On the Depathologisation of Transsexualism

There has been a lot of talk about the depathologisation of transsexualism recently, including mentions of a petition to the ‘World Health Organisation’ to have it removed from the ICD11. Interestingly, the trans community appears to be divided on the subject with many being behind the move as they feel that they are not mentally ill and so should not be treated as such, whilst others are against the move fearing the affect this might have on their access to treatment – especially those in countries with socialised healthcare systems (such as the NHS).

As both a healthcare professional and as a member of the transgender community, I am firmly against the depathologisation of transsexualism for precisely this reason. I feel that in a world where it is necessary to fight for treatment – as I did – despite the fact that it is included within publications such as the ICD and DSM, depathologisation would make it nigh on impossible for someone to access the care they need. However, I also do not feel that transsexualism (as it is currently called clinically) should be perceived as a mental illness.

There is an important yet subtle distinction between depathologisation and reclassification of the condition from psychiatric to another more suitable heading. Depsychopathologisation – as this process is known – has actually been called for by the ‘World Professional Association for Transgender Health‘, whilst outright depathologisation has not. Similarly, it is worth noting that several western governments have also already stated that they will no longer consider transsexualism to be a mental illness; most notably the British government in 2002, the French government in 2009, and the European Parliament in 2011.

It seems fair to say that progression is forthcoming and has been for some time. As such, as a community we no longer need to be asking whether we are getting anywhere, but rather whether we are heading in the right direction. Whilst it might be tempting to follow in the footsteps of our friends and allies within the Lesbian and Gay Communities by setting our sights on outright depathologisation, I fear this would be incredibly foolish. After all, although our communities face many of the same trials and tribulations there is a key distinction; we are seeking medical intervention as a consequence of our identity.

A number of people have taken to attempting to construct parallels between pregnancy and transsexualism, in an attempt to highlight the fact that medical intervention can be routinely given for something that is not recognised as a medical condition. Whilst I do not deny that pregnant women receive medical attention, it is important to note that this would be best described as ‘watchful waiting’ rather than ‘active intervention’. This is to say that the care given during pregnancy is preventative in nature, designed to bring down what has traditionally been a very high mortality rate. Meanwhile, the treatment given in transsexualism aims to correct a diagnosed underlying condition.

Pregnant people are provided with dietary advise, medical imaging and easy access to specialist practitioners so that any problems which might arise are caught early and dealt with. Additional treatments are reactive in nature and there is no definitive pathway in terms of intervention. In fact, I would go so far as to state that the treatment provided is not for the pregnancy itself, but rather for the numerous health conditions which are associated both with foetal development and with the additional strain which pregnancy puts on the body. This is completely different to the treatment of transsexuality in which – following the standard series of assessments – there is an almost standardised linear treatment pathway of hormonal and then surgical intervention.

So, why is transsexualism even classified as a psychiatric condition to begin with? The simple answer is that it’s not so much due to the condition itself, but rather the differential diagnoses which it needs to be distinguished from. In short, these can be classified into the two categories; intersex conditions and delusions. The former should be excluded by karyotyping* (i.e. chromosomal analysis) whilst the latter can only be excluded through psychiatric assessment. Since, from a clinical perspective at least, the intervention of a psychiatrist is required it would be sensible to classify the condition as being psychiatric in nature, in spite of a lack of evidence that this is the case.

I’m certain that a number of people reading this article will question why the intervention of a psychiatrist is needed at all. If I know – and am certain – that I am a gender other than that which I was assigned at birth, then why does this need to be confirmed by a member of the medical community? After all, a small number of hour-long interviews can never give a true representation – or even a representative cross-section – of the underlying cognitive processes of something as complicated as a human being. Especially with regard to something as subtle as gender dysphoria, or anything based on a complex amalgamation of nature, the products of socialisation and of the perception of both the self and of gender roles within society, right?

I feel that the role of the psychiatrist is largely misinterpreted within the transgender community. Yes, this might be down to individual experiences of psychiatrists who take a more domineering or controlling role than maybe they should, or even a general distrust of psychiatrists or doctors in general. However, the fact of the matter is that in the case of transsexualism the role of the psychiatrist is akin to a safety net. The issue with surgical intervention and, to a lesser extent, hormonal intervention is that the effects are [largely] irreversible and – as such – have the potential to do a great deal of harm if left without proper regulation. As such, it would a failure in the duty of care of the medical profession at large if this ‘safety-net’ was not in place. Although some might argue – and have experienced – otherwise, the role of the psychiatrist in the treatment of transsexualism should not be one of a gatekeeper, but rather that of a concerned ally assessing your certainty so as to ensure you do not do irreparable damage to your life. This might not be the case in all practice; but should be the case in best practice.

This places transsexualism in the unique position where it is a non-psychiatric condition which requires psychiatric intervention so as to ensure that the medical profession can still fulfil their ‘duty of care’ prior to involving the endocrinologist or urogenital surgeon. The obvious question which arises therefore is under which heading – if not psychiatric – should this condition be classified? Neurobiological? Endocrine? Surgical? Other? Moreover, which of these headings actually have distinct sections within the ICD?

Personally, I would suggest it be reclassified as a form of intersex condition. Yes, there may be no evidence to suggest that it should be treated as such but there is little to no evidence which would suggest it should fall neatly into any other category either; psychiatric included.

*In reality this is not usually undertaken due to the costs associated with karyotyping. Moreover, it could be argued that actually performing a karyotype would be a waste of resources since it would not affect the underlying dysphoria or alter the treatment pathway.
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Edited 21/10/12 to include references. Apologies for the delay – I was having issues with my internet connection.

On the Nature of Trans Sexuality

I had an interesting conversation last night. It’s been a while – quite frankly too long – since I’ve had time to write a blog-piece despite both inspiration and intention, but I’m hoping that will start to change today. I’m hoping that this conversation will, in a strange way, mark a turning point in more ways than one.

As with many interesting conversations, the context is irrelevant. The time, the setting and the framing all fade away into insignificance when placed alongside the topic which was on the proverbial table. The topic, in this case, was the nature and nomenclature of sexuality and how in some strange way – unrelated as they maybe – the concept of gender identities divergent from biological sex once again complicates matters to such an extent that a complete re-evaluation is required. Predictable though the question might be, the root of this discussion was simply; “If a girl – who happens to be trans – is dating a [cis] guy, would that be a heterosexual or a homosexual relationship?”

The vast majority of people I know – choosing my friends and acquaintances the way that I do – would consider this to be a heterosexual relationship since to them – at the end of the day – the girl who happens to be transgender is still a girl, and as such it is a relationship between a guy and a girl (What can I say? My friends are well trained ^_^). More generally, were the average person to pass such a couple holding hands on the street they would see a man holding hands with a woman, and as such the little “heterosexual” flag in their head would fly high. It seems, therefore, that the sexuality of a transgendered individual in the eyes of society is dictated less by the person themselves and more by the perception of strangers passing by on streets. So, in some strange way whether a transgendered individual is deemed heterosexual or homosexual is based solely on how well society judges them to “pass”.

On the other hand – and [somewhat disgustingly, I might add] often in the case of pre-operative transgender individuals – some people have a tendency to believe that sexuality is defined simply by the number of penises or Y chromosomes in the room. In my experience, the people which rely on this method are often prone to miscounting but nevertheless entitled to their opinion. The issue with this, however, is that I don’t imagine that many people would be willing to expose themselves publicly or to schedule a karyotype simply so that tallies can be verified. As a result, I feel it is fair to say that – regardless of what these people might claim – most people define the sexuality of others based solely upon what they perceive, rather than what they see (or do not see, as the case may be).

So, when gender identity and sexuality are so distinct – by which I mean a transgendered individual might be into guys, girls, both or neither – why should gender identity have such a bearing on how sexuality is defined? The issue, I believe, is one with the nomenclature. Whilst the terms heterosexual and homosexual are thrown around commonly, the clarity that they have when applied to cis-gendered individuals falls to nothing when applied to a transgendered individual. Without prior physical examination, with any given couple (or poly group/family) which involves a transgendered individual you would be unable to say whether the intercourse that they were having would be considered to be heterosexual sex or homosexual sex, in the traditional sense of the terms. In essence, the terms heterosexual or homosexual lose all meaning when the sex of a person involved has changed.

The issue with the terms heterosexual and homosexual is that their meanings are gender dependent [by which, in this context, gender refers to “perceived sex” (i.e. that which is assumed by ‘strangers on the street’ when they pass by)]. By heterosexual we mean “male and gynephilic” or “female and androphilic”, whilst by homosexual we mean “female and gynephilic” or “male and androphilic” – both of which turn out to be unwittingly sex-based statements. Even if we momentarily ignore this issue, what of the terms androphilic and gynephilic? These are defined to be “attraction to males or masculinity” and “attraction to females or femininity” respectively, but these definitions fail to mention whether they should be taken to be speaking in terms of the sex [physical element] or the gender [psychosocial element] of the person in question. In essence, is androphilia the attraction to people who are male, or merely attraction to the male genitalia?

If we break down these words into their component parts, androphilia would quite literally translate as “love of men” [‘andro-‘ stemming from andros; the greek word for ‘man’; ‘-philia’ meaning love] whilst “gynephilia” would be “love of women” [‘gyne’ meaning woman]. Neither psychosocial nor physical elements are touched upon here, and we are simply left faced with the words “man” and “woman”. As such, it seems we have managed to go full circle and are left to question what it is that makes someone a “man” or a “woman”? Is it a purely physical divide which can be based purely on genetics and genitals, or is the perception of others what actually defines gender in this way?

One could argue that if we want to think of sexuality in a purely physical context, then we could reduce it down to a mater of genitalia and ignore the whole concept of “men” and “women” entirely. Nomenclature for attraction to the genitalia of a particular sex is not in widespread use, and may in fact be worth considering when discussing sexuality; especially when that discussion is staged in the area when the lines of gender identity and sexuality overlap. Presumably one might use ‘phalliphilia’ [‘phallus’ being used as a term for the penis] for attraction to penises, and ‘yoniphilia’ [‘yoni’ being considered to be the female equivalent on phallus] for the love of vaginas, but is this actually useful?

Well, yes. If we take these words (‘phalliphilia’ and ‘yoniphilia’) to mean attraction to the physical aspect of what it is to be a “man” or a “woman” then it – for want of a better phrase – “frees up” the term androphilia to mean “the love of one perceived as male” and the term gynephilia to mean “the love of one perceived as female”, thus allowing us begin to untangle the mess that lies between the physical and the perceived. In essence, this allows transgendered individuals to move out of any grey area that could be seen to lie between androphilia and gynephilia by separating what it is to be male or female, and what it is to have male or female genitalia.

So how does this work in terms of heterosexuality and homosexuality? At the end of the day, in terms of pursuing a relationship, people are usually attracted to their perception of another person rather than what lies between their legs. Yes, someone may later feel uncomfortable if they find that the genitals present are not those they were expecting, but the fact of the matter is that a person – at least in the circles I run in – does not tend to find themselves in such an intimate situation without attraction having been felt (fleeting though this may have become). In essence, we leave these definitions as they were whilst simple clarifying what it is to be androphilic or gynephilic.

This system allows more specificity, better expression and greater self-awareness in terms of the sexual orientation of any and every given individual, whilst enabling transgendered individuals to fit within the realms of heterosexuality and homosexuality. The aforementioned relationship between the girl – who happens to be trans – and the [cis-]guy would be firmly heterosexual regardless of what lies between the girl’s legs. Were the girl to have male genitalia, and the guy to be attracted to that particular quality then the guy could be said to be ‘phalliphilic’, likewise if she had female genitalia and he were attracted to that then he could be considered ‘yoniphilic’. Of course, the two terms are not mutually exclusive and merely descriptive scales of genital preference, which will likely be considered alongside other factors – rather than exclusively – in the context of a given prospective partner.