“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!

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.

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).

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.

Gender statistic guidelines revised by HESA

The Higher Education Statistics Authority (HESA) have announced a welcome revision of their new gender and sex categories for student records within Higher Education.

I originally posted about this issue after HESA’s original proposed revisions – which appeared to ask about “legal” or “birth” sex and removed any possibility for the recognition of non-binary genders and intersex bodies – caused confusion and concern.

An impressive lobbying campaign in which trans people and allies emailed and tweeted HESA to explain our concerns has now led to a change in policy.

The revised fields contain the following categories:

SEXID (sex identifier)

1 Male
2 Female
3 Other

This replaces the current options (male, female, indeterminate) and the original proposed revision (male, female).

It is important to note that HESA acknowledge for the first time that the “other” category might be used to record non-binary genders in their advice to institutions:

The use of ‘other’ is more appropriate for people who associate with the terms intersex, androgyne, intergender, ambigender, gender fluid, polygender and gender queer.

As Jane Fae explains, this is an enormous step forward.

It’s also worth noting that institutions may, if they wish, institute additional gender options in their student record surveys (e.g. genderqueer, androgyne) and map these options onto the third category (“other”) for the sake of data provision to HESA.

GENDERID (gender identity)

Suggested question:
Is your gender identity the same as the gender you were originally assigned at birth?

01 Yes
02 No
98 Information refused

These revisions are a massive improvement, representing a step forward from the existing guidelines as well as the flawed original revisions. HESA certainly deserve credit for listening carefully and responding positively to the complaints they received.

However, there is still some ambiguity in the SEXID question. No doubt some institutions will title this question “sex” whereas some may title it “gender”, and students may still experience uncertainty when formulating a response. For instance, how are intersex individuals who define as female or genderqueer individuals who wish to note that they have been assigned a male sex meant to respond to such a question?

Moreover, it is important that trans activists based within Higher Education continue to lobby institutions to recognise gender identity within student records purely on the basis of self-definition – a matter that is largely out of HESA’s hands.

Genderfork and trans feminism

I’ve just had an academic article published in MP: An Online Feminist Journal:

Inadvertent Praxis: What Can “Genderfork” Tell Us About
Trans Feminism?

The paper explores trans feminist perspectives on self-definition, body sovereignty and intersectionality in the context of the Genderfork community, and is based upon research I undertook for my MA in 2010.

NUS Women’s Campaign recognises gender complexity

I have a special place in my heart for the National Union of Students Women’s Campaign. The Campaign is (broadly speaking) a truly inclusive, progressive body. I met some amazing women and learned a great deal about the contemporary feminist movement during three years as an elected volunteer on the Women’s Campaign national committee.

However, I was disheartened to hear about the Campaign’s poor record on trans issues in the past year; most notably, a female-assigned genderqueer committee member’s very place in the Campaign was called into question after they explained to other committee members that they do not exclusively identify as a woman. The poor manner in which this democratically elected representative was treated flew in the face of both the spirit and the letter of trans-inclusive policy passed in 2009.

I therefore find it heartening to hear that NUS Women’s Conference 2012 today passed new policy to ensure that this never happens again. Delegates voted unanimously for a motion that will change the Women’s Campaign standing orders in order to permanently clarify the membership of this autonomous liberation campaign.

The motion, entitled “Gender complexity and inclusiveness in the NUS Women’s Campaign“, notes that:

That not all those who are oppressed as women necessarily identify exclusively as women, or would choose the word ‘woman’ or ‘female’ to encapsulate their gender identity […]

Whilst the NUS Women’s Campaign does not have a large amount of explicit policy on issues specifically related to people with complex gender identities who self-define into the campaign, it has a duty to make its spaces safe and welcoming for them.

The following is therefore added to the Women’s Campaign standing orders:

The NUS Women’s Campaign is open to all who self-define as women, including (if they wish) those with complex gender identities which include ‘woman’, and those who experience oppression as women. The NUSWC affirms that self-definition is at the sole discretion of the individual in question.

This really should have come about without an individual being treated poorly, but it’s great to see Women’s Conference so ready to address the Campaign’s mistakes. Full credit to everyone who voted through the change!

In a gender liberated world…there would be no moral panic over trans parents or trans children

And so the Bizarrely Busy Month of Trans News rolls on.

On the subject of trans parents, the Daily Mail has effectively outed a trans father; on a slightly brighter note, Green MP Caroline Lucas has tabled an Early Day Motion condemning the ongoing media witch-hunt that’s currently targeting pregnant trans guys. Kudos once again to Trans Media Watch and Jane Fae for their ongoing work on this. Meanwhile, bookmakers Paddy Power are under fire for a transphobic advert, and today saw a five-year-old trans girl splashed all over the tabloids (including front page stories in the Metro and the Sun).

Paddy Power will no doubt defend their advert (basically a “spot the tranny” competition themed around Ladies’ Day at Cheltenham) on the grounds of humour: it’s just a laugh, right? Meanwhile the tabloids will continue to defend their almost fetishistic obsession with the private lives of trans people on the grounds of “public interest”. Both actions serve to dehumanise and objectify trans people even as they build public interest in the queer freak show we supposedly offer.

This is all, of course, of massive concern to the so-called trans community. But we’re not the only ones who are affected.

In today’s front-page article, the Metro quotes “social commentator” Anne Atkins (who?) Atkins – clearly a great expert on gender diversity – says:

“Between the ages of about five and eight, I wanted to be a boy more than anything in the world. Acute though my longing was, it was relatively shortlived. I am grateful to say that there was no one around at the time to diagnose me with GID [Gender Identity Disorder]”

If I had a pound for every well-meaning cis friend who’d told me this at the beginning of my transition…well, I wouldn’t have a huge amount of money, but I’d definitely be able to afford a better toaster. But my problem with this isn’t one of cis privilege. It basically runs as follows:

What’s intrinsically wrong with a kid spending part of their childhood as a “boy” and part of their childhood as a “girl”?

What’s intrinsically wrong with the idea of a man having a baby?

What’s intrinsically wrong with (or, for that matter, funny about)  gender being complex or fluid or aligned with their body in a non-normative fashion?

I’ve not come across a single answer to any of those questions that isn’t inherently sexist in one way or another. We shouldn’t have to subscribe to an ideology of gender difference that necessitates people being placed in boxes that restrict their self-expression. We shouldn’t have to rely on old-fashioned gender roles. At the same time, we shouldn’t have to demand that “gender” be obliterated altogether. Why can’t five-year-old Zach live as a girl? Why couldn’t Anne Atkins live as a boy for a few years before settling into womanhood?

In a gender liberated world, gender expression would be free and fluid. Adults could be men, women, genderqueer, polygendered or non-gendered as they desire. Children could be children, and explore gender as one set of social possibilities amongst many. And everyone benefits, not just trans people. We’d all have more space to be ourselves.

If you think this is hopelessly utopic and ultimately impossible, try dropping by spaces such as Genderfork and Wotever, where users/attendees are pioneering gender liberated approaches to language and social interaction.

We don’t need to do away with gender, but at the same time we don’t need to subscribe to fixed, binary ideals of gender in order to live in a decent world where people value one another’s work and care for one another.

In a gender liberated world, neither the media nor the medical world would care about five-year-old trans girl, a pregnant man or a trans person at Cheltenham because it simply wouldn’t be a big deal.

The trans girl could live out her childhood as she desired and privately transition physically – or not! – at an appropriate point in her teens. The man could access appropriate care during his pregnancy without fearing the consequences of doing so. And at Cheltenham…well, isn’t the very concept of “Ladies’ Day” totally regressive?