Slide 1 Greetings from Australia and thank you JoAnne. Slide 2 I d like to acknowledge the Aboriginal and Torres Strait Islander people as the traditional owners of the land known now as Australia as a mark of respect to their Elders past present and future. Slide 3 Imagine you ve just gone through a lengthy and traumatic operation the day before; an expensive operation that you have worked so hard to achieve with possibly years of indecision before your time was right. An operation where for two years prior and sometimes longer, you ve had to bare it all to psychiatrists, psychologists and the like to prove to them you could have this life changing surgery. You re in extreme pain, vulnerable and quite emotional; you re crying. Then your surgeon comes in to see how you are doing and the first thing he says is Why are you crying? You got what you wanted! How would you feel?
Dee Dee, a trans* woman who had undergone a vaginoplasty the day before experienced just that. At the time of her interview for this research, Dee Dee remembers crying and being in a significant amount of pain following the procedure but those words by the surgeon shocked and angered Dee Dee. Her response to the surgeon was I don t know. The surgeon s response disregarded the social and psychological supports required to make a smooth transition at this life changing moment in time. Slide 4 The findings presented here today are embedded in a PhD project undertaken in which I looked at SRS from a whole of life approach. The analysis was grounded in the four concepts of self. Today s presentation is interested in how the 14 trans* men and women who participated in my study navigated the medical self. The medical self is concerned with the participants interactions with the healthcare system in pursuit of SRS. However, the findings of this study suggest inconsistencies in medical processes where the needs of the clients may or may not have been met. This research honours their voices.
Slide 5 The surgical process begins with psychiatric and medical assessments. John s interaction with his psychiatrist was perceived as intrusive, neglectful and disregarded the support needed at this time. It was an abuse of the doctor-patient relationship resulting in John feeling humiliated and degraded. Andrew E felt a loss of social control, identity and a sense of social disconnectedness as the surgeon performed his duties. As Andrew E said Oh well, shit, I ll just have to stand here then. Psychologically at that moment while you re standing there awake while they re drawing on you where they re going to cut you are so vulnerable. While the physical aspects of the surgery met Andrew s needs, the psychosocial support was ignored and was reduced to the replacement of faulty parts which defined his sexual body as a commodity to be maintained. It is moments such as these that disempower and socially disqualify trans* people such as Andrew E and John.
Slide 6 In an ideal world, the readiness for surgery should be a collaborative effort between the client and the medical/surgical team based upon the notion of informed consent. Perceptions of surgical readiness varied between participants and their needs were sometimes not met or disregarded. Robert had known for a long time his readiness for surgery, but for him, readiness was also grounded in the knowledge and support of, and effective communication with the surgeon. His relationship with his surgeon was reframed through mutual understanding, and the recognition that a collaborative model of treatment based on trust resulted in a negotiation of the power dynamic. Equally, the level of support was deemed appropriate and his needs were met. On the other hand, there was a lack of knowledge and information about the surgical process which lead to uncertainty and the possible psychosocial consequences of a lack of knowledge, indicating needs have not been met. Despite being personally ready, John was hesitant and confused and therefore it was possible that the tools to navigate the practical and psychological aspects of surgery were not provided. Andrew E felt totally unsupported during the process, despite asking for assistance. He felt isolated and vulnerable about his new embodiment indicating a lack of psychological assessment following treatment which can affect wellbeing. As he said, I didn t really have any support and I asked them for it, and they said Well, we ve got that for family members, not for you. Clients expect this type of instrumental support. Levels of psychosocial support were inconsistently applied at the individual health professional s level, suggesting support was
based upon the knowledge of trans* issues and the acceptance of trans* people by healthcare providers. Slide 7 Some participants felt affirmed and comfortable with the gendered language and approaches of health professionals. On the other hand, some participants felt emotionally upset by misgendering and unsupportive language. Leroy felt supported, respected, affirmed and his needs were met by the use of correct pronouns. However, being in a debilitated physical state following radical surgery left Daniel feeling unacknowledged and nullified as the person he is at a time when thoughts of the euphoria of previous surgeries were on his mind. As Daniel said, and the nurses confused the pronouns and that was just bad. This misgendering was disruptive and delegitimised his personal identity. Disrespectful communication also reinforces the notion of medical pathologisation in dealing with trans* identities and implies the notion of institutional erasure. The stigma and discrimination of misgendering is a site of disruption at a personal level, and the language imposed upon people like Daniel from a biomedical perspective does little to improve the healthcare they receive or meet their psychosocial needs.
Slide 8 Psychosocial processes exist in tandem with the physical transformation through the recovery period. This is a time of great adjustment and therefore it is important that healthcare professionals provide a supportive role. The participants in this study often reflected on their recovery period, both while in hospital and following discharge. One participant felt confused, upset, confronted and resigned to the process in hospital. This disregard of Dee Dee s psychosocial needs in the guise of scientific neutrality and professional authority further objectifies the trans* body as a site of disruption and resulted in a nullification of her emotions and the fluidity of her transition was disrupted. From another participant, support following surgery was dependent upon the profession. While there was support for the physical aspects of the transition, psychosocial support was perceived to be lacking. This lack of support left Irish feeling isolated and alienated at the time with nowhere to turn. This perception is supported by Andrew E who said, you have to deal with it and you kind of get asked to do it on your own. I was sort of staggered in a way that post-surgery there wasn t a nice list of who you could go to if you wanted to.
Slide 9 All the participants in this study indicated their personal satisfaction in transcending their physicality. However, meeting the needs of trans* people pursuing SRS goes beyond the physical; needs are dependent upon the knowledge of wider social networks, including the healthcare network. From Dee Dee s perspective, As far as doctors and psychiatrists go, they seem to be interested in getting you to the point of surgery and healing and that s it. Well that was my experience anyway. This account suggests that the psychosocial aspects of surgical transition are disregarded. On the other hand, Andrew E felt confused to his options. For Irish, there was a perception that knowledge of what trans* people need is lacking in the medical community. Equally important, the account suggests that trans* people themselves appear to be part of the problem and need to be part of the solution. Slide 10 Overall, participants perceived that navigating the healthcare system was an intrusive, positive, confusing, supportive, lacking, dismissive but necessary experience to obtain approval and subsequently undergo SRS. Participants accounts suggest that some health professionals provided the supports needed. However, in contrast, other health professionals did not provide best practice, and in some cases, it was a requirement to make it through the gate. This suggests that, for some participants, navigating the system was a challenging process. Therefore, I would suggest that there exists a need for medical professionals and trans* people to be mindful of the complexity of transition.
Slide 11 One objective of this PhD study was to explore the implications of these findings in relation to the Standards of Care. The findings of this study reflect the view that relationships between health professionals and trans* people are important. As described, participants highlighted examples of respectful and disrespectful language in their interactions with health professionals. Therefore, communication and language become important issues. However, there is nothing in the SOC concerned with effective, common-sense communication strategies with trans* people, excluding a comment in relation to terminology in various cultural locations. The SOC does include communication strategies on the relationships between mental health professionals and the multidisciplinary team, stating it should be open and consistent. Several examples such as this exist throughout the document. Mine and other studies (eg Hagen and Calupo, 2014) have highlighted improved healthcare of trans* people can be achieved through respectful and welcoming language that doesn t misgender. Therefore, my research suggests inclusion of a section on respectful communication into the SOC. Psychotherapy is also an important component. While not mandatory, it is a valuable adjunct to the therapeutic process. The SOC states that changes to gender are implicated in psychological, social, physical, occupational, financial, and legal ways (WPATH, 2011a, p. 24) and that trans* people should be aware of what these challenges are likely to be. The SOC fail to indicate what challenges trans* people may face throughout the transition process beyond those challenges being described as above. Participants accounts in my study suggest that there is a range of issues to consider such as body image, loss and grief, sexuality, spirituality, social
acceptance, legal recognition, internalised transphobia to name a few. The guidelines offer scant information about these issues especially in consideration of the medical professionals across the board who have no or very little knowledge of the types of things trans people go through. Work has already been done in this area. Some of Bockting et al s (2006) work on clinical pathways could easily be incorporated into the SOC and updated as an ongoing resource for all health professionals. Slide 12 That concludes my presentation. Any questions?