A Transgender Client Bill of Rights

With the depathologization of the International Classification of Diseases (ICD) expected in 2018, its time to tell the Mental Health and Medical practitioners that serve the transgender community what we expect of them. The rewrite of the ICD is expected to create a non-pathological section of the ICD which includes “gender incongruence for adolescents and adults.” Admittedly, the fight continues with the reparative therapy crowd over whether “ gender identity disorder and transsexualism in childhood” will also be moved to the non-pathological gender incongruence section but hopefully the good guys will eventually get it moved. As the clinical administration battle over transgender pathologization hopefully nears an end, we need to tell the practitioners how we expect to be treated going forward.

I suggest the following bill of rights for transgender clients:

Transgender Client Bill of Rights

• Practitioners will provide assurance, information, counseling and transsexual surgeries within the limits of their expertise and skill. We have a shortfall in the number of practitioners with the expertise and skill to deal with the needs of transgender clients. It is worse in the UK and other countries with national healthcare systems. Appointment delays for initial discussions with mental health practitioners now take up to 18 months in some countries. While WPATH and other organizations are trying to help U.S. practitioners with remedial continuing education courses (CEU), it is acknowledged by WPATH that the CEU courses are not enough to qualify practitioners to serve transgender clients. Internships with skilled practitioners for several months are needed. Marcie Bowers worked with Stanly Biber for several years to become expert in transsexual surgeries. Acknowledging that there was more to learn about FTM surgery, she recently spent considerable time in Serbia studying their methods. But so far, there is no organized national or international internship program.

As practitioners are often taught, if a client needs services that are beyond the capabilities of a particular practitioner, then the client should be referred to another practitioner with the requisite capabilities. Practitioners should not try to help transgender people unless they have been properly trained. I went through several useless appointments with psychiatrists that knew nothing about being transgender. There was the Freudian “Ice Maiden” who barely spoke a word, and the cognitive psychiatrist who wanted to straighten out my thinking and not what I was doing, and the psychoanalytic who said that I dressed in feminine clothes because I missed my mother (the Linus blanket syndrome).

• Practitioners should not try to “cure” being transgender through psychotherapy, reparative therapy or drug administration. There is no cure for being transgender because it is not a disease or disorder. Instead, mental health practitioners should provide support and information as needed for transgender clients. While there is no cure for being transgender, there is a need to provide help for some of the social consequences of being transgender. The other task for mental health practitioners is to attempt to rule out actual mental disorders that need treatment or might interfere with transsexual transition if left untreated. Although recently, a TV psychiatrist suggested that giving transgender people doses of same-sex hormones (same as birth sex), there is no reason to believe that such drugs will cure or eliminate the phenomenon of being transgender. I have first hand knowledge about this because I took testosterone for 3 years to see if I could shake being transgender. All I got for my trouble was burn marks on my thighs. Transgender people do suffer from depression, the reactive kind, not the brain malfunction kind. There is evidence that the reactive depression which some transgender people experience can be addressed with short-term administration of anti-depression drugs. Reactive depression is a reaction to external events, usually social rejection or violence. However this is only needed in extreme cases for short-term use.
• Practitioners should not use pathological terms either in public or private. Psychiatric terms such as “gender identity disorder,” “gender dysphoria,”  “transvestism,” and “autogynephilia” were used for a long time to characterize transgender people as diseased and were actually misused given their original formal definitions. For example, according to the APA, a transgender person does not have the disease of gender identity disorder unless the person is incapacitated or in distress about being transgender. But the term gender identity disorder was and is used frequently as an alternative to “being transgender” or just stating that one is a woman or a man.

The term “gender identity” is particularly disturbing because of its pathological roots and because it is used in sociology to describe affiliation with a group without objective evidence. Identity comes from the psychiatrists Freud and Erikson as an unobservable phenomenon in the mind. It was mated with gender by Richard Green just in time for the Diagnostic and Statistical Manual of Mental disorders version 3 to provide a new pathological term, “gender identity disorder” for transgender people. In sociology, it means a term of affiliation as in “I identify with being a Georgian or a football coach or a parent, or a U.S. citizen.” Objective referents are sometimes available for identities but sometimes not as in the case of Rachel Dolezal. Race is a hard thing to define because we all came from the original humans in Africa, many thousands of years ago and there have been many interphases between groups that favor genetic diversity.

The term “gender identity” has also been coopted by the transgender community as in “my gender identity is woman” but it does not mean anything more that “my gender is woman.” So there is no reason to use this term unless one is seeking status as having been treated by a psychiatrist.

The word “transgender” has a psychiatric origin meaning a transsexual who is motivated by changing their gender, not their sex. But transgender people coopted this word and changed its meaning to be an umbrella term for people who cross-presented. It is probably too late to stamp this word out.

Practitioners should use terms like “gender” meaning one of the two categories of the Western gender system, or “gender predisposition,”  “gender congruency/in-congruency” and “verbal expression of past gender behavior.”

Although WPATH discourages the use of pathologizing words, it will probably take the turnover of the current generation of practitioners to totally rid ourselves of transgender pathological terms. Using such words is a hard habit to break and practitioners are focused on actual disorders and diseases in other areas, so they tend to speak in “pathological” language.

• Practitioners should be careful to distinguish the terms sex and gender. Sex has to do with the organs of reproduction while gender has to do with behavior. These two words are misused as synonyms by practitioners, the public, the media and even some transgender people. Conflating these terms results in miscommunication, and scientific confusion about being transgender. For example, it is nearly impossible to adequately define being transsexual as one who changes their sex organs as opposed to other kinds of transgender people who do not. Practitioners should take care to define these terms at the outset of discussions, particularly public discussions, until this conflation abates.
• Practitioners should make it clear that being transgender has to do with an innate gender behavior predisposition that is in conflict with a culture that is cisgender, binary and inflexible. Transgender people should not feel shame because they can neither control their biology nor the culture into which they were born. Too often, practitioners become the defenders of the culture. Some protect the culture because they actually believe that culture is fixed and cannot be changed. Others reason that they have to prepare clients to fit into neat gender behavior categories. The outcome of this thinking is that practitioners put too high a premium on passing. In fact the probability of successful passing used to be a criterion for starting transsexual transition. It also results in rules and laws that require sterilization and divorce during transsexual transition. Over 30 European cultures still have transsexual sterilization laws on the books and others have only recently relaxed the divorce rule because same sex marriages are now allowed.
• Practitioners should not be the only ones speaking for the transgender community. They should insist that transgender people be included in any discussion about being transgender. The very fact that they are associated with professions which are involved in curing diseases and disorders means that can pathologize transgender people. Practitioners need to make it clear that being transgender is neither a disease nor a disorder. They also should insist that transgender people take part in discussions, particularly in the media. After Caitlyn Jenner came out, almost all of the “talking heads” were either non-transgender mental health professionals or gay leaders. When they did appear in the media, transgender people were cut off and given little time to speak. The transgender community has some good presenters which should not be given short shrift.
• Practitioners should know and be prepared to discuss the state-of-the-science in transgender causation. Most providers (and some transgender advocates) hem and haw when asked about causation or mumble something about prenatal hormones or drug exposure. Current science points to a genetic origin although it looks like epigenetic mechanisms can block the expression of transgender genes. There is no solid evidence that people become transgender because of the prenatal environment or from improper child rearing. Mothers and fathers cannot be blamed for having transgender children, although it is true that some parents abuse their children for being transgender, as supported by culture.
• Transgender people should have access to sex hormones from those practitioners skilled in hormone therapy (HT) as long as they provide informed consent. The real danger of taking sex hormones is taking them on a do-it-yourself basis. Somewhere between 20-45% of those initially asking for sex hormones from a practitioner are already taking them. Although hormones can be obtained from other countries that do not require a prescription, obtaining them outside the U.S. results in some severe dangers. The dangers include drug counterfeiting, substituting ethinyl estradiol for estradiol valeate, hormone variants that have not been vetted by the FDA for safety and effectiveness, and drug overdose. Transsexual people taking sex hormones should be monitored periodically by an experienced practitioner for blood levels of several hormones in order to adjust dosages. In particular, it takes an experienced practitioner to know that precise levels of sex hormones in the blood can only be obtained from testing laboratories that are certified by the Centers for Disease Control. Some people with chronic conditions such as deep vein thrombosis and other blood clot syndromes, should probably not take estrogen at all except under very careful supervision of an endocrinologist. Finally, practitioners can make their clients aware of the potential warning signs of blood clots from taking estrogen and too many red blood cells from testosterone.
• Practitioners should not use culturally influenced criteria in approving genital plastic surgery (GPS). The ability to pass and appreciation of “core gender principles” set by culture should not be criteria for GPS. These as well as other irrelevant criteria used to appear in guidelines. From a mental health practitioner perspective, the only hard showstopper for GPS should be that a transsexual has a mental health problem that might interfere with being transsexual and that cannot be treated. From a medical perspective the important criterion is whether the person provides informed consent and can physically withstand the operation.
• Practitioners should insist that biological sexual and gender diversity be taught and researched in academia. Culture puts pressure on academia not to teach or conduct research on biological sexual and gender diversity. For example, there are numerous cases of legislators trying to change the curricula of state schools. At the national level, I remember the cautionary tale from my graduate school days where Ellen Berschied had her career ruined for many years from being awarded a grant to study human love. She was awarded the “golden fleece” award by U.S. Senator Proximire for fraud, waste and abuse. As I was forced to do, she made her living in human factors psychology. As a result of cultural pressures on academia, even most educated people have limited knowledge of sexual and gender diversity. Practitioners need to educate themselves on the science of these diversities and should push back against these cultural pressures in their alma maters, schools and medical institutions. A good start is to read Joan Roughgarden’s book Nature’s Rainbow. She points out in this book:

“But as I reflected on my academic sojourn, I wondered why we did not already know about nature’s diversity in gender and sexuality. I came to see the book’s [her book, Nature’s Rainbow] main message as an indictment of academia for suppressing and denying diversity. And in the social sciences, variation in gender and sexuality is considered irrational and personal agency is denied. Gender and sexuality variant people are thought to be motivated by mindless devotion to primitive gods, or compelled by farfetched psychological urges, or brainwashed by social conventions and so on: there is always some reason to avoid taking gender-and sexually-variant people seriously. The fundamental problem is that our academic disciplines are all rooted in Western culture, which discriminates against diversity.

Although transgender people can and should advocate for transgender science and diversity, requests coming from practitioners could have considerable impact.

I view this draft Transgender Client Bill of Rights as a start for a longer discussion between practitioners and transgender people. I am sure that I have missed something and other people may define terms differently from me. Practitioners should not take this list as a rebuke for the caring work that they do. But it is time to establish a new relationship between practitioners and the transgender clients that they serve.

Tags: featured, opinion, Transgender, transgender rights, Transsexual

Category: Transgender Body & Soul, Transgender Opinion