My first reactions on reading an article in the China Daily (link here) reporting that the Ministry of Health (MoH) has issued its “first clinical guideline on sex-change surgery” were surprise that China doesn’t already have such guidelines, and curiosity about how many trans people there might be in China.
Taking the NHS’ estimate that “one in 4,000 people in the UK is receiving medical help for gender dysphoria” (link here), and the CIA’s estimate (link here) that the population of China is 1,330,044,544, as being accurate, then that suggests there may be some 332,511 trans people in China.
No wonder, then, that the guidelines have been compiled as part of a process of “regulation and standardisation“. And the idea that appropriate medical support is currently only available in an uncoordinated and haphazard way isn’t such a big surprise when one considers such things as the infamous postcode lottery for healthcare access in the UK.
The draft document sets out minimum criteria for both trans people and medical institutions. To that extent, it seems to be trying to achieve a similar result to the widely-followed WPATH Standards of Care for Gender Identity Disorders (SoC) (direct link to PDF here) without actually referring to them directly, for whatever reason. The China Daily reports that the MoH lists three main criteria for diagnosing gender dysphoria:
- Candidates for the surgery must be older than 20 and single
- They are also required to prove a persistent desire for a sex change, to live for at least five consecutive years full-time in the new gender role, and to engage in mental therapy for at least one year.
- Before surgery can take place, a candidate must receive a recommendation for the operation from a psychologist after an appropriate series of therapy sessions.
So how does this compare with the SoC?
To begin with, the minimum age requirement for surgery is described in the SoC as being the “legal age of majority in the patient’s nation“; in the UK, this is 18. As far as I’m aware, there’s no specific requirement in the SoC that one must be single, and the inclusion of this is a telling demonstration of how a moral code is interwoven with the more empirical medical criteria.
The first part of the second clause (“to prove a persistent desire for a sex change“) in principle echoes the SoC – or, more accurately, the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) and the International Statistical Classification of Diseases and Related Health Problems (ICD-10), to which the SoC refers.
The ICD-10 is quoted as saying that one of the criteria of transsexualism is:
The desire to live and be accepted as a member of the opposite sex, usually accompanied by the wish to make his or her body as congruent as possible with the preferred sex through surgery and hormone treatment
And the SoC quotes the DSM-IV-TR’s diagnosis of Gender Identity Disorder (GID) as applying to:
those with a strong and persistent crossgender identification and a persistent discomfort with their sex or a sense of inappropriateness in the gender role of that sex
The second part of the second clause – the requirement for five years’ Real Life Experience (RLE) – seems draconian in comparison to the SoC. Its section IX, The Real-Life Experience sets no specific time period; although elsewhere it requires a minimum of “12 months of successful continuous full time real-life experience” as one of the criteria for surgery.
However, even this prerequisite seems flexible: a person transitioning under the UK’s NHS is likely to be required to undergo at least 24 months RLE, whereas the Thai surgeon who carried out my surgery asked for only 6 months RLE. It remains to be seen if the Chinese proposal will be strictly enforced.
The third part of the second clause – “to engage in mental therapy for at least one year” appears to overlap with the third clause which demands that a “recommendation” for surgery is required from a psychologist “after an appropriate series of therapy sessions“. The SoC, however, states that:
Not every adult gender patient requires psychotherapy in order to proceed with hormone therapy, the real-life experience, hormones, or surgery.
It seems that the main proposals of the Chinese model have more similarities with the SoC than they have differences, albeit with some significant variations in detail.
However, the Chinese proposal also includes two additional, quite specific legal requirements that must be met:
The candidate must provide proof from police that he or she has does not have any criminal offenses in the past.
Police must also agree to change the sex status on the identity card of the prospective receiver before the operation can take place.
I have to say that I really don’t understand why the police need to be involved in the transitioning process at all. I’m not aware of any comparable requirements in the SoC although, in addition to medical and social aspects, it’s not gone unnoticed that my own transition includes legal elements too. However, these relate, not to criminal law, but civil. For example, to qualify for a Gender Recognition Certificate, which “enables transsexual people to be legally recognised in their acquired gender“, I had to follow the procedure laid down in the Gender Recognition Act 2004. Having successfully jumped through those hoops, I am now “legally recognised for all purposes in your acquired gender“. This includes being able to obtain a new birth certificate showing my “legally recognised gender“.
No police officers required…
I have much the same feelings about the Chinese guidelines as I do about the WPATH Standards of Care which govern my own transition. I can understand and – to some extent – even agree with the need for support and assistance from healthcare professionals regarding the medical aspects of transitioning. But I’m deeply uncomfortable about the amount of the involvement of the state. Just as I don’t understand why a trans woman in China should need police approval to change her ID card, neither do I understand why I needed a covering letter from my doctor to change my passport.
To be honest, most of the questions and discrepancies arising from the SoC look to me that they will simply happen under the Chinese proposals too.
It’s hard to see how things like the ‘no-match’ situation (where a person’s official documents don’t match the state’s records for that person) won’t occur under these proposals. It’s hard to see where non-binary ID’d trans people fit into the picture, too.
But most of all, it’s hard to see how the proposals will be implemented in such a way that trans people in China aren’t pathologised and stigmatised in the way that trans people are in other places, which in turn exposes us to unacceptably high risks of discrimination, bigotry and violence from cis people.