Whimsical, queer exploration of all things gender.

Posts tagged ‘transition’

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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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.

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.

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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’.

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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.

 

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.

For any FtM readers in the UK in particular…

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

Research Context

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.

Research Questions

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.

 

Methodology

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).

Policy Implications

“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.

References

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.

When reporters write on transgender – common and subtle problems

The subject of this week’s post was inspired when a couple of friends contacted me separately to bring a particular news article to my attention. To each of you – thanks for your interest! And for making choosing a topic for this post that much easier.

The article to which I was directed was published on the 11th December on the website of The Boston Globe Metro, and can be found here.

But before we get onto that, let’s talk about today’s topic title more generally. For the longest time, it was basically impossible to find mention of trans people in mainstream media. It was a topic that made people uncomfortable. People didn’t generally want to hear about ‘that sort of thing’, either finding it irrelevant, uncomfortable, morally outraging, or any combination of these things. Without going off on a massive tangent on this background of LGBT in media, things are slowly changing and finding pieces of mainstream journalism looking at transgender issues is no longer like finding a four leaf clover by the light of a blue moon. However, the problem with more people taking notice is that more people can – to paraphrase Hugh Laurie’s Prince George from Blackadder III – be absolute arseheads.

Aside: Why did society start having a problem with men wearing wigs and make-up anyway?

Many, many incredibly shitty things have been written about trans people. A (perhaps) surprising amount of this has come from feminist and gay/lesbian sources, with (simplistically speaking) some of the former considering trans men to be ‘traitors’ to womanhood, and trans women are ‘just men invading female spaces’. I wish I was exaggerating. A particularly infamous piece of damaging refuse can be found in the form of the 1979 book The Transsexual Empire by Janice Raymond, which contains this charming quotation:

All transsexuals rape women’s bodies by reducing the real female form to an artifact, appropriating this body for themselves … Transsexuals merely cut off the most obvious means of invading women, so that they seem non-invasive.

In a similar vein, the lesbian feminist journalist Julie Bindel has written some really horrible stuff about transgender people. She was nominated for Stonewall’s 2008 ‘journalist of the year’ award, not exactly a great message sent out from this huge LGB charity (note the absence of the ‘T’).

This offensive horror was printed with Bindel’s 2004 article (linked to above) in ‘The Guardian Weekend’, 21st January 2004. The gist of the article argues that transwomen are not real women, and their experiences as women are invalid. The badge reads ‘I’m a girl’. 

So yeah, this stuff is pretty unequivocally offensive – but you could easily be forgiven for asking how this relates to the original link to the news story ‘Led by the child who simply knew’, at the top of the page. I’d like to add, that in writing this piece, I conferred with a few trans and non-binary friends, to see what they thought of this article. I did this because of my cis-privilege. Having this doesn’t make me a bad person, but it is undeniably there, and important to bear in mind when I’m talking about transgender experiences. If I simply bust out a load of opinionated stuff on such issues without ever actually discussing it with someone it affects directly, I would be in danger of speaking for a minority group I cannot claim membership of, and in fact risk silencing that group despite my intentions. So yeah. Obviously the people I spoke to could only talk for themselves, but at least I can say I haven’t made sweeping and unchecked assumptions about how this article may be received.

The problems here are less loaded with malice. More comparable to the accidental but nevertheless cringeworthy racist comments that elderly grandparents can sometimes pop out with. It’s not okay, but to some extent we can understand why it happens, due to lack of a certain specific bit of education. To borrow a term from the (fabulous) writer Julia Serano, the original article engages in oppositional sexism, which Serano defines as:

[T]he belief that female and male are rigid, mutually exclusive categories, each possessing a unique and nonoverlapping set of attributes, aptitudes, abilities, and desires.

Right from the start, we catch phrases like “Jonas was all boy. He loved Spiderman, action figures, pirates, and swords.” – would he be less so if he didn’t? In the case of his twin, Nicole, is her being female only justified through the presentation of stereotypical feminine behaviour and traits?

It’s not wrong to talk about Nicole’s experiences. If she likes pink, and mermaids, and Barbies, that’s great! But it’s important to not imply that this is what makes her female identity ‘real’. Little boys can like these things too, and not be any ‘less’, even if some people might argue otherwise.

See, Barbie can be fun for some boys too…

It’s also problematic that the name Nicole was given at birth is repeatedly used, and that she is referred to as ‘he’ repeatedly. As a baby and small child, she clearly wasn’t in a position to understand or communicate any gender identity. So why now her personal identity is clear, are inaccuracies of the past referred to? Gender identity isn’t immutable, but to frame the experience as ‘he’ was a boy who ‘became’ a girl implies both choice, and that being defined as ‘boy’ was the natural state of affairs – creating a hierarchy whereby genitals trumps identity. Not good!

The old cliché of “a girl in a boy’s body” is also touted. What is it that makes a body that of a boys? Lack of breasts? Oh hang on, little girls don’t have them. How about the other physiological markers? I’ve already talked about how this doesn’t really get one anywhere. Nicole identifies as a girl. Therefore, she has a girl’s body. Even if people ‘know what you’re talking about’, it’s potentially rather offensive to call a transwoman ‘biologically male’, or vice versa.

The article does do a valuable thing in providing some insight into the experiences of a trans girl and her family. The quotations from her parents about the experience help make the story relatable to people for whom this is totally alien territory. Whatsmore, Nicole’s self expression wasn’t smoothed down to being textbook-feminine:

“I would say my brother got lucky with me. Because we grew up with only boy neighbors, I developed a liking to shoot-’em-up and military video games,’’ she says. “I could have come out a lot girlier.’

It is important to recognise that the breadth of experience amongst trans people, just like cis people, is immense. Not everyone ‘knows’ from such a young age like Nicole, and that’s okay. Not everyone detests the bodies they were born with and want surgery, and that’s okay too. There aren’t ‘more’ or ‘less’ valid experiences of transgenderism. Unfortunately, breadth of experience isn’t something the mainstream media seems to have represented well just yet. There’s only a certain degree to which papers are prepared to challenge their majority readership. This article seems to me to be more sincere than simply a voyeuristic look at an atypical child, but could also be vastly improved upon with just a certain specific bit of education.

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