Gatekeeping models of transition-related healthcare are embedded with assumptions about sexed bodies and gender identity. These processes assume that the concepts of ‘sex’ and ‘gender’ are straight-forward, stable categories that can be proven through measurable standards. The over-emphasis on proving one’s dysphoria1 situates trans experiences within a deficit and pathologised model of health, instead of respecting the bodily autonomy of trans and gender-diverse people. Medical gatekeeping further undermines the negative effects that delayed healthcare can have on people’s mental health. For many gender-diverse people, access to transition-related healthcare is a literal lifeline, and being told to wait because a doctor is not convinced of one’s internal reality can exacerbate distress and depression. Current medical systems need to reconsider the role of healthcare professionals in people’s gender transitions. Healthcare providers must be aware of the complex social and medical aspects of sex, gender, and transitioning, to support clients in making informed decisions about their health.
To better understand the role of the medical system in shaping and affirming trans and non-binary experiences, we must examine the relationship between social and biological explanations of sex and gender. Sex refers to the biological, genetic and psychological make-up of characteristics that we use to categorise people as ‘female’, ‘male’, or having diverse sex characteristics. Although the materiality of sex is situated in the body, the process of categorising sexed bodies is influenced by cultural norms. The experiences of intersex people whose bodies defy rigid sex categories because of hormonal, chromosomal or anatomical diversity, destabilise the social fact that every human has a definable ‘sex’. It is not uncommon for doctors to perform normalisation surgeries on intersex infants without their consent, to fix what is considered a ‘problem’ within western biomedicine. The impetus for doctors to perform surgeries on intersex bodies illustrates how integral having a clearly defined sex is to being a human; without one, we are unintelligible. Sex does not only refer to the categorisation of material bodies, but also to a person’s self-perception of their physical embodiment. Although our psychological sex – how we see our own bodies – may not be tangible, it is just as important to give equal consideration to people’s self-perceived embodiment. This is something which cisnormative healthcare practices2 too often overlook.
It is not well understood why some people feel an intense mismatch between their psychological and physical sex. Biological studies offer a range of hypotheses which, through their inconclusiveness, demonstrate just how complex the process of physical and psychological sex development is. Biological research into sex development poses a big challenge for medical models based on sex binaries which typically reduce the concept of sex development to a straight-forward biological ‘truth’. Simplistic ideas that chromosomes or anatomy always define biological sex fuel the idea that trans and non-binary people who require medical transition want to go from living as ‘one’ ‘ sex’ to the ‘other’, and must therefore also desire normative bodies that align with cultural definitions of each sex. This is not always the case, as each person experiences their gender diversity and dysphoria differently.
Sociological understandings of gender add a crucial and often overlooked perspective to the growing scientific discourses around sex and gender diversity. The generalisations that have formed about how sexed bodies are expected to behave in society based on biological functioning produce what we call gender, a construct whereby biological differences between sexes are given social meaning. Gender organises bodies and identities, and the consequences of this shape our daily lives in both subtle and significant ways. Our gender identities are influenced by the ways we are read and seen in a broader social context based on our assumed sex.
Gender is created by and exists within social relations. Our bodies are gendered by other people and this can agree with or deviate from the way we see ourselves fitting into society. Gender identity is therefore also influenced by how a person’s self-perceived body is positioned in relation to other gendered subjects. The development of gender identity is understood to be informed through our socialisation from an early age; the messages we are exposed to both consciously and unconsciously influence our behaviour and the ways we negotiate our gender. We are experiencing a major discursive shift in the ways we speak about gender; the growing number of nuanced terms to describe our identities, and the more flexible use of grammar such as the singular use of the pronoun ‘they’, are challenging our binary systems of thinking.
Because sex and gender are arguably products of both biology and society, we cannot rely solely on social or scientific factors to explain why some people experience such an intense disconnect from their bodies. Gaining a deeper understanding of gender and sex diversity requires us to understand how the scientific theories of sex development and the social aspects of gender interact. There is a risk that through focusing too much on biology, gender diversity will be taken out of the social domain and reduced to a pathological issue or a glitch in brain development. On the other hand, emphasising the socially constructed nature of gender is insufficient to understand the inherent disconnection some people feel from their sex characteristics.
While the exploration of gender diversity within the biological sciences contributes to our understanding of its complexity, a biological explanation of trans identities does not warrant its pathologisation in the ways it is currently understood. As gender theorist Judith Butler argues, ‘we do not have to agree upon the “origins” of that sense of self to agree that it is ethically obligatory to support and recognise sexed and gendered modes of being that are crucial to a person’s well-being’.3 This idea can be further explored through looking at the ways in which psychiatric and social models of gender diversity have been co-constructed.
The history of gender diversity as a psychiatric condition illustrates one of the ways in which social and medical discourses on trans identities have influenced each other. The first attempts at understanding sex development in trans people in the 20th century have had long-lasting implications on the way medical practitioners and trans people themselves understand gender diversity. Harry Benjamin was one of the first physicians to write about what has come to now be known most commonly as ‘gender dysphoria’. His influential book The Transsexual Phenomenon, written in 1966, became a popular text which physicians would refer to when treating gender-diverse people. In 1980, transsexualism was entered into the DSM-III as a psychiatric disorder. While it is currently listed as ‘gender dysphoria’ in the DSM-V, health professionals are increasingly using the term ‘gender incongruence’ to remove the negative connotations associated with the prefix ‘dys-‘, because it perpetuates the dominant but often misleading narrative of being born in the wrong body.
Trans activist and writer Sandy Stone notes that people who sought transition-related healthcare would often rote learn the diagnostic criteria outlined in Benjamin’s book so that they would be taken seriously by their physicians.4 This is not because they did not experience gender dysphoria, but because they were aware that only certain narratives of being trans were perceived as legitimate within medical institutions. The limitations of diagnostic criteria still pressure trans people to conform to binary trans narratives today. Some surgeons only perform gender affirmation surgery on those who are taking gender-affirming hormones. As a result, people whose gender identity falls outside of the gender binary, or do not require find it difficult to access medical transition services.
Gender dysphoria, like other diagnoses, has been reduced to a list of pre-requisites. A trans person experiencing mental illness might diminish their illness when being assessed by a psychologist, out of fear that the healthcare professional might conflate their mental ill health with being trans. Healthcare providers must realise that for many people, taking gender-affirming hormones alleviates existing mental health conditions and reduces the stress of being perceived as a gender or sex one does not identify with. Categorising gender diversity as something for which one must obtain a psychological assessment, hinders efforts to recognise gender diversity as a non-pathologised human right.5
In recent years, the global movement to depathologise trans identities has gained momentum. The movement advocates for the right for trans people to make informed decisions about their body without unnecessary medical or legal interventions. The movement is critical of current diagnoses of gender diversity that have been constructed according to Eurocentric ideals, and aims to shift the conversation away from thinking about gender diversity as a pathology to a human right. It further recognises the importance of finding a compromise between taking gender diversity out of medical discourse, without its removal adversely affecting trans people’s ability to access healthcare and transition services. As the official statement for the International Day of Action for Transgender Depathologization in 2017 made clear, communities will be ‘working together to accomplish trans depathologization while ensuring full access to healthcare and its coverage’.6 The movement achieved considerable success when in May 2018, it was announced that gender incongruence would be removed from the ICD-11 as a mental illness, and re-classified as a condition related to sexual health.7
However, as with any effort to change institutionalised systems, the trans depathologisation movement faces challenges. Some people, including trans people themselves, believe that completely removing the diagnosis of gender dysphoria from the medical realm poses issues to current policies that require medical evidence of transitioning in order to change legal documents. Similarly, proponents of this view argue that keeping trans identities diagnosable in this way serves the interests of trans people as it legitimises access to insurance and publicly-funded healthcare.
Despite these challenges, depathologising gender diversity will eventually change social attitudes towards people whose gender identity differs from the one they were assigned at birth. Medically and legally identifying as one’s self-perceived sex will be recognised as a universal human right, rather than a problem. Transition-related healthcare therefore has an important role to play in affirming people’s sense of physical self. The movement to depathologise trans identities is an ambitious yet necessary undertaking, one which requires healthcare providers to become allies for trans communities. The question may not be whether to remove gender diversity from medicine entirely, but to re-define the role that healthcare providers play in people’s transitions. Instead of building bureaucratic barriers to transition-related care, healthcare professionals should be supporting trans people to affirm their own identities, rather than sending them down convoluted healthcare pathways.
Healthcare providers in Aotearoa New Zealand are already demonstrating that alternative models to the current pathway are possible. The student health service at Victoria University of Wellington have been working alongside gender-diverse and district health board working groups to develop a trans-affirmative clinic, whereby students are able to acquire gender-affirming hormones directly through their primary healthcare providers. This service guides students through making informed decisions about taking gender-affirming hormones, and to ensure they have adequate support systems in place throughout their transition. The clinic is based on a comprehensive model which other primary care services around the country can adapt and scale to their needs. Healthcare initiatives such as these prove that pathways informed by trans experiences which eliminate needless waiting times and costs are entirely feasible to implement.
Unnecessary medical gatekeeping contributes to the high levels of frustration within gender-diverse communities. As the demand for transition-related services grows, we must implement new pathways and guidelines which ensure safe access to medical care while respecting trans people’s autonomy. It is promising that a shift in healthcare systems’ understanding of gender diversity is already underway. According to a survey conducted by Transgender Europe, 88% of healthcare providers do not agree that gender dysphoria is a psychiatric disorder.8 In Aotearoa, this shift will demand both a willingness for district health boards to re-evaluate current processes and funding models, and to provide training for staff on gender diversity. Most importantly, those who have the power to affect change must listen to the experiences of people who have faced barriers to healthcare because of their diverse gender identity. As patients, activists, researchers, community members, and healthcare professionals, we must collectively support the movement towards trans-affirmative, person-centred healthcare.
- ‘Dysphoria’ refers to the intense feeling of distress or discomfort a person feels between their assigned sex and their self-perceived sex, or gender identity. Not all trans and non-binary people experience dysphoria.
- ‘Cisnormative’ describes the social norms which assume that all people identify with the sex they were assigned at birth.
- Williams, C. (1 May 2014). Gender Performance: The TransAdvocate interviews Judith Butler. Retrieved from http://transadvocate.com/gender-performance-the-transadvocate-interviews-judith-butler_n_13652.htm
- Stone, S. (1993). The Empire Strikes Back: A Posttranssexual Manifesto. Department of Radio, Television and Film: University of Texas.
- Human Rights Commission. (2007). To Be Who I Am: Report of the Inquiry into Discrimination faced by Transgender People.
- TGEU. (21 October 2017). Statement on the International Day of Action for Trans Depathologisation 2017. Retrieved from https://tgeu.org/statement-on-the-international-day-of-action-for-trans-depathologization-2017
- World Health Organisation. (18 June 2018). WHO: Revision of ICD-11 (gender incongruence/transgender) – questions and answers (Q&A). [Video file]. Retrieved from https://www.youtube.com/watch?time_continue=2&v=kyCgz0z05Ik
- Transgender Europe. (2017). Overdiagnosed but Underserved. Retrieved from https://tgeu.org/wp-content/uploads/2017/10/Overdiagnosed_Underserved-TransHealthSurvey.pdf
Alex Ulrich Ker has been exploring his own gender identity for the last five years, and views his transition as an ongoing adventure. He sees gender as a puzzle and is trying his best to solve it. He is particularly interested in the relationship between gender and the body, and how individuals can challenge the gender binary through ordinary interactions in everyday life.