WPATH 2016 poster: “A time of anticipation”

Here’s the poster I presented at this year’s WPATH Symposium:

Anticipation poster.png

You can also download a PDF version here.

The magnet is a metaphor for anticipation, which is both a product of and shapes feelings, emotions and experiences of time. This process is mediated by both trans community discourses and medical systems.

It’s very important to note that the majority of research participants had good things to say about the health professionals who helped with their transition. However, there is also a high prevelance of transphobia and cisgenderism within medical systems and clinical pathways. Anxiety and mistrust of practitioners within the trans patient population is endemic, and this is compounded by long waiting times.

My wider research looks critically at how discourses of trans health are differently understood within and between community/support spaces, activist groups and the professional sphere; however, the purpose of this particular poster was communicate some of the difficult experiences that current patients have with waiting. It sparked some productive conversations and I hope that further work will follow from this.

Sources:

Transitional Demands (Jess Bradley and Francis Myerscough)

Experiences of people from , and working with, transgender communities within the NHS – summary of findings, 2013/14 (NHS England)

Current Waiting Times & Patient Population for Gender Identity Services in the UK (UK Trans Info)

 

No, I will not help Sundog make a documentary on trans “regret”

This afternoon I received an unsolicited email in my work account from an employee of Sundog Pictures. An excerpt follows:

I’m currently working on an idea alongside Channel 4 following transgender individuals who have come to regret their sex changes and are keen to undergo further treatment / operations to reverse the change. The doc will be insightful and sensitive and will look at the way in which transgender individuals are treated in society and whether the process before someone is permitted an operation is robust enough.

I’m currently looking for real life cases to include in my pitch document and was wondering whether you might be able to recommend people I could speak to, or places I could contact to find individuals who are currently thinking about a reverse sex change. Any help would be really appreciated.

Given the email account used, I feel that I can safely assume that I was contacted because of my academic work, which looks at discourses of trans healthcare provision. Sundog seem to hope that I will (without compensation) draw upon my community contacts and research findings to recommend participants for their television programme.

I couldn’t think of anything more inappropriate.

There’s a lot to be said about research ethics and a duty of care towards participants, but plenty has been written about that elsewhere (the BSA Statement of Ethical Practice offers a decent broad overview). So in this post I focus on the huge problems that come with the proposed topic of the documentary: that of trans “regret”.


The numbers

The mainstream media take an undue interest in trans “regret”. It’s very easy to come across such stories on daytime television and in both tabloid and broadsheet newspapers. The popularity and frequency of such stories suggests that it’s not too unusual for people who have undertaken a physical transition from male to female, or from female to male, to consider or undertake a “reverse sex change”.

In reality, research has shown time and time again that the actual rate of regret is extremely low. For instance, only 2% of respondents in the Trans Mental Health Study (the second-largest trans study undertaken in the UK) reported “major regrets” about the physical changes experienced during transition. Reported regrets from participants included:

“…not having the body that they wanted from birth, not transitioning sooner/earlier, surgery complications (especially loss of sensitivity), choice of surgeon (if surgery required revisions and repairs), losing friends and family, and the impact of transition on others.”

It’s clear therefore that “regret”, when it occurs, is likely to stem from societal and surgical issues rather than the process of physical transition in and of itself. The Trans Mental Health Study also demonstrates a clear link between physical transition and wellbeing in terms of mental health, body confidence and general life satisfaction.

With so few trans people regretting physical transition – and even less considering some kind of “de-transition” – it’s no surprise that sometimes the same individuals are trotted out time and time again to re-affirm a discourse of regret.


What’s missing from this story?

It’s pretty clear from the email I received that that the author has not done their research. Given the existence of organisations such as Trans Media Watch and All About Trans who are entirely keen to offer advice, this does not exactly inspire confidence.

For a start, transition is conflated with “sex change”, a term that is not only most frequently associated with transphobic tabloid headlines, but is also broadly meaningless. At what point can we talk about a “sex change”? When an individual undertakes hormone therapy? Chest surgery? Genital surgery? What about individuals who transition socially, but only undergo some (or even none!) of these processes? It’s not the kind of language that suggest an “insightful and sensitive” documentary can be made.

There’s a couple of more fundamental mistakes in the proposal, however. The first is the question of “whether the process before someone is permitted an operation is robust enough”. My own initial research findings suggest that if anything, the process in question is too robust – in that patients requiring surgery are typically required to wait many years before treatment is available.

The World Professional Association for Transgender Health Standards of Care require patients to undergo at least 12 months of hormone therapy prior to genital surgery. In reality, patients in England and Wales face a substantial waiting list (sometimes lasting years) before they are able to attend an NHS Gender Clinic, where two separate clinicians are required to approve a regime of hormone therapy before it can be undertaken. An additional two opinions are needed at a later date before a referral for genital surgery can take place. There are many, many opportunities and a great deal of time for patients to consider and re-consider their option – and that’s even before we take into account the horrific scale of the current crisis in surgery provision for trans women.

The current system is not constructed to facilitate transition so much as prevent the very possibility of regret. The result is increased suffering – in terms of the mental and physical health impact upon individuals who are forced to wait many years for hormones and surgery, whilst fearing (sometimes with good reason) that they will be denied treatment on spurious grounds. It’s no surprise that the Trans Mental Health Study found that “not transitioning sooner/earlier” is a major cause of “regret”, as individuals who have waited until breaking point to transition soon discover that there is still a long, long road ahead of them.

The second fundamental problem with Sundog’s proposal is their idea that trans people who aren’t too happy with their transition might be “keen to undergo further treatment / operations to reverse the change”. This is a very binaristic notion that both stems from and reinforces the notion that transition is a one-way process, from one (binary) gender to the other. In reality, there are many people for whom transition is a complex, ongoing process. For instance,  an individual who initially transitions from male to female might later feel that their identity is better understood as genderqueer, and may allow or pursue further physical changes to reflect this.


The wider political context

Given the tiny proportion of trans people who “regret” transition and the realities of service provision, the choice of a documentary about the subject appears at best to be somewhat misguided. However, the impact of insensitive coverage on this topic is such that I believe that I believe this documentary could be actively harmful, particularly as Sundog’s email asks “whether the process before someone is permitted an operation is robust enough”.

This is in part because the way in which discourses of regret are handled makes it harder for trans people to get treatment. Gender clinics in the UK require urgent intervention to make life easier for individuals who transition, not harder. Media hysteria over the possibility of regret reinforces the current system’s approach, which is to require people to demonstrate over and over again that they are trans before there is any hope of treatment.

But it’s also because discourses of regret are employed by those who campaign against trans liberation, including conservative commentators and anti-trans radical feminists who would deny funding for transition on the NHS altogether. Writers such as Julie Bindel are all too keen to use any example of individual regret to argue that transition is unnecessary mutilation, undertaken by sad, sick individuals who might have done otherwise if only they’d been given the option of, say, some form of reparative therapy.

The focus on the medical process is therefore politically loaded. Yes, some people do de-transition, and their stories are important and of worth. But these stories have yet to be told by the mainstream media in a non-sensationalised manner, in a way that doesn’t reinforce (intentionally or otherwise) a pernicious anti-trans agenda. Sundog’s proposal appears to feed right into this agenda.

This proposed documentary should not be regarded as a curiosity piece taking place in a cultural vacuum. It draws upon and will contribute to damaging and inaccurate tropes about transition. Ill-informed media accounts ultimately play a part in creating and maintaining a situation where “regret” frequently stems from the responses of friends and family, delays to transition and other negative experiences that come with transitioning in a transphobic society.

I hope therefore that any future attempts to examine trans health issues in this way will involve better research into the topic at the initial stages, and a greater sensitivity to both the personal and political consequences of exposing trans lives to media scrutiny.

DSM-II

On Monday we released the second Dispute Settlement Mechanism EP, DSM-II. You can listen to it below. I perform on lead vocals, and also play clean bass guitar on our cover of Seven Nation Army.

NHS Vulva may be of particular interest to readers of this blog. It deals with issues of medical malpractice, transphobia in the legal system, and cultures of transition.

Laura Jane Grace subverts MTV with style

Having previously written a little bit about Against Me! frontwoman Laura Jane Grace’s recent appearance on MTV’s House of Style, I finally got around to watching it.

And, you know what, I really am impressed.

Grace makes the most of every moment of air time: she seems determined to convey a whole series of positive messages. It seems like the editing team who put together the short were pretty respectful of this. The whole programme is also largely free of the usual transphobic tropes, which is an achievement in and of itself.

I’m not normally a fan of this kind of thing. I don’t care how celebrities dress. I don’t care how they “choose” their “style”. I associate such programmes with shallow consumerism and damagingly limited ideas about how people should and shouldn’t express themselves.

But the messages that come from Grace are powerful, important and – to my mind – broadly feminist. Be true to your tastes and interests (“You can see like the texture of it? That’s real dirt”). Dress in a way that makes you feel good. Passing doesn’t need to be an end in and of itself. If you’re a young trans people, it’s okay – other trans people exist, in public!

Grace is self-consciously making herself into a role model. That’s not always a good thing, but the message here isn’t “be like me”, it’s “be yourself”. Sod the naysayers: this is punk as fuck.

Video embedded for readers who (like me) aren’t based in the US, and hence can’t watch this on the MTV website.

There’s more to (public) life than being trans

A news feed informed me the other day that Against Me! frontwoman Laura Jane Grace had appeared on MTV’s House of Style to talk about her, uh, style. On one level, I suppose this is pretty typical of the vapid programming you’d expect from MTV – celebrity turns up, talks about her wardrobe, nobody learns anything of value but some mild entertainment supposedly takes place.

Except this is a big deal in one sense, because Grace is trans, and transitioning. By appearing on this kind of programme talking about her favourite clothes and showing off her collection of obscure punk records, she normalises transness.

There’s part of me that feels a bit uncomfortable about this – social inclusion is a worthy goal, but should it really come at the expense of a dull assimilation into corporate cultural mediocrity?

Still, I went looking for the video. I didn’t manage to find it because MTV really aren’t keen on British people watching American video content (and I can’t be bothered with proxies, at least not over this). However, I did come across a bunch of punks arguing about Grace’s participation in the programme. Some of them were unimpressed, arguing that the singer was engaging in shameless self-publicity. Others pointed out that Grace has stated before that she’s being public about her transition entirely so she can help young trans people who are struggling with their feelings. I sympathise with that latter position pretty strongly.

And so Laura Jane Grace is all over the media, talking to MTV (in a variety of contexts), Rolling Stone, newspapers, webcasts and suchlike about being trans. Like other prominent LGBT people who have come out in a high-profile way, she’s taking advantage of celebrity culture to talk about something real and important for a change.

So I feel okay with Grace being on MTV, and I feel okay with these appearances currently centring on her transness. But there’s still a danger of her becoming a one-dimensional public figure, and the rest of us have to take responsibility for this.

If you look at pretty much any Against Me! video on Youtube or read any piece about the band’s current musical plans you’ll find comment threads filled with people talking about Grace’s transition and/or arguing about her pronouns. No-one, even Grace’s supporters in this context, seem bothered with the idea that there might be anything to talk about other than her gender identity (obviously the rest of the band don’t get a look-in!)

You could blame Grace’s current media presence for this. But it’s not like she doesn’t have plenty else to say. She’s written songs about economic inequality, war, love, solidarity, terminal illness, drug abuse and the death of good friends. None of them have magically disappeared just because she’s since come out.

I realise that arguments over gender in comment threads are a somewhat inevitable consequence of the ongoing cultural contestation of transness. I’m also probably contributing somewhat to the issue by writing about it on a trans-oriented blog. Still, when I’m singing along to I Was A Teenage Anarchist I tend to think about what that might mean about youth, personal growth and political affiliation – stuff that’s important regardless of how the songwriter might define her gender. I hope others are able to keep sight of this.

Shameless self-promotion!

I found myself in a studio recently with my Not Right bandmates, recording a number of the songs we’ve written together in the last year. The resulting EP is pretty rough and ready, but we feel it sums up pretty well we are as a band right now.

If you like angry female-fronted punk and/or music with trans themes, you might enjoy it!

(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.