By Dr Tracie O’Keefe DCH presented at the Health in Difference Conference (part of the Sydney 2002 Gay Games conference programme) 2 November 2002.
Sex and gender diverse people include a series of identities of people who are transsexual, transgender, intersexed, androgynous or who choose to be absent of sex and gender identity. Some of these identities occur due to a physical manifestation of differences in primary and secondary sex characteristics; other people need, want or desire to live as a sex and gender other than was ascribed to them at birth. In formulating these descriptions I would like to say that such descriptions are general and dependent upon our current understanding in the world of medicine, physiology, psychology, and sociology.
When looking at the access of medical, psychological and social services for sex and gender diverse people, within state funded social medicine, it is important to consider the global perspective. This of course gives a very different picture in different parts of the world. We have to look not only at different cultures, political systems, religions, economic situations and family dynamics, but also at the individual’s access to knowledge about sex and gender diversity itself. Sex and gender expression is dependent on the individual’s ability to describe their physical sex and social interactions as well as a reflection of their understandings of such concepts.
Primarily access to state-funded healthcare in assisting people with sex and gender diversity in different countries is dependent upon the availability of social funding in healthcare systems to treat individuals who complain of having a medical, psychological or social problem. Generally no healthcare system pays for treatment which it deems to be of a vain nature and considers unnecessary according to that country’s social belief systems.
As far as accessing professional help in the private sector is concerned, that is a panacea of choice for those seeking to alter their sex and gender identity who can afford it. Money, as they say, talks and people seeking any kind of treatments in the private sector are able to choose from many centres of excellence in the world and many other private practitioners who do not generally impose the kind of restrictions encountered in social healthcare systems.
In the UK the National Health Service (NHS) provides funding for people complaining of sex and gender dysphoria (commonly known as Gender Dysphoria) (Press for Change website archives). This is a medically recognised pathology (DSM IV), with high suicide rates and high rates of depression unless treated. This is also true in Holland, France, Germany, many parts of Europe, parts of Australia and some other countries. Even China is now included in this group of countries.
In the USA there is a movement that seeks to get insurance companies to pay for the help that sex and gender diverse people need. Since that help can often be very expensive, those companies over the years have tried as hard as they can to treat sex and gender dysphoria as cosmetic surgery for which the insured may not be covered. Many medical and non-medical civil rights campaigners have, however, tried to classify sex and gender dysphoria as a life threatening illness and the insurance companies are now finding themselves in the position of increasingly having to foot the bill for treatment.
Such treatment may include counselling, psychotherapy, use of psychological or psychiatric and social services, endocrinology, and sex and gender realignment surgeries that are designed to bring the person’s body in line with what the individual believes is comfortable for them. The impetus of those treatments from the average clinician’s perspective is to move the client away from any distress they are suffering because of their physical and psychological manifestations.
There are countries where there is sufficient social funding within government coffers for healthcare facilities to afford the system to help people complaining of sex and gender dysphoria, but it is not made available due to political or religious objections. The objections to helping people who are sex and gender diverse can come from religions and political systems that have extremist points of view and see sex and gender diverse people as being mentally ill, morally depraved, sexually perverted or possessed by evil spirits.
The political objections are generally an extension of vilifications that politicians use against minority groups to try and gain popularity support for right-wing policies that can include phobic reactions against people who are sex and gender diverse as well as lesbian and gay groups. Those objections are often confused forms of homophobia that translate into varying forms of transphobia. Intersexed people are often confused with people who have varying forms of trans-identities and also suffer from the same kind of misplaced prejudices.
Places like Saudi Arabia, Malaysia and other countries have laws that prevent many sex and gender diverse people integrating into society and realising their health needs. In these countries sex and gender diverse people are often seen as being gay and those countries have very high levels of homophobia both legally and socially because of many of the religious views held in that country. When a person is too afraid to seek healthcare because of fear of persecution, they often prefer to remain with their problems rather than expose themselves either to healthcare professionals or generally in society.
Another major problem sex and gender diverse people face is when they find themselves in need of help from healthcare professionals and either they or the professionals themselves often know very little about the natural sex and gender variance that occurs both via nature and nurture. They can suffer clinical abuse through ignorance and much more education needs to be done in training those professionals.
In an ideal world people should not have to concede to being patronised and pathologised with sex and gender dysphoria in order to qualify for treatment that will help them define their sex and gender diversity. We do not, however, live in an ideal world and when health systems spend money helping people with sex and gender issues they are always thinking about how they will justify that expenditure to the tax payer.
Times are changing, as we understand more about variance in nature and nurture, and sex and gender diverse people need to be able to access social medicine and ancillary services through the healthcare systems the way they have been able to access care through the private sector. Once sex and gender diverse people have undergone medical, psychological and social assistance to help them with their physical or mental problems they generally become contributing members of society, who pay back into the tax system, and are responsible citizens. It is a false economy to discriminate against this sector of society and deny them the kinds of physical and other help they need. It is also an abuse of human rights to discriminate against anyone on the basis that they do not physically, psychological, or socially fit into the typical sex and gender stereotypes.
Poverty is also a very real factor concerning sex and gender diverse people as they suffer high levels of social ostracisation and denial of access to work. Many become virtually imprisoned in the poverty trap as social rejects who are unable to survive to minimum social standards within those societies. Passing as male or female is often seen as a ticket to liberation from that social imprisonment, but ultimately if passing as male or female is taken as the standard for accepting sex and gender diverse people, then they are reimprisoning themselves or being reimprisoned back into a society that is phobic about diversity. The people who do not or choose not to pass are further pushed into an even lower class of disadvantaged sectors of society.
People are able to access conception, abortion, IVF treatment, circumcision and vasectomy without being pathologised, so sex and gender diverse people need to be able to access help for sex and gender diverse expression in the same way through public sexual health services.
DSM 1V: Diagnostic and Statistical Manual of Mental Disorders, American Psychiatric Association, USA 1994.
Press for Change (UK campaign and lobby group) website www.pfc.org.uk