Reading between the lines

International Day for trans depathologisation

The news announces it this way: “For the first time in history, the World Health Organization (WHO) will throw out transsexuality from the chapter on ‘Mental and Behavioral Disorders’”. But (full) depathologization of gender diversity still seems a remote point on the horizon. What is good and what is better? We asked a key activist who helped create the Argentinian Gender Identity Law, a model for global policy. Mauro Cabral is co-director of Global Action for Trans* Equality (GATE), where he coordinates an international initiative to reform the Eleventh Edition of the International Classification of Diseases (ICD).
After two years of deliberation and pressure from depathologization activists, WHO recently removed the current diagnosis of “transsexualism” from the Mental and Behavioural Disorders chapter of its online [beta edition, transl.] version of the ICD-11, replacing it with a new category of “gender incongruence” in a new chapter on Sexual Health. Does this mean that trans people are not pathologized in the proposed classification? What does it mean, to “depathologize”?
For many trans advocates, depathologization is an emancipation struggle. The terminology itself also is contested. For some, it means full access to rights without any diagnostic requirement; for others, depathologization means eliminating diagnosis andmedicalized control over individuals’ bodies. There are tensions among advocates round the role of medicine in defining diverse trans experiences and around ownership of the body. Does the need for surgery and hormones represent a radical prosthetic incorporation with medicine as the tool, or does it express conservative forms of technological expropriation of the body in alienating times of biocapital?
Mauro Cabral summarizes it this way: “From one perspective, depathologization looks in a way like a Moebius band: striving for the maximal personal freedom seems to put he masking of biomedicine as regulatoryprinciple for transition on the line; settling for less personal freedom risks perpetuation of current biomedical dogma, which diagnoses the wish to transition as personal and political pathology.”

There was a consensus in activism that transsexuality should no longer be considered as a mental illness by 2012. Now it is 2014, and this dream is still unmet. Is everything lost?
You are right. The world in which identifying as a gender different from the one assigned at birth is considered pathological did not end. However, in that time both the Diagnostic and Statistical Manual of Mental Illness (DSM) and the ICD went through an intense process of revision and reform.
What does this new version [of DSM] entail?
First, we need to clarify that, categorically, any diagnosis in the manual of mental disorders is by definition a mental disorder. Now they renamed “gender identity disorder” with an older clinical term of “gender dysphoria.” Where the previous diagnosis pathologizes trans people just for who they are, the “new” category can be seen as a step forward, because it puts the clinical focus on the trans specific experience of (the) suffering and stops when this disappears. In all the world materially or symbolically governed by the DSM and its codes, trans people stay trapped in one form or another of mental illness, and we continue to be cataloged as sufferers.
We need to remember that diagnosis in the DSM Manual is still a conditio sine qua non in many countries in the world, to access rights, like legal recognition and physical medical interventions. For example, the “treatment” for diagnosed suffering, that are still seen under this mark, and never as a biotechnologically mediated self-expression.
And in the case of the ICD reform?
The ICD Working Group called together by the World Health Organization agreed to reduce the scope of the diagnosis and proposed to scrap the current mental diagnostic categories that affect trans people, including “gender identity disorder” and “transvestic fetishism,” among others. This is fundamental: they finally recommended to remove any mention of trans issues in the chapter on mental health disorders. They also proposed new categories in a new non-psychiatric chapter on Sexual Health, including “gender incongruence of adolescents and adults,” and “gender incongruence in childhood”.

In what sense is the new category “gender incongruence” better than the previous?
Gender identity disorder” is such a damaging diagnosis that almost any replacement category would be at least a bit better. In that sense, “gender incongruence” also avoids diagnosing trans people just for who they are, paying attention to the discomfort that the incongruence could cause between the gender identity and how it is embodied. However, obviously, you can only pathologize incongruence by implicitly invoking a cissexist ideal of (bodily, identitary or expressive) congruence. Also, incongruence is taxonomically linked to suffering and congruence is linked to happiness, with medical approval enjoyed by the congruent, but missing for the others. In other words, it is proposed that identifying as a gender different from the one they gave us at birth stops being a disorder (mental or otherwise), but now the possibility of living our gender in a non stereotypical, dissident, incongruent way could be in danger.
Why then not fight for eliminating any diagnostic mention once and for all?
The answer is both ground for pride and pain: only one country in the world, ours, Argentina, admits access to legal gender recognition and transitional health services without requiring a diagnosis, psychiatric or otherwise. Denmark recently enacted a similar policy, but only for legal recognition. This means that, in the rest of the world, people who need to have their legal registration or their bodily configuration changed will still need a DSM or ICD code to access these modifications (every time that access not only means authorization but also public or private health coverage). None of these considerations, however, justify the introduction of the category, “gender incongruence of childhood.” Resisting this classification is a focus of our efforts.

But why pathologize trans children?
The simplest explanation is that gender diversity in childhood is still culturally unacceptable, but the “rational” arguments are different. One focuses on the anxiety that daddies and mommies of children, who rebel against social expectations around their sex, may have. So children are pathologized as therapy for adults. Another argument emphasizes diagnosis to facilitate expansion, funding and publication of research on gender diverse children. This argument is both perverse and faulty. There are decades of research and publication on homosexuality, which has long been depathologized. A third argument asserts that diagnosis guarantees inclusion [of gender diversity topics] in education, in a world where sex segregation is so naturalized and depoliticized, and where, sadly, a diagnostic framework still is considered more effective than a human rights framework. Last, both the old and the new diagnoses are justified as providing an archive of clinical history.
What would the function of this archive be?
Inasmuch as the first biotechnological transitional intervention is the administration of puberty hormone blockers, there are [experts] who consider a childhood diagnosis necessary for immediate access to treatment. This position universalizes the need for diagnosis, based on a treatment that is only available in a couple of countries, and it naturalizes that need. Unsurprisingly, the “gender incongruence in childhood” diagnosis is defended precisely by those medical teams that provide the treatment. Even worse, this argument installs hormone treatment as common fate, imposing early diagnosis as a way of ensuring later transition. As medical policy experts like Sam Winter and Simon Pickstone-Taylor have stated: it is obvious that those arguments fail at the hour of tending to the two biggest necessities of the children: to grow up in a world that does not impose normative forms of masculinity or femininity on them through submitting them to a diagnosis, and the need for information, support and containment.
If they eliminate the diagnostic criteria that pathologize gender diversity in childhood, what would happen with those trans children that need special health care?
The ICD already contains and will keep, non-pathologizing codes, that permit access to assessment and professional support when needed, without any diagnosis of physical or mental disorder. In those circumstances where treatment is needed for depression or anxiety of the child (oftentimes produced by hostility and rejection around them), the ICD already contains general codes that cover the issues1.

Can intersex also be approached from a depathologization perspective?
Without a doubt, although the processes and the issues are different. Approaching intersex from a depathologization perspective affirms bodily diversity, which should never be seen as a pathology. It also means the careful work of distinguishing in every intersex body those characteristics that need medical attention those that don’t. Depathologization activism must also articulate the irreversible consequences of pathologization, including the chronic pain, the sterility, the mutilation and the genital insensitivity, post-surgical trauma, fistulas, chronic infections, and metabolic changes caused by surgical removal of the gonads or pharmacological treatments to “normalize” the body. This is the register of how pathologization makes us ill.
What impact do terms of “disorders of Sex Development” have on the fight to depathologize intersex?

Since the mid-1990s, the intersex movement has disputed the jurisdiction of biomedicine over intersexuality. Even the medical terminology evidences bias and cruelty. At the end of the 19th Century, mythological hermaphroditism was redefined as a category for clinical use and accompanied by many pseudo-hermaphroditisms to expand diagnostic range. By the mid-1920s, a more specialized vocabulary emerged with terminology about intersex bodies, although the old terms still remained. The struggle and success of the intersex movement in the 1990s, to depathologize intersexuality and to appropriate, subvert, and transform diagnostic intersex terminology into a political identity was answered in a new pathologizing attack.
In 2006, a new classification was created, that reorganized the spectrum of intersex bodies into a taxonomy of “Disorders of Sex Development.” As intersex researcher Georgiann Davis argued, this label reestablished medical authority over that jurisdiction in dispute: our bodies. A central aspect for the depathologization of intersex today is resistance to the imposition of this vocabulary and its variations. For the intersex movement, there is an intrinsic relationship between nomenclature and treatment. Mirtha Legrand notes: “As they see you, so they treat you”. Advances in genetic and in fetal monitoring technology has extended the boundaries of medicalization to reach intersex embryos. They are often de-selected in preimplantation diagnostic procedures that promote selective abortion of intersex fetuses and prenatal drug administration to “prevent” the birth of intersex children.
Which are the political consequences of intersex pathologization?

Intersex activism itself is being psychopathologized and dismissed as a political symptom of disordered bodies. Because normalizing medical interventions usually take place in early childhood, intersex genital mutilation in infancy seems to infantilize the movement. In that way they mutilate our capacity to be seen as adult activists with more than 20 years of experience in a sustained struggle. In spite of this oppression, the strong presence of intersex activism in regional and international human right systems has decisively contributed to the recognition of these medically unnecessary and non-consentual practices as forms of torture. Like medical abuse and forced, coerced or involuntary sterilization, these medical practices are violations of human rights.
What does depathologization mean for someone who like you lives the consequences of trans and intersex pathologization?
For years there was a prayer in the Spanish-speaking world that affirmed:
My body, primary territory of peace”
I would like to able to subscribe to that, one day. Today is not that day. As long as this war continues (or as I live), what remains of this body is my primary battleground.
1 These existing codes may be augmented with Z-codes, to clarify special needs of trans and gender diverse children (for example, when anxiety is caused by transphobic school bullying).
This interview appeared first in Spanish in the Argentinian newspaper Página 12, on the occasion of the International Day for the Depathologization of Trans Identities, October 18, 2014

 Κυριακή, 26 Οκτωβρίου 2014 | 20:30 

Παγκόσμια ημέρα ευαισθητοποίησης για τα Μεσοφυλικά-Intersex άτομα.


 Της Πάρβη Πάλμου για το

Σήμερα 26 Οκτωβρίου είναι η παγκόσμια ημέρα ευαισθητοποίησης για τα μεσοφυλικά-intersex άτομα και αποφάσισα να πάρω λίγο χρόνο ώστε να παραθέσω κάποιες πληροφορίες.

Δυστυχώς είναι αδύνατο να γνωρίζουμε επακριβώς τον αριθμό των μεσοφυλικών ατόμων διότι τα στοιχεία που έχουμε είναι ελλιπή και τα μεσοφυλικά άτομα βρίσκονται στην αφάνεια. Υπολογίζεται ότι ένα παιδί περίπου στα 1500-2000 άτομα γεννιέται με γεννητικά όργανα που δεν μπορούν να καταταγούν στο δίπολο του φύλου και από αυτά το 0.1-0.2 % υποβάλλεται σε επανορθωτική επέμβαση γεννητικών οργάνων (Blackless et al., 2000). Τα άτομα που γεννιούνται με ασαφή γεννητικά όργανα απ’ ευθείας παθολογικοποιούνται διότι δυστυχώς “το σύστημα υγείας θεωρεί ακόμα παθολογικό οτιδήποτε ξεφεύγει από το δίπολο του φύλου” Woweries (2012: 71). Οπότε σε αυτό το σημείο τα προβλήματα που αντιμετωπίζουν τα μεσοφυλικά άτομα πλησιάζουν τα προβλήματα που αντιμετωπίζουν τα τρανς άτομα διότι σε πολλά σημεία αυτές οι προκλήσεις συγκλίνουν.

Τα μεσοφυλικά άτομα υποβάλλονται σε μικρή ηλικία σε επανορθωτικές επεμβάσεις χωρίς τη θέληση τους με την απόφαση των γιατρών ή του κηδεμόνα. Οι επεμβάσεις αυτές πρακτικά δεν έχουν καμία θεραπευτική εφαρμογή, είναι επεμβάσεις που αποσκοπούν στην καταναγκαστική ένταξη των μεσοφυλικών ατόμων στα δυο φύλα (Lembke 2011, Moron-Puech 2011). Τέτοιου είδους επεμβάσεις δημιουργούν αλλεπάλληλα τραύματα στον ψυχισμό των ανθρώπων αυτών. Παραθέτω μια συμβουλή από γιατρό σε γονείς intersex παιδιού “ να γνωρίζετε ότι το παιδί σας θα καταστραφεί κοινωνικά εάν κάποιος μάθει για αυτό, σκεφτείτε το σχολείο η τα μαθήματα κολύμβησης”(Plattner, 2008). Οι επεμβάσεις αυτές έχουν καταδικαστεί από την intersex κοινότητα που υποστηρίζει ότι είχαν καταστροφικά αποτελέσματα , όπως ψυχολογικές διαταραχές, κατάθλιψη, διαταραχές ύπνου, πρώιμη οστεοπόρωση, χαμηλή libido, προβλήματα στο θυρεοειδή, αφαίρεση της ικανότητας αναπαραγωγής και πολλά άλλα. Αυτές οι διαδικασίες που πολύ συχνά εμπεριέχουν ακρωτηριασμούς μελών του σώματος, στείρωση, ευνουχισμό και κλειτοριδεκτομή και παραβιάζουν την σωματική ακεραιότητα των παιδιών αυτών και το πιο σημαντικό είναι ότι όλα αυτά γίνονται χωρίς ενημερωμένη συγκατάθεση του ιδίου του ατόμου που συνήθως είναι πολύ μικρό σε ηλικία για να υποστηρίξει δικαιώματα του.

Η λανθασμένη ανάθεση φύλου στα παιδιά απειλεί και την ψυχική τους ακεραιότητα, οι στατιστικές δείχνουν ότι πολύ συχνά η λανθασμένη ανάθεση αγγίζει το 40% των περιπτώσεων. Η κατάληξη είναι ότι τα άτομα αυτά απορρίπτουν το φύλο που τους αποδόθηκε ”(Tammar-Mattis, 2012).

Παραθέτω παρακάτω μέρος μιας μαρτυρίας μεσοφυλικού ατόμου “μου αποδόθηκε το θηλυκό φύλο άλλα πολύ σύντομα συνειδητοποίησα ότι η συμπεριφορά μου είναι αρρενωπή. Μετά την επέμβαση οι γονείς μου έλαβαν τις οδηγίες να με μεγαλώσουν ως κορίτσι με έναν τρόπο που να υποστηρίζει τη θηλυκότητα μου. Ξεκίνησαν με τα παιχνίδια και τα ρούχα που επέλεγαν για εμένα και στην συνέχεια με μετέφεραν σε σχολείο θηλέων και δεν μου επέτρεπαν να έχω δραστηριότητες οι οποίες συσχετίζονται με άλλα αγόρια όπως ποδόσφαιρο, ξεκίνησα μαθήματα ραπτικής. Παρόλα αυτά η αρσενική ταυτότητα παρέμενε. Κατά τη διάρκεια της εφηβείας μου η μητέρα μου κατηγορήθηκε από τους επαγγελματίες ψυχικής υγείας ότι δεν ήταν αρκετά αυστηρή μαζί μου. Σε αυτή την ηλικία η μητέρα μου άρχισε να καταλαβαίνει πόσο μόνος και δυστυχισμένος ήμουν και σιγά –σιγά άρχισε να με αποδέχεται και εγώ προσπάθησα να την συγχωρήσω διότι κατάλαβα ότι δεν είχε την ενημέρωση να πράξει διαφορετικά. “Το γεγονός ότι είμαι Intersex δεν με σόκαρε τόσο όσο το γεγονός ότι οι δικοί μου άνθρωποι μου έλεγαν ψέματα όλη μου τη ζωή”(Tammar-Mattis, 2012).

Αυτές η πρακτικές καταλήγουν σε βαθύτατο τραύμα και κακοποίηση. Το γεγονός ότι υποβάλλονται σε εξευτελιστικές εξετάσεις σε όλο το σώμα και τα γεννητικά όργανα, φωτογραφίσεις και εξευτελισμό παρουσία και το ειδικευόμενων, καταλήγουν να έχουν παρόμοιο συμπτώματα με τα θύματα της σεξουαλικής κακοποίησης. Αυτά τα συμπτώματα συνεχίζουν για όλη τους τη ζωή που βιώνουν συνεχόμενο μετατραυματικό στρες που καταλήγει σε αυτοκτονικές τάσεις, χρήση ουσιών και διατροφικές διαταραχές. Τα παιδιά αυτά είναι λοιπόν θύματα της ιατρικής βίας όπως και τα τρανς άτομα. Οι νόρμες του φύλου έχουν μεγάλη επιρροή στη ζωή των intersex παιδιών, κοινωνικά άλλα και νομικά και υποστηρίζουν την παραβίαση των δικαιωμάτων των ανθρώπων αυτών σε πολλά επίπεδα.

Πάρβη Πάλμου


Blackless, M.e.a (2000): How Sexually Dimorphic we Are? Review and Synthesis. In: American Journal of Human Biology 12:151-166.

Lambke, U. (2011): Zur Situation Von Menschen mit Intersexualitat in Deutschland. Stellunghame. Deutscher Ethikrat.

Platner, K (2008): Erfahrunggesbericht einer Mutter.In Inersex Geschlenchtsanpassug zum Wojl des Kindes? Erfahrungenund Analysen, Groneberg, M. et Zehnder, K. (dir) Academic Press Fribourg, 13-17.

Schneider, Erik (2014): An Insight Into the Rights of Trans and Intersex People in Europe.

Tamar-Matis, A. (2012): Report to the UN Special Rapporteur on Torture: Medical treatment of People with Intersex Conditions as Torture and Cruel, Inhuman, or Degrading Treatment or Punishment.
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