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.

Legal gender recognition in the Netherlands – an update

As you may have seen on the social media already, or on trans mailing-lists: change in Dutch gender recognition legislation just took a big leap this afternoon of 9 April 2013.

Already five years ago Dutch trans people contacted the minister for Emancipation (and Education, Science and Culture) complaining about the ridiculous and human rights violating legislation that goes back to 1985. The minister then promised to get it changed fast.

Fast forward to 2011. Human Rights Watch presents a report on the situation of trans people in the Netherlands and precisely then a watered down proposal is presented. National and international trans organizations complain heavily, only being happy with the removal of the requirement for medical (physical) interventions. After discussions and comments in the first (written) lecture in parliament some improvements are made.

TweedeKamergebouw

Last week the debate took place and today the change proposal has been voted to continue to the next round, the Senate. After that only a signature of the head of state is needed for the law to come in to force.

What does the law entail when accepted?

  • Every person with a Dutch birth certificate or residence can amend it without medical intervention. If at least 16 years old.
  • Provided with an expert letter confirming the applicant’s durable conviction being of the other gender. The expert is to be a doctor or psychologist of the gender teams. Others are to be cleared by the gender teams.
  • Go to the civil registry and it will be adapted.
  • Evaluation of the law after five years

Amendments have been brought to the floor to change some important aspects:

  • LGBT organisations (incl. the trans organisation) want a wider group of experts to be authorized to write an expert opinion, like social workers, reverends, sexologists, gender experts, trans organisations … Alas: rejected
  • It has been requested to bring the evaluation term of the law back to three years because of the rapid developments in the field. Alas: rejected
  • Lower the age limit to 12 years. Alas. Also rejected
  • Also it has been requested to investigate the possibility for a third gender marker or nothing at all. This motion has been accepted. Results are to be in within two years (to prevent the ongoing UK “investigations”). The precise order has not yet been commissioned.

All in all a good result, but it leaves still room for improvement on essential points. Life for trans people will be enormously improved, probably per Jan 1, 2014 as hope is the changes will then have effect.

As a note: this has no implications for the availability of trans specific health care. These issues are not legally coupled.

Call me Kuchu

Toen ik vrijdag aan mijn inleiding werkte, zag ik het volgende bericht:

Verwerping, angst, schaamte, schuld, ziekte, dakloosheid, armoede en degelijke overheersen in de LGTBi gemeenschap in Jinja, Oost-Oeganda. Vanwege het stigma dat veroorzaakt wordt door de Oegandese strafwet, religieus onderwijs, culturele overtuigingen en de negatieve berichtgeving van pers en media. Deze haatcampagnes waar politiek leiders aan deelnemen hebben onze levens verwoest.”

Dit bericht geeft goed aan wat de gevolgen zijn van een negatieve houding ten opzichte van mensen die anders zijn. Want deze weerzin tegen niet-heteroseksuelen geldt ook tegen mensen met een handicap, of met epilepsie, gekte …

In mijn praatje probeer ik u een beeld te geven van de achtergrond van de film. Meer dan wat kranten en nieuwsrubrieken vertellen of dan ik in Wordt Vervolgd heb gevonden. Over activisten, een moordwet, dollars, kolonialisme en religieus imperialisme in Oeganda. Continue reading

Fucked up lip service

The proposal for change of the existing gender recognition legislation in the Netherlands is out. This proposal will be debated on the floor. It is – as the previous version – not good enough. Actually it hardly changed since last time we saw it.

The news came in the mail. An update of the website of the Justice and Security ministry. The proposal for change of gender recognition legislation is ready for second reading. Written comments have been worked through and answered. The secretary of state for Justice and Security apparently was not impressed by the questions and by the comments of the trans-movement. We are not impressed by him. Never were. Some refreshers:

  • It took a Human Rights Watch report for government to come up (immediately!) with a proposal for change.
  • This after some three years of talking and checking back with the legal advisor of government and of several ministers speaking of their worry for the current situation.
  • Extensive comments for all national (TNN, COC, ..) and international  (TGEU, HRW, GATE) stakeholders have been given.
  • Then again the government needed reminding not to stall. Promise is debt.
  • Comments again from national actors went to all political parties that took up several important questions but – of course not required – government took up maybe one point
  • The trans movement is only taken seriously where it is advantageous for government

So what does the proposal of Dutch neoliberal cum ex-social ex-democrats comprise?

  1. An expert in gender dysphoria must check if you are sincere and that you have an enduring conviction. If you are not deluded or doing it out of delusion. If it is not done out of criminal intent
  2. Appointed gatekeepers consist of current doctors and psychologists gender teams,  and others accorded by the ministry. They proposed a nice package deal.
  3. “Real Life Experience” or long time living in the role of preference has no influence on the legal part of the process. But gatekeepers may take that more serious than other expressions of trans-gender
  4. You must be at least 16 years of age
  5. After giving birth as a (legal) man you will still be the mother. Mater semper certa est. No wishes to make pedigree law gender neutral. Tendency is more re-biologising
  6. Good thing: no need for hormonal or surgical treatment
  7. Good thing 2: no court procedure necessary anymore
  8. The law will be evaluated after five years

So, two or three important good changes, and lots of lost opportunities in this proposal. Where good thing 3 may be that the expert opinion may not be a diagnosis. But how will this go if the applicant later goes on to medical procedures? Will it then be taken as a (psycho) medical diagnosis?  So you must be gender dysphoric to get help?

Government gave in on the easy part: the world moves to outlaw coerced medical treatment (actually already for some time). Lately by UN Special Rappporteur Juan Méndez who now moves required and coerced medical interventions for trans people and infant genital mutilation as with intersex children explicitly into the Convention against Torture (absolute, never relative, always enforceable human rights law).

Yogyakarta Principle 18 is about this issue: medical maltreatment, unnecessary medical interventions. The Yogyakarta Principles on human rights regarding sex, gender and sexuality, that Dutch government says to wholly support.
Principle 3 however is about recognition before the law. Apart from making change easier than before, government still requires trans people to see an expert in effing gender dysphoria. who must check if we feel to belong to The Other Sex. We are never the experts on us. The trans movement has not been consulted on the issue of the expert, the medical experts have.

It is a long way to Tipperary. And an even longer one to gender justice.

Progress at the UN

This week the Special Rapporteur on Torture of the UN released his report on torture in health care. A topic important for trans and intersex people. Thanks to two interventions of human rights advocates involuntary surgery now equals torture

Continue reading

Trans in je hoofd

Eerder is geargumenteerd dat trans geen ziekte is en dat transfobie eerder het probleem is dan gendervariatie zelf. We hebben laten zien hoezeer we vastzitten in binair denken dat z’n globale pretenties moet opgeven. Een uitweg kan liggen in perspectief dat fuzzy sets bieden. In de toekomst ben je ‘trans in je hoofd’. 

Een boekje dat de strijd aanbindt met het idee dat transgenders een geestesstoornis zouden hebben, doet er goed aan met perspectieven te komen. We kijken hiervoor onder andere naar Ecuador. Continue reading

Online course sex, gender, sexuality and human rights

I am happy to announce that I will be teaching a course on Human rights, sexual orientation and gender identity with HREA soon.

From 10 April to 21 May I will be the course instructor for a course that I designed on human rights with regard to sex, sexual orientation and gender identity and expression. The title is somewhat shorter, but all five aspects will get their required attention. It will be a course with several articles per week on specific subtopics like the history of human rights for LGBTI  people, where it exists, in which fields and regions it is difficult  What is the philosophy behind accepting or refusing the application of the human rights system on people that do not conform to the sex, gender or sexuality norms.

hrea

This certificate course analyses the rights regarding sex, sexual orientation and gender identity. These human rights are not acknowledged for people who, for one reason or another, do not (want to) belong to the recognised and legitimised constructions of sex, gender and sexuality. Since the public political struggle for equal rights for gays and lesbians took off in the global North (1965 and 1969 in the USA; local less known actions also) and later for different reasons in the global South and East, the struggle is globalising. A coalition of NGOs and activists now is influencing the UN and other, regional bodies like the Organization of American States, European Union, Council of Europe, African Union … In 2007 the Yogyakarta Principles were adopted, growing into soft law, the OHCHR released a report on global discrimination of lesbian, gay, bisexual, transgender and intersex (LGBTI) people. These developments and documents will form the basis for this course on human rights and sex, sexual orientation and gender identity and will be discussed more in depth.

Course outline

Week 1: Sex, sexual orientation, gender identity and human rights
Week 2: Participation: freedom of association, expression, assembly
Week 3: Access: health, education, employment
Week 4: Protection: violence, asylum
Week 5: Privacy: family relations, legal gender recognition
Week 6: Implementation of legal standards, complaint mechanisms

For technical and price  information see the HREA website

Hierarchy in Human Rights?

On Friday january 25 I attended the 25 year anniversary of the Dutch Helsinki Committee (NHC). Several important people held speeches, and they were interesting. But it also confronted me with a question.

The anniversary was celebrated with a one day conference themed “The future of human rights in Europe” with several eminent speakers and or workshop leaders. Council of Europe Commissioner Nils Mužinieks held a keynote speech full of “doom and gloom” but also with a bit hopeful conclusions. strategic consultant Dirk Steen (ex global planning Amnesty) gave some very interesting possible scenarios for the year 2020; One where the bankers finally have been arrested, production is localized thanks to 3D printing and energy is solar, or aeolic. Or a doom scenario: The Greek crisis continues in the rest of Europe, dictatorships on the rise, unemployment on the rise everywhere, censorship and surveillance on Internet business of the day … A global sociopolitical economic SWOT. The future might lie with “Occupy 2.0”, the Young Angry Women. An organized and coordinated fight with the powers that be. Interesting to see the reactions in the audience on the different scenarios.

Much was spoken on the collapse of the (western) economies, the barbaric contemporary capitalism, the rising racism in Greece and Hungary, the dangers for the constitutional state … Very important.

There were workshops on EU human rights strategy, on the situation of the Roma people, transitional justice, the problems of migration politics in Europe (what we did not learn). Masterclasses on the European court and on anti terrorism and human rights. And there was one workshop on sex work and trafficking, plus a lecture on LGBT human rights work in Europe.

25 yrs Dutch Helsinki Committee

That brings me to my observation: there was very little attention for sexual and reproductive rights. Nor for gender related issues. The sex work workshop was good, considerably more positive for sex workers rights than I had imagined beforehand. But it was only about women in sex work, so a limited perspective. I brought the trans perspective in (many many trans people are doing sex work for some time in their life). A perspective of gender and power was not clearly present. But I think the many attendants found it a useful or informative workshop. The lecture on LBGT human rights as human rights was a useful summing up of the recently created human rights ‘jurisprudence” and soft law, statements by high-placed functionaries. But hardly a thing more than this enumeration.

This makes me wonder: is it so difficult to bring women’s rights, LBGTIQ human rights, sexual and reproductive health issues into the mainstream human rights discourse? Why do issues about sex, gender and sexuality always stand apart? Only when mass rape is used as a weapon of mass terrorization in a war, sex and sexuality enter mainstream discourse. Is this because of judicial or political unease?

Of course there is the recent CoE convention combating and preventing Violence against Women. Very young still, not much signatories yet (Turkey, being the host country, ironically the first state to ratify it). Mužinieks thinks it has a great future. Further practically it is best to use the entry way of combating and preventing hate speech and hate crime. And to get ombudsmen cooperating. They are many times very silent. The European approach is to take measures close to home, whereas the UN system is more of global and regular, regulated control instances. But still, to me that does not explain why sex, gender and sexuality issues stay outside mainstream human rights discourse, that does take racism as an issue.

Consultatie Mensenrechteninstituut

College rechten vd mensAfgelopen weekend heb ik de internetconsultatie van het College voor de rechten van de mens ingevuld met de volgende bijdrage over systematische, structurele en ernstige mensenrechtenschendingen in Nederland:

Ik wou graag uw aandacht richten op twee punten van ernstige en structurele punten van mensenrechtenschending in Nederland die voor velen helaas niet vanzelfsprekend zijn en nog steeds maatschappelijke weerstand oproepen (de groepen wier rechten geschonden worden, niet de schendingen).

Als eerste groep wijs ik u op de Roma en Sinti in Nederland. Een aanzienlijke groep van hen leeft als statenloos en heeft dus geen goede toegang tot de maatschappij. Door hen niet te erkennen wordt hun recht op onderwijs, goede gezondheidszorg, een veilige woonplaats, vrijheid van discriminatie, onthouden. Ze behoren – in heel Europa – tot de meest gediscrimineerde, slechtst opgeleide en meest verwaarloosde, gecriminaliseerde groepen. Evenals de tweede groep die ik ga noemen, worden zij om hun zo-zijn, hun etniciteit i.c., gediscrimineerd.

De tweede groep waar ik aandacht voor vraag, om gelijke ernstige en structurele mensenrechtenschending is de groep mensen die zich niet thuis voelt in de hen toegewezen genderrol en identiteit. Zij zijn bekend onder de naam transgenders. Arbeidsdiscriminatie is groot 40% van de gemeten populatie zit zonder werk (WW,Wajong, WIA). Het percentage tentamen suicide is extreem hoog, en om officieel in de ‘juiste’ geslachtsrol te kunnen leven moet men een tijdrovend en kostbaar medisch en juridisch proces doorlopen. Deels wordt aan verandering gewerkt, deel niet. Het volgende grote probleem hierbij is de verplichte man/vrouw indeling, waar niet iedereen in past omdat niet iedereen man of vrouw is.

Transgenderzorg biedt geen ‘maatwerk’, sluit niet aan bij behoeften en gaat uit van pathologiserende ideeën. Niet uit vergoedingsoverwegingen, maar uit geloof daarin. Het verantwoordelijk ministerie VWS is niet van zins om daar verandering in aan te brengen. Het recht op goede zorg wordt met voeten getreden, zonder dat daar fatsoenlijke redenen voor worden aangedragen.

Ook worden transgenders hun huis of wijk uit gepest waarmee hun recht op wonen geschonden wordt. Discriminatie om wie ze zijn is veelvuldig aanwezig.

 

Als bronnen draag ik de volgende rapporten aan:

1. Tussen wal en schip. Staatloze Roma in Nederland. Justitia et pax 2012

2. Worden wie je bent. Het leven van transgenders in Nederland. SCP 2012

3. Trans and intersex people. Discrimination on the grounds of sex. gender identity and gender expression. EC, 2012