|Illustration photo by Evgenyata Manenko|
Here is the story about a member of the Crossdream Life forum, a Portuguese MTF transgender youth, who was committed to a mental hospital by force, most likely for being transgender.
Last fall the Crossdream Life Forum (CDL) got a new member, a Portuguese, 19 year old, male to female transgender.
I always use the term transgender in its wide umbrella sense, indicating some kind of gender variance. As far as I am concerned it is always up to the transgender person to decide what this means as regards gender identity and pronouns. She accepts both female and gender neutral pronouns. She thinks of herself as feminine transgender and non-binary.
Since this article is about a person who is still in a legal conflict with the medical establishment, I am going to refer to her as LT here.
The threat: Hospitalization and anti-psychotic drugs
I had met LT for a couple of times in the CDL chat room. She normally kept herself in the background, but would offer a comment from time to time. I remember I tried to entice her to tell us something more about her, but at the time she preferred not to.
Later on, however, she became more open in the chat room, and in July this year, I got a disturbing personal message from her. A doctor threatened to put her in a mental hospital, planning to give her anti-psychotic drugs.
She told me about parents who did not understand her, and who definitely did not accept her transfeminine nature. LT argued that her parents thought of her as “crazy”. I doubt they used the term in its clinical sense.
Much of the conflict between her and her parents seem to reflect typical parent/teenager issues, like “being lazy at school”, “being immature”, “wanting to go hitchhiking”, “spending too much money on videogames” and so on.
She on her side, describe them as “hating her” and “wanting to hurt her”, while at the same time admitting that they also love her (or at least love the person they think of as their son).
There is, as far as I can see, nothing unusual in this parents/teenager conflict, and most certainly not anything that requires commitment to a hospital.
Anger and frustration
There is, however, one episode in this story that might have triggered the whole chain of events leading up to the hospitalization. Her anger and frustration had caused her to become physically violent towards her mother.
This is something she regrets, but there is no doubt that such an incident took place.
Parallel to this development, there was also this: LT had gone to a psychologist for a while, and this therapist had asked LT if it was OK if she told LT’s parents about her gender issues. LT had accepted this, and the psychologist did talk to her parents.
This did apparently not have any effect on their view of LT. To this day they refuse to think of her as any kind of transgender.
LT was now asked to talk to a psychiatrist. LT believes her parents had told this psychiatrist what her psychologist had told them.
The psychiatrist did ask LT about her sexual orientation. LT responded that this was about her gender identity, not sexuality. She is right about that, and the question itself indicates that this psychiatrist has a rather rudimentary understanding of what transgender means.
Xeplion - an anti-psychotic drug
|Illustration photo by Katarzyna Bialasiewicz|
Xeplion is an antipsychotic drug used in the treatment of schizophrenia and psychosis. Schizophrenia is thought of as one possible cause of psychosis. It is never used in the treatment of gender dysphoria.“He said somethin’ like u know it’s hard to get into hrt so u gotta be prepared for it, take these monthly injection prescriptions so u will feel better.”
Disregarding gender variance
If the doctor was serious about this comment regarding hormone replacement therapy, this comment would have to mean that he believed the anger issue would have to be sorted out first, before any gender related issues.
Anyone who knows anything about the stigmatization, shaming and invalidation transgender people are facing on a daily basis, knows that potential anger issues are closely related to the gender issue, however. If transgender people get angry this is nearly always because they are not seen and respected as their real gender, and because they are forced to play the role of someone they are not.
The normal way of treating gender dysphoria is talk therapy combined with counselling and -- if relevant -- hormone replacement therapy and surgery.
You might give a gender dysphoric client a mild anxiety reducing drug, if they are in a panic, but you do not give them Xeplion, which will make it hard for them to process their feelings and come to a clear understanding of their real identity.
Xeplion is a paliperidone, a antipsychotic drug primarily used for schizophrenia and schizoaffective disorder. The side effects most frequently reported are insomnia, headache, anxiety, upper respiratory tract infection, injection site reaction, parkinsonism, weight increase, akathisia, agitation, sedation/somnolence, nausea, constipation, dizziness, breast growth and musculoskeletal pain. (More here).
The problem with the schizophrenia diagnosis
From what I understand, the only meaningful reason for diagnosing her with psychosis, would be if this psychosis was caused by schizophrenia.
The American Psychiatric Manual, The DSM-5, says that a schizophrenia diagnosis requires persistence of two of five symptomatic criteria ("delusions, hallucinations, disorganized speech, disorganized behavior or catatonia, and negative symptoms").
I have been communicating with LT for a long time now. She seems like a very clear headed, intelligent and intellectually coherent teenager. She is angry, yes, but who wouldn't be, given these circumstances.
What’s truly ironic is that the whole schizophrenia diagnosis is being dismissed by more and more experts for being a pretty random collection of symptoms caused by a wide variety of factors, not all of them biological, and not all of them similar.
In other words: Schizophrenia is not a real illness “out there”. It is just a concept doctors use when psychiatrists are facing behavior they do not understand. (More here and here).
LT's objections were ignored
In her message to me LT expressed outrage at this suggested treatment. It seemed to her this was yet another way of invalidating her female identity, and that the drug was an attempt to cure her for what the doctor believed was psychotic delusions:
“So it’s likely he diagnoses transgender or at least someone who’s a bearded man on the outside and claims to be trans as a delusioned schizophreniac and uses these awful injections as a way to cope with both.”There is much in the series of events that follows that indicates that LT was right in her assertion.
There is one more point regarding this psychiatrist that has to be raised. He might argue that the reason he suggested Xeplion was not that she suffered from gender delusions, but that LT had said that her parents were out to kill her. She might have said something to that effect.
To me LT argued that “Denying my real self like that and trying to kill it is no different from actually killing me.”
Again I am reminded of the kind of language used between teenagers and their parents. Hyperbole like this is a linguistic effect used constantly by teenagers. There is no doubt that LT feels that her parents represents an existential threat to her ability to live her life as herself, however. They have told her that her being transgender is just a phase caused by bad influences, and what she experienced later on seems to prove that.
LT told me at the time that her parents had threatened to send her to a psychiatric hospital, if she did not take the drug the psychiatrist had suggested. The psychiatrist said the same thing.
Hospitalization and forced injections
She was committed to a psychiatric hospital a couple of days later. Apparently it was not the parents who had her committed, though. This is where the sequence of events becomes unclear to both LT and me.
She was fetched by the police and firemen in her home and brought to the hospital. LT does not know who alerted the police, but suspects that neighbours or a teacher had alerted them about the physical attack. Her father had apparently talked to a teacher about this.
I must admit I find this cause of events unlikely. In order to get a warrant for compulsory hospital admission (mandato de internamento in Portugal), the police would normally have to contact a psychiatrist, which indicates that the psychiatrist who had interviewed LT was involved somehow.
My suspicion is strengthened by the fact that as soon as LT was committed, the female psychiatrist in charge of LT argued for the very same treatment as the first psychiatrist: Xeplion injections.
LT resisted for as long as she could, but in the end they injected Xeplion by force and added Invega (paliperidone) pills to check the effects.
No talk therapy
During the hospitalization LT was offered no talk therapy. No one suggested that she should get help for handling her gender variance or diagnosing it. They did not contact her psychologist and they did not transfer her to an institution that has a specialist in clinical sexology.
Indeed, it seems that the only thing they did was keep her imprisoned in the hospital while administering the drugs. That would be malpractice even if she was psychotic. It is most certainly not a way to treat gender dysphoria.
Violating patients' rights
Moreover, this treatment also violates fundamental patient's’ rights in other ways. Here are some important points from the Portuguese Charter of the Rights and Duties of Patients.
- The patient has the right to be treated with respect for human dignity (I see no respect for human dignity in the treatment of LT).
- The patient has the right to receive appropriate care for his or her health, in the context of preventive, curative, rehabilitative and terminal care (Giving a patient a drug without any follow up in a case like this one is not good healthcare).
- The patient has the right to continuous care (We have seen no plans for continous care or therapy).
- The patient has the right to be informed about the existing health services, their competences and levels of care (There has been no information about alternative health providers that could take her transgender side into consideration).
- The patient has the right to give or refuse consent before any medical act or participation in research or clinical teaching (This right was not respected).
From our discussions with LT, there also seems to be a profound lack of information about her own health status (beyond the diagnosis itself). They have not given her any substantial information about why they have chosen such an extreme diagnosis.
They have not formally denied that LT might be gender variant, though, but stick to the story that LT suffers from a mental problem that requires a separate approach, independently of her gender issue.
Indeed, they seem to argue that the main reason is that she is a threat to her parents. That didn’t stop them from sending her home to her parents, when they finally released her from hospital, though, so that explanation sounds hollow.
She was kept in the hospital for more than a month. CDL members Barbara, Bobbie and I could follow her treatment as she, at times, had access to the internet, using facebook to communicate with us and Casa Qui, a Portuguese social solidarity LGBTI organisation.
Casa Qui works specifically for LGBTI youth victims of violence (domestic/family or bullying) and in vulnerable/emergency situations and more.
We contacted Portuguese LGBT organisations as soon as we realized LT had been hospitalized, and Casa Qui has done a great job following up on LT and communicating with her lawyer and the hospital. I send my warmest thanks to the Casa Qui their excellent team!
There is no "cure" for being trans
Needless to say, taking Xeplion has not “cured” LT’s gender issue. She is still the same person as she was before. Nor has taking Xeplion “cured” the resentment she feels about the whole system violating her freedom and personal dignity in this way. Why should it?
Anyone who have read the history of psychiatry will know that the medical system has been used actively for nearly two centuries to keep marginalized people in check. This applies to people of color, women, homosexuals and transgender people.
Independent women were treated for "hysteria", homosexual and trans people were given so-called “conversion therapy” using electroshock and nausea inducing drugs. This is no longer possible in civilized countries, Portugal included, but it is possible to use the system in other ways.
It seems to me that this is a clear example of how that can be done.
Intimidation and invalidation
By suppressing and invalidating LT’s identity, LT’s parents caused her much suffering and pain. This pain led to anger and that anger caused LT to become violent. This kind of violence is obviously not acceptable, but it is understandable, given the context.
Even if LT’s parents did not want her to be committed to the hospital (and LT believes they did not), they have contributed to building a narrative where the main problem is not her being transgender, but her being rebellious. This has caused the whole system to focus on the symptom (aggression) and not the cause (gender dysphoria).
Even if the psychiatrists involved hadn’t denied that LT may be transgender, they have stuck to the idea that her anger issue can be treated separately from her gender issue.
If you want to establish a diagnosis of schizophrenia or psychosis, you should think you have to consider the obvious alternative explanations for the aggression you see, before you dismiss them. But no, these psychiatrists have not even let LT talk to gender specialists who could have given them relevant input.
Indeed, for what we who have been involved in this from the LGBT side (CDL and Casa Qui) see, it looks like they have not gone beyond the symptoms described. The symptoms equal the cause, and the drug is there to fix it.
This is the kind of simplistic reductionism I had hoped was gone from modern psychiatry, but it clearly isn’t. As Portuguese transgender activist Sandra Lopes has told us, the sad thing is that they can use this simplistic division into two separate diagnoses (psychosis vs. gender dysphoria) as an excuse for not taking LT’s gender identity into consideration. This is accordance with the rules given.
I should add, that the hospital psychiatrist has actually told LT that she does not believe LT is transgender. This doctor is not a gender specialist, and is not qualified to make this diagnosis, all of which strengthens my suspicion that the delusion their diagnosis refer to is LT’s gender variance.
Note also how the system hinders LT from protecting herself. She has gotten a lawyer and she may pursue this matter in the courts, but since the doctors are allowed to treat the aggression separately from the gender issue, they have now given her a diagnosis that will make it harder for her to convince judges and others involved that she is not delusional.
|Illustration photo by Diava P|
Indeed, this is a diagnosis she will have to carry with her for the rest of her life, unless she manages to get someone else to prove that she is not psychotic, and the people who could potentially do that are all part of the same system.
And now: To a better future!
LT is now planning her future, as regards being transgender, getting an education and finding her own way.
Casa Qui are focusing on arranging the possibility for Luna to get a third-party psychiatric evaluation, while my friends in CDL and I are exploring other possibilities for helping LT out of this horrible situation.
If you have any ideas, please add them in a comment or send me an email (firstname.lastname@example.org).
I would like to thank LT herself and Bobbi, Barbara and Sandra of Crossdream Life for important input to this process and this article.