Unconditional healthcare - Claire Axiak
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Unconditional healthcare - Claire Axiak

Now that our country is considered a trailblazer in the field of LGBTIQ rights throughout Europe and beyond, the next steps have been taken to ensure that transgender and intersex persons are afforded the same rights as their fellow cisgender citizens when it comes to access to medical care.

The Ministry for Health has published a consultation document outlining an ambitious plan to develop a trans-inclusive healthcare system based on the standards of care issued by the World Professional Association for Transgender Health (WPATH).

The plan primarily tackles the medical, psychological and social aspects of gender affirmation in healthcare. Gender affirmation is the process whereby transgender persons receive social recognition and support for their gender identity and expression.

Studies have shown that the fundamental key to achieve a truly trans-inclusive healthcare system is to remove any unreasonable and unnecessary conditions for such gender affirmation to take place. For instance, many European countries that allow transgender persons to change their legal sex, require such persons to first undergo surgery or sterilisation.

Even worse, other countries require a formal medical diagnosis or a diagnosis of “gender identity disorder” before allowing legal sex change or before granting access to specialised medical care including gender reassignment surgery.

Maltese law has since 2015 provided that any change in gender identity cannot be subject to any psychiatric evaluation or surgical intervention. Furthermore, the law categorically rejects the pathologisation of any form of sexual orientation, gender identity or gender expression as may be classified under the International Classification of Diseases or any other similar internationally recognised classification.

The State should as a bare minimum go out of its way to ensure that they access the best treatment with the least inconvenience

 The rejection of such classification however does not impact negatively the provision of any healthcare service related to sex or gender so much so that “Gender Identity and Sex Characteristics Related Conditions” have been expressly added to the list of conditions in respect of which free medical aid may be accorded by the State.

What does this mean in practice? It means that although according to the ICD-10 (the most recent medical classification list by the World Health Organisation) transsexualism is classified as a mental disorder, the Maltese State refutes such categorisation (and the stigma that this produces) but at the same time provides all medical care required to transgender persons even though there’s no formal diagnosis of a medical condition so to speak.

The good news is that in the most recent revision (ICD-11, to be published imminently), being transgender shall now no longer be a mental disorder but where gender incongruence results, such diagnosis shall be considered as a condition related to sexual health.

The concept of gender incongruence was adopted from the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which came out in 2013 that reclassified “Gender identity disorder” (i.e. transsexualism as a mental disorder in itself) as “gender dysphoria” which applies only to the discontent experienced by some (and not all) persons resulting from gender identity issues.

Many transgender persons readily point out that their biggest problem is not the fact that they are transgender but that society either pressures them to conform to “accepted” societal roles relating to the male or female gender (with anything in between being shunned and rejected) or else subjects their decision to affirm their desired gender to unreasonable obstacles such as a psychiatric evaluation and diagnosis.

Inevitably this societal rejection and pressure brings untold distress and it is not surprising that, as stated in the consultation document, trans persons are reported to have higher rates of depressive symptoms, mental distress, substance abuse, STIs and HIV rates as compared to non-trans persons.

The plan outlined in the document proposes that access to medical carefor transgender persons is not only readily available but also provided in aspecialised setting using the standards of care issued by the World Professional Association for Transgender Health (WPATH).

For this purpose, the proposed strategy is to offer such care through a multi-disciplinary clinical team consisting of specialists in endocrinology, urology, gynaecology, plastic surgery, psychiatry and paediatrics (in the case of children and adolescents) together with a psychologist, social worker, speech language pathologist and nurse working in a dedicated gender clinic.

Transgender persons who desire state-funded hormonal or surgical treatment or other medical care will be referred to this multi-disciplinary team. This ensures not only the provision of specialised care in a uniform and coordinated manner but also provides for periodic follow-ups by the right people.

The establishment of such clinic does not in any way mean that transgender persons are automatically sick and in need of treatment but on the contrary recognises that since such persons typically face great challenges due to social stigmas and barriers, the State should as a bare minimum go out of its way to ensure that they access the best treatment with the least inconvenience.

Anything less than that and the State would be failing in its moral duty to ensure true equality among its citizens.

Claire Axiak is a psychiatrist working at Mental Health Services (Malta).

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