On TDoR 2013

Remembrance

Every year another candle
Every year another list
Every year another number
Every year yet more are missed
And every year on streets we gather
To hear an endless list of names
To ensure they’re not forgotten
Or just another fading flame

With each teardrop we remember
Every teardrop shares the pain
In every teardrop that they shed
And the fear it might return again
So every year on streets we gather
To listen, as the list is read
Not for us, and not for action.
We gather to respect our dead.

——

So, International Transgender Day of Remembrance (TDoR) rolls round again, and the death toll never fails to shock me.

238 murdered for daring to be who they are.

And this isn’t taking into account unreported murders, or those driven to suicide.

RIP.

 

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From Psychiatry to Endocrinology – A social transition for Transsexualism?

The interplay between social factors and medicine has always been both complicated and fascinating, in that social opinion is influenced by medical interpretation whilst medical ethics, nomenclature and policy are driven by popular opinion. This is illustrated in how conventional therapies can be seen as ethical violations when viewed in retrospect, or more poignantly in how Homosexuality was removed from the International Classification of Diseases in 1990 following sustained social pressure. Recently, the World Health Organisation has been experiencing similar social pressure to remove Transsexualism from the ICD in an attempt to likewise achieve depathologisation.

Since individuals with Transsexualism do indeed require medical intervention, unlike their counterparts who define elsewhere within the LGBT spectra, the situation currently arising is too complex to be seen as a direct parallel to that of Homosexuality in the early nineties. If the World Health Organisation were to succumb to current social pressures, and so to the associated petitions being presented to them by the so-called ‘transgender community‘, this may indeed succeed in reducing the social stigma associated with the condition. However, it could also trigger the withdrawal of the treatment provision currently available to those individuals. The issue which therefore arises is that of whether the social stigma surrounding transsexualism could be relieved whilst ensuring treatment provision is not withdrawn in the process.

Social stigmatisation of mental health conditions is commonplace at present, and I can only speculate that a desire to move away from this label and the associated discrimination is at the heart of this campaign. However, there have also been calls from within the medical community for depsychopathologisation – specifically from the World Professional Organisation of Transgender Health (WPATH) – which is unsurprising given that there has never been a published report in either a psychiatric or psychotherapeutic journal of transsexualism or transgenderism being cured. Indeed, it is accepted by majority of authorities that “in almost all cases the only successful treatment [for transsexualism] is gender reassignment” (Pfafflen and Junge, 1998) – a process achieved through a combination of purely physical interventions. As such, the necessity of traditional psychiatric intervention within the treatment of Transsexuality is questionable at best.

At present, the role of psychiatry within the treatment of Transsexuality is akin to that of a safety net. The condition is affective in nature and so the diagnosis is one of exclusion, as opposed to being based upon empirical evidence or scientific testing. Indeed, it is the case that the psychiatrist merely excludes differential diagnoses whilst assessing patients for co-morbidities prior to referring them on to other specialties for physical intervention. In the absence of a more definitive method of confirming the diagnosis this is indeed essential, although continued involvement from the psychiatrist may be unnecessary after the completion of this initial process. However, at this point it is important to recognise that psychiatric and psychotherapeutic interventions are both distinct specialties in their own right, and whilst the involvement of a psychiatrist may be unnecessary, psychotherapeutic interventions might still prove beneficial.

So, if depsychopathologisation were to be facilitated through the reduction of psychiatric input, which specialty might be best placed to assume responsibility for these patients? Aside from the general practitioner, who is charged with the coordination of care, arguably the most important input comes from the Endocrinologist. Shortly after their initial psychiatric assessment, patients undergo hormone replacement to facilitate physical transition and, unlike the transient nature of the associated surgical intervention(s), this intervention continues throughout life. As such it is clear that the contribution of the Endocrinologist in the treatment of this condition is not only one of the most critical, but also one of the most enduring.

So, is there even any evidence to suggest that the medical community might be justified in revising the classification? From a clinical standpoint, a major advantage of this reclassification would be the increase to patient safety. At present, although General Practitioners are advised to monitor hormone levels through blood testing, many fail to do so and even more are uncertain as to what would be considered abnormal. Explicit guidance is made available to GPs, both through the WPATH and through booklets provided by specialist endocrinologists based at Gender Identity Clinics, but it can often be excessively time consuming to find the information required within these documents, or too difficult for the GP to interpret the data which confidence. Consequently specialist Endocrinologists are frequently consulted despite best efforts to make this information accessible.

Further to this issue is that of the of availability of treatment. The Engendered Penalties study commissioned by the Equalities Commission in 2007 found that as many as 1 in 3 GPs still refuse to provide treatment in the case of transsexualism, either due to their own prejudices or due to a gap in their own knowledge surrounding treatment protocols. This results in a postcode lottery based not on the availability of funding, but rather based on the attitudes of the doctors surgeries or individual clinicians from whom help might be sought. Whether this issue arises as a direct consequence of the known inequality faced by those with mental-health conditions in primary care is unknown, however it seems fair to say that, even within the medical community, changing attitudes towards transsexualism would be beneficial to those with the condition. Especially when the recent restructuring of the NHS means that GP commissioning bodies are now an inevitability.

Would this be achieved simply by the removal of the mental-health label? Naturally, disassociation from such a label would help Transsexualism to be seen as less ‘abnormal’ by the general populace, and thus closer to being perceived as part of natural variation rather than as a horrific ailment. Indeed, a number of cultures have developed centred around alternatives to the hetronormative, binary-gender system commonplace in the west and the differences in attitudes towards those who reject their assigned gender is striking. Not only do a number of these nations – most famously, Thailand – have innate, non-derogratory terminology in the common vernacular used to refer to these individuals, but they are even seen by outsiders to be a part of the national culture. Furthermore, the media have a positive attitude towards these individuals; newspapers will often print winners of female and ‘kathoey’ beauty contests side-by-side, and prominent figures in film, music and modelling are able to be openly Transsexual without fear of persecution. In fact, the reputation of such nations on their handling of such issues are such that many people, from what are traditionally seen as more developed countries, travel great distances to such places just to seek medical treatment. If a signifiant proportion of our patients are willing to go to such extreme measures to ensure that they are treated with dignity, respect and to get the quality of treatment they deserve then surely we should be paying greater attention to the policies of these nations?!

It almost seems fair to say that Trans* people within the UK are scared of their doctors, so much so that they actually feel the need to run away. This is unsurprising considering evidence which has consistently arisen in the form of direct quotes included in studies conducted into this area (see, for example, Engendered Penalties [2007] or the Trans Mental Health Study [2012]) but, more recently, also through social media. Twitter has become an increasingly powerful tool in the past few years for groups of people to share their experiences and disgust at failing systems, and this is particularly true in the case of the #transdocfail hashtag which sparked an article in the New Statesman and triggered further investigation by the GMC in the process. The stories shared show a pattern of discrimination, abuse and cruelty against those seeking help from doctors and other professionals within the NHS. A pattern which needs to be broken, and a pattern which surely warrants internal change.

This being the case, could it be that Transsexualism could find a new home under the umbrella of ‘endocrine conditions’? Consistently studies have suggested that the brains of those with transsexualism are anatomically different to those without the condition, which would imply that the condition might be better classified as a ‘Disorder of Sexual Development’ (DSD) similar to many intersex conditions, and so fall into the remit of endocrinology. Similarly the treatment methodology, which effectively centres around the correction of what some may consider to be an extreme hormonal imbalance mirrors that of other conditions found within this classification. Finally, and as previously discussed, the social ramifications of this change have the potential to completely revolutionise the way that the condition is seen both by the medical community and by the general populous. This alone has the potential to do more for the health and wellbeing of those with transsexualism than any medical intervention or breakthrough ever could, and if that is not reason enough in itself to plant the seeds of change then I, for one, do not know what is.

—-

The above essay was written by a friend of mine as an entry for the Society for Endocrinology’s Undergraduate Essay Prize. Both they, and the society, have kindly granted me permission to repost it here. I hope you found it interesting. 

– TransMedic

On Remembering Our Dead

So, we now find ourselves at the back-end of November, and as the world gets both colder and darker it seems only right that we should once again gather to pay our respects to our dead. I speak, of course, of International Transgender Day of Remembrance which falls every year on November 20th, during which events are held all over the world to pay respect to those who were murdered horribly just for daring to be true to themselves. Transgenderdor.org maintains both a list of those killed in the past year, as well as a list of events being hosted around the world and I would urge anyone who reads this blog to please go along and participate in the candlelight vigil or any other type of event that might be going on in your area.

I remember lighting 216 candles – each representing a person – this time last year and I suspect that this number won’t have changed much in the past year. There has been a shocking statistic circulating for some time now; 1 in 12 trans people will be murdered and this goes up to 1 in 8 for those in an ethnic minority. Granted, as Christina at WWTJD has found the precise source for this is incredibly difficult to find, but it remains clear that there is a disproportionate number of murders of trans people relative to the general population. As such, I feel it is both incredibly important to stand as a community and offer one another support, to raise awareness that this is indeed an issue, and – most importantly – to remember those we’ve lost.

I leave you with the reading I’ll be giving this year:

Smothered

Whispers on a wind
Of families forced to frame farewells
And bade goodbye as a bitter breeze blows
Back at souls who shone so strong,
Twice as bright, now not as long.
Flames flicker – forced to fade before their finish,
A dream diminished, doused by disgust,
As discussion dances in the distance
Resisting rationality in reality
For the beauty in brutality.
Caught in a cacophony of cruelty,
To mangle mirrors to identity.

The betterment begins.
With the sinner sought, silenced and seated
And the standardised sermon sorely repeated.
Kicked off with quick-fire questions,
Ever intending to impart an impression.
Pressured pleas passively pass by the pedagogues.
A vicarious verdict vomiting virulence
As silence screams for sanctuary,
A mandate for the maelstrom’s mercy
As candles are crushed completely
And embers exhausted eternally,
Smothered by a sanguine sea.

With sentence struck
The pack of peers who policed ‘perversion’
Open auditions for another aversion,
Control cast aside to commit to contusion
And style surpassed to ensure execution.
Letting loose the lunatic; a Latino lust for life
For contrived convictions of crimes of courage
And encouraging extremist re-education
Of those perceived to be doing wrong.
Of those who wouldn’t play along.
Souls which once shone so strong.
Twice as bright, now not as long.

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.
—-
Edited 21/10/12 to include references. Apologies for the delay – I was having issues with my internet connection.

More on *the* Institution of Transgender Discrimination Within Healthcare

I opened my inbox this morning and was surprised to find that a friend had sent me a link to the Equality and Diversity page on The University of Warwick pertaining to their policy on Gender Reassignment. The policy document linked to on that page, which hasn’t been – it seems – updated since 2008 [so, prior to the passing of the Equality Act] states the following:

15.0 SICKNESS AND ABSENCE FROM THE UNIVERSITY

15.1 In putting together the transition action plan the time the student or employee will need in order to undergo gender reassignment treatment should be discussed. When the individual is absent for treatment or surgery then normal sick pay arrangements or absence arrangements should apply. The normal policy for medical appointments should also apply, flexibility should be offered in taking holiday or rearranging working hours or academic commitments in order to attend medical appointments. A sick note will be required, but the sick note does not need to state the procedures performed.

I have highlighted the aspect which I found most interesting in bold, since it seems to be clear that – with regard to story I commented on late last week – that the Warwick Medical School have not only breached the Equality Act 2010 but also policies laid down by the University. Interesting, no?

On *the* Institution of Transgender Discrimination Within Healthcare

Anyone who’s read some of my earlier blog posts will know that I’ve a keen advocate of education of LGBT issues with in Medical Schools, as I feel early education – and thus the removal of ignorance – is an important and effective tool in the prevention of LGBT discrimination at the hands of doctors. I feel that the example that is set in the early years of medical education – as is the case in life – has a heavy hand in shaping the sort of doctors which are produced and, as such, it is hugely important not only that medical students are taught the skills and knowledge that allows them to be effective healers, but that it is done so in an environment free from prejudice and discrimination. In many ways, whether the attitudes held by staff – and especially senior staff – are explicit or more implicit is completely irrelevant as it still eventually sets the same negative example for young doctors, and nowhere is this issue currently more pressing than at Warwick Medical School.

In a story broken in tandem by TransActivist and NoMoreLost (both of whom have very different, but equally interesting takes on this story) it seems that Warwick Medical School have shown a pattern of transgender discrimination towards a student who has been consistently doing their best to assist the school in improving their record in terms of LGBT issues. Given the article which the school were so proud to have printed in a prominent medical journal earlier this year –  in which it is stated that they were discussing rectifying the lack of education given to their students on LGBT issues  – the irony that arises from is practically caustic. It seems that Warwick Medical School are keen to present themselves as LGBT friendly, progressive and anything other than transphobic to the public eye, whilst fostering an atmosphere which – according to students I’ve been in touch with – is hugely homophobic, ablest and generally unsupportive toward anyone less-advantaged or in need of assistance. This is, according to friends and colleagues, an attitude which they have held – and have failed students with – for a number of years, and one which doesn’t look likely to change any time soon.

So, what does this say for the Warwick Doctor? If a child were raised – or in this case educated – in an environment where discrimination is tolerated and support is, effectively, neglectful at best then what sort of adult would you expect them to become? Would they be emotionally healthy or stunted? Would the environment really get the best out of them? And, particularly important in the context of this article, would they know that discrimination – whether to an LBGT patient, disabled parent or (in the case of one colleague) a carer – is simply not acceptable?  At the very least, I feel it is fair to say that these adults would lack empathy, sympathy and as such not be the sort of person you would like to be shaking hands with on the way into the consultation room. Luckily for their students – and even more fortunately for NHS patients – they are not raising children, as else I fear social services would have a field day. It is probably important to point out that even in spite of this adversity the so-called “Warwick doctors” I have met are competent and hugely caring, but very few of them have anything positive to say about how their Medical School treats their students, and even fewer of them would say that the School sets an example which should be followed.

Whilst I am certain that Warwick Medical School are not alone in their failure in this area, I find this particular case of discrimination to be especially troubling since it appears to be the case that any other Transgender student who passes through their doors will find themselves subject to exactly the same heinous treatment. According to Elusia over at NoMoreLost, WMS are currently refusing to make changes to prevent further violation of the Equality Act 2010. This is particularly surprising at a time when, according to the most recent quality assurance visit conducted by the GMC, the school is currently undergoing a curriculum review; and so one would hope that they would be particularly open to positive change. Especially when Tomorrows’ Doctors – the document which governs the curricula of british medical schools – effectively states that a medical school must be able to provide evidence of addressing equality and diversity matters within  assessment covering (amongst other characteristics) gender identity [article 62]. As such, if this situation is as clear-cut as it appears to be, it is not only seems that Warwick Medical School are not only guilty of Indirect Discrimination under the Equality Act 2010, but that they are also failing to meet the requirements laid down by the GMC.

It is interesting to consider what the response of the Medical School might have been in the case wherein she had been required to undergo excision of a tumour as opposed to Sexual Reassignment Surgery [SRS]. If they had indeed agreed that in the case of an excision a reasonable adjustment could and should be made (i.e. in the form of an individual examination) then it would indeed be the case that Warwick Medical School are discriminating against transgendered individuals in their totality, but what of the opposite? Were no reasonable adjustment made here either (bearing in mind that transgender also counts as a disability under the definition of the Equality Act 2010) then it would be the case that Warwick Medical School are discriminating against injured, sick and disabled people in their totality. Not what you would expect – or hope to see – from an institution that hopes to train people to care for those very people it appears to be showing prejudice against.

Perhaps even more interesting to this is the current stance being taken by Coventry and Warwickshire Friend who are currently refusing to take sides in this dispute, stating as their reason that this has happened before with Warwick Medical School and as such they feel it would be unwise to get involved. Their trustees cite specific examples of  “a student who was diagnosed with cancer and had to take a temporary withdrawal but tragically died”, “another student being given the choice of either 2 weeks or a year to recover from depression” and numerous “students who make the choice to become pregnant have to also take a temporary withdrawal for a year”. I guess, Warwick Medical School are nothing if not consistent in their appalling treatment of students (not to mention the example they’re setting!).

Further to this is what appears to be a flagrant disregard for the student’s right to confidentiality on not one, but two occasions – especially given her status as transgender and the additional protection this grants to her under the Gender Recognition Act 2004. It goes without saying that confidentiality is hugely important within medicine since doctors are essentially strangers that we allow to be privy to the type of information usually reserved for those closest to us so that they might assist us with whatever our ailment may be. Confidentiality, and the importance thereof, is drummed into trainee doctors from day one, as is the fact that the breaching of that confidentiality – that inherent trust that is given to us based solely upon our position – is completely unacceptable (and, quite rightly, a disciplinary matter). The fact that a Medical School could set such a poor example to its students – even if we completely disregard the additional protection bestowed by the Gender Recognition Act – is completely deplorable and, quite frankly, the school should be ashamed.

Warwick Medical School have been asked for comment by numerous people at this point, but as of yet have refused to comment. Meanwhile, the GMC have responded, saying: “We encourage med students to contact us if they have evidence that their school isn’t meeting our standards”. Personally, I feel that it will also be interesting to hear what the GMC have to say about this matter is the student does indeed choose to get in touch with them; especially at a time when both they and the department of health need to be being seen as acting – and improving – on issues relating to LGBT discrimination.

 

Update 03/09/2012 = More on this topic here

 

——-

I intend to keep a list of articles on this subject below. Please contact me if you would like yours to be added:

Trans? Disabled? In need of surgery? Best to avoid Warwick Medical School – Writings of a Trans Activist

Discrimination? You Bet! What might you expect from Warwick Medical School – No More Lost

LGBTQ Summer 2012 Newsletter Supplement – National Campaign Against Fees and Cuts

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.