Introduction: Over the last few months, I have expressed my support for the International STP2012 campaign, which calls for the declassification of Trans as a mental disorder.
It has been a successful campaign, particularly in Europe and parts of Latin America.
Now, Miguel from the STP 2012 campaign has put out a letter asking for some Trans people who are supporting the campaign to stop their support for STP 2012. The reason for this is apparently these trans people want to have transsexualism reclassified within another medical category. Miguel writes:
“I just want to remember that the STP2012 campaign doesn't ask for the "reclassification”, and we don't think transsexuality is something biological, we don't think IN ANY CASE we have an illness, a trouble...nothing. So, if there is a movement asking for the reclassification please don't call it STP2012..?”
And he asks:
”I just want to understand what happens? In our groups everybody cannot read in English and all these discussions are in English. We are trying to follow your debates but it's impossible.
I am now a mature, middle aged, middle class and middle income trans man - that is a great improvement on poverty, the key feature of my transition and younger years. Growing older and starting a professional career as an academic has afforded me the luxury of thinking back over almost 35 years as a trans guy, to ponder some of these great questions. I believe, like many of us who have been around some time, and who have seen the vast diversity in the trans community, that the answer is simple: "I am here, therefore I am'. So let me live my life in peace, and do my own thing as a responsible world citizen and please do not try and put my life in a little box".
But that doesn’t answer the question as to why so many people are seeking a new ‘label’ within medicine. I will attempt to answer that question and try to give you some of the reasons reasons as to why some trans people hold these views. My apologies that this is long, but I have tried to keep my English simple for the translation to the other members of STP2012
Reason no. 1: these things happen – you do one thing, you inspire someone to do something else. That’s life, you can’t control it, it can be irritating, but you must just be grateful that your work has provided inspiration for another person and you may have even given reason to their life. If your arguments are sound, and you stay calm, they will win through in he end. Often people do respond, but it is very rare for one’s critics to commit themselves to the sort of dedication you will have put into getting this campaign going and keeping it alive.
The Other Reasons, 2, 3, 4 etc: There are some fairly straightforward reasons why some Trans people are calling for the removal of Gender Identity Disorder from DSM IVr where it is a classified as a mental health disorder to another sort of medical classification, maybe within endocrinology. I will go through their reasons to help the people from STP2012 understand:
The Label Provides Access to Treatment
Life is not simple. I agree – why should we be labelled by a group of 19th century white , middle class, middle aged, able bodied, straight men? I’ll take that back, many of them were gay albeint closeted - and mostly they were men.
One of the consequences of the taxonomy (categorisation) of Trans people by medicine, where it was wrongly assessed as an undesirable and abnormal behaviour and not as an identity, has been its placing within the classification framework of mental health disorders. This has unfortunately meant that non-trans people treat us as if we are of less value in this world? That gets Trans people really mad (but not in a mental health way). We are not, as a general rule, mentally ill unless others persecute us, and then we can become very depressed, anxious and even suicidal.
Who Decides Who is mentally Ill: The patient or the doctor?
It might be asked "what makes trans people a special case?" Why should our classification be changed, rather than the classification, say, of those who hear voices?
Just as we are not ‘mad’ how certain can we be that the people who hear voices are mad. According to my friend Dr Philip Thomas, former Navy doctor turned Psychiatrist and founder of the Hearing Voices network in the North West of England; often people who hear voices are not 'mad'. Though a large number of voice hearers seek help from the psychiatric services, a similar number never do that, but rather see their voices as being inspirational, friendly, and almost ordinary.
Phil will point out that quite a lot off us will hear voices at some time, mostly after a close bereavement. My personal voice wakes me in the middle of the night; it either barks loudly or shouts at me to turn the telly over to Channel 4. Almost certainly the voice or sound I hear in the middle of the night is a consequence of neurological discharge of electrical activity which is distorted solely because I am asleep. My voice or sound is so irrelevant to my life that I often forget about it for months, until one night it happens again. It is just a background feature in the brain activity that makes me the person I am.
Having said that; many people, who hear the most grotesque voices see psychiatric help because the voices are ruining their life. According to Phil, these people can also start to place the voices into the background once they know why they happen. When they hear that it is just a crossed wire; a common and ordinary natural variation of human life and brain, similar in numbers to those people who cannot taste tomatoes, or have the recessive gene to roll their tongue, or are colour blind, they can place the voices to one side, and get back to living. The voices don't go away, they just become an ordinary and natural variation in that state known as 'being human',
Being a trans persona used to worry me, as worrying goes, it was a huge compared to the night time voice worry. In someone else, the same combination of features might have the size of the worries reversed. Now I know that the night time voice is a common and natural variation on life, and just a little crossed wire between some neurons, it has never caused me to think about it again.
Until recently, people who heard voices were treated as having a schizophrenic disorder and were often heavily tranquillised and sedated in an attempt to control the voices. Historically, trans people who tried to live as a member of their preferred or internal gender would similarly be tranquillised or placed in asylums. Some were chemically castrated in an attempt to cure them.
I use the comparison of Hearing Voices, because the person most often thought of as persecuted for hearing voices, St Joan d’Arc was not burnt for heresy because of her voices, but went to the stake because she insisted on cross-dressing in men’s clothing.
If trans people we are to be de-psychopathologised - declassified as mentally ill - perhaps there are many other 'mental illness / disorder' labels in the DSM IV should also be declassified.
If trans people hate being being labelled as having a mental health disorder because that means being treated as less worthy, which invariably it does, by rights as Trans people we should also be campaigning for the removal of all of the mental health labels and classifications that people are given, which result in them being held in less worth.
Is it because we believe we are more worthy than them, that we seek the ending of this classification (or reclassification?) We have vested interests; consequently our motives are everything in this debate.
If we sort out society would there be any need for psychiatry.
Ever since Emil Kraepelin (1856-1926) introduced the new medical category called mental illness, there has been an anti-psychiatry movement.
Kraepelin's taxonomy of types of ‘mental illness’ were a problem from the start – they were based on behaviours, what he referred to as symptomatic", observations, rather than on any pathological evidence of causation, bodily illness or disorder.
How could we know if these ‘mental illnesses’ were true illnesses of the mental state.
In the 1960s, the anti-psychiatry movement became internationalised through the mass media. South African psychiatrist David Cooper and Philadelphian psychiatrist R.D. Laing argued that mental illness was a “transformative state” - a coping mechanism in response to a sick society.
Sort out society they said and there will be no need for psychiatry.
Thomas Szaz, a psychiatrist who also worked on mental illness. argued that mental illness is simply a fiction, it does not exist, mental illness is a myth, counterfeited by psychiatrists to provide themselves with worth, value, status and a large income. Or as the psychiatrist J Geller said to describe Szazs’s work
“Schizophrenic" provides the necessary structure from which to hang stigmatised images of a person—a lonely person with inadequate social skills and poor hygiene in one language, and a person who is bizarre, grubby, smelly, a street person, or a zombie in another language.”
So, should trans people actually be campaigning that the entire DSM is also burnt at the metaphorical stake? Well let’s think of what the consequences of that would be?
My wife is a psychiatric nurse turned lecturer in recent years. She believes in mental illness, though, she agrees, not all things labelled as that are in fact illnesses. And from her tales from the wards (always discretely anonymous)it is clear that mental illnesses can be devastating, and whilst not all, some of those illnesses can in fact be be ‘cured.’ By which she means people become happier, more able to cope with the behaviour they sometimes manifest, and are able to go home and restart their lives in a more optimistic way.
She would argue that if we destroy the bible of psychiatry, as is our desire, and it seems our moral obligation to do so, would that mean clinically depressed people are no longer be able to access anti-depressants because what they feel is just a normal variation of the human condition.
If they were unable to access their medication, we know some would kill themselves, some would eventually feel better, and a large number would be inside our prisons raising the already large percentage of the prison population with a mental health disorder from 10% to many more.
Further, Bio-medical companies would no longer research, make or supply the medicines that make many people feel better. It is only by knowing that it is because of studies in evidence based medicine, that many doctors will feel they are worth supplying to patients , that they have the confidence to put millions of dollars into their research and development. Current supplies would run dry – or I suppose they would have never existed in the first place. Might we find the treatment of choice be as follows:
FOR THE SLIGHTLY MISERABLE:
“’ave a nice cup of tea, dearie”
FOR THE TRULY MISERABLE:
Mum:
“for heaven’s sake Jim, your 16, I was working at your age. Now just stop floating around, get out of that bed, NOW, … pull your socks up, take some responsibility, get a job, put a grin on it …. And put that razor blade down .. NOW”.
FOR THE IMPOSSIBLY MISERBLE:
Doctor:
“Mrs Brown, this ‘post-natal’ thing you have, what did you call it – depression, humph – never heard of it before. Well, anyway we have a solution for this very obscure thing that is happening to you. Well not that obscure it seems, apparently we have another 20 of you languishing in the hospital. Clearly, you have chosen not to pick yourself up and be a good wife and mother. But we have a solution. Tom is divorcing you, well at this moment he’s in the court. Clearly you are not up to attending the court, so we felt it best not to tell you.
Rupert, your son is going to live with him and his new partner. Your 3 year old daughter Ellie, and the new baby are being adopted … …………….
Now, now, there is no point in screaming, it has all happened whilst you’ve been in here having this appointment with me. But as I said, don’t worry, you are sorted, you can carry on behaving like this for the rest of your life, which is what you would obviously like to do - and it won’t bother anybody. We have a place for you at a Nunnery, there are flowers, magazines, and a lovely set of padded straightjacket and shackles in your room.
“What was it you called it … depression? How do you spell that, oh right, d e p r e double S- ion. Is that some foreign, oriental, concept. … very interesting … perhaps you would be game for coming and taking part in one of my public lectures next week. I mean, it’s easy, you would just sit there and I would ask you a few questions. Then you would go behind the screen, undress, -- yes, yes - everything , and then -- well, well .. I’d examine you. You know, measure you head, the size of your nose, your clitoris, things like that, and then you could slip on your robe. And if you would like, I think I can make a special exception on this occasion, you could sit in the audience for the rest of the show. Of course there would be security, you would have to wear the shackles, and there would be a couple of armed guards – but no more than that.
“oh dear, you don’t look very well Mrs Brown”
The anti-psychiatry movement of the 60s and early 70s failed miserably, because people really do suffer, and I remember that suffering and how badly I wanted to get those hormones. There is the fear that if we do not exist within a medical framework, somewhere, those of us who wish to have medical treatments would not be able to access them.<- em="">
For many trans people; they really do feel the need to engage with the medical services (as I have done) because of the sheer scale of the dissonance they feel with their body. It is a long time ago that I transitioned and first started hormone therapy, and then later had my first chest surgery. I cannot really remember what that felt like, but I can still remember the absolute desperate need to be seen as the person I am, as a man – or as it turned out, in the end, as a trans man – and how driven I was.
It is in America, and other countries with similar private health insurance systems, where the community are most fearful of change without reclassification. Their health insurance systems are very different from those we have around Europe. Our health insurers are either like that of the UK; a taxation based insurance scheme whereby access to (unlimited) health care is guaranteed. In other European countries the private health insurers are very highly regulated by government, so much so, that they could almost be called government schemes. And here again there is a very strong guarantee that if a doctor says you need a treatment, it will be paid for.
Other parts of the world are very different. Trans people are dependant upon minimal provision schemes for the poor, or the alternative expensive, often work related, private health insurance. In those countries trans people have to work very hard to get most insurers to meet any of the costs of trans related treatments – whether it be for therapy, hormones or gender reassignment surgeries. It is only a label of some sort that has enabled most to get anything. The vast majority of trans people in this world have no access to free or insured health care, nor the money they would need to even gets their kids some painkillers.
With STP2012 you started an International Campaign without thinking of the International Consequences.
There is a great fear, in the US where these issues are most vocalised, because the community is most organised. There is real fear that without a ‘classification’ in one of the major standards (such as the DSM IV which is for mental health problems) the medical insurers will refuse to pay for anything. In that sense, they probably are right to be fearful. Health insurance is so very expensive, only those in work are likely to be able to meet the cost of insurance. And health insurance generally only covers those conditions recognised by medical professionals, through the consensus systems that develop the major diagnostic manuals.
Without insurance coverage, the cost of any healthcare treatment in the US is extremely expensive, and the costs of gender reassignment treatments are in themselves high up on the expensive scale. I have friends work dangerous jobs down mines, or as line men (they are the people whom climb large pylons and fit phone lines and power lines), for 10 years or more to raise the money for chest and hysterectomy surgery after being refused health insurance.
Of course it is not just trans related costs that are affected, it can happen for any other health problem also, if the insurers can find the way to disbar you from the benefits – they will. I have one US friend in his late 70s who is still working to meet the very basic health costs for his sick wife, even then only she gets minimal treatment – nobody will pay for life saving methods in her case, though they do exist, and if she had been a European citizen she would have almost certainly received the treatments by now.
Those who oppose Obama’s health care plans, most notably the elderly who say that treatment will be less available to them, if the plans to give more health care to others go ahead, are also quite fearful, of losing benefits as they see a very thinly spread pot of money now having be spread even more thinly to meet the costs of those people often thought of as the ‘undeserving poor’, the low wage earners, the single mothers, the chronically sick, the people with mental health problems and so on.
Their fears are unfounded; those I have described will have got free or low cost basic care under the current Medicaid system as it is. But despite all that is promised - and I believe it is promised in good faith by Obama, those elderly people may well find the pot becomes more thinly spread anyway. The fact that they are living longer is what will cause the problem. Care is bound to be spread more thinly in practice – but that is demographics, and not new patients.
US Health providers are loath, like in my friend’s case, to spend money when they can avoid spending it. Like the Health insurers themselves, they have shareholder profits to think about, so of course they will cut corners. Obama’s government will need to put in place strict controls at the managerial and board level of health care providers, but in a state where the very idea of government control in any aspect of private life is an anathema, they may find that very difficult.
It is the fears of any loss of the paltry levels of health insurance coverage that Trans people in the US have that leads to calls for reclassification. Obviously, any reclassification seems to fall into the trap of labelling our life experiences as abnormal, and as we know, that is something that intersex people have also been fighting against for decades.
I think there is a problem out here in the real world beyond the theoretical gender queer position some of us feel able to embrace, and the harsh realities of trying to life a safe, sane and healthy life as a trans person in the US. And there is a long list of countries I could add in here.
I advise many real Trans people out there in the wider real world beyond that of Europe and the US, in places where life can be really tough I know what they think, and that is they can not be doing with all this theory nonsense, they are far too busy as they need to access some low cost hormones, get a job, stop being beaten up by their pimp, or having their stuff stolen by their brothers, and so on, in a whirl of misery and a life barely worth living in many cases.
The Stop2012 campaign needs to stop – for a short while to spend some time considering the lives and health care access issues for those outside of the European context; the people whose health care access is virtually impossible within the chaotic and corrupt regimes of Africa for example. The people who need to access treatment within Middle Eastern and other Muslim states where as we know, having a medically recognised condition really can be the difference between life and a public hanging in a packed football stadium. Have you considered what happens in the former Soviet Block countries – when communism collapsed so did the provision of gender reassignment treatments as the constitutional laws collapsed, and health care workers were not paid for years. In Japan, gender reassignment treatments were only made unlawful after a campaign in the 1990s to claim it was an illness in the DSM IV and should therefore be treated. And does anybody really know what happens in China, or in the truly repressive states of Burma & North Korea.
My concern has always been, despite my support, that the Stp2012 campaign is naïve. There was always going to be this problem because of the corrupt nature of health care provision in the US, and the lack of health care systems in so many other parts of the world. Until that is sorted out, most Trans people will feel unable to express a position ‘in between’ or ‘outside of gender’ whist doing so prevents access to any, never mind low cost, basic trans related health care needs.
So, the campaign is great as an idea, but in the execution of it, you failed to realise that the very people you have tried to help, might have been better helped with engagement in the debate, rather than just simply brushing them and their healthcare concerns under the North Atlantic. To be united we must listen to each other.
I don’t think we should need classifications which fit us in little boxes which are specifically designed to lock most people out, but then I have the luxury of a social health care system that is free. Before we make pronouncements on other people’s lives, and by ‘we’ I also mean the West, and the medical establishment, as well as health insurers, governments and US, as trans people we need to be offering solidarity to those less privileged, rather than threatening to take away their only access to gender reassignment treatments.
We must engage with those people in the world who have no funding or insurance for health care and for whom, gender reassignment treatments are a distant dream. We must also engage with the many others who could have some health insurance but for whom their health insurers will do everything they possibly can to refuse to pay for care.
The Shame of Being Trans
We must also try and understand those many trans people who are still carrying a huge sack of shame for being trans. Most older trans people, and many young ones, year after year, have been told, firstly by their parents, then teachers, then priests, then doctors, then employers, then so-called friends, then loved partners and often their children, how unworthy they are of even the right to live. They are abandoned from the minute their ‘secret’ is discovered. Being told how disgusting, dirty, and perverted you are, how worthless, how you deserve to die, how it would be better if you committed suicide and how much you are hated, makes most of us very ashamed of themselves.
That shame can be so big it causes many to take their lives, for others though it means that even a small idea that perhaps this ‘mental illness’ is not so mental, but it might be physical – that it can be found by counting cells in a tiny part of the brain, or decoding the genome to find a tiny part of our DNA were the causes of our ‘condition’, ‘syndrome’ becomes a lifeline.
When people contact press for Change, or myself, for help, they are often very angry, and that anger can be so great that it is directed to us, the very people who are volunteering their time and expertise. We try to remember that they almost certainly have good reason to be angry. The STP2012 campaign group needs to recognise the privileged position they are in, and try and understand that when starting an International campaign, they must have an international perspective.
I hope that better explains why some people seem to want reclassification, and why some people are unhappy that the campaign exists at all.