Transgender and Gender Identity Issues (higher central academic course)

1. Transgender and Gender Identity Issues(higher central academic course) Sam Winter and Jackie, Kwai Chung Hospital, 8th Jan 2010

2. This session Sex, gender, sexuality and transgender people: key terms and background information. Jackie’s story: growing up Cultural, social and legal issues for transgender people. Jackie’s experiences and opinions Mental health work with transgender people: ‘diagnosis’ and ‘treatment’ issues Jackie’s experiences, opinions and recommendations Q and A

3. Sex, gender and sexuality

4. When we are born each of us is labelled ‘boy’ or ‘girl’ • As we grow up, most of us learn to think of ourselves as either male or female, and adopt the appearance, behaviour, interests and traits associated with being male or female in our culture • Most of us develop patterns of attraction (physical, romantic, erotic): males to females, females to males. *

5. When we are born each of us is labelled ‘boy’ or ‘girl’ SEX • As we grow up, most of us learn to think of ourselves as either male or female, and adopt the appearance, behaviour, interests, and traits associated with being male or female in our culture • Most of us develop patterns of attraction (physical, romantic, erotic): males to females, females to males. *

6. When we are born each of us is labelled ‘boy’ or ‘girl’ SEX • As we grow up, most of us learn to think of ourselves as either male or female, and adopt the appearance, behaviour, interests, and traits associated with being male or female in our culture GENDER • Most of us develop patterns of attraction (physical, romantic, erotic): males to females, females to males. *

7. When we are born each of us is labelled ‘boy’ or ‘girl’ SEX • As we grow up, most of us learn to think of ourselves as either male or female, and adopt the appearance, behaviour, interests and traits associated with being male or female in our cultureGENDER • We develop patterns of attraction (physical, romantic, erotic): males to females, females to males.SEXUALITY *

8. When we are born each of us is labelled ‘boy’ or ‘girl’ SEX • As we grow up, most of us learn to think of ourselves as either male or female, and adopt the appearance, behaviour, interests and traits associated with being male or female in our culture GENDER • Most of us develop patterns of attraction (physical, romantic, erotic): males to females, females to males. SEXUALITY *

9. 1. Sexuality: about sexual attraction (‘libido’), sexual preference, sexual behaviour, sexual identity • Two traditional categories: heterosexual (‘straight’) v homosexual (‘gay’ / ‘lesbian’) • Homosexuals have been viewed as deviant, immoral, criminal, mentally ill. • Shift in opinion : different not disordered. • Two extremes of a continuum Bisexuality very common, at least over a life span. *

10. 1. Sexuality: about sexual attraction (‘libido’), sexual preference, sexual behaviour, sexual identity • Two traditional categories: heterosexual(‘straight’) v homosexual(‘gay’ / ‘lesbian’) • Homosexuals have been viewed as deviant, immoral, criminal, mentally ill. • Shift in opinion : different not disordered. • Two extremes of a continuum Bisexuality very common, at least over a life span. *

11. 2. Sex: our biological status as male / female. Four aspects Chromosomes ( XY v XX ) Gonads (sex glands) (testes (testicles) v ovaries) Hormones (androgens (e.g.. testosterone) v oestrogen, progesterone) Genitals (sex organs) (penis, scrotal sac v clitoris, vagina / womb) *

12. 2. Sex: our biological status as male / female. Four aspects Chromosomes ( XY v XX ) Gonads (sex glands) (testes (testicles) v ovaries) Hormones (androgens (e.g.. testosterone) v oestrogen, progesterone) Genitals (sex organs) (penis, scrotal sac v clitoris, vagina / womb) *

13. A fifth aspect of biological sex? Brain Sex

14. A fifth aspect of biological sex? Brain Sex

15. 3. Gender: • about gender identity: how you see yourself (male or female) and want to live; • about gender stereotypes (gender norms): your own and your culture’s beliefs about what behaviour, interests, traits, appearance males and females typically (and/or ideally?) display; • about gender performance (gender expression): your own behaviour, interests, traits and appearance (consistent with those gender stereotypes and your own gender identity);

16. 3. Gender: • about gender identity: how you see yourself (male or female) and want to live; • about gender stereotypes (gender norms): your own and your culture’s beliefs about what behaviour, interests, traits, appearance males and females typically (and/or ideally?) display; • about gender performance (gender expression): your own behaviour, interests, traits and appearance (consistent with those gender stereotypes and your own gender identity);

17. 3. Gender: • About how you develop • not what you are like in your mother’s womb • About psychology • (though there may be roots in biology) • About ‘what is between your ears’ • (not between your legs,,,,or inside your body!) *

18. Transgender people

19. Transgender people (transpeople) • Transgender people grow up identifying and wanting to express as members of another gender (i.e. different to the one associated with their birth-assigned sex) • Gender expression • Behaviour • Interests • Traits • Appearance • Gender variance • Gender identity • as a member of the other gender, or, in some cultures, as a ‘third sex’ (or a blend of genders). • Gender identity variance(GIV)

20. Transgender people (transpeople) • Transgender people grow up identifying and wanting to express as members of another gender (i.e. different to the one associated with their birth-assigned sex) • Gender expression • Behaviour • Interests • Traits • Appearance • Gender variance • Gender identity • as a member of the other gender, or, in some cultures, as a ‘third sex’ (or a blend of genders). • Gender identity variance (GIV)

22. Transgender people: more information • Transwomen (assigned ‘male’ at birth, but identifying as female) • (=‘transgender women’, ‘MtF transpeople’, ‘women of transgender experience’) • Transmen (assigned ‘female’ at birth, but identifying as male) • (=‘transgender men’, ‘FtM transpeople’, men of transgender experience’ ) • May make the gender transition(towards presenting socially in accordance with their identity) • May undergo sex / gender reassignment surgery ( = sex / gender confirmation surgery) • ‘Transsexual’ people *

23. Transgender people: more information • Transwomen (assigned ‘male’ at birth, but identifying as female) • (=‘transgender women’, ‘MtF transpeople’, ‘women of transgender experience’) • Transmen (assigned ‘female’ at birth, but identifying as male) • (=‘transgender men’, ‘FtM transpeople’, men of transgender experience’ ) • May make the gender transition(towards presenting socially in accordance with their identity) • May undergo sex / gender reassignment surgery ( = sex / gender confirmation surgery) • ‘Transsexual’ people *

24. Transgender people: more information • Often believed to be low prevalence. • DSM-IV-TR cites figures for adults: approx 1:30,000 males / 1:100,000 females • From clinic studies (i.e. ‘transsexual’ people). • From old studies (in UK number approaching clinics doubling every 5 years) • But what about those who do not approach clinic? • e.g. ‘non-op’ transgender people? • e.g. those who are GIV but choose not to transition? *

25. Transgender people: more information(Hong Kong) • Centralised Gender Clinic 1985-2006, making possible an incidence study: • 34 ‘transsexuals’ referred for assessment for SRS over 11 years (1.1.1991-31/12/2001). • 15 females (birth-assigned), 13 males (birth-assigned) • 6 did not satisfy diagnostic criteria. • People don’t know about service? • People referred for other treatment? • People going elsewhere? for hormones? for surgery? • A rise in referrals inevitable. John Ko ‘A Descriptive Study of Sexual Dysfunction and Gender Identity Clinic in the University of Hong Kong Psychiatric Unit’. Extracts from a HKCP dissertation, posted on the TransgenderASIA website.

26. Transgender people: who they are not • Notthe same as transvestites (cross-dressers) • who they feel they are,,,,,,,, • not simply how they like to dress. • It’s about gender identity *

27. Transgender people: who they are not • Not a subset of homosexuals • who they feel they are ,,,,,, • not who they are attracted to. • (it’s about gender identity,,, not the same as sexuality). • Many adult transpeople are heterosexual • boys who grew up to be women who like men • girls who grew up to be men who like women • Some are homosexual • boys who grew up to be women who like women • girls who grew up to be men who like men *

28. ….Do gender identity variant children always grow into transgender adults? • Most GIV children appear to become adults who are not transgender adults • A GIV boy may grow up happy to be a man. • A homosexual man? (46%) • A heterosexual man? (23%) • But some do become transgender people as adults (5%) • and there are a lot more we don’t know about (26%) • And many transgender adults recall being GIV children. * Figures from Zucker, K. (1985). Cross-gender Identified Children. In Steiner,B. (Ed.) Gender Dysphoria. New York: Plenum.

29. Is transgender a modern and western phenomenon? • Universal phenomenon • throughout history and across cultures. • evidence for a biological factor (brain sex?) • Transgender people can now change appearance with hormones and surgery • sex / gender reassignment surgery (SRS / GRS).

30. Transgender people: some key points to remember It’s not just about gender expression, it’s about gender identity. About psychology, not biology (but there may be biological causes). A ‘mismatch’ between mind and body. • desire to live as, be, a member of another gender. Universal and timeless aspect of human diversity Not the same as transvestism or homosexuality. GIV often starts in childhood, sometimes persists into adulthood. Some transpeople want to undergo sex reassignment surgery * *

31. Jackie’s story: growing up

32. Transgender people: cultural, social and legal issues A focus on Asia-Pacific This next section based on a presentation at a meeting (Bangkok, 13-16 Dec 2009) to set up the Asia and Pacific Transgender Network (APTN)

33. Transgender people: cultural, social and legal issues Largepopulation

34. Large population: CLINIC STUDIES Iran: 1:2200 – 1:3300 (transpeople) Taiwan: 1:1030 (transpeople) Singapore: 1:2900 (transwomen) 1:8300 (transmen)

35. Large population: COMMUNITY ESTIMATES India: 1:600 (transwomen) Thailand: 1:300 (transwomen) Malaysia 1:75 to1:150 (transwomen)

36. Transgender people: cultural, social and legal issues Large population Deep cultural roots and old social roles

37. Deep cultural roots:a place in society for transpeople Japan; China, Korea, Myanmar, Laos, Thailand, Indonesia, Oman, Pakistan, Bangladesh, Afghanistan India Philippines Siberia Pacific (Okinawa, Hawai'i, Samoa, Tonga, Tuva etc) . Gender Identity Variance: Universal, Timeless. A part of human experience.

38. Transgender people: cultural, social and legal issues Large population Deep cultural roots and old social roles Local identities and genders

39. Yirka-la-ul-va-irgin, Ne-uchica Khanith, Xanith Some local identities and genders (modern or traditional, affirming or offensive) Hijra, Kothi, Meti, Aravani, Khusra, Zanana Mahu, Fa’afafine Fakaleiti Pinapinaine Bakla, Transpinay Bayot, Bayog, Asog, Bantut, Binabae Apwint, Acault Waria, Banci, Bencong, Calabai, Kedie, Wandu Maknyah Kathoey Pumia, Pumae, Phet thee sam, Sao praphet song, Phuying kham phet

40. Transgender people: cultural, social and legal issues Large population Deep cultural roots and old social roles Local identities and genders Modern stigma and prejudice

41. Modern stigma and prejudice. • Challenging rigid (Western?) ideas about sex and gender • two sexes (biology), two genders (psychology) • within any person the two must match. • In those cultures transpeople seen as: • deviant (an unfortunate defect), • immoral (disobeying God’s will), • deceitful (homosexuals employing a strategy to get partners), • mentally ill (‘Gender Identity Disorder’). • Responses of: • incomprehension, shock, embarrassment, fear, disgust, hatred. • family, friends, neighbours, employers, broader society. • transphobia ( = transprejudice) • = fear, hatred or disgust in reaction to transgender people (and their GIV) • GIV ‘boys’ less easily accepted than GIV ‘girls’? *

42. A seven country study • of prejudice: • 841 university students. • A questionnaire: • on attitudes towards • transwomen Stigma and Prejudice Transpeople, transprejudice and pathologisation: a seven-country factor analytic study. Winter,S., Chalungsooth,P., Teh,Y.K., Rojanalert,N., Maneerat, K., Wong, Y.W., Beaumont,A., Ho,M.W., Gomez,F., Macapagal,R.A. International Journal of Sexual Health, 21, pp96-118

43. Seven societies: a range of prejudice Transacceptance United Kingdom Philippines Thailand Hong Kong, Singapore Malaysia – United States Transprejudice

44. Stigma and prejudice Trans-stigma and trans-prejudice clear in all 7 societies. Some sample figures: Rejecting transwomen’s right to marry a man: 63% Malaysians 53% Filipinos Rejecting transwomen’s right to work with children 33% Malaysians 14% Filipinos 13% Thais

45. Transgender people: cultural, social and legal issues Large population Deep cultural roots and old social roles Local identities and genders Modern stigma and prejudice Discrimination and marginalisation (social, economic and legal)

46. Discrimination and marginalisation • Family and school • dropping out and leaving home

47. Discrimination and marginalisation • Family and school • dropping out and leaving home • Wider society • employment, housing, health services, access to public spaces

48. Discrimination and marginalisation • Family and school • dropping out and leaving home • Wider society • employment, housing, health services, , access to public spaces • drift towards ‘ghetto’ employment

49. Discrimination and marginalisation • Family and school • dropping out and leaving home • Wider society • employment, housing, health services, access to public spaces • drift towards ‘ghetto’ employment • Government • documentation: ID cards,

50. Discrimination and marginalisation • Family and school • dropping out and leaving home • Wider society • employment, housing, health services, access to public spaces • drift towards ‘ghetto’ employment • Government • documentation: ID cards, • documentation: legal gender status