The Conscience Chronicles

UPDATE: As this was being readied for posting, the Standing Committee on Private Bills and Private Members’ Public Bills voted to recommend that Bill 207 not move forward in its current form, meaning that the bill will not be proceeding to the floor. I have elected to post this anyway, given the possibility that the proposal might be resurrected and amended at a later date.

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At a first casual glance, the stated premise of Alberta’s Bill 207, Conscience Rights (Health Care Providers) Protection Act, might sound reasonable: most people wouldn’t expect medical professionals who object to procedures like abortion to be required to perform them.

In practice, Alberta’s College of Physicians and Surgeons already allows medical professionals to opt out of medical procedures that they have a religious objection to (a status quo that is at times problematic), so long as they provide any referral or direction to comprehensive information needed, ensuring that their patient still receives care in a timely manner. Bill 207 removes the obligation to refer and / or ensure patient care — using the reasoning that providing a referral is sort of like participating in the procedure. Regardless of any urgency or medical appropriateness of care in any given situation, this change allows refusals to increase the time delay to accessing care (regardless of any urgency), put the burden of medical care back on the patient, and be a kind of barrier and discouragement, if not more. Indeed, it can be like making someone start over from scratch. Proponents of the bill say that because medical care is still available elsewhere, it isn’t really being denied, which is technically true… but the time, emotional and informational barriers cannot be discounted.

But while those advancing the bill claim it is only codifying that status quo in law, there are more things that Bill 207 does, many of which have received little attention by media.

The bill extends conscience rights to health care organizations, as well. While religious care organizations have already asserted conscience objections in many ways already, this codifies it in law. It also allows organizations to assert their conscience-based decisions over those of their facilities, staff and resources. By way of example, Covenant Health (Canada’s largest Catholic health care provider) owns 16 health care facilities throughout the province, including two major hospitals in Edmonton; its affiliate Covenant Care owns another seven assisted living and long-term care facilities. In some rural areas of Alberta, all or most facilities are religious-owned.

In short, this moves Alberta down a landscape in which anyone in the chain of service provision — from facility administration to lab technician and pharmacist — can create a roadblock to services, without consequence. This becomes even more concerning when one realizes the potential for administrative staff, clergy or even outside groups to apply pressure to doctors and clinics to deny services that they might not otherwise have initially had objections to.

In fact, by the text of the law, it is left entirely up to the health care provider or religious health care organization to determine if their conscientious beliefs would be infringed, and there really is no appeal process to see if there is some agreeable compromise. No record is kept, leaving no way to follow up to ascertain if the patient has ever received the care they needed or sought. Gathering statistics about patients denied care in order to inspect what consequences the law has had becomes impossible, as demonstrated elsewhere.

By the text of the law, if a regulatory body receives a complaint about denial of care having to do with conscience, the complaint must be discarded (there is a caveat that complaints or portions thereof that are not conscience-related are not discarded). They are not allowed to investigate or question the decision:

5(1)  On receiving a complaint in accordance with section 55(1) of the Health Professions Act, the subject matter of which is a health care provider’s decision not to provide a health care service based on their conscientious beliefs, the complaints director for the regulatory body that received the complaint must immediately

(a) dismiss the complaint, and

(b) provide notice of the dismissal to the complainant.

It also specifies that by law, “a health care provider’s decision to not provide a health care service based on their conscientious beliefs is not to be considered as unprofessional conduct,” and providers and / or organizations are immediately shielded from legal liability.

There is also an amendment to Section 7(1) of the Alberta Human Rights Act, to immediately shield any employee from termination or discrimination based on their conscientious beliefs. This amendment is not restricted in any way to the medical profession, and could conceivably provide a shield for harassment and abuse of one’s co-workers or customers because of one’s religious or conscientious beliefs.

The bill’s proponent, MLA Dan Williams, has promised a number of amendments to Bill 207, but in those proposed changes, none of these points is substantively changed. One of his proposals — to restore a duty to assist “if not providing the health care service would result in an imminent risk of death” — isn’t altogether reassuring about the thought that was put into the bill in the first place… but even with that change, there is no clarification on whether or how the legal shield and barriers to reporting and investigation might be changed in the event of a patient’s death (especially in cases in which it was not thought that there would be an “imminent risk”).

There are many hypothetical situations that one can suggest could arise as a result of this legislation. But this is not uncharted territory. It is very easy to look at places where “conscience” exemptions have been implemented or attempted — or where medical personnel or organizations have attempted to assert their conscience rights — and see how it has affected medical care for patients.

“I was nervous and excited about the consult for my first intrauterine device (IUD) at MedStar Georgetown University Hospital. After a brief conversation, Dr. Case (a pseudonym) asked me to get off the exam table and follow her to her office for a ‘chat.’ But in her office, when the door was safely shut, my excitement slowly started to fade. ‘Well, first things first, this is a Catholic hospital,’ she said in a mock whisper…”

Evann Normandin, writing at Rewire this past May, described what happened to her when hospital policy prevented her from getting an IUD. She left with a referral… and shaming. Although referrals don’t come with the added expense of multiple visits in Alberta, like south of the border, the expense of time and transportation remain, and can pale in comparison to the emotional cost of the refusal itself:

“… On my way out of the labyrinthian building, I scrunched up the unofficial paper in my hand. The ripped edges felt sharp against my skin. In the Uber ride home, after paying transportation to and from my apartment to a world-class hospital and forking over a $50 copay for unsolicited advice about my vagina, I cried…”

At Huffington Post, Ace Ratcliff described her fight with doctors over her need for a hysterectomy:

“My illness’ severity [hypermobile Ehlers-Danlos syndrome] led me to the conclusion early on that childbirth would irreparably damage my already broken body and would never be the right choice for me. My joints dislocate painfully and at random. I have difficulty swallowing food. I bruise like an overripe peach. I faint if I have to stand for too long. Wounds take much longer to heal on me than on a normal human.

“… Somehow, my personal autonomy, my health and my comfort didn’t rate high enough to outrank the desires of my future, then-nonexistent partner. And nothing I said could change my doctors’ minds [about a surgical hysterectomy], not the stories about my frequently dislocating hips, my mom’s complicated pregnancies or the increased rate of miscarriage and preterm labor for EDS patients…”

In another instance, the hospital’s policies would have allowed the removal of a dislodged IUD, but the doctor thought the policies wouldn’t, and refused care. The patient was sent home, limited in her options by her insurance company (not applicable in Alberta, but limits on options can occur because of other factors, such as rural accessibility), and she ultimately had to file suit:

“Her doctor confirmed the IUD was dislodged and had to be removed. But the doctor said she would be unable to remove the IUD, citing Catholic restrictions followed by Mercy Hospital and Medical Center and providers within its system.

“… It felt heartbreaking,” Jones told Rewire. “It felt like they were telling me that I had done something wrong, that I had made a mistake and therefore they were not going to help me; that they stigmatized me, saying that I was doing something wrong, when I’m not doing anything wrong. I’m doing something that’s well within my legal rights…”

Something that Bill 207 does not address at all is any duty of physicians to discuss every option available to a patient. If referring is equated to participating in an objected-to procedure or medication, then one might tacitly assume that providing comprehensive information on that procedure or medication can be denied. Withholding medical information can have serious consequences:

“… a woman was traveling across the Midwest when she developed abdominal pain. She and her husband went to the nearest hospital, where she was diagnosed with a potentially fatal ectopic pregnancy. The doctors recommended immediate surgery to remove the fallopian tube containing the misplaced embryo, a procedure that would reduce by half her future chances of conceiving a child. They failed to mention that a simple injection of Methotrexate could solve the problem, leaving her fertility intact. (In fact, at a secular hospital she found on her smart phone, it subsequently did.) Why the omission? The Catholic hospital where she got diagnosed was subject to the “Ethical and Religious Directives” of the Catholic bishops, which state, “In case of extrauterine pregnancy, no intervention is morally licit which constitutes a direct abortion…'”

In fact, denial of comprehensive information is a recurring issue when medical conscience exemptions are asserted.

Of course, some of these examples focus on the emotional impact, but that doesn’t mean that there aren’t serious physical consequences potentially at stake:

“After about 10 hours, the patient’s temperature soared to 102 or 103 degrees, Ralph recalled in an interview with Rewire in June, a few months after the incident. Ralph and her team gave the patient medication to induce labor. But Ralph could not administer mifepristone, which the American College of Obstetricians and Gynecologists (ACOG) considers part of the most effective drug regimen for such cases. The Catholic hospital didn’t carry the drug, which is commonly used for medication abortions—a failure Ralph believes was religiously motivated and needlessly prolonged her patient’s labor.

“… For more than 24 hours, the patient labored through painful contractions. She bled heavily, requiring at least one blood transfusion. Her lips and face lost their color. Finally, she delivered a fetus that had no hope of survival…”

The full extent of Bill 207’s reach isn’t understood either, until you realize that “medical provider” covers a wide range, as noted in an Edmonton Journal editorial:

“The list is long and includes emergency, primary and critical care paramedics; midwives, chiropractors, podiatrists, psychologists and psychiatrists; lab, respiratory, ultrasound and X-ray technologists; pharmacists, physiotherapists and physical therapists; opticians and optometrists; dieticians and nutritionists; anesthesiologists, surgeons, and social workers; audiologists, dental professionals and speech-language pathologists…”

The inclusion of pharmacists in that list raises the question about access to birth control, an issue that has already surfaced in Alberta and elsewhere in Canada:

“Joan Chand’oiseau of Calgary recently posted a photo on Facebook of a sign on her physician’s office door that read, ‘Please be informed that the physician on duty today will not prescribe the birth control pill…’”

It also raises questions about access to hormone therapy for trans patients, or the possibility of throwing in a bit of public humiliation for good measure:

“‘Sir, we canceled your prescription because we couldn’t figure out why a man would need female hormones,’ said the voice. ‘You’ll have to have your doctor call us to confirm this is correct because it doesn’t make any sense…'”

Indeed, trans health is just as likely to be impacted as reproductive health, and doesn’t even have to be about transition-related medical concerns. Trans people regularly report what they’ve nicknamed ‘Trans Broken Arm Syndrome‘ — that is, the refusal of care for basic health services just because they’re trans. And it does indeed happen in Canada:

“According to the College of Physicians and Surgeons of Saskatchewan’s charge of unprofessional conduct and the penalty presentation, the incident took place on Jan. 5, 2016, when Anderson saw a patient for “reasons related to bronchitis” — something completely unrelated to the patient’s transition to male from female.”According to the documents, the disciplinary hearing committee found it ‘probable’ that Anderson ‘launched into an unsolicited running commentary’ regarding transitioning. Anderson made statements ‘which were insensitive and unrelated to the reasons for which the patient requested your medical services,’ according to the charges against Anderson…”

It should also be asked what conscience protections might do to protect the still-persistent practices of reparative therapy in Alberta (albeit with coded language). But that aside, denial of basic care is something that all LGBTQ+ people have had to worry about, sometimes even with lethal effect in situations that didn’t initially seem to pose an “imminent risk”:

“Refusing to treat patients can be be deadly, as was the case in 1995, when Tyra Hunter, a transgender woman, lost her life after emergency medical technicians refused to assist her at the scene of a car accident. According to the Center for American Progress, had Hunter received care, her chances of surviving were 86 percent — she should have lived…”

Medical assistance in dying is another area in which medical access is an issue, and in this instance, access is even more seriously limited. It is estimated that the aforementioned Covenant Health (and affiliates) oversee up to 90% of the long-term care beds in parts of Alberta, and regardless of whether long-term care patients are healthy enough to be moved, doing so is sometimes necessary just have questions answered, because of facility policies:

“Covenant Health stated in May of 2016 that it has an ‘ethical and moral opposition to medical assistance in dying’ and that the organization’s ‘unequivocal position to not provide or explicitly refer’ must be recognized. Functionally, this means that any assessment of capacity, any answering of technical questions, and the act of assistance in dying itself would require a transfer away from a Covenant facility.

“… The case of Ian Shearer, an 84-year-old Calgary man living in Vancouver with palliative heart and kidney disease and severe chronic pain, brought attention to how transfers can do harm. Shearer was denied a request for medical assistance in dying from St. Paul’s Hospital, a Catholic facility near where he lived and where he’d been admitted for care. On the day he chose to die, his ambulance was delayed three hours and his medications were withheld to allow him to confirm consent. The ordeal, last August, was described by his daughter as ‘unnecessary… excruciating suffering…'”

Obviously, the out-of-province and out-of-country examples won’t exactly mirror what would happen in Alberta, because of circumstantial differences in things like medical coverage, but what this demonstrates is the extent to which individuals might be willing to abuse a conscience protection, and the twists of logic involved. From the firing of doctors for not adhering to an organization’s conscience policies, to the chilling effect on medical care caused by activism from anti-abortion groups against clinics just for hiring doctors who’ve performed abortions elsewhere in the past, to medical residents who openly vowed to give the wrong medications to specific groups of people, to some some truly backwards beliefs about medical interventions…

“Throughout the conference’s diverse and highly academic presentations, one discernible theme emerged, namely, that “brain death” has been invented to harvest viable organs from still-living people. Only when a person’s heart stops beating and their breathing ceases for a determinate amount of time can it be said that death has truly occurred…”

… the politics surrounding medical conscience exemptions raises a broad range of concerns.

It is likely that Alberta’s Bill 207 would not survive a legal challenge. Indeed, the same day that the bill was introduced in the Alberta Legislature, a similar policy was overturned in the U.S. Likewise, a ruling in Ontario last May affirmed patients’ rights to referrals when care is denied.

But getting there could be another long, legally costly process, with very real human collateral damage caused along the way.

Photo: Adobe Stock

(crossposted to rabble.ca)

Canada’s forthcoming “drop your pants” trans* blood donation policy

In addition to reducing the required wait time between having sex and donating blood to one year for gay men, Canadian Blood Services is poised to release its first-ever guidance on how CBS personnel should respond to potential trans* donors: if it’s in you to give, then drop your pants.  While the policy has not yet been released officially, it was leaked to Buzzfeed, and is being corroborated by the health organization’s representatives on Twitter.

Oh, you don’t have to literally drop your pants. Canadian Blood Services doesn’t actually want to see your junk — they just want to know what’s there. Because that’s not invasive at all.

That is, I assume that no one is checking your junk. But it depends on whether voluntary information is sought by CBS, or some other proof. Identification doesn’t help verify genital status, because most provinces allow ID changes prior to surgery.  Requiring surgery proved to be discriminatory, prohibitive and created significant hardships for lengthy stretches of trans* peoples’ lives, if not indefinitely. [There is an interesting historical fact about that: surgery-based ID policies followed a precedent set by Sweden, where lawmakers in the early 1970s deliberately chose that benchmark, because it would ensure that sterilization occurred.]

The reasoning to the new CBS policy is that if your partner is male and you’re a pre- or non-operative trans* woman, post-operative trans* man, or a not-medically-inclined-at-all gender diverse person who has a penis, then CBS considers you to be a man who has sex with men (MSM). Besides seeming very reminiscent of ultra-conservative judgments about what constitutes a “real” woman or man, it also makes presumptions about one’s partners — i.e. insisting that a straight male who dates a trans* women is actually gay — and other judgments that are potentially shaming in nature.

It does raise some questions, though. For example, why would it take a year following genital surgery to become safe enough for trans* women with male partners to donate blood (by contrast, genital surgery would be immediately disqualifying for trans* men with male partners)? And if a potential trans* donor has slept with trans* partners, does the surgical status of everyone need to be disclosed?

The change follows a similar policy enacted for gay men in the U.S. last year, although that policy honoured trans* peoples’ own self-identification and considered their self-disclosed sexual history, rather than demanding intimate medical information.

Incredibly enough, this is actually an improvement over the previous situation with Canadian Blood Services, in which the ability to donate blood was mostly dependent on the subjective decision of clinic staff, and often saw trans* people of either and / or neither gender automatically classified as “MSM” — and sometimes, the sex of their partner(s) or whether they’d been sexually active at all were considered altogether irrelevant details.

Probably nothing better illustrates just how arbitrary and regressive abstinence-before-donating policies and adherence to narrow-sighted MSM classification are.  The change is also very poorly-timed, following the shocking massacre at Pulse Nightclub in Orlando, Florida, which saw the community hardest hit by the violence — predominantly Latinx LGBT people — unable to donate blood to help their loved ones and siblings-in-spirit (despite some misinformation circulating at the time).

Now, to be entirely fair to the Canadian health agency, this mode of thought didn’t originate with Canadian Blood Services.

For example, “Men who have Sex with Men (MSM)” terminology originated with the Centers for Disease Control (CDC) and other early public health organizations. It was ironically intended to be more inclusive than only focusing on gay men, but had the (theoretically unintended) result of invalidating trans* peoples’ gender identification. For the longest time, though, international health NGOs resisted acknowledging the existence of trans* people, and stubbornly insisted the classification was adequate… which only reinforced the impression that the invalidation was deliberate.

In fact, “MSM” language, thinking and subsequent HIV activism and education (aside from whatever mitigation occurred at the grassroots level) has a history of alienating trans* people, and confounding safe sex initiatives, outreach and data-gathering among trans* populations — a tragic situation for a community in which infection rates remain significantly high.  Even LGB(t) organizations perpetuated the problem, although this gradually improved around the start of this decade. [I first wrote about this (albeit with imperfect terminology, too) back in 2010, after being excoriated by an LGB(t) organization representative collecting data, who launched into a tirade saying that by declining to push a horribly-phrased survey on trans* people, I’d be “‘guilty of the murder of’ every transsexual woman who perished from HIV who might have benefited from the study.”  Yes, things have not always been amiable.]

Canadian Blood Services came into being specifically because of the scandal raised in the 1980s and 1990s resulting from screening failures of NGOs like the Red Cross during the AIDS crisis.  Its policies are directed by Health Canada.

Being fair to CBS also requires one to acknowledge a few further facts:

1. There is a short window of time (roughly a couple of weeks in most cases, but sometimes up to a few months) in which HIV still evades detection, and
2. Penile-anal intercourse (PAI) remains a high-risk mode of transmission.

Of these, penile-anal intercourse — the premise on which the “MSM” policy is premised — notably also occurs with some frequency among heterosexual partners, while not all gay men engage in it.  On the other hand, targeting specific communities instead of activities has created an inherent bias, and allows homophobic and transphobic organizations and figureheads to perpetuate stigma.

The number of sexual partners one has had in the previous year is also a crucial factor, which “MSM” screening on its own fails to account for.

Before forming government, the Liberal Party had petitioned to end the blood donor deferral policy altogether. When the one-year deferral policy for men was released, Health Minister Jane Philpott was quoted as saying:

“The desire is to be able to have those deferrals based on behaviour as opposed to sexual orientation.” 

This statement, of course, is the right direction.

The new practice, on the other hand, is destined to be an embarrassing anachronism.

As incremental as it may be, the policy that has been issued for (non-trans*) gay men fails, exactly because it continues to fixate on who is donating, rather than what their specific sexual history and risk factors are.  And when the attempt is made to extend that same policy to trans* people, its shaky logic disintegrates altogether.

(Crossposted to rabble.ca)

On conscience-based medical exemptions

The College of Physicians and Surgeons of Ontario is currently reviewing its Human Rights Code policy on conscience-based exemptions for medical professionals, and their effect on access to medical services.

This review was sparked by a number of news reports of doctors in Ontario and Alberta refusing to prescribe birth control because of their religious beliefs. In some of those cases, patients were refused in clinics where there was only one doctor on duty.

Concurrently, south of the border, the United States Supreme Court ruled in favour of a corporation’s right to deny medical insurance to its employees when doing so would violate the owners’ religious beliefs — a case that was specifically about access to contraception. The Hobby Lobby case has been followed by several new attempts to widen the exemption, and calls to extend it to other sectors and in ways that would allow businesses to refuse service to LGBT people.

These events reflect a major shift in the way that conscience rights are being seen and applied in North America.  It is my hope that the experiences of trans* people in Alberta with conscience-based medical exemptions might provide some insights for those considering a conscience policy review in Ontario.

Alberta has had a policy for some time which allows a doctor to refuse to prescribe treatments that violate their religious beliefs in non-emergency situations. However, they are required to state that the refusal is because of their religious beliefs, and to provide a timely referral for patients to someone who will provide care, so that patients still receive service and experience a minimum of undue hardship (although to be fair, having to jump through referral hoops can be considered an undue hardship of itself, especially when one factors in the difficulties in scheduling time off from work and other real life concerns).  Ontario’s policy is similar, though not identical.

Alberta’s policy was created to protect medical professionals from having to participate in any situation that might lead to an abortion.  But in the past year, there has been an upsurge of discussion about the need for a religious or conscience-based exemption in every sector and every practice.  Access to birth control is one of the pivotal issues in play in that discussion, although it is not the only one.

As an advocate for transsexual and transgender people, I’ve needed to assist a great number of people over the years who’ve been denied medical services because they’re trans* under Alberta’s conscience exemption policy.  Sometimes people have even been denied services for things like urinary tract infections, routine checkups and cases of the flu.  To be fair, the conscience exemption is not the only factor: denials are sometimes made by doctors who say they’ve never been trained in trans* health — although this complaint is made not only in regard to trans-specific health concerns, nor does there appear to be a willingness to learn from many of those doing the refusing.

Most often, trans* people who are refused care are also not provided a referral to anyone else.  This exploits the public’s unfamiliarity with this part of the law, and that they’re entitled to a referral.  It is certainly not every medical professional who refuses to assist, but it occurs frequently enough that the trans* community has had to try to keep a list of “trans-friendly” doctors — a list that is constantly plagued by doctors no longer being able to accept new patients, or making changes in their practice or habits.  I’m always happy to add doctors to the list, with the only requirement be that they adhere to the WPATH Standards of Care (which is also the policy of Alberta Health Services).  Two years ago, someone obtained a copy of our records and stormed into the offices of several listed clinics in Calgary, raising a ruckus about doctors’ willingness to treat trans* patients, and this resulted in several requests to be removed from our list.

Although commentators sometimes note theoretical possibilities like a Jehovah’s Witness practitioner denying blood transfusions, I can say from experience that conscience policies already can and do result in people being denied access to the care they need… and are not always given “timely” alternatives.

I am sensitive to a person’s right to opt out of something because their conscience, and not just a religious-based conscience.  However, in practical experience, exemptions tend to be abused, and marginalized people pay the heaviest price.  If there is to be a conscience-based exception to medical care, a province also needs to have a much better way of coordinating timely and accessible care alternatives, and better enforce the responsibility to provide those alternatives.  In Alberta, this is difficult, since there is no centralized means of communicating with medical professionals and provide some forms of training after they’re already in the field, short of making laws — so strengthening things at a policy level proves difficult.

With the recent shift of thinking among the religious right toward making provinces “abortion-free” and denying access to previously uncontroversial things like birth control, this issue will worsen in coming years.  If there is to be a conscience-based exemption to medical care, provinces need to seek a solution to the policy quandaries this creates now.  For example, if a walk-in clinic’s only physician on duty  will not prescribe contraception, then it’s worth investigating what responsibility the clinic should have in providing a doctor who will, and in a manner that suits the patient’s needs, rather than the doctor’s.

Or what responsibility the province is taking upon itself by sanctioning health care exemptions.

(Crossposted to Rabble.ca)

Nova Scotia Extends Health Care Coverage for Reassignment Surgery

After originally saying that it would not fund genital reassignment surgery, the Nova Scotia government has now said that it would extend health care funding coverage for the procedure.

Health Minister Dave Wilson is quoted as saying, “This is the right thing to do.”

I’ve written previously about why GRS is recognized as being medically necessary by medical experts, specialists in trans health, social agencies and human rights organizations.  Here is a snippet:

… There is more. Current legislation asserts that most forms of identification and legal documentation can only be changed to reflect one’s new gender after surgery has been verified. Without GRS, many pre-operative transsexuals experience severe limitations on employment, travel beyond Canada’s border, and treatment in medical, legal and social settings in which verifying ID is necessary. Prior to GRS surgery, transsexuals also face limitations on where they can go (i.e. the spa or gym, or anywhere that involves changing clothes) and difficulties in establishing relationships — as well as being in that “iffy” area where human rights are assumed to be protected, but have not yet been specifically established as such in policies and legislation. In hospitals, prisons and such, they are housed by physical sex rather than their gender identity, creating potentially risky situations, unless the authorities directly involved choose to keep them in isolation instead. And at the end of the day, without GRS surgery, one’s gender is always subject to being challenged or stubbornly unacknowledged by those who don’t realize that a transsexual’s gender identity was not a matter of choice. There is also an extremely high risk of violence faced upon the accidental discovery that one’s genitalia does not match their presentation.  No other supposedly “cosmetic” issue so completely affects a persons rights, citizenship and safety…

This is the fulfillment of several years of work for Nova Scotian trans people.  While details of the program are not yet known, the community had been advocating for comprehensive trans health coverage:

This points to a trans* health care model that includes, but is not exclusively reliant upon, SRS; that is driven by the individual and their particular requirements; that serves all of the trans* community, including those who do and those who do not seek SRS. This is exactly the kind of culturally competent, patient driven, community health care model that both Minister Wilson and his predecessor, the Hon. Maureen MacDonald, have been advocating for Nova Scotians. This is exactly the model that we, as a community, should be asking for.

Nova Scotia also recently added trans people to that province’s human rights legislation.

In a note on Facebook, Kevin Kindred and the Nova Scotia Rainbow Action Project are encouraging people to contact their MLA and send letters of thanks and support.

Most Canadian provinces provide some form of funding for GRS, now (albeit sometimes imperfect) — only New Brunswick and PEI do not.  Attempts to defund GRS have been met with sustained pressure from the public and human rights complaints, with Ontario delisting coverage in 1998 (restoring it ten years later), and Alberta delisting funding in 2009 (restoring it in 2012).

(Crossposted to Rabble.ca)

The non-operative word is not “sorry.”

I’m going to be writing about transition regrets and/or reversal of transition (sometimes from folks who remain trans-identified).  Before I do, though, it seemed necessary to finish and put this article out there, as it lays the groundwork.  I’d written about the decision to be non-operative previously, and had intended to leave it at that, but it remains one of the most hotly-contested and misunderstood subjects that I touch upon.

When it comes to genital reassignment, the non-operative word among trans people should not be “sorry.”

That’s not a very popular statement in transsexual communities.  But as much as I don’t like “rules” for being trans, I have arrived at one guideline:

Do as much or as little as you need to achieve the peace that you need.

It’s not quite that clear and simple, of course, especially given the pressures to conform and integrate as either male or female, which have been idealized as binary opposites in society.  Trans (that is to say, both transitioning from one sex to another and/or living between genders) challenges those absolutes, but it’s also a lot to ask, for someone to remain a life-long challenge to society.  And phrasing it as a “pressure to conform” oversimplifies something that also includes fears about going swimming or to public places of semi-nudity, going through airport scanners and traveling internationally, being in sex-segregated spaces like homeless shelters or correctional facilities, or the possibility of being challenged in a public restroom.

Relationships can also factor into the equation.  Genital reassignment surgery is inevitably going to change a dynamic within intimate relationships, and raise questions about our sexualities and those of our partners.  While the decision for or against GRS shouldn’t be dictated or coerced by our partners, when we love someone, it’s inevitably going to be on our minds.  Some individuals will be able to consider foregoing surgery as an act of love and sacrifice, while for others it would be far too much to ask — we’ll see why, shortly.

Another factor that blurs the lines is the fact that we live in a nation where our enfranchisement in society is largely affected by our identity documents.  In Canada, only the Province of Ontario has a provision to change a birth certificate without multiple verifications of surgery — and in many provinces, the same is true of lesser documents like driver’s licenses.  While our Social Insurance card does not display a gender marker, potential employers can do an S.I.N. check which displays a gender marker in the resulting report — and that, too, cannot be changed without a new or amended birth certificate.  When our ID is incongruent, it potentially exposes us to harm and/or discrimination when we’re carded, and at many other stages of just trying to live and work and access services.  At no other time is a person’s enfranchisement in society dependent on them having surgery.  But because that is the status quo in Canada and most parts of the U.S., it will inevitably be a point of consideration, for the time being.

Medical issues can also be factors affecting whether one can or can’t obtain surgery.  This might take the form of a serious health condition that precludes undergoing other procedures (some of these — such as diabetes or HIV — can be worked around by finding surgeons with better hospital access, but other conditions can be completely prohibitive).  It might also refer to fear of undergoing a major invasive surgery, an aversion to the medical process overall, a desire to wait until techniques improve, or living in a province where GRS is not funded and not being able to afford it.  Occasionally, health care funding is an influence for GRS, such as situations where vaginaplasty or phalloplasty are funded by insurance while orchiectomy, metoidioplasty or other options are not.

But for the moment, let’s put all of these things — health, cost, relationships, social pressures, legal identification and enfranchisement — aside.  In an ideal world, the decision to have surgery should hinge on an individual’s needs and the advice of their doctor.

This may seem a little confusing for people who have read my writing about surgery being a medical necessity.  I still maintain that its availability is, and that when surgery is necessary for an individual, it is an absolute necessity.   Relationships and legal enfranchisement obviously underscore this need, and there is also an economic benefit to resolving gender identity conflicts, so that a person is better-able to function and be productive.  But it’s also important to remember what GRS is designed to do:  alleviate distress.

Gender dysphoria encompasses a number of aspects: body dysphoria (in which genital configuration causes anxiety, revulsion, discomfort, or simply unease), social dysphoria (in which the social dynamic that we experience with people is ill-fitting), and self-identification (the inner core of who we are and the face we need to present to the world).  Each of those can vary in degree, and trans individuals can experience an emotional, psychological and/or even physical distress and anxiety about their body.  Living as the gender we identify with will often alleviate the social dysphoria and self-identification conflicts… only surgery addresses the body squick.

Body dysphoria is not always a conscious thing, but can be experienced as a discomfort or aversion to the genitalia, or a sense that those parts are out of place and don’t make sense to be there.  At the most extreme, this aversion becomes even violent, driving a person toward self-harm or self-destructive behaviour.  For people who experience it less severely, it can be a discomfort toward sexual intimacy in general, or a feeling of being out of place, without being completely clear on why.  Obviously, in these situations, it makes sense to align the body with what a person understands that they need to be.

At the lower end, the stress may not be as urgent, although a sense of closure might still be needed.

Not everyone experiences this.  Sometimes transition alone, minus surgery, is enough to resolve a person’s dysphoria, while other factors pose more significant reasons not to have surgery.

Non-operative trans women are sometimes considered button-pushing because they challenge the traditional trans narrative (there is often an exception made for trans men because of the limitations of phalloplasty and metoidioplasty procedures), in the same way that some bisexual people are unfairly seen as a challenge to the “born this way” narrative of sexual orientation.  The idea that we are fixing a predominantly medical condition seems undermined by the existence of people who don’t want to completely “fix” their bodies through surgery.  And yet, individuals exist who genuinely need to transition and live as their identified sex, but don’t urgently need or want GRS.

In transsexual culture, there seems to be this perspective that all roads lead to the holy grail of GRS, and that after one has the surgery, one has “arrived.”  Part of the reason that so many post-operative trans women and trans men leave the community is because once they’ve reached that point, the weighty discussion about GRS is no longer relevant to them.  The GRS-heavy direction has also tended to exclude non-operative and other trans people, because of the implication (intended or not) that they “must not be real” if they choose not to pursue surgical methods.

Yet GRS was only ever supposed to be one step toward self-resolution.  It’s neither all-completing, nor is it always a final endpoint (and this calls for a discussion of post-traumatic / minority stress), although it does have the ability to bring closure when that body distress exists.  By comparison, cissexual (non-trans) women never stop discovering what it means to them to be a woman; cissexual men likewise.  One does not “arrive” simply from the flick of a scalpel.

The basic reality of the trans condition is that our bodies do not define us.  If we allowed that to happen, we’d have never been able to start a transition — we would still be living in the misery and shame of having to live up to everyone else’s expectations.

The trouble with a heavy (or exclusive) focus on GRS as the “endpoint” of our transition is that we can become so intent on becoming “wholly” female or “wholly” male that we abandon, hide or feel ashamed of characteristics and histories which make us truly unique, perhaps instead embracing stereotypes.  It’s important that surgery does not become a case of simply trading one mask for another.

The overarching focus on surgery also does people an injustice, as it means that we fail to talk about bodies, hygiene issues, sex, the down-sides of post-operative care, and those things that we fear might cause a person to stray from the One True Path™ of GRS, or have doubts.

And sometimes –oh, not for everyone, but sometimes — non-operative-by-choice trans people arrive at a point of personal resolution from transition alone, and find that they can take pride in how unique they’ve become.  That perspective is hard-won.  It’s a shame to bury it.  Once in awhile, it’s important to embrace one’s uniqueness, and take pride in it.

Anyone who fails to understand this needs to take themselves out of the comfort zone of their own experiences, for a moment, to remember that one size rarely fits all.  Because the non-operative word is not “sorry.”

In the end, we are who we need to be.  Nothing else matters.

(As I was wrapping this up to post, Helen at en|Gender pointed to Non-Op.  For those who want to know more, it looks like an interesting resource.)

(Crossposted to The Bilerico Project)

Archive: Swedish Government’s (Now-Ended) Sterilization Requirement for Trans People

As of January 1st, 2013, Sweden no longer requires that trans people be sterilized in order to transition. This follows a move by the the Stockholm administrative court, after the Forensic Legal Council for Sweden’s National Board of Health and Welfare did not appeal a victorious legal challenge to the requirement.

What follows was being composed and near posted, when this change was announced.  Consequently, this article is out of date, but is being posted here to point out some of the distinctions that made this situation urgent — distinctions which media have often overlooked, and which were often eyebrow-raising of themselves (such as the ban on storing sperm or ova for in-vitro fertilization).  It also provides context for what will likely follow, such as the seeking of compensation from those who’ve been sterilized under this policy (which mirrors a previous precedent).  Additional discussion on the drive to end sterilization requirements can be found in TGEU’s Human Rights and Gender Identity Best Practice Catalogue, although the newest edition does not discuss Sweden specifically.

About that “GID is removed from the DSM” thing…

Oh god, please make it stop.

Yesterday morning, I woke up to a rash of headlines proclaiming that transexuality was no longer considered “disordered” by the American Psychiatric Association. This morning, it grew worse, with a rash of panicked emails from people who were wondering if their medical access would be jeopardized, after some LGBT and even mainstream news sites and blogs reported this as meaning that “Gender Identity Disorder” (GID) will no longer be considered in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), or had been “removed” from the DSM altogether.  No, it hasn’t.  That’s not true at all.

I hate to be a wet blanket, but the change that’s being heralded is mostly just in name, and “Gender Dysphoria” remains in the DSM — and in the “Sexual and Gender Identity Disorders” category (although that name may change too), if I recall correctly, of a manual that governs mental health.  The parallel being drawn to when homosexuality was removed from the DSM wildly overstates this change.

And because it has not been completely removed (something I’ve previously cautioned about the risk of doing too hastily, regarding both the DSM and ICD volumes), peoples’ medical processes are not affected in any way.  The panic I’ve heard from some people wondering if their medical treatment will be hindered is unfounded.

There is something to see here, though:

There is a positive in this, though, in that people are finally paying attention to the problems associated with another DSM category: Transvestic Disorder (formerly Transvestic Fetish). When the alarm was raised about Drs. Ray Blanchard and Ken Zucker having administrative roles in the DSM revision, that protest lost some steam when the APA announced that Zucker would be in an oversight position rather than hands-on, and Blanchard would be working on a separate category not related to GID (Paraphilias). Some of our allies decided we were making much ado about nothing.  Now, people are perhaps realizing the problem with that arrangement, in that it gave Blanchard full license to develop Transvestic Disorder (TD / TF).

A few trans advocates (including Kelley Winters, Julia Serano, and myself) have cautioned about the problems with regard to TD / TF and what could happen if that diagnosis is expanded in scope while GID diminishes or is eliminated.  Well, indications thus far are that Transvestic Disorder has certainly been expanded, and evolved to encompass Ray Blanchard’s theory of “autogynephilia” as a subcategory (plus the addition of “autoandrophilia,” to make it an equal-opportunity pathology).  All that anyone really needs to do to technically qualify for this diagnosis, as Serano notes, is to be “sexually active while wearing clothing incongruent with their birth-assigned sex.”

This diagnosis sexualizes and invalidates, and frankly, it has become a wide, sweeping pathology encompassing a significant amount of non-harmful behaviour.

Backgrounder: The Little Case Study That Autogynephilia Forgot

(Crossposted to The Bilerico Project)

Trans Depathologization: the spark of change.

I watch a lot of news stories unfold, reading left-wing, centrist and right-wing media alike.  In the course of a news story, issues ignite, blaze hotly and then smoulder into memory.  After awhile, one develops some sense of when a campaign will spread like a prairie fire or when it will extinguish itself.  The quest to depathologize transsexual and transgender people (or more likely just transsexed individuals) has smouldered for several years, but recently, something is happening.  It reminds me of looking at a match at the moment of ignition.  Flame shoots out in every direction, then chaos, and then it wraps itself up in whatever movement of air there is… or is blown out by it.  This effort, this time, I think will ignite into a blaze — with the only unknown being whether or not the World Health Organization will listen and respond.

There is a rejuvenated movement to have trans diagnoses removed from mental health classification, under the common belief that if transsexuality were no longer considered a mental illness (in the way that happened with homosexuality was in 1973), that it will lead to the level of acceptance that gay men and lesbians have attained.

This as something that has to happen.  But if not done with care and consideration, it could become more chaotic than it needed to be, and burn more people than necessary in the process.  Here’s why, and what can minimize this.

First, the Background.

Jenna Talackova, the beauty queen who fought for the right to compete in the Miss Universe Canada pageant regardless of her trans history, wants you to know that she’s not sick.  In a petition at change.org, she writes: “… the World Health Organization (WHO) insists that I, and millions of other trans people are sick. The WHO actually considers transsexualism to be a mental disorder.”

To that end, she is petitioning the World Health Organization to stop considering transsexual people to be mentally ill, as the WHO revises the International Classification of Diseases (ICD 11).  The ICD includes transsexuality as “Gender Identity Disorder” (GID).  The American Psychiatric Association does the same in their similar volume, the Diagnostic & Statistical Manual, although the petition is addressed to the WHO only.  The DSM is the volume used in the US, while the ICD is the reference used in most nations outside North America.  The APA has proposed to change the name to “Gender Dysphoria” for the upcoming DSM-V, which some have trumpeted as being a change from mental health classification… but it really isn’t.  In fact, the proposed revision to the DSM has gone backwards, by annexing intersexed conditions into the definition of GID.

Jenna’s petition is part of a larger project through Change.org, with a single petition split into six campaigns.  The U.S. version of the letter is written by blogger Maxwell Zachs, a cast member of  the UK reality TV show, “My Transsexual Summer.”  There are others for Spain (with Carla Antonelli), Italy (with Vladimir Luxuria), Germany (Kim Schicklang), and France (Rochelle Gregorie).  49,000 people have signed on since the petition launched in early October.

The genesis for this project appears to come from Stop Trans Pathologization 2012, even though petition links don’t appear on that group’s website, and it may be only loosely affiliated. STP2012 recently marked its International Day of Action on October 20th, for which this campaign was apparently conceived.

The Need.

There is no doubt that there is a need for change, and that sooner would be better than later.  Some of this is optics: as long as the public thinks of transsexuality as mental illness, it provides seeming justification for creating roadblocks, denying employment, denying housing, blocking access to services, blocking access to health care funding, and more.  Throw a rock in the air, and you’re sure to hit any of thousands of right-wing commentaries that use mental health classification as reason to oppose even basic human rights inclusion for trans people.

Depathologization is the benchmark “marriage” issue of trans people.  Medical classification actually affects more than just transsexed people, although nobody seems to be questioning the categorizations that affect non-transsexed trans people.  Which is why there is some temptation to see this as an effort that benefits mostly those in trans communities who are privileged and not affected by some of the more urgent forms of disenfranchisement.  Especially when over 40 years later, gay men and lesbians are still routinely accused of mental illness (although that argument has no value, other than to challenge peoples’ expectations), and even still off-and-on classified that way in some areas.

But it’s not just optics.  Pathologizing diagnoses are sometimes used to adversely affect custody of children, employment, access to support services, participation in the military (most notably in the U.S., where the end of Don’t Ask Don’t Tell didn’t help trans servicemembers) and more.  There are many tangible instances where this classification becomes a roadblock.

The current diagnosis also sets itself up to be a pre-existing condition, thus allowing it to be exempted from coverage.  In this case, any trans-specific diagnosis would be a problem, and the problem lies with the overall concept of “pre-existing condition” exemptions.

Diagnosis is not treamtent.

The current diagnosis also directs people to a horribly gatekeepered medical system, although it should be remembered that the standards of care are not directed by the DSM or ICD, and removing the classification may not necessarily change this aspect… other than perhaps changing who the individual gatekeepers are.  Gatekeeperism has always been a double-edged sword.  When the person in question is a genuine ally, this has proven to be a reliable route through transition.  But unfortunately, that has often not been the case.  And even when the gatekeeper is an ally, the waiting list to see them is itself an unusual barrier, and the pathway often comes with an expectation of a person fitting a narrow cookie-cutter template.

As it is, though, there are significant challenges to finding medical professionals who are: willing to take on trans patients; not doing so for an opportunity to dispense aversion or reparative therapies; willing to treat according to current WPATH or harm-reductive standards of care; and preferably also experienced in trans health issues.  What we have isn’t working.  But without something to point to the medical process and to demonstrate medical necessity (which a diagnosis does), the net result for trans people could be significantly worse.

But it needs to be remembered that diagnosis is not treatment.  While the two are connected, and affect each other, addressing a diagnosis does not necessarily change the existing treatment processes, other than to sometimes throw them into chaos or abandon them.

Be Careful What You Ask For…

Unlike when homosexuality was declassified from mental health arenas, transsexed people do have very specific medical needs (such as genital reassignment surgery, mastectomies and hysterectomies for trans men, tracheal shave, facial hair removal and breast augmentation for trans women).  And if depathologization isn’t addressed with the greatest of care, the result on access to trans health care could be disastrous.

In April 2008, I wrote an article entitled Destigmatization versus Coverage and Access: The Medical Model of Transsexuality.  That article has been picked up by a number of sources and even a couple academic texts, and cited often — usually as a “No” vote on the issue of depathologization (which frustratingly mischaracterizes what I wrote).  In it, I wrote about the quandary presented by the current diagnosis, and argued that declassifying the diagnosis of GID is inevitable — but before it can be done, an alternate medical model that does not depend on a mental health diagnosis needs to be developed and established, so that existing medical access for people in transition would not be compromised or lost.  A bit of that article is out of date, other aspects reflect some misconceptions of my own when writing, which saw the diagnosis and treatment as more interwoven than they actually are.  The ICD and DSM classifications merely classify, they do not recommend treatment, and that does provide more optimism than reflected in that article.  A diagnosis justifies seeking medical care, though, so they’re not completely decoupled.

When I wrote that article, it was in hopes that someday soon, I’d need to follow it up with happy news of some new development, a brilliant new direction being explored, and a new diagnosis and medical model being imagined and refined.   Instead, nothing has really changed.

The Risk.

Here are some things that are risked in removing classification:

1. Funding.  In most public and private health insurance structures, a medical code is required to justify the paying out of money for surgical and non-surgical health procedures and services.  So public and private health funding of sex reassignment surgery (GRS/SRS) are vulnerable.  Insurers see them as “cosmetic” procedures, and switching to an elective medical model will only reinforce that perception.  Mastectomies and hysterectomies for trans men might also be affected in this way (unless an alternate justification is given), and conceivably also counseling, or visits to a family doctor for HRT prescriptions and monitoring (depending on billing requirements and local regulations).  And then there’s the HRT itself.  Not all of these are funded in all areas, and in fact, some regions go to great lengths to deny funding for any or all of these things.  But some do, and they could be compromised if GID / GD is simply declassified, with no contingency plan.  Moreover, delisting would significantly hamper the potential to gain funding from insurers that don’t currently cover trans health.
2. Access.  Simply put, if there’s no diagnosis, a doctor doesn’t have any obligation to care.  If there is a medical classification in some form, there is an obligation to provide care, or at least not stand in the way of it.  This doesn’t always work this way, but the existing situation provides us some recourse when access issues occur.  Further, many surgeons and doctors may not be willing to take on trans patients under a personal elective system, because of fears that we’d change our minds and sue.  The existing 1-to-indefinite year of therapy process has provided a comfortable barrier against legal liability.  How many medical professionals would simply walk away rather than accept that new risk to help trans people — especially with any obligation to treat removed from the equation?
3. Identification correction and citizenship.  Given that many regions also require a change of physical sex in order to change major identity documents, financial and access barriers to trans-related procedures also extends the time before legal and social enfranchisement is attained.  It shouldn’t be that way (and has been fixed in a couple fortunate jurisdictions), but it is.
4. Counseling.  While it’s a problem that transition is dependent on therapists, there’s also some need for caution about taking psychiatry entirely out of the equation, at least for those who want it.  Transition does bring with it some emotional upheavals, particularly related to associated stigmas (which won’t simply be gone when transsexuality is no longer considered mental illness) and challenges (unaccepting families, depression from things like job loss, etc).
5. As twisted as it has been, the existence of a medical classification has provided a form of validation, even if the specific application also invalidates.  It has forced people to acknowledge that we exist.  The problem is that validation has focused on what’s in our heads rather than on what we’re actually bringing into alignment, which is our body.  But regardless of the mistaken focus, this validation has helped to push for legal support.  Just as easy as it is to find right-wingers pointing to the mental health classification as a reason to disparage, you can also throw a rock and randomly hit a reference used to justify and defend.  From a statement made by 20 local and regional NGOs operating in Malaysia, responding to a ruling upholding a law making the wearing of clothes which are considered incongruent with one’s birth sex punishable with a fine of up to RM1,000 and / or up to a year in jail:

In the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) the American Psychiatric Association (APA) replaced the diagnostic term “Gender Identity Disorder” with the term “Gender Dysphoria”, “a marked incongruence between one’s experienced/expressed gender and assigned gender”.

The APA too, in a statement urged the repeal of laws and policies that discriminate against transgender and gender variant people.

This is probably a bad example, because the four women who challenged this law lost their case.  They were met with a court ruling that cited Islamic texts and ordered that “religious authorities give counseling to the four and that they act prudently during enforcement.”  Having a diagnosis to cite does not always help.  But sometimes it does.  And when it does, it can mean everything — even a person’s freedom, or their life.

Having the standards of care carry over into physical health treatment in a way that would avert these risks is a greater challenge than many believe.  In the case of the DSM, that volume only has province over mental health issues, so its editors can only declassify.  But the ICD, which is the subject of the petition, does govern both physical and mental health classifications.  Its editors at the WHO can bring about a reclassification, and in fact are best positioned to do so.  But…

Is it congenital?  The challenges to reclassification.

Before a reclassification outside mental health can occur though, a cause needs to be ascertained, and diagnosable criteria defined. Is transsexuality congenital?  Would classification as “Congenital malformations, deformations and chromosomal abnormalities” (Q50-Q56) be just as stigmatizing and warrant yet another future change?  Some intersex groups are fighting against just such a classification, or at least the language used.

Recategorization is not yet feasible, although there have been many intriguing research avenues found in biological sciences which call for more study.  Convincing the medical profession to move a diagnosis when they believe that the current model is workable in their eyes (even if not perfect) is difficult, especially if the alternatives are not yet conclusively proven or causes defined tangibly.

The Informed Consent Model of Care.

The only new development in adult trans health since 2008 is that more people are using what they prefer to call an “informed consent” model of care.  Campus Progress discussed this earlier this year:

Clients at many of these clinics [PDF] can acquire a prescription for hormones after basic laboratory tests, a consultation about hormonal effects, and signing a waiver stating that they know the risks of treatment.

“When we’re working with clients as therapists, the goal is to help people self-realize. We want to allow space for that when it comes to people realizing themselves in the context of their gender,” Talcott Broadhead, a licensed social worker in Olympia, Wash., told Campus Progress.

The informed consent pathway is not yet available in most areas — mostly just a few major population centres in the U.S. — and it’s accepted as a given that funding is entirely the individual’s responsibility.  It also doesn’t state here whether this process facilitates surgical access, and if that means the provision of doctors’ letters to surgeons (in which case, informed consent becomes not much different from a harm reduction model).

If you live in an area where funding isn’t available anyway and is heavily gatekeepered, the informed consent path is 100% better. But it’s also a model that favours the privileged and lucky.  Informed consent remains an elective process, without the use of a medical classification at all, and treats transition as entirely cosmetic, not as medically necessary, even if individual doctors involved realize otherwise.  And since billing is often tied to categorization, I’m not sure how that would work.  In any event, though, the voluntary nature has a tendency to undermine the necessity and validation needed for funding and widely-available access.

WPATH has revised its standards of care to be compatible with both informed consent and harm reduction models.

The harm reduction model.

What many in the medical field have been turning to is a harm reduction model, reducing the stigma as much as possible, while utilizing its strengths to make it available everywhere.  The results vary considerably by region.

The change made from “Gender Identity Disorder” to “Gender Dysphoria,” for example, is made to try to reduce the harm of the mental health stigma.

And then there’s “Transvestic Fetish”

If GID were listed tomorrow, there would still be people who seek counseling to deal with their sense of feeling out of place, and believing that changing their mind is easier than changing the body.  There would also still be people coerced or forced into treatment, especially youth, who are often not given any personal agency of their own.  And it would take time for medical professionals to become aware of this change, let alone warm to it.

One of the issues mentioned in Destigmatization… regarding the DSM volume, was that if GID is dropped from medical classification while Transvestic Fetish (TF) remains, this opens up the possibility that for anyone who crosses paths with the mental health system (and possibly the health system overall), TF could become a diagnosis of choice.  TF is also found in the ICD, as Fetishistic Transvestitism, F65.1.  This classification puts an emphasis on the clothes one wears, and implies a sexual motivation (which are besides the point and inaccurate, respectively), but it doesn’t take a lot of imagination to see how those who are adverse to transitioning people would take advantage of the existence of a TF-style classification and its exclusive status… and weaponize it.

The intent of the latest petitions may be to depathologize, but the result could very easily be a far more damaging pathology.

The way we think about mental health.

The discussion actually says a lot about the way we think about mental health, and the idea that “mental illness” is anathema. The movement to depathologize is based on a shallow understanding of what a diagnosis means, let alone a mental health one.  The assumption, of course, is that a mental health condition either automatically means insanity or else is a figment of a person’s imagination.  The stigma trans people face is more rooted in the public belief about what constitutes “normal” than anything that’s actually in the diagnosis itself, and that societal obsession with normativity won’t change just by reclassifying or declassifying anything.

In a way, the underlying motive is an injustice to the many people who are diagnosed with depression, autism, bipolar or social anxiety conditions, addictions, ADD / ADHD and more, some of whom travel in trans communities as well.  And it can easily translate to horizontal violence, if people choose to ignore this fact.

The spark of change.

There’s probably a reason that this latest movement reminds me of a match catching fire.  There is incredible potential there, but without the certainty yet of whether that power will warm or consume.  It’s all in how we use it.

The problem is that change essentially never comes easy.  There appears to always be some turmoil, at which point, society has to adjust, and figure out how to deal with it.  The question, then, is this: is society at a place where it’s ready to do so?  Are we at a place yet where the benefits outweigh the price that will be paid?  And have we adequately thought about ways to minimize the harm between points A and B?

I’m not satisfied that this is the case, especially when one looks at the question globally.  In some parts of the world, even what we have now is a hard sell.

And yet, it’s igniting now.  Now is the time for change, for many of us — perhaps it’s even long overdue.  Given that cautions in 2008 have gone unheeded, blowing out the flame is not the right thing to do, either.  So instead, I ask that people be aware.  Handle that flame with care.

A Solution.

Problems are easy to point out.  Solutions, usually not so much.  There is a possible solution, here, albeit one that doesn’t neatly solve everything.

Most of the risks outlined above hinge upon the existence of a medical diagnosis.  There is an apparent need for one, but that diagnosis does not have to be a mental health diagnosis.

If the petition were to focus on asking the World Health Organization to actively and urgently investigate the development of an alternate diagnosis in a way that would make transition not dependent on a mental health diagnosis — and which would involve some level of community consultation (probably the harder-sell request of the two) — well, this would be absolutely worth doing.

This solution doesn’t address the point about the way we think about mental health.  That would take a changing of hearts and minds, starting with our own.  But I’m not optimistic that that will happen in any near future.  Even just getting people to think about the political, medical, financial and social realities outside of Theirtown, USA (or Canada) is a bit of a stretch, at times.

But it is a solution.  And it could be do-able, in a way that maintains the spirit of the original petition, which says:

“This doesn’t mean that trans people should be excluded from the health system: pregnant women are not sick, but they have medical protocols and assistance. The same should happen with trans people.”

Pregnancy is covered at length in Chapter XV of the ICD, in classifications O00–O99: “Pregnancy, childbirth and the puerperium.”  Just in case anyone was wondering.

(Crossposted to The Bilerico Project and Dented Blue Mercedes)

One More Thing.

Oh, and, uh, here’s one more thing.

This is for Albertan trans folks who filed human rights complaints following the delisting of GRS funding in 2009 and on into 2012,

Who’ve been lobbying through up to (I think it’s) five tries to pass trans-inclusive human rights legislation at the federal level,

Who called or visited your MP,

Who called or visited your MLA,

Who joined us on the Legislature steps,

Who told your stories despite the risk of being out,

Who showed Alberta people, instead of myths,

Who wrote letters,

Who allied and mobilized even if you’re not trans and don’t fully understand the experience,

Who took the time to read and find out more, rather than stick to old misconceptions,

Who organized,

Who worked behind the scenes and may or may not get public credit for it,

Who gave us the opportunity to speak,

Who supported us in the Legislature and Parliament from the beginning,

Who came to understand how our minority issues intersect with and run parallel to others’,

Who rode the ups and downs and tried not to lose hope,

Who marched.

You did this.

This is how a movement begins.

Alberta reinstates funding for Sex Reassignment Surgery

The Alberta Government has announced that it will be reinstating health care funding for sex reassignment surgery (often called gender reassignment surgery, and abbreviated as GRS by the province and its clinicians), effective June 15th.

In the recent provincial election, Premier Alison Redford was returned to power by an electorate that appears to have been hoping her government would track back toward progressive politics.  Albertans have been watching to see if her government would indeed follow through, and in what manner.  An Angus Reid poll placed Ms. Redford as the second most popular Premier currently in power.

The province had cut funding in 2009 as a “cost savings measure” — however, the $700,000 savings (provided for approximately 16 people per year) wasn’t even a sliver of the provincial health budget.  Since then, the Province has been on shaky legal ground with the funding cut, since human rights tribunals have typically recognized the procedure as being medically necessary.  It was for this reason that the Province of Ontario ultimately reinstated funding, and B.C. abandoned an attempt to defund the surgery.  Judicial court rulings (eg.) in Canadian case law also indicated a likelihood that the medical necessity of GRS would be upheld.

The Trans Equality Society of Alberta responded to the announcement with a media release:

We are pleased that the current administration sees value in caring for all Albertan’s needs, enabling them to live happy, fulfilled lives.  The return of this coverage, who’s removal only saved Albertan’s $0.18 each annually, will give hope to those for whom GRS was previously out of reach.  While there are many other issues facing Trans-identified Albertans, this is a huge step in the direction of respect and dignity for the Trans Community by the Alberta Government. Thank you for taking this important first step.

The American Psychiatric Association and American Medical Association both stress that sex reassignment surgery is a medical necessity, and a 2008 resolution by the AMA emphasized that insurance companies should cover the procedure.

Most Canadian provinces have some form of coverage for GRS, although some have problematic quirks of process or costs that can create barriers to obtaining the procedure, and some still do not fund sex reassignment procedures for trans men.  In 2008, Nova Scotia’s Liberal Party added working toward GRS funding inclusion to their political platform, although it has not yet been accomplished in that province.

Internationally, several nations have also added coverage to their public health insurance programs over the past couple of years, including Cuba, Brazil, and Chile.  Argentina recently passed the most comprehensive policies on trans enfranchisement, which included GRS funding, new name change guidelines, anti-discrimination inclusion in their human rights code, and legal protections from hate crimes.  A number of Australian provinces are under renewed pressure to provide funding after an incident of attempted self-performed surgery in an act of desperation.  There have been (trigger warning) at least three other major self-mutilation incidents reported in international media in the past year, including one person in China who self-castrated and then jumped to their death because they couldn’t deal with the pain.  Although not all trans people decide that they require surgery, for those who do, it can be an absolute necessity.

Corporations have also been rapidly adding health plan coverage to their benefits programs, including Apple, Chevron, General Mills, Dow Chemical, Chubb, American Airlines, Kellogg, Sprint, Levi Strauss, Eli Lilly, Best Buy, Nordstrom, Volkswagen’s U.S. division, the University of Pennsylvania, Whirlpool, Xerox, Raytheon and Office Depot (note: some of these may not apply in Canada).  According to the Human Rights Campaign’s Corporate Equality Index (CEI), over 200 major U.S. businesses now include trans-inclusive health care coverage featuring surgical transition-related care, including 50% of Fortune 500 companies — an increase of over 1500% in that group since 2002.

Alberta’s 2009 announcement was followed by a mass filing of human rights complaints.  Due to changes in grandfather-through decisions, some of those complaints were negated when funding was given, and others are still in process.  Due to the backlash at the time of the announcement, the province had eventually conceded to provide funding for people already in transition prior to the cut, to a maximum of 20 per year.  A number of others who had not qualified for the “Phase Out” program (usually because of the timing of their first medical appointment after starting transition) had been typically offered GRS funding as part of a settlement during negotiation stages of their human rights complaints, but have not spoken to media due to confidentiality requirements.

Although this victory is huge, some concerns about medical access remain.  It can be difficult or near impossible to find trans-friendly (let alone trans-aware) medical practitioners in several regions of the province. This can make it hard to even find general practitioners willing to treat people for medical issues that are not trans-related.  For transition care, there is one clinic in Edmonton (therapy only, currently with an 18+ month waiting list) — in Calgary, there is also a once-a-month trans health clinic operated by a psychologist and a family doctor who’ve teamed up to try to help, but the need is one that is difficult to fill with a once-a-month model.  The previous Stelmach government had shut out attempts by the trans community to speak about these matters, and advocates are hopeful that this can now change.

On Wednesday, the Federal government voted to allow a human rights bill proposing protections for transsexual and transgender Canadians to committee for review and possible changes, toward a final vote.  The bill had passed in the previous Parliament, but died in the Senate upon the election call.

(Here is a full backgrounder on why GRS is medically necessary.  It is also available as a trifold brochure)

(Crossposted to The Bilerico Project Dented Blue Mercedes and Rabble.ca)