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Written by Li Sam and first published March 4,
2008.
This article is open and
free to use with the only restrictions that you are not allowed to change or tamper with the wording and you must clearly
cite the source and provide a link to the original article at this website.
For courtesy, please email me
such details as a contact name, email address, and associated journal, website, seminar or the like, and date of publication,
at: li-sam@telia.com
Introduction
For
many reasons this article is still valid, as nothing much has happened to change the situation for people born transsexual.
There are talks, and one investigation made by the Swedish National Board of Health and Welfare was released at the end of
June 2010, but in spite of that, any actions that will bring about real changes here in Sweden have not happened yet.
However,
there is some light at the end of the tunnel, some appearing from a direction rather unexpectedly I would say, and I will
comment on that at the end of this article. But there are serious threats too, coming from people who, either purposefully
or through ignorance, darken the skies, and I will comment on that too.
I think this article could
provide useful insights for people in other countries struggling with the transsexual issue as we do here in Sweden. In order
to maintain continuity, I will follow up with a new article in November 2010 on what has happened, how things stand now, and
what could be expected in the near future.
Please feel free to make use of this article within the
above restrictions. I’m a positive person by nature, but I’m also aware that it’s necessary to consider
reality as it is, if any improvements we wish for are to be made.
Numbers by Li Sam
In paper they are cut, labeled and put away,
always "other"without knowing.
In
paper they are wrapped up and archived,
prohibiting their souls
from showing.
Like soldiers
behind a desk we then number our victims
to escape our doings.
And as in court, humanity doesn’t count.
The Current Situation for Transsexuals in Sweden and What Can
Be Expected in the Near Future
In social terms Sweden is looked upon as one
of the world’s leading democratic nations: compassionate, accepting, and with free healthcare for all. Sweden is internationally
known also for our policy of protecting minorities and encouraging diversity. And we stand very much in the front line arguing
for human rights. However, can we uphold Sweden as such a model when it comes to the transsexual phenomenon and everyone affected
by it? What exactly is Sweden’s policy on transsexuals, and how is this policy carried out?
The Swedish Approach to the Transsexual
Phenomenon of Gender Identity Disorder (GID) and Its Consequence, Gender Dysphoria (GD)
There are several ways to understand transsexualism. These various understandings
directly influence the policies officials use to decide who is and is not transsexual as well as what to do about it.
Each
country seems to have its own official view based on legislation and/or other forms of regulations. However, the official
view often can be quite different from what the public thinks, including those people who experience GID, their families,
and the professionals who work with these issues on a day-to-day basis. Among all these different understandings and policies,
what exactly is transsexualism?
The truth is, we still don’t know for sure. Despite many setbacks
though, we are closer now to understanding the facts about who transsexuals are and why they must change gender. However,
politics in any form often has very little to do with facts, and this is certainly true regarding transsexualism.
This
article does not claim to provide the one and only truth about this complex phenomenon. Instead I hope to raise awareness
and to promote an understanding about it, and in the end it’s you who have to choose what to believe. One day we will
learn what the truth is and what it is not, and then hopefully we will learn to act with compassion accordingly.
Sweden: a Country of Compassion?
To understand the Swedish approach to transsexualism
we must face some ugly historical facts. In 1921 Sweden was the first country in the world to establish an institute for scientific
racism, developing theories that Hitler later adopted and practiced during World War II. In Sweden these theories were considered
officially true and were practiced within the national healthcare system until 1976 (i.e. after 1976 these ideas were not
officially held as true anymore).
Until 1976, handicapped people, people with mental disabilities,
and homosexuals (in other words, people who are different from the norm) by law could be compulsorily sterilized. In Sweden
we didn’t want these “other” people to have children or to be visible in society. To protect society they
were put away, often hidden in closed institutions.
In 1972, Sweden was the first country in the world
to pass legislation regarding transsexuals (note that scientific racism was still officially valid at that time).
However, what might appear to be a positive mark of progress is not necessarily so.
What was that legislation
all about? Before it there was no law prohibiting people from changing gender and no law legalizing it either. With this new
legislation, changing gender was to be controlled. Whether this control was for better or worse is hard to say, because all
previous gender changes were a private, individual matter, so there is no official data to compare.
The
new legislation from 1972 doesn’t prohibit change in gender, but based on previous scientific-racism laws and other
related national healthcare regulations, now so-called “transsexual people” have to agree to be sterilized in
order to have their gender changed. In Sweden today we want to prevent transsexual people from breeding and multiplying.
You might ask: Why would transsexuals want to have children in the first place? The answer is many-fold.
Primarily, like most people transsexuals value family and want one of their own.
This legislation also
determines who can and cannot qualify for a gender change, a qualification that many people’s lives depend upon. We
are all aware that surgery in Sweden is controlled by the State, because the State is healthcare. This socialized healthcare
is said to be free, and to a certain degree that is true, if you are prepared to accept the treatment offered and have
the time to wait your turn in line. For transsexual people this means that you don’t have to pay for the surgery
that changes your gender or for some related treatments (such as hormones and electrolysis for men and removing breasts for
women). On the other hand, the time it takes to be acknowledged and approved for treatment can be life-long.
In
Sweden we don’t execute transsexual people by law and we don’t prohibit people from changing gender,
but if a transsexual person never is assessed as being transsexual and as a consequence never is able to change gender, is
there really any difference? Many people don’t realize that for transsexuals, life in the wrong gender is so difficult
and painful that it can be not worth living.
The Swedish compassion for transsexual people could be
said to exist for those approved for gender change, but what about all the others? Do they even exist legally? And those transsexual
people who have been shown this Swedish compassion: what do they say? Are there any complaints?
How Many Swedes Are Transsexual?
As a reference:
• In 2007, Sweden had about nine
million citizens, and among them approximately 550 had, at some time in their lives, changed gender. (These people were assessed
as transsexual and acknowledged as being so by the State.)
• Until 2006 about 20 to 30 people a year changed gender
in Sweden. (How many applications were not acknowledged is unknown.)
• In 2006, approximately 55 applications were
filed, and “most likely” they will be acknowledged for surgical change.
Is this sudden
increase to 55 people a year applying for surgery relevant or not? Could it be that the previous recorded number of transsexuals
in need of surgery should have been much higher? And if so, what happened to them?
And even if this
more-than-double increase is accurate, could there perhaps be many more people seeking gender change who never got or never
will get to the application stage? What kind of barriers are there?
In Sweden there are no valid or
reliable statistics regarding transsexualism (perhaps the reason for this is that we really don’t want to know).
Therefore, to delve any deeper into further investigations is unproductive, as figures can’t be verified.
However,
by interviewing some key healthcare providers for this article, by talking to others with relevant information, and through
my own experiences, I have discovered a clear pattern of how barriers have limited and currently do limit gender changes.
At the crux of these barriers is the fact that you have to be officially categorized as transsexual in order to have
your gender changed.
How Is Transsexualism Determined?
In one sense it could be said that Swedish authorities
and healthcare providers treat all transsexual persons equally. In all other senses this depends very much on the decision
of who is transsexual and who is not.
Our healthcare system directs you to a doctor depending
on what area of Sweden you live in. It’s said that you can select a doctor of your choice regardless of where you live,
but in reality that’s not so: the Swedish healthcare system is not designed that way and any such requests are strongly
rejected by healthcare doctors and staff.
Furthermore, depending on where you live there can be no
transsexual care whatsoever, and people have had to move to have their case examined. If you attempt to get assessed and approved
directly by an assigned special transsexual ward (there are only five in Sweden), you will be rejected right away. Trying
to make direct contact is very strongly prohibited by doctors and staff. You have to be recommended to these wards as
being transsexual by a local psychiatry doctor from the healthcare area where you are registered.
(Recently
a healthcare area in Sweden, Kronobergs lans landsting, has decided not to finance gender change for citizens registered there,
which means no healthcare is available for this situation whatsoever, and private alternatives do not exist even if you are
prepared to pay for your gender change yourself.)
In all of Sweden, to begin the process of gender
change you have to see a general practicing psychiatrist, who assesses you as a transsexual person based on standardized,
impersonal forms such as the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Furthermore, your social status
has to be investigated (whatever that has to do with it), as well as the psychiatrist’s personal thoughts about you
and his or her opinion of your ability to act and assimilate in society as a person of the opposite sex. In Sweden transsexualism,
Gender Identity Disorder (GID), and Gender Dysphoria (GD) are classified as psychiatric conditions, i.e. you are looked upon
as a mentally ill person and, as a consequence, must be treated accordingly no matter what.
As you
contemplate the fact that a person’s suitability for gender change is based on a psychiatrist’s categorizations,
consider that most general practicing psychiatrists in Sweden have no idea what transsexualism is. If you request a gender
change, it’s most likely that you will be the first transsexual person he or she meets. In Sweden there is no education
or information whatsoever for psychiatrists about this group of patients.
So when you seek help for
your condition you will be looked upon as a psychiatric case, and most likely your psychiatrist will try to cure you. This
is attempted by trying every method and psychopharmacologic drug your doctor can think of. Eventually (but not always), the
doctor will run out of ideas, and then you will be classified as transsexual for the first time and referred to the next stage,
again for assessing you for a gender change and for Gender Reassignment Surgery (GRS) only.
As
a Swedish citizen you are not regarded as transsexual until you have been classified as such by Swedish doctors, i.e. passed
all tests. You have to go through this first stage no matter what, and it doesn’t matter if you have specialist doctors’
referrals for GRS from abroad and/or have been assessed by the internationally recognized organization HBIGDA’s “Standard
of Care,” which is said to be followed in Sweden. In fact, even if you have had your GRS abroad and have lived many
years as the opposite gender, Sweden can refuse to change your gender in national registers.
A special
case is young transsexual people: children and teens. In Sweden as in most countries, you are not allowed to change gender
before you are 18, but in Sweden that is when you are allowed only to begin to seek care for your condition, and
there are other legislations in effect that are used to delay any serious assessment for up to seven years after that.
In true Swedish style, the intended implication of these regulations is that there are no transsexual
children in Sweden. As a consequence, transsexual children can’t be treated for their condition because they don’t
exist. And within the Swedish healthcare system there is nowhere they can go to get help for their condition; they are rejected,
unless of course they are to be regarded as mentally ill.
So who is transsexual then, if it’s
definitely not anyone under the age of 25, anyone who undergoes GRS abroad, or anyone who can’t access or fails the
psychiatric testing in Sweden? In Swedish terms the answer is very simple: Swedish authorities and healthcare providers
decide who is transsexual. Decisions by anyone else are irrelevant. The Swedish official view of who is transsexual or
not is the only valid truth, and reality is inconsequential.
For a transsexual person beginning to
experience the illness of Gender Dysphoria , changing gender is a life-and-death matter, and I am certain, as many like me
are, that a gender change is this person’s only option for survival. But there are many additional aspects involved
in a gender change other than surgery, such as being allowed to change your name, all the official records about you, your
passport, your CV, your work associations, etc. And many older adults face the issue of their civil status, such as marriage
and the status of their children in case of divorce, etc. The social scope of gender change is about family, friends, and
the need to be welcomed as a part of society, like any other “normal” human being.
In
the grander scope, transsexualism is not about spreading diversity or wanting to be different. Transsexualism is based on
a need to be normal, to have a normal life, to live pain-free.
Who Are Those Few People Approved for
Gender Reassignment Surgery (GRS)?
First, to be approved for surgery, you have to be assessed one more time by so-called “specialist doctors” in
a more thorough manner than before. If they decide that you are in a psychiatric state of imbalance, you are dismissed and
told to continue the assessment when you are in balance again, such as after a year or so. In the meantime you are in limbo
and have to try to help yourself.
This judgment is especially ironic considering that for people experiencing
transsexualism, GID, and GD, it’s commonplace to feel extremely ill and to even be suicidal. Who wouldn’t feel
imbalanced living as the wrong gender? The phenomenon of transsexualism is a life-threatening situation, forcing you to
change gender to survive. This fact has been proven true so many times during the last 50 years, but still the Swedish
healthcare system ignores it and, on doubtful grounds, dismisses their patients who seek help for their condition.
Therefore,
very few people survive this judgment and are approved to change gender. Based on a reliable international source , the prevalence
of transsexualism can be said to be 1 person in 500, if not more. This statistic indicates that more than 18,000 Swedish citizens
could be experiencing this transsexual dilemma, and only 550 of those are recognized by the Swedish state as being transsexual
and therefore have been approved to change gender.
There is talk among these specialist doctors that
you have to be a “primary” or, even better, a “genuine” transsexual to be approved, which means you
must have early memories from childhood of wanting to be and behaving as a child of the opposite gender.
(This
criterion is in sharp contrast to their opinion that when young people seek help, they are not to be recognized as transsexual
at all, as they haven’t been and can’t be assessed because of their young age. Even though forbidding genital
surgery in children is not the same as denying that childhood transsexualism exists, Swedish authorities and healthcare act
as if it is. There are no support systems or healthcare available to children, and the condition of these children is very
much denied to protect the system.)
Another sad side-effect of the State’s control over approval
for GRS is that who is approved for it and who isn’t is the basis for segregation and discrimination of transsexual
people in Sweden today, and sadly this inequality is within the Swedish transsexual community as well. There are several ways
to understand transsexualism. These various understandings directly influence the policies officials use to decide who is
and is not transsexual as well as what to do about it.
Each country seems to have its own official
view based on legislation and/or other forms of regulations. However, the official view often can be quite different from
what the public thinks, including those people who experience GID, their families, and the professionals who work with these
issues on a day-to-day basis. Among all these different understandings and policies, what exactly is transsexualism?
The
truth is, we still don’t know for sure. Despite many setbacks though, we are closer now to understanding the facts about
who transsexuals are and why they must change gender. However, politics in any form often has very little to do with facts,
and this is certainly true regarding transsexualism.
This article does not claim to provide
the one and only truth about this complex phenomenon. Instead I hope to raise awareness and to promote an understanding about
it, and in the end it’s you who have to choose what to believe. One day we will learn what the truth is and what it
is not, and then hopefully we will learn to act with compassion accordingly.
Who Does the Approving for GRS?
In order to understand the “specialists”
working with transsexual patients, we have to remember that at the first stage of the process you are not officially considered
transsexual unless you are referred to these specialist doctors, and before that happens, these specialists have no knowledge
of your existence.
Interesting is the fact that these specialist doctors instruct the staff at psychiatry
wards, which are first in the process of receiving requests from transsexual patients for referrals to the specialist doctors.
If you can untangle that knot you see that the specialists decide for themselves which types of patients they want to see.
When I asked a specialist about this situation, I was told, “How do you think it would be if everyone wanting to
come here was allowed to? That would be way too many people.”
Another crucial issue is about
the concept of healthcare versus paperwork. In Sweden it’s always said that assessments by these specialist doctors
is healthcare, but in reality it is not. Their job, assigned by the National Board of Health and Welfare, is only to judge
and report if a person is transsexual, and if the person is deemed not to be, their job is to send him or her away
and close the file. Healthcare, therefore, is never the issue. If a person shows signs of not feeling well, he or she is simply
dismissed. If a person is assessed as being transsexual he or she is referred for surgery and other “approved”
physical treatments, but nothing else. There is no healthcare involved in this assessment process whatsoever.
Therapy
(and other kinds of support to help transsexual people facilitate the process) does not exist in Sweden, so transsexual patients
have to help themselves. The Swedish way of assessment is intentionally designed to make the process difficult in
order to identify those who seem to want to change gender the most; the excuse for doing so is to prevent any regrets after
surgery. The healthcare specialists do not consider that people often die in this deliberate long-term process; considering
this is not within their assignment.
The internationally acknowledged Standard of Care is
not followed in Sweden, as the time schedule for approval can be extended for years and years until forever. In Sweden the
Real Life Test (RLT) is used as the ultimate diagnoses for whether a person is transsexual or not. The RLT takes one year
at minimum and is something you must do before hormone treatment, and you are very much left alone during it. After
that the assessing doctor can add an extra year or even longer before the next step, depending on whatever is thought necessary
before he or she can consent.
For the next step of consideration, you must fill out an application
and stand before “The Committee for Forensic Psychiatry, Social and Medical Legal Questions” to have your case
reviewed. This session most often lasts an hour or two, if you have all your papers in order, including an approval
file signed by Swedish-acknowledged specialist doctors. When you have gotten your case acknowledged, in general you will get
your details changed rather quickly and can have your GRS within six months, performed by Swedish doctors in Sweden.
To
summarize assessment by these special transsexual wards, I refer to an independent dissertation written in 2006 by a “Health
& Society” student who, by chance, chose to study transsexual healthcare in Sweden. From this study some base-line
quotations are well worth mentioning: “an authoritarian health-care-practice” and a “lack
of psychosocial support… force[s] the patients to help themselves.”
Who Are the Swedish Doctors Performing
GRS?
Sweden is well known for
having highly educated and skilled doctors, and in general there is no reason to doubt that. But there are only a few Swedish
doctors performing GRS (as of this writing only two or three), and together they perform only 20 to 30 surgeries per year,
and it’s not their main task (and maybe not in their interest either).
To perform GRS well you
need practice; therefore the result after surgery can vary. However, in every other aspect Swedish healthcare standards are
high, so once you have been approved and gotten that approval acknowledged, most remaining tasks will be done swift and smoothly.
Who Are the Officials Responsible for
Giving Directives for GRS?
It’s
easy to point out the official Swedish route of approval, but who are the people really in charge along this route?
A: The Committee for Forensic Psychiatry, Social and Medical Legal Questions
By being the last step in officially determining gender change, this group decides what a transsexual person has to comply
with and what documentation is needed to meet their demands. This body is a branch of B (below), and their so-called experts
submitting each case are the same few doctors running these specialist wards that assess transsexual people. However, these
experts don’t officially acknowledge the transsexual status of their own patients; their colleagues do that. This way,
in theory, they can’t be challenged.?
B: The National Board of Health and Welfare
This body gives directives, and its experts are the same “expert” doctors as in A. The only written directive
available is from 1996: it is only four pages long, and not once is the international Standard of Care mentioned. Basically
this directive is written by the same doctors who in the mid-90s were active within A as well as former colleagues of the
“expert” doctors who are active today.?
C: The Ministry of Health and Social Affairs
This body controls B and is responsible for legislation regarding Swedish healthcare. Their experts are
the same “expert” doctors as in A and B.?
D: The Swedish Government
This body is the same as in any other democratic country, and in Sweden the experts they consult are the same “expert”
doctors as in A, B, and C.?
E: The Swedish Parliament by their votes
The body is the same as in any other democratic country, and in Sweden their experts are most often again the same “expert”
doctors as in A, B, C, and D. Of course all political parties depend on their own expert groups, but in the end they have
to choose what to believe in and what views win them the most political points.
However, there are
signs that they can take advice from within the transsexual community, and sometimes some party members do.
F:
The Swedish citizens by their votes
As in any other democratic country, in the end
the people determine the party. And in Sweden it seems that the majority of the population would have no problem with people
changing gender if they just knew who they were.
The lack of relevant information is just
too obvious, and what the media reports is limited and doesn’t always give the full picture.
So,
this small A to F list reveals that only a few “expert” doctors—probably fewer than ten—are in charge
of the process of gender change in Sweden today. And, most likely, only one of them leads the group. With this in mind as
well as the fact that people in general don’t really want to know about transsexualism, it is clear to me that nothing
will change: this small group of “expert” doctors can continue to unrestrainedly rule the Swedish way of
treating transsexual people without any questions asked.
There are some organizations representing
or claiming to represent transsexual people, but the biggest and most powerful are run by homosexual people. There are few
transsexual people within these organizations, and the general term you have to adopt to fit in there is to be a so-called
“trans-person.” An understanding within these circuits of transsexualism on a wider scale—that these “trans-persons”
can be heterosexual men and women as in society in general—seems non- existent. And if the “trans-person”
label doesn’t fit, you might even be called “queer.”
On the other hand, there are
organizations run by people who have changed their gender, but their organizations are small, members are few, and their arguments
are most often met with silence. A problem within the Swedish transsexual community is of not wanting to accept variations
in what transsexualism is or variations in its possible causes, and this is probably the reason why a stronger common organization
doesn’t exist composed of all variations of transsexual people in Sweden today.
What’s the Near Future of the Swedish
Approach to Transsexualism?
There
is a proposed law regarding transsexualism scheduled for the summer of 2008 intended to replace the old one from 1972. It’s
obvious from the text and the 259-page document on its background that Swedish authorities and healthcare officials want to
tighten rules to make it even more difficult to be approved and acknowledged for changing gender. Note the difference: Sweden
says it will support making it easier for transsexual people to change gender, but in reality very few people in the future
will be classified as such.
A scary scenario is what will happen to those “intersexual”
children for whom doctors can’t decide by their genitalia what gender they belong to. These children are going to be
assigned a gender immediately after birth that will be decided by doctors and parents, and if later that decision turns out
to be wrong, these children will have to stand in line like any other transsexual person seeking to change his or her gender.
Even though there is a 50/50 chance of being assigned the wrong gender, these intersexual children will be denied correction
at a young age, and the consequences of that are of no concern whatsoever if you ask the Swedish healthcare system and those
people in charge.
The suicide rate in Sweden is 1,500 people a year, and according to statistics none
of these suicides was caused by transsexualism. Within the transsexual community worldwide we know that this in not true.
In Sweden it could be calculated that about 440 people take their lives each year because of the transsexual phenomenon.
Sweden has a spoken aim of zero suicides in the future and is said to raise funds to achieve that goal.
How can we achieve this goal without acknowledging that the transsexual suicide rate is extremely high? And how can we
achieve that goal without any proper transsexual care?
As usual in Sweden, protests will be met
with silence, and, again, people don’t want to know. The fact that this proposed law still demands compulsory sterilization—a
criminal act according the Human Rights Treaty—does not in the least bother the Swedish government and those people
in charge. They can’t say they didn’t know, as they have been reminded in writing.
Swedish authorities just don’t care.
If there are
to be any hopes for the future, it’s with the little man (as always) … the Swedish people, those regular Joes
out on the street whom we all are. You have the power to make a change; it’s not as difficult as it might seem;
and it’s all about wanting to know. Through curiosity, a willingness to learn, and asking for the truth, lies
will vanish. It’s through your own positive thinking and common sense that you won’t be fooled.
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Li Sam: This is what
transsexualism
is really about
RSMH article 4/2011
National
Association for
Social and Mental
Health (in Swedish)
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