My presentation at the Nordic Conference of Transgender Studies, Linkoping University, November 18th 2009
Psychiatry’s Grip on Transgender Patients in Sweden
All treatments by the six gender teams in Sweden are based on a strict psychiatric protocol and the physician in charge of the patient must be a trained psychiatrist and the person seeking treatment is viewed as mentally disordered.
Psychotherapy and counseling which are typical in many countries are virtually absent from the process. A psychiatric evaluation based on control and a highly normative approach are the methods of treatment
Psychologists and social workers play a marginal role in the treatment process.
Due to the strict psychiatric treatment model those patients who need support, counseling or psychotherapy are left without any form of support.
The recent Swedish study “Sex Reassignment of Transsexuals is Associated with Increased Mortality and Psychiatric Morbidity - A Retrospective Matched Cohort Study”, draws the following conclusions;
“Sex reassigned individuals have substantially higher mortality and are at higher risk for psychiatric morbidity and suicide attempts than the normal population. To reduce the risk of both suicide and suicide attempts it is important that clinicians don’t neglect the psychiatric co-morbidity both before and after sex reassignment. More research is needed to prevent and elucidate the causes of higher mortality rates for sex reassigned individuals”
The Need for Counselling and Psychotherapy
In spite of a very obvious need for social, psychological and emotional support that transgender people who going through transition do require, no such support is available. The entire process for transsexual people going through treatment at any of Sweden’s six official gender teams lacks any resemblance of the process that is described in the WPATH Standards of Care.
The entire focus lies on evaluating, controlling and gatekeeping the patient. Typically a patient will see a psychiatrist once every three months for about 30-45 minutes during the duration of the process. The roots of the protocols used in Sweden can be found in the protocols developed in the early 1970-ies by US university based teams such as Stanford and John Hopkin’s.
Until recently the dominant discourse was that a genuine and true transsexual had no relationship to other Trans identities and a strict division was made between primary transsexuals and secondary transsexuals.This had the effect that only those patients who could convince the psychiatrist in charge that they indeed were primaries would be accepted for treatment.
This did exclude a large number of Trans people from any hope of receiving treatment and hence legal gender recognition(according to the act of 1972).Gay, lesbian and bisexual transmen and Trans women until the last decade were excluded from treatment as a true genuine transsexual always was heterosexual in his or her transitioned gender.
Sweden’s Treatment Protocol and the Standards of Care
The present Swedish treatment protocol includes a minimum period of 12 months of psychiatric evaluation before a recommendation for HRT can be made. A further evaluation period of at least 12 months is required before the patient will be given a recommendation for GRS.
Transgender individuals who do not meet the WHO ICD-10 diagnostic criteria Transsexualism, F 64.0 will not be accepted 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 reassignment surgery), breasts augmentation, mastectomy, ochiedectomy, or HRT (hormonal reassignment treatment).
What furthermore puts a burden on the vast majority of transgender individuals in Sweden who do not meet the narrow criteria of genuine transsexualism is the fact that due to a decision of the National Board of Health and Welfare’s body that oversees medical practitioners in Sweden, it is illegal for any physician to prescribe HRT to a patient that has not met the diagnostic criteria of F64.0 and who has a referral from one of the six approved gender teams.
This practice leads to several alarming health consequences for transgender people in Sweden such as an abundance of black market hormones as well as various unofficial sources of hormones and hormone blockers. The transgender persons using this form of unmonitored treatment are risking their health due to overdoses and other problems. The very necessary monitoring of hormone levels by health professionals is thus not available.
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 they are approved. According to the Standards of Care the unmonitored use of hormones is one criteria to approve HRT as soon as necessary blood level tests are made, however this is not the case in Sweden, any more.
A patient waiting the 12 months for approval for HRT is then already is on hormone medication without supervision while being screened by the psychiatrist if 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 Swedish gatekeeping system before being able to access HRT under medical supervision.
Exclusion of transpeople from legal recognition
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 under certain circumstances.
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 certifies that the patient meets the criteria in WHO ICD-10 F.64.0 and that this condition has prevailed since the patient’s youth. This is in effect a stricter diagnostic criteria than that present in the ICD-10. It also in effect classifies the applicant as mentally disordered.
Problematic Research on Trans People
This creates a research tradition that is deeply entrenched in a psychiatric and pathological discourse and where the subjects are seen as disordered people who need to be assesed and further diagnosed. Almost all research in this field is done by the very psychiatrists that serve the role as strict gatekeepers and upholders of this pathologizing system.
Most trans persons going though the hoops of gatekeeping in Sweden are made to take part in various research projects and very few patients would dare to say no to this as they then might risk being denied hormones and approval for surgery and hence the chance of legal gender change.So bear in mind, all these data’s are collected by the very same people who view their trans patients as mentally disordered and who are given the opportunity to play God.
This is important when judging the reliability and validity of the research presented by researchers. The following presentation is illustrates my point; Johansson, Annika, PhD; Strömsten, Lotta, PhD student; Bodlund, Owe, MD, Associate Professor in Psychiatry; Sundbom, Elisabet, PhD, Professor in Medical Psychology.
“Assessment of Self-Conscious Emotions in a Five Year Follow up Study of Swedish Adults with Gender Identity Disorder.”
In conjunction to a prospective longitudinal study in Sweden with the aim to evaluate the outcome of sex reassignment from different perspectives, 31 persons (18 M to F and 13 F to M) filled in the TOSCA questionnaire. In addition, 10 persons (5 MtF and 5 FtM), all approved for SR surgery, were added. So, in total 41 persons (23 MtF, 18 FtM) participated in the study with the aim to make a comparison between transsexuals and controls concerning self-conscious emotions using the TOSCA instrument.
The control group consisted of 361 healthy adults – with sex and age corresponding as well as possible. The preliminary results showed that some significant differences existed between the groups. For example, the FtM transsexuals showed significant less shame proneness than the females in the control group, while the MtF individuals reported significant more guilt proneness than the control males. The effect sizes were satisfactory. Shame proneness was also significantly related to a variety of personality disorder symptoms, according to the DIP-Q (self assessment of personality traits and disorders, according to DSM-IV). These correlation patterns differed between the MtF and FtM groups.
One might wonder in what way this research will have any impact on the future treatment of trans patients, but that’s beside my point. The transsexual men and women are compared to ”healthy” person, i.e. non trans persons are healthy and trans people are viewed as not healthy, mentally disordered.
The other interesting aspect of this research is that trans men are compared with non-trans women and hence trans women are compared with non trans men. For what purpose one might ask, apart from the fact that these gatekeepers never will consider trans people as anything but severely disordered.
The Need for an Unbiased Transgender Research Tradition
A paradigm shift in research is needed concerning transgender health and the wellbeing and welfare of transpeople that will move from a pathologizing approach to a multifactoral, empowering and humanistic approach.
We need to liberate trans health studies from what some might call psychobabble and begin to approach this subject focusing of the needs of the transgender client as defined by him/her/hir specific needs. We need an unbiased and evidence based research on which we can build an entirely new transfriendly supportive and identity affirming health care.
As long as we accept transidentities as disorders and as pathological we will be made to jump the gatekeepers hoops and coninue to be the victims of internalized homo- and transphobia and indeed come out as human beings with mental disorder, not because we are disordered but because the treatment protocols and the norms of the society views us as disordered.
Scrap the gatekeeping systems and work on a truly equal and client focus treatment model based on informed consent!