A diagnosis of Trans

Why should a trans person go to the doctor?

Last century, there was the concept of “Gender Identity Disorder”. The idea was that a man who thought he was a woman, or a girl who thought she was a boy, had a mental illness, a delusion, that should be cured if possible. So children who “desisted” were counted as cured, and some children were referred to psychiatrists merely for non-stereotypical gendered behaviour. That’s why there is old research claiming huge desistance rates, which transphobes still trot out to oppose treatment of actual trans children.

Or, there was “transsexualism”, a syndrome where people believed they were of the other sex, and the treatment was transition, hormones and surgery, to help them express themselves as well as possible in the other sex. In DSM V, the diagnosis is “gender dysphoria”. The idea is that being trans is not a disease, and needs no cure, but the distress arising from it is.

From the 1930s, some doctors were prescribing hormones and performing surgery, but in Ancient Rome trans women, the priestesses of Cybele, might drink the urine of pregnant mares to get the oestrogen they needed. They did not know what a hormone was, but they knew what it did.

This is the ICD 11 definition of “Gender incongruence”, classified as a “condition related to sexual health”: Gender incongruence is characterised by a marked and persistent incongruence between an individual’s experienced gender and the assigned sex. Gender variant behaviour and preferences alone are not a basis for assigning the diagnoses in this group.

That is, you need a diagnosis if you want hormones or surgery. A doctor, probably a gender specialist, decides that the incongruence between your gender and assigned sex is such as to justify treatment.

It does not say that anyone who does not want treatment is thereby not trans. Trans is just part of ordinary human diversity. You can transition to live in your true gender, without ever taking hormones or having surgery.

There is no reason for trans people to be medicalised. Sometimes the cis ask us if we’ve had surgery, as if they would grudgingly tolerate a trans person who has, because they were in some way “really trans”. But that’s their stuff, not ours.

And some trans people want hormones and surgery. Dora Richter attempted to remove her penis with a tourniquet when she was six. That is a deep, psychological need. They have gender incongruence, and that will remain a medical condition, though not a psychological one.

The British Government wants doctors, in fact gender specialist psychiatrists, still involved in gender recognition in England and Wales, even though “gender dysphoria” is outdated. But what diagnosis? If the specified diagnosis is “gender incongruence”, that means that you can’t get gender recognition unless you desire surgery. That would be worse than now.

They suggested the doctor assess psychological readiness or “fitness to proceed”. Dr Michael Brady, the LGBT medical adviser, rejected that. How can doctors assess it? Transitioning is stressful and difficult. The prejudice you face is terrible. They don’t know what will happen.

So, because the government want doctors still to be involved, we end up with a diagnosis of gender dysphoria. In the DSM V, that diagnosis makes some sense. Psychiatrists want to argue that they should be able to claim money from medical insurance for helping people with distress. In gender recognition, it makes no sense at all. Someone might be so delighted with their imminent transition that they feel no distress. On a two year waiting list, someone might have transitioned already, and the doctor is reduced to writing, “they tell me they used to be distressed, presenting in the assigned gender”. Again, it’s medicalising trans people, who only need doctors if they need hormones or surgery.

What of the JR111 judgment? It says that it is not against our human rights to require a medical diagnosis, but it is against them to use the word “disorder”, which is in the Gender Recognition Act. The judge can make an order that the Act is to be interpreted in a particular way, or declare it incompatible with human rights- which puts a moral but not legal obligation on the government to amend it.

The government wanted doctors involved to avoid applications variously described as vexatious, unmeritorious, frivolous or unadvised. The first three seem to be from cis people mocking the system. Perhaps Graham Linehan would try it. The British public has enough common sense to deal with Graham Linehan. He would gain nothing, and if there’s a requirement for a statutory declaration he might face a charge of perjury.

The fourth, unadvised, is particularly obnoxious. A doctor would have to decide that, though we were trans, we just could not cope with the stress of transition. People transition on a wing and a prayer, because we have to. No-one knows it will be successful.

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