Depathologising the future of trans health care: Does saying it make it so?
“policies produce ‘problems’ with particular meanings that affect what gets done or not done, and how people live their lives” (Bacchi 2012, 22)…”
Rebecca Howe
University of Sydney
Bio
Rebecca Howe is a PhD candidate at the University of Sydney with a background working in the LGBTIQA+ youth homelessness and health policy sectors. Her research scrutinises policies concerned with granting access to gender-affirming medical care, and in doing so, considers how the governing of gender operates within contemporary settler colonialism.
Abstract
Depathologisation in trans health exists because of sustained, polyvocal opposition to the structural violence of imposing psychiatric classifications upon people who request access to gender-affirming medical technologies. Despite these efforts, the half-century legacy of classifying various forms of gender identity and expression as mental disorders continues to ripple out across trans health. This paper discusses two policies operating in a dynamic space between preserving or potentially abolishing structures that maintain pathologisation in trans health care. I argue that it’s important to question whether a professional association can say it is depathologising trans health when the foundation of medicalising gender self-designation remains in place. Similarly, I stress the importance of questioning whether an uncritical application of a rights-based approach to redesigning healthcare systems and their “care” carries the potential to abolish both an illness-based and a colonial mode of governing. Considering the recent release of the SOC8, I present a critical comparative policy analysis and an abolitionist political vision for the future of care in trans health.
Keywords
depathologisation, trans health policy, medicalisation, settler colonialism
Introduction
This paper discusses a critical comparison of two policies concerned with “care” for people seeking access to gender-affirming medical technologies. It draws a connecting line from a contested illness-based paradigm and an alternative, rights-based model for “care” through to a vision for a future that scrutinises how the depathologisation of trans health can preserve or potentially abolish the structures and practices of colonial projects. I have been circling around the phrase “saying it doesn’t make it so” for a while now. I am a settler and a cis, queer, social worker. I have spent over ten years working in the youth homelessness sector, where young people who are trans, gender diverse, and non-binary were, in a variety of ways, negotiating (resisting) the privileging of so-called expert knowledge over their own (Howe, Harper, and Hammoud-Beckett 2019, 8).
My research comes from noticing that when it came to trans health, the word de-pathologisation was used in various ways. Yet, when it came to care for people requesting access to medical technologies that would modify their bodies, all kinds of pathologising practices were continuing, business as usual. I analyse and compare version 7 of the World Professional Association of Transgender Health (WPATH) Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People (the SOC7) (Coleman et al. 2012), to the Best Practices Guide to Trans Health Care in the National Health Care System created by the Spanish Network for Depathologization of Trans Identities (the Guide) (STP 2010). I chose the Guide for this comparison because it is a stand-alone alternative rather than a revision or an addition to existing policies. I compare the SOC7 to the Guide using the What’s the Problem Represented to be? or the WPR approach to policy analysis. It posits that “policies produce ‘problems’ with particular meanings that affect what gets done or not done, and how people live their lives” (Bacchi 2012, 22). The Foucault-influenced approach uses a set of interrelated forms of questioning and analysis to scrutinise how governing occurs. I am using the WPR approach, in conjunction with Scott Lauria Morgensen’s (2011) theorisation of the biopolitics of settler colonialism, to analyse the governing of gender through policies governing access to gender-affirming medical care.
Indigenous theorists and their collaborators have long argued that while race and racialisation are foundational, colonisation is also a normatively gendered and gendering process (e.g. Anzaldúa and Moraga 1981; Arvin, Tuck, and Morrill 2013; Lugones 2010; Moreton-Robinson 2015; Kauanui 2017; Smith 2021). This critical scholarship implicates the heteropatriarchal governing of gender and sexuality as it draws attention to situated mechanisms regulating multiple modes of non-normative identity, expression, kinship, and social position. Wiradjuri anti-colonial scholar Sandy O’Sullivan (2021) illustrates how the colonial project of gender requires persistent erasure of multiplicity and complexity because it is about rendering specific formations of bodies, genders, and relationships visible for governing. For this reason, Susan Stryker (2014, 39) argues that when approached biopolitically, gender is “an apparatus within which all bodies are taken up”, thus making it “an integral part of the mechanism through which power settles a given population onto a given territory through a given set of administrative structures and practices”. I am discomfited by this rhetorical use of ‘given’ while researching as a settler in a place where Country is not ceded. Consequently, this analysis attempts to scrutinise mechanisms that secure processes of settlement. It asks, how attempts to contain Indigenous lands under settler-state authority for occupation act as both horizon and template; how it comes “to be lived as given” for non-Indigenous considerations of personhood, place, and belonging across time (Rifkin 2014, xvi). These pervasive processes are why Morgensen (2011, 73) calls for a critique that denaturalises settler societies and attends to “their conditioning of liberal modernity along global scales”. I respond by scrutinising how the SOC7 and the Guide function as administrative structures and shape the practices through which power settles populations as part of ongoing colonial projects.
Analysis of the SOC7 and the Guide
Version seven of the SOC is a policy on responding to requests for access to gender-affirming medical technologies. It offers flexible “standards for promoting optimal health care” and guidance on “the treatment of people experiencing gender dysphoria” (Coleman et al. 2012, 2). Recognising that “most of the research and experience in this field” originates from North American and Western European standpoints, the SOC7 considers these adaptable to any setting by “thinking about cultural relativity and cultural competence” (Coleman et al. 2012, 1). It reiterates WPATH’s (2010, 5) De-Psychopathologisation Statement that self-designated gender identities and expressions are not to “be judged as inherently pathological or negative”. Instead, the term “gender dysphoric” appears throughout the text, referring to people who “experience gender dysphoria at such a level that the distress meets criteria for a formal diagnosis that might be classified as a mental disorder” (Coleman et al. 2012, 5, emphasis added). I read the SOC7 as implicitly representing the “problem” to be the distress of gender dysphoria, for which the solution is to guide health professionals in administering “treatment”. Preserving a psychiatric diagnosis effectively naturalises the external verification of a particular kind of distress as the threshold for “care”. The concern is this maintains the role of health professionals and institutions in regulating specific modes of living.
Published amid revisions to the SOC6, DSM-IV, and ICD-10, the Guide explicitly states the “problem” is an illness paradigm. It uses a paradigm of rights to establish an alternative protocol for the Spanish healthcare system focused on a person’s right to access quality gender-affirming medical technologies that are publicly funded and free from psychiatric requirements (STP 2010). It identifies “the scientific model developed in the West” regarding “sexuality, the body and gender … as an imperialistic colonizing mechanism” that invokes notions of progress and “progressive” to elide alternative understandings of gender and negate the extreme violence that many trans people suffer (10). Consequently, the Guide insists that its proposal must be understood within the Spanish context for which it was created and not as an attempt “to establish a new universal model” (16). It wants to see multiple trans depathologisation projects that are “responsive to specific local political, cultural and social environments” (16). Esther (Mayoko) Ortega Arjonilla’s (2014, 41) analysis of the Guide shows how it substitutes a diagnosis and treatment model “for a new one in which every single trans person is responsible for the process, because they are considered experts on their own processes”. The relationship a mental health professional has with a person seeking gender-affirming body modifications changes to one of “professional accompaniment” (Stop Trans Pathologization 2012, 6). This commitment to autonomy exceeds several informed consent models currently in practice (Ashley, St Amand, and Rider 2021). The Guide is unmaking the relations between the “gender dysphoric” and the gatekeeper subjects constituted in the SOC7. It is strategically making an autonomous, self-determining subject and an accompanying subject, placing them on an equal footing, and rendering both governable through rights. Following Arjonilla (2014), I read the Guide as an attempt to democratise both the structures and practices of “care”.
My analysis suggests that problematising distress at an individual level attributes authority to psychiatric knowledges in determining access to “care”. The SOC7 prioritises the judgement of expert health professionals in ways that preserves a hierarchy of subject positions. It also promotes such practices as adaptable for worldwide use. In contrast, problematising “care” at a paradigmatic level, the Guide says it’s insufficient to take on a non-pathologising viewpoint. It uses a human rights paradigm to prioritise a person’s right to access state-funded gender-affirming medical technologies unburdened by psychiatric requirements. It links an underpinning medico-scientific model to a colonising mechanism and troubles assumptions of its universal application. Moreover, it de-subjugates the experiential knowledges of people with self-designated genders by substituting diagnosis and treatment for accompaniment in self-determination. Consequently, the Guide signals a democratisation of both the model (structure) and practices of “care”.
Limitations and possibilities in the depathologisation of trans health
Consistent with current research (Riggs et al. 2019), my analysis of the SOC7 highlights the limitations of a depathologisation that preserves an illness paradigm. While the Guide’s critique signals the potential for disrupting the underpinning colonial structures, this analysis also highlights the limitations of an uncritical use of a rights-based approach as its alternative. These include identifying the scientific model as an imperialistic colonising mechanism without identifying Spain’s contribution as a colonising nation; seeming to sidestep how producing an autonomous, self-determining, rights-bearing “subject” in healthcare aligns with its pervasive neoliberal responsibilisation; and normalising the liberal notions of universal human rights premised upon assumptions of proprietary ownership, bodily integration and citizenship that are central to colonial projects. The purpose of these policies is to facilitate “lasting personal comfort” on the one hand (Coleman et al. 2012, 1), and support a person’s “subjective self-worth” on the other (STP 2010, 20). Yet, the unspoken conclusion of such action is the recognition of people who modify their bodies within existing structures of citizenship that are a basic component of coloniality. These limitations of the depathologisation of trans health can be read as what Mark Rifkin (2014, 3) calls settler common sense, or the ways in which “processes of settlement” are treated “as a given in developing … ethical visions” for the future.
Settler common sense is not the only thing that shapes the futures of trans health. There are crucial community- and theory-driven visions operating on its periphery that carry possibilities for shaping trans depathologisation while challenging settler futurity. For example, Yugambeh writer and scholar Maddee Clark (2017), with O’Sullivan (2021), and their colleague Madi Day (2020) show how rigorous Indigenous theorising, research, and practice articulates different horizons for relations. In theorising curatorship, Clark (2017) describes how Indigenous transgender and transcultural practices shift an exhibition’s scrutiny onto different experiences and matters of concern to facilitate different relations and dialogue for different possibilities. O’Sullivan (2021) also offers a reckoning with complexity in their challenge to the colonially inflected practices of gendering the past in museum spaces. Insisting on the complexities of gender is a position against the reductive representation that “acts as a marker” for Indigenous peoples “continued management within the colonial project, through the colonial structures and restrictions still held in place” (O’Sullivan 2021, 8). In yet another context, Day (2020) situates the recent institutionalisation of Indigenous queer and trans studies at an Australian university within a set of separate-yet-related origins. Day (2020, 372) argues that “while Indigenous queer and trans studies connects to trans studies at intersections”, important legacies “of Aboriginal and Torres Strait Islander engagement with education institutions” torques “our approach to research and our expectations of disciplines” toward Indigenous self-determination and futures. There are humbling lessons for trans depathologisation in this re-shifting of scrutiny, emphasising complexity, and recognising the legacies of strategic engagement with colonial institutions for resistance through transformation.
Conclusion
Considering the increasing conservative mobilisation of an incoherent anti-gender discourse to bolster white supremacy (Vincent, Erikainen, and Pearce 2020), it is vital to analyse how the SOC7 and the Guide function as part of the biopolitics of settler colonialism. With the official release of the SOC8 (Coleman et al. 2022), there appears to be a remarkable, positive transformation in its development and content. There is a direct reference to how a human rights perspective influenced the development of each recommendation statement. Yet, there appears to be little movement away from an illness model for “care” and the hierarchy of subject positions it produces. Consequently, I advocate continued questioning of whether a professional association can say it is depathologising trans health while preserving a foundation of medicalisation. Also, questioning whether redesigning healthcare systems according to an alternative, yet uncritical application of a liberal rights-based model has the potential to abolish the dominant mode of governing or its concomitant coloniality. My analysis of approaches to depathologisation in trans health policy at the level of governing gender and access is made possible by the critical scholars and activists who have gone before me. This examination of how depathologisation functions as part of the administrative structures and practices of colonial projects contributes to ongoing attempts to build a future for trans health in accordance with a broader anti-colonial and abolitionist political vision.
References
Anzaldúa, Gloria, and Cherríe Moraga. 1981. This Bridge Called My Back: Writings by Radical Women of Color. First ed. Watertown, Massachusetts: Persephone Press.
Arjonilla, Esther Ortega. 2014. Reframing Care Practices on Transgender Health: The International Campaign Stop Trans Pathologization. In Yearbook 2014 of the Institute for Advanced Studies on Science, Technology and Society, edited by Arno Bammé, Günter Getzinger and Thomas Berger. Graz, Austria: Profil.
Arvin, Maile, Eve Tuck, and Angie Morrill. 2013. “Decolonizing feminism: Challenging connections between settler colonialism and heteropatriarchy.” Feminist Formations:8-34.
Ashley, F., C. M. St Amand, and G. N. Rider. 2021. “The continuum of informed consent models in transgender health.” Family Practice:1-2. doi: 10.1093/fampra/cmab047.
Bacchi, Carol. 2012. “Introducing the ‘What’s the problem represented to be?’approach.” In Engaging with Carol Bacchi: Strategic interventions and exchanges, edited by Angelique Bletsas and Chris Beasley, 21-24. Adelaide: University of Adelaide Press.
Clark, Maddee. 2017. “Becoming-with and together: Indigenous transgender and transcultural practices.” Artlink 37 (2):76-81.
Coleman, Eli, Walter Bockting, Marsha Botzer, Peggy Cohen-Kettenis, Griet DeCuypere, Jamie Feldman, Lin Fraser, Jamison Green, Gail Knudson, and Walter J Meyer. 2012. “Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7.” International journal of transgenderism 13 (4):165-232.
Coleman, Eli, Asa Radix, Walter P Bouman, G. R. Brown, A. L. C. de Vries, M. B. Deutsch, R. Ettner, et al. “Standards of Care for the Health of Transgender and Gender Diverse People, Version 8.” International Journal of Transgender Health 23, sup 1 (2022): S1-S259.
Day, Madi. 2020. “Indigenist Origins: Institutionalizing Indigenous Queer and Trans Studies in Australia.” TSQ: Transgender Studies Quarterly 7 (3):367-373. doi: 10.1215/23289252-8553006.
Howe, Rebecca, Amy Harper, and Sekneh Hammoud-Beckett. 2019. “Uncovering Games of Truth: A Collaborative Exploration of the Ways Transgender and Non-Binary young People Access Health Care and Support.” In Working Across Difference: Social Work, Social Policy and Social Justice, edited by Donna Baines, Bindi Bennett, Susan Goodwin and Margot Rawsthorne, 137-152. London: Red Globe Press.
Kauanui, J Kēhaulani. 2017. “Indigenous Hawaiian Sexuality and the Politics of Nationalist Decolonization.” In Critically Sovereign: Indigenous Gender, Sexuality, and Feminist Studies, edited by Joanne Barker, 45-68. Duke University Press.
Lugones, Marìa. 2010. “Toward a Decolonial Feminism.” Hypatia 25 (4):742-759. doi: 10.1111/j.1527-2001.2010.01137.x.
Moreton-Robinson, Aileen. 2015. The White Possessive: Property, Power, and Indigenous Sovereignty. Minneapolis, London: University of Minnesota Press.
Morgensen, Scott Lauria. 2011. “The biopolitics of settler colonialism: Right here, right now.” Settler Colonial Studies 1 (1):52-76.
O’Sullivan, Sandy. 2021. “The Colonial Project of Gender (and Everything Else).” Genealogy 5 (3):67. doi: https://doi.org/10.3390/genealogy5030067.
Rifkin, Mark. 2014. Settler Common Sense: Queerness and Everyday Colonialism in the American Renaissance. Minneapolis: University of Minnesota Press.
Smith, Linda Tuhiwai. 2021. Decolonizing Methodologies: Research and Indigenous Peoples. Third ed. London & New York: Zed Books.
Stop Trans Pathologization. 2010. Best Practices Guide To Trans Health Care In The National Health System. Spanish Network for Depathologization of Trans Identities.
Stop Trans Pathologization. 2012. Reflections on the SOC-7. International Stop Trans Pathologization Campaign.
Stryker, Susan. 2014. “Biopolitics.” TSQ: Transgender Studies Quarterly 1 (1-2):38-42.
Vincent, Ben, Sonja Erikainen, and Ruth Pearce. 2020. TERF Wars: Feminism and the fight for transgender futures. London: Sage.
World Professional Association for Transgender Health. 2010. “WPATH De-Psychopathologisation Statement.” Last Modified May 26. https://amo_hub_content.s3.amazonaws.com/Association140/files/de-psychopathologisation%205-26-10%20on%20letterhead.pdf.
World Professional Association for Transgender Health. 2021. “Standards of Care Version 8.” accessed 20 Dec. https://www.wpath.org/soc8.