Tag Archives: Trans Healthcare

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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Setting the record straight on trans issues

This is a more fully referenced copy of a letter I sent to the BACP Journal Therapy Today

I read with dismay the two letters published in December’s Therapy Today in response to Kaete Robinson’s excellent piece Look beyond the binary. I have been reflecting to myself whether such prejudice would have been published were it related to another minority group, although it is of course impossible to draw comparisons between the struggles of different marginalised minorities.

Obviously, Therapy Today does not publish all letters, and as such it must believe the ones it does publish have some merit. I wish to contradict this assumption.

Bev Gold’s letter first: In it she compares gender dysphoria with anorexia, and with negative self beliefs that lead someone to be “uncomfortable in their own skin”. But we have recently heard conclusive evidence from a Lancet study that gender dysphoria is indeed not a form of mental illness, but a legitimate phenomenon that needs not to be pathologised. She talks about the mental distress of trans people but ignores the sizeable body of evidence that suggests any mental health issues are created by stigma, negative attitudes, and barriers to transition, with studies demonstrating that support in transition and acceptance alleviate this distress, while efforts at reparative therapy, what she is clearly suggesting, only do harm.

I am left wondering if someone was as clearly arguing for reparative therapy of gay people, would their letter have been published? As someone who is a member of both trans and LGB communities, I experience a disparity between a growing intolerance of anti-LGB ideologies and an abiding tolerance and dissemination of anti-trans ideas.

In addition, Ms Gold makes the frustrating conflation that accepting someone as transgender will necessitate them having surgical transformations. Many trans people do not have medical treatment. For those that do, it has been proven to be inordinately successful in alleviating dysphoria, with very low evidence of regret. Ms Gold infers the opposite, that this is somehow a dangerous and tragic path.

Ultimately, trans identities need to be accepted and validated whether or not someone has made medical changes. The underpinning message of Ms Gold’s letter is that if a client enters the room and states their name and pronouns and how they experience themselves, we should cast doubt on this, pathologise it and force them to explore it, whether or not that is what they are asking for in their therapy. This is profoundly unacceptable and contrary to the principle of Autonomy in the BACP Ethical Framework.

The second letter is referenced, which lends it a veneer of respectability, however it transpires that one of the references, although appearing to be a reputable journal, is actually a renowned anti-trans blog, another reference is from Tumblr, a social media site, and that the author herself is a prolific anti-trans campaigner. The letter trots out some well-worn anti-trans myths. That detransition is common (it is rare); that the fact detransition occasionally happens means that transition is overall harmful (strong evidence refutes this); and that 80 per cent of trans children “desist” – this is evidenced in many places as a conflation of trans and gender non-conforming children.

In fact, studies have shown that genuinely gender dysphoric children have gender identities that are as consistent as those of cisgender children. In other words, if we talk about not allowing trans children to express their gender through pronouns, clothes, and gendered names, then we should equally be concerned about gendering cisgender children in the same manner.

Most concerning of all is her characterisation of “the autistic spectrum disorder teenage daughter [sic]who suddenly declares herself [sic] to be a boy”. First, let’s be clear that while there is a known correlation between autism and gender dysphoria (birth differences come in clusters, no surprise there), there is no evidence that autistic people lack the self-knowledge to understand their own gender. In fact, my local gender clinic in Nottingham has an autism specialist on staff whose main role is to help gender doctors to take autistic trans people as seriously as they would any other trans person, and not engage in blatant discrimination or infantilisation of the autistic community.

Secondly, she talks about “sudden onset” of symptoms, apparently having no knowledge or understanding of the lengths of time involved in obtaining a diagnosis of, and treatment for, gender dysphoria, or that clinicians will be looking for a consistent pattern and enduring and stable gender identity. Evidence demonstrates most trans people identify their dysphoria from a young age, and any “sudden onset” symptoms would not lead to treatment in anything less than years. Meanwhile, this child will be subject to the relentless doubt, questioning, bullying and attack that you trans people are subject to. It is far more plausible that trans children are dissuaded from transitioning by this stigmatising and hostile world than that we live in a culture where being trans is over-enabled. Anyone making this assumption is fundamentally unaware of the reality of trans lives and likely to do considerable harm.

There are many other inaccuracies and prejudices, too numerous to comment on. I experience the disrespectful tone of Ms Davies-Arai as unprofessional, and not appropriate for a journal, again out of chime with the Ethical Framework’s principles. She talks about “Transgender Indoctrination” as if it is possible for our tiny community to outbalance the from-birth indoctrination of cissexism – that is, the assumption that we should attach entire legal and social structures, names, pronouns, toilet arrangements and much more to the shape of people’s genitals. Not forgetting that intersex children often endure normalising surgery in infancy and later sometimes hormonal treatment, to artificially fit this binary – an issue that somehow incites considerably less outrage than the treatment of trans children in adolescence with entirely reversible puberty blockers.

The treatment of transgender children and adults is, contrary to these letters, slow-paced, conservative, well studied over nearly a century, and very well clinically evidenced. While there are intersections between the gay and trans communities, to suggest that trans people are simply confused gay people or that being trans is somehow more accepted and supported than being gay is not only ludicrous, it is a deeply regressive attitude that does not merit sharing in the pages of a professional journal.

My own article referenced below contains links to many of the studies referenced in this letter, and further information is available in the resources section of my website.

Sam Hope

MBACP, Accred.

FURTHER REFERENCES

https://hopecounsellingandtraining.wordpress.com/2016/11/17/it-is-vital-we-talk-about-the-welfare-of-trans-kids/

http://www.chicagotribune.com/news/nationworld/ct-transgender-mental-illness-classification-20160729-story.html

https://hopecounsellingandtraining.wordpress.com/research-papers/

http://www.torontosun.com/2015/06/08/suicide-rate-much-higher-for-transgender-canadians-study

Update 2018: 1. It transpires Ms Davies-Arai is behind Transgender Trend, a well funded anti-trans organisation that have been sending glossy booklets to schools, urging them not to support trans children. BACP have since published a second letter from her.

It is vital we talk about the welfare of trans kids

Transgender children have once again been in the news spotlight, following the NSPCC’s cancelled debate and the somewhat confusing story of a possibly trans child taken away from their mother.

A spate of troubling Daily Mail headlines ensued, attacking the charity Mermaids and the BBC and stirring up some hefty moral panic about children being encouraged to be transgender, as if it’s possible to make somebody trans when they are not.

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The impact this will have had on trans children and their families is considerable.

Child welfare is a serious matter. As a therapist who has mainly worked with children and young people, and a trans trainer for schools and colleges, it is my number one priority.

It is absolutely right to want a thorough analysis of the welfare of trans children. Far from wanting to close this discussion down, many in the trans community want to open it up, and deepen it.

But how can we have a discussion when there is such a profound lack of knowledge of the issues? When people instinctively worry about “child abuse” when a trans child is raised as their identified gender, but not when we raise cis (non-trans) children in deeply gendered ways?

Often, as with the NSPCC debate, we are offered theatre rather than an education on the issues. We offered the opinion of journalists, rather than the assistance of experts to analyse a complex issue.
Trans children deserve better.

Clarifying what we are talking about

First, let’s be clear on terminology, so we know what we’re discussing.

Trans is an umbrella term, describing anyone who feels incongruence with the gender they were assigned at birth. We say gender here, not sex, because words, pronouns, birth certificates, gendered clothes, toilet doors, the letters M or F on a passport, etc are all social, not biological processes.

Some trans people experience physical incongruence (medically known as dysphoria) with their bodies. Some do not.dysphoria-diagram

Throughout history, there have always been people who need to live differently in relation to social gender. Also throughout history, there have been people who have modified their bodies. Medical technology has opened up many possibilities in this area.

The NHS now offers ways for trans people to modify our bodies. Why? Because they have discovered that for some people medical changes through hormones and surgery can lead to those people living healthier, happier lives. The solution is cost effective, which is why it gets funded.

Healthier, happier people; benefits everybody, takes away from nobody.

In the UK, trans people have also been given legal rights to live as a different social gender than that assigned to them, whether or not they have medical treatment. Although recognition of non-binary trans people is still being fought for, this has been a positive advance for the trans community and again, despite panic and fear from some, nobody has been harmed by trans civil rights being gained.

How do we deal with transgender children?

Anti-trans campaigners will tell you that c.80% of trans children grow up not to be trans. This is a wilful misreading of the evidence. It is true that c.80% of gender non-conforming (GNC) children do not grow up wanting to medically transition, but it’s equally true that this 80% figure bears no relation to the group “children treated for gender dysphoria”, but includes a much wider trans/GNC  “umbrella”.

There are children who “crossdress” and those children need to simply be allowed to crossdress. There are children who don’t conform to gender norms. We need to let them not conform, and leave them be. There are children who experiment with different identities or are fluid, but don’t show a consistent desire to live as another gender. We should accommodate them to express themselves as they need.

Then there are children who show a persistent need to live as another gender. Studies show their gender identity is just as consistent as that of cis children. So, why not allow them to live as their gender? Or, if we believe children are too young to live gendered lives, then why gender them at all?

assigned_male_webcomic_july_23_2016

Healthcare for trans children

“But what about medical treatment of trans children?” critics ask, while meanwhile staying silent over the medical and coercive gendering of intersex children. If there was any doubt over whether “assigning sex” was a purely biological process, the experiences of intersex children evaporates it.

There is general opposition, which I largely share, to irreversibly treating children for gender dysphoria prior to the age of Gillick Competence.

The treatment available to young trans people in the UK is counselling and (reversible) pubertal blockers. The latter pause the physical changes that happen at puberty. Under the NHS, doctors wait until a child has started puberty, to see if the already persistent dysphoria is still present.

Few GNC kids have physical dysphoria. They will not be diagnosed by competent doctors with something they don’t have. “Is it possible to identify a child as trans without relying on sexist stereotypes?” Critics ask. Well, yes, of course – feeling incongruence with your physical body has nothing to do with sexism, and that will be the criteria upon which doctors treat pubertal adolescents.

There is no evidence that this particular subset of gender dysphoric GNC kids are going to “grow out of it“. There is evidence that their outcomes will be better if they are allowed medical treatment. Treated dysphoric kids have “similar or better” mental health to their cis peers, contrasted with a generally high mental health impact for trans young people.

Gillick competent young people, who have a clear and consistent narrative of who they are, can be given the autonomy to make (still reversible) choices about their own bodies. Always remembering that to do nothing will bring the irreversible changes of puberty. Increased suffering, and increased risk to the young person.

Meanwhile, we need to learn the difference between children wanting to socially fit in with their own gender by following some of the conventions of that gender and some bizarre myth that there are doctors diagnosing kids as trans because they like the colour pink.

There is no evidence that children are being medically treated because they wore the wrong clothes or played with the wrong toys. The problems of sexist gender stereotyping are incredibly important but separate issues.

toys

Knowing where the real concerns are

The medicalisation of trans people is problematic; for instance, referring to a trans women as “pre-op”, or misgendering those who have not had medical intervention. Many critics are against gender recognition for trans people who have not had surgery. Such prejudices push trans people towards medicine, in the hopes of social acceptance and clearer civil rights.

I share many trans people’s concerns that parents of trans children may also push them towards treatment that will “normalise” them, so they don’t stand out as transgender. This is why we must put the decision as much as possible in the hands of young people who have capacity to make such decisions. Supported by unbiased and knowledgeable doctors who are able to offer thorough, informed consent.

However, I think the evidence stands that however hard parents push their children to be any particular gender, the child’s gender will not change. Pushing gender onto children is pervasive and normalised, and deeply damaging to trans children, and yet pushing gender is only seen as “abusive” when the parent is perceived as pushing a trans identity. This needs to be understood as society asserting that trans identities are significantly less desirable.

Social acceptance will always influence the choices trans people make, because welfare depends so much on acceptance. This is why it is so vital, particularly in reducing unnecessary medical intervention, that we simply allow children and adults to express their gender, through their clothes, pronouns, names, activities and in any other way, without requiring they undergo medical treatment to be acceptable.

But we need segregation, don’t we?

But what about toilets and changing rooms? It often comes down to these issues. Well, we know that decades of trans women using gendered facilities has not created a risk for cis women.

But actually facilities that are made safe for all genders, for instance individual locking cubicles in an open plan space, are places where less crime and bullying can occur. Segregation is loved by the right wing, but we really don’t need an entire social order built around where and how we pee.

Just accept trans children

We know that trans people often recognise their identity early in life. Trans children authentically experience an untenable incongruence with their socially assigned gender, and sometimes with their bodies as well. This is never going to change.

Allowing children to change their social gender harms nobody. Even if they change back, the sky will not fall in. Yes, we should be exceptionally diligent before we allow medical treatment, but let’s stop treating names and pronouns with such over-loaded reverence. They are merely words that for some have been spun into traps.

 

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