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Scotland hands unprecedented power to trans patients

The big news from Scotland today is all about gay marriage. But last week, the Scottish government quietly unveiled an equally important move.

The new NHS Scotland Gender Reassignment Protocol will have a massive impact upon those who seek a medical transition. It dramatically cuts the time required for “real life experience” prior to surgery, confirms the necessity of contested interventions such as hair removal for trans women and chest surgery for trans men, enables teenagers to begin transition from 16, and – crucially – reinforces the right of trans people to refer themselves to Gender Clinics.

Some background
Last year saw the publication of the latest edition of the World Professional Association for Transgender Health (WPATH) Standards of Care (SOC). This seventh edition of the SOC saw a number of important changes that acknowledged critiques from trans communities as well as clinicians, leading to a focus upon gender variant identities and experiences in terms of diversity, rather than pathology.

Treatment is individualized. What helps one person alleviate gender dysphoria might be very different from what helps another person. This process may or may not involve a change in gender expression or body modifications. Medical treatment options include, for example, feminization or masculinization of the body through hormone therapy and/or surgery, which are effective in alleviating gender dysphoria and are medically necessary for many people. Gender identities and expressions are diverse, and hormones and surgery are just two of many options available to assist people with achieving comfort with self and identity. (p.5)

Thus, transsexual, transgender and gender non-conforming individuals are not inherently disordered. Rather, the distress of gender dysphoria, when present, is the concern that might be diagnosable and for which various treatments are available. (p.6)

This emphasis upon individual difference and patient agency differentiates this seventh edition of the SOC from previous editions published by both WPATH and its predecessor, the Harry Benjamin International Gender Dysphoria Association. The change follows decades of lobbying from trans activists, academics and progressive professionals. We’ve gone from a world where post-doctoral researchers who happened to be trans – such as Virginia Prince – could publish research only with the approval of cis clinicians, to a world in which trans professionals like Stephen Whittle are setting the agenda.

WPATH are still far from perfect: see, for instance, the fact that they seem to think they are qualified to speak for intersex people. But, broadly speaking, the latest SOC is a definite step in the right direction.

Competing guidance
When WPATH speaks, medical providers don’t necessarily listen. Trans people are often diagnosed according to criteria set out guidance such as the American Psychological Association’s Diagnostical Statistical Manual of Mental Disorders (DSM), which treats us as mentally ill. Gender clinics in the UK often follow previous editions of the SOC, which encourage a patronising, controlling approach in practitioners.

For instance, a recent Freedom of Information request revealed that Leeds GIC “…follows the stages laid down within The Harry Benjamin International Standards of Care (this differs from the WPATH guidance), as we believe that hormone treatment is best undertaken after real life experience has begun…“: i.e. the clinic is relying upon outdated guidance, under which patients are forced to go “full-time” for some time before they are prescribed hormones. This will clearly cause difficulties for individuals who have trouble passing as cis without hormone therapy, and may leave them open to harassment or violence.

Even less regressive GICs in the UK currently do not comply with with the most recent edition of the SOC. This can be seen in the imposition of binary ideals of gender, the absence of treatment protocols for most trans adolescents, and a “real life test” of at least two years before requests for surgery are considered (as opposed to the 12 months recommended in the new SOC).

Of course, any revision of national medical practice takes time, particularly within a public body such as the NHS. Changes to the NHS care pathway in England and Wales are currently under discussion. Moreover, hormone regimes for teenagers are currently being trialled in London. I don’t know enough about the situation in Northern Ireland to write about what’s happening there.

It is against this backdrop that the new Scottish protocol has been introduced.

NHS Scotland Gender Reassignment Protocol: the headlines
The new Scottish guidance has been shaped by trans activists working with key figures within Scottish equality bodies and NHS Scotland. It won’t have an immediate impact upon the availability of services, with implementation being a long, complicated process. However, it is historic in that the published care pathway clearly empowers trans patients in a number of ways.

The Scottish Transgender Alliance highlight a number of important points from the protocol (emphasis mine):

  • people can self-refer to NHS Gender Identity Clinics (GICs) in Scotland.
  • that psychotherapy/counselling, support and information should be made available to people seeking gender reassignment and their families where needed.
  • that two gender specialist assessments and 12-months experience living in accordance with desired gender role are needed for referral for NHS funded genital surgeries and that arrangements for delivering agreed procedures are under review with the objective of ensuring that an effective, equitable and sustainable service is implemented.
  • only one gender specialist assessment is needed for referral for hair removal, speech therapy, hormone treatment and FtM chest reconstruction surgery and that these can take place in an individualised patient-centred order either prior to starting the 12-month experience or concurrently to the 12-month experience.
  • that, in addition to access to genital surgeries, access to hair removal is regarded as essential to provide for trans women and access to FtM chest reconstruction is regarded as essential to provide for trans men.
  • that surgeries which are not exclusive to gender reassignment, such as breast augmentation and facial surgeries, continue to need to be accessed via the Adult Exceptional Aesthetic Referral Protocol but there will be a more transparent and equitable panel process for making funding decisions in such cases.
  • that young people aged 16 are entitled to be assessed and treated in the same manner as adults in terms of access to hormones and surgeries.
  • that children and young people under age 16 are entitled to child and adolescent specialist assessment and treatment as per the relevant section of the WPATH Standards of Care. NOTE: at the time the protocol was created the staffing of a specialist Under 16s service at the Sandyford GIC in Glasgow was uncertain but it now looks likely that there will be a sustainable Under 16s service provided at the Sandyford GIC in Glasgow and this part of the protocol will soon be updated.

As the Scottish Transgender Alliance note, this protocol isn’t perfect, but it does represent an important step forward. If the protocol is properly implemented, trans people will no longer be forced to spend months (or even years) fighting for a referral, before waiting even longer for treatment as a GIC patient. Trans people will be able to access vital interventions such as hair removal on the NHS, and should be able to access proper counselling and therapy services.

A personal perspective
If a protocol such as this had been in place in England when I came out as a teenager, I could have gained a referral (or even referred myself!) to a GIC at the age of 16. Even with the massive waiting list for the GIC, I might have been on hormones at 17, and had surgery at 18. I wouldn’t have had to undergo anything like so many painful laser hair removal sessions, and those that I did undergo would have been paid for by the NHS.

Instead, my first GIC appointment was at the age of 19. I didn’t go on hormones until I was 20 (causing all kinds of havoc with my university grades during my final year as I underwent a second puberty) and had surgery shortly before my 22nd birthday. I paid for several laser hair removal sessions privately. One day I hope to afford a few more, as I never finished that particular treatment.

And I’m one of the lucky ones.

The future
I can’t really understand why this isn’t already all over the LGBT press, let alone the trans blogosphere. It’s a deeply important development.

The progressive nature of the new Scottish protocol provides a positive precedent for the rest of the UK. We can only hope that NHS protocols for England and Wales and for Northern Ireland follow suit. In the meanwhile, trans activists throughout the UK could do well to pay close attention to the situation in Scotland. The success of organisations such as the Scottish Transgender Alliance provide important lessons for the rest of us.

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THT publish sexual health guides for trans people

The Terrence Higgins Trust (THT) has published two groundbreaking booklets on sexual health for trans people. Each one contains basic – yet valuable – information on trans bodies and health needs.

Each booklet tackles a whole bunch of common questions, such as: do post-op trans women still need prostate examinations? and: can trans guys get pregnant after going on T? There’s some trans specific information on HIV prevention, and also some more general health advice.

The language is broadly respectful and acknowledges the great range of trans identities. There isn’t as much of a binary division as might appear to be the case from the titles, with each booklet noting that the information contained within is also relevant to queer or non-binary individuals:

Words matter and in this introduction we are using the term ‘trans* women’ to indicate that this guide is not exclusive and is intended to speak in a  non-evaluative and non-judgemental way. It is aimed at people across the whole spectrum of trans* feminine-identified presentations and behaviours; by this we mean anyone on the gender variant spectrum who was labelled ‘male’ at birth and who identifies as female – including gender queer or otherwise non-binary people labelled ‘male’ at birth.

It’s really great that these booklets have been created – there’s a lot of confusion and misinformation about trans health needs, so this kind of intervention from a respected community organisation is really welcome.

The booklets are available online in PDF format:

Trans Women: Trans Health Matters

Transmen: Trans Health Matters

They’re also both available in physical form via mail order for the very reasonable price of 40p each (to cover postage costs).

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A note on the “space” issue

I’ve noticed a lot of questions in social networking spaces about the fact that there’s a space in “trans women” but not in “transmen”. People wonder why there is discrepancy between the two guides, and wonder if a mistake has been made.

A friend of mine was involved in the production of the guides and offered some explanation. Apparently each one was produced by THT with a great deal of input from two steering groups, one for each guide. The “trans women” group was very insistent on having a space between “trans” and “women”, presumably for political reasons. The “transmen” group didn’t want a space.

There will inevitably be arguments over this, and complaints sent to THT. Some favour the space because “trans” stands separately from one’s gender: e.g. I am a “trans woman” because I am trans and a woman. My womanhood is not defined by my transhood. Others favour not having a space because they argue that we should be proud of being trans, and that it is inevitably part of our gender.

We’re never all going to agree on this. I use “trans women” very deliberately within my writing because I broadly subscribe to the first argument, but I recognise that there are plenty of people who have good personal reasons for preferring “transwomen”.

THT aren’t going to please everyone. As such, I think it’s a pity that people are complaining to them about this, particularly as the language came from trans steering groups on this occasion. We should be all means continue to have these conversations about language, because language is important, but there are far more important things to campaign about than a space on a sexual health booklet.

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There’s something oddly reassuring about Radfem Hub

A (cis, feminist) friend of mine posted in horror on Facebook this afternoon. Said friend had just visited Radfem Hub for the first time. “UNBELIEVABLE,” she exclaimed.

I’m fairly certain I had a similar reaction when I first went to the site. It’s always unpleasant to stumble across a series of staggeringly unpleasant attacks upon your being and personhood; as such, I recommend that any readers approach Radfem Hub with extreme caution.

At the same time, I don’t find it particularly threatening any more.

I mean, let’s take a look at what Radfem Hub actually stands for. It’s described as “a radical feminist collective blog”, and as such you might expect to find articles on all kinds of different subjects related to patriarchy and the oppression of women. Instead, the current front page of the site displays article after article dedicated to the evils of trans people, trans activists, trans allies, and the insidious influence of trans ideology upon the wider feminist world. You have to scroll way down the page before there’s even mention of a pro-choice agenda and a now-obligatory potshot at  50 Shades of Grey*. And then the transphobic posts start up again.

Radfem Hub isn’t really a radical feminist site. It’s an anti-trans hate site.

I don’t say this because I’m interested in redefining radical feminism. I say this because, surely, a radical feminist site – even a radical feminist site populated by transphobes – would have something else to talk about beyond hating on trans people. There are so many other things to worry about in the world! I mean, take for example the London Feminist Network yahoo group: it’s pretty clear that trans people aren’t welcome there unless they toe a particular line, but the group’s members at least have far more to discuss than whatever it is we’ve done to annoy them lately. In contrast, the population of Radfem Hub seem to have little to do other than hate on trans people.

Ultimately, it’s not that threatening. Sure, the actions of those such as bugbrennan (who has a nasty habit of publicly outing trans people) are pretty disturbing, but the site itself is bound to only ever appeal to a small group of bigots. There’s no way it’s going to appeal to the radical feminist mainstream, who are way too busy tackling stuff like the gender pay gap, capitalist exploitation of women’s bodies, nasty propaganda from “pro-life” groups and the like.

In a way, I’m reminded of The Christian Institute. This lot are a non-denominational group who state that they exist for “the furtherance and promotion of the Christian religion in the United Kingdom”.  Their actual activities seem to consist largely of posting homophobic witterings on the Internet and shouting in vain at the government to do something about that awful homosexual agenda.

The Christian Institute cast their net a little wider than Radfem Hub (going for Muslims and pro-choice activists almost as much as they go for LGBT people) but it’s pretty obvious what they are. They’re a hate group. And as such, they’re never going to gain too much sway within the world of mainstream Christianity, even as the Catholic and Anglican churches desperately try to block the government’s plans for the legalisation of gay marriage.

So here’s the thing. As long as groups like Radfem Hub and the Christian Institute remain dedicated to hate, they’re only going to gain so much traction. I’d be much, much more worried if they had much to say on issues that might actually interest anyone beyond their core audience.

* For the record, I agree with Radfem Hub that 50 Shades of Grey is deeply dodgy, although I dislike their predictable “kink is necessarily bad!” approach to the issue.

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See trans performers in London tomorrow!

Trans youth charity Gendered Intelligence are running a fundraiser at London’s Royal Vauxhall Tavern tomorrow (Friday 13th July).

On the off chance you’re around, you should totally come because it’s going to be amazing.

There will be performances from a whole bunch of trans artists and allies, including:

Lashings of Ginger Beer Time

Bird la Bird

CN Lester 

Naith Payton

Cyndi Rogers

…and DJ sets from myself and Puja Maniar.

Entry: £8 (£6 concesssions)

Doors: 7pm – 2am

There’s a Facebook event page here.

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Passing as cis: why I’d love to stop shaving my legs, but don’t

Several months ago, a friend of mine sent out message inviting participation in a new feminist video-blogging project. This seed of an idea grew into Those Pesky Dames, in which five women say awesome things about body autonomy, self-care, inspirations, intersectionality and pop culture. And then this week, the Dames stepped beyond the realm of YouTube (and Facebook, and Twitter and Tumblr…) to appear on the good ol’ fashioned television.

You can watch them talk about body hair on Cherry Healey: How to Get a Life for the next couple of weeks (it’s available on BBC iPlayer until Wednesday 18th July).

The Dames’ contribution to the programme is fantastic: they talk about how body hair is entirely natural, and shouldn’t be regarded as unfeminine. Why should women have to spend hours shaving in order to conform to the beauty myth? Why should we feel bad about baring our natural fluff in public? And why regard hairy women as unhygienic, but not hairy men?

I was so happy not only to see my friends on TV, but to see them discussing a vital feminist issue. Michel Foucault came up with this idea known as “governmentality” to describe the relationship between individual people and social rules. We enforce social norms through self-governance, tailoring our actions and behaviour to uphold the status quo. We police our own conformity through the application of self-esteem (when we conform) and shame (when we fail to conform). I felt that the programme beautifully highlighted the governmentality at play in the maintenance of female body hair: our self-esteem depends greatly upon our lack of hair, and when our legs or armpits are hairy in public we feel shame. In this way, women come to enforce sexist ideals of appropriate female behaviour. We can escape by embracing an alternative, feminist ethic of selfhood whereby shaving is not required. I went to bed reflecting happily upon this liberatory potential.

The next day was warm and sunny, and I planned to see my friends in town. I pulled on my shorts…and then took them off again and wore jeans instead, because I didn’t want the world to see my hairy legs. My boyfriend insisted that my short, very thin crop of leg hair wasn’t even visible and that it really didn’t matter. The rational part of my brain agreed wholeheartedly. I still couldn’t do it.

A great part of this response was no doubt down to your bog-standard governmentality at work. I was ashamed at the thought of being an Inappropriate Woman, and tailored my behaviour accordingly. Knowing that you’re a sucker in this way only gives you so much power! But there was an additional element at play: my fear of not passing.

I feel that being trans greatly complicates body hair issues. I don’t really fear being read as different or somewhat deviant, and happily flaunt my subcultural identity as a rocker on an everyday basis. I don’t worry too much about looking feminine or conforming to female stereotypes. But at the same time, I don’t want anyone thinking I’m not a woman, and I certainly don’t want anyone thinking I’m a man. I spent 18 years of my life being read as male, and those 18 years were quite enough.

My fear is not that people will look at my hairy legs and think “urgh, a hairy woman”. My fear is that people will look at my hairy legs and thinking “urgh, she’s actually a man!” This is somewhat irrational given how well I pass as cis, but the fear is real, and powerful.

The problem is that passing as a cs woman is important to me. Not because I think it’s better to look cis than trans (I most certainly don’t!) Not because I aspire to some outdated, patriarchal ideal of womanhood. It’s because I hate being heckled on the street, and I fear the violence that can come with transphobic responses. I realise that I’m deeply unlikely to suffer an assault in broad daylight in my home town, but past experiences of violence – however minor – can exert a powerful control. I aim to pass for my own mental and physical well-being.

And so I shave my legs and my armpits when I think they’ll be seen in public, because I’d rather be seen as an Acceptable Woman than not be seen as a woman at all.

The thing is, I hope this might change with time. At the start of my transition, I used to wear eye make-up and straighten my hair daily. I used to shun baggy clothes, instead aiming to highlight what curves I had. As time has gone on, I’ve become more and more relaxed about my appearance. This is partly because I’ve become generally more chilled with time: I’m no longer bothered about people who know me being aware of my trans status, and this blog is hardly anonymous these days. But it’s also because of the impact of hormones, meaning that I pass more easily as a cis woman regardless of how I dress. I now wear make-up and dress in a more feminine manner on special occasions, when I want to put on a certain appearance: in this way, I’m now doing these things for me, rather than for others.

One of things I really like about the kind of feminism espoused by Those Pesky Dames is that it leaves room for all these complications. There wasn’t really time for an exploration of this in How to Get a Life, but it’s all there in their vlogs. They argue for a feminism in which you shouldn’t have to shave your body hair…but you should be able to if it’s the appearance you’re going for. A feminism in which you don’t have to wear make-up, but should feel empowered to do so on your own terms. A feminism that accepts that some of us really want to escape the governmentality that leads us to shave our legs, but for now, we remain constrained.

As such, I’m going to keep shaving my legs, despite acknowledging that (in my case) I’m not really doing it for me. Meanwhile, I’m going to celebrate the achievements of those who aim to break down this norm.

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New coming out guide for young trans people

LGBT Youth Scotland have produced a fantastic new booklet with advice on coming out for trans people. Some of the information and language is a little Scottish-specific but there’s some good stuff in there that could be useful to anyone.

Contents include general advice on coming out to friends, family and in school/college/uni etc, as well as links to further resources in terms of general advice and UK law.

You can download the guide in PDF format here:

Coming Out: a coming out guide for young trans people