Abstract
Trans and gender diversity (TGD) has become one of the ‘hot topics’ in the academic and contemporary world. The celebrity Caitlyn Jenner made news headlines in 2015 coming out as transgender. Movies, for example, ‘Boys Don’t Cry’ (1999), ‘Transamerica’ (2005), and The Danish Girl (2015), have highlighted the challenges that trans people face within society. Even National Geographic published a special issue in January 2017 called ‘Gender Revolution’. In the past 10 years, there has been an increase in academic research in this field (American Psychological Association [APA], 2015).
TGD
TGD is seen as an umbrella term for people whose gender identity is different from their assigned sex at birth and/or who express their gender in non-traditional ways (World Health Organisation [WHO]), 2015). Gender identity is defined as the person’s internal sense of being male, female, both, on a spectrum or neither (APA, 2015; Wilson, Marais, De Villiers, Addinall, & Campbell, 2014). TGD is not related to a person’s sexuality, sexual preference, and/or attraction. It does not need to be in opposition to a person’s sex assigned at birth or one of the intersexes.
TGD persons experience incongruity between their self-identified gender and the sex assigned at birth (World Professional Association for Transgender Health [WPATH], 2011). They challenge, disrupt, transgress, play with, and/or blend cultural beliefs and social constructions about gender and sex (Psychological Society of South Africa [PsySSA], 2017). A recent study in South Africa indicated that over 3 million South Africans present themselves in gender non-conforming ways, of whom nearly 2.8 million people were assigned female at birth and about 430,000 people were assigned male at birth (The Other Foundation, 2016).
Many TGD people live their inherent gender identity through social transitioning, for example, dress code, behaviour, and cultural roles. Furthermore, an increasing number of trans and gender diverse people initiate change in their sex characteristics through gender affirming healthcare.
Depathologisation
Psychological and psychiatric theory and diagnosis of what are now known as transgender and gender diverse people began in the 19th century in the Western world (Drescher, Cohen-Kettenis, & Winter, 2012). Trans people were classified under the sexual deviation category as transvestitism. Over the years, the categories and diagnostic terms have changed. In the DSM-5, the term Gender Dysphoria is used, referring to:
[T]he distress that may accompany the incongruence between one’s experienced or expressed gender and one’s assigned gender. Although not all individuals will experience distress as a result of such incongruence, many are distressed if the desired physical interventions by means of hormones and/or surgery are not available. (American Psychiatric Association, 2013, p. 451)
In South Africa, and internationally, no formal epistemological study has been conducted concerning the epidemiology of gender dysphoria. Furthermore, the estimated prevalence is unknown due to TGD people’s fear of stigmatisation and marginalisation. Distress regarding the person’s gender incongruence, if not acknowledged, can lead to stress, anxiety, adjustment disorder, and major depression. Furthermore, most TGD people experience minority stress as they often encounter discrimination and marginalisation, which in turn can impact their mental health. Research indicates that suicide rates and life-threatening behaviour are elevated among TGD people. In the United States, the estimation is that 41% of trans people have attempted suicide (WHO, 2015).
The International Classification of Diseases (ICD) is currently under revision. In the ICD-10, the diagnostic term used is Gender Identity Disorder (GID) and falls under the mental and behavioural disorders (WHO, 2007). A person with GID desires to live as a person of the opposite gender to their natal sex (WHO, 2007), thus upholding and subscribing to the gender binary. As clinicians’ and experts’ understanding of TGD identities develops, the revision process has engaged in finding a new category for the diagnosis.
Although a strong argument has been made towards depathologisation (WPATH, 2011), the Southern African trans community has raised concerns regarding the depathologisation movement. In South Africa, access to gender affirming healthcare requires an ICD or DSM diagnosis. Usually the psychologist or psychiatrist will do an evaluation and issue a report to the endocrinologist, surgeon, or general practitioner.
The African context may be more sympathetic towards a person who has a diagnosis and is identified as having a mental condition than a person who diverges from what is seen and/or constructed as the norm. This would grant ‘the patient’ access to gender affirmative healthcare in order for the person to be ‘healed’ and become part of the ‘normative discourse’.
It has thus become important to find diagnostic criteria that will protect TGD people from being stigmatised while simultaneously facilitating access to healthcare (Wilson et al., 2014).
The model being developed by the ICD-11 task team is:
‘[M]ore reflective of current scientific evidence and best practices;
more responsive to the needs, experience, and human rights of this vulnerable population; and
more supportive of the provision of accessible and high-quality health care services’. (Drescher et al., 2012, p. 575)
Gender affirming healthcare
Gender affirming treatment focuses on medical interventions that effect physical changes to the TGD patient’s body, in order for their physical bodily presentation to align more closely to their gender identity (WPATH, 2011). Gender affirming healthcare can include the use of hormones, gender affirming surgery, speech therapy, as well as laser therapy. For some TGD people, the use of hormones and gender affirming surgery is a necessity in order to live authentically (McLachlan, 2010). However, for others, medical interventions are not necessary to live their self-identified gender (WPATH, 2011).
In South Africa, feminising and masculinising hormones are included in the National Health Department’s Essential Medicine List. But only a few hospitals in public healthcare provide hormone treatment due to the unavailability of endocrinologists and the lack of training in trans healthcare. Fewer hospitals provide gender affirming surgery, with Grootte Schuur hospital’s waiting period for surgery being 15–20 years (Wilson et al., 2014).
In the private health sector, hormone therapy and gender affirming surgery are more readily available, but most medical aids (health insurance) do not support trans healthcare. Hormone therapy and gender affirming surgery can alleviate gender dysphoria for many TGD people (WPATH, 2011). However, the struggle to access gender affirming healthcare creates further stress and anxiety.
Gender affirming healthcare is individualised, due to the diversity of gender identities and expressions (WPATH, 2011). Trans binary people (a person moving from one side of the constructed gender binary to the other side), people presenting with gender dysphoria and genderqueer/gender fluid persons may wish to access gender affirming healthcare. In South Africa, trans healthcare providers tend to uphold the gender binary and only offer support when a person wants to transition from one gender to another. This creates a further burden on the trans and gender diverse person as he or she/they struggle to access healthcare.
The role of the psychological professional
The psychologist frequently assesses the client before they access gender affirming healthcare. Through this assessment, the psychologist explores the development of gender identity; childhood experiences, interaction with the gendered world; development and experience of gender dysphoria, and/or incongruence; possible psychopathological comorbidity; the impact of stigma; support systems; ability to consent, as well as the client’s hopes and dreams of change through gender affirming healthcare. The psychologist also explores the person’s understanding of treatment, possible consequences and side effects, and their understanding that many aspects will be irreversible (WPATH, 2011).
The psychologist has often been seen as the gatekeeper, since the psychological assessment and diagnostic process determine who could access gender affirming healthcare. The repercussions of this paternalistic model have severe consequences within the TGD mental healthcare field, as many clients do not trust the clinician and see the psychologist as a person wielding too much control and power.
WPATH (2011) Standards of Care–7 (SOC-7) states that psychotherapy is not essential before accessing gender affirming hormonal treatment and/or surgery highlighting a preference for the informed consent approach. The patient’s understanding of the physical and psychological benefits, limitations and risks of gender affirming healthcare, the possible psychosocial implications, as well as the ability to consent underpin the informed consent approach (APA, 2015; WPATH, 2011).
This approach has contributed to a participatory model in mental healthcare. The psychologist explores with the client their reasons for accessing gender affirming healthcare as well as viewing the client as the expert regarding their own lives. The psychologist can also play an important role as the TGD person transitions. Not only will the person experience physical changes but also mental and emotional fluctuations. The person may also experience changes within their relationships (romantic and sexual attractions may shift) and interactions in certain contexts. The client might also experience feelings of loss and the psychologist and/or counsellor can play an essential role as the person goes through a stage of bereavement (McLachlan, 2010).
Often the psychologist advocates (WPATH, 2011) on behalf of their TGD client in the following areas: access to gender affirming healthcare, gender marker change at the government department responsible for the registration of citizens (in South Africa the Department of Home Affairs) within the workplace, the community context, as well as in the client’s family structure. The psychologist can also support the significant other, children, and family members through the process of transition and by providing relevant information. Support groups have played an important role in the world of trans healthcare and offer the opportunity for TGD people to explore their gender identity and express their gender role. The group can also share valuable information including their own lived experience in the gendered world.
Mental health professionals can contribute to the world of trans healthcare through research, training, advocacy, and policy development (WPATH, 2011). The psychologist needs to be aware of the ethical guidelines, as well as being involved in continued professional development in this fast-evolving field. PsySSA’s affirmative stance on sexual and gender diversity, as well as the newly developed guidelines (PsySSA, 2017), can support the psychological professional working in this field.
Conclusion
Although the field of trans and gender diverse healthcare is still in its infancy in South Africa, research opportunities are vast, as the experience and narratives of African trans and gender diverse persons need to be shared. As psychologists and their clients explore the gender binary, the psychologist can support clients’ coming into being through embracing their own gender identity. Research indicates that through accessing gender affirming care, the trans and gender diverse client is able to alleviate gender dysphoria and live a more fulfilling life. As psychologists, we are advocates for our clients and can challenge institutional obstacles and unwelcoming spaces.