The slight limit between helping and pathologizing trans identities

Mariana Winocur

Mariana Winocur

Communications Officer at ARC International
Mariana Winocur is a communicator consultant and a journalist. She has been working as a senior specialist in the design and implementation of communications strategies with a gender and a human rights perspective. Mariana has served several women’s rights organizations as communications coordinator and consultant. She also publishes stories, articles, and reports in the media.
Mariana Winocur

What does depathologizing trans identities mean?  Why is the discourse about body “normalization” of people born intersex still prevalent?

From November the 2nd to the 6th, LGBTI activists, physicians, and many others who work to improve trans people’s health met in Buenos Aires, Argentina, to attend the 25th Symposium of the World Professional Association for Transgender Health (WPATH). As stated in the invitation, this Symposium was “dedicated to training professionals in the field, and to the dissemination of scientific research and sharing of clinical practice expertise. To network and set up new collaborations.” It was also a space to give the “State-of-the-art reviews in key areas, such as mental health, endocrinology, surgery and law.”

The WPATH2018 was meant to be a space to share the latest on trans health. And it probably was. Nevertheless, there was a tension between a medical approach and an approach based on human rights, and the medical approach seemed to be the predominant one. Many trans activists noted this imbalance with panels on medical advances being prioritized over panels on different kinds of violence experienced by trans and intersex people on a daily basis.

A program overview showed what the main orientation of the Symposium was: a strong focus on gender affirming therapies, and a lesser focus on what trans activists are doing to change socio-political context with the objective of enlarging social and legal acceptance of their identities. There were more sessions working on medical approaches rather than discussing trans people’s experiences and needs within hostile contexts.

I saw quite a division between what doctors do to help trans people regarding their gender identities, and what those people experience because of not being cis-gendered, non-binary, or having sexual characteristics that don’t fit the medical norms for female or male bodies. Stories about discrimination, pathologization, normalization, and compulsory surgeries were quite frequent throughout many activists’ sessions. During WPATH2018 these activists spoke their own experiences. Nevertheless, not many doctors attended those sessions where these issues were addressed. In fact, some activists stressed the absence of physicians during their panels.

Some sessions to highlight

A remarkable moment was that WPATH2018 gave the opportunity to present the Yogyakarta Principles Plus 10 (YP+10) in Argentina for the first time. A panel made up of four of the experts who developed this set of new principles, focused especially on how the new Principles have introduced intersex issues. The ones highlighted were Principle 32, which especially refers to bodily and mental integrity, and Principle 37, that guarantees the right to the truth (and is a way to recover the harm done to intersex people, among others). Their content resonated with many of the attendees, who shared their own experiences with the audience.

Despite a lot of advances, there are still many things to do in order to respect intersex people’s human rights. Mauro Cabral (GATE) pointed out the lack of hospitality or welcome that intersex people face not only when they are born, but also during pregnancies (prenatal surgeries). The hospitality frame to think of intersex people is not only interesting, but also revealing in terms of them “coming to this world”. When intersex people are born, they are confronted every time and everywhere with a lack of hospitality. That hospitality has to do with being recognized as a human being and having their bodily autonomy respected. Cabral was very clear about not mixing up gender identity issues with being intersex. Even more: he made clear that gender identity laws do not protect intersex people. He also talked about some of the typical forms of action or policy where gender identity is presented as the key way to protect the rights of intersex people, when in fact it doesn’t help intersex people in their way to legal recognition.

“Procrastination form” refers to the actions taken when an intersex baby is born and we hear things such as “this is not my problem”, and that person will find out a way to get their gender identity recognized. Some of those babies don’t even have birth certificates. The “conditional form” is related to the reality that often for an intersex person to have their birth certificate, a surgery must be performed. The “instrumental form” is where trans people claim to have intersex sex characteristics as the best form for a trans person -who is not intersex at all- to get access to legal recognition.

“Trans can be presented as a form of intersexuality then it should be used, as intersex exist in this world to provide an instrument to access gender recognition”. Some trans people become a “type” of intersex as an instrument to achieve legal gender recognition, or to explain their trans identities. As an example of equating being trans with being intersex, some can consider that the sex is in the brain, hence there are cases of people claiming their brain sex is different from their body one, therefore accessing gender affirming surgeries. Another variation of instrumental form is to use intersex people to advance gender recognition of non-binary people.

“All over the world there are legislators or policy makers addressing one or more of these forms of policy or action to avoid paying attention to the real concerns affecting intersex people”, said Cabral. All these forms of considering intersex as a matter of gender identity are not only considering intersex people as if they were trans, but also are taking attention away from the consequences of normalizing interventions and the legal status of those interventions. There is still a lot to be done in terms of legal recognition, right to choose or right to compensation when taking into consideration laws and practices that affect intersex people.

Jack Byrne (human rights researcher) noticed that the pathologization/medical diagnosis that trans people face is one of the root causes behind human rights violations of LGBT persons: Imposing physical examinations as a requirement for accessing human rights; using clinical criteria as a basis for drafting gender recognition laws; relying on the availability and discretion of a consultant psychiatrist to authorize a gender recognition certificates. Separating out medical from legal processes is key to understand that gender identity and expression is not a matter of illness. As Aisha Mughal (WAJOOD) stated, it is important to have the possibility to self-identification without medical intervention, and with no State or police interventions.

Lawyer and signatory of YP+10, Eleonora Lamm, delivered an engaging presentation on “Gender identity and reproductive autonomy. Deconstructing sex, gender and roles”, during which she showed the many possibilities reproductive technology can offer in terms of parenting roles. Quite a good number or combinations of roles and provisions of eggs and sperm, donation and subrogation between cis and trans men and women, as well as within homosexual or heterosexual couples, led to the certain conclusion that the strict concept that the provider of an egg is the mother, and the provider of the sperm is the father, has definitely been challenged and no longer shows the diversity of parental identities. In fact, these possibilities of new and diverse kind of families and parental roles is very good news!

In terms of the right to found a family, Lamm highlighted that “transgender reproduction is still invisible. The family has been found on a cis conception”. Therefore, the fight for every person, regardless of their identification, is about accessing assisted reproductive technology (ART). Profiting from ART possibilities for people with diverse identities, and if neither the sex, nor the biological or the genetic contribution in terms of the definition of the role matter towards parenting, what defines a parental role?  This is a big question still to be answered.

It is also worth noting the mini-symposia “Trans refugees: escape to invisibility” co-presented by Zhan Chiam (ILGA World) and Cianán Russell (TGEU), during which three trans refugees shared their experiences with few attendees. The refugee testimonies were really poignant. The struggles they face daily are a reminder to decision makers to act immediately to put a halt to their difficulties. All of them made visible several kinds of violence they face regarding their situations of both being trans and refugees. The problems include their documents not being legally changed, thus their names don’t match their appearances; they are often rejected from many spaces because they are not believable by decision makers; and cannot apply for jobs due to their legal identities. They experience isolation, don’t speak local languages, deal with problems when accessing any kind of services, and face lots of prejudices by health providers. Therefore, they have to deal with difficulties to be selected to get hormones, or be rejected.

Final words

After hearing so many stories of people who fight for their gender identities and bodily integrity to be recognized and respected, I cannot help but claim that it would be a great achievement if doctors and activists worked closer to end pathologization and help push boundaries towards guaranteeing the right to self-defined gender identity, the right to freedom of expression, and the right to bodily and mental integrity. All these rights are addressed by Yogyakarta Principles and YP+10. Even more: some activists encouraged WPATH to endorse the YP.

Meanwhile, discrimination, mandatory surgeries or hormone treatments as requirements for the legal recognition of gender identities are still the many obstacles in the way for a true depathologization of trans identities.

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