In Buitenland

Deze toespraak van Dinah Bons is geheel in het Engels, desondanks wilden we hem jullie niet onthouden omdat het zo herkenbaar is en zo goed de gevoelens van zovelen vertolkt.

Yesterday was an important momentum for the Depath work of our trans community and the policy work by TGEU – Transgender Europe, done for years on this topic. We delivered the keynote speech at EPATH 2019 in Rome Italy.

A with delegates packed conference hall listened to the speech of our strategic director Dinah Bons.

Below the transcript of her speech.

EPATH CONFERENCE KEYNOTE SPEECH DEPATHOLOGISATION: OPPORTUNITIES AND CHALLENGES

Honorable guests and participants gathered here in Rome. I am thankful and honoured to speak to you and it is with delight to share a narrative key note.

I would like to start by telling you about my friend. She wanted to start a hormone treatment. She went to her family doctor, but they couldn’t tell her where they had to refer her to. My friend had done her research, as she expected this to happen. She was able to have an appointment with the endocrinologist two months later in which she was asked all sorts of personal questions. The doctor was confused. My friend wasn’t as feminine as he expected. She wasn’t wearing a purse, but a backpack. She didn’t wear make up and had short hair.

She had to attend sessions with a psychologist for 8 months before she could start hormones. It wasn’t an easy process for her. She had to face questions related to her personal life, her childhood, her sexuality, her body, her gender expression, that made her feel scared, powerless, frustrated and humiliated, but she had to carry on if she wanted to have access to the treatment. She is a lesbian, but she said she liked men to make sure she fit the category the psychologist wanted her to be in. She put make-up on in the hospital’s bathroom before entering her sessions. When she didn’t meet femininity standards, she received negative feedback and was suggested that she might not be “really trans”.

She also took psychological tests to prove that she didn’t have any psychological disorder that could “explain why she felt this way”, as if her transness could be a side effect and then she could not be “truly trans”. She is my friend, but she could also be many other people I know. She could be almost any trans person seeking healthcare in almost any European country.

And why do we have to face this kind of situations? Well, because the trans people in western societies have been subjected to pathologisation for decades. It was the medical field that started conceptualizing trans people’s identities and experiences. Being trans was understood from a biomedical perspective and interpreted as a disorder.

However, this only reflected society’s views on trans people and reinforced them. Society and medical professionals only start to see now that this has always been wrong.  The pathologisation of trans people – considering our identities mental disorders – has and continues to influence every aspect of trans people’s lives. Today, this perspective still keeps us from having access to fundamental rights such as accessing healthcare on equal terms as the rest of the population or having our name and gender legally recognized just to name a few. In most countries our rights are still dependent on a psychiatric diagnosis, that is and can only be, based on stereotypical ideas of gender and sexuality. And therefore takes away the right to identity, self-determination and autonomy from trans people and subjects our lives and rights to the will of others; mental health professionals.

It is up to someone else to say if we are truly trans, if we are really the gender identity we claim to be, based on if we are masculine or feminine enough according to society’s ideas. It is also up to someone else to decide if we can access the care we need. This perspective excludes those of us who do not have binary identities or who do not conform to society’s gender roles, and puts a burden on all of us trans people.

Pathologisation is violent in itself and it also reinforces social transphobia by sending the message that we are mentally ill for being trans and that we as trans people are the problem. Sentences like “trans people are born in the wrong body”, “being born one gender and wanting to be another gender” or using the terms dysphoria or incongruence only perpetuate the idea that there is something inherently wrong with us.

However, the main problem we have is transphobia. The constant discrimination that we suffer ultimately impacts our lives, safety and wellbeing. This is even more severe for those of us who belong to groups that face more discrimination and experience greater vulnerability. Prejudice towards disabled people may exclude them from accessing trans specific healthcare. People with a mental health diagnosis may automatically be rejected, despite good results when attending to their individual needs.

Lack of accessibility may make it impossible for migrants, asylum seekers or refugees to approach healthcare and if they do, they may feel forced to accept anything offered by the providers. Sex workers and persons of colour may face more discrimination by healthcare professionals.

This is the reason why depathologisation has been, for many years now, one of the main goals for the trans movement. In order to reach it, we have been working so that the main institutions would remove trans identities from their diagnostic manuals or from the mental health disorders chapters.

The American Psychiatric Association in the latest edition of their Diagnostic and Statistical Manual of mental disorders still includes the diagnosis of Gender Dysphoria in relation to trans people.

However, the World Health Organisation finally removed trans identities from the mental health disorders chapter in its latest edition of the International Classification of Diseases and included them in a new chapter called “Conditions related to Sexual Health”. Let’s not forget that this change includes a diagnosis for children, Gender Incongruence in Childhood, contributing to their pathologisation when no medical treatment is needed.

We urge you to join our fight for this category to be removed as soon as possible. Nevertheless, this long-awaited change lays the foundation for a new era in which the rights and lives of trans people are valued and respected, and trans people are seen as what they really are, part of human diversity. This will ultimately assist trans people in exercising their right to self-determination at all levels.

We will be able to have our legal gender recognized without any kind of medical requirement. We will have free access to healthcare without our identities being put into question or anyone acting as gatekeepers. At school and at our jobs our name and gender will be respected without questions or medical reports. When we see trans people in the media, their stories won’t always be about how we feel about our bodies, how terrible it is to be trans and how we desperately need to physically transition. Finally, our voices and identities will just be enough.

Unfortunately, at the moment we can only dream about such a society. There is much work to be done from here to ensure that trans and gender diverse people are able to live in total fulfilment of their human rights. In that sense, more and more laws regarding the rights of trans people that are compliant with human rights are developed; they are solely based on self-determination of gender and prohibit the requirements of mental health examinations and trans-related diagnoses. Only thirteen European states still require sterilisation, while in 2013 a whooping twenty-four did. This is thanks to the tireless efforts of trans activists and allies fighting for our human rights.

In the field of health, Argentina and some Spanish regions like the Community of Madrid, the Valencian Community give hope with laws paving the way for trans-specific healthcare protocols that are based on the model of informed consent. Here, psychological or psychiatric care is only given upon the trans person’s request, so following the same process as any other healthcare patient. European institutions become increasingly aware of the violations of human rights of trans people in healthcare settings and support the rights of trans people.

The Parliamentary Assembly of the Council of Europe adopted a resolution in 2015 calling upon member states to make trans-specific healthcare accessible and ensure that trans people (including children) are not labelled as mentally ill in national or international classifications among. Since 2016, the European Commission has committed to actively follow the work of the World Health Organisation on trans depathologisation, to support Member States in the development of legislation and to gather data about inequalities faced in healthcare settings.

The implementation of the ICD-11 will be a great opportunity to continue the work on depathologisation, self-determination and informed consent at local and state level. And in order to do so, we need everyone’s commitment. We invite you to be part of this great wave of change.

Social awareness on these issues is also growing as the trans community and its demands become more visible. These last years we have been able to see how society’s perception of trans people has become more and more positive and we hear good experiences of trans people in different spheres of their lives; with their families, their work environment, accessing healthcare, etc. However, as we are advancing in terms of social equality and recognition of rights, we are also observing the rise of a hatred movement, that among others, directly targets trans people. This very organized backlash brings together influential actors from different institutions (associations, political parties, religious groups spanning from Catholic to Orthodox faith. This organised backlash reinforces the still present social resistance towards change and equality. This movement represents a real threat for many people, including the trans community. We are at risk of being pushed back in time.

Not only trans people risk losing the few rights we fought for, but there is an inherent greater danger of suffering from discrimination and violence and eroding democratic principles and values of diversity.

We will have to continue standing up against this threat.

As you can see, huge steps are being taken towards the complete depathologisation of trans people, but there is also a lot to be done to ensure it in practice while also facing a strong countermovement. That is why we must work together towards this common goal. We need you in this. Healthcare professionals can be key in the development of non-pathologizing healthcare for trans people.

Spaces like the one we are sharing here today at the conference are a great opportunity to create networks, share knowledge and good practice examples with the wellbeing of trans people as the aim of our work. We believe in the strength of collective power and commitment. In order to improve the wellbeing of trans people there are still quite a few areas that need improvement and that we have to make sure to continue working on. We still find a lack of training and awareness of trans issues in the healthcare field in general terms. Our health survey from 2017 found that 60% of the providers that had received training on trans issues, did so on their own initiative and on a voluntary basis. The majority of the healthcare providers wants to be trained. Specialised providers and trans organisation are the top choices as trainers.

On the other hand, 92% of the trans respondents thought that training providers would improve access trans specific healthcare. This situation needs to change for a strong move forward towards a future of good practices in relation to trans people. There is a pressing need for the inclusion of gender diversity content in the education of future professionals.

We are inviting development of legislation that puts trans people and their right to self-determination in the centre of educational curriculum and will promote trainings for current practitioners. On the other hand, the implementation of the ICD-11 will constitute a turning point in the history of trans-specific healthcare and will provide a base and support for the changes ahead. We need to make sure we work together towards the adoption of non-pathologizing legislation and protocols.

In that sense, we will soon release TGEU’s guidelines on “Human Rights on Trans-Specific Healthcare” and work together with regional, state and local institutions, organisations and professional associations to promote the development of protocols based on informed consent and self-determination and their further implementation and monitoring. These protocols must be compliant with human rights principles. As an example, they must respect the principle of bodily integrity and autonomy and that of informed consent. This will allow trans people to be in control of their bodies, by being provided with the information they need and making a decision on when and how to receive healthcare.

By also respecting the principles of self-determination of gender, non-discrimination, quality care, specialized care and proximity, trans people will stop being questioned about their identities and validated or not by providers, but rather they will just receive physical or mental health care that responds to their needs. They should also receive the highest quality, that means having trained and respectful professionals, healthcare processes being transparent and effective, free of discrimination and accessible in proximity.

We believe many professionals are committed to this goal and that together with the trans community, we will be able to raise awareness in healthcare settings, promote the creation and implementation of protocols that are based on informed consent and self-determination and foster the inclusion of gender diversity content in the education of future professionals.

In order to do that, healthcare providers must critically reflect their role. We need health care providers to commit to a self-determination approach to their work, constantly strive on how they can improve their work and what they can do to bring up the topic in their context and raise awareness, while always making sure they are in contact with the trans community and take into account their demands.

I want to make note of trans-led grassroots health services providers, in the UK and in the Netherlands, that mark an important development. In the Netherlands, where I  and dr. van Diemen initiated a Trans-led genderclinic with the help of the Amsterdam Municipality, I witnessed incredibly inspiring dynamics of empowerment, trust, respect and dignity between transgender healthcare providers and their patients and chain partners in the medical field. Patients isn’t the right word, cause what I witnessed was far from the painful, stigmatising and humiliating pathologizing and medicalised interactions like the one I described early.

My friend, that I told you earlier about, is one of our most enthusiastic volunteers, determined to prevent anyone else from going through what she did.

It is important that we all commit to the nurturing and support of trans-led initiatives. It is important that we learn from them as well! By doing so, we will be together – contributing to the improvement of trans people’s healthcare and wellbeing and creating a more just and inclusive society for all.

(met dank aan Frederique).