This piece was written for YouTube, and the full transcript is below.
This piece contains discussions on psychiatric abuse, transphobia, disablist violence and mental health.
Who do we trust to make decisions? Who do we trust to make decisions about their own lives? Who do we trust to make decisions about their own bodies?
This first point may seem obvious, but everyone has rights to make decisions about how they want to live. This second point may also seem obvious, but there are many people whom society prevents from making those decisions. I’m going to be exploring a specific example of that today.
I’m a professional human rights defender – that’s the legit term – and my work over the past number of years has focused on transgender people’s rights within healthcare in the UK and Ireland. Trans healthcare has become a massive focus of media and political discussion over those same number of years, particularly in this part of the world, and this is perhaps most true in the case of trans healthcare for young people.
First things first, I’m not going to be debating whether trans young people should be able to access the healthcare they need – that is an obvious right, the same as every young person holds. What trans young people medically need varies between individuals, but trans young people have the same ability and rights to consent to treatment as their peers, and global practice is clear on this. The World Health Organisation has now fully approved the removal of trans-related diagnoses from the mental health chapter of the International Classification of Diseases, the global standard for healthcare diagnostics. Everything to do with being trans is now being placed in a new chapter on sexual health, where they’ll sit alongside things like contraception management. So it’s clear – consensus has moved trans healthcare out of the control of psychiatric medicine.
However, it’s going to take some time for this to happen in reality, and there’s some big risks to different groups of trans people along the way. One of those groups is disabled trans people, and particularly those with mental health, developmental or learning disabilities. That’s what I want to explore today.
The tactics I want to focus on are being used by anti-trans activists in ways that affect different groups of trans people in different ways, but from what I’ve seen, the principle topic I’ll discuss today is primarily aimed at trans boys and young men, as I’ll explore.
Many trans writers and scholars have written about how anti-trans activists have shaped their arguments using sexism and ableism. Trans poet Jay Hulme writes in a July 2019 piece, “As a trans man, I am, and always will be, belittled, disrespected, spoken down to, and patronised, by transphobes. After all, they think I have been brainwashed and fooled into “thinking I’m a man” what could I possibly know? What value could my words or experience possibly have? This is the same with all trans men. No matter how old they are, they are treated like children by transphobes. […] At the heart of all of this is a desire among transphobes to control trans men. They obsess over our surgeries, our ages, and our presentations. The prospect of a trans man exercising his right to bodily autonomy horrifies them. They speak of trans men as “girls” even when we’re well into our twenties, and even beyond, and if they are older than us, or parents, they use age and/or motherhood as a form of rank – “I know better than you” – to silence us, belittle us, and undermine us – even as we speak about our own lives and experiences.”
This need for control of trans bodies mimics and learns from a lot of public arguments on disability rights and misogyny. Rights issues as diverse as mental health detention to “growth attenuation therapy”, a form of torture which prevents disabled children from growing into adults, are powerfully influenced by the idea that disabled people need to be protected for their or their carers’ wellbeing, rather than having decision making control themselves.
One of the big ~controversies~ raised in the discussion of trans young people accessing gender-affirming care is that of the number of disabled people within the trans population, and particularly the number of neurodivergent people – of Autistic folks and those like me with ADHD. The central argument of many ~concerned individuals~ and anti-transition lobby groups revolves around the idea that unprecedented numbers of young people are saying they’re trans, after seeing trans role models online and trans classmates in school, and that they’re being pressured by social media, sex-change clinics and their parents into hormones and surgeries at young ages. Concerns have been raised.
The idea of “rapid onset gender dysphoria” was coined in 2016 to describe this phenomenon of increases in young people coming out, and it relies heavily on the idea of social contagion – the propagation of a pathology or set of behaviours through social groups, peer pressure, and cultural bias.
The social contagion argument then informs concerns around Autistic young people by proposing that those Autistic young people are latching onto black-and-white thinking about gender, are misunderstanding what being trans is, or are straight-up being recruited by TRAs – trans rights activists – like yours truly.
It is indeed true that an atypically high number of trans young people are Autistic – this is seen in the literature and anecdotally in many trans youth spaces across the world. However, it’s worth noting that in many gender-affirming health services, young people are screened for autism diagnoses, unlike the general population of young people, and therefore it’s very likely that there’s a huge number of invisible Autistic young people who don’t interact with mental health or gender-affirming care. This doesn’t mean that there isn’t a higher percentage of Autistic trans people than Autistic cis people, but it’s worth considering.
As noted in a July 2018 article in human rights journal the Daily Mail, some clinicians are expressing concern about this high number of Autistic people coming out as trans:
Autism expert Dr Sally Powis said that autistic teenagers searching for a reason why they did not fit in could fixate on the idea that they were born into the wrong body. ‘If you know you’ve been different since you were a small child, there’s the possibility you consider it’s your gender that’s the issue, rather than autism,’ she said.
We’re going to ignore the fact that this can be argued for literally any disability, health condition or minority status.
A lot of these arguments are based in the idea that young people are either trans or autistic, not that young people can be trans and autistic. Others are based on the premise that some autistic young people may well be trans, but that intensive additional scrutiny and assessment is required for those individuals. Research published by the only trans young person’s clinic in Great Britain suggests that this may be necessary to prevent them from making the “wrong decision”.
The wrong decision. We’ll come back to that.
It must be noted that a lot of arguments against young people coming out as trans – or indeed mixing with other trans young people – mirror arguments used in decades past against lesbian, gay and bisexual people. The theory of social contagion, of peer pressure, of unnatural acts involving their bodies and indeed of much darker accusations of sexual predation and grooming long predate the current cesspool of tabloid discussion.
In the UK, the main sources of anti-rights arguments against trans young people come from a fairly small number of academics, social commentators and media figures. The nature of the lobby groups presenting anti-trans arguments to the national press is hard to tell for sure, but they are evidently of very limited size, and are supported by an increasingly interesting – and indeed suspicious – pattern of funding and institutional support from elsewhere in the world – namely, the United States.
Lesbian, gay and bi people have experienced decades of being maligned by public policy and the media as – if not outright involved in paedophilia or sexual predation – then certainly associated with it. This was an informing argument in the legislation known as Section 28 in Britain, which prohibited schools and local authorities from in any way “promoting” LGBTI subjects or issues. The idea that young people would be prevented from harmful information that would otherwise cause them to make bad decisions and enter disordered lifestyles was a successful argument for legislative restrictions at the time. The idea that LGB people were a risk to kids activated the “think of the children” impulses in many people.
Doesn’t… doesn’t that sound familiar?
The longstanding caricature of trans women being individuals of sexual perversion, and perpetrators of sexual abuse is a common factor in the contemporary arguments around protecting children. Whether it’s the arguments around the law that suggest improving trans legal protections will result in men entering women’s bathrooms to assault girls, or that the very nature of being trans is inherently devious or inappropriate for kids to be around, these “think of the children” impulses are being relied on heavily in current arguments.
All of this applies to efforts to restrict the rights of trans young people as a whole, but have heightened effects on the rights of disabled trans people. Although the UK broadly considers itself to be a good place for disabled people’s rights – a fiction becoming more egregious every day – the law and culture here still relies on old and paternalistic attitudes when it comes to disability.
The UK Government ratified the UN Convention on the Rights of Persons with Disabilities in 2009, a landmark international step to protect and promote disability rights. Alongside UK disability discrimination law introduced in the 1990s and the Equality Act introduced in most of the UK in 2010, we generally consider the rights of disabled people to be well protected – at least on paper.
However, the way public services treat disabled people – and in particular the way healthcare services do – is telling of a different lived reality for many. The same is true across other countries too.
In a 2017 article in the National Post, Canadian consultant child psychiatrist Susan Bradley made a fascinating and accidentally profound statement on how mental health professionals and legal systems see some disabled people:
“Activists would have the public believe that anyone who expresses a wish to be the other gender should be allowed and encouraged to do so.”
We’re back to the wrong decisions discussion again.
”To date, however, there is no evidence that there is such a thing as a “true” trans, just as there is no marker that would identify a “false” trans. To accept the thinking and wishes of those with ASD [sic] at face value, without understanding why they feel the way they do, is not a kindness, and may in fact be extremely damaging.”
Isn’t that just a fascinating comment? That because there aren’t biomedical tests for someone truly being transgender, it would be cruel and unacceptable to accept disabled people’s own lived experiences and their own testimony as truly reflecting their needs and wishes. This is, unwittingly, a devastating summary of how society thinks about decision making for some disabled people today.
In 2018, philosopher Oliver Thorn published a fantastic video on suicide and mental health, showing how although informed consent is assumed to be the basis of healthcare provision in the UK, there is a major exception to that – the area of mental health. If you are thought to have a mental health disability and you are deemed a risk to yourself, you can be violently arrested with handcuffs and be detained without trial, and indeed, detained without trial indefinitely. Autistic rights advocates in the UK are currently campaigning on the fact that despite autism not being a mental health condition, autistic people are routinely removed from their communities and homes under the Mental Health Act and incarcerated in secure hospitals for “their own protection”, or because there aren’t suitable services in the community anymore due to spending cuts.
The experiences of those detained can only be described as torture – the use of seclusion, also known as solitary confinement, is rampant, as is the use of physical and chemical restraint – forced medication. Nominally short-term facilities are called Assessment and Treatment Units – ATUs. Restraint was used against disabled people in ATUs nearly 29,000 times in 2017 – that’s 29,000 restraints on a patient population of 2,000. Some disabled people in the UK are sectioned under mental health legislation for years. 60% of ATU patients have been there for more than 2 years, and 16% for more than a decade. For those years, some disabled people are detained in featureless rooms without showers or access to family, and in some cases are fed through a six-inch hatch in a door.
I bring this up because the reality is for many disabled people in the UK, their freedoms and rights are entirely at the discretion of their healthcare providers, and that these human rights abuses can also manifest in less severe forms for disabled people in other areas of healthcare.
The approach to disability rights that locks people up for being disabled is the same approach that denies people healthcare for being disabled. The mechanisms for providing informed consent to treatment are understood to apply to nondisabled people by default, and to some groups of disabled people only if proven that they’re justified.
So, how does this connect in to trans healthcare?
Well, being trans can feel different to people with neurodivergent brains. To provide a personal example, I never understood myself to be trans like other trans people described things online in the 2000s, and it was only when a neurodivergent trans person I met described how their sensory processing difficulties made it harder to understand that it clicked with me. I still struggle to actually articulate how I know I’m trans – as many people do, particularly neurodivergent folks – but I definitely know I am.
US-based clinician Johanna Olson-Kennedy has said that for some autistic people and folks with ADHD, their “neurodivergent traits” change and substantially reduce when they transition. Now, I don’t think people become neurotypical when they transition and I disagree with some of Olson-Kennedy’s framing, but transition does often make life more comfortable for trans people – that’s often the point of it. It makes sense then that difficulties associated with developmental and neurochemical disability may be lessened by having less stress to cope with overall. I’ve worked with hundreds of neurodivergent trans people over the last number of years and have found that to be a consistent observation – we – neurodivergent trans people – benefit from transition just like neurotypical trans people do. However, because neurodivergence can be interpreted by clinicians as being misunderstanding, or being mistaken about being trans, or interfering with the consent process where that’s not the case, many people are denied the opportunity to explore medical and social transition options because of their disability.
Autistic people may need adjustments made in healthcare assessments just like any disabled person may. In my work a few years ago, I watched a number of autistic trans people end up in an acute mental health emergencies because they were denied gender-affirming care for years, simply because the care providers wouldn’t change the way they asked questions to make them answerable for Autistic folks. I’ve also worked with several others who’ve found themselves being delayed by years just for having an autism or ADHD diagnosis, or even as adults having to have a parent support their transition, because they aren’t deemed to be capable of making decisions themselves, despite having legal capacity.
My point here is that denying trans people – including young people – including disabled people – including disabled young people – access to care because of uncertainty of outcomes, clinical suspicion or because of arbitrary age limits is not a value-neutral decision. It’s not a decision that cannot cause harm. In the same way denying any other care from people who need it is a specific form of medical harm, denying gender-affirming care to trans people who need it, regardless of disability, is a specific form of medical harm.
Adding a 12 month assessment on top of typical assessment because a trans person who’s been waiting for treatment for years, just because they’re disabled, often won’t benefit that person, and in many cases can harm them, especially if it’s 12 months of inaccessible assessment. The underlying concepts that transition is harmful to young and disabled people, that transitioning is the lesser of two possible outcomes, and that disabled people do not have the same decision making rights as others, need to be challenged.
The realities are that some disabled people will need supported decision making when accessing gender affirming care, and may benefit from additional exploration of identity etc if that’s what’s right for them, but this is best defined by that individual. Building high fences around transition care and making people jump them isn’t the best way to protect patients – providing accessible care is. This is the case in all areas of long-term healthcare and in medicine involving fertility. For those that worry about people who transition “for the wrong reasons” or end up needing aftercare or complications support or who need to detransition or retransition, accessible care that doesn’t pathologise disabled people or place pressures on social conformity also benefits these groups.
A call of independent living movement activists in decades past has been that disabled people deserve the right to make decisions, including when other people deemed that these decisions weren’t perfect or even acceptable. If a non-disabled person can make a decision about something, it follows that a disabled person’s inalienable human rights grant them the same opportunities.
There will never be certainty as to whether anyone embarking on transition will make perfect choices. That’s the reality for everyone about everything in this world, in all forms of choice, from the mundane like choosing your route to work, to making long-term decisions about your family, or about the best mortgage to take, or even deciding how you want to die. These decisions can lead us to great experiences and poor experiences, sometimes both at the same time, and always provide the best lessons in hindsight. There’s little reason this can’t apply to disabled people and to trans folks too, and indeed human rights law is clear on this – it does apply. Supported decision making is something we all do regularly – if you ask your mum, or your colleague, or your girlfriend, or your awful followers on twitter what they think about something you’re considering – that is supported decision making. Being helped to make decisions about transitioning, whether we think they’re individually good choices or not, is something that all trans people should be provided with, and this doesn’t change due to disability.
The good thing here is that practice globally is moving forward quickly. Not necessarily in the UK, but in the US, Canada, Australia, New Zealand, Argentina, parts of mainland Europe, plenty of gender-affirming care providers are moving to a model that doesn’t pathologise trans identity, and towards one that centres informed consent, bodily integrity, and disability rights.
We should be looking at those places, learning from them, and accepting where the ways we do things here are failing. I only hope we in the UK and Ireland can take the steps needed to look beyond our borders to see that we don’t need to do this to people. We can be better.
My ask for you is that – when you see these arguments being made – when you see disability being used as a reason to deny care, as a reason for public alarm, as a reason to put people’s lives on hold – that you see them for what they are, and call them out as such. Stand up against this current torrent of abuse coming our way, and give disabled trans people the protection that comes from the people in their lives standing firm against this threat. It’s on us, it’s on you, it’s on all of us to call it out when disabled people are used as klaxons by the Sunday Times.
Thanks so much to Jay Hulme for providing some of his work for use in this video, and to the good folks who support my work on Patreon. If you have individual issues with accessing trans healthcare as a disabled person, I probably won’t be able to help individually, but I can provide resources for what might help you, including who to contact locally.
If you thought this video was useful, do let me know however you wish, and you can get in touch anytime via the PO Box address or email address down below in the video description.
Have a lovely day.