“Living as a woman” – MPs take on the Real Life Test

I’m currently writing up a section of my thesis that describes trans people’s experiences of navigating the public health system in the UK. A large part of this is related to the “real life test”, a stage of treatment which patients are required to live for a period of time in their “acquired gender” in order to demonstrate that they are suitable candidates for hormone therapy and/or surgery.

This requirement (which, incidentally was absent from the latest version of the international World Professional Association for Transgender Health Standards of Care) has a lot of issues. These include the prioritisation of cisnormative standards, little-to-no recognition of non-binary identities, white-centric cultural insensitivity, and the frequent demand that patients hold down “an occupation” as part of the test (particularly pernicious in a time of high unemployment).

It was therefore very interesting to see MPs questioning the idea of the real life test during the fourth and final session of the UK Parliament Women & Equalities Committee’s inquiry into transgender equality earlier this week. The conversation, in which MPs quizzed Ministers and NHS England representative Will Huxter, went as follows:

Jess Phillips MP:
“I think I’d like to go back again to this idea of living in one gender identity: I wonder if you can tell me – clinically – what ‘living like a woman’ – or alternatively, man – actually means?”

Will Huxter:
“I’m not a clinician I can’t tell you what that’s – ”

Jess Phillips MP:
“Do you think that there is a clinical way to live as a woman? Or a man?”

Will Huxter:
“The point I am making is that we are guided by specialists who work in this area, the clinical consensus among gender identity specialists about how services should operate. We are absolutely open to looking at how that might change, but I’m not in a position to make a change to the way in which those services are commissioned without having gone through a clinical process”.

Maria Miller MP:
“Mr Huxter, sorry, I think we’re going to have to press you on that. Is – this is just factual, we have read that people have to ‘live like a woman’ or ‘live like a man’, we as a committee have struggled to know what that looks like in a day and age where men and women live in very similar ways. What do you – factually – what does that mean?”

Will Huxter:
“Well in terms of what is required by the clinic I’d be very happy to provide some details from clinical colleagues after this because it’s not – I don’t deliver the services nor am I a clinician. I feel I could give a better representation to the committee if I provided that outside.”

Maria Miller MP:
“Is the Minister comfortable with the fact that the government requires this information to be available, or that individuals have to live ‘like a man’ or ‘live like a woman’ in order to be able to change their identity?”

Jane Ellison MP:
“Well, I mean, put as you put it to us, I mean obviously you know it gives cause for concern in a sense that, you know, who wouldn’t have sympathy for someone put in that situation etc , clearly the committee has heard I know some really difficult evidence and I quite understand why you wish to reflect that. I mean I think that as Will has said you know there is actually currently a review going on anyway about this very issue, which is essentially about looking at the current guidelines, about understanding that represents current better practice, about giving some challenge to that. There are a number of – compared to even five years ago – there wasn’t a mechanism for the NHS to receive that sort of, you know, feedback from critical friends or otherwise. Those now exist, the transgender network has been set up, the various stakeholder groups that are, you know, really locked into the process. So I think what I’m saying is I don’t think there is ever, you know, clinical understanding of situations is rarely completely frozen in time, I mean this one particularly isn’t, because for a lot of people this is a very new speciality, and therefore I would imagine over the next ten years for example, the next few years, you will see an evolution. And that process is underway, which is exactly why the NHS is consulting and is looking at, particularly at its clinical, you know, specification. That process is actually going on at the moment and, as Will has said, very open to the committee’s recommendations being fed into that. But I know I’m not a clinician too, and I know from other areas of my portfolio perhaps better than this one because I’ve been doing it longer, I do know that you do need to test. Because once you commission to a standard, once you’ve got that, you know you do, you need to make sure you’ve tested your views, and that you actually capture a clinical consensus, because that’s the only way you can move forward. But that consensus will evolve.”

Jess Phillips MP:
“Okay, I just – from the Minister – just, I suppose, what I’m looking to hear, is that you recognise that there is not a single list of attributes that represents what it is to be a woman and/or a man; and therefore, there cannot be a clinical list of things that a person can be told to do by a doctor in order to tick those boxes. Do you recognise that fact?”

Jane Ellison MP:
“Well I understand what you’re saying and I think that it would be very helpful if we – subsequent to this hearing – write to the committee with some – with an example from a clinician operating in the field as to what they would mean by that, because obviously you know people are sitting down with individual people and saying, you know, requiring them to do that and they must have an idea of what that requirement is, what that looks like. So I think we should ask the question of clinicians and supply the committee with some, perhaps some examples, obviously anonymised, of where that’s already happening in clinical practice, and what that looks like.”

You can watch the footage here.

women and equalities

All of this is relevant to the law – in addition to clinical practice – because of the current functioning of the Gender Recognition Act. In order to gain “full” legal recognition as female or male (non-binary options aren’t available) people who have transitioned are required to apply for a Gender Recognition Certificate (GRC). In addition to £140, a whole load of paperwork and scrutiny from the national Gender Recognition Panel (no, really), individuals wishing to acquire a GRC need clinical approval. It’s no wonder that many trans people simply refuse to play along, leading to consequences such as the Tara Hudson case.

As it turns out, there is an answer to be found in the clinical literature. Charing Cross GIC clinical lead James Barrett has the following to say on the subject of the real life test in his book, Transsexual and Other Disorders of Gender Identity: A Practical Guide to Management:

“The question immediately arises of what constitutes ‘success’ in a chosen gender role. In essence, ‘success’ amounts to occupation, sexual, relationship and psychological stability. Of these, the first can be measured by whether or not the patient can manage to hold down a full-time (or equivalent part-time occupation in the chosen role for a year, in the course of the real life experience […] ‘Success’ in an occupation is achieved if the patient is treated by most others as if they are of the assumed sex. It is not necessarily that those around the patient believe that they are that sex […] Rather than being believed to be the assumed sex, the goal should be taken as an treated as that sex.”

[…]

“Some patients fiercely maintain that they do not care what others think of them, and that their own conviction of their gender is what matters. This position is at odds with the philosophy of a real life experience and if followed seems not to be predictive of a good longer-term outcome.”

Barrett further qualifies that “success cannot occur within a “purely transvestite or transsexual environment”, because “others may be supranormally accepting”.

So there you have it: “living as a woman” or “living as a man” means being taken as such within a cis environment. A very postmodern basis for clinical excellence!

(Guest Post) Draft Protocol Review

A review of England’s draft protocol for gender dysphoria services by CL. You can read a copy of the draft protocol here, respond to the survey here, and read my own analysis here.

Following the lead of an information note published by the department of health, the draft protocol confirms and compounds the problems of treating gender dysphoria on the NHS. It would at least mostly standardise treatment protocols across England, burdening everyone with the same problems: We’re all in this together, right?

The Gender Services Clinical Reference Group is aiming to implement standardised service provision by April 2013 and has given interested groups until September 30 to respond. GIRES has responded, as has Terrence Higgins Trust’s Trans* Women’s Sexual Health and Wellbeing Group, whose submission I contributed to. Our issues with the Department of Health’s Information Note are seen again here, and I’d like to focus on those in particular: the framing, tailoring and requirements of treatment.

Framing Gender Services Treatment

A problem in the protocol that has carried over from the information note and current practice, is the framing of gender dysphoria treatment as the property of psychiatric specialists. Even in updating the condition being treated to ‘gender dysphoria’ from Gender Identity Disorder, which explicitly frames the problem as one with our gender identities rather than our physical characteristics and the dysphoria resulting from them, the protocol places gender dysphoric people under the care of “a mental health professional (eg. psychiatrist or psychologist) who specialises in transsexualism/gender dysphoria and has general clinical competence in diagnosis and treatment of mental or emotional disorders.”

The logic behind this in the current protocol is not forthcoming. Perhaps it is because there’s a likelihood of additional mental health issues due to the stress of dysphoria. Realistically, it’s because dysphoric people have always been treated as mentally ill, and tradition has kept us under the exclusive care of psychiatrists.

Assessment is a large part of the GICs role: confirming that we have Gender Dysphoria and are not merely deluded about our gender identities. Gender Dysphoria strong enough to necessitate transition is rare, certainly, and doctors are warned to be warey of ‘Zebra diagnoses’ (as House of God, the inspiration for ‘Scrubs’ described them). That is, when you hear hooves, think horse, not zebra. That’s sensible advice, but if you’re in southern African plains, thinking Zebra first might not be so unreasonable. In this case, if someone is distressed by their assigned gender and sexed body, identifies strongly as another gender and feels relief when living as that gender, a diagnosis of ‘trans*’ is the most likely answer. Trusting this principle would rob the GICs of hours of questions about your childhood hobbies and masturbatory habits, but it would free up a lot of unnecessary appointments.

Scotland has already moved away from the complete ownership of Gender Services by mental health teams, allowing patients to self refer to a GIC. This saves an appointment with a GP, one with a community mental health team and allows direct access. For those who need a diagnosis, removing these two stages of waiting, where ignorance or prejudice can delay or waylay a patient, can get them that diagnosis quicker. Given the burden on admin staff and funding, a time, appointment and money saving move like that is far better than the protocol’s recommendations.

Tailoring Service

The introduction to the protocol claims that it is ‘informed by the 7th edition of the WPATH Standards of Care’ – sadly, it isn’t based on them. Some key recommendations from the 7th SOC were: HRT could be prescribed without RLE and one assessment, Lower Surgery required only one year of RLE (rather, one year of HRT). None of those recommendations are followed here, so the role of the 7th SOC’s ‘informing’ is not apparent. As Ruth points out, this is essentially just the existing Charing Cross treatment.

The protocol makes references to giving patients time to consider other options, other approaches, time to reflect and, of course, the RLE’s time to consolidate. There can be great value in this and many people seek the GIC to explore and understand their gender identity. Chances to really assess their history, feelings and situation can be very valuable. A friend in this situation said that her diagnosis brought her great relief and confirmation of her feelings.

For others though, this is unnecessary. Many others will have thought, reflected and considered extensively, almost exclusively at times, before seeking a GIC: they know who they are and what they need. For them, the numerous stages to access a GIC, double assessments and arbitrary RLE periods merely delay them, take up clinic time and appointments and cause additonal frustration as they wait for their treatment.

Clinics shouldn’t be forcing surgery on everyone at the first appointment, but the slowest common denominator approach is hardly ideal either, and unnecessary, arbitrary waiting is positively detrimental in many cases.

Requirements

Despite the 7th SOC’s ‘informing’ of the protocol (perhaps they were low on coasters?), RLE remains a key feature of the proposed gender services. The protocol is unclear about RLE requirements for HRT, but indicates that full HRT can be prescribed ‘Dependent on whether an individual has socially transitioned in the sense of living full time’ or is likely to ‘do so immanently’. Top surgery needs a year of RLE, lower surgery needs 2 years.

The problems with this are numerous:

  • It’s arbitrary. There are medical reasons for a year of HRT for lower surgery, but not for living full time in role.
  • Requirements of being employed have nothing to do with a stable, well founded gender identity.
  • Whilst individuals vary greatly, some people have considerably more difficulty being read as their gender prior to HRT, and AMAB people are more likely to recieve certain forms of harassment if people read them incorrectly. Forcing people into public facing roles to get the treatment they need puts them at direct risk of violence, harassment and discrimination.
  • What ‘real life’ is being experienced? From my own and others’ experience, I know that living full time as a woman pre HRT is vastly different to being full-time after a year on HRT. The near daily abuse and marginalisation, with incumbent stress, is not the real life I’m  experiencing now, but was a feature of living as a woman who was visibly trans*. The RLE required is entirely unrepresentative.
  • For all the regional variation and obfustication, the 2 years of RLE for surgery is well known, and patients work to it. The lengthy requirement can prompt patients to ‘start the clock’ running on RLE long before they are ready. Who knows how much suffering has come from that, or from knowing that no help will come before an arbitrary deadline?
  • Patients remain on the GIC’s book during this period: the aforementioned zebras get called in for appointments to needlessly check that they’re still serious, then sent away to wait another 5 months. This takes up appointments that could help patients who are less certain of their needs.

Overall, this protocol standardises existing Charing Cross treatment, which is already behind the times in not adjusting to WPATH’s SOC 7, and seems particularly inadequate when compared to the updated Scottish protocol. Most worryingly, its requirements standardise the appointments that add to the waiting times, administrative burden (which currently means Charing Cross are taking 2-3 months to send appointment summaries) and sense of disempowerment that service users experience. With multiple screenings, assessment and ‘time for reflection’, it is particularly unsuited to those who have a clear understanding of their identity and wish to proceed, and who have thought over their option extensively prior to seeking a referral. If this protocol is to last for any significant time, it will hold service users to standards that are already inadequate – If the next update will last, we need to fight for a protocol that truly moves treatment forward, so make sure to give your views in the protocol’s survey.

Business as usual? A look at the draft English protocol for gender dysphoria

The main achievement of England’s new draft protocol for transition-related services is not to offer progress, but to codify certain elements of existing practice.

In this sense, it somewhat resembles Scotland’s new protocol, which was published a couple of weeks ago.

The Scottish protocol appears to have been based largely upon the services offered by Sandyford, the nation’s largest gender identity clinic. The English protocol seems rooted in current practice at Charing Cross, which plays a similar role within England and Wales. The differences between the documents hinge largely on the differences between the progressive policies instituted at Sandyford, and the more conservative attitude of Charing Cross.

In this article I’m going to examine some aspects of the draft English protocol that have really struck me, before discussing political elements of difference between the English and Scottish protocols. I also briefly talk about the survey that is being distributed alongside the draft guidance.

The Good

LanguageThe language used within the draft English protocol largely acknowledges the complexity and diversity of trans experience. It encourages a respect for patient identities in terms of correct name, pronoun usage etc. (regardless of legal status). There’s even an explicit acknowledgement of non-binary identities, although this is somewhat undermined by binary assumptions elsewhere in the document, and a focus upon transitions that follow the typical “female to male” or “male to female” routes.

Referrals – The document provides some important clarifications for referral to a gender clinic: that individuals do not have to have lived in their preferred gender role prior to referral, that neuro-diversity and mental/physical health issues should not be a barrier to referral, and that psychotherapy is not a necessary precursor to referral. However, these points are not made as strongly as they could be, leaving some room for (mis)interpretation.

Treatment process The document states that two appointments should be sufficient for a diagnosis of gender dysphoria (to be diagnosed according to the ICD-10 criteria, as opposed to DSM-IV). The prescription of hormones should (if appropriate and desired) follow this diagnosis, and surgery should follow within approximately two years. This might all sound very familiar to Charing Cross patients, but may work to reign in some of the more eccentric practices of smaller gender clinics such as Nottingham.

Overall – It will be beneficial to have this protocol at hand to bring local referral practices and the actions of smaller GICs in line with national standards.

The Bad

Referrals – Referrals must come from a GP or specialist (psychiatrist or psychologist), with clinics able to insist upon referral from a specialist. This means that long-winded battles for referral look set to continue as normal. In contrast, the new Scottish system appears allows individuals or GPs to refer to any clinic.

Treatment process – The protocol states that it is informed by the most recent edition of the WPATH Standards of Care. However, it seems (again, contrary to the Scottish protocol) to ignore large parts of the Standards of Care in favour of current Charing Cross practice.

For instance, FtM spectrum individuals must have been on hormones for at least six months and full-time for at least a year before top surgery is considered, and patients must wait at least two years before being offered genital surgery (although a referral appointment for surgery may take place after 18 months under some circumstances). This last point in particular is justified with reference to ICD-10. Interesting here that guidance for diagnosis from 1992 is given precedence over guidance for care from 2011.

Trans youth– There is an acknowledgement of the benefits of hormone blockers for under-18s, but (unlike the Scottish protocol) no real engagement with the possibility of hormones and surgery for trans people aged between 16 and 18. The protocol continues to relegate all young people to specialised – and limited! – youth services.

Overall – The document pays lip service to the WPATH Standards of Care but does not really live up to the spirit of those guidelines. This is particularly evident when the draft document is compared to the Scottish protocol. Patients are expected to put up with a long-winded, complex system in which treatment is spread out over many years.

The Ugly

Get a job – Patients are still expected to be in education or employment in order to gain a referral for genital surgery. If you don’t have a job or you’re not on a course, you’re expected to be involved in some volunteering role. It’s all about demonstrating your ability to move through the world in your “new” gender prior to irreversible surgery.

This requirement is patronising, stupid, and fetishises trans genitals. What other surgery requires that those who undergo it are in work? Why is it that genital reconstruction is seen such a massive step, but the permanent changes that come with long-term hormone therapy is not? Yes, surgery is a big deal, but it’s clear that clinicians regard this surgery as something else entirely.

I can’t understand how this can possibly be acceptable at the best of times, but at a time of recession and mass unemployment it strikes me as particularly cruel and unreasonable. How to account for individuals who cannot find a volunteering role in their local area? Individuals with anxiety issues? Individuals who are told by the Job Centre not to volunteer, with the threat of benefit withdrawal hanging over this order? And how can this possibly be acceptable when trans people face considerable inequalities in the job market (with trans unemployment estimated at 50% in some European countries).

Physical examination – GPs are apparently “expected” to perform a physical examination of trans patients. Why? No reason is given. The document simply states that: “The GP will be required to carry out a basic physical examination and investigations, as a precursor to those physical treatments which may later be recommended.

I simply cannot comprehend where this idea comes from. For many trans people – particularly those contemplating physical transition – the very idea of a physical examination is extremely unpleasant and can cause severe distress. There are times when pre-operative trans people might require a physical examination: such as immediately prior to surgery, or during a sexual health check-up. These experiences can be deeply unpleasant, but at least they’re necessary.

GPs are not trained to understand the complexities of trans people’s relationships with their bodies. In fact, most GPs don’t receive any training on trans issues whatsoever. What are they meant to be looking out for during such an examination, and how are they supposed to know? An invasive examination such as this should only be performed when necessary, by someone who knows exactly what they’re doing.

Discussion: England vs Scotland

The headlines from the Scottish protocol included a number of moves to bring treatment more in line with the most recent edition of the WPATH Standards of Care. These included provisions for self-referral and referral by GP, less waiting time for surgeries, access to a wider range of treatments (e.g. hair removal) and full access to treatment for individuals aged between 16 and 18.

Whilst representatives from groups such as the Scottish Transgender Network played a vital role in putting provisions such as these on the national agenda, it’s important to recognise that many of them had already been implemented by Sandyford GIC.

The message seems to be that the English clinics – who are almost entirely responsible for the development of this draft protocol – are not interested in developing new practice, let alone conforming with the seventh edition of the WPATH Standards of Care. Instead, they seem keen to maintain a tight control over the processing of patients, an approach that renders the draft protocol even more strict than a new national commissioning policy that is being simultaneously developed.

Survey

The survey that accompanies the draft protocol is extremely short. This makes it quick and easy to fill in, but the form also seems to have been designed to shut down unwanted criticism. The Department of Health appears interested only in how current experiences match up to the proposed protocol, and seems keen to avoid any kind of critical feedback on the document.

It is, however, possible to offer you opinion on the nature of the protocol itself. Here are some tips for doing so:

  • Where your experiences differ from the protocol in a positive manner (e.g. you didn’t receive a physical examination from your GP), emphasise how your experience was more positive than would be the case should the protocol be implemented as-is.
  • Where your experiences differ from the protocol in a negative way, emphasise any manner in which you think the protocol could go further to ensure better treatment.
  • If you have sought care outside of the NHS for necessary treatments (e.g. hair removal for trans women) explain why this treatment should be a necessary part of the protocol

Final thoughts

The introductory text to the survey suggests that current political and financial pressures on the NHS prohibit the introduction of any real changes within the draft protocol:

DH wants the final document to outline the current position for transgender people seeking gender reassignment services through the NHS. The document should outline what support and services a transgender person can expect to receive in the tight financial constraints currently placed on the NHS.

This doesn’t really make a huge amount of sense. Yes, if more trans people have access to services (e.g. laser hair removal), this will cost money. But surely there is a lot more money to be saved through progressive reform?

Insisting on longer real-life tests, longer waits for surgery and so on won’t save a lot of money in the long term. A similar amount of trans people will be accessing services: they’ll just have to wait longer as individuals in order to access the a services. The money will still be spent. So why have such long waiting times?

Insisting on referral through a specialist (i.e. psychiatrist or psychologist) won’t save money. How does the NHS possibly benefit financially from insisting that trans people see more specialists rather than having them directly referred to a gender clinic by their GP? This is particularly the case when specialists decide that they need to assess people over multiple appointments before referring them to a gender clinic. The individuals concerned experience a frustrating delay, and it costs more money because the NHS is paying for all these extra appointments.

This isn’t really about the money. It’s about gatekeepers maintaining a certain level of control over patients, and putting certain ideologies into practice. It’s about picking and choosing which parts of ICD-10 and WPATH SOC 7 fit best with their pre-existing ideas, and using those elements to justify existing practice. It’s about conservativism over progression: a wasted opportunity.

Transphobic conference CANCELLED

The Royal College of Psychiatrists have cancelled “Transgender: Time to Change“. This isn’t just a victory for the trans movement: it’s also a victory for angry blogging, community organising and the threat of peaceful protest.

Pink News have a really positive piece on the cancellation.

RCPsych claim that the cancellation was down to low ticket sales. However, it’s pretty telling that the event was cancelled right after Charing Cross Gender Identity Clinic put out this statement:

The team at the WLMHT Gender Identity Clinic (GIC) at Charing Cross Hospital notes the apparent shift of emphasis in the Royal College of Psychiatrists Gay & Lesbian Special Interest Group conference, ‘Transgender: Time To Change’ on May 20th and feels compelled to withdraw on this basis.

When we were originally asked to take part, GIC clinicians understood that our role was to outline the work we do within our own service and explain the very considerable evidence base which underpins it. We are very happy to do this and our more than 55 years of experience as the country’s leading NHS provider gives us a rich and robust data set from which to draw observations.

It now appears that the conference comes at trans issues from a very specific agenda, namely, to explore the validity or otherwise of gender diagnoses as medical and psychiatric phenomena. So long as this is the case, we feel we can’t support it.

Although we were somewhat wary of engaging in what is essentially a clinical discussion with a predominantly non-trans panel, which, moreover, features a non-clinician whose personal opinion is already well known, we agreed to do so in order that discussion might focus on evidence rather than anecdote.

The Royal College should be aware that there is a great deal of disquiet around this event within the trans community and interested parties should note that the discussion as it now stands will be one-sided at best..”

On the subject of “numbers”, it’s also worth pointing out that registration was meant to be open until 9th May. That suggests that the number of people signing up for the event was really low: an encouraging turn of events! Commentators elsewhere have suggested that many psychs will have been put off by the outdated views held by many of the speakers. I only hope this is the case.

This is well worth celebrating, but the good news shouldn’t be the end of the matter. There’s a few really important lessons we can learn from the whole affair, and some things we need to think about regarding future action.

Trans people are still treated awfully by the medical establishment in general, and the psychiatric establishment in particular. We need to explore how to bring about change: through research and its dissemination, through lobbying, and through protests. The simple threat of a colourful, vibrant protest on the PCPsych doorstep clearly had a massive impact, as did the actions of those who talked to psychs and to Charing Cross.

The gender clinics and gatekeepers of this country have a troubled relationship with the trans community, but it benefits us to work with them. Currently, they’re not particularly accountable: Charing Cross has a patient feedback group, but how many trans people even know of this group? How many know how to contribute to its feedback? How many know the vast majority of groups invited to attend the meetings are London-based? This situation needs to change, but the clinic’s actions on this occasion suggest that it can.

Julie Bindel will probably kick up a fuss. Personally, I feel we should let her get on with it. Any opportunity for us to promote our arguments against the approach taken by the cancelled conference is a good one.

Finally, I’ve been informed that activists are planning to go ahead with the community “teach-in” that was originally planned to coincide with the transphobic conference. After all, there are speakers and facilitators booked, so why not? People are talking about focusing on the continuing problems within trans health in general and psychiatry in particular, and exploring where we might go from here. The venue and timetable are still being arranged, so I’ll post again once there’s news on that front.

Psychiatrists plan transphobic conference

The Royal College of Psychiatrists’ Gay and Lesbian Special Interest Group (an organisation clearly well-qualified to meddle in trans affairs) are planning a delightful meeting in London next month.

Described as an “extremely stimulating meeting exploring the most recent academic, clinical and contemporary thinking on transgender issues, for all people interested in this field, Transgender: Time to Change will include contributions from a number of disturbingly transphobic speakers.

Let’s have a look at the programme for the day, shall we?

A meeting organised by the
Royal College of Psychiatrists’
Gay and Lesbian Special Interest Group
Friday 20th May, 2011
15 Belgrave Square, London SW1X 8PG

9.30am Registration

10.00am Morning session: Chair: Professor Michael King

10.10am Dr Domenico Di Ceglie: From Disorder to Diversity: Current views and controversies in the management of Gender Identity Disorder in Young People

10.45am Ms Julie Bindel There is no such a thing as a real woman (or a real man, for what matters). A feminist perspective on Gender Identity Disorder

11.20am Ms Christina Richards: Trans: What the empirical literature tells us

11.55am Discussion

12.30pm Lunch

13.15pm Afternoon session: Chair: Shawn Mitchell

13.20pm Dr James Barrett: Disorders of Gender Identity – what works

14.00pm Dr Az Hakeem: Deconstructing Gender and Parallel Processes: Features specific to a Specialist Transgender Psychotherapy Service

14.40pm Panel discussion – all speakers

15.15pm Finish

15.30 – 16.15pm GLBSIG AGM – all welcome

My, what a line-up. Where to begin?

The most obviously questionable speaker is Julie Bindel, a woman with a long history of transphobia. Bindel makes it her mission to subject trans people in general – and trans women in particular – to the very same treatment that she (rightly) decries as sexism when it is aimed at cis women. She has consistently argued against the provision of medical treatment for transsexed individuals. She has threatened to sue trans individuals and feminist organisations that dare condemn her damaging actions. What the hell gives her the right to comment on the psychiatric treatment of trans people?

However, Natacha Kennedy rightly points out that Dr Az Hakeem is considerably more dangerous. He runs a “specialist psychotherapy service for patients with transgender and other gender identity disorders” (source) at the Portman Clinic, meaning that he has a great deal of power over trans patients. Let’s have a look at what he has to say about us:

“The experience of many psychiatrists, psychoanalysts and psychotherapists working with transsexual patients is that they are individuals who, for complex reasons, need to escape from an intolerable psychological reality into a more comfortable fantasy. By attempting to live as a member of the opposite sex, they try to avoid internal conflict, which may otherwise prove to be too distressing.”

Regarding Hakeem’s approach to trans research, Kennedy points out:

There is so much wrong with Hakeem’s 2010 paper in which he claims to be able to ‘cure’ trans people it is hard to know where to begin. These kind of claims have been repeated throughout the chequered history of psychiatric engagement with trans people. His kind of treatment “talking therapies” as Julie Bindel calls them, “reparative therapy” being one of the many euphemisms employed by the “treatment has also been tried on gays and lesbians and been shown to fail, causing only feelings of trauma, guilt and suicidal tendencies.

His paper makes assertions for which he provides no evidence and his methods, selection of research participants and the nature of their participation in the study appear to be opaque in extreme. In addition there is no mention of research ethics which are particularly important when one is publishing research about individuals with whom one has a professional-client relationship.

Gosh. I’m sure glad this man is going to be sharing a platform with Bindel.

Who else do we have? Ah yes, Dr Domenico Di Ceglie. The conference blurb points out that he works for the Tavistock Clinic, a service that offers approximately sod all a very limited “service” for trans children and adolescents. Contacts of mine who have attended this clinic explain that therapists have patronised them, steered the conversation away from any real discussion of gender, and refused to offer treatment. Realistically, hormones are banned until you’re 18 for the vast majority of trans teens in the UK. Looks like you’re doing a sterling job, doctor!

James Barrett is a controversial fellow, to say the least. He’s deeply unpopular with some of his patients at Charing Cross, whilst others like him. He’s provided a great deal of help to many, but is a bit obsessed with the idea that people need to be in employment or education in order to earn treatment. He has been known to block treatment for individuals who have disabilities that prevent them from working.

Finally, we have Christina Richards, another Charing Cross psych. Shockingly, Christina brings the number of trans people speaking at this conference up to a grand total of one.

As a community, we shouldn’t simply let this pass. Most of these speakers aren’t just dodgy, they’re downright dangerous. We need to be asking the Royal College of Psychiatrists’ Gay and Lesbian Special Interest Group what the heck they think they’re doing, raising awareness of this travesty in the LGBT media, and if necessary picketing the meeting. If we let this go without a fuss then the vile propaganda of individuals such as Hakeem and Bindel will only spread unchecked.

Why the NHS shake-up leaves me baffled

If you live here in England, you’ve probably noticed that the government has decided to give £80 billion of public money to GPs (read: private companies working with GPs) and scrap primary care trusts. David Cameron claims “We are not reorganising the bureaucracy, we are scrapping the bureaucracy.”

One of my biggest problems with the NHS is that the bureaucracy of the health system is incredibly unwieldy. All too often the left hand doesn’t seem to know where the right hand even is, let along what language it speaks. I’m also usually in favour of devolution and the localisation of services. I can’t conceive of how this particular change will be an improvement though.

We currently have 150 primary care trusts (PCTs) and the government is proposing to replace them with between 500 and 600 GP consortia – in order to save money. Surely though the cost of doing this in the first place is going to be ridiculous?

Surely this move will do nothing to remove the NHS bureaucracy: it’ll just shift it from (publicly owned) PCTs to (privately-owned, but publicly funded) consortia. This will mean that thousands upon thousands of people working in admin will lose their jobs…and thousands of new jobs will be created elsewhere. It’s being claimed that individuals who currently work for a PCT could seek work with a consortium but…this is just stupid. Thousands of admin workers will basically be relocated to new bodies, and this is going to cost a huge amount of money: it’ll cost to close down the PCTs, it’ll cost to make redundancies, it’ll cost to advertise for the new jobs and to run interviews and to basically re-train pretty much all of the non-hospital admin staff for the NHS in England. What planet is Andrew Lansley living on?

Additionally, each PCT tends to have its own individual policies, guidelines, patient booklets and outreach/advertising schemes for various services. It costs money to produce all of this: surely it’s going to cost more money for 500+ variations on a theme than 150?

Okay, so suppose the government is right about how best to save money whilst providing better services on the NHS (hah!) and all of the above will be cancelled out by the long-term savings. How easy will it be to hold all of this hundreds of these new consortia to account?

A few days ago I posted up a new policy for trans name changes we’ve sorted out with the local PCT. Within three years that change is probably going to be a bit pointless, and I won’t be surprised if things regress within the Coventry area. There’s a lot of very decent GPs out there, but others aren’t: a bunch of them are bigoted arseholes who will deny treatment to LGBTQ people at the drop of a hat. If GPs are going to be responsible for deciding who gets funding and hospital referrals, trans people who seek medical treatment could be in a lot of trouble. I’m not just talking about trans people who want to transition medically: I’m talking about any trans person who wants any kind of treatment, since the whole “we don’t serve your kind here” attitude is still highly prevalent. Of course, under current rules the NHS as a whole in the UK has to provide treatment (including aspects of medical transition) for all trans people, but that hasn’t stopped certain areas (such as, say, Wales)  from refusing to provide treatment.

Right now, if we’re lucky enough to have the PCT on our side (as we finally do in Coventry…tentatively, at least) then we can have them pressure the GP to sort it out. This system is far from perfect, since many PCTs simply don’t want to listen (see: Oxfordshire) but I imagine it’s going to be far harder to bring about positive social change in five or six local consortia than it is with a single PCT.

Moreover, one of the biggest problems with the NHS is communication. One of my friends was given a referral to Charing Cross gender clinic by a psychiatrist after years of waiting, but then had to move house and ended up in a different PCT. The PCT refused to acknowledge the referral and made her start again from scratch, effectively postponing her access to hormones by two years. I can’t imagine that this kind of thing will be less common with the NHS split up into more bodies.

So what can we do? Well, I suspect there’s very little we can do, but now is the time to act. We should be fighting on every front: writing to politicians, talking to the media, participating in protests and taking part in any consultation event we can find out about, and at every stage we should be asking awkward questions about how these changes will impact minority groups such as trans people (‘cos I’m pretty certain it will disproportionately screw over others, such as people living in poorer areas).

Finally, a couple of thoughts from The Guardian:

GPs are doctors, not accountants

“Imagine this bedpan is full of money…”

I used to get angsty, but now I get angry

This post is part two of my response to misha the Duck of Doom, who commented on this post.

In the second half of her comment, misha wrote:

“Its easy. Why do so many of you lot {Angst transsexuals}
get in such a tizzy.
Frak, transitioning is dead easy.
So enjoy it

Also stop making it “the world is against me”
coz it isn’t.
TBH, most of the world doesn’t give a stuff & barely notices us.

So get a grip!
And don’t overcomplicate things.
It really is easy.”

I’ve come across various versions of this argument in different trans communities and in different parts of the net. It’s reflected also in the attitude of many cis people who decry identity politics, suggesting that we’d be more accepted if we piped down and stopped trying to claim special rights; after all, this is the 21st century and we’ve moved beyond the need to define people by particular traits they happen to have.

I don’t buy it.

The world is a very, very difficult place for many trans people. When I say “trans” here, I’m not just referring to transsexed people, but also to the wider spectrum and gender/sex diversity…cross-dressers, drag kings and queens, genderqueer individuals, transgender…what brings us together is that we’re all discriminated against for defying societal sex/gender norms in one way or another.

There are those, of course, who don’t have such a hard path. As misha says, transitioning (for those who transition) can be “dead easy” for some. In my case, for instance, I think I’ve been pretty lucky. Despite the fear, shame and guilt about being trans, I managed to come out in my teens, and generally had a good reaction and support from my friends and family. I managed to access most of the medical services I needed for free on the NHS, a process which took a mere six years with minimal incompetence on the part of Charing Cross. I’ve received relatively little direct discrimination: it’s very rare that I’m denied services or harassed on the street, and these occurrences have become increasingly uncommon as my appearance has changed. I’m very grateful for all of this.

I’m also highly privileged to have had such a smooth transition. It helps that I’m a white, abled, middle-class woman, but I’ve got lucky more generally. I had access to online support networks, meaning that I was able to come out to myself and understand my transness at a relatively young age. My supportive friends and parents mean that, unlike some of my trans friends, I didn’t get abused or kicked out of my home as a teenager or beaten up in the street. The fact I’ve always lived in a PCT that has a decent care pathway means I haven’t had to self-medicate, I haven’t had to wait over a decade to get through the medical system, and I haven’t had to threaten legal action to get treatment which is meant to be guaranteed on the NHS. The fact that I “pass” with ease means that my appearance doesn’t constantly mark me out as different.

This doesn’t mean that my path has always been easy. After all, I have been discriminated against, I have been harassed and insulted in the street, I have experienced extreme shame before coming to terms with myself, and I did have to put up with years and years on waiting lists whilst my body became broader and more hairy. I knew that until recently, it was perfectly legal to deny me access to shops and services.

Knowing that these experiences are pretty tame compared to what other trans people have to go through makes me pretty angry. If I shouldn’t have had to go through what I went through, then there’s absolutely no excusing what others experience. Trans people are likely to be discriminated against in every aspect of public life: when accessing services, in the workplace, during leisure activities and in the street. The attempted suicide rate is unusually high, and violence from others is common. Our identities are systematically erased in the media, which (when not portraying us as freaks) ensures that the only trans bodies that are ever seen are those of middle-aged, middle-class white trans women.

I have a good life and am generally happy these days. The positive benefits of transition have pretty much eliminated most of my angst. But I am so, so angry about the injustices committed in the world. I don’t want a complicated life, but I can’t stand by and let others suffer. I want to harness my rage, and use it to bring about positive social change. This is why I’m an activist, and it’s why I’m ready to take on the world.