No more boxes: A person-centred approach to non-binary friendly healthcare

I gave this talk at a seminar on trans affirmative models of healthcare today at De Montfort University, organised by Prof. Julie Fish (#tgaffirm). The key speakers were Jeremy Wiggins from the Equinox Centre in Melbourne Australia and Dr Ruth Pearce, a Research Fellow in the School of Sociology and Social Policy at the University of Leeds. I would like to thank Julie, and the other speakers for the work they are doing, particularly around establishing an informed consent model for trans related healthcare.

[Content note: mention of mental health problems, abuse incl. csa, suicide, physical and mental conditions]

[image: two new baby cards, one reads "brilliant boy" one "beautiful girl"]An assumption is made on the day we are born that has consequences for the rest of our lives. That assumption is; we should be assigned into a legal and social category based purely on the shape of our genitalia. And if those genitals are ambiguous, we may even have them surgically altered as infants or children, to fit the categories more neatly.

This legal binary of gender has profound implications. For intersex children, it is perhaps the hardest, but women, trans and gender non-conforming people all suffer in different ways from being legally and socially segregated according to their assumed reproductive characteristics. The assumption that our genital shape should say something about who we will be in society can be profoundly damaging. For trans people, it can be impossible to live with.

Since 2004, trans people have had the option of legally re-assigning into the one other prescribed option – they are allowed to change the M for an F, or vice versa. For those who unambiguously align with the “opposite” gender, this is enormously helpful, indeed it is essential. But for many trans people, these two social and legal options, sold to us as non-overlapping opposites, are fraught with difficulty, and may even be impossible to navigate and inhabit.

We are non-binary (NB) trans people, we do not fit the prescribed legal and social binary. Our stories and experiences are many and varied.

So taken-for-granted is the idea that you can force somebody into an identity based on their genital shape that we are surprised when this doesn’t work for some, rather than surprised it works for anyone at all. Society, as a whole, is schooled to look at people and quickly assess from various clues in their appearance what their genitals look like. This will determine our interactions – what salutations and pronouns we use for them, and subtle differences in how we behave that are almost invisible to most of us.

[image: an a diagram of reproductive parts with an arrow saying "this is biology" pointing to it. A sequence of images - school uniforms, birth certificate, toilet doors, with an arrow reading "this is not biology" pointing to them]

What are the implications for this in healthcare settings?

The first issue is about information – what information do we get from a tick on a form that gives options M or F? We are schooled to believe this information is valuable and essential, but in reality if we want to know biological information about our patient – what kind of sex they have, what fertility they may expect, even what their chromosomes are, the tick box approach is neither necessary nor sufficient. Just ask the cisgender lesbian with a cisgender woman partner who is insisting for the 15th time that she cannot possibly be pregnant, or the heavily bearded trans man who has been legally male for many years but is now pregnant with his first child.

One solution is a person-centred approach. To build a relationship with the person in front of you so that you fully understand who they are, what they are here for, and what their needs are, without relying on little boxes that many of us do not fit into, or processes and procedures that are thought to be “one size fits all”.

A person-centred approach liberates us from the idea that biology or identity is simple, and allows us to meet the full complexity of our patients or clients.

I am going to present two essential “anti-box” truths that are central to my work:

  • Both social and biological identity are multi-determined and multi-faceted
  • Wellbeing is founded in human relationships.

What both these things have in common is how important it is not to reduce complex information and interplay down to a set of tick boxes. That does not excuse you from learning all you can about trans people, it simply means you always need to ask the question “I have some understanding of what that means generally, but what does it mean to you?”

Why trans patients are more complicated than most

Research demonstrates that there are a whole bunch of divergent traits that cluster together in the population – non-heterosexuality, left-handedness, genius, synaesthesia, certain tissue disorders such as EDS, gender variance, certain physical appearances, dyslexia, dyspraxia, ADHD, intersex conditions, sensitivity, sensory issues, autism, etc.

[image: A cluster of shapes with various traits as listed previously. The legend reads "Differences (like being trans and autistic) often cluster together - this does not imply causality]

So, “different” people tend to be different in lots of ways.  Break down some of these “things” a bit more, and we see that they are in fact clusters of other traits that come together, like Seurat’s dots, to make a certain kind of picture – and that actually, when you start looking at these individual traits, you discover that no two geniuses, and no two autistic people, have quite the same formula of traits, even though the overall effects can have something in common. Genius isn’t a “thing” and neither is autism, nor transness – these are all many threads of experience woven together to create overall effects that are broadly similar but often diverge in the detail.

How we respond to these traits is interesting in itself. A hundred years ago, left-handedness was seen as unacceptable. In my (left-handed) grandmother’s time, children were forced to write with their right hand. In my (also left-handed) mother’s time, left-handedness was still disapproved of, but reluctantly allowed. Now, I hope, prejudice against left-handed people has all but vanished, though the vestiges of it remain in language in words like sinister.

Society decides which traits are a “problem” and which are not. Nobody is going to diagnose somebody with “genius disorder” and raise funding for a cure. Thus Alan Turing was celebrated for his genius, treated (relatively) neutrally for his left-handedness, isolated for his (probable) autism, and driven to suicide as a result of horrific criminal and medical interventions for being gay.

In an increasingly standardised world, where differences are things to be fixed and overcome, rather than allowed to just be, the pressure on non-binary autistic people is particularly acute. To fit a more normative trans narrative, and to follow the “rules” of gender expression and behaviour that will make them more socially comfortable and acceptable.

How do we include divergent people?

I am going to come back to the person-centred, relational, anti-box approach. Unconscious bias is the biggest obstacle here. It is hard to build a relationship with someone who differs from your internal model of how people should be.

Trans people, and non-binary people in particular, also find their various differences can compound each other. They may, for instance, find it harder for their gender identity to be taken seriously or treated because of co-occurring disabilities, and likewise their narrative around other issues may be disbelieved due to their gender identity. This makes trans people particularly vulnerable.

Because of the way studies seek to standardise participants, gender non-conforming people or people with co-occurring issues have traditionally been excluded from research, meaning diagnostic criteria are often inherently biased against them. This means, for instance, that gender non-conforming people are less likely to be identified as autistic due to skewed and reductive diagnostic criteria.

To give some other examples of what can happen – an autistic, gender non-conforming non-binary trans woman who speaks loudly might have her vulnerability missed and her gender identity doubted. The high intelligence of an androgynous young university student might obscure their emotional vulnerability and mental health symptoms. The level of need of an intersex person who is requiring trans healthcare, treatment for a physical disability that has yet to be diagnosed, and is also claiming a trauma history and a need for assessments for both autism and ADHD, might lead healthcare providers across the board to question the validity of all these issues, and yet these are the kinds of issues that frequently co-occur. Factor in that people who are gender non-conforming are likely to be non-conforming in other ways, such as having non-monogamous relationships and other less common lifestyles, and we have a recipe for prejudice and judgement from professionals, disbelief, and dismissiveness.

Non-binary patients are very quickly labelled as difficult, untrustworthy, unlikeable, attention-seeking, aggressive. Instead of understanding that they HAVE more problems than the average person, they are often seen as BEING the problem.

One of the things that perpetuates this is the lack of recognition of non-binary identities in our current culture and the media backlash against us. The judgement of trans, and particularly non-binary, identities is so automatic we don’t even see we are doing it.

[image: a mosaic of negative headlines about non-binary people]

Minority stress

Back in 2003, an academic called Meyer proposed a phenomenon called “Minority Stress” for LGB people. It’s equally applicable to non-binary people. Meyer’s theory, in a nutshell is that the increased mental health issues for LGB people is directly attributable to the trauma of being mistreated by the general population – stigma, abuse, isolation, erasure, lack of support, all add up to take their toll.

A few studies seem to bear this out for trans people. A Canadian study demonstrated that trans mental health improved given certain factors – family support, access to gender recognition and treatment, social acceptance. A landmark Lancet study provides robust evidence that mental health issues do not directly correlate to gender dysphoria itself, but to the treatment trans people experience.

The horrendous figures for childhood abuse of trans people are just one indicator of how bad things can get when you are not socially supported. The abuse of LGBT people has long been cited by bigots as a “cause” of gender and sexual variance but there is no evidence of this. Rather, it is known that abusers are rather good at picking their prey – like any predator, they look to the margins, to the potential victims who have less pack protection – ones easier to isolate, with less friends, who are less likely to be listened to, supported or believed. Long before many of us consider articulating or asserting our identities, sadly others are spotting our natural and visible differences and realising we can be easy targets for bullying and abuse. Some statistics suggest that both assigned female and assigned male trans people have a close to 50% chance of being abused as children.

Other non-binary related statistics show that 43% of NB people have attempted suicide and 50% of NB employees left a job because the environment was unwelcoming (36% for trans men and women).

The antidote to minority stress is relationship.  If we look at minority stress through a pluralistic lens, we can see it as the result of the many fractures in social relationships a person has experienced.

[image: titled "web model" a diagram that shows how minority stress links to numerous social disadvantages and exclusions]

Walking in the world, a non-binary person receives a continual message – your superficial appearance is more socially valid than the self-experience you have amassed over a lifetime. We know you better than you know yourself. This can chip away continually at a person’s sense of self and threaten their peace of mind and mental health.

If we cannot bring ourselves fully into view then how can we have an authentic relationship with anyone? But if we assert our identity in a world that’s uncomfortable and hostile to it, we risk another kind of rejection. Either way, this threatens our sense of place within the human pack.

Our sense of survival as humans is deeply connected to our sense of belonging. Being outside of the pack in primitive times would have almost certainly meant death, and so our primal fears are triggered by feelings of rejection and unbelonging. To be uncertain of our inclusion in human groups is not simply uncomfortable or unhappy, it is potentially traumatising over time.

The opposite of this is all the hidden social support people get if their experience is better understood and socially validated.

[image: previous slide in reverse, how positive or neutral social interactions create a web of hidden support for people]

Finding our way out of judgement

How do we offer better relationships to non-binary patients and clients?

Hard work.

Like gaining an ear for music by diligent practice, making space for non-binary people in our imaginings takes effort and repetition. To practice no longer gendering the people we see, to practice using “they” as a pronoun whenever possible (e.g. in reports, rather than he/she) so that it rolls off our tongue. To simply notice how the structures of gender influence so much of our thought and behaviour. To reflect on our own deep processes around gender.

Such work will be beneficial to everyone we meet, but it may just give the opportunity to non-binary people for something very rare indeed – the experience of not being automatically judged and found wanting.

The difficulty of inhabiting a socially erased and legally illegitimate identity may seem quite an abstract and academic idea to some. Non-binary people are often dismissed as trendy youngsters, “special snowflakes”, or even the result of political correctness run amok.

But of course, non-binary people (in essence, if not in name) have always been here, and at certain times in history, including in 18th century England, and across the globe we have been recognised perhaps more than we are now. And now, we are having a moment. We have found a new word, “non-binary” to describe ourselves, we are organising, telling our stories, asking for our voices to be heard.

At the root of the current clamour from our community is a need to be met, to be accepted as we are, to be understood as legitimate. Our language, the way we describe ourselves, is communication. It is relational. We need a relationship with the rest of society, including our healthcare givers, and we need inclusion.

Find Sam on Twitter 

 

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