A queer exploration of all things gender

Posts tagged ‘non-binary’

I am your trans patient

I’m really delighted that a team (of which I was a member) comprised entirely of trans voices has been published in the BMJ (the British Medical Journal). Our article provides basic information for GPs providing healthcare to transgender people. Of course, we could’ve said a great deal more, and desperately wanted to. However, both the word count and editorial decisions created firm limitations around what this piece could do. Nonetheless, my colleagues and I are all proud of the piece, and would be hugely grateful if you’d take a look. Perhaps most importantly, if you know any medical practitioners, we’d be indebted if you’d send the link their way – the more practitioners who are comfortable and equipped to assist trans patients (with transitions and generally) the closer we come to best practice, and equal treatment.

The link is below. The language is non-technical, and there is no paywall (article is approx. 1000 words):

http://www.bmj.com/content/357/bmj.j2963

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healthcare, non-binary, Transgender

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Book Review: trans like me – a journey for all of us, by CN Lester

I was honoured to be asked by CN to offer a round of feedback on the manuscript for this book prior to publication (with Virago Press). I inhaled the text in a single evening, despite generally dragging my feet when reading longer pieces on my computer screen. The research was incredibly thorough, but at no point did this become dry or stuffy. This book isn’t an academic text in the traditional sense, but it’s certainly a very educational one – I’ve already cited it in my own academic writing.

Once I got my hard copy of the book, I felt it had been a long enough time since that editing process that I should really read it again before reviewing – plus, it wouldn’t be fair to assess a pre-final version. Generally I struggle with re-reading books, as my attention often wanes as a result of half-remembering what I’m encountering and having to fight the urge to skim. I was surprised with trans like me, that I was touched more deeply second time around than the first. Divided into 15 chapters over 214 pages, Lester’s conversational style creates an intimate and effective sense of a meaningful conversation over coffee with a friend. Before the journey has really begun, they explain how “to learn how to learn about trans people, about the ways in which what we know about gender is shifting and growing, we must first unlearn” (p. 5); their experience as a teacher comes through (which we are explicitly told about later, through their careful threading of personal anecdote through the narrative), and an attentive, skilled one at that.

Lester effectively conjures compassion in their audience through beginning by engaging with the worst exploitation of the tabloid press. Their points are consistently reasonable, relatable, and simple. There is no sense of polemic, only kindness. They give of their personal experiences and history generously, but without allowing any reader to fall into voyeurism. Lester gets us thinking about who has the power to tell stories, helping the reader to understand the incredibly invasive expectations, demands, and groping hands trans people can by explicitly targeted with. While there is a partial element of autobiography, trans like me reads as a collection of interrogative, well-evidenced essays that are absolutely committed to an empathetic and intersectional appreciation of many of the central discussions and concerns that come up when trans is on the discussion table. How race and class are profoundly relevant and necessary in any understanding of trans people is also not lost or buried.

It wasn’t far into the book that I started marking ‘wow moments’ in my margins. Brilliant, succinct ripostes to some of the most dangerous and disingenuous (yet pervasive) myths about trans people and communities. These are not incinerated in a blaze of adjectives, but quietly and decisively collapsed. The book manages to do this in a way that is not only affirming to those already familiar with the subject matter, but accessible to those who are not. Lester’s anger is something that one would hope everyone can agree with – anger about bigotry, injustice, violence, callousness, unequal rights, access, and experience. Lester hits the nail on the head by centring empathy in their education and discussion.

I mentioned that I was touched more deeply second time around. For me, this was most profound on page 35: “a question I am often asked is why, as someone who wants to subvert gender norms, i would want or need an additional gendered label. Couldn’t I simply refuse all descriptors? Or, failing that, call myself a feminine man or a masculine woman?”. This made me think of a line from Alan Bennett’s History Boys: “The best moments in reading are when you come across something – a thought, a feeling, a way of looking at things – which you had thought special and particular to you. Now here it is, set down by someone else, a person you have never met, someone even who is long dead. And it is as if a hand has come out and taken yours”. Now I knew this wasn’t unique to me, but I remembered being asked by an exceptionally well-informed and sensitive friend “but aren’t you just a feminist man?” in relation to my own non-binary experience. The discussion that Lester unfolds in response to the rhetorical questions they use is far more helpful (and humble) than a discrete, essential ‘answer’. It made me feel better equipped to have these conversations when (and it is when, not if) they come about.

There’s no such thing as a perfect book. However from my perspective, any critiques feel embarrassingly trivial or unnecessary. When discussing how trans women have been portrayed in popular culture (“the victim, the freak, the joke, the threat” – p. 29) I felt a mention of Julia Serano as quite a marked absence – albeit undoubtedly many of the readers of this book wouldn’t be familiar with Serano’s work. Further, as an academic, while I was glad to see extensive references in the endnotes, I found the system of links listed by page a bit imprecise. These things say much more about me than about the book, and most certainly don’t detract.

CN Lester is one of quite a small handful of people capable of introducing so many aspects of trans lives so well. Doing so to a heterogeneous popular audience is doubly difficult. I can only echo Shami Chakrabarti’s back-cover comment that “I challenge anyone not to have both heart and mind a little more open after reading this book”. This is a book for everyone, living up to the title’s implication of ‘a journey for all of us’. I believe this book can make its readers both wiser and kinder, and makes an incredibly important contribution as a result, that I enthusiastically recommend.

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Book Review, Feminism, non-binary, Popular Culture, Transgender

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Why We Should Stand Up For Trans Rights and Recognition at the University of Toronto

My good friend and colleague S.W. Underwood and myself wrote a piece in response to Dr. Jordan Peterson’s recent comments at the University of Toronto, regarding his refusal to use the pronouns individuals identify with. Please see here for the article!

http://torontoist.com/2016/10/u-of-t-trans-rights/

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News, non-binary, Popular Culture, Science, Theory Literature

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Review: The Transgender Equality Report, January 2016

Released on the 14th January, this 98 page report has already been usefully digested and impressively considered by a range of groups within the trans community (including Action for Trans Health, the Non-Binary Inclusion Project, and Beyond the Binary). I’ll be going through it section by section, aiming to break down the content for those who haven’t read it, and provide some points of consideration for those who have. The report can be found here.

The report comes from the Women and Equalities Committee, chaired by Mrs. Maria Miller. The committee contains 6 Conservative MPs, 4 Labour MPs, and 1 MP from the Scottish National Party. The bolded subtitles are parallel with the sections of the report itself.

Over 250 written evidence submissions were received, and five oral evidence sessions were held. Each submission was however limited to 3000 words, which rather caps those expert trans organisations and individuals who may have a lot of useful information to say on a range of sub-topics.

1. Introduction

Here the report provides a breakdown of terminology – what is a trans woman, what is a trans man, what is cis, etc. etc. They do take a simplified approach to non-binary, simply saying it is “located at a (fixed or variable) point along a continuum between male and female; or “non gendered”, i.e. involving identification as neither male nor female” (p. 5). They also specify here that it wasn’t possible to undertake an ‘in-depth’ consideration of non-binary needs in the report, but highlight a need for this, likewise for intersex people, whom they recognise as having potentially overlapping but distinctive needs.

They mention that “before commencing the inquiry, we consulted informally with representatives of two key stakeholder organisations, Press for Change and Stonewall”. PfC is a long standing champion of transgender legal rights, and Stephen Whittle (who founded the organisation) acted as Specialist Advisor – quite appropriately as he is both trans himself and a professor of law! The fact that Stonewall only began considering trans issues less than three months ago makes me wonder if there weren’t more experienced groups that might’ve assisted, and whether Stonewall somewhat rode on the coattails of its recognisability due to its sexuality based work.

2. Cross-Government Strategy

In this small section, the Government Equalities Office (GEO) is introduced. They published ‘Advancing Transgender Equality: A plan for action’ in 2011, which was criticized as largely unimplemented. They highlight that within 6 months the government must agree a new strategy which it can deliver, with full cross-departmental support, and must make a clear commitment to abide by the Yogyakarta principles, and Resolution 2048 of the Parliamentary Assembly of the Council of Europe. Given that these pieces of legislature were created in 2007 and April 2015 respectively, I am disappointed but unsurprised that these have not been explicitly incorporated sooner.

3. Gender Recognition Act 2004

Topics considered under this section include:

  • Applying for Gender Recognition Certificates (GRCs)
  • Spousal consent for gender recognition
  • The age limit of 18+ for gender recognition
  • data protection and excessive requests for GRCs

It’s good to see the committee recognising here that despite the step forward it was at the time (albeit obviously imperfect), there are aspects that are particularly dated and lacking, and in need of updating. It is highlighted that the requirement to provide documentation of a diagnosis of Gender Dysphoria (then Gender Identity Disorder) is necessary for a Gender Recognition Certificate to be awarded, is pathologising and problematic. The arbitrary and uncritical requirement of two years living ‘in role’ (whatever that actually means) before surgical gender affirmation will be provided was also highlighted as a failing. The committee concludes that “in place of the present, medicalised, quasi-judicial application process, an administrative process must be developed, centred on the wishes of the individual applicant, rather than on intensive analysis by doctors and lawyers” (p. 14). This is a welcome change, but desperately needs more specific functionality to be formulated and disclosed. As gender is assigned at birth on the basis of genital appearance, it is ludicrously unfair for those individuals for whom this cursory assessments turns out to be inaccurate to have to pay £140 for a certificate to have this revised. Whilst it is pointed out that the fee can be waived, an effective replacement system would benefit from being transparent, costless to applicants, and respectful of the self-determination of gender. Zac at Transistence points out that the report makes some factual errors about the requirements for a GRC, which may make it a more difficult process than they imply.

The next section on spousal consent has been reviewed as one of the more disappointing aspects of the report (among the reviewers cited at the start of this article). As it stands, an individual in a marriage who wishes to undertake a legal change of how their gender is recognised requires the agreement of their spouse on the basis that marriage “takes the form of a contract between two people of different sexes or two people of the same sex”. Action for Trans Health quite astutely makes the point that the basis of consent required for the status of the marriage to change from ‘opposite to same’ sex (or vice versa) is a clumsy, inefficient, and ultimately unnecessary (unless one is still attempting to preserve the ‘separate but equal’ feel to marriage based on the genders of the couple). No discussion is present over the idea of marriage contracts being de-gendered specifically (although it’s a good thing that on page 63 it is suggested that the government “should be moving towards “non-gendering” official records as a general principle and only recording gender where it is a relevant piece of information” – though the question remains, what criteria would be used to define gender as relevant?). For the government to fail to recognise the need to modify any system that allows one individual the power to prevent the legal recognition of another person’s gender (even for a time) is deeply concerning. No action was advised, despite advisory recognition that an abusive spouse may take advantage of this policy. Also, Scotland’s solution to this avoids delay or restriction on the trans spouse:

Under the Marriage and Civil Partnership Act (Scotland) 2014, which came into force on 16th December 2014, a married trans person whose spouse does not consent to the granting of a full GRC is able to apply to a Sheriff Court for a full GRC, on the basis of an interim GRC, without divorce or annulment having taken place. The process of obtaining a full GRC is thus expedited. The spouse of a trans person is entitled to be notified of the issuing of a GRC and can initiate divorce proceedings on that basis. (p. 16)

If Scotland can do it, why can’t England? It is one of the most insufficient responses that the committee concludes that any abuse of the legislation would be “deplorable and inexcusable” (p.17) yet they simply “more ensure it is informed about the extent and ways of addressing the problem”. The implication is that the ‘right’ to not be married to your partner for one single second as a legally recognised trans person is equal to the right to have one’s gender recognised. Thus the argument that marriage is a legal contract and that the non-trans spouse has equal say is rooted in transphobia.

A point many may regard as a victory, the report recommends that “provision should be made to allow 16 and 17 year olds, with appropriate support, to apply for gender recognition, on the basis of self-declaration” (p.19).

That not a single person has been prosecuted under the bit of legislation (section 22) to protect trans people from being outed illustrates how it has failed to protect anyone from or hold anyone accountable for this particular manifestation of transphobia. The report indicates the Ministry of Justice must investigate why, and work with courts to deal with this. The report recognises that there are “very few” situations where asking for proof of legal gender is appropriate, and yet the fact that this occurs raises cause for concern at how an individual’s trans status may be responded to by an organisation. As it is not unlawful to ask a person to produce a GRC under the GRA, it seems sensible to me that a clause be inserted that this is with the proviso that the request is justified and substantiated, and that absolutely no negative consequences occur if the request is refused on the basis of not being necessary.

4. Equality Act 2010

  • ‘Gender reassignment’ as a protected characteristic
  • Exemptions – separate sex and single sex services
  • Separate gender sport

This section paid some important attention to language, recognising how scrutiny of the terms ‘gender reassignment’ and ‘transsexual’ can be problematic for many, not least because of the increasing number of trans people for whom these terms are not reflective for. Lack of clarity can prevent the act from being fully effective, as it is illustrated that many erroneously believe that a GRC is necessary for protection when it is not. However, with regards to whether non-binary people are protected, it was stated that:

When the Equality Bill was going through Parliament the then Solicitor General had clearly indicated that it was only the provision in respect of discrimination by perception which would protect those members of “the wider transgender community”who did not come under the protected characteristic of gender reassignment. That is, they would only be protected if they were discriminated against because they were perceived to be proposing to undergo, to be undergoing, or to have undergone gender reassignment. The difficulty with this provision is that there are likely to be cases where an individual from the wider trans community, is discriminated against because of who they are and not because they are perceived to be transsexual.

That the report wishes to amend the act to protect on the basis of ‘gender identity’ is a positive step, but as with all aspects of this report, actual results will speak louder than good intentions.

The next point considered by the report was ‘separate sex and single sex services’, referring particularly to women’s shelters (such as rape crisis, or domestic abuse shelters), and prisons. A group called ‘Women Analysing Policy on Women’ reported a position ringing of uncritical TERF based arguments, saying there is a ‘clash’ when women who would feel unsafe accessing a service that is open to trans women should have the right to access services that exclude trans women – which is permissible as an exemption under the Equality Act. It is obviously terrible if any woman feels unsafe because of others using a service for those who have experienced violence. However clunky the comparison however, the debate would not be being had if it was a question of white women feeling unsafe around a service allowing black women access. That there is zero examples of pre, post, or non-operative transgender women committing a sexual crime in a womens’ shelter, the argument rests upon an implicit delegitimisation of trans women, as ‘really’ men. Such legislation not only endangers and discriminates against vulnerable trans women (who are statistically more likely to be at risk of sexual violence, or engagement in underground economies which may lead to imprisonment), but also polices a trans woman’s ‘authenticity’ on the basis of how well she ‘passes’ – a trans woman who is not read as such may be able to access exclusionary services anyway, whilst others would not. Worryingly, the Minister for Women and Equalities thought that such exclusionary practices were being used “proportionately, appropriately, and fairly”, despite this including facilities as broad and vital as public changing rooms, bathing facilities, and toilets (p. 30). That they only recommend amendment of the Equality Act such that “the occupational requirements provision and/or the single-sex/separate services provision shall not apply in relation to discrimination against a person whose acquired gender has been recognised under the Gender Recognition Act 2004” (p.32) – that is, awarded a GRC – is insufficient, and lacking in critical consideration.

Finally for this section was the consideration of separate-gender sport. The report recognises that exclusion of trans people from sport in their acquired gender should be a much rarer than than it is. Sports have to demonstrate that they are ‘gender affected’, and that a trans person would have some kind of unfair advantage, or for there to be a ‘safety risk’ to competitors. They recommend that the government works with Sport England to produce some guidance to avoid exclusions, as they recognise the unlikeliness of an exclusion being justified.

5. NHS Services

Obviously there’s a lot to be said here. and it is divided by:

  • GPs attitudes
  • Education and training of doctors
  • Professional regulation of doctors
  • GICs (adults)
  • Treatment protocols
  • Capacity and quality of services
  • The Tavistock Clinic (children and adolescents)

There are some recognitions that are important here, most clearly at the start of this section the clear admission that “the NHS is letting down trans people, with too much evidence of an approach that can be said to be discriminatory” (p. 35). There is further explicit recognition that “GPs in particular too often lack an understanding of: trans identities; the diagnosis of gender dysphoria; referral pathways into Gender Identity Services; and their own role in prescribing hormone treatment. And it is asserted that in some cases this leads to appropriate care not being provided” (p. 42). Whilst the report asks the General Medical Council to “provide clear reassurance” that they take transphobia seriously as a form of professional misconduct, there isn’t any more specific discussion of the importance of implementing a holistic and integrated consideration of gender identity into medical training.

It is positive the the problematic association between transgender identity and mental health services is recognised. I particularly support the notion of Gender Identity Services being established as a specialty in its own right, as it is a profoundly intersectional discipline that cannot be readily reduced to or conflated with only endocrinology, or surgery, or gynecology, etc.

Disappointing however is the seeming misunderstanding of the informed consent model illustrated by point 212 (p. 47). They suggest that the model is unconvincing because it would allow anyone to access whatever service (hormones, surgeries) they want on demand with no further scrutiny. It is accepted that there is a significant difference between accessing different gender affirming treatments – the ramifications of hormones are fundamentally different to phalloplasty or vaginoplasty. Not only do these have different ramifications for the individual, but also restrictive NHS budgets (that very much could be expanded were it not for ideological Conservative decisions… though that’s not a discussion for here) mean that the clinical urgency for an individual needs justifying in terms of need. A difficult topic, when it comes to finite resources I can at least understand the wish to prioritise say, those experiencing dysphoria over those who do not, or not as badly, but creating that hierarchy of need is never going to be without ethical issues. However, I do think this committee has been too quick in dismissing the merits that an informed consent model would offer, at least in the provision of hormones. That many trans people seek access to hormones only, with either no need/desire or at least no firm commitment on surgical intervention would allow those who are on the enormous NHS waiting lists to rapidly have their needs met. That there is a double standard regarding when cis individuals access hormones for a wide range of medical reasons is evidence to suggest that the refusal to allow trans people to take responsibility for their choice to take hormones or not, is at the very least, cis-centric. Were informed consent utilised for hormones, I posit that the waiting lists for GICs would decrease dramatically, allowing greater speed, attention, and resources to be provided to those individuals negotiating surgical gender affirmation.

I am somewhat perplexed by the claim that “The requirement to undergo “Real Life Experience” prior to genital (reassignment/reconstructive) surgery must not entail conforming to externally imposed and arbitrary (binary) preconceptions about gender identity and presentation. It must be clear that this requirement is not about qualifying for surgery, but rather preparing the patient to cope with the profound consequences of surgery” (p. 47). Does it require two years to do that? Are there other examples where surgeries are delayed for that long on the basis of preparation? What is the period meant to be an experience of, if not to satisfy to clinicians that the trans person has shown they’re super-serious enough? How does living in a gender role relate to practical preparations on genital surgery (given that major genital surgery in cis people doesn’t involve this). Obviously it’s good that they’re saying this isn’t for the imposition of external, socially constructed binary values, but I fail to see how as it is currently enforced, it is actually justified – and indeed, it has been long criticised as arbitrary, cis-centric gatekeeping.

In point 230 (p. 50) the report discusses how lack of specialist clinicians is a major, underdiscussed barrier to the introduction of more services. Whilst I think that a revision of hormone access ease would go a long way, this point could have been related to an explicit making-visible of gendered medicine within medical training, but wasn’t. Again, it’s great that the committee recognise how appalling it is that waiting lists for GICs are so long when the legal obligation under the NHS constitution is for treatment provision within 18 weeks, at this stage they’re simply reiterating that things are bad – when a lot of people want to see something done. So – good, but I’ll celebrate when we get some change, thank you.

It’s been a long time coming, but it’s pleasing to see the committee recommend a reduction in time required for young service users to wait before puberty blockers can be accessed – due to their reversibility (primarily), and the sensitivity of time as a factor. Such a vague (albeit welcome) conclusion could benefit greatly from some practical recommendation of how the time scale might practically change – well within the capability of discussion given the high involvement of the GICs and NHS in the discussions underpinning this report.

6. Tackling Everyday Transphobia

Here the committee makes points about:

  • Hate crime
  • Recording names and gender identities
  • Prison services
  • Online services
  • Schools and post-school education
  • Social care

It is a breath of fresh air to see the report explicitly state that the Ministry of Justice must ensure it consults fully with the trans community (p. 57) – and indeed, this should be the case for every sub-topic of the report. Low conviction rates, practical issues of intersectionality (which box do you tick when a trans woman of colour is a victim?!), and a (shocking) lack of parity between trans hate crimes and other hate crimes were all specifically acknowledged.

The report highlights that the laws on names in the UK are commonly incorrectly assumed, in that there is no such thing as a ‘legal name’ (p. 59). It is very positive that the committee recognises the necessity of dropping the pathologising practice of requiring a doctor’s letter in order to change a name on a passport. Further, the fact that Australia allows for passports with the gender marker ‘X’ rather than M or F was received positively as evidence that the UK would be quite capable of following suit. The claim by Karen Bradley that “The gender identifiers are important in making sure that somebody can be identified” fails to recognise that 1. there’s a *picture* and 2. there’s a host of additional identifying information, and that the gender marker doesn’t actually tell you anything, in and of itself. I believe the report would’ve benefited from deconstructing this flimsy counter-point. Overall however, the recommendation to move to a de-gendering of official documents where unnecessary (that is, most of them) should be praised. It was a missed opportunity not to link this discussion to that of marriage licences.

The recognition of the report of the deaths of Vicky Thompson and Joanne Latham underlined the sobriety and importance of the topic of prisons. Whilst the report recognises the importance of protecting trans prisoners and that housing individuals in prisons which affirm their gender identities, a lack of statement calling upon the Ministry of Justice to guarantee the respect of gender among trans prisoners (GRC or not) does not in my view engage with this topic with enough dedication. Access for Trans Health illustrate how there is impetus for prison services to allow trans charities and researchers more transparent access in order to collect necessary data about trans prison experiences, and also highlights the conspicuous lack of discussion of immigration detention, or how non-binary prisoners are to be located (one of many important points relating to non-binary that could be made, given that the report specifically states that non-binary was not engaged with in depth).

The assertion that trans issues should be taught in schools under Personal, Social and Health Education (PSHE) is an overdue but welcome conclusion. As with many of the points in this report, that certain things should happen is a given, and the details of how they will be properly introduced so as to be effective is the real question. Inclusion of transgender issues as part of teacher training is another excellent point – although consistency across private schools, academies, and religious schools are all concerns that necessitate attention.

————————————————————————–

As I have highlighted throughout, there are some very positive points and some letdowns. My overall sense at this point is one of caution – because fundamentally, nothing has actually changed yet. Whilst I do not wish to play down the hard work of many passionate and informed people for their part in this report, it’s undeniable that this publication marks the beginning of the execution of the next generation of change, not the end. Also it’s important to note that transgender equality does not exist in a vacuum from other social issues, and thus factors such as wages, income support/tax credits, the junior doctor’s contract (by proxy), NHS and prison privitisation and a wide range of other government policies will have very serious impacts on many transgender people.

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News, Transgender

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Non-binary gender identity negotiation – My PhD explained!

I gave this talk at the 2015 ESSL (Education, Social Sciences, and Law) conference at the University of Leeds. Enjoy!

Category:

LGBT, The gender binary, Theory Literature, Transgender

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Review: Louis Theroux Documentary – Transgender Kids

The Documentary Transgender Kids is available to watch on BBC iPlayer until 30th April 2015 – which can be found here. Apologies if you are outside of the UK and this link doesn’t work.

lt

On the 5th April, Louis Theroux’s latest documentary aired on BBC 2. To quote the BBC’s description of the programme: “Louis travels to San Francisco where medical professionals are helping children with gender dysphoria transition from boy to girl or girl to boy”. Whilst even this is an oversimplification (structuring transgender narratives as always having a binary ‘end result’, and also trans narratives or realities being dependent on gender dysphoric feelings, non-intuitive though this might be for some), the content of the program has been well received.

I agree with Paris Lees when she says that Louis excels at asking questions designed to aid the average viewer’s train of thought in understanding the subject matter. Whilst maintaining his position as ‘guy who doesn’t know much but wants to learn’, he also avoided tired issues of etiquette such as referring to people by the names and pronouns they identify with – as this is easily Google-able, but they moved through this in such a way so that viewers who didn’t already know this kept with the program.

The start of the documentary is strategically important and intelligent. We meet the parents of the little girl Camille, who iterate that their chief concern is doing right by their child, and learning how to best ensure their welfare – a position anyone can get behind. We are also introduced to Diane Ehrensaft who for me, was a highlight of the programme in demonstrating exceptional warmth, sensitivity, and wisdom. One would hope to see Diane’s approach in any professional working to support transgender and gender variant people, but which the voices of the transgender community tell us is sadly not the case.

People with little to no knowledge of transgender often ask the question ‘but how do you know’, and more so in the case of children. The anxiety surrounding the notion of supporting a ‘mistaken’ transition, of the risk of ‘getting it wrong’ is at the front of many people’s minds. It’s a big problem that many people (including medical professionals) can assume that it is ‘safer’ to prevent any kind of gender expression or transition that runs contrary to assignation at birth, because of potential risk. Louis raises this question (at 14.17 in, to be exact). Diane Ehrensaft is worth quoting directly in her response:

Is it a risk? Let’s call it a possibility. So with that possibility then we think, the most important thing is the same exact idea – to find out who you are and make sure you get help, facilitating being that person *then*. We have one risk we know about. The risk to youth when we hold them back, and hold back those interventions – depression, anxiety, suicide attempts, even successes – and if we can facilitate a better life by offering those interventions, I weigh that against there might a possibility that they’ll change later, but they will be alive to change. So that’s how I weigh it on the scales.

Bravo.

It’s also worth mentioning that whilst stopping or reversing transitions does happen, it is comparably rare. These examples shouldn’t need to be ‘hushed up’ because of the fear that they will be used to de-legitimise transgender people’s access to gender affirming services. Indeed one can see that being able to access such things and then stop can also be highly beneficial for an individual, to help work out who they are, and what they want.

The program didn’t make the mistake of trying to make a fictional debate about whether kids should or shouldn’t be given access – it was clearly sympathetic. I felt the show helped lead its audience to accept the importance of this point. It skillfully managed to do this without reducing the transgender voices on the program to one ‘line’ – there were definite differences between the children appearing on the show.

This was perhaps illustrated most clearly by Crystal/Cole, who exhibited a non-binary gender (although the show didn’t name it as such), sometimes expressing herself as Crystal and sometimes as Cole. They broached the fact that for some children (and indeed, plenty of adults as well) gender expression and pronouns could depend upon environment (‘he at school but she at home’) or on time (‘some days I’m Crystal but some days I’m Cole). There are also some conflicts within this particular narrative – Crystal’s mother (at 24.56) says that:

She has said in private with her therapist that she is a girl. Almost 100%. When I’ve sat down and had private conversations with her and said would you ever be interested in [transitioning medically], how do *you* feel about it? And her answer is ‘I can’t do that mommy, I have to be a boy’, and I enquire further as to why and she says ‘because I’m poppy’s only son, and it would destroy poppy’.

Louis_Theroux_Tran_3256908c

This hints heavily at a father who isn’t supportive/understanding/accepting of his child’s gender expression, though we also hear Crystal herself say that she doesn’t prefer one name over the other, and later in the program says she wants to be male when she grows up (though for the very normative reasons of liking the thought of a wife and children, as if one must be male to have this). The show deals with this complexity well, and reflection upon Dr. Ehrensaft’s words are fitting. Crystal/Cole may be a transgender woman who, as a child, is navigating her father socially. They may be a non-binary person, with male and female identities, or some further understanding of themselves may manifest over time. I felt we were invited as an audience to recognise that ‘searching for truth’ is not the point of engaging with transgender people, but the most important factors are respect within the moment, and facilitation of what is needed for happiness and health. Which is not as complicated as critics might make it.

The mainstream media has responded positively to the documentary, although not all the conversations to have come out of it have been positive. For example, BBC Women’s Hour disappointingly attempted to create a very artificial ‘for vs. against’ debate’. Quite rightly, this inspired anger from transgender activist CN Lester, fed up of trans voices and narratives legitimacy being framed as a debate, as if each ‘position’ had equal evidence and importance.

Bottom line – this is a strong and sensitive documentary which I would recommend. Whilst obviously positioned within an American context (and the differences with the healthcare systems are important to consider), many people could learn from the compassion of some of the parents who recognise how important it is to become an advocate for their child. By challenging cisnormativity (the idea that identifying with the gender one is assigned at birth is ‘normal’ or ‘correct’), society is slowly dragged towards being safer and easier for those under the trans umbrella.

 

Category:

Children, LGBT, Popular Culture, Science, Socialisation, The gender binary, Transgender, TV

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The 32 Problems I Found with this Gender Identity Service FAQ Guide.

Transgender people have, as a group, an enormous amount of awareness of the problems with accessing gender related support through the NHS. This post will highlight some of these problems. Below is a letter received in February 2015 from the Leeds Gender Identity Clinic, copied verbatim (including all errors, down to mis-spacings and grocer’s apostrophes). The quality of this letter is pretty dreadful, and prompted my critique and questions, to be found below the letter.

The numbers in square brackets are references for my points. Some numbers will repeat, indicating the same response to a repeat of a problem.

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Leeds Gender Identity Service

Frequently asked questions August 2013 [1]

Leeds Gender Identity Service is well established, around 20 years old and has evolved over the years. It is a dynamic process. Below are some frequently asked questions and our answers as they stand in 2013.[1]

1) What are the team’s views and commitment to the client group?

The service has a very committed multi disciplinary team. Fortunately all members of the team (Consultant Psychiatrists, Medical Practitioner[2], Endocrinlogist, Clinical Nurse Specialist’s[3], Occupational Therapist, Prescribing Pharmacist, Clinical Team Manager, Clinical Service Manager and the Team Administrators) Share the belief in the bio psycho social model[4] and its application within physical, mental, social and general health and Gender Dysphoria in particular. All members of the team believe in the recognition of Gender Dysphoria[5] and the need to facilitate and co ordinate gender reassignment in the safest and most effective manner.[6]

The service believe in mutual respect between service provider and service user, informed consent, capacity ,[3] guidelines and a flexible application accordingly[3] to individual needs are paramount to the success of an agreed outcome.

2) What standards of care are followed by the service?

The Harry Benjamin International Standards of Care have a well established and historical influence on standards of care which are considered worldwide, over recent times these have evolved into the WPATH, version 7, and standards of care for the health of transsexual, transgender, and gender nonconforming people. As a team we are mindful[7] of this guidance. The team are guided by the National Royal College of Psychiatrist standards; however these have not been ratified[8] are recognised by NHS England. The Gender Act, ICD10, DSM IV, Nice guidelines, Act of parliament 2004 and the policies of the trust including First Do No Harm all guide our practice.

The service has an active involvement in the development of the National standards of care professionals group. This includes other leading, NHS, Gender Identity Services in the UK. The purpose of the group is to define agreed, UK, baseline standards of care.

A proposed DSM V is due for publication; however this is still in draft format.[9]

The DOH[10] published guidance for G.P.’s[3] and other health care staff in May 2013. Leeds Gender Identity Service along with other NHS teams[11] were involved in the preparation of this document.

3) What is included within the care pathway?

The care pathway is guided by the standards of care which are stated above however has the ability to be flexible to meet individual needs. It includes all the stages of Gender reassignment, assessment, hormone treatment, social gender transition and surgery[12]. The service initiates the 2nd opinion and surgical referral but these are completed outside of the Leeds Gender Identity Service[13] therefore any waiting times associated with these are outside of our control.

4) What is the assessment?

The assessment stage takes up to 4 sessions (4 months) however a minimum of 2-3 sessions completed over a 2-3 month period could be agreed according to individual needs.

The criteria of the assessment is confirmation of the diagnosis of gender Dysphoria and exploring aspects of physical, mental and social health. Issues of eligibility and readiness to move into the next stage would be evidence based.

5) What is the social gender transition (SGT)?

Social gender transition is in its entirety approximately 2 years[14]. In order to complete an assessment of social gender transition the information gathered during this stage of social gender transition needs to be evidence based, this would include:

Living in role full time[15]

Change of name[16]

Some form of occupational activity[17] this could include voluntary work, paid employment, further studies or evidence of engagement/ daily living in the new role[18]. The service looks at occupational activity in the most flexible way and will agree with each service user how they will meet this requirement depending on their individual circumstances. If extra support is required by the service user a referral to the occupational therapist is available.

It is the service user[3] responsibility to collect this evidence. The team’s responsibility is to document it [19].

The hormone stage describe3d in question 6 would also fit into the SGT and will last 12months this would include a surgical referral once a positive 2nd opinion has been received.

Leeds Gender Identity Service is keen to learn from our experiences, working safely and flexibly within the care pathway to meet the changing needs of the client group.

For those clients who feel they are unable to live in full time SGT or do not wish to live in role at all in a specified area of their life e.g. employment ‘special circumstances’  this can be discussed with the clinician. If ‘special circumstances’ is agreed the following criteria must be met:

The client will be assessed as fitting the diagnostic criteria of Gender Dysphoria with a high level of confidence[20]. (In accordance with ICD 10)[3]

Psychotherapy opinion / treatment will be accessed and a detailed report provided to the Gender Identity Service supporting a referral for hormone treatment.

A 12 month plan will be agreed if appropriate to identify additional objective evidence for all other aspects of SGT can be ‘agreed between client and clinician.

6) What is involved in the hormone stage?

The service has an appointed Medical Practitioner, Consultant Endocrinologist and a prescribing pharmacist they are responsible for this stage of the pathway. The lead professional remains involved throughout the stages including the hormone stage. Close liaison with General Practitioner[3]/other professionals are a must. This stage could last for 12-18 months or significantly shorter in individual cases. While attending the hormone clinic Clients[3] will receive regular blood test[3] from their GP and blood test monitoring by the gender service, until such a time that it is safe to transfer all hormone treatment care to the GP including appropriate prescriptions.

7) What is the surgical stage?

Surgery stage:  2nd opinion is a prerequisite to a surgical referral. Once we receive a positive 2nd opinion a referral to the appropriate surgeon is initiated.  Any delays within this stage would be due to delays in variables[21] totally outside the control of the team.

The service will be responsible for referring clients to an NHS Gender Specialist for a 2nd opinion appointment however if individual clients wish to access private 2nd opinion appointments to speed up waiting times it will be the responsibility of the client to self refer or negotiate[22] this with their GP.

Leeds Gender Identity Service is happy to receive and act upon a positive, private 2nd opinion from a reputable[23] Gender Specialist at the appropriate time within the care pathway.

The service usually refers clients to specific identified surgeons however will consider referral to other areas if a client has a specific request and the CCG[24] are willing to fund surgery in the requested area.

Clients will need to have completed 12months,[3] full time, SGT before receiving a mastectomy and have received 6 months hormone treatment[25].

Breast Augmentation is not currently a core treatment[26] commissioned through Leeds Gender Identity Service; however clients can apply for this following completion of 18 months on hormone treatment[27] if there is clear failure[28] of breast growth. This treatment can be applied for through individual CCG’s via individual funding requests.

On occasions clients have requested orchidectomy surgery without a penectomy, the service will work collaboratively with clients to ensure the treatment provided is in line with supporting client choice and within the safety of clear clinical boundaries.

This would include:

Confirmation from the endocrine clinic that current hormone levels are safe, stable and within range.

And

A ‘one off’ appointment from an independent NHS gender Specialist is obtained.

8) How long will it take me to move through the care pathway?

The service follows a care pathways which can be adapted to individual circumstances taking into account transition which has already taken place before attending the service and specifically for those clients holding a Gender Recognition Certificate. An illustration of the pathway could be represented as follow:

The full process from start to finish around 3-4 years[29]

The shortest flexible process depending on individual needs could be condensed to 18-24 months; this has to be realistic taking into account waiting times for second opinions and surgery which are outside of the services[3] control[30].

9) How do the team keep abreast of new developments and ensure client safety and satisfaction?

The service is part of a wider governance group which include most other UK, NHS Gender Identity Service’s[3]. This group meets on a 6 monthly basis and shares views, takes learning’s[3] and discusses standards and guidelines within the area of Gender Identity.

The team are also part of the Specialist Services Clinical governance group within Leeds and York Partnership NHS Foundation Trust who meet on a quarterly basis and also have a team monthly Clinical Governance meeting where issues can be discussed in more detail. Clinical audits, rigorous clinical supervision, evidence based practice are all essential parts of our practice.

Service user feedback is an area which we have worked particularly hard on over recent years. We always provide clients with feedback forms following any new developments and we also ask service users to complete satisfaction questionnaires. Information taken from these forms is used to develop and inform practice in the service[31].

10) Will I get funding to access the service?

The service is commissioned by NHS England therefore potentially we could accept referrals from around the country. Individuals are funded for assessment and if appropriate core treatments which are funded by NHS England.

11) How will I know what is happening in the service?

The team have a specified lead in service user involvement she works alongside service user volunteers to produce a six monthly newsletter. The Newsletter will update all readers on any new developments within the service, will provide feedback on any completed service user feedback form and how this has informed practice and provide service users with an opportunity to display thoughts, feelings, poems or information to others!

The newsletter is posted out to all service users and is available in the waiting area.

You can also access the News letter via Leeds and York Partnership NHS Foundation Trust website.

12) What if I am discharged from the service but am experiencing a Gender related problem?

The service offers “one off” appointments to clients experiencing an issue they need to explore within the specialist service. To access this you will need support from your GP[22] so they can write to the team and ask us to see you. Again this will be funded by NHS England. The “one off” appointments may cover issues which are stated below:

“One off” assessment lasting for an hour n order to advise GP about outstanding problems and submit a medical (psychiatric) opinion.

A “one off” assessment lasting for an hour carried out by our Medical practitioner who is able to advise GP’s on endocrinology issues.

GP’s can also request “one off” extended full day assessment in complex referrals where specialist advice / recommendations are required.

13) How long will I need to wait to be seen once I have been referred?

The service is commissioned to see a specified number of new clients each year by NHS England[32]. Once we have seen these clients a waiting list will start to form for the next financial year. NHS England are kept informed on the waiting list on a monthly basis and will use this information to help identify new assessments to be funded on each rolling year.

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…And now my bit.

[1] – Well, at least this makes it easy to identify as out of date. Major changes have occurred in the provision of gender based care (such as the release of the DSM V – an important diagnostic tool which actually redefined gender related diagnoses). An update is essential.

[2] – Wait. Only one medical practitioner? For the whole practice? This is alarming not only because of how understaffed it makes the practice appear, but also if any service user has a bad experience with that doctor, there is no-one else. The implication is that access to services all go through this one person.

[3] Grammar is hardly the most important issue here, but when I read an official document providing medical guidance, and it reads as if it was thrown together and not given a second glance, that translates into an uncertainty about the meticulousness and professionalism of the institute being represented. Such primary-school-level errors simply give an unprofessional air, and are easily avoided.

[4] Even with a biology degree I needed Google here, so they could really rephrase to be more user-friendly. How about ‘we understand that personal, social, and psychological factors play a vital part in experiences of gender, and do not seek to reduce service user’s needs to something purely biological’?

[5] – Um. Whilst this is clearly meant to be reassuring, it’s so basic as essential as to come off as alarming at the idea that anyone possibly might not recognise Gender Dysphoria in a Gender Identity Service. If I went to the GP for a vaccination and they said ‘don’t worry, I believe in these!’ I really wouldn’t feel better. There is a history of medical practitioners failing to respect transgender people’s agency, but this statement is hardly an effective way to gain trust.

[6] – I’m so relieved they clarified they wouldn’t do things an unsafe and ineffective manner. Pointless waffle.

[7] – ‘Mindful’ – this is so vague as to be useless. It implies they don’t actually have any external code they’re bound to follow, and can choose to ignore any guidance as and when they see fit. I’m not an alarmist, and I don’t for one minute think guidance would be actively rejected. But not referred to, in preference of one’s own considerations? I can see that happening. Especially as they go on to blanket name six other sets of policies, as if trying to universally appease without actually committing to anything.

 [8] – If not ratified, why chosen/used? I couldn’t easily verify whether this has changed since 2013, but practising with unratified standards seems like it requires explanation, at best.

[9] – This is simply out of date. The DSM V has been published, and this is a really important point. The service is potentially then misinforming service users who may not have much knowledge on the topic.

[10] – Explaining what an acronym is when you use it is widely regarded as a good idea – Department of Health. Should also get a [3] tag for not being ‘DoH’.

[11] – If they’re going to say this, they might as well say who.

[12] – This demonstrates how practice is still quite focused on a model of transgender care that emphasises the gender binary, heavily implying ‘one state of being to another’. It of course is fine for individuals who do feel this way about their gender, but is an approach that fails some of those trans people who are most invisible and marginalised within society.

[13] – Why?

[14] – It doesn’t ‘take’ any time at all, because this is an arbitrary and artificial measure created by the medical establishment. This functions as a method of restriction and control, again policing gender identity along arbitrary and binary boundaries. See here, here. and here for some further considerations, though it’s fair to say it’s a point of contention and much discussion, but lacking much research, especially that which emphasises trans voices.

[15] – Further absolutist, binary conception of gender. The very existence of bigender people blows this out of the water.

[16] – If a person is happy with their name, why should they have to change it? Once again ignoring non-binary people, this also ignores unisex names even amongst binary trans people (Alex, Charlie, etc.)!

[17] – The argument for this is to essentially force trans people into being exposed to the world, again to demonstrate a performance of seriousness and sincerity for medical gatekeepers. Whilst this is argued to provide time within which to learn about oneself and gendered practices, it is highly problematic. Not only the danger this puts people in who wish to and may not pass (before being given access to hormones and procedures that can significantly aid in this) but also for those trans people who may experience mental or physical conditions which makes these demands difficult or impossible. The validity of an individual’s gender identity is not dependent upon how that individual is viewed by others in society.

[18] – ‘new vs. old role’ – a dated, binary based requirement and phrasing that doesn’t work for many trans realities.

[19] – And judge what can or can’t count as ‘acceptable’ evidence, which is coloured by binary and cissexist positionality.

[20] – I went into the ICD (International Classification of Diseases) 10. As it was endorsed in 1990, it was no surprise that it still included ‘transsexualism’ and ‘duel-role transvestism’, and used wince-inducing terms like ‘the opposite sex’. There was no obvious mention of ‘confidence levels’ in relation to diagnoses. Therefore what this actually means, I have no idea and I don’t see how anyone else could readily be expected to either.

[21] – ‘Variables’. Nice and vague there. Such as?!

[22] – The expectation to do this is problematic if someone has a GP who is cissexist or transphobic. Which isn’t as rare as one would hope or expect.

[23] – What defines reputable? Obviously this isn’t easy, but such vagueness only serves to emphasise the position of power which the Gender Identity Service occupies. Obviously it’s vital that standards of care are maintained in private practice as well as state funded, but this wording doesn’t help anyone.

[24] – Clinical Commissioning Group. But everyone knows that, apparently.

[25] – No explanation as to why this is. Further relates to problems with the Real Life Test/Social Gender Transition (SGT) as it stands. Fails to account for those trans people who are very knowledgeable, secure, and stable in relation to their needs.

[26] – More unanswered questions. Why? Estrogen does stimulate breast development yes, but frequently produces small or even unnoticeable development. To create a hierarchy of gendered traits/procedures seems inherently nonsensical as what different trans people value and need for their well-being is obviously variable.

[27] – An excessive, arbitrary, and under-justified restriction. Whilst one can appreciate that with change being stimulated by estrogen, an immediate surgery around that time may risk complications, this absolutism runs contrary to the pledge to individual service user needs and desires.

[28] – And a further restriction. Who decides what, and at what size, ‘failed’ breast development is?

[29] – In true cissexist fashion, prioritising the intensely small minority of individuals for whom gender affirmation procedures are not appropriate, to the disproportionate suffering of a very large number of trans people.

[30] – It’s not the first time, but the service has very clearly distanced itself from responsibility for delays. Obviously this is a recurring problem which has invoked complaints and righteous demands for explanations. Are all of these interactions outside of the service strictly necessary? Could the system be made more transparent so that service users can see what aspects of the pathway causes delays? These are questions that trans people deserve answers to.

[31] – Might it be prudent for the service to also engage with transgender groups, so as to get informed guidance from members of the transgender population who aren’t in the (often stressful) process of accessing these services? Of course the feedback from service users is essential, but by no means the only resource available to them for the optimisation of their services.

[32] – This is of particular note. The idea that only a certain number can be seen, in a way that isn’t dictated entirely by resources (as different individuals require different amounts and types of time and care) but is decided upon in advance doesn’t make sense. It also emphasises one of the biggest problems at the heart of the insufficiencies of NHS Gender Identity Services – lack of funding. The number of individuals seeking aid is growing exponentially, and this remains unrecognised by funding bodies. This isn’t a criticism of the document per se, but highlights one of the more important frustrations with the larger system.

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LGBT, Science, The gender binary, Transgender

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