Upon receiving a copy of Transgender Persons Rights in the EU Member states from the Policy Department C, Citizens’ Rights and Constitutional Affairs, European Parliament in Brussels, I noted substantial discrepancies in the information contained on Sweden. So I wrote the following mail the the person in charge of the report, Ms Cristina Castagnoli .
I suggest that you thoroughly read through what’s written about your various nations. I suspect that some of the errors on Sweden are due to the fact that the person giving the information on Sweden had no specific knowledge on the legal sitauation in Sweden concerning trans people and no familarity with Swedish legal and adminstrative tradition.
Dear Cristina,
It is with a great interest I've read the report Transgender Person's Rights in EU Member States. However there are some inforation that seem to be incorrect.
Page 6
3.1 Gender reasignement in Member states
a/ memebr states where there is no requirement of hormonal treatmentor surgery to obtain gender reasignment (ie legal gender recognition) ES, HU, FI and UK.
If you do read the Finnish Law on this subject 2002:563 you will find that this law, partly modelled on the Swedish law of 1972 do indeed require surgery, as it requires sterilisation.
The follwing prerequistes for legal gender change in the Finnish law are, A document that establishes that the applicant is gender dysphoric, is sterile (ie can not procreate), of legal age of majority, unmarried, a citizen of Finland or a resident.
A married person may convert his or her marriage to a registred partnership if the spouse/partner agrees.
The legal gender reconition is done through an administrative process (not in a court of law).
3.1 c/ You write Member states where there are no provisions on this matter IE, EL, CY, LV, LT, LU, MT, RO, SI, SK and SE.
As there is a law from 1972 on legal gender change, the first of it's kind in the World, this is erronous, indeed.
These are the provisions;
The demand is that the applicant feels as he or she belongs to the opposite sex, lives accordingly for a long period of time and is to be expectod to do so forthwith (quite similar to the provisions in the Gender Reconition Act/UK) this reuirement correspond with the evidence of gender dysphoria, that the applicant is sterile (ie can not procreate), of legal age of majority, unmarried, a citizen of Sweden.
The legal gender recognition takes place on application to the Forensic Council of the National Board of Health and Welfare which in these matters act as a first level adminstrative court.
There is one issue where the two legislations differ further, in case the applicant wishes to undergo genital reasignement surgey (that is a procedur to re-shape the primary sexual organs) the applicant need the permission of the council. This technically only applies to genital surgeries of preformed within the Kingdom of Sweden.
As you can see both legislation are in regard to hormonal treatment and demands for surgery equal.
Page 7
3.1.1.1 Possibility for a transgender person to get married
a/ member States permit post-operative transsexuals to marry a person of the opposite sex to their aquired gender; BE, DK, DE, EE, EL, ES, FR, IT, LV, LU, NL, AT, SK, FI, SE, UK
This is not quite correct, in the first place a person who has obtained a legal gender recognition in Sweden can marry a person regardless of legal gender since the gender neutral marriage act was promulgatred on May 1st, 2009. Secondly, there have never been any requirement of being post-op per se to be granted legal gender recognition in Sweden. In case of FtM (transmen) this is rather the norm, to abstain from GRS due to poor quality of the surgeries available in Sweden at present.
Page 8
3.2 Change of Name and or forename in cases of legal gender reasignement
b/ In 14 Member States CZ, DK, EL, ES, FR, IT, LV, HU, NL, AT, PT, FI, SE the name can be changes after medical health evaluation and/or surgery and/or hormonal treatment.
In footnote 19 the report further states “In Sweden the procedure is is very heavy and requires Mental health evaluation, real life experiance, hormone treatment, surgery to alter one’s secondary sex caharcteristics and permanet sterility.”
This is quite erronous as there are no other requirements for legal change of name than the requirement stated in obtaining legal gender change until October 2009. In October 2009 the Supreme Administrative Court (Regeringsratten) decided that any person above the age of majority could upon his or her own application change their name to any name the chose to have.
Finally the Index 1 General Table contains errors concerning Sweden.
Gender Reasignement requirements
No provision – this is of course false there is a Law
Possibility to change name in case of gender reasignment
After medical evaluation and/or surgery this is also incorrect
Possibility to change birth certificate
No, but under rewiev
This is utterly false and is most likely due to an erronous note in the Transgender Eurostudy 2008, the person submitting the Swedish replies had no specific legal knowledge and hence this was entered as not possible.
If you go to the 1972 law, this is exactly the provision. If you obtain a legal change, all you personal records are changed.
In a number of European nationals Birth Certificates are not used, at least not in the same sense as in say, UK , Ireland and Aglo-Saxon nations.
Traditionally the records in Sweden were kept by the State Church and the parishes, upon the division of the State from the Church of Sweden this task was left to the Taxation Authorties.
A legal gender recognition has allways the consequence that all birth records are changed in the new gender. There is no such thing as a birth certificate in Sweden. In the situation that you need a document stating when or where you were born, you apply for a certificate that states this and this certificate will allways contain what’s on the official registrary on the day of issue.
I also suggest you update the information on Sweden in Annex 2 as well.
Best wishes,
Ms. Maria Sundin
fredag 9 juli 2010
tisdag 6 juli 2010
The Price of Enforced Gender Norms and Internalized Transphobia
Being the social worker and councellor I am, I love case histories – sort of eat them for breakfast. And one of the blessings with the internet are all the autobiographies out there. Many are very touching and deeply moving making feel so very humble to listen in. And during the small hours of the Barcelona GATE pre-conference we sat around and talked of our lives and memories growing in a multitude of cultural settings. Still I think we all recognized our selves in our sister and brothers stories, regardless of you came of age in Asia, Africa or the Americas and Europe.
Still on the internet and in counselling sessions I come across the stereotypical text book stories on being a girl trapped in a boys body that makes me think and wonder why would one fabricate histories like this, as I do belive they’re often fabrications, but for wht purpose? Is it that we do form hierachies within the trans and gender variant community? That being born a trans kid is like the cream of the crop and realizing you are gender variant and want to “transition from male to female” past 50, say would be at the bottom of the food chain? It is so sad, as it deprives those trans men and women of their sense of worth and dignity. No matter when you realize your difference or act on it you are just a human being that deserves respect and love.
Being one of those trans kind, still I acted on my my feelings of difference well into my middle age, for a number of reasons – many of them too self-destructive to be told here, which I hope will be fine with you. But I have no problem identifying with people who came out late. Still one task for us is to make peace with our inner demons and horrors of the past and count the blessings of being gender variant and part of a world wide tribe of people who have been around for ever.
BTW way, when the anger and rage of a stolen childhood and youth bubbles up, I either start to write something personal or political or put on some music, the best cure for this is playing bands like Ramones, Pistols, Sham 60, Cock Sparrer to name a few as loud as hell while writing. The music sort of absorbes my despair, hatered and anger and strangely the whole process turns into some sort of creative process. And yes,the personal is indeed poltitical!
The Cock Sparrer song “Take thm all, take’em alla – put them up against the wall and shoot them, short and tall watch them fall, come on boys take them all” sum up much of my feeling. And I do get into that mood, destructive yet constructive and empowering when I reflect of my childhood and adolescence. When I grew up, assigned male at birth, with a different gender expresson and completely oblivious of the reason why I was being told to behave normally, harassed, riduculed, beaten, sent to the psych ward and what have you, I still had no concept of that gender was something that came in a binary. That you were either the one or the other, a boy or a girl never dawned upon me until I was say eight – ten years old.
Well hard to belive as it might be, I was quite convinced that there must a number of genders and expressions of gender out there somewhere. I was convinced that there must be other kids like me – who were assigned boys at birth and that lived like girls. I was a reasonably smart kid, learned to read at four and read all sort of strange books before I went to elementary school and on top of that started my first stamp collection (yes I was a nerd allready at that tender age). I certainly did know what boys were and that they grew up to become men and girls would eventually become women. But how could I explain that there were so few kids like me, I must belong to a rare and unusual kind of gender och why was it that people seemed to hate my very existance. I didn’t matter what I did and how I behaved I wouldn’t be accepted as anything but human trash..
Apart from all the abuse and hatred I encounterd things grew from bad to worse when my little brother was born. I was six years old and soo thrilled, I would have a brother and I was there at all times to help my mum change diapers, wash him and giving him the pacifier when he dropped it and staeted to cry and just caressed him affectionately. My mum didn’t think that much of my behaviour, kids come in different packages don’t they, seemed to be her attitude.
My father was working abroad and would be away for weeks and months. My misfortune was that my father, eager to make a mark for him in the society, joined the Freemasons, and all important people in my town belonged to them. So one evening my dad asked one of the other Freemasons about the way I acted and it turned out this guy was a psychiatrist and to make things worse in charge of the child psychiatic ward. To make things even worse he was a dyed in the wool Freudian.
The reaction my father got was one of horror. You must stop this at all costs if you valeue the life of you new born. You devious son is trying to lure you into belive he shows love for is baby brother, but as soon as you turn your back, he’ll kill the baby instantly.
My father bought the whole thing and before I knew it I was put away with a dozen other maladjusted kids, mostly kids who were intectually challenged. They were BTW the first kids that tereated me as one of them and we became very good friends. I finally got out after a number of sessions of having my behaviour analyzed. The price was that I was put on a strong anti-psychotic drug called Thorazine (Hibernal) which would eventually transform me into a normal kid. The only thing it did was nearly to kill me as I went outside in our garden to enjoy the sun.
Slowly it dawned on me that there were no other genders and that the binary was stricktly enforced and that I would grow up to be a boy, and yong man and eventually a grown man. This seemed completely incomprehensible. The only thing I could think of was to escape this somehow. Sitting one summer afternoon in my grandparents outhouse looking through the magazine put ther in lieu of lo paper, there was this article on a Brittish marine officer and dentist, that changed from a man, in his navy uniform, to a woman that looked like most women did back then in the late 50-ies.
Well, I dared not keep the article but remember it by heart and the thought never leaved me, well if I could not find other beings like myself, being a woman was definitely a lot better that growing up to be a man. So while thinking of various ways of getting rid of what would make me grow into a man I had all sorts of fantasies. I used to make small figures of clay, complete with male genitals and then I would remove their penises and testicles and thought I got the solution of the problem.
Still my main problem remained unsolved. I tried to shove my genitals back into my body, but no chance they were there what ever I did. I became more and more depressed and gradually turned into an autistic adolescent kid whithout any hope of having a life.
To make matters worse, we moved to a big city and a new set of kids to torment me. I did go to school but never formed any friendships with the other kids in my boys only grammar school. The on my way to school, I stopped at a tobacconist who I knew also sold stamps just to see if he had any new and interesting stamps. In the window was a paperback book, Mario Costas book “From Man into Woman – the Extraordinary Life of Coccinelle”, I mustered all the courage I had and pointed and said that one. All my savings and money to buy stamps for was gone, but I had the book.
I spent the whle night reading about a young kid that grew up like me and who hade the guts to go her own way and become a woman and a beautiful woman to that. In spite of making me exited and pointing a way out, I went into an even deeper depression. Coccinelle was good looking and had the fortune to find a doctor to prescribe hormones and finally have her GRS at Dr. Bourou in Casablanca.
After leaving my blissful state of looking for other kids of my kind, I began to hate myself, my body, my penis and all that made me into a horrible, unlovable freak. There were now chance in hell a freak like me could turn into a young woman. Shortly after our daily newspaper hade an article that Dr. Jan Walinder was working with men who wanted to become women. I was so exited but the realized if I told my parents I needed to be a girl, I’d be sent back to the psych ward, and maybe they would never let me out again. So I began to be obsessed by getting rid of the poison in my body.
One dark night, all were at sleep in our apartement, I went an brought out a dozen ice cubes and salt. In physiscs class we have learnd that salt and ice would produce a low, low temprature and that you would be numb and not feel a thing. So I numbed my scrotum and proceded to open it up with a razor blade. I felt like nothing, but all of a sudden blood began to pour out of the incission. At first I thought it was ok, but after some minutes I began to suffer from the blood loss a d slowely drifted in to a semicouncious state.
My feelings were divided, one part of me said well no more pain no more hopelessnes, the other said maybe my mum would be sorry if I’m gone and as she was a very good mother I did get a bad consience. After an eternity I managed to slow the bleeding and stuggled to stay awake, knowing that if I fell a sleep I would never wake up again.
Still on the internet and in counselling sessions I come across the stereotypical text book stories on being a girl trapped in a boys body that makes me think and wonder why would one fabricate histories like this, as I do belive they’re often fabrications, but for wht purpose? Is it that we do form hierachies within the trans and gender variant community? That being born a trans kid is like the cream of the crop and realizing you are gender variant and want to “transition from male to female” past 50, say would be at the bottom of the food chain? It is so sad, as it deprives those trans men and women of their sense of worth and dignity. No matter when you realize your difference or act on it you are just a human being that deserves respect and love.
Being one of those trans kind, still I acted on my my feelings of difference well into my middle age, for a number of reasons – many of them too self-destructive to be told here, which I hope will be fine with you. But I have no problem identifying with people who came out late. Still one task for us is to make peace with our inner demons and horrors of the past and count the blessings of being gender variant and part of a world wide tribe of people who have been around for ever.
BTW way, when the anger and rage of a stolen childhood and youth bubbles up, I either start to write something personal or political or put on some music, the best cure for this is playing bands like Ramones, Pistols, Sham 60, Cock Sparrer to name a few as loud as hell while writing. The music sort of absorbes my despair, hatered and anger and strangely the whole process turns into some sort of creative process. And yes,the personal is indeed poltitical!
The Cock Sparrer song “Take thm all, take’em alla – put them up against the wall and shoot them, short and tall watch them fall, come on boys take them all” sum up much of my feeling. And I do get into that mood, destructive yet constructive and empowering when I reflect of my childhood and adolescence. When I grew up, assigned male at birth, with a different gender expresson and completely oblivious of the reason why I was being told to behave normally, harassed, riduculed, beaten, sent to the psych ward and what have you, I still had no concept of that gender was something that came in a binary. That you were either the one or the other, a boy or a girl never dawned upon me until I was say eight – ten years old.
Well hard to belive as it might be, I was quite convinced that there must a number of genders and expressions of gender out there somewhere. I was convinced that there must be other kids like me – who were assigned boys at birth and that lived like girls. I was a reasonably smart kid, learned to read at four and read all sort of strange books before I went to elementary school and on top of that started my first stamp collection (yes I was a nerd allready at that tender age). I certainly did know what boys were and that they grew up to become men and girls would eventually become women. But how could I explain that there were so few kids like me, I must belong to a rare and unusual kind of gender och why was it that people seemed to hate my very existance. I didn’t matter what I did and how I behaved I wouldn’t be accepted as anything but human trash..
Apart from all the abuse and hatred I encounterd things grew from bad to worse when my little brother was born. I was six years old and soo thrilled, I would have a brother and I was there at all times to help my mum change diapers, wash him and giving him the pacifier when he dropped it and staeted to cry and just caressed him affectionately. My mum didn’t think that much of my behaviour, kids come in different packages don’t they, seemed to be her attitude.
My father was working abroad and would be away for weeks and months. My misfortune was that my father, eager to make a mark for him in the society, joined the Freemasons, and all important people in my town belonged to them. So one evening my dad asked one of the other Freemasons about the way I acted and it turned out this guy was a psychiatrist and to make things worse in charge of the child psychiatic ward. To make things even worse he was a dyed in the wool Freudian.
The reaction my father got was one of horror. You must stop this at all costs if you valeue the life of you new born. You devious son is trying to lure you into belive he shows love for is baby brother, but as soon as you turn your back, he’ll kill the baby instantly.
My father bought the whole thing and before I knew it I was put away with a dozen other maladjusted kids, mostly kids who were intectually challenged. They were BTW the first kids that tereated me as one of them and we became very good friends. I finally got out after a number of sessions of having my behaviour analyzed. The price was that I was put on a strong anti-psychotic drug called Thorazine (Hibernal) which would eventually transform me into a normal kid. The only thing it did was nearly to kill me as I went outside in our garden to enjoy the sun.
Slowly it dawned on me that there were no other genders and that the binary was stricktly enforced and that I would grow up to be a boy, and yong man and eventually a grown man. This seemed completely incomprehensible. The only thing I could think of was to escape this somehow. Sitting one summer afternoon in my grandparents outhouse looking through the magazine put ther in lieu of lo paper, there was this article on a Brittish marine officer and dentist, that changed from a man, in his navy uniform, to a woman that looked like most women did back then in the late 50-ies.
Well, I dared not keep the article but remember it by heart and the thought never leaved me, well if I could not find other beings like myself, being a woman was definitely a lot better that growing up to be a man. So while thinking of various ways of getting rid of what would make me grow into a man I had all sorts of fantasies. I used to make small figures of clay, complete with male genitals and then I would remove their penises and testicles and thought I got the solution of the problem.
Still my main problem remained unsolved. I tried to shove my genitals back into my body, but no chance they were there what ever I did. I became more and more depressed and gradually turned into an autistic adolescent kid whithout any hope of having a life.
To make matters worse, we moved to a big city and a new set of kids to torment me. I did go to school but never formed any friendships with the other kids in my boys only grammar school. The on my way to school, I stopped at a tobacconist who I knew also sold stamps just to see if he had any new and interesting stamps. In the window was a paperback book, Mario Costas book “From Man into Woman – the Extraordinary Life of Coccinelle”, I mustered all the courage I had and pointed and said that one. All my savings and money to buy stamps for was gone, but I had the book.
I spent the whle night reading about a young kid that grew up like me and who hade the guts to go her own way and become a woman and a beautiful woman to that. In spite of making me exited and pointing a way out, I went into an even deeper depression. Coccinelle was good looking and had the fortune to find a doctor to prescribe hormones and finally have her GRS at Dr. Bourou in Casablanca.
After leaving my blissful state of looking for other kids of my kind, I began to hate myself, my body, my penis and all that made me into a horrible, unlovable freak. There were now chance in hell a freak like me could turn into a young woman. Shortly after our daily newspaper hade an article that Dr. Jan Walinder was working with men who wanted to become women. I was so exited but the realized if I told my parents I needed to be a girl, I’d be sent back to the psych ward, and maybe they would never let me out again. So I began to be obsessed by getting rid of the poison in my body.
One dark night, all were at sleep in our apartement, I went an brought out a dozen ice cubes and salt. In physiscs class we have learnd that salt and ice would produce a low, low temprature and that you would be numb and not feel a thing. So I numbed my scrotum and proceded to open it up with a razor blade. I felt like nothing, but all of a sudden blood began to pour out of the incission. At first I thought it was ok, but after some minutes I began to suffer from the blood loss a d slowely drifted in to a semicouncious state.
My feelings were divided, one part of me said well no more pain no more hopelessnes, the other said maybe my mum would be sorry if I’m gone and as she was a very good mother I did get a bad consience. After an eternity I managed to slow the bleeding and stuggled to stay awake, knowing that if I fell a sleep I would never wake up again.
söndag 4 juli 2010
Who's the person behind Transgender Health?
Well I’m Maria, a midlde aged trans activist, gender-variant woman and intersectionalist queerfeminist from Sweden. If you wish you can mail at ms.mariasundin@gmail.com
Born in Karlstad, and spent youth and childhood in Karlstad, Gothenburg, London and Grenna At six years of age incarcerated at the children’s psychiatric ward, Karlstad for GID in childhood – treatment not successful then treatment with Hibernal (powerful outlawed antipsychotic drug – but not diagnosed as psychotic just for GID). Sufferd abuse by other children and grown ups on a daily basis, I would bescribe my child hood and adolesence as living hell.
An the reason behind all this, I acted, walked, talked and behaved lika a girl, so a Freudian pshrink said to my parents, that I was a severly disturbed child and there was an iminent risk that I’d try to kill my new born baby brother, whom I adored and fussed about like any big sister.
After an even worse adolescence with suicide attemps and a botched autocastration attempts I had a mental breakdown. At puberty I changed from a thin stick insect of a child into a boy of sorts. My pelvis was wide as a girl’s (basically inherited my mother’s body shape), my breasts started to grow and my voice never broke.
The good thing finally was that I came to a boarding school in my late teens where people most of the time accepted me for who I was. After school, started out as a reporter/ journalist and left wing activist. Later trained in Social work and worked as a socialworker and councellor since the late 70-ies and from the mid 1990-ies in a senior position in social work and healthcare for the elderly and disabled.
Began building networks with trans activists on a personal level in the USA in San Francisco, late 70-ies and then in a more organised for from the early 1990-ies. Networking with gender activists in the USA and Canada such as the Transgender Nation people, TNT – Transsexual News Telegraph in San Francisco ( people such as Gail Sondegaard, Susan Stryker etc), TransSisters in St. Louis, Mo – the AEGIS Group at Atlanta, Ga, and Riki Anne Wilchins and the Transexual Menace groups. In Canada the Gender Trash people (Mirha Soleil Ross, Viviane Ki Namaste etc) and with Press For Change and Stephen Whittle and a number of German groups. Joined Benjamin, the Swedish TS group under the chairmanship of Anna Kristjansdottir and was active at various levels until it disbanded 1996. One of three trans women that founded RFTS in february 1997, later on in history changed it’s name to Benjamin and became a hotbed of TS separatism.
Worked as an activist for trans issues since then as well as extensive work with support groups, hotlines and individual counselling. Main focuses today is counselling, building support groups, and networking for trans human rights and for a paradigm shift in trans care – se my email for details.
I began HRT in the early 90-ies and came out as woman in 1997 and got my GRS and legal gender change in 1999. In 2000 I met my present partner and we got married in 2002.
I serve on the board of RFSL, the Swedish Federation for LGBTQI rights and my main focus are transgender health and human rights issues. I also serve on the board of the trans organsation KIM, and am in charge of the Local Organiazing Committee for the 3rd European Transgender Council in Malmo 2010. I’m also a member of the World Profesisonal Association for Transgender Health (WPATH) and serve on it’s Membership Committee. Representing RFSL and Sweden at the International Congress on Gender Identity and Human Rights in barcelona in June 2010.
Born in Karlstad, and spent youth and childhood in Karlstad, Gothenburg, London and Grenna At six years of age incarcerated at the children’s psychiatric ward, Karlstad for GID in childhood – treatment not successful then treatment with Hibernal (powerful outlawed antipsychotic drug – but not diagnosed as psychotic just for GID). Sufferd abuse by other children and grown ups on a daily basis, I would bescribe my child hood and adolesence as living hell.
An the reason behind all this, I acted, walked, talked and behaved lika a girl, so a Freudian pshrink said to my parents, that I was a severly disturbed child and there was an iminent risk that I’d try to kill my new born baby brother, whom I adored and fussed about like any big sister.
After an even worse adolescence with suicide attemps and a botched autocastration attempts I had a mental breakdown. At puberty I changed from a thin stick insect of a child into a boy of sorts. My pelvis was wide as a girl’s (basically inherited my mother’s body shape), my breasts started to grow and my voice never broke.
The good thing finally was that I came to a boarding school in my late teens where people most of the time accepted me for who I was. After school, started out as a reporter/ journalist and left wing activist. Later trained in Social work and worked as a socialworker and councellor since the late 70-ies and from the mid 1990-ies in a senior position in social work and healthcare for the elderly and disabled.
Began building networks with trans activists on a personal level in the USA in San Francisco, late 70-ies and then in a more organised for from the early 1990-ies. Networking with gender activists in the USA and Canada such as the Transgender Nation people, TNT – Transsexual News Telegraph in San Francisco ( people such as Gail Sondegaard, Susan Stryker etc), TransSisters in St. Louis, Mo – the AEGIS Group at Atlanta, Ga, and Riki Anne Wilchins and the Transexual Menace groups. In Canada the Gender Trash people (Mirha Soleil Ross, Viviane Ki Namaste etc) and with Press For Change and Stephen Whittle and a number of German groups. Joined Benjamin, the Swedish TS group under the chairmanship of Anna Kristjansdottir and was active at various levels until it disbanded 1996. One of three trans women that founded RFTS in february 1997, later on in history changed it’s name to Benjamin and became a hotbed of TS separatism.
Worked as an activist for trans issues since then as well as extensive work with support groups, hotlines and individual counselling. Main focuses today is counselling, building support groups, and networking for trans human rights and for a paradigm shift in trans care – se my email for details.
I began HRT in the early 90-ies and came out as woman in 1997 and got my GRS and legal gender change in 1999. In 2000 I met my present partner and we got married in 2002.
I serve on the board of RFSL, the Swedish Federation for LGBTQI rights and my main focus are transgender health and human rights issues. I also serve on the board of the trans organsation KIM, and am in charge of the Local Organiazing Committee for the 3rd European Transgender Council in Malmo 2010. I’m also a member of the World Profesisonal Association for Transgender Health (WPATH) and serve on it’s Membership Committee. Representing RFSL and Sweden at the International Congress on Gender Identity and Human Rights in barcelona in June 2010.
Transsexualism in Sweden - a mental disorder and the need for a paradigm shift in research and treatment
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!
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!
onsdag 30 juni 2010
National Board of Health and Welfare published their report on the recent overwiev of transgendender care in Sweden
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.
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.
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.
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