Below is my PhD proposal, which has been accepted to start later this year. I am going to be looking into problems that exist within medical policy and the medical establishment that unfairly hinder transition.
I am a cis (queer, but cis) white male, and I want you to believe that I recognise how problematic it could be, me trying to do this kind of work without having directly experienced the relevant issues myself. This is why it is going to be of utmost importance to me for this project to be lead by trans* voices. Not to just go around begging for interviews and treating people like data and stats. I intend to earn and keep the trust of anyone and everyone who agrees to work with me in the course of my work over the next few years.
What’s my motivation? Other than the obvious anger anyone who knows even a little bit about systematic cissexism should experience with regards to legistlative and policy structures, my best friend was an incredible trans man who I was very close to, but tragically he took his own life. Also I have been privileged in supporting my (now ex) long term partner through his own transition some time after this.
Bottom line is: please be in touch if you have anything to say about this project. I will take all criticism/encouragement/suggestions very seriously, as my cis-privilege means I should. Do feel free to pass this on to anyone you may feel would be interested, and follow this blog for further updates on this project – most of which won’t take off until October or afterwards, but yeah. So below is my proposal, as it was accepted:
Female to Male Transgender Transitions through the NHS – Addressing Policy Problems
There is no reason why psychiatrists and other mental health professionals cannot be charged with the responsibility of recognizing gender-identity issues without the necessity of labelling them as disorders.
Gianna E. Israel and Donald E. Tarver in Transgender Care: Recommended Guidelines, Practical Information and Personal Accounts
Transgender people often experience an urgent need for medical treatment in order to facilitate a transition in gender presentation. Whilst data is lacking, it has been estimated that suicide risk in post-operative trans people is potentially seventy times higher than the risk for the overall US population (Haas et al. 2011), and suicide risk has been estimated at 19-25% for those seeking surgical gender reassignment (Dixen, Maddever, van Maasdam, Edwards, 1984). Whilst distress for trans individuals may result from the dissonance experienced between the mental and physical self (characterised as gender dysphoria), lack of support, as with any serious personal issue, may have an extremely detrimental effect on the individual’s ability to cope with their situation. This research will address medical (and legal) policy in the UK regarding transgender transition for AFAB (assigned female at birth) individuals. The reason for this particular focus is that treatment routes and transition difficulties are extremely different depending upon the direction of transition, and this focus will allow for both a wider consideration of AFAB experiences and greater depth of analysis. This research is particularly timely due to the new edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) being due for release in May 2013, which should have some ramifications for how gender identity dissonance is addressed clinically.
Currently there exists no specific gender and sexuality minority training as part of UK medical degrees or clinical training. This leads to primary care physicians often being ill-equipped to deal with the needs of trans patients – and in some cases directly doubting or dismissing the patient’s needs, resulting in risk of harm. Of the knowledge of transgender issues amongst the primary care medical population, much is extensively pathologising. This is due to the historical status quo of the power dynamic between doctor and patient, whereby medical ‘expertise’ trumps lived experience and identity (Cohen-Kettenis and Friedemann, 2010). Similarities can be seen with the discourse generated by the reversal of knowledge/power relations between the medical establishment and HIV positive gay men in the 1980s, who also often had a more detailed grasp of their options and needs than their physicians did (Weeks, 1990). However, a key difference is the grassroots push towards recognition by the medical establishment that trans* identities are not inherently pathological – as reflected partially by the upcoming revisions to theDiagnostic and Statistical Manual of Mental Health Disorders (DSM-V). ‘Gender Identity Disorder’ will henceforth be understood as ‘Gender Dysphoria’, and ‘Transvestic Fetishism’ as ‘Transvestic Disorder’.
Relating to the Literature
Whilst the crux of this project will be the analysis of qualitative data generated by interview schema (as detailed in the methodology section), it will be important to further contextualise individual’s experiences in terms of queer theory. This will provide evidence of the extent of cissexist positions and behaviour within gatekeepers and other positions of social authority, and the social context of how this has come to be the case. Cissexism (the belief and treatment of transgender people as inferior to non-trans people) within society has already been considered by such important authors as Julia Serano and Riki Wilchins. It is also important to consider that in the formation of policy concerning gender and health, a binary model of gender is likely to be utilised, which may not provide recognition of the identities of all individuals who wish to transition (Bilodeau, 2005). The way in which any individual’s behaviour patterns (such as a doctor to a patient) are externally effected will depend upon the local cultures, geographies and other individuals they find to be their environment (Stevens 2004). A nuanced understanding of this may be aided by consideration of Social Identity Theory (Tajfel, 1981) and concepts such as dramaturgy – The idea that human actions are dependent upon where, when, and with whom they occur (Goffman, 1959).
Feminist epistemology will be used to address the intersection of patriarchal oppression (particularly when presenting as female) and trans identities, such as with the ‘border wars’ of butch lesbian, transmasculine and trans male identities (Halberstam 1998), transition from one group to another and how this can impact upon support networks and involvement in (for example) female-only spaces.
A key question of the thesis will be how and why did undesirable scenarios experienced by trans men happen? It is recognised that demand is greater than supply regarding appointments with NHS gender identity clinics, with 22% of users in October 2006 of the Charing Cross Gender Identity Clinic waiting over a year for a first appointment (Reed, Rhodes, Schofield and Wylie, 2009). Patients are required to have two meetings at such a clinic before being granted access to hormonal treatment, and the desperation and loss of morale that can accumulate in this time can result in risky self-medication using the internet to purchase hormones, self-harm, and suicide. The research will explore the space that exists between medical claims that may exist for the importance of the current framework that governs these appointments and the demands for improvement and change vocalised by the trans male population.
Other questions include asking to what extent may dissatisfaction with the medical establishment be a lack of detailed understanding of well founded (as opposed to well-intentioned but ultimately flawed) commitment to the well-being of patients? To what extent is the current medical establishment policy built on subtle cissexist assumptions and responses? A common argument for example, for the extent of hoops that need to be jumped through is that treatment with testosterone has certain irreversible physiological changes, and that protection must be offered to those who may ‘change their minds’, and be later caused distress and dysphoria by the retrospective treatments. The cisgender (to hold the same gender identity as was assigned at birth) perspective of how traumatic it would be to have one’s physiological gender markers (voice, fat distribution, breast tissue, musculature, etc.) altered in an undesirable way is arguably given a greater sense of importance than the provision to the treatment of trans people is (Taylor, 2010). It is considerably easier for a cis person to empathise with the former hypothetical scenario than it is with a trans person’s lived experience. The negative impact of undesirable physical traits is not at issue, but the insidious way in which what one is born with (or without) can be afforded a privileged position over the need for change.
This project will have a multi-faceted and interdisciplinary approach, utilising both empirical data and queer theory to synergistically explore the reality of trans experiences and the political and social frameworks within which these exist and are shaped. The precedent for transgender activism leading to a revision of policy is the framework upon which I will build this thesis. Through qualitative methodologies such as semi-structured interviews and surveying, I will collect and analyse accounts of trans men’s experiences with both NHS and private medical establishments, paying particular attention to delays and dissatisfactions with prescription to testosterone and approval for surgical procedures.
Whilst the focus of this project would be the experiences of self-defined male experiences, I believe it is also important to cross-examine such data with the experiences and knowledge (or lack thereof) of both primary and secondary care medical practitioners regarding their practice and knowledge of both transgender treatment provisions and what may be termed political considerations, such as pronoun usage and the phrasing of questions, and their necessity and appropriateness. Collecting qualitative data from staff who are involved with any of the administrative processes which dictates a trans person’s trajectory through medical systems may also prove valuable, though whether this direction is taken or not may be informed by information gathered from trans reports. Recognition and treatment of those AFAB individuals with non-binary gender identities is also to be involved. Whilst medical transition processes and lived experiences do vary in a clear and divisible way based on assignation at birth (before consideration of intersexed individuals at any rate), the social model of binary genders is being increasingly recognised as a dissatisfactory lens through which to view the wide spectra of queer identities which have gained visibility over the last fifty years (Hubbard, 1996). It is a common conception by many trans people that in order to achieve the (variable) desired end-goals of engagement with the medical establishment, a favourable narrative may need to be constructed in order to be considered ‘right’ (Rubin, 2003).
“I just want a therapist who ‘gets’ me. I don’t want to have to explain gender, sex, and all that other stuff. I have been to so many therapists where I have to educate them. I have to tell them first that I am not a ‘freak’. Then, I have to make sure they feel comfortable. And then we get down to my real issues.” – Luke, 21 year old transgender man
Handbook of Multicultural Counselling Competencies, Erickson Cornish J. A. et al.
The ultimate goal of the project is to offer a rigorous academic approach to both assessment of the efficacy of systems designed to alleviate suffering, whilst also exploring important questions of identities and power. The ramifications of such work would hopefully lead to policy review such that trans voices and experiences are better heard by medical establishments. Systems for recognising cissexism in policy (or where it could be enacted by free agents in positions of authority) can be created and used in protection from and prevention of cissexism, for transgender populations. This work will provide a rigorous, empirical approach to policy formation that will help provide a greater voice for an often poorly understood minority, undeniably improving lives.
Biloeau, B. (2005) ‘Beyond the Gender Binary: A Case Study of Two Transgender Students at a Midwestern Research University’, Journal of Gay and Lesbian Issues in Education, Vol. 3, Issue 1
Cohen-Kettenis, P. T., Friedemann, P., (2012) ‘The DSM Diagnostic Criteria for Gender Identity Disorder in Adolescents and Adults’. Archives of Sexual Behaviour, 39:499-513.
Erickson Cornish J. A. et al. (2010), Handbook of Multicultural Counselling Competencies, John Wiley & Sons.
Dixen, J. M., Maddever, H., van Maasdam, J., Edwards, P. W., (1984). Psychosocial characteristics of applicants evaluated for surgical gender reassignment. Archives of Sexual Behaviour, 13(3), 269-276.
Goffman, E. (1959), ‘The Presentation of Self in Everyday Life’. Anchor books.
Haas, A. P. et al. (2011), Suicide and Suicide Risk in Lesbian, Gay, Bisexual, and Transgender Populations: Review and Recommendations. Journal of Homosexuality, 58:10-51.
Halberstam, J. (1998) Female Masculinity, Duke University Press.
Hubbard, R. (1996) Gender and Genitals: Constructs of Sex and Gender, No. 46/47, Science Wars, pp. 157-165.
Reed, B., Rhodes, S., Schofield, P., and Wylie, K. (2009) Gender Variance in the UK: Prevalence, incidence, growth and geographic distribution, GIRES.
Rubin, H. (2003) Self-Made Men – Identity and Embodiment Among Transsexual Men, Vanderbilt University Press.
Serano, J. (2007) Whipping Girl – A Transsexual Woman on Sexism and the Scapegoating of Femininity. Seal Press.
Stevens, R. A. (2004), ‘Understanding Gay Identity Development Within the College Environment’, Journal of College Student Development, Vol. 45, No. 2, pp. 185-206.
Tajfel, H. (1981), ‘Human Groups and Social Categories: Studies in Social Psychology’, Cambridge University Press.
Taylor, E. (2010) ‘Cisgender privilege: on the privileges of performing normative gender’, in Gender Outlaws: The Next Generation by Bornstein, K. and Bergman, S. B., Seal Press.
Weeks, J. (1990) Coming Out, Quartet Publishing.
Wilchins, R. (2004), ‘Queer Theory, Gender Theory’. Alyson books, Los Angeles.