Transzorg zonder diagnose. Wanneer?

Voorlopig niet. Want de meest nabije progressieve wijziging in classificatiesystemen – staat het er niet in, dan wordt het niet erkend – geven ons nog altijd het label “gender incongruentie” of “genderdsyforie”. En omdat het gender betreft dat met geslacht te maken heeft, krijgt het een speciale lading. Tegelijk zijn er mogelijkheden tot een andere benadering van zorg die her en der al werkelijkheid zijn. Dit artikel gaat daar nader op in.

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Training in trans* and intersex rights

From the beginning of 2014 Vreerwerk will offer a training in human rights with a focus on transgender and intersex issues. This course aims at staff of government and inter-governmental and non-governmental organisations, students and activists interested in trans* and intersex issues that need a basis in human rights for their work, but are not looking for an expensive academic course. Continue reading

Trans in the head

Earlier I argued that trans* is not a disorder and that the problem is more likely with transphobia than with gender variation. I showed how much we are stuck in binary thinking that needs to get rid of its expectations of universality. A way out may lie in the concept of “fuzzy sets”. In the future, trans is in the head.

Who enters into combat against the idea that trans people would have a mental disorder, would best give perspectives for another way/outcome/solution. That is why we look amongst others to Ecuador.

In the end the battle for trans rights is not about identities, One should be able to freely live the gender identity one feels comfortable with. Since we have a basic right to identity, this should not lead to so many issues, we should be able to continue building a lovely en just world. Alas the struggle for identity (instead living and celebrating identity) is being used in a power struggle to privilege a particular conservative morality. The fight for identity is only a small and bloated (inflated) part of a broader struggle for justice. Though not everyone makes that step from acknowledgment to further action.

Only a small group of the trans* population enters (medical) transition. Some 12,5% in the Netherlands. Many do not because they do not want to, do not  dare or just cannot. Some love comfortably in two genders or fluctuate between two genders, others again just don’t take gender as a reference point anyway. Gender queers who throw the system over board  in that sense don’t have much with identity struggle either. Except that you must be able to be or to become whoever you feel to be. Afterwards: shall we now continue to change/improve the world?


Some good developments in the direction of autonomy and respect come from the Spanish speaking world. More and more you encounter the term “trans en la cabeza” there, “trans in the head”. That idea leads to a totally different, not by default male or female, gender expression. oftentimes no medical intervention either which in turn has to do with archaic and arrogant treatment y psychiatrists, that mostly check if you are “trans enough”. Partially this (trans in the head) is rather sub-cultural, partially it is mainstream.

In Ecuador mostly trans people so seek medical assistance, be it official or not. Apart from the ID card that needs to be adapted to the gender one lives in. For that a campaign is waged these days, titled “Si es mi cédulo, tien que ser mi género”, “My ID must read my gender”by the organization “Cuerpos distintos, derechos iguales” (Different bodies, same rights). They warn for colonial concepts when the psychiatrist presses forward western ideas of how masculinity and femininity. In this sense the struggle for trans rights fits well in current anti colonial struggle.

This leads to a multitude of bodies and identities and thus to an explosion of what we understand by “men” and “women”. A revolutionary development: less than ever identity will relate to being born in a certain body and more to a certain conviction. Also it is a revolutionary appeal to the human right of autonomy of the body. So revolutionary alas that frequent and fierce resistance of the gender powers that be is to be expected. Nevertheless this is the way forward and we are on our way.


Nothing but fear

The current health care model for trans * people many times is defended as protecting the patient. Protecting them against regrets. A physician wants to be sure the patient they see, is serious, is not acting on impulse. This worry we can understand, the solution however is wrong.

A large part of the worries that physicians have regarding autonomous trans people comes from fear and ignorance. Fear of loss of work and also loss of authority.

Fear of people taking decisions they will later regret and will hold the doctor responsible for. Only to bring them before the disciplinary board. That is traumatic for the physician, when they have done their best to deliver a good job on explicit request. Incomprehension because they do not understand trans* people. They haven’t learnt a thing about them during their studies of psychology, psychiatry or medicine. And if something is taught, that is mostly rather out of date. Only this year thinking progressed slightly with the introduction of the new DSM and a new nomenclature for trans* issues.

A trans* patient does not need more or different protection than a non-trans* patient. Just as a Swedish patient needs no more or better protection than a French one. Where a doctor cares for the mental health of a patient because they do not appear to be stable, this mental stability is the problem. Not the being trans* of the person. The question should be: If I would have a patient with an appendicitis, or for cancer surgery, would I also require a psychologist’s certificate about their well-being? The fact that something is culturally loaded, is not enough reason to as for extra intervention/extra control.


Also everyone has a right to regret. However cynical that may sound. It is very well possible a trans* person who comes out is not sure of themselves. Identity develops. The same with gay and lesbian and bisexual people. Many times they are not coming out because they feel so great with the idea. Often they only do so when a lover is in sight, although they feel their being different for a much longer time already. They don’t need to see a psychologist, they have no longer a disorder (since 1991). Not coming out, living a non-authentic life, is something you can regret also. Like you can regret marrying, or not marrying. Or having children, or deciding not to have them. No one can tell if things will work out the way it was intended. So I would almost state: also trans people have the right not to be happy with their life and their choices. It is anyway not up to the state or the medical profession to always try to prevent us from failing, from regretting. Or should we also send prospective parents first to a psychologist or sexologist? Prospective spouses to a marriage counselor to have their love tested on stability, on longevity?

That fear we would decide for ourselves, for prosecution because they helped the ‘wrong’ trans person also stems from fear and ignorance. First of all, informed consent should be a requirement. With or without a psychologist, if the patient doesn’t understand what is involved, at is where it ends. Secondly, it won’t be the first time a medical psychologist would be involved when a patient has to undergo invasive treatment. But not all patients that undergo say oncological treatment will have to see a psychologist.

When society stops freaking out about trans* people, the suffering will decline enormously. After all, it is the outside world that gives us a lot of our trouble. And we as a part of that world got the message that it is not good to behave as we do, to feel like we do. So, stop freaking out and join the revolution. We are nothing more than a threat to your mental status quo. So what.

(Translation of “allemaal angst”, that appeared here on 21-12-2013)

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?


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.


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


 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


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


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.


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..