Tuesday, June 11, 2013

Cuban Paper Adds Weight To Wider Swing in Transgender Classification


Far from the stereotype. Cuban medicine reflects a growing narrative in other Latin countries, rejecting the dominant western view that has pathologised departures from narrow gender role expectations.

The modern western explosion in consciousness about the lives, needs and expectations of trans people can be traced back a quarter of a century to the late 1980's and early 1990's … with a massive acceleration driven by access to first personal computers, then email and finally the world wide web during those years.

In the past 6 or 7 years another acceleration has occurred because of social media and the easy access to blogging platforms.

This is not to suggest that there was no debate about trans lives previous to that point.

The Just Plain Sense Podcast channel illustrates several first person accounts of life when trans people networked and discussed the way they were portrayed through social encounters, conferences and letter post. (See here, here and here)


Those discussions were limited back then by geography and the ability for people to find one-another. People in Britain saw themselves mainly in the context of only their own culture. There was a similar pattern in the United States, but with people spread even further apart.

A wider consciousness needed to wait for the arrival of electronic communications. And then discussions moved to being limited by language. There was wider comparison of views, but only to a point.

It is not surprising, perhaps, that as British and American activists enthusiastically embraced email and list servers and then the web, the writing was in English and about western anglophone ideas.

As that experience of life was moulded by a transatlantic consensus among a small number of clinicians who brought the same medical viewpoint to both shores, it is also not a surprise that so much of what you will find online … in either activist or clinical narratives … follows the same pattern, critiquing the effects of the same medical viewpoint.

You could be forgiven for imagining that nobody outside of the United States, Britain and Europe has (or had ever had) anything to say about the existence of trans people.


That notion is incredibly naïve of course.

The most cursory historical and anthropological analyses reveal that trans people are found in all human societies and throughout history.

Colonisation may have tried to suppress the ways that societies embraced trans people, and history has to be recovered from attempts to erase it, but it is all there.

As activism grew and matured, westerners have realised the need to piece together the other parts of the puzzle.

Through networking and overcoming the language barriers, people have developed a wider view … understanding that whilst people and societies in far flung places may have adapted and conceptualised transgender-like lives differently, the underlying human phenomenon was essentially the same.


Ironically, whilst trans activists may have developed that kind of understanding over the last two decades, the dominant medical narratives have been slower to move from a landlocked state.

Clinicians have been through the same horizon-widening experience … only more conservatively.

When the International Classification of Diseases (ICD) was last ratified in 1990 (and published in 1992) the classification of trans experiences had changed very little from the previous version published in 1975. And these were exclusively western classifications, created by North American and Western European clinicians from essentially a single stable, imposed as a viewpoint for the rest of the world to follow.

This is not a phenomenon restricted to trans medical diagnoses. It happens across medicine and has been particularly felt in the areas where western pharmaceutical interests have had a stake in controlling classification.

This is why it is important and refreshing that the World Health Organisation seems to be embarked on a much wider consultancy-based process, based on modern web tools, to involve many more people in agreeing and ratifying the next ICD revision.

And this, in turn, is throwing light on a much more diverse understanding of trans identity, as clinical teams start speaking up to show that they don't embrace the kind of western-led pathologisation of difference which has passed for evidence-based medicine before.

Consensus process

It is now almost six months since WPATH and international advisors such as myself met in San Francisco to discuss a wider consensus for how the ICD revision should look. I reported on that event in February and noted the wide spread of countries involved: Canada, China, Venezuela, Bahrain, Argentina, Cuba, Australia, South Africa, Turkey and plus the Europeans (Belgium, Sweden, the Netherlands, Norway, Spain and the UK).

The formal report on that meeting will be published in a few days from now. It will add layers of detail about the discussions which I didn't cover in my blog report … although the bottom line is the same of course.

The Cuban viewpoint

One appendix to that forthcoming report will be a paper from the Cuban National Commission for Comprehensive Care of Transsexual People. The paper was something which we had discussed during the meetings, with the Cubans joining us by video link.

I haven't been able to share the content before as we were unable to determine whether the Cubans were happy for this at the time. However, as it is now being published as part of the WPATH report, I think I can now safely share the substance.

The authors explained that the National Commission for Comprehensive Care of Transsexual People (Cuban Gender Team) is working on the modification of the protocols of health care for transgender people in Cuba.

Our group believes that progress should be made towards psycho-depathologization of trans-sexuality and other trans identities, as expressed in the Declaration of the Cuban Multidisciplinary Society for the Study of Sexuality (SOCUMES), adopted at its General Assembly in 2010. Therefore, we support the position of the World Professional Association for Transgender Health (WPATH) on the legitimacy of multiple trans-identities and the need for psycho- depathologize them.

They continue:

We do not support to uphold gender dysphoria as a requirement for transgender people, transgender or gender nonconformity to be able to access to hormone treatments and surgical sex reassignment. Not all ailments requiring health care should be interpreted as diseases. Health care is a human right. However, we understand that the current characteristics of most health systems in the world, do not allow for other alternatives. The Cuban health system meets the standards designed by the WHO in relation to universal and free access to all services. Public health in Cuba has a social and preventive approach; it does not only focus on the attention to syndromes or diseases, but also deals with the attention to aches and social demands of quantitatively minority groups. For this reason, we advocate the possibility of including health care of trans-people in a Z Code (health ailments that are not considered diseases and contact with health services).

The insertion of transsexualism in the DSM and CIE was not based on scientific evidence, but on a pathologizing interpretation of all those expressions that deviate gender from the binary standard. Throughout history, many people have suffered from anxiety, depression and   rejection to their body due to their anthropomorphic features, such as skin color, and they are not classified as mentally ill. So, we wish to imply that in the absence of scientific evidence showing that trans-sexuality and other gender identities/roles are mental disorders, we support the removal of trans identities form the section of mental illness.

(CIE is the Cuban acronym for ICD)

At the WPATH consensus meeting on the nomenclatures proposals for health care of trans identities of CIE-11 the inclusion of the term «gender incongruence in adults and adolescents», «body-gender dissonance» and «gender incongruence in childhood» were discussed. Our positions on these issues are: We disagree with the use of the term «gender incongruence» because it reinforces stigma and discrimination against these people. The term incongruence implies anomaly or disorder. We do not consider gender should be deemed «incongruent» in its diverse, fluid and heterogeneous expression. Moreover, the use of the term «body-gender dissonance» means recognizing gender construction exclusively from the sexual difference viewpoint. Many trans-people do not take the appearance of their genitals as a reference for their identity and gender role; nor does it apply to persons with ambiguous genitals who feel they belong to either gender. The term dissonance also has pathologizing implications. For these reasons, we prefer the term «gender nonconformity» as it has no implications of abnormality or disturbance and means that, regardless of the body, the person does not identify with the legally and culturally assigned gender. The above nomenclature, although not quite perfect, can be applied also to persons who are identified as intersex or those who express a gender different from the one assigned. In regard to «gender incongruence in childhood», we believe that it should not be considered a mental disorder and should not be included in any classification of CIE-11. The infants with gender nonconformity do not require hormone treatments until reaching puberty or surgical treatment until they reach adulthood. Health care to this group of people consists in the psychological attention to relieve distress that the mismatch with the gender assigned at birth generates them. Most infants with gender nonconformity do not show a gender transition when they reach adolescence and adulthood. It is also essential to relieve the distress of parents and to work with the rest of the family and the school and community contexts from a more flexible and fairer gender approach. We also reaffirm the need to consider the bioethical aspects in managing gender variant children, concerning respect for their dignity and autonomy, as well as to decide the actions of affirmation of gender identity/role together with the family, considering always the child's best interests.

This contribution is significant because it widens the consensus for moving away from earlier narratives. It ensures that the movement for this is not seen as a parochial one, but a viewpoint which is emerging in widely different health systems and cultures.

For the Cubans this is no sudden overnight change. Early in 2010 the Cuban Multidisciplinary Society for the Study of Sexuality (SOCUMES) proposed a clear declaration on depathologisation and a paper published in April 2012 sets out the reasoning in more detail.

The rest of the world

Some may regard Cuba as separate from the rest of the world ... trapped in a bubble by long isolation. But we see this kind of language emerging more widely among other latin countries, with countries such as Argentina passing laws which put parts of the West to shame.

The proposals from the WPATH/ICD consensus process will now be subjected to much wider international scrutiny, through a process which determines whether clinicians think the new language works in their own practice. This will highlight whether there are parts of the world which cling to past ideas and don't like such moves to depathologisation and more facilitative language.

The language adopted by Cuba's clinicians gives hope that change really is rolling in though.


Alex Kingsley said...

One only has to look at the treatment of two-spirit people amongst native americans to see what lengths western european settlers were prepared to go to to eradicate them. Hopefully, we will start to get a more universal perspective on gender non-conformism, not just the western european/non-native american misconception. looking good, so far.

HenryHall said...

I'm always amazed that the people who discuss these things fail to see the crucial difference between clinical utility and convenient diagnostic taxonomy.

An argument, advanced most recently by Jack Drescher but frequently by many others, for retaining a pathological gender nosology is that it opens the door to (funded) treatment. How can people miss that such an argument is inherently unethical? Without a good faith belief in a genuine psychopathology or in a genuine somatic cross-sex pathology it is plainly immoral, as well as unethical, to justify a transsexualism (etc) diagnosis on that basis.

The Cubans have it right. Z-code(s) are needed. The only justification that is (should be) needed to invert a person's sex in their medical records is that (in an attending physician's professional opinion) it would promote the patient's health to do so. ICD Z91 or similar.

No other justification is needed and medicine will henceforth never be cross-sex relative to the newly assigned sex. This simple Z-coded paperwork change removes the so-called ethical dilemma of cross-sex medicine from being a factor.

Medicine has forgotten that it is the art of health, and not the science of human organisms. At least they have conveniently forgotten it where transfolk enter the picture.

Christine Burns said...

I agree with you there Henry, and indeed it was raised in the course of the February consensus meeting.

Classifications should only exist because they describe real conditions or needs which clinicians have a part in understanding, treating or ameliorating. If diagnostic categories are created or maintained just in order to satisfy the needs of accountants and policymakers then the whole process is called into question. And then, as you say Henry, the form of the classification must provide clinical utility. It must help, not hinder.

The WHO clearly recognise this in their principles for this revision of the ICD. The fundamental test for inclusion is clinical utility. This brings a different discipline than has hitherto applied.

The other thing that I see as important is global consensus, as an essential check on culturally relativistic diagnosis.

If western clinicians regard something as an illness when others regard the same symptoms or behaviour as normal variation then the alarm bells should ring. I contend that this hasn't happened in the past because of the ways that revision processes have been dominated by some countries and their social or religious beliefs. The hope is that modern communications can ensure a far wider search for consensus this time around. Of course this is something that could not happen to the same degree in revising the DSM, which reflects the parochial social content of North America.

HenryHall said...

Christine writes: The WHO clearly recognise this in their principles for this revision of the ICD. The fundamental test for inclusion is clinical utility.

The crucial point is that inclusion on a basis of clinical utility, without more, is unethical. If money is involved it is fraud. Clinical utility may be desirable but as justification it is insufficient.

By way of illustration you could imagine diagnosing hypertension for everyone who has headache. For reason that it has clinical utility in that Aspirin is proven to cure headache and Aspirin is a scientifically valid accepted treatment for hypertension. Clearly bogus, clearly unethical in that example.

So too the diagnosing of dysphoria in transsexual people.

What should be diagnosed is the thing that it is proposed to treat. Not the mind.

Vivienne said...

Several comments to make here. First, what I see is yet another attempt to add a layer of complexity to what is already a hopeless morass of bewildering and unhelpful terminology and nomenclature about gender.

Second, medicine must be based on science. Even now a lot of medicine is based on history, superstition, media distortion and opinion. We are just beginning to make some headway in this regard, and to abandon that would be foolhardy.

That said, once the foundation of medicine is science, the rest should be about compassion. I think in general Western medicine has not been especially compassionate to transgendered individuals. I welcome initiatives to correct this.

But I think there should be safeguards; some limitations imposed on who has access to hormones and surgery. Especially where children are concerned. That's not anything to do with money but a careful balance of risk vs harm, as with any intervention.


HenryHall said...

@Vivienne >> Second, medicine must be based on science.

That is definitely not a settled issue. There are those, including myself, who believe that medicine should be based on healing and health.

Science and health typically coincide in medicine, but not always. Transsexualism being possibly the best example of collision (some might say allision).

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