Today Wednesday the 30th of June 2010 the National Board of Health and Welfare published their report following the recent overwiev of transgendender care in Sweden that was initiated during the 2009 Stockholm Pride Festival by the Board after demands from RFSL, the National Federation for Gay, Lesbian, Bisexual and Transgender Rights.
The report suggests farreaching changes for Sweden’s trans and gender variant people and the most important change is that the Board have put forward a solution on the legal issue. Instead of suggesting that the Parliament (Riksdagen) will initiate yet another proposal, the Board proposes that the present law shall be stripped of those parts that are in violation of the human rights of trans and gender variant people such as described by Thomas Hammarberg the Comissioner for Humans Rights at the Council of Europe in his Issue Paper and in alignemenet with the Yogyakarta principles.
The proposed revison of the law is suggested to be effective of January 1st 2011 and the will grant any resident in the Kingdom of Sweden on application to have his/her legal gender changed to the gender the person feels he or she belong to.
In §1 the conditions laid down for who may apply for a legal gender changeare “ a person who, since youth experiances that he belongs to a different gender then the gender put down in the national register and since considerable time is acting accordingly, and must be assumed to continue to live in this gender can apply for a decision that he belongs to the other (legal) gender.”
The former prerequisites of being a Swedish citizen, unmarried and sterile are removed from the proposed law revision. Only two things remain from the old law of 1972, the age limit for legal gender recognition wich is 18 years of age. The other part of the old law that will be in effect is the special permission by the the Forensic Council of the National Board of Health and Welfare needed to undergo GRS/SRS in Sweden which is due to the present laws on sterilisation and castration. This doesn’t apply to similar procedures performed outside of Sweden.
The report proposes an separate overwiev in general of the conditions for trans and gender variant youth and hopefully this age limit will be scrapped. Furthermore there is a suggestion that two regional gender teams that exclusively will work with trans kids shall come into existance as well as a much wider use of hormone blockers.
Generally speaking, transgender care will be made available to all trans and gender variant people and not as is the case now, only persons with the ICD-10 diagnosis of F64.0 Transsexualism.This means that persons not desiring GRS/SRS can obtain HRT or other forms of treatment.
The Board has been listening to the LGBT and transcomunities with the support of the most progressive representatives of the profession. The new law will separate the requirements for legal gender reconition from the forensic and medical issues. So if the law is effectiv January 1st 2011 you will only need to apply to the Section for adminstrative decisions and peromissions at the Board of Health and Welfare, which will simplyfy the procedure imensely and once an for all do away with the grip that psychiatry has had on legal gender reconition in the past in Sweden.
onsdag 30 juni 2010
måndag 28 juni 2010
In the light of the use of RLT/RLT by numerous so called Gender Clinics, and often for a much longer time that is stipulated in in WPATH:s Standards of Care and somtimes without any aid of hormones or other mecial support, there have been an interesting developemnt in the discussion on the validity of RLT/RLE in the upcomming version of SofC.
During the work to revise the World Professional Association for Standards of Care various apects of the SoC have been revised and scrutinized from a number of angles by various WPATH-members.
Professor Stephen B. Levine reports on the work with a common fixture of transgender care for over forty years, the Real Life Test(RLT) or as it is sometimes call now, the Real Life Experience (RLE).
In his very thorough study he found that although RLE is refered to and mentioned in numerous works on transgender care and health, no scholarly journal article on this subject has even been published that is devoted to the scientific study of RLT or RLE.
Stephen B. Levine concludes “The abscence of a firm scientific foundation to support the utility and validity of the RLE generates unease about setting policies for the management of gender identity disorders. This absence creates at least two ethical objections. First, the principle of Nonmalfeasance reminds us to “above all, do no harm.” The employment of the scientifically unsubstantiated scientific requirement of a Real Life Experiance can be a needless, cruel, and harmful obstacle for patients who are eager to use hormones or undergo genital surgery.
Second the principle of Respect for Patient Autonomy reminds us that the imposition of a scientifically unfounded RLE may be a disrespectful abrogation of allowing for patient self determination.
This article was published electronically on December 10th 2009 in the International Journal of Transgenderism, the official organ of WPATH. Stephen B. Levine is a clinical Professor of Psychiatry at the Case Western Reserve University School of Medicine in Cleveland, Ohio, USA.
I think that it is vital that we trans and gender variant activists really and wholeheartedly take part in the upcomming discussion on the Standards of Care version 7 that is going to be adoped at WPATH Symposion in Atlanta, Ga, USA next fall.
At least two leadning members of WPATH, Professor Sam Winter and Professor Aaron Devor, have proposed that in order to make the upcomming version of SofC more inclusive and in line with the needs of the trans and gender variant people seeking medical and surgical intervention, there should be a broad discussion on the version 7 of the SofC before they are adopted in Atlanta in September 2011.
As a WPATH member and as a member of WPATH Membership Committee I could only urge transgendered proffesionals to join WPATH and to use their influence on the upcoming version of the Standards of Care. Who knows, we might even manage to do away with gatekeeping for good in favour of some form of informed consent.
During the work to revise the World Professional Association for Standards of Care various apects of the SoC have been revised and scrutinized from a number of angles by various WPATH-members.
Professor Stephen B. Levine reports on the work with a common fixture of transgender care for over forty years, the Real Life Test(RLT) or as it is sometimes call now, the Real Life Experience (RLE).
In his very thorough study he found that although RLE is refered to and mentioned in numerous works on transgender care and health, no scholarly journal article on this subject has even been published that is devoted to the scientific study of RLT or RLE.
Stephen B. Levine concludes “The abscence of a firm scientific foundation to support the utility and validity of the RLE generates unease about setting policies for the management of gender identity disorders. This absence creates at least two ethical objections. First, the principle of Nonmalfeasance reminds us to “above all, do no harm.” The employment of the scientifically unsubstantiated scientific requirement of a Real Life Experiance can be a needless, cruel, and harmful obstacle for patients who are eager to use hormones or undergo genital surgery.
Second the principle of Respect for Patient Autonomy reminds us that the imposition of a scientifically unfounded RLE may be a disrespectful abrogation of allowing for patient self determination.
This article was published electronically on December 10th 2009 in the International Journal of Transgenderism, the official organ of WPATH. Stephen B. Levine is a clinical Professor of Psychiatry at the Case Western Reserve University School of Medicine in Cleveland, Ohio, USA.
I think that it is vital that we trans and gender variant activists really and wholeheartedly take part in the upcomming discussion on the Standards of Care version 7 that is going to be adoped at WPATH Symposion in Atlanta, Ga, USA next fall.
At least two leadning members of WPATH, Professor Sam Winter and Professor Aaron Devor, have proposed that in order to make the upcomming version of SofC more inclusive and in line with the needs of the trans and gender variant people seeking medical and surgical intervention, there should be a broad discussion on the version 7 of the SofC before they are adopted in Atlanta in September 2011.
As a WPATH member and as a member of WPATH Membership Committee I could only urge transgendered proffesionals to join WPATH and to use their influence on the upcoming version of the Standards of Care. Who knows, we might even manage to do away with gatekeeping for good in favour of some form of informed consent.
fredag 25 juni 2010
Sweden and the issue of human rights for trans people.
This is a part of the report from Sweden in the Periodic Rewiev of Human Rights concerning trans and gender variant people written by myself and submitted in november 2009 by RFSL/RFSU in Sweden.
It highlight the human rights situation for Sweden's trans and gender variant population.
In Sweden most transgender individuals are denied the right to change their legal gender. Under the provisions of the present law, Lagen om fastställelse av könstillhörighet i vissa fall ( SFS 1972: 119) only those individuals who have undergone treatment by one of the six regional gender teams will be granted the right to change their birth gender.
According to this law the applicant must be a Swedish citizen, unmarried and sterile and above the age of 18. With the application a statement by the treating psychiatrist must be submitted that the patient meets the criteria in WHO ICD-10 F.64.0 and that this condition has prevailed since the patients youth. This is in effect a stricter diagnostic criteria than that present in the ICD-10.
In Sweden such applications are handled by the forensic advisory board of the National Board of Health and Welfare. The main tasks of this board is to deal with various aspects of forensic medicine and forensic psychiatry. In case an application is denied the decisoon can be appealed to the Administrative Court of Appeal and the Supreme Administative Court. But permission to do so can be denied without explanation.
Only after the approaval of the Forensic board will a permission to undergo genital surgery be issued and after undergoing sterilisation will the applicant handed a decsion that will give him or her a new personal identification number corresponding to the new gender. All public records can then be changed, but there is still the problem with older records and records kept by a non officail body such as scools and other institutions of learning etc.
A person undergoing a legal gender change have no legal right to have his or her credentials changed in the new name and gender. The Naional Borad of Health and Welfare has been know to deny transgendered nurses, psychologists, psychotherapists etc. to have their professional license change which in effect will stop them from working in the professions they are trained and licenesed for.
A revision of the present law from 1972 is taking place and if this law is enacted will in some respects be more restrictve that the present law. In lieu of sterilisation will be a requirement of gonadectomy ( ie castration) and the proposal is that only those who meet the ICD-10 F64.0 diagnostic criteria will have the righ to apply for gender recognition. This will in effect strengthen the position of the psychiatrist in the treatment process and the pathologisation of transgender people in Sweden.
(UPDATE: This proposal is at present sidetracked and work is in progress to lobby for a different law, that entiltels all trans and gender variant people the right to legal gender recognition with demans for surgical, hormonal or psychiatric intervention.)
In order to approved for said treatment the applicant must be refered by either a a psychiatrist in a primary psychiatry facility. This can take considerable time due to a lack of resources, competence and funds at the six regional teams that are located in Lund, Alingsås, Linköping, Stockhol, Uppsala and Umeå.
Transgender individuals who do not fulfil the WHO ICD-10 diagnosis Transsexualism, F 64.0 will not be acceptet for treatment and hence will have no possibility of having their gender legally changed from their birth gender. As a consequence they will not be accepted for any form of gender reaffirming treatment such as GRS (genital reasignment surgey), breast augmentation, mastsectomy, ochiedectomy, HRT (hormonal reasignment treatment).
All treatment at the gender teams are based on a strict psychiatric protocol and the physician in charge of the patient must be a trained psychiatrist. Psychologists and social workers play a very limited role in the the process. Sweden does not adher to the Standards of Care (2003 version 6) adapted by the World Professional Association for Transgender Health.
The Swedish treatment protpcols do include a minimum period of 12 months of psychiatric evaluation before a recomendation for HRT can be made, in comparison by the 3 month period prescibed in the Standards of Care. A further evaluation period of at least 12 months are requered before the patinet will be given a recomendation for GRS.
One of the provisons for this recomenation is that the patient is regarded as a genuine transsexual and earlier the definition of was that the patient must be diagnosed as primary transsexual and secondary transsexuals and person with gender identity disorder not otherwise specipied (GIDNOS) would be denied treatment of any kind.
The process can take anything from around three years and upwards. All treatments for those who meets the approval of the gender teams are met by the Swedish Social Insurance on par with other treatments.
For those transgendered individuals that do not meet the very narrow and exclutionary treatment criteras in use in Sweden there will be no forseable way of changing one’s legal gender. Until the fall of 2009 this also was the case in being granated the right to name. Due to a decision by the Supreme Administrative Court in the case Madeleine Jan-Olof Ågren and the Administrative Court of Appeal in Sundsvall the deciosn was made that an adult Swedish resident can and will have the right to chose whatever name he or she wishes.
Still those underage (18 years) kids have no option doing this even with parental consent. This is a cruel and damaging tratment of you transkids and in my opinion in violation not only of their human rights but furthermore of the United Nations Convetion on Childen.
What furthermore puts a burden on the vast majority of transgender individuals in Sweden who do not meet the narrow criteria of genuine trassexualism is the fact that due to decision of the National Board of Health and Welfare’s body that oversees medical practitioners in Sweden, it is illegal for any physician to prescibe HRT to a patient that has not met the diagnostic criteria of F64.0 and that have a referral from one of the approved gender teams.
This practice leads to servel alarming health consequences for transgender people in Sweden such as an abundance of black market hormones as well as various unoficial souces of hormones and hormone blockers. The transgender persons using this form of treatment are risking their health due to overdoses and other problems. The very necessay monitoring of hormone levels by health professionals is not available and the Gatekeeprs in the system flatly deny their paitents request until a F64.0 dia.
Due to the long time of waiting before approval for HRT for those who are accepted by the teams most MtF TS and several FtM TS are already on unmonitored HRT long before this. According to the Standards of Care the unmonitored use of hormones is a criteria to approve HRT as soon as necessary blood level tests are made., however this is not the case in Sweden.
It is not uncommon that a patient waiting the 12 months for approval for HRT already is on hormone medication with out supervison while beeing sceened by the psychiatrist is he or she is a possible candidate for HRT. For those transgender people that have moved to Sweden and have transitioned abroad the requirement is that they also must go through the the Swedish Gatekeeping system before being able to access HRT under medical supervision. Sometimes this will lead to a situation that a post-op TS man or woman will be without any form of hormone treatment for months of years before being accepted into a program.
Transgender persons that are residents of Sweden going through GRS and other gender reaffirming tratments abroad have no legal right to a gender change unless being approved by one of the six regional teams. In extreme case this means that transgender men and women are forced to out the selves at every single instance they will have to identify themselves and they will not be legally be precscibe continuing hormone replacement therapy which presents a grave health hazard.
It highlight the human rights situation for Sweden's trans and gender variant population.
In Sweden most transgender individuals are denied the right to change their legal gender. Under the provisions of the present law, Lagen om fastställelse av könstillhörighet i vissa fall ( SFS 1972: 119) only those individuals who have undergone treatment by one of the six regional gender teams will be granted the right to change their birth gender.
According to this law the applicant must be a Swedish citizen, unmarried and sterile and above the age of 18. With the application a statement by the treating psychiatrist must be submitted that the patient meets the criteria in WHO ICD-10 F.64.0 and that this condition has prevailed since the patients youth. This is in effect a stricter diagnostic criteria than that present in the ICD-10.
In Sweden such applications are handled by the forensic advisory board of the National Board of Health and Welfare. The main tasks of this board is to deal with various aspects of forensic medicine and forensic psychiatry. In case an application is denied the decisoon can be appealed to the Administrative Court of Appeal and the Supreme Administative Court. But permission to do so can be denied without explanation.
Only after the approaval of the Forensic board will a permission to undergo genital surgery be issued and after undergoing sterilisation will the applicant handed a decsion that will give him or her a new personal identification number corresponding to the new gender. All public records can then be changed, but there is still the problem with older records and records kept by a non officail body such as scools and other institutions of learning etc.
A person undergoing a legal gender change have no legal right to have his or her credentials changed in the new name and gender. The Naional Borad of Health and Welfare has been know to deny transgendered nurses, psychologists, psychotherapists etc. to have their professional license change which in effect will stop them from working in the professions they are trained and licenesed for.
A revision of the present law from 1972 is taking place and if this law is enacted will in some respects be more restrictve that the present law. In lieu of sterilisation will be a requirement of gonadectomy ( ie castration) and the proposal is that only those who meet the ICD-10 F64.0 diagnostic criteria will have the righ to apply for gender recognition. This will in effect strengthen the position of the psychiatrist in the treatment process and the pathologisation of transgender people in Sweden.
(UPDATE: This proposal is at present sidetracked and work is in progress to lobby for a different law, that entiltels all trans and gender variant people the right to legal gender recognition with demans for surgical, hormonal or psychiatric intervention.)
In order to approved for said treatment the applicant must be refered by either a a psychiatrist in a primary psychiatry facility. This can take considerable time due to a lack of resources, competence and funds at the six regional teams that are located in Lund, Alingsås, Linköping, Stockhol, Uppsala and Umeå.
Transgender individuals who do not fulfil the WHO ICD-10 diagnosis Transsexualism, F 64.0 will not be acceptet for treatment and hence will have no possibility of having their gender legally changed from their birth gender. As a consequence they will not be accepted for any form of gender reaffirming treatment such as GRS (genital reasignment surgey), breast augmentation, mastsectomy, ochiedectomy, HRT (hormonal reasignment treatment).
All treatment at the gender teams are based on a strict psychiatric protocol and the physician in charge of the patient must be a trained psychiatrist. Psychologists and social workers play a very limited role in the the process. Sweden does not adher to the Standards of Care (2003 version 6) adapted by the World Professional Association for Transgender Health.
The Swedish treatment protpcols do include a minimum period of 12 months of psychiatric evaluation before a recomendation for HRT can be made, in comparison by the 3 month period prescibed in the Standards of Care. A further evaluation period of at least 12 months are requered before the patinet will be given a recomendation for GRS.
One of the provisons for this recomenation is that the patient is regarded as a genuine transsexual and earlier the definition of was that the patient must be diagnosed as primary transsexual and secondary transsexuals and person with gender identity disorder not otherwise specipied (GIDNOS) would be denied treatment of any kind.
The process can take anything from around three years and upwards. All treatments for those who meets the approval of the gender teams are met by the Swedish Social Insurance on par with other treatments.
For those transgendered individuals that do not meet the very narrow and exclutionary treatment criteras in use in Sweden there will be no forseable way of changing one’s legal gender. Until the fall of 2009 this also was the case in being granated the right to name. Due to a decision by the Supreme Administrative Court in the case Madeleine Jan-Olof Ågren and the Administrative Court of Appeal in Sundsvall the deciosn was made that an adult Swedish resident can and will have the right to chose whatever name he or she wishes.
Still those underage (18 years) kids have no option doing this even with parental consent. This is a cruel and damaging tratment of you transkids and in my opinion in violation not only of their human rights but furthermore of the United Nations Convetion on Childen.
What furthermore puts a burden on the vast majority of transgender individuals in Sweden who do not meet the narrow criteria of genuine trassexualism is the fact that due to decision of the National Board of Health and Welfare’s body that oversees medical practitioners in Sweden, it is illegal for any physician to prescibe HRT to a patient that has not met the diagnostic criteria of F64.0 and that have a referral from one of the approved gender teams.
This practice leads to servel alarming health consequences for transgender people in Sweden such as an abundance of black market hormones as well as various unoficial souces of hormones and hormone blockers. The transgender persons using this form of treatment are risking their health due to overdoses and other problems. The very necessay monitoring of hormone levels by health professionals is not available and the Gatekeeprs in the system flatly deny their paitents request until a F64.0 dia.
Due to the long time of waiting before approval for HRT for those who are accepted by the teams most MtF TS and several FtM TS are already on unmonitored HRT long before this. According to the Standards of Care the unmonitored use of hormones is a criteria to approve HRT as soon as necessary blood level tests are made., however this is not the case in Sweden.
It is not uncommon that a patient waiting the 12 months for approval for HRT already is on hormone medication with out supervison while beeing sceened by the psychiatrist is he or she is a possible candidate for HRT. For those transgender people that have moved to Sweden and have transitioned abroad the requirement is that they also must go through the the Swedish Gatekeeping system before being able to access HRT under medical supervision. Sometimes this will lead to a situation that a post-op TS man or woman will be without any form of hormone treatment for months of years before being accepted into a program.
Transgender persons that are residents of Sweden going through GRS and other gender reaffirming tratments abroad have no legal right to a gender change unless being approved by one of the six regional teams. In extreme case this means that transgender men and women are forced to out the selves at every single instance they will have to identify themselves and they will not be legally be precscibe continuing hormone replacement therapy which presents a grave health hazard.
The unmonitored use of hormons by trans and Gender variant people in Sweden
In Sweden the number one health hazard for trans and gender varaint people is the unmoniterd use of hormones, I would without doubt say that a solid majority of all trans and gender variant people here, when they see their gatekeeper for the first time are already on hormones, many for a long time..
When I first went to see a my physiscian, Bjorn Lundquist of Lund, Sweden MD,PhD and nothing short of the man that saved me from suicide, I had been on varios estrogens for about eight years. For some strange reason unknown to me, I had managed to avoid any serious health hazards. My body had developed the way I wanted, my hormone levels were well within the range of a woman of my age and my teststeron levels were, to quote my doctor who was a direct and outspoken man, on castration levels.
Sweden have six regional Gender Teams with Gatekeepers who have absolute power over their patients. Their patients have no other option than to accept their antiquated treatment protocols. This means a minumun 12 months before they will give their diagnosis, and it must be consitent with ICD-10 F64.0 Transsexualism, if you are unfortuante and is diagnosed GIDNOS (Gender Identity Disorder Not Otherwise Speciafied) you have two basic options, suicide or hormones from the black market – an easy choice for most trans and gender variant human beings, I guess.
Well, after you lived trough the 12 month minimun, you will hopefully get your diagnosis and the long awaited referral to the endocrinologist. But here comes the next snag, you must accept the endo that the Gatekeeper appoints. No other endo may prescribe any hormones to you.
By a decision handed down last year, by Sweden’s National Board of Health and Welfare, any physician who prescribe hormone to a transpatient without the approval of the Gender Team in their region will receive a warning and then risk being struck off and have their license revoked.
In my region with some 1,5 million people we have one endo and the waiting list is very, very long. So it might be several months more before you get your hormones. Even beeing way over 15 years on hormones and legally female for over 10 years, I need to see this one endo as there is no-one else working with our group of patients.
According to the World Professional Association for Transgender Health:s Standads of Care version 6, 2001 the Gatekeeper have an option of prescribing hormones and do lab tests in order to reduce harm for clients taking unsupervised hormones, when seeing the client initially. But does this happen in Sweden? Of course not, these Gatekeepers won’t even accept a request for blood level lab tests or any other form of screening, let alone prescibing hormones.
They know that some 70-80% of their MtF patients have been on HRT on their own, sometimes for years and some have lived as women and are fully tranitioned when they see the Gatekeeper. And without the Gatekeepers approval, they stand no chance of getting a legal gender change or for that matter to approval to have GRS (Genital reasingement Surgey) performed in Sweden.
Sweden is the only country in the world, as far as I know, where you need a special government permission, based on a government appointed pshrink to have to GRS. So, quite a few go the see Preecha, Sanguan or any other Thai surgeon.
Mind you the situation for our FtM brothers and Gender Queer people are just as bad.
When I first went to see a my physiscian, Bjorn Lundquist of Lund, Sweden MD,PhD and nothing short of the man that saved me from suicide, I had been on varios estrogens for about eight years. For some strange reason unknown to me, I had managed to avoid any serious health hazards. My body had developed the way I wanted, my hormone levels were well within the range of a woman of my age and my teststeron levels were, to quote my doctor who was a direct and outspoken man, on castration levels.
Sweden have six regional Gender Teams with Gatekeepers who have absolute power over their patients. Their patients have no other option than to accept their antiquated treatment protocols. This means a minumun 12 months before they will give their diagnosis, and it must be consitent with ICD-10 F64.0 Transsexualism, if you are unfortuante and is diagnosed GIDNOS (Gender Identity Disorder Not Otherwise Speciafied) you have two basic options, suicide or hormones from the black market – an easy choice for most trans and gender variant human beings, I guess.
Well, after you lived trough the 12 month minimun, you will hopefully get your diagnosis and the long awaited referral to the endocrinologist. But here comes the next snag, you must accept the endo that the Gatekeeper appoints. No other endo may prescribe any hormones to you.
By a decision handed down last year, by Sweden’s National Board of Health and Welfare, any physician who prescribe hormone to a transpatient without the approval of the Gender Team in their region will receive a warning and then risk being struck off and have their license revoked.
In my region with some 1,5 million people we have one endo and the waiting list is very, very long. So it might be several months more before you get your hormones. Even beeing way over 15 years on hormones and legally female for over 10 years, I need to see this one endo as there is no-one else working with our group of patients.
According to the World Professional Association for Transgender Health:s Standads of Care version 6, 2001 the Gatekeeper have an option of prescribing hormones and do lab tests in order to reduce harm for clients taking unsupervised hormones, when seeing the client initially. But does this happen in Sweden? Of course not, these Gatekeepers won’t even accept a request for blood level lab tests or any other form of screening, let alone prescibing hormones.
They know that some 70-80% of their MtF patients have been on HRT on their own, sometimes for years and some have lived as women and are fully tranitioned when they see the Gatekeeper. And without the Gatekeepers approval, they stand no chance of getting a legal gender change or for that matter to approval to have GRS (Genital reasingement Surgey) performed in Sweden.
Sweden is the only country in the world, as far as I know, where you need a special government permission, based on a government appointed pshrink to have to GRS. So, quite a few go the see Preecha, Sanguan or any other Thai surgeon.
Mind you the situation for our FtM brothers and Gender Queer people are just as bad.
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