EPATH 2017

EPATH is the European Professional Association for Transgender Health. Between 6th and 8th April, it held its second conference in Belgrade. I was fortunate enough to be able to go because I am a PhD student whose university makes some funding available for events such as conferences – many people who could have productively contributed to the conference are not in such a position.

It was the first time I’d been to any PATH events – however, as a trans person, several aspects of my life and healthcare have been shaped by the guidelines and standards put in place by the World Professional Association for Transgender Health, and by the practices of its members.

One thing that was absolutely clear throughout the event was that every professional I spoke to or heard a presentation from was dedicated and enthusiastic about helping trans people. However, something that also came across very strongly was just how different the frames of reference for that were. Europe’s a diverse place, and indeed there was discussion of healthcare systems outside what would usually be considered Europe, such as countries in central Asia. During the course of the conference, we heard that that the European Court of Human Rights has ruled sterilisation of trans people as a condition of legal recognition is a violation of human rights. But many of those present had prepared their presentations in countries where this violation is still the law. Many professionals present worked in countries where there is limited social acceptance of LGBT people, and gender roles are relatively restricted. Several clinics were helping their patients navigate restrictive legal systems, or indeed legal systems which made little or no provision for trans people at all. Many medical professionals (perhaps all of them!) were also working in the context of trans health being seen as something of a suspect field by their colleagues, in which even the well-established basics of supporting trans people continue to be seen as controversial and requiring justification.

As a consequence, it perhaps isn’t surprising that there were points in some presentations where it was very clear that some professionals saw their role as involving a lot of gate-keeping, with a focus on creating heterosexual, gender-binary individuals, who would engage in penis-in-vagina sex and could be counted a success if they ‘passed’ for cis. In some cases, I’m sure this impression was heightened by translation issues – it can be hard to get trans terminology right even if English is your first language, and I can only imagine how difficult a task it must be to present on this subject in an additional language at an international conference which brings together such a diverse range of people and experiences. And of course, part of the point of such a conference is to bring  different viewpoints together for discussion. Nonetheless, it didn’t always make the conference feel particularly welcoming for me as a trans attendee

There was one incident during the conference which was particularly overt,  and which I found much more personally distressing than I would have anticipated. It was at the publicly open session of the conference, and one presenter showed multiple slides of naked trans people, which small black boxes over their face, showing their bodies before hormones and then at timed stages while on hormones, with close focus on breasts, chests and genitals. It was hugely pathologising, there was no discussion of consent, and the commentary was all about appearance to the cis gaze. (I understand of course that photographs may at times be appropriate to illustrate surgical techniques etc: this was not such a situation, and the poses complete with small black squares over faces felt like medical textbooks from fifty or sixty years ago). I found it difficult to believe that any trans person would volunteer to be photographed and have their body displayed in this way, unless they felt that doing so was required in order to access to treatment (which of course would not meet academic or medical standards of ‘consent’). I felt unable to continue to sit through that session, but my understanding was that the presentation continued to its end.

I want to stress that the EPATH organisers made a very full apology afterwards, and I do believe they were genuinely mortified. There was a discussion the following day about conference language policy, which also included statements about the use of images. I do think there remains an issue about how such guidance is enforced: I would lean towards every presenter using photos of individuals having to make an explicit statement that they have that individual’s free and informed consent to the display of those images. (Similar to declarations of participant consent for academic journals). I think there should also be consideration of under what circumstances a presentation should be interrupted by organisers/chairs if it does become clear that there is a substantial volume of inappropriate content (and perhaps especially if it is a session where there will be no opportunity for subsequent questions/comments from the floor, in which case there is not even the option for offering a counter perspective afterwards). This is particularly the case given that a code of conduct was issued asking attendees to commit to not disrupting presentations: if EPATH don’t want attendees to interrupt inappropriate presentations, we need confidence that organisers and chairs will.

It was particularly unfortunate this presentation preceded the TGEU presentation, which felt like the only point on the main conference floor where there was very direct consideration of trans people’s own views and lived experiences of healthcare systems  – but I missed the first part of that session because I had been unable to sit through the previous session, and was still too furious to focus for much of the TGEU session when I did come back in. Some of the year in review sessions on the final day of the conference, particularly the legal and social sciences ones, also gave weight to trans people’s lived, situated experiences. There were other trans professionals present at the conference, and several gave interesting presentations or chaired sessions, but these were mostly not on the main conference floor, and the streaming approach within the conference meant that trans experiences and perspectives were frequently discussed very separately to discussing medical interventions. Overall, the main conference sessions which brought everyone together, did quite often feel as if they were “about trans people, without trans people”, which certainly in the UK context is something healthcare is supposed to be moving away from.


EPATH was predominantly arranged in different ‘streams’. In most time-slots, there was a surgery stream, an endocrinology stream, a couple of mental health streams, a child and adolescent stream, and a social science stream. There were a couple of sessions on issues like trans people’s perspectives on ICD changes – but again, those were often up against surgery sessions. Of course, streaming is common in academic and health conferences, and it’s important and beneficial that time is used sensibly and professionals attend sessions relevant to their interests and practices.

However, one thing that gets stressed a lot in trans healthcare is multidisciplinarity. Mental health professionals refer their patients for surgery. Surgeons take on patients who are having hormone therapy. Professionals working with children may be asked by children or their parents about what might be possible in terms of later medical interventions. Endocrinologists and mental health professionals should be making sure their patients understand fertility options and implications. And as I have outlined, one thing that really came across in this conference was how different the underpinning social frames were, and that it would have been beneficial to have some cross-conversations on people’s assumptions and beliefs.

My concern therefore is that if (for example) a masculining surgeon attended the conference, believing that sexual function for trans men was dependent on phalloplasty (and comments to this effect were made in at least one presentation that I saw) I’m not sure they would have necessarily have heard from professionals from other disciplines, who might have pointed out that there are other ways of thinking about sexual satisfaction and function. Greater awareness of different perspectives and considerations might be helpful to a surgeon who is talking through options with a patient. So while streaming is beneficial, I think the very hard delineations betwen the streams was not necessarily conducive to open discussion and multi-disciplinary, patient-centred practice, especially given that there was relatively little representation of trans lived experience of health on the main conference floor.

Overall, I want to stress that the event was interesting, the organisers had clearly put a lot of work into it, and the host venue were incredibly welcoming. The event ran pretty smoothly, and there was a lot of intelligent, interesting discussion. As I say, all professionals I spoke to were clearly enthusiastic, dedicated and well-meaning, and even the presentation which I found uncomfortable was clearly at heart motivated by a desire to help trans people, within a cultural context which is quite different to the UK. EPATH is a relatively new event, and I suspect EPATH may face quite different challenges in conference organising and reaching consensus on language compared to USPATH or CPATH, given the sheer diversity of countries involved, and that English was not the first language of the majority of attendees. The issues I have highlighted are therefore intended constructively to make improvements for the future, rather than as a criticism of this event.

Drinking Games and Knowledge

So a couple of weeks ago, I was in a room with a group of about 20 trans guys at a weekend away. And someone suggested playing “I have never”. (For those not in the know, it’s a drinking game. Someone says “I have never done x”, e.g. “I have never gone skinny dipping” and everyone who has done it takes a drink.) And as these things go, everyone gets a bit drunk and asks daft questions and you learn things about each other.

A few days later, I was back in the office, and confronted with my PhD thesis, in which I need to provide a proper academic reference for everything I write, preferably from a peer-reviewed journal. And for a lot of trans stuff, especially trans masculine stuff, especially stuff that isn’t about the mechanics of transition there just isn’t that much written. Some of the questions which got asked during that game of “I have never” are questions which have rarely been officially investigated with trans communities – to what extent are trans men attracted to other trans men, for example?

Now, plainly a drinking game between me and some mates is not a proper academic reference (though I suppose could write it up as participant-led research among a convenience sample, and frankly there are worse designed studies out there). So I can’t refer to it in my thesis, and even if I could, I wouldn’t, because it would be wrong to take private information outside that space without consent. But it means that I know something that I don’t officially “know” for research purposes.

In fact, it happens quite a lot. I belong to Facebook groups where thousands of trans people post comments, queries, discussions. Those are secret or closed Facebook groups: not publicly accessible. I belong to a trans Yahoo group (I know, prehistoric!) and while no-one posts in it any more, there are ten or fifteen years worth of trans queries about surgery, or changing names, or the passing of the Gender Recognition Bill (which I was reminded recently used to be known as the GerBil, since obviously major pieces of equality legislation should be equated to rodents). Again, for ethical reasons I would never, ever lift out those private comments from private groups and use them for my academic research. But when I’m writing on trans health, and I know I’ve seen dozens of threads and posts and comments on something that isn’t in the academic literature at all, it’s hard to know quite what to do.

There’s a sort of principle in academia that you don’t have to reference stuff that is general common knowledge. I don’t have to reference  that the sky is blue, or that chickens lay eggs. But there is a lot of stuff that is common knowledge to me as a member of a trans community that other people don’t know. Most days I hear the same complaints about health services on trans discussion groups. I hear about the same problems with getting details switched over, or GPs refusing referrals to gender clinics for stupid reasons, or confusion over pathways. As far as I’m concerned, those things are common knowledge. But they aren’t common knowledge to people who aren’t embedded in trans communities. And half the time, I can’t find a proper reference for them.

This kind of imbalance is something that has, of course, been pointed out by feminist scholars and black scholars and queer scholars and all sorts of others. And of course, there needs to be research to fill these gaps, not just personal anecdote: it would be entirely wrong to assume that the issues I discuss with people I socialise with are representative of trans people as a whole. But if the best knowledge available to me on a subject is conversations I’ve had on Facebook, or getting pissed with mates in a youth hostel, then surely it’s more honest to acknowledge that I have that knowledge than to pretend I know nothing.