Amy Hamm vs BCCNM - 23 September 2022
Incomplete notes from Amy Hamm’s Tribunal taken on 23rd Sept 2022 (early part of session missed)
Greta Bauer (GB): describing definitions of cis and trans. Gender diverse is an expanding gender category beyond TG or transexual, woman or man. Gender Expression (GE) is how you present yourself, which might be different to GI (gender identity).
Q: What’s the difference between gender and GI?
GB: Both are multidimensional and everything isn’t linked
Q: Is GI biological?
GB: It’s self understanding. We don't have a clear answer for reasons. Some kids have early knowledge. But aspects can be social and can be moulded that way.
GB: Sex assigned at birth: This captures the starting point. There’s also the social gender a child is raised as. Sex and gender relationship: We’re absolutely not trying to get rid of sex. All researchers must look at both.
Q: Talk us through the tables of your Sex & Gender multidimensional tool to help with cross classification
GB: Tool covers dimensions in health outcomes. Appearance vs biological systems. Both sex and gender can affect health. Dimorphic species so there is overlap. Goal is to think about what is being measured vs what they think they’re measuring. Be more critical about measures and what they mean or don't mean.
Gives example of hangnails: this has sex and gender multidimensionality. Think through the hypothesis of how sex and/or gender impact health outcomes. Gives a more nuanced analysis.
Q: Potential change over the life course: is this mutable over a lifetime?
GB: Yes. This helps as data is usually assessed at one point in time and we don’t want to make assumptions that gender or hormones wont change over lifetime. Reminder that you can't assume consistency over a lifetime.
Q: You say sex is not one thing?
GB: Sex has many dimensions eg look at uterine status. These markers change over time. Intersex status or transness affects uterine status but it’s usually hysterectomies that impact. There are also racial disparities.
Q: Is GI a real thing?
GB: It’s not imaginary. I’ve done cognitive interviews. People know to answer sex at birth but people are also clear about their personally held gender.
Q: What is the scientific understanding of the way in which sex and GI fit together?
GB: Biological sex and social gender are seperate. They are functionally distinct but how you are treated depends upon your gender. Look at the biological effects and the social effects. Both are multi dimensional, eg hormone effects. Move towards doing gender sensitive research.
Q: How do sex and GI connect in a person?
GB: A person holds a GI. Society and time changes, there’s always been diversity. There may be alignment as no friction between sex and GI. Although we all do have friction, eg some women are unable to get pregnant. This is true for transwomen and some cis women. They’re not necessarily in alignment.
Q; Give us an understanding of the importance of GI - it’s deeply held.
GB: We don't know what causes it. See in the passion with which it is held by some. Some have a stronger one and some a less strong GI. Can be important to well being as it is how you see yourself and how others see you. [Similar to] race or invisible disability. It can cause a lot of distress as people expect to be seen as how they know and see themselves.
Q: In what way are transgender people marginalised in Canada and what are the effects on healthcare (HC)? What is erasure?
GB: The humanities have been looking at HC access. TG people have not been getting their HC needs met, even with a supportive health team. Hearing people and mapping onto mind maps, processes through which invisibility is made or maintained. Information erasure is the lack of data, the lack of inclusion in training or textbooks. There’s also institutional erasure - clinical intake forms not giving space to fill out health histories that make sense and provide info, eg providing names in ways that make sense. Which means for example on hospital intake forms, trans lesbian menstrual history.
Segregated wards: If you have informational erasure you can't make policy and plan services. Removing barriers to get accurate information and where to place people, not in an emergency situation. Systems can maintain trans invisibility.
Q: What if the information required was only sex?
GB: We know with trans people it was cognitively challenging for them to complete their health histories so we get a mix of information that isn't clear. Which could be a problem in healthcare with mixed information on the database. If HC providers want specific information they need a higher level of skill to get the multidimensional information.
Q: Trans people are guessing at what information HC providers want?
GB: Yes it is challenging as they don't know how to answer. It feels that the HC system doesn't understand them. It’s a barrier to HC. Also tests could be different for M&Female.
GB: The design of systems can exclude trans people. It’s not a deliberate policy; not active transphobia to create that erasure but cisnormative assumptions. Require us to take active steps to remove barriers actively. Indigenous people especially felt this applied to them, eg having to dress a certain way in order to get HC. Needs intervention to overcome barriers.
Research on trans experience with HC: from an erasure paper looking at how people felt inside HC settings including primary care. Some need gender affirming care but some don't yet still have HC needs. Harassment was very common. There were negative interactions in primary care especially for TWOC. Only half felt comfortable discussing trans HC with their primary care doctor. Re trans-specific HC: negative interactions in 38% of cases, for example “you're not really trans”, refusing to examine parts of the body, or being told to go away. They experienced a reduced level of comfort talking with their doctor re trans HC.
GB: Erasure creates structural barriers: it’s very common including in emergency care. The gender marker in records might be a mistake as it has not been changed to reflect gender expression. When you see it all play out - it leads to the avoidance of care. 21% didnt go to hospital as they were worried about entering. Reasons given included: as their ID isn’t correct, concerns about being housed in the wrong room, interpersonal mistreatment worries.
Q: What active interventions can be made?
GB: We’ve seen changes of additional fields in records, look at providing both [sex] reference ranges for results, efforts on education re room assignments, reproductive HC and emergency and primary care. When a sexual health clinic had mens and womens days, which days should trans people go? It’s about access to services: “This is where I fit in”.
Q: What is Misgendering?
GB: It is calling them or treating people as how they don't identify.
Q: Might this discourage access to HC?
GB: Some find it less of a problem. It's common and is a barrier for people accessing HC. Interpersonal issues - we didn't ask about violence. There have been assaults in HC settings in the US but we’ve not asked this question in Canada.
Q: Are marginalised people, eg indigenous people, also trans?
GB: Yes.
Q: Do multiple marginalised people face more difficulties because they’re trans?
GB: This is a more complex question to answer. Social position has an impact. It varies.
What’s an epidemiologist?
GB: It’s systemic research in HC. Explanation: how to remove bias. Discussion on research methodologies.
Q: Asked about research on disgust-related purity concerns in bathrooms rather than concerns about harm, eg disease threats.
GB: This is others research. One third avoid eating/drinking as they want to avoid washrooms. Policies to use washrooms according to their GI. Opposition is based upon safety - a concern for cis and TG people. Disgust was found to be strongest. Pathogen disgust is what keeps us safe but also it applies to people. In the past, US racial segregation happened in swimming pools (water was drained after Black people used) or drinking fountains. The main driver for restriction to bathrooms was disgust. The main support for bathroom restrictions is from disgust.
Q: Most people are opposed because of pathogen disgust?
GB: That’s not quite how they did the analysis. The strongest predictor wss pathogen disgust. Purity achieved by separating. Fits together with [missed]. I didn't find research into actual harms but there was fear of harm. Purity concerns and pathogen disgust.
Actual harm in washrooms: epidemiology on violence. If there were serious concerns we’d be looking at it. We’re busy looking at detransitioner research, a couple of colleagues are looking at this- if there's evidence of violence we’d look at it.
Q: What about ROGD (rapid onset gender dysphoria) and Desistance?
GB: Litmann’s idea of ROGD is a hypothesis from a survey,:in the perception of parents whose kids had a sudden announcement. This theory has taken on life of its own. It has no criteria. Different from what we’ve always known of social contagion from friends. We published the first study looking at actual adolescents, using dsm 5. It acknowledges it's prime time for GD (gender dysphoria) to arrive and parents might express concern. It fits with what we’ve understood from before and we didn’t find any support for the idea of ROGD from our analysis.
GB: On desistance - if we go back to multidimensionality, this could refer to changing an identity or to stopping medication, often with the assumption that real gender [missed] Often people wait until their parents die or they move out, so it isn't clear cut and there might be other factors. We’re following this up with the trans clinic. You see claims of huge numbers but I’ve not seen that. Although increasing numbers are starting care .. It's a bit of a mess conceptually and we want to understand what’s happening. Individual approaches and things don't work for all. Figuring themselves out - older and adolescents.
Q: Young people’s gender issues being resolved - roughly 60-80%?
GB: True if you take in the limited context of younger kids referred to therapists. But caveat that many don't fit the criteria for GID (gender identity disorder). Mixed population of different areas and many didn't fit the criteria . It looks very different for the older children as GD often emerges at puberty rather than younger groups. Very few younger children with GD come into the clinic.
Q: Do you see the parallels with LG people - the social marginalisation view?
GB: That’s interesting - HC access too as there’s been so much change. There’s been movement on forms re relationships and sexual relationships. There are definite parallels, eg with bathroom issues. There are the same arguments as before, that could also be pathogen disgust issues.
GB: Gendered washrooms: a third reported they’d had kidney or bladder infections in the US due to restricting fluid intake. Safety concerns - it’s a perception of safety. Gyms are the 2nd most avoided space, esp a problem for young people. Targeted sessions for TG people in the US led to increased harassment. Risk of being sexually assaulted in the past year increased if outed people by accomodation. This was a correlation only. Birth sex designation- that would also out people as you’d have bearded men in womens rooms and it would be socially alarming. We see people’s gender from their faces. I couldn’t find a study on cis people.
Re prisons - there’s not much data. 23 people who’d ever been in jail. 65% experienced verbal harassment, they felt unsafe. From Trans Pulse Ontario. In the US, found LGBTQ people more often in restricted conditions including isolation, supposedly for their own safety, with a poor impact on mental health. So they’re put in unsafe situations.
Q: Cis assaults in prison too?
GB: I haven’t compared the risks.
Q: What about rape crisis centres?
GB: I’ve not looked for this
Q: Looking at the Cosbar(?) physician statement now, from the Canadian Assoc for Womens Sex-based Rights:
GB: I generally agree with Statement 1. I’d argue that all dimensions of gender are reality. Otherwise none of the rest of the statements are factually correct.
GB: There are only two sexes? No - sex is multidimensional and you might miss some sex characteristics. It doesn’t fall neatly into 2 sexes.
GB: Statement on DSDs? No - based on chromosamal sex. Is Turners M or F with X0 chromosomes? It could be either but most Turners ID as F and reproductive systems are under developed. Androgen insensitivity - they look like girls but have an XY phenotype. They aren’t strictly M or F in a neat way. Only looking at one dimension, even if they’re not common.
GB: Sex chromosomes do change over your life, eg having a blood transfusion or a bone marrow transplant, or fetal micro chimeras in utero. They are not immutable. There is Y chromosome depletion in ageing men’s white blood cells. And cross sex micro-chimerism where some cells are genetically different, following having a male child or twins.
Q: Aren’t these outliers?
GB: I’m only talking about chromosomes here, which aren’t immutable. So general truths but not absolutely true.
GB: GI & GE aren’t in law and socially determined: they’re not stereotyped now. It used to be TWAW previously with hyperfemininity, which was for accessing care. GI is what you know yourself to be, and isn’t the toys you used to like as a child. With GE, similarly you don't have to be stereotypes.
GB: GI/GE dont negate biology. They’re all real, eg the wearing of particular clothes to particular events. There’s strange opposition here! Cis and GI research on masculinity & femininity so it wont make sense to talk about. I haven’t looked at. Gendered roles.
GB: I’m not a lawyer on sex based rights. Covered sex and gender based concerns
GB: Women's oppression? This is obviously about reproduction. But not limited to reproduction and not just women. Also include trans concerns. My understanding is that sex based provisions are broadly conceptualised based on reproduction. I don't know the history of the laws.
GB: Are cis women the only people that give birth? No, there’s also those with the capacity to carry a pregnancy, eg non binaries or transmen.
GB: Gender self-ID laws: Are cis men included as women anywhere? I’ve not seen that.
Q: Is it harmful to insist there are only two sexes?
GB: Its wrong as the argument is usually based on chromosomal sex and this doesn’t always ally with hormonal sex. So all of these dimensions fit into the M or F category so therefore the trans experience doesn’t exist. “It disallows the possibility of their existence”.
GB: Homeless shelters - there’s no infrastructure for trans people. If only cis women are allowed to these retreats etc, it excludes TW. Creates a system - how do trans people navigate it? There’s no care for trans people who are homeless or after rape. These are needed in emergencies. There aren't any alternatives. There’s never been a problem in women’s spaces. It’s incorrect to say there are issues in women's spaces. There’s usually nowhere for TW to go.
They’d avoid male spaces as they’d feel unsafe, just like cis women.