Gender teams need to quit diagnosing trans* people

The press release of the Amsterdam gender team they sent out on Wednesday December 18, stating they cannot treat all the people who applied in recent times constitutes a brilliant opportunity to stop diagnosing trans people with gender dysphoria and start an informed consent based treatment process.

The day after the glorious victory of the passing of a strongly improved gender recognition law in the Netherlands, the Amsterdam Gender team that treats 85% of Dutch trans people who need a bodily and/or legal gender change, published a press realease saying they may stop accepting new patients within half a year.  Where there is an increase of 500% of applications in recent times, they do not get enough extra money to help them.

Of course this a bad development. When health care cannot be delivered people lose their right to health on certain points. On the other hand, with the attention because of the adoption of the new law, this is a form of blackmail. A way to hopefully get government and insurance companies around the table. Completely legitimate.

But as usual there is a back story to this. Dutch government designated the VUmc team as the Expert Centre on transgender Health in the Netherlands. And persistent rumours have it they use this position to create an oligopoly, having only the UMCG in Groningen that caters for the northern provinces, as their collegial competition. A small department at LUMC in Leyden treats trans* children.VUmcVUmc actively discourages surgeons or endocrinologists working elsewhere to treat trans* people. When psychologists elsewhere want to diagnose trans* people so they can have their bodily and legal changes, these are also discouraged.

I do no tell this to badmouth the work they do. This means to explain part of the origin of the problem. And probably from their point of view it is completely legitimate. So they need a good solution. Well, that is easy. Tell the psychologists to stop diagnosing their “patients”. That will save millions of euros.

Alternatively a better way of spending the money they got and the money they still need, lies in helping trans* people cope with the transphobia they experience. And with their internalised transphobia they develop from all the bad reactions. Psychologists are good at helping people get rid of many complaints and otherwise learn them cope with other issues. Transphobia (society’s reaction to people who do not fall within the accepted limits of male/female) causes depression and anxiety and more. Suicidal tendencies. That needs to be helped. But diagnosing trans people with gender dysphoria (DSM-5) or gender identity disorder (ICD-10) or gender incongruence (ICD-11, proposal) does not work. I imagine these psychologists would be far more proud of their work also, would feel more qualified ease these complaints than diagnose people with a non existing disorder. Additionally it will still be cheaper since not everybody needs this help.

 

 

Trans law in the Netherlands passed. Now what?

In the early morning of the 18th of December 2013 the Dutch Senate passed the proposal for updating the existing legislation of now 18 years old. It has been a long and bitter fight, in which some core demands have been realised, but it is not over yet.
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Against a third gender

For some time now the German decision to require parents of a child with ambiguous genitals to register their child without a sex marker and without protection or time limit, is making the news. To the growing displeasure of intersex activists.

Displeasure because intersex activists have not been consulted and if consulted would have advised against this law. Because of the utter confusion about a “third gender” or “third sex”. Because the way it works, parents and doctors will be inclined more to cut up the childs genitals instead of less. Without education or protection: who wants a sex ambiguous child?

To first tend to the misunderstanding about Germany that the press still furthers. Germany does not have third gender option. Not even or intersex infants. If a child is born in a German hospital (or at home) and on grounds of the genitals its se cannot be defined without a doubt, the requirement is to leave the sex marker (gender marker) open in the birth certificate. There is no time limit to it.

"Is it a boy or a girl?" "Isn't it a bit early to tell?"

Where the power to decide on the childs sex lies in medical hands the tendency will be to try to prevent any ambiguity, out of professional pride (“Look! We can fix this!”). Be it through prenatal hormone therapy (with certain intersex conditions the mother gets off-label prescription of dexamethasone), surgical or postnatal hormone treatment prescription Or even abortion. Preimplantation Diagnostics and other screenings are unwelcome interventions where it concerns intersex “discovery”.

This will not help prospecting parents in handling the body diversity of their child. The most friendly it will be frowned upon and run into problems when for example registering it for Kindergarten. Given the ttal lack of support in society, the enforcing of a sex and gender binary everywhere in life, already the child’s start will be complicated. How will it be treated by family (“we don’t now what it is”), in Kindergarten where everything is pink and blue ..

The way it works, intersexed children (they fit within a diversity of bodies, but through medical scrutiny they intersexed, made intersex or having a “Disorder of Sex Development” to make it worse) only get the worst of possibilities, not the best.

Would anti-discrimination legislation help then: Well, yes. Though there is a risk of making thngs more complicated to keep the system. Instead of creating a limited extra category, German government could have had the courage to open it up for everyone to have no sex/gender marker in the birth certificate and other documents. At least let it die out. So that from end 2013 all children would be free of a sex/gender marker, and after some years that population will have grown and gender registration starts dying out with the deceased.

A word about terminology here: usually we speak of gender marker, but it happens at birth on the view of the genitals of a baby. The “no sex marker” solution the german chose and others are eyeing, shows that sex and gender are constantly conflated. Because of specific genitals, a specific gender identity  and gender role is attributed too the child. naturalistic thinking with biologistic arguments then takes care of the rest: your gender is supposed to stay the same through life, apart from errors. in classic legislation the legal problem trans people present is solutioned along these “error” lines. Apparently the person develops differently than we expected, so we grant the right the correct this error. Another reason the Argentinean solution for gender recognition is so revolutionary.

The solution to havng a two option system and people that do not fit in can theoretically be solutioned by introducing a new category, or leave the field open. But that leaves two important questions: is it the best solution, and waht do the people involved say of it? There is a saying “Nihil nobis sin nobis”, nothing about us without us. Decent politics involves the group that has to benefit or suffers from a certain solution. This has not happened here. Elsewhere, in the Australasian region third gender solutions have been introduced through the explcit wish of part of the population. Not in Germany however.

What would be the best solution to the problem of having non fitting categories? One could opt for opening up a real third sex/gender category, indicated with an X on all official documentation (this is the internationally recognized solution from the ICAO). But for legsilation there must be  a need and it must be proportionate in its effect. In Europe (Council and Union) there also is the equality principle. New categories , new distinctions may only be introduced in legislations where equalilty is protected. In Germany this is definitely not the case, neither in Australia where inter* people cannot marry a man or a woman since they are not one. The very least to do is introduce protection against discrimination. If not it is a solution on unequal footing and against the equality principle.

Next there is the risk of wanting to create even more categories. Why not one or inter* and one or trans*? Sensile lawyers will rejext this idea since it makes no sense to discriminate between so many not really essential traits. Which in turn brings us to the question: if continuing to create categories is senseless, do the existing categories make sense? Does sex registration in the civil registry make sense? Medically speaking, sex registration might make sense. But the civil registry is not for medical information. With equality legislation covering more and more terrain, inequality between men and women seen as a somewhat retarded way of thinking (although still very much alive), what is the use of registering? Just because bodies are different and they have different roles? That is hardly a good argument.

The best way then is to simply abolish sex/gender registration at the civil registry. Make those categories moot, uninteresting, without importance. It is not about abolishing men and women ro male and female identities, it is just about quitting to enforce them. Most reasons to keep the status quo come from the same realm as objections against marriage equality between genders or the possiblity to change genders, sc. moral conservatism.

Of course between act and dream stand laws and moral objections – to quote the Dutch poet Willem Elsschot – but that should not be insurmountable.

Spanish trans activists start hunger strike

From midnight tonight six trans* activists In Andalusia, Spain will start a permanent hunger strike until either the bill for better trans legislation that is stuck, will be really introduced in Parliament or until they die.
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Trans kids need support not diagnosis

October 19, 2013 is the international day on the depathologisation, declaring not a disorder but a positive diversity, of trans people. And because of high level developments in the World Health Organisation, that is responsible for revising the International Classification of Diseases, that is used for understanding what is a sickness, a disease, a disorder – be somatic or psychological. This is a global Classification – unlike the DSM that is still mostly US based but having a wider use. Here in NL psychologists use it, health insurers use it. For adolescents and adults there is a positive change going on, although the battle is not yet won. Because of this last issue, introducing a diagnosis for children, and 2014 being a decisive year for the new ICD, the pathologisation of trans children has been chosen as the theme for this year.

Stop Pathologizing Gender Diversity in Children

The suggestion for a theme usually comes from Spain where the campaign started in 2009. It was the time that the process to change the DSM started and they started to create global awareness for the changes. After all: the DSM still declares trans* people having a mental health problem. And when the process to change the ICD got under way, this had been taken into the campaign. Nowadays a strong focus of advocacy for trans health lies in getting a good description in the ICD-11. Since that will be decisive for how many people in the medical and political world will see us. If trans people are not (mentally) ill, but instead suffer from society, we will be taken more seriously. So that is why today and why the theme.

What is today about?

I will first define the situation: gender kids are not welcome as who they are, most learn to hide very early in life. I have recent data from the UK on that. Next I will give an overview of several developments in the social and the medical world. I will focus on how the big international classifications that are in use. By that I mean the infamous Diagnostic Statistical Manual of menatl disorders (DSM, version 5) of the American Psychiatric Association (APA)  and the global, more responsible International Classiication of Diseases (ICD, version 10) of the World Health Organisation (WHO). Developments there are going in the wrong direction. And that has pretty much to do with it being children and with queerphobia.

Also I will give an update on developments in the Netherlands; what support is there, how are parents reacting? What does the clinic do? What would be good ways to advance our case for gender freedom?

Trans*

To start with trans*: this is not just transgender in the transitioning variant. It can surely mean transgressing gender norms, being and behaving gender non conforming. Because trans* is who trans* does. In a way many of you are also trans*: you do trans*, you transgress gender norms. Don’t come to me “Hey, but I’m fine with my body”. That is just one version of gender diversity, of trans*. Being trans* does not require gender dysphoria or gender incongruence or however you call it. And trans* is not just identity, it is also expression. Since so much what we all gay or lesbian or bi, is more gender expression than sexual orientation or gender identity.

So trans* can be anything non gender conforming. And acceptance for that already is quite low for kids. While the Netherlands may be relatively tolerant of it, and many young parents seem to be, recent UK data show that also the seemingly more accepted tomboy behaviour of girls and non apparent trans boys is not really accepted. Non-apparent then stands for people who later in life tell to be trans already from early on but didn’t tell anybody back then.

Kids

And by kids I mean children before puberty hits them, which roughly mean between 10 and 12 years old. Usually one says: puberty starts with Tanner stage 2. Then physical changes start appearing. In the Netherlands that gets ever earlier, and in several other countries also.

Although it is a generally accepted idea that children change, that change and development are the core phenomena of a child’s life, many implicit norms govern this period. A good example is that there is an Amsterdam kindergarten where children of many gay and lesbian parents spend their day. The personnel are very happy with the lesbian and even more with the gay parents. However all the kids are neatly divided in boys and girls and treated differently. I think this has much to do with idea that being gay and lesbian is seen as only a relationship thing, a sexuality thing, something private. Gays can be great parents also! But this goes completely beyond the point that so much is gendered behaviour, based on gender identity and/or expression.

Sterlisation is for cats, not for me

Sterlisation is for cats, not for me

ICD

 It is clear that the Committee that manages the chapters relevant to trans people is convinced gender identity issues must be relabeled en get a different position. The name is in the process of being changed from “Gender Identity Disorder” to “Gender Incongruence”. A mismatch between body and felt identity. That is better already, better also than Gender Dysphoria. But:

  1. Why must there be such a diagnosis? The gender identity is not wrong, just different.
  2. Being non trans*, the default situation of being cisgendered, still is the definition of Normal
  3. A new diagnosis is being introduced that concerns trans* children. So a child living differently is still bad, wrong

It is the WHO that decides through scientific research what is to be considered a sickness, illness or disorder. Everything health related is in their remit. For the description of diseases etc. there is the International Classification of Diseases, ICD for its abbreviation. It is going to version 11 now, after the longest time between versions. ICD-10 is from 1990 and got in to function in 1994. Since 20 years is a long long time, the changes will be drastic, and many things will change: biomedical sciences have advanced enormously and everything may be streamlined more than before. So it will also be in things transgender related.

But the WHO is not only purely scientific and apolitically health care related. LGBTI issues face enormous contention from the usual suspects of human rights refusers for LGBTI people: the Vatican, the African group Russia and some consorts, several countries united in the Organisation for Islamic Cooperation. Recently there was to be a discussion about discussing LGBTI health issues and the issue got removed form the agenda thanks to pressure from these countries. For now the tendency within WHO is to declare it a technical issue and remove it from the agenda because of too fierce resistance.

Trans identity issues are now going from the horrible: Gender Identity Disorder” to most probably “Gender Incongruence”. The DSM 5, that American horrible psychiatric classification uses gender dysphoria. Incongruence is the least harmful term of the three, but still does not take its departure in gender diversity with all gender identities equally valid. So tis still not good. Gender dysphoria means one has lots of stress, anxiety, depression because of ones trans identity. Which is another case of wrong angle: it is not the identity in itself that causes so much trouble, it is how the world reacts and how one learns to look at it. And you know already quite young if it is OK to live like you feel. Which is why many trans people only come out later in life. Lucky the people who have enough to support to come out young. And can more or less freely develop their identities.

Gender Incongruence only means that your body and your identity do not match, are not congruent. But that still is not good enough of course. It is doable and better than dysphoria, but still.

The bad new thing for this Classification is that suddenly trans kids*, those who are not adolescents, the K-12 kids, need a separate, autonomous diagnosis of their Gender Incongruence. It will then be called, gender incongruence in children. But there are a couple of strange or incorrect things with this.

An important detail to add is that the proposal is to have the diagnosis onl apply to those children with severe complaints. Not every kid with a non traditional gender expression would fall under it. Only those whith “severe incongruence” as I imagine the wording might be. The fear for gendernon conforming behaviour seems to lessen in these circles. because they aslo say this with adults adn adolerscents, lready in the DSM-5.

First and foremost: they are sort of de-pyscho-pathologising adults. Because adults will be in a separate chapter for gender identity stuff, or in a chapter on sexual health. Not any more in the current chapter (F.64) of mental and behavioural disorders. But since children below puberty cannot get puberty blockers, there is nothing medical with them, so diagnosing them is diagnosing their – changing and developing – identity, means putting them with mental health issues.

When there is nothing medical, there is no need for diagnosing. So it is irrelevant. Surely since psychosocial support can be arranged through already existing constructions. This way a new class of experts and of treatment will be created. And once created, a specialism doesn’t want to close down.

Situation of trans kids according to research

Since this is all about trans* kids, it would be good to know a bit more about how they live, what their problems are. The problem is: there is only very little research in this. And most comes form the medical/psychiatric division of society. Not only that, it comes from researchers with a strong agenda for normalization. A name to remember in this is Kenneth Zucker from Toronto. In Berlin, Germany there is professor Klaus Beyer working with trans* kids who also has clearly non respecting ideas. Don’t get your kids to the Charité hospital in Berlin if they are queer.

The problem with Zucker and his pal Richard Green is their disrespect for the autonomy of trans people. Green is the author of “The sissy-boy syndrome”. He is Zucker’s predecessor and together they try to make a strong case for reparative therapy. This means: attempt to -de-transgender the kids, to un-gay them. Because gay and trans is Wrong. And trans is worse than gay (that is at lest within the gender binary). In the Netherlands people like these do not work at the gender clinics, but they might run loose as independent psychiatrists. Which might be even more dangerous: if the parents don’t know about the gender clinic’s youth program or better about Transvisie Zorg, the child might suffer much.

Natacha Kennedy

Natacha Kennedy

From recent UK research by Natacha Kennedy we know that of the respondents to an online survey most were ‘non apparent” trans kids. That is: they felt different already early in life but came out far later because they knew it was not considered a good thing to be trans. Already at age 8 the social radar of all children is god enough to realize this. There is no majority of one type of trans* in this research: the respondents have come out as cross dressers, transgender, genderqueer, mixed gender. The consequence of this feeling already quite young to be apart, different form the others leads to the feeling of not being able to live as one wants, to invest a lot in a gender identity that is not one’s own.

That does not have to contradict our cherished idea that gender is doing. It appears many people who live one thing, slurp, suck in what they are actually more interested in. To quote Butler in this: “Femininity is thus not the product of a choice, but the forcible citation of a norm, one whose complex historicity is indissociable from relations of discipline, regulation, punishment.” (Bodies that matter). Anyone wonder about the appearance of “gender dysphoria” then?

This nonrecognition of gender diversity is something seemingly universal. Surely here in the Netherlands the idea of gender expression is not very developed in general discourse.

transvisie zorg

 Support

So what is there in support? As it is said the Netherlands is doing very well in medical support for adolescents, the question of course is: what is there for the young one? Well, there is support from Transvisie Zorg that have a social worker and a sexologist who see the parents, visit schools, talk to schools, see the kids if they want. Most of their work is with the adolescents, but a growing number of parents call for support. Their list of visited schools grows at 40 schools per annum!

The most common phenomenon roughly from 10 on, is bullying. More girlish boys than boyish girls get bullied. However every school got protocols against bullying. When talking with schools Transvisie points at bullying and the need prevent this, but it is mostly up to the kid and their parents to go to school and tell the staff they get bullied.

 And then there is the gender clinic that gives “temporary” diagnoses. Precisely in the idea the ICD want s to have that diagnosis: to make it easier to enroll in the adolescent program. How good the support is, depends very much on the quality and opinions of the psychologist.

Free & equal

unfe_image_357_full

A gay rights conference in Antwerp

From July 31 to August 2 the World Outgames LGBT Human Rights Conference took place in Antwerp. The conference was titled: “From safe harbours to equality. A changing LGBT world: transitions and migrations.” For a LGBT human rights conference I am sad to say it was an absolute failure for being not inclusive and run mostly by Gay Inc. The only good thing being mainstream gay being called out on racism. Continue reading

The pain in Spain

Recently Carla Antonelli, actress, trans* activist and social-democrat politician in the regional parliament of Madrid sent in a bill to improve trans* rights in the region. It contains quite some positive elements, but on several important points like, access to health care, it is worrisome and not depathologising.

Precisely in the right wing times with a cold anti-rights wind blowing,  in an autonomy and civilian-centred hating climate, it is of utmost importance to not only strive to keep what we got but to further our agenda. When playing the parliamentary game, staying is loosing.

Spain is the second country in Europe to have abolished the requirement of gender affirming surgery, in 2007 as one of the first significant civil rights acts of the Zapatero government – although it took a hungerstrike by Carla Antonelli and others to convince them of the seriousness. The results were good for the times, but not standard setting. Still psychiatric evaluation is needed with a diagnosis gender identity disorder. The clinics are called  “Gender-identity-disorder units”. While requirements for medical treatment are strictly not part of the text of the law, there is a requirement to show you have (formally) undergone two years of cross sex hormone therapy.

antonelli y zerolo

In the 2007 law no anti-discrimination provisions has been recorded, and in a transphobic and homophobic country as Spain that is an important grief of many trans* People. Attempts to improve the current law into an “integral law” that takes care of all issues touching trans* people is stuck since there now is a conservative majority in the national parliament in Spain. In the regions, the autonomous communities (somewhere between provinces and states), alternatives are being brought to the floor of parliament with a different character, dealing with elements in the power of the region. Thus Andalusia in the South (with Seville as Capital) has a different proposal than Madrid.

The Madrid proposal is attached here as Antonelli-saenz-transexual (Spanish!). The law is meant to eliminate all kind discrimination that may be directed at trans* people. Some highlights are:

  • No discrimination on the basis of gender identity or sexual orientation is allowed
  • Reparative therapy is absolutely prohibited
  • The law would protect the rights for recognised trans* people to the correct gender in municipal administration
  • Protection  in the workplace
  • Undertakes action against transphobia
  • Medical transition support for recognised trans* people, be they minors or adults
  • Attention or trans* people in education and to educational material

Swear dissonance

The shortest way to summarize my comments on this proposal is: anything that falls short of the Argentinian law on legal gender recognition of 2012 is not good enough. However that is very concise and I will explain this is more detail referring to the proposal at hand.

The Spanish use of transexual is problematic because it creates a separation between those eligible for medical assistance and those not eligible. Because they don’t want the kind of treatment offered or because they cannot – for whatever reason. In the Spanish context this may make sense but still, conceptual confusion is conceptual confusion. Leaving that for what it is, I start with the basic question: who counts as a transsexual? Title 1, art. 3.2.2o reads:

 Any person that states to the Community’s authorities through a sworn declaration to experience a stable and persisting dissonance between the morphological birth sex and the felt gender identity. This declaration does in no way imply a medical, psychological or other one that pathologises transsexuality.

So, no external authority has the right to pathologise you, but a sworn declaration by yourself of dissonance/incongruence, mismatch of sex and gender is sufficient. That leaves agnostics and atheist with a huge problem: they cannot and will not swear to any deity. We need to get rid of religion on legislation (apart from legislation that safeguards the right to religion). God or which ever deity has nothing to do with state affairs.

Next there is the problem of auto-pathologisation. Doctors, nor psychologists or therapist are allowed to tell you that  there is an inherent problem with your difference, that you suffer form a (mental) illness. One might say: stating your dissonance is not the same as declaring not to be an illness. But why would you have to give a reason then? This means you are not taken serious in your wish if you don’t have a Serious Reason to change. And then: why should you experience dissonance? Why not because it feels better that way? The reason you have to give is the new phrasing of the old Gender Identity Disorder paradigm. So much hasn’t changed, the book’s new edition has a different spelling, maybe a different colour. The emperor wears new clothes …This is no change at all. If you want to prevent pathologisation, you shouldn’t ask people to swear they experience a dissonance. It should be enough to give a written and signed statement, that you identify as or prefer to registered as the other acknowledged gender (since Spain like all of Europe does only recognise male and female). As Pablo Vergara says in his post on this law to be: don’t we trust ourselves then? That we ask (the proposal has been written by two trans* people! so “We” ask it) for a sworn statement?

ley integral andalucia

Sex and gender

Also the law assumes there is a correct, logical, fixed combination of sex and gender. The authors are absolutely not informed  by (post) modern theory that demystifies, deconstructs this sex/gender combination. For now I refer to Judith Butler’s excellent analysis in the introduction to Bodies that Matter (1999) where she explains there is no sex beyond or before gender (which as we know also is constructed, not natural or obvious). In different ways Michel Foucault already in 1976 (The will to know) explained how gender and sexuality are constructed, stimulated in a specific directions because of specific power relations, and repressed in other directions. That law doesn’t know this yet, is a juridical failure we must not go with but try to fix – or otherwise circumvent in our own proposals.

Minors

The above explained also applies to minors. If an adolescent or child comes with this wish they need a written statement by a psychologist or doctor affirming “transsexualsm in minors”. The children to who this applies to usually know very well what they feel and who they are. Having an unusual gender identitiy than society expects you may have given a certain genital layout, is only gender diversity, a natural phenomenon. Given the world’s reaction these children may need counselling, psychosocial support to further develop their gender identity and cope with a rejecting society. This also applies to adults by the way: learning how to deal with rejecting society and with internalised transphobia. But a diagnosis of gender dissonance? No.

The biggest problems reside in the paragraphs concerning definitions and access to trans* specific health care and how this is defined.

Logo StopTrans Pathologisation

“The multidisciplinary Gender identity Unit will be led by professionals in health care in in psychological. psychotherapeutic and sexological help that will decide and give the most adequate assistance according to the personal circumstances and state of health of transsexual persons.”

Because what does title II say, on health care service for trans* people? It says all information available should be given freely to who asks for it and all interventions are made with explicit informed consent of the patient. But then: what constitutes treatment? Who decides if certain treatment is available to a patient? What is the “most adequate treatment” (Art. 11.2) and who decides  this? The law does not explain how this most adequate health care should be interpreted. Meaning that they leave it to the doctors who are not used to having the expertise doubted or contested. Nor that patients decide for themselves against their professional opinion. Spanish (nor Dutch) doctors are known for their patient oriented supportive approach.

The term “state of health” and also personal circumstances leave open the possibility of a psychologist who because of the (supposed, interpreted) mental health state of a client thinks this person not apt for treatment because of certain aspects of their private life (e.g. they engage in BDSM with gendered roleplay and kink). Mentioned professionals are not guaranteed to be without prejudice and being dependent on a doctor or one unit introduces a bottleneck. If full, informed and prior consent is not well defined and when there is a relation of dependence (doctor-patient), it is an unequal power relation. In case of minors two doctors must be involved which makes the person’s autonomy (and that of their parents or guardians). Given the moral panic that spreads where it concerns children, and the attitude (and the – lack of – knowledge) I am not sure it is a good idea to leave this to two doctors. Normally one doctor decides what is the problem and in compel cases they consult a colleague, but  it remains a one person responsibility. So an extra strong requirement is introduced here. That does not sound logical, that sounds like exertion of power, of bad ethics.

Could be worse

Not the best law, not the worst. I think by explicitly legislating against transphobia, by clearly putting in the right to no discrimination this would be very good to become a local law. It has enough merits to be  accepted as a national integral law. But please chicas, your health paragraph and some of the basics are a disaster. Change that.

In Spain I now look out for the Andalusian proposal which is better, but experiences more political intrigues in getting the right version on the right tales. More on that when it gets really gets somewhere..

Why the change in the DSM-5 doesn’t mean much

The last word on this may not yet be said, but the people shouting victory over what for The American Psychiatric Association is a big step but just a very tiny one for humankind, means some clear language is needed to provide an exit out of this quagmire of pathologisation, half depathologisation and repathologisation.

Once upon a time, some twelve years ago the latest edition of the DSM saw the light: DSM-IV-TR. A text revision of the DSM IV that is even older (1994). There transgender was classified under 302.x “Gender Identity DIsorder” Jawohl,  a full fledged mental disorder. Before it was transsexuality. Also something not be happy with. You had to suffer quite a lot, and conform to the descriptions in bible of transsexuality, Harry Benjamin’s Transsexual Phenomenon, absolutely feel The Other Gender, from the moment you had any self perception. You wanted to be a woman (mostly, sometimes a man). You may live in a homosexual relationship but was because you actually were a woman, so it was straight after all.

In the DSM-IV one was to have strong negative reactions to one’s body, one’s role in society, one’s clothing; sexual preferences also played a role; it was recorded and mostly your becoming gay (post-transition) would be negative specifier.

dsm-5

The current edition now has some improvements. The identity itself is not a disorder anymore, only the dysphoria counts. They say. However this is not all true. To start with: GD gets a category of its own. The positive element in this is it is not placed anymore  among the sexual or paraphilic disorders. But why does it need a place in DSM anyway? Because we want treatment costs covered? Then it should be in a medical manual. Since the APA itself also claims the identity is not a disorder, it should have no place. And the mental problems that come from (outside or inside) transphobia don’t need a trans specifier.

To be able to get medical assistance as trans in a country that uses the DSM (and many do) a diagnosis is needed that you experience severe dysphoria, a strong conflict between your anatomy and the idea of who you are. And of course the strong conviction to be of the “the” other gender. That also applies for the Netherlands, not quite so progressive as it sees itself.

Several countries, not the least the USA, use the DSM for their insurance reimbursement and coverage criteria. Where these insurance companies are commercial molochs that have an interest in covering as little as possible, weird things as gender dysphoria only qualify if they exist as a reference/entry in a diagnostic manual. Practically this leads on the one hand to trouble for those who need access and cannot pay for themselves. Ultimately this is a grave and structural human rights violation that takes place in some of the most developed countries. This costs lives.
On the other hand – and not as a compensation but a parallel development – the model that trans* is mostly and heavily relying on medical technology, is less strong there. Other ways to live as trans, other transsexual technologies are found and used. Emphasis may lie stronger on the expression and less on the genitals. Different ways of living their trans life are invented. After all centering on hormone treatment and surgery is something that is only a recent possibility. With diminishing the logic of “trans, thus medical intervention is needed”is othing wrong. With keeping the same rationale for recognition under the new description and still needing medical gatekeepers, all is wrong.

What is needed is an approach that recognises the social-psychological character of gender diversity and takes its departure ppoint in heping the client with what they indicate they need: moslty adaption to growing in their deeply felt identity. Confirmation, not criticising. Help with overcoming the results of transphobia and cisgenderism. This may include medical interventions, but does not need to. When needed, this must be available at a high level of competence and be imbursed by health insurance. Governments should take also trans* related medical assistance within the default care package they regulate imbursement for.

Entanglements

This post highlights some nasty details hiding in the shades of the current Dutch transgender bill, as imposed upon Dutch trans people by obscure deliberations between the Justice ministry and the gender teams. Where informed consent on the one hand is the only criterion for LGR, the gender teams through a back door still have their say who is credible and who is not, who will be recognised and who will be scrutinised.

In many countries medical interventions are required in order to be able to change your gender registration on birth certificate and/or passports. Think France, Spain, US, Scandinavia, Poland, Chile, Brazil Japan, Philippines … From a human rights perspective requiring medical intervention for legal change constitutes a violation of the right to be exempt form medical maltreatment. And recently the UN Special Rapporteur in Torture classified obligatory medical interventions as such. He explicitly mentioned infant genital mutilation and forcible trans genital surgery to equal torture. And then there are countries that do not require it to be so, but do expect it. Even if they say to rely on the informed consent of the applicant. As it stands, the new Dutch law presupposes the wish to medical intervention. Also there are some countries that do not require any medical intervention. Examples are Argentina of course, the UK, Hungary, Portugal …

With the recently adapted legislation for legal gender recognition the Netherlands now opts for a strange hybrid that has some devils hiding in the details. The formal construction to be is that anyone (with a legal registration in the Netherlands) of sixteen years or older can request a confirmation letter of their long term and/or deeply seated feeling of not belonging to the sex/gender they are registered under. The only requirement is they have to understand what they are engaging upon. But as stated: the devil hides in the details. For the professionals allowed to issue such a letter of understanding, are the doctors and psychologists of the gender teams. Which is surprising. If the applicant is not by definition suffering from a mental disorder, then why have them screened by a psychologist? If going down that way, one might expect obstructive co-morbidities. These are given in the explanation of the law: the legislator fears for applications by people suffering from psychoses or other delusions. Not that there have been many reports of misuse. Most psychoses or delusions of people that apply for trans health care interventions, concern trans people with mental coping problems, trans people with co-morbidities. Not madmen playing trans. Nor villains wanting to abuse the system. And anyway, if this might be the case sometimes, the statistics are really low and the harm done is only to themselves. So the legislator is confused, fearful or influenced by the medical establishment.

Brain

The second and related problem lies in how the gender teams will react. How they will perform their task. Here word on the street is not really positive either. What is to be expected is a conflation of tasks. On the one hand psychologists still have to inform prospective patients on the medical gender reassignment protocols and procedures. On the other hand they get a new task, to screen if the applicant understands what this change of legal gender entails. When the setting is mostly assisting people with coping with their cross gender feelings, filtering out who is eligible for gender reaffirming treatment, then this is not an illogical step. But the legal requirement is different. The psychologists however – from professional pride? – insist on not just checking the measure of informed consent, but already inform and check the client’s readiness for medical treatment. This does injustice also to the current population of people that come to the gender team. Not all those rejected are not transgender (enough). Also applicants for medical assistance that are not ready for medical treatment – in the current setting or not ready at all – are being turned away.

Up to now everyone passes through a psychological diagnosis of gender dysphoria. If you just want acknowledgement of your identity, partial treatment, the whole package or maybe counselling. No discrimination this way. That starts behind the first gate. It very    much looks like the amount of people requesting a consult will grow, potentially a lot, and next there will be quick and a slow path/trajectory. The fast route is for who only wants legal gender recognition. They get in principle one talk and are free to go then. Until they want medical treatment. Group two wants immediately medical assistance. It is not clear now if they will get the offer to first change their gender marker. Or will be side lined with longer waiting times until there is more capacity. Or the other way round: if you only need a certificate, you can wait. This approach is plain wrong. Not from a medical/psychological point of view. Then it is logical to first do a thorough anamnesis. But these people do not come for a medical anamnesis, they want their gender marker changed in order to easier decide how to continue with life. In order to find out how to make sense of their gender difference. Now the processes of gender change have the chance to be more separated, it also could become more clear that there is a need for more counselling. The psychologists at the gender teams only check if you conform enough to the diagnostic criteria for (full) medical treatment. And then they only take your pulse during transition. Which leaves trans people in limbo again for the most important element of health care: support.

So, the applicant for legal gender change who does not want or need (any more) medical assistance inquires at the civil registry for the conditions to change their gender marker and then hears they have to go and see a psychologist or psychiatrist from the gender team. That means the state considers the requester to be mentally incapacitated for an autonomous decision regarding their gender.

Transgender Network Netherlands asked the secretary of Justice for clarification, since he is making a mess of it. I am very curious what he will come up with, but something tells me we still have to wait some years before we will get real informed consent.