I know that title sounds dramatic, but bear with me, because transgender lives are at stake.
If you aren’t aware, the World Health Organization (WHO) recently announced changes to gender non-conformity guidelines. These guidelines remove “gender identity disorder” (GID) as a “mental disorder”. Instead, the guidelines have been moved into the sexual health portion of global health guidelines.
At first glance, this seems like a good thing. There are more than a few trans* activist groups that have worked diligently for this move. However, I believe that this will make it harder for trans* people (especially people of color and poor trans* people) to access proper medical care.
The fight against pathologization has me worried
Are trangender people just scared of conversion therapy?
Let’s face it, our world has issues with people that have mental illness. Otherwise, why would it matter if GID was in the mental disorder or sexual health sections of the WHO guidelines? Our society’s fear of mental illness seems to come from the idea that those with mental disorders are “broken” and must be “fixed”. And that’s really where the problem lies here.
You may remember or be aware of the pathologization of homosexuality, a “disorder” which could be “treated” with methods such as electroshock therapy and conversion camps. And if it happened to gays, why not trans* people?
Sadly, we have come to associate the trans* population with the homosexual one. (Sidenote: because this often leads to confusion about gender and sexuality, along with other issues, I’m in favor of “Sexual and Gender Minorities” – SGM – over LGBTQ…or separating the two completely)
Trans* people don’t like being thought of as crazy any more than cisgender (non-trans*) people. I’ll come back to this point later. But I believe that in addition, calling trans people “mentally ill” reminds our community of the horrors of the past. In other words, conversion therapy.
Gender dysphoria that comes along with being transgender has an effective treatment
I would argue that in general, a “mental disorder” or mental illness should have some kind of treatment. Importantly, any person with mental illness should have the right to refuse treatment, within reason. For trans* people like me, there is an extremely effective treatment. Transition through hormones and/or surgery (and also through community support) works wonders to help many trans* people cope with GID. Many other trans* people don’t feel the need to undergo one or both of these options. It’s a very personal and complicated decision, and there is no one size fits all.
Just as boring holes in people’s heads to relieve head pressure was a barbaric treatment, so is conversion therapy for trans* people. But the fact that gender dysphoria HAS a treatment makes a decent enough argument to me that pathologization can help with access to those treatments.
In my opinion, many trans* people say they are against pathologization because they are afraid of the stigma against trans* people. But it seems like they are ACTUALLY propagating that same stigma against people with mental illness.
These trans* people don’t like being told they have a mental disorder despite actively benefitting from the diagnosis (benefit = ability to transition). Many trans* people (including me) have other mental health issues: anxiety, depression, autism, among others. We are not “bad” or “lesser” because of this. The fact that we live with this, survive, and flourish even in a world where mental illness is demonized shows how resilient we are.
It was through pathologization that transgender people were given access to transition-related healthcare. I believe that moving GID will offer an excuse to deny healthcare to trans* people.
Sadly, the state of mental health and how we see and deal with it is pretty horrible. I think it is arguable how the WHO guidelines should be organized. In other words, I don’t necessarily agree or disagree with the logic of the change. But I also think a tangible benefit to the trans* community will be lost in the wake of the new organization system.
And as with most policy changes nowadays, this change will likely harm the poor and people of color the most.
You know what? Let’s continue with a story about my own transition.
My Physical Transition
I had insurance when I decided to transition, which is the only reason it was possible.
Lots of money, lots of time
Current guidelines in the US to start testosterone as a transman included 6+ months of psychology appointments. At the end of this, if that psychologist agreed with my own assessment of my identity, I got a letter that “proved” I had GID and should undergo hormone replacement therapy. I had to travel 3 hours one-way every 1-2 weeks for these appointments because no one closer would give me a letter.
That’s days off of work, lots of driving (which I hate), and a hundred dollar per appointment in addition to gas money. After that, I was able to go to a clinic that would prescribe my testosterone. The doctor and staff were extremely transphobic but offered the services to transmen because it somehow fell under their services for women. They were one of only a few doctors in the 5 surrounding states that prescribed testosterone.
I lost my insurance, and that clinic closed their trans* services suddenly. I bounced from doctor to doctor (and insurance to insurance, who kicked me off for being transgender) and stockpiled testosterone while I tried to find another doctor who would treat me long term.
Some of this has improved since then in the form of “informed consent”, where I can say “Really, I’m f***ing transgender. Can I please start testosterone treatment?” and certain clinics and doctors will gauge subjectively whether you’re telling the truth and then oversee your hormone replacement therapy.
If I wanted surgery, many surgeons required 2 more letters from another psychologist and psychiatrist in addition to a 1-2 year “real life test”, showing that you’ve lived in your chosen gender successfully while possibly not being able to pass as that gender.
The medical transition process is not ideal, but a step in the right direction
I hope at this point, you’re saying “Well, this system doesn’t seem so great. Why are you arguing against recent guideline changes again?” No, it’s not perfect. It was a horrible and sometimes traumatic experience. With informed consent, some things have gotten better, but there’s still plenty of room for improvement.
But the reason I’m against the recent change in guidelines is this: before the American Psychological Association (APA) added GID to its rulebook (the DSM – Diagnostic and Statistical Manual of Mental Disorders), it was even harder to start the transition process. If the World Health Organization says that GID is no longer a mental disorder, how long before organizations like the APA make the same change? All those hoops I had to jump through? No more hoops will even exist.
40% of transgender people reported attempting suicide, according to the 2015 National Transgender Discrimination Survey (NTDS), compared to 4.6% in the general population. We have no reliable statistics on the number that actually commit suicide.
How do you think those numbers will change without access to transition care?
Everyday care for transgender people
Even with everything above, a larger problem is that many trans* people have problems accessing basic care. The NTDS reported that 33% of trans* people have had negative experiences with healthcare providers in the past year (note: I’m in that group).
I believe that our focus should move away from depathologization and toward educating the medical community on the needs of trans* people. I have been denied care before because I was trans*, and I’m not alone. The 2012 NTDS reported that 19% of trans* people had been refused care because of being trans* and 28% were subjected to harassment in medical settings.
These data are confined to the US, but I’ve heard anecdotal tales from people all over the world about a lack of access to care.
The State of Sexual Health Ain’t Much better
I’ve benefitted from having just one more mental disorder, because it got me access to the transition resources I needed. In a world where our most trusted citizens (doctors) are against us, health guidelines can play a crucial role in allowing us to advocate for ourselves. There’s a certain power in being able to say “This is a medical problem with an effective medical solution, and I deserve proper treatment.”
Sadly, we may be doing better with mental health than sexual health these days. With the fight against Planned Parenthood and access to birth control and free safer sex aids being defunded, we are doing ourselves a disservice by thinking GID belongs in that section. In my opinion, it only adds to the continual problem of seeing transgender as just another sexual identity (sex and gender are different!), just the T at the end of LGBT. And in doing so, this action will result in the loss of access to transition-related care for trans* people.