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.

 

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.
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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

 

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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 Radfem Explicit Exclusion of Trans Women

I’ve been reading a lot about the whole Rad-fem vs. Trans Activist debacle lately, which has once again been exacerbated – this time by the explicit exclusion transgendered individuals at Radfem 2012 through the use of the phrase “women born women living as women”. It’s an interesting phrase in itself; if you were to take it as law it would also exclude anyone who might consider themselves to live androgynously as well as – to use that classic shakespearean twist – anyone born by a caesarian section. The intent, however, remains clear – the exclusion of women who are also trans.

I should make something clear at this point, clunky though this phrasing is I am “a woman who is also trans”. I would not choose to describe myself – or to have myself described – as a trans woman, I have not ever chosen to describe myself – or to be described – as a trans woman and I don’t think it’s likely I ever will. My objection is simple; I am a woman first and transgender somewhere far further down the list. I am not ashamed to be transgender – far from it, I honestly believe I am a far stronger person as a result – but it is not a characteristic that I feel defines me any more than the terms caucasian, blonde or tall might apply to you. To me it is simply a trait and not a definition, and as such – to me  – the line that has been used by Radfem 2012 might as well read “women born in the UK living as women”. As such, I’m lead to wonder whether this explicit exclusion of women who are trans at Radfem 2012 – or, for that matter, in any rad-fem spaces – is simply a manifestation of a dislike of the transgender stereotype as opposed to an actual objection to their inclusion.

The argument which seems to be made in defence of this policy is that of a shared upbringing and a common experience, but I have to admit that this baffles me. When you start to consider the almost infinitesimal combinations of inter- and intra- cultural, geographical and demographic differences even amongst a small group of people, it’s not hard to accept that early experiences are going to vary significantly between any two people. Even if you take a smaller subset – taking culture, geography and demographics out of the equation – then you still need to consider the even larger number of possible individual differences. Some people may have grown up with two parents, some with just one, others still with 3 or 4 or (in the case of one girl I know) 5; some were raised with siblings, others were not; some experienced unexpected deaths, illness or tragedies whilst others were blessed in that regard; the list goes on. When it comes down to it we’re all different – even if this is – such as might be the case may be with twins – down to something as simple as the result of the countless chance interactions we have every day. And if you don’t believe that we are the product of our experiences then genetics just makes these differences quantifiable…

So with this in mind, for this argument to be tangible this leaves one of two options; either there is something magical about the second X chromosome which overrides all other differences, or there is a small series of experiences which must be shared by all women who are not trans – regardless of any environmental factors. Considering first genetics, I end up wondering “Well, what about men who are trans or, for that matter, Kleinfelter’s males?” – clearly these people have the aforementioned magic second X chromosome and yet you would not consider these people to be women by any measure. Ergo, I struggle to accept that it is as simple as this.

So, what about this series of shared experiences which is independent of environmental difference. Well, thinking about it the only way that these experiences could be shared the world over would be if they were biologically determined, at which point we end up discussing differences between males and females. If you consider women who are trans who underwent transition prior to puberty – and thus were raised female – then you can immediately discount socialisation [remember, this is a blanket ban…]. Even if you weren’t to do so, socialisation is so varied depending on where you were brought up, who raised you and what was going on in the world immediately around you that finding this universal shared experience would be a task akin to finding a very small needle in an almost infinitesimal number of very large haystacks. So then, biology?

Due to the affects of hormone replacement, individuals who are trans effectively undergo a second puberty meaning that the only experience which natal women have which women who are trans do not would be menarche. However, again, this is not something which – unfortunately – all natal women will experience due to a number of developmental conditions which can result in primary amenorrhoea. In some cases this is medically correctable but in many cases it is not. This does not make these people any less female; it simply makes them unfortunate and deserving of whatever help we can provide to them.

So, this leads me back to my initial concern – is this simply transphobia at a community level? Worst still, is it that particularly dangerous brand of American transphobia trying to travel across the atlantic? Even if it is not, the danger is that by including this statement they set a precedent wherein it becomes normal for the Radfem community to discriminate again women who are trans and thus helps to make transgender discrimination justifiable to members of its community. I am never one to assume the worst of people, and thus would love to believe that this is just a policy which has been implemented with the best of intentions but a lack of consideration of possible consequences and ramifications. Unfortunately the fact that they have also given a platform to a speaker who is well known for being fiercely anti-trans makes this incredibly difficult to accept, and instead makes me concerned that parts of this conference have the potential to become a sermon of hatred, when they should be trying to facilitate much needed change. As such, I would urge the organisers to reconsider their exclusionary policy but I fear my cries may fall on deaf ears.