiatric evaluation before access to hormones and surgery) works relatively well, with the exception of the long waiting times. Also, doctors are becoming more aware of gender diversity. The psychiatrists, however – those useless gatekeepers – create a severe obstruction to health care access. Those who live ‘outside the box’ often have to place their life on hold for six months longer than necessary, through the requirement of psychiatric evaluation, before being granted access to medical transition (hormones and/or surgeries).

Quick solutions

The above shows there are quite a lot of issues facing trans people before they can live a decent life. There are, however, a couple of quick solutions that I want to offer, so that we can enjoy our rights and have a better life.

  1. Abolish psychiatric evaluation and engage in an informed consent process where the health care user has an active role and the final say in their own healthcare. This is demonstrated at Callen Lorde Community Health Centre in New York City. Eisfeld and Radix write extensively about this in the German Zeitschrift für Sexualforschung (Vol.27; 31-43).
  2. Establish more facilities for trans-specific health care in the country, with culturally competent providers, so that good experiences are not limited only to white trans people.
  3. Better management of existing facilities. A year waiting time is outrageous. Look forward, go off the beaten path, and work collaboratively with trans communities.
  4. Create a curriculum for general health care based on social scientific research around transgender communities with a focus on practical issues. Make use of experiences in relation to homosexuality or bi-culturality and health care needs. Teach providers to think differently.
  5. Encourage students and providers to choose trans-specific health care as a career path. Do not leave it to spontaneous initiative. Transness is too stigmatised for that.
  6. Improve the position of trans people on all fronts and create a health care budget for this.
This piece discusses the Dutch context where trans-specific health care is only available in an institutionalised context from two clinics. This version is updated from the original Dutch language piece that appeared on Dec 14, 2017 on Tijdschrift Lover website.

Thanks to Naomhán O’Connor for proofreading!

New rights for LGBTIQ people?

On November 27, 2017, the first expansion of the historic Yogyakarta Principles since their inception in 2006 was presented to the world. This 2017 edition (known as YP+10) builds on the authoritative interpretation of human rights legal practice of ten years earlier that clearly lays out State obligations under international law. The YP+10 document contains nine new Principles and 111 new recommendations mostly focused on the rights of trans and intersex people. The original Principles (2007) had been finalised at an expert meeting of human rights scholars and activists in Yogyakarta, Indonesia, and the YP+10 process took place in Geneva in 2017.


Anniversary

In December 2016, during the ILGA World Conference I attended in Bangkok, a 10-year celebratory event of the Principles’ existence was held. Three (of 29) of the original (2007) signatories were present: Mauro Cabral Grinspan (executive director at GATE) and prof. Vitit Muntarbhorn, the then UN Independent Expert on Sexual Orientation and Gender Identity (UNIESOGI). Co-signer Maina Kiai (UN Special Rapporteur on the Freedom of Opinion and Expression, UNSRFOE, until April 2017) was also present. The occasion was used to announce that a necessary update to the Principles was to commence in 2017. Undoubtedly, the global significance of the Principles as a soft law document in UN and regional forums, national courts, individual governments and in academia is undisputable – they are widely referenced.
It is said that the creation of the 2006 Yogyakarta Principles was largely a white Western cis person led process (around 60% of the Committee was white and Western, and 7% non-cis). Only two non-cis persons participated: Stephen Whittle, the man behind the then revolutionary UK Gender Recognition Act 2004, and Mauro Cabral Grinspan. This cis/non-cis representation balance had clear consequences in both the processes of textual construction, and in the resultant Principles; trans and intersex related provisions and interpretations were underrepresented. Many people feel that the 2007 Principles were largely drawn up with sexual orientation featuring most in mind. Fortunately YP+10 corrects this omission and re-balances the emphasis.
The original and the revised Yogyakarta Principles centre on the status of individuals rather than on their identity – therefore, for example, there is no mention of trans or bisexual identities. The Yogyakarta Principles refer to legally binding international human right laws that are already encoded in UN Treaties and to which countries have signed up. The Principles indicate what governments need to do (or not do) to meet their existing obligations “irrespective of sexual orientation, gender identity and expression or sex characteristics” (these words are at the end of each Principle). As human rights are universal, it is imprecise to conceive these Principles as defining ‘gay rights’ or ‘trans rights’ – or ‘new rights’ – they are simply showing how universal human rights already apply to us.

United Nations

If you have kept an eye on developments in the UN as an LGBTI+ human rights activist or as a professional, you will have observed that at least since the beginning of the 21st century human rights for gays and lesbians became an issue at the UN. Though at the same time they have been heavily contested, such as during the appointment of the Independent Expert for SOGI rights. Resistance went (uniquely!) up to the highest levels. Sexuality and gender clearly make some stakeholders fume with rage. However, during the recent replacement of prof. Muntarbhorn attempts to protest have been curtailed
Within the UN more and more work is being done to make human rights more LGBTI+ inclusive, but that is not where the focus of the Yogyakarta Principles lies. Because states in general have ratified several human rights treaties, such as the Convention on the Rights of the Child (CRC), the Convention on the Elimination of all Forms of Discrimination Against Women (CEDAW), Covenant on Economic, Social and Cultural Rights (CESCR), Covenant on Civil and Political Rights (CCPR), Convention on the Rights of Persons with Disabilities (CRPD). They all impose – voluntarily entered – obligations on states. But because these treaties are formulated so that they don’t take sexuality or gender into account, the Principles were needed. They mostly provide guidance to activists and to states, on how to implement existing human rights legislation and jurisprudence for everyone, thus inclusive of LBGTI persons.

From 2006 …

The original edition covers a multiple of human rights issues: 29 in total. These find sources in a number of Treaty Bodies and include the right to human rights, through to the right to life and recognition, the rights of freedom of expression, assembly, association, family life, the highest attainable standard of health and the prevention of medical abuse. And last, but not least, the right to reparations and redress. That essential right—the right to life without which all others fall away – appears as Principle 4. This Principle is about not tolerating killing or capital punishment for people on the ground of their SOGI status. This plays strongly in Indonesia or Chechnya e.g.. From here it is a smooth move to Principle 7: arbitrary deprivation of liberty because of SOGI status.
The name of Dutch trans health rights collective Principle 17 finds its source in the Yogyakarta Principles. Principle 17 is about the right to the highest attainable standard of health. The Principle contains nine obligations for duty bearers, and the new 2017 edition adds ten more. These explicitly include accessible, publicly funded, trans specific health care (TSHC), the right to PEP and PrEP relating to HIV, and the right to abortion. Principle 18 – protection from medical abuses— has not changed.Added to that is an additional Principle 32, the right to physical and mental integrity: “No one shall be subjected to invasive or irreversible medical procedures that modify sex characteristics without their free, prior and informed consent, unless necessary to avoid serious, urgent and irreparable harm to the concerned person.”
Principle 3, the right to recognition before the law has been amended with the new Principle 31, the right to legal recognition, and is trans specific and also intersex related: “obtain identity documents, including birth certificates, regardless of sexual orientation, gender identity, gender expression or sex characteristics.” This is more comprehensive than only certain forms of state documentation (like ID papers). Principle 31 states “everyone has the right to change gendered information in such documents while gendered information is included in them.” Also a real choice must be there, thus “Make available a multiplicity of gender marker options”: the Principles accept no limitations. Irrespective of whether you are old or young, mad or sick, criminalised, you have the right to the correct gender marker. And all this through a procedure which, as coined by TGEU, must be “quick, accessible and transparent”.

… to 2017

The new Principles are a deepening and completion of what was published in 2007.
There is a new principle (#30) on state protection. Every persecuted person has the right to state protection from violence, discrimination and other harm, irrespective of SOGIESC status. Whether it is State or non-State actors that persecute, the state has the obligation to protect people who are persecuted because of an unwelcome sexual orientation (homo- or bisexual, polyamorous) or gender identity (not recognised identities like queer, fag, butch, transgender) or sex characteristics (intersex related, because of how someone’s sexuation leads to severe medicalisation because of superfluous and grievous medical intervention).
Also there is Principle 35 The Right to Sanitation that confers responsiblities in many settings: at school, on the job (private or public), or in prison. And of great importance is the second-last principle: the Right to Truth. As the victim of a human rights violation one has the right to know precisely how and why this happened. Therefore one has the right to redress and reparation and support in rebuilding one’s life (like after having been imprisoned as a transperson in Turkey; or when maimed by lack of protection from violence).
It should be clear that the Yogyakarta Principles are important for the issues of sexual orientation gender identity and expression, and sex characteristics. Thus for everyone (including agender and asexuality here in the definitions), irrespective of being gay, lesbian or bisexual, trans or intersex. That is how the universality of human rights works.

Application

But how to use the Principles? How do they achieve more impact, and get more influence while being soft law instruments or guidance for States? First of all by always using them in your advocacy efforts with the state. The Dutch government e.g. has recognised the Principles as a human rights tool but at the same time needs to be held to that. In the considerations on changing the law on gender recognition they played an important role. So integrate them in your work. And don’t worry about being selective. With Principle 17 (right to health) I only focus on one field (albeit in conjunction with Principle 18, protection from medical abuses). It’s useful to note that some Principles are not of much use to us (trans/intersex activists).
Use them strategically. When convincing a public transport company to use gender inclusive language the Principles may not be useful, though when talking with local government on transgender and joblessness, it may be extremely useful to employ them, and tell where their wisdom comes from. how various issues are connected and intersect. They abundantly illustrate the universality, indivisibility and interdependence of all human rights.

Perspective

From a human rights perspective, we have great tools to get gender recognition and tailored health care by using Principle 3 combined with Principle 31, and Principles 17 with Principle 18. And as every professional knows, you don’t use only one tool from your toolbox. And if you don’t work with rights at all, it is still essential to know you have them, and to know your rights have just been sharpened.

 


This text is a translation of a Dutch original, published on December 11, 2017 on https://www.transgenderinfo.nl/nieuwe-mensenrechten-lhbtiq-mensen/

I am grateful for the editing assistance for this article by Aengus Carroll and Nathan Gale. Thanks a lot, gentlebeings!

Gendererkenning voor kinderen

Jazz Jennings is de ster van TV-show “I am Jazz”, kwam op haar zevende voor het eerst op TV en nu zet zich nu in voor andere genderkinderen

 
De huidige situatie in Nederland is dat kinderen/jongeren vanaf 16 jaar hun genderregistratie kunnen wijzigen. Maar velen die al in hun gewenste rol leven willen dat liever als ze naar het secundair onderwijs gaan, dus met 12 of 13 jaar. En een groeiende groep weet al heel jong wie ze zijn, neem Rens uit Amsterdam die op de lagere school al van rol is gewisseld. En Rens is beslist niet de enige.
 
Veel transkinderen die voor hun zestiende omgaan lopen tegen problemen op. Even er van uitgaande dat hun ouders of verzorgers positief zijn, heeft een school het recht hun registratie niet aan te passen, kunnen koppige leraren het in de klas moeilijk maken. Het feit dat de registratie niet is aangepast leidt tot problemen.Ook in de zorg kan het tot problemen leiden. Er is het voorbeeld uit Duitsland waar een gescheiden moeder haar kind na rolwisseling naar school begeleidt, en de klassenlerares antwoordt: “De vader was hier heel duidelijk over en ik wil mijn baan houden.” Of in Barcelona waar een kind al vanaf het vierde jaar is omgegaan maar pas met 18 en na psychiatrische evaluatie de papieren mag veranderen.
 
Hiertegenover staan landen als Malta en Noorwegen die in respectievelijk 2015 en 2016 hun wetgeving hebben aangepast en geen(Malta) of een heel lage (Noorwegen) leeftijdsgrens kennen. Zij hebben ook wetgeving die het kind sterk beschermt, op grond van het belang van het kind. Het recht van het kind gaat voor de wens van de ouders. Noorwegen laat een kind eventueel al met zes jaar wettelijk van geslacht veranderen en maakt er geen punt van als mensen heen en weer gaan daarin.
 
Het schaduwrapport dat COC Nederland, TNN en NNID in 2015 hebben ingeleverd bij de VN voor de laatste evaluatie van de rapportage hoe het ervoor staat met de rechten van het kind in Nederland, stelt een leeftijdsgrens van 12 jaar voor. Zonder medische of psychologische evaluatie. Men beroept zich hier op artikel 3 van het Kinderrechtenverdrag over “het belang van het kind”(“best interest of the child”). Algemeen Commentaar 14 bij het Kinderrechtenverdrag spreekt over het serieus nemen van de zich ontwikkelende capaciteit van het kind. Artikel 8 van het verdrag gaat over het recht op behoud van identiteit (“right to preserve his or her idenitity”) en geeft een niet-uitputtende lijst van criteria en daar horen religieuze, culturele en genderidentiteit beslist bij.
 
In eerdere instantie was bij de behandeling van de wetswijziging de vorige keer de wens van een veel lagere leeftijd ook de reden dat er uiteindelijk een deskundigenverklaring is gekomen. Regering en parlement hadden weinig problemen met volwassenen die zelf beslissen, maar kinderen was wat anders. Een SP-senator (oud-kinderrechter) stelde zelfs voor dat het dan maar gewoon via de rechter moest blijven gaan. De toetsing is van groot belang. En dat is nu waarschijnlijk nog steeds een heet hangijzer. De Kamer is er tenslotte niet progressiever op geworden.
 
Zoals gezegd willen we liefst de leeftijdsgrens gewoon weg hebben. Wanneer een kind zelf aangeeft niet de jongen of het meisje te zijn dat het zou zijn volgens dokter, geboorteregister en ouders, moet het dat ook in werkelijkheid kunnen omzetten. Er zijn verhalen van kinderen die met drie of vier al de boel op z’n kop zetten als ze de voor hen verkeerde kleren aan moeten.
 
Dit alles heeft natuurlijk niets te maken met medische transitie. Dat gebeurt pas wanneer de puberteit aanbreekt, en dan vaak nog pas rond twaalf jaar en niet als het al eerder begint. En als kinderen in die tijd zorg nodig hebben is dat vooral psychologische en sociale ondersteuning (later gaat het natuurlijk ook vooral om ondersteuning, maar dat werkt anders). Wanneer het goed gaat met het kind is er misschien zelfs vooral steun nodig voor het sociale circuit van het kind: familie, buurt, school. Dat die weten dat het goed is zolang het kind blij is met zichzelf. En dat ze eventueel boosheid en droefheid over de buitenwereld moeten onderscheiden van verdriet over zichzelf.
 
Onderzoek van de laatste paar jaar geeft ook helder aan dat transkinderen geen cent minder duidelijk hebben wie ze zijn dan ciskinderen. Zoek naar Kristina Olson en naar Diane Ehrensaft. En er zijn genoeg ouders en kinderen zelf die kunnen vertellen hoe hun leven positief veranderde toen het kind als zichzelf mocht leven. En als de kinderen later toch niet meer willen leven in de rol die ze eerder gekozen hadden, wat is daar mis mee? Mensen veranderen. We komen allemaal terug op keuzes. Ook jongeren. Zonder medisch ingrijpen is er niets aan de hand. En het kind zal zelden of nooit helemaal teruggaan naar hun oude rol en hun oude naam weer gebruiken.
 
Jonge kinderen kunnen dus net zo serieus zijn als oudere, waar het gaat om wie ze zijn. Veel transpersonen herinneren zich ook dat ze al voor hun puberteit wisten dat ze geen meisje/jongen waren. Op grond van internationale wetgeving (Kinderrechtenverdrag) en recent onderzoek vragen we de wetgever dus vroege gendererkenning mogelijk te maken, zonder extra poortwachters. Het is maar een letter tenslotte.
 
(Eerder gepubliceerd op 3 mei 2017, op facebook.com/vreerwerk/)

Why “transsexual” is an inappropriate term

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.

Western

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.

Ways forward

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.

 

The evil of psychiatrisation of trans people: just two bad examples?

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.

The cases1

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.

Action

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.

1The stories of person A and B are based on their own orally or written shared experience. My summary has been approved by them as accurate.