What does it mean to be trans in Britain today?

Hello, this is Dr. Helen Webberley. Welcome to our Gender GP Podcast, where we will be discussing some of the issues affecting the trans and non-binary community in the world today, together with my co-host Marianne Oakes, a trans woman herself, and our head of therapy. We’re going to talk today about what it means to be transgender in today’s world, in 2018 and beyond. I suppose that leads us on to the first concept, really. Marianne, help me out. How many gender identities can there possibly be? Someone said to me a while ago that there are infinite gender identities, and I was telling my son that, and he told me that if I ever said that publicly, I was going to have it ripped out and that kind of thing. And so, is it true? Can we have an infinite number of gender identities? What does it mean?

Personally, I think the simple answer to that is “yes”. The only reason I would say that is I had gender explained to me really simply by one of my clients in the therapy room. They were explaining to the dad, who was struggling with the concept of non-binary, that he sees the world as men, women, boys, girls. And he’s got his child there trying to explain, “Actually, dad, I’m not a girl.” So imagine that men are black, and women are white. They said to the dad, “Actually, I’m a funny colour grey. I’m not quite one or the other.” We are all shades of grey along that spectrum. If we were to divide that spectrum to finite segments, then yes, there will be an infinite amount of gender identities. I’m not sure there is an infinite amount of ways to describe those identities. That would be a different subject altogether. But even if you see what we would term a cis-woman, she could be wearing more masculine clothes or she could be wearing more feminine clothes. What shade of grey would she be? Likewise, for a cis-gender man, what does it even mean to be a man? What does masculinity mean? So yes, I think there is an infinite amount of gender identities. Is there an infinite amount of words to describe it? I’m not sure.

I love that concept. It’s brilliant. If you think about it, that colour grey, which was talked about elegantly by your client in the therapy room, when the sun goes behind the cloud, that grey sort of changes a bit, which means that whatever shade of grey you are on the spectrum, it can also change with the day, with the month, with the feeling of support you have. It is not a static place on that spectrum. I wish we had a little bit more colour. I’m not sure about the colour, I prefer a whole rainbow colour. An infinite number of gender identities on the spectrum. So let’s put in a little bit of colour and make that grey happy. But I totally agree with you. So it brings us over to another point. Can external influences, in some way, dictate what gender you are? So, if for example, you are supporting your wife, husband, or partner, to be transgender, and allowing them to express themselves through clothes, makeup, or hair, are you encouraging them in some way? Are you making this “worse” for them? Are we influencing them, or are we supporting them? And on a similar vein, can we possibly iron this out, if we just put some fixed hard rules in the household that would make this transgender thing go away?

No to both, I have to say. Can we make somebody transgender? This isn’t nurturing. Again, I can only go off my own experience, both my life and the experience from clients in the therapy room. And, you know, the world has taught them that this is wrong. The signals that they picked up as they grew up was that this is wrong. Everything before coming out has told them that this is wrong. So you know whether it is a six year-old coming out, or a sixty year-old, there’s been nothing to encourage this at all. Quite the opposite. So can we make them, by giving them a friendly ear and saying that it’s okay –  what you’re actually saying is you can discover what it means to you because I think that’s always the question. People say to me “I think I might be transgender” and my first response is let’s talk about what that means to you. Most people have never had the environment to actually talk about what it means to them. We have this fixated idea that it’s transition. And it doesn’t always need to be transition. Again, we move along that spectrum, and we need to find our place on it. Can we stop being transgender? And again, no. We either are, or we are not. I’m just going to temper that by saying that I think “are you male or female?” or “are you man or woman?” you know, but “are we who we feel we are?” The truth of the matter is; we are who we are. And we can no more change that than we can change our DNA. It’s just who we are.

You’re completely right in coming on from that. I’ve had people explain to me that they were assigned male at birth, then everyone thought they would grow up to be a young boy and a young man, but it became very evident from early on that this didn’t sit right, and it turned out they were a girl. But they did not want it, they did not want to be transgender. They tell me stories from throughout their life, how they tried to do everything. They tried to grow a beard, they tried to cut your hair, they’ve done the tattoos, they’ve done the bodybuilding, anything that they could possibly do to reinforce the maleness and they would self force their male identity. And it came to a point where they just couldn’t fight anymore. And the femaleness has to be allowed to come out. Once that happens, once that fight is over, the exploration of what it means to be a woman, even if they still have the stubble on their chin, the tattoos on their limbs, or the slightly rounded beer belly type thing – they have to have the course to explore what it means to be a woman for them, and how they are going to fit now as a woman in society. I’m not saying it will be an easy ride, but often people when they put up that initial fight, and they come up with this new way of living this identity, a lot of that dysphoria – that unhappiness that we talked about before – it goes away.

I think one of the most pleasurable sides of being a therapeutic counsellor is how you can reduce everybody’s pain. To see real change in people. Whether I see them on Skype, or whether I see them in the therapy room, I see this nervous person – many of them have never moved it out of the bedroom. It’s very private, it’s very deep. Over a period of a few weeks, sometimes a few months, they start to embrace who they are. And then when therapy finishes and you see them moving out into society, presenting as their true self – I have to say, I am talking about transgender women here and we shouldn’t forget the trans men, but for the trans women, especially the older ones, you see them start to flourish and it’s one of the most precious parts of my job and one of the most privileged parts as well for them to have shared that journey with me. I wanted to go back to the trans men as well on this. The interesting thing I do find is that trans women are very repressed with their presentation, and one of the things we are seeing now, and I think you’ll agree with me, is that trans men and trans boys are becoming more visible now. There’s this idea that they’d never been there before, that there’s this kind of contagion. I think it’s the trans boys and trans men that have unnerved society a little bit. But the one thing I have learned through the therapy room is that a trans guy who presented more masculine as a child was able to achieve masculinity in a way that a trans woman couldn’t. but you know, actually saying it and admitting is is equally as difficult, despite the presentation. That actual saying of those words and then the thoughts of coming out to other people and actually sharing it with them is equally difficult for both sets.

That’s a really interesting concept, isn’t it? Because we have this concept that men just get on with it and they manage and don’t suffer the same kind of turmoil. And we look at our trans men and we expect them to buck up and get on with it, and “man up” as it was. But you’re so right. The difficulties that they have to go through with their mind and their body and their family and their world in order to work out how best to fit in themselves and outside themselves are the same struggles. But I have to say, one thing I have found is if you go out in the streets and you’re walking up and down and looking at people, if there is an older transgender woman who has had to endure full male puberty, there is no doubt that her features will have some masculinity to them. So maybe her hands will be bigger, maybe she’ll have an Adam’s apple, a deeper voice, some stubble on her chin – all these things which identify her as a trans woman, and make it obvious that she’s a trans woman as opposed to a cis-woman. And she has to bear that all her life. I’ve also seen the taunts and pointing and the comments that she would have to endure, very sadly. On the flip side, for trans men, you don’t see them. And you don’t see them because once they start testosterone as a medical treatment, we switch their hormones from the female hormone which is estrogen, to the male hormone which is testosterone. And they go through a male puberty. Their voice will break, their Adam’s apple will develop, the chin and beard will swell. Walking down the street, they just mingle and they don’t get that finger pointing and giggling behind the hand that I see trans women have to put up with. So, in those terms, I think that they are luckier in some ways. We will talk about children later on in the series, but why there are people presenting early asking for help to stop puberty, it’s so important for the future. But I know that you, Marianne, have some thoughts on this whole idea of melding and passing and mixing into society, don’t you?

Yes. In the therapy room, passing is always present in the conversation. So whether it’s somebody right at the start of their journey, or somebody that is partly through their journey, they talk about passing. They never go out of the house until they can pass. Or start hormones, or get changes, because only then will they be able to pass. And passing really is probably, in the minds of most transgender people, the biggest block to moving forward. I could say that for trans men and trans women as well. This idea that they will feel judged when they step out on the street, and everybody is going to see them for who they really are, and that they’ll never be able to get to that sweet spot where they can just get out and go about their business. What I do see is, though, as they go through their journey, it actually starts to get less. In the therapy room, when they start becoming comfortable, and accepting themselves for who they are, when they start to love the body for what it is, I try to encourage clients to see their body as the scaffolding. That it’s going to change, because we can change the outside to a degree, to make them feel comfortable. But once you start getting that and being accepting of who they are, then the talk of passing gets less and less. And I think the way I describe it is when we are comfortable in ourselves, the people that we meet are comfortable with us. If we are furtive and guilty, if we go out there and we feel that we are not authentic, and that we have no rights to be there, then people will treat us with suspicion. Part of the process, I find, passing isn’t about how we look. It’s about how we are and how accepting of ourselves we are.

You mentioned people living with us. I think we’ve talked a lot about transgender people today. If we take that conversation further out, and we start to consider those people who are touched by those people we are talking about, we talk about children of transgender parents. Siblings, brothers and sisters, grandparents. In schools, employment. If we start to talk about the wider world, if we start to pick what it means for everybody, and surely everybody somewhere on the line has been touched by issues that a transgender person has faced. I see a lot of upset and tears and heart-wrenching and soul searching when people are exploring their identity and exploring what the future holds for them in terms of what it means for their children; “I don’t want you to call me ‘daddy’ anymore” or “I want you to call me mummy.” Maybe it’s saying I’m sorry I’m not your son, I know I’ve been your son all my life, but actually I’ve been wrong. I’m your daughter. These are difficult things, aren’t they? We’ve seen people in female orientated jobs going forward and saying “I’m a man”. What do you think of this concept? Are these people being selfish to their children, sisters, parents, grandparents? Are they being selfish in society saying that I’m not keeping this just to myself anymore, I need you to make changes so that I can be encompassed more easily? Do you think people are being selfish there?

I think it would be really harsh to suggest that anybody going through any kind of questioning of their identity, whether we are talking transgender or any identity, that they’re being selfish by being true to themselves. I would have to say no. I think what is selfish is we’re not careful, is o not be accepting of the journeys that the people’s going on who are around us, the people that love us. We talk about transitioning and trans men and trans women, and we can get so focused on them that we forget that the ripple effects of this travel far and wide. When we come out, we get in this euphoric place. And we just think that everybody is seeing it. And is happy for us. I think our family members in particular can start celebrating with us, and inside they’re breaking their hearts, because all the hopes, dreams, and aspirations that our parents and loved ones have had for us are being blown apart. So I think it would be selfish to think that we’re the only people involved. That would definitely feel selfish to me. Is it selfish to want to go and explore this and embrace it? No, but we’ve got to have an empathy for the people who are supporting us and who love us.

You’re right. The first time that anybody is brave enough to bring the subject up is so important, isn’t it? I’m going to tell a story that someone told me, and this was an adult patient, so in their forties. They so clearly remembered the time they were at school and they were assigned male at birth. So sitting on the mat at school, they brought in an Indian lady, and she was showing the students about the clothes that they wear and the culture that they have, and she brought up this beautiful sari and the patient was explaining the colours and textures of the silk – so she brought out this beautiful sari and said, does anybody want to try the sari on? Does anybody want to see what it’s like to wear a sari?” and my patient’s hand shot up and he was saying choose me, and then that little boy that everyone thought was a little boy sat there and thought “oh no!” and the whole class dissolved into laughter and started giggling and pointing because why would ever he want to dress in a sari? And so that person put away their gender feelings for years and years and years, that experience shocked them to the core and waited until they were in their forties or fifties to bring it up again. It’s so important, that first ripple that you were talking about, the start of that ripple is so important. We see it in medicine as well. I say to people, how did you get on with the doctor, have you talked to your GP about this? That first time when you’re ready to go to your doctor and say, “okay, this might be a little bit different, or hard to understand, or I’ve been building up a long time to say this, but I think I might be transgender or I need to transition or I need some help.” And the reaction of that doctor is so important, because I heard the stories of where they’re like no, it’s not going to happen. Off you go. How could you possibly be a woman? You look so much like a man. And back that person goes into their bedroom, as you were talking about earlier, Marianne. And they hide away and lock everything in a box under the bed for many years to come. So the first ripple is so important, and anybody out there who might ever have that first disclosure from someone, “I think I might be trans,” however you might feel about it, however you think you don’t know anything about this – just open your arms and allow that space to talk. That’s all that people are asking for.

I couldn’t agree more, actually. You just reminded me talking then about my – I went to my GP twice, actually. I went probably ten years before I asked for a referral. I think that’s where I got the first counselling from. And I went in and I remember sitting in the waiting room and there was nothing in that waiting room to tell me that this was a safe place, and I was thinking, do I tell them that I have an ear infection? I thought about an escape route. And I went in and I didn’t know the words. I had never actually, apart from within my marriage, ‘d never articulated this. And I remember going and sitting, my palms were sweating, and I’m sweating right now just talking about it, in the awaiting room. I got called in, and I sat down, and the doctor told me what can I do for you. And I said, “I think I am questioning my gender identity.” And he said, “Right, and how can I help?” and I said, “I think I could do with some counselling.” And he said, “Great, I can arrange some counselling for you.” Actually, I came out of there thinking his response was perfect. He didn’t default by sending me to the gender clinic, he didn’t start saying I don’t know anything about this. His first words were “how can I help?” and I think if every doctor could just say that, and put the patients at ease to say exactly what they hope, then maybe some counselling would be the first. But I had chosen that. maybe it isn’t about jumping up and down. When the doctor goes into meltdown, then the client closes up, if that makes sense. My second experience I have to say was pretty similar. I thought that I would have gotten used to it by then, ten years down the line. I was asking for referral then. He did everything that I didn’t want him to do. He started telling me that he knows nothing about this, and that he’s going to have to go away and research. I start thinking how serious is this. Am I going to get knocked back? But to be fair, he did what he said he was going to do, and he came back a week later with a phone call and I got my referral. That “how can I help?” thing says a lot.

It brings in the concept, doesn’t it, that actually the patient is the expert? Although the doctor has the key to the next step, or the key to the medicine cabinet, or the key to the referral letter that’s going to facilitate the counselling or therapy that the patient needs, while understanding that not everybody needs that, everyone has different needs – so this idea that it is the patient who has it, who is having the identity issues is the expert on this. We talk about education, and your second GP there, who was holding his hands up. And I don’t know anything about this, I’m going to go look it up. Fair play to him, he went and looked it up. But education is such key here. I don’t understand why it’s such a scary topic, I don’t understand why it’s been left off the curriculum so much. When I was in medical school, this wasn’t talked about. When I did my GP training, this wasn’t talked about. It’s not talked about in any post-graduate training. Even the specialist training for endocrinology doesn’t talk about it. Psychiatry, it’s not talked about. In some ways, I feel sorry for my colleagues who don’t have any experience or knowledge in this area because the education is sorely lacking. And we need more. That’s where the community can come in and help. They completely understand what it means to be transgender. They really help because they’ve done so much research. They know all about hormones and counselling and referral. But on the other hand, it’s not their job to be the educators. On the one hand, we must refer to that lived experience of the person to help us understand what it means to be transgender to them, but we as healthcare professionals have a duty, that if we don’t know enough about it, that we should go read up about it now, just in case someone comes through the door, and sits down to say “I think I am questioning my gender.” So education in society, schools, in the healthcare sector, in the workplace, in the government, it is key. It sounds cliché, but education is the key to the future.

I think something that you might be able to answer better than I can, is I get a sense from the doctors that this is unusual. And as much as when we go to the doctors, we are going to them as the expert – whether it’s a cold, a virus, an ingrowing toenail, or whatever – the doctor becomes the expert, and in this particular case, we’re going in and we’re telling them something, we’re not asking them. So I’m not going in there saying I’m transgender, what do you think? I’m going in there saying that I am questioning my gender identity and I need some support from the gender clinic. I think the doctor feels that they’ve got to have an opinion on it. I don’t know if that’s something. Am I just misreading that?

Yes, you have to understand that doctors are a funny breed, if I may say that sort of generalist thing. If you look back ten or twenty years ago, there was this situation where if you entered GP surgery, your GP was perhaps male, perhaps sitting in a suit at the other side of the table to you, and you would come in through the door, and he would perhaps be writing through your notes, and he would look up and go, “Yes, please sit down. How can I help you?” and you sit down opposite with terror or what have you. And it was a very direct approach. In more recent years, we’ve learnt to get the best out of your doctor-patient relationship. You don’t sit facing each other, you sit side on. When you go to GP surgery now, the doctor sits on one side of the table, and you perhaps sit at ninety degrees, so that there’s not that confrontational power shift. And instead of, like you said with your example, “How can I help you?” is such a powerful word that doctors use these days. You are welcome. How can I help you, and how can I help you with that? it shifts away from the doctor being the (unclear 26:59) to the doctor being an expert in medicine. But how can he apply that knowledge to your particular situation? And can you as an expert help your doctor to guide you through the process that’s going to apply medicine to you, if that makes sense. And I get a lot of doctors who say to me that they’ve never met a transgender patient. I don’t know what you’re talking about, this is not common. We don’t have any transgender patients. And I think to myself, and I often verbalise it, “Have you ever met anyone – did any of your patients duck out and say they’ve got an earache?” instead of “I’m questioning my gender”. I defy any doctor who has seen a decent number of patients that they’ve never met a transgender patient or person. They just don’t know that they have.

So, recently I was asked to talk at a conference of nurses in practice. The brief was that they wanted to understand how they could make their practices more inclusive of diversity, in particular, the transgender community. The first thing that I asked them was if anybody came across or met a transgender patient in their practice in their day to day work. And two thirds of them raised a hand to say no. my response to that was, “Yes you have, you just didn’t know it.” What I went on to say was the question to ask was why have they not felt safe to tell you? I know I sat in the GP’s waiting room. I know I’ve been in a waiting room at hospital. I know that I’ve been in an environment where I’ve come across nurses. And I am transgender, and I didn’t always feel safe.

That’s an interesting concept, isn’t it? Of safety. That you left that paragraph on, Marianne. We should all feel safe, and no more in a GP surgery or a hospital. We are supposed to feel safe in that situation, and yet, for so many people, they don’t feel safe. Whether we talk about the debate of which sex ward the patient should go on, who should look after transgender patients, which toilets should they go in, what gender of a chaperone should they have? We all deserve to feel safe with our gender and our hospital and our GP surgeries. I think next time we meet, I really think we should unpick what it means to get transgender healthcare for you or your family or someone you love. Or perhaps you’re one of those people who’ve been affected by the ripple that we talked about before. And actually, the ripples are really hurting. You know, how do those people get support and help from our NHS healthcare system? I’d really like to unpick some of that – how to feel safe, how to be safe, and how to provide safe care for these very exciting and rewarding and needy patient group. Let’s see if we can bash this out next time.