We must abolish the coercive apparatus of health insurance all together. We must abolish the coercive apparatus of health insurance all together.

What does your community lack in terms of medical care?

For my community, for trans* communities, I wish that they don‘t just stay self-centred, but that they are able to see the bigger picture. I wish that people would not exclusively demand better trans* healthcare, because this is embedded in the larger healthcare system. If trans* healthcare is not working, it can be used to infer problems and challenges in the health system in general. So I would like for trans* communities to say, for example: to strengthen trans* healthcare, we need to support the hospital protest movement, we need to support the strikes of care workers and healthcare workers, we need to join bigger movements. Because this single-issue logic, which is often followed in liberal approaches to health policy, is not effective there. Keyword: sensitisation regarding how to address trans* people, how to deal with diverse physicalities and self-identifications – How much reserve do I have for this when my hospital is underfunded, I am overworked, I am tired and I am already working on the edge of burnout all the time anyway?

One of the big problems I keep encountering is simply that trans* health is seen and presented as a separate field of healthcare, which formally it is not. There is not a health sector on one side and a trans* health sector on the other side, but the care of trans*gender people and people who are not trans*gender takes place in exactly the same health sector. The consequence of this is that when it comes to the care of trans* people, many practitioners say: I don‘t know about that, I don‘t do that.

Many trans* people who want certain services are dependent on psychotherapy or psychiatric support. You can also call it coercion, because it is not about the actual psychological need for treatment, but this support is a prerequisite to receive certain measures. Oriented towards the assessment guidelines of the statutory health insurance providers, the aim is to find psychotherapeutic means first in order to avoid having to apply for somatic medical means if possible. The aim is to treat the suffering of trans* people, which is simply not possible. When looking for therapists – and this example is representative of what I mean – it often happens that they say: No, we don‘t know about that, we don‘t do that at all. Yet trans* therapy is nothing other than therapy. Of course psychotherapy or psychiatric treatment looks different if a person has no need for treatment. In many cases, trans* people are in treatment without an actual need for treatment and are just doing their time. But that doesn‘t mean that trans* people don‘t have other needs for psychotherapy. Keyword: minority stress, traumatic experiences and so on. Anything can become a topic in therapy.

But the people don‘t find access to it at all because the therapists believe: It‘s about trans* issues and that‘s something different than what I usually treat in therapies. On the one hand, this denies access to specific services that trans* people need, such as somatic treatments, operations, hormone therapy, etc. But on the other hand, even if a trans* person is simply coming for standard care, treatment providers think that they are not able to offer that. This is part of the bigger problem in my eyes: the challenge of making trans* care understood as part of standard healthcare and at the same time working to make healthcare better in order to improve trans* care as well.

What would have to change in the area of access and training to health professions?

On the one hand, this is of course a question of education. On the other hand, it is also due to material conditions, such as the assessment guidelines of the medical service and the health insurance companies, which reinforce the whole thing. Currently, we have the situation that there are specialised therapists who take care of trans* concerns, but there are comparatively few of them and these few are very overcrowded. We are not talking about a waiting list of half a year, but of twelve months and more. In the UK there are specialised gender clinics. In Germany, too, there are a few places that are trying to implement something like this. For example, the UKE in Hamburg with its special outpatient clinic for sexual health and transgender care. But I would rather warn against saying that only these contact points should be used. This causes a monopoly to be formed and the offers become scarce and concentrated rather than being widely spread. I think that is unwise. I know from my own experience that trans* people are often able to avoid facing prejudices. The pathologisation of trans*gender tends to happen less often when my/a practitioner is trans* themselves and knows that it is not a disease.

The pathologisation of trans*gender simply creates hurdles. This also continues in standard healthcare, in the regular visit to the doctor, when I am asked about the contents of my trousers, even though it‘s about a flu. That‘s why it makes sense to have more trans* practitioners in the field, that can only be helpful. One form, for example, is to sensitise staff through the presence of trans*gender colleagues, so that they realise: “Yes, trans* people are completely normal people”.

But I think that a kind of quota system is not the only way. To say: If we have more trans* practitioners, then everything will be better, is ultimately like a colourful plaster. It will not be better if the health system itself remains underfunded, if training remains superficial in the topics that are finally being tackled or if they do not address social or social constructivist approaches to certain health phenomena. Many specific minority health phenomena are socially made. But this, of course, gets far too little attention in research, education and curricula.

What kind of awareness would people currently working in the health sector need to have?

There needs to be better funding and better working conditions. Because when we say: educate yourselves, people say: I don‘t know when to do that. Awareness-raising measures are needed for people who are already working in the health system. That is already happening in parts. But I think it is very important not to lose sight of standard healthcare. As I said, so many things are exclusively about trans* health. In practice, those who are most likely to have to deal with trans* people anyway because of their specialisation come forward. These are mostly psychotherapists or psychiatrists and maybe other specialists such as endocrinologists. But even there it wears thin. Because they say: “We only treat the somatic part, we don‘t care about the personal concerns of these people“. This then leads to a lack of knowledge and consequential experiences of discrimination. German endocrinology in particular is at an interesting moment of awakening. At the same time, there is still a lot lying dormant where treatment is simply done according to the old pattern. But here, too, we are still talking about very specialised treatments. There needs to be a general awareness, as a GP, as an orthopaedic specialist, as a gastroenterologist, etc. I know many queer people who have had negative experiences with gastroenterologists and proctologists. So practitioners in this field urgently need sensitisation. But if you do something about trans* health, the gastroenterologists don‘t knock down the doors because they say we have nothing to do with trans* health.

What changes would be necessary on a legal level?

It‘s important that we counter privatisation of the health system in a timely and decisive manner. Because I believe that only raising the awareness of those who are already in the system does not make the situation better. A core demand that I miss in broader trans* movements is – in short – the abolition of the Asylum Seekers‘ Benefits Act (Asylbewerberleistungsgesetz). Because this ensures that precisely those trans* people who have one of the greatest needs are faced with closed doors. If, for example, a person experiences an interruption of an already ongoing treatment due to flight and arrives in Germany, they are first told: Your special needs are now not covered for eighteen months.

After that, we can maybe talk about whether you can continue a hormone therapy that you have actually been doing for two or three years. It would be important to implement the ICD-11 quickly while ensuring that the depathologisation of trans*gender provided for therein does not eliminate the right to healthcare. I simply wish for a greater openness to the interconnection of struggles. On the one hand, this must be done by the trans* groups themselves, i.e. the will and the ability to stand shoulder to shoulder. On the other hand, also by possible allies.

It can help, for example, to create this awareness and this ability to form alliances by having other movements explicitly state that they are also concerned with trans* health. For example, the hospital strike can say: in addition to the difficulty of carrying out our work, we can provide even worse care for certain marginalised perspectives, for example trans* people. This means that we are striking for good health care also for marginalised people, whose access is difficult anyway, and thus perhaps enable a closing of ranks. To show that the struggle for the participation of trans* people is part of current labour struggles and struggles for health care.

Having trans* hostility on the radar does not automatically mean having trans* misogyny on the radar. There is often a lack of awareness of the fact that there is also a hierarchisation within trans* perspectives. Not to mention an awareness of the perspectives of trans* people who are racialised as non-white.

What is also really needed in the health system, and what already exists in part, is an appreciation of the incredible work that self-organised counselling centres do with their amazing expertise. For example, Casa Kuà as a self-organised health centre where trans* people advise each other, educate each other and inform each other about the different possibilities of hormone replacement therapy. There is probably at least one queer centre with counselling in every larger city.

This is also obvious. Because when it comes to hormone replacement therapy, there are questions that I am much more likely to ask people with a similar or shared experience than medical professionals. Example: trans* female sexuality. I know moments, also from my own professional experience, when a person only notices during counselling what questions they have about hormonal dosage or their care in general, in connection with their sexuality. She would never have asked these questions to her doctor because trans*female sexuality is extremely stigmatised and/or forgotten that it even exists.

It is also important to simplify application procedures, de-pathologise them and thus make them more financially accessible. As cannot be said often enough: Trans* health must not be understood as this other health sector. Rather, it must be ensured that application procedures and their success rates are improved. At present, it is often the case that every application for medical services for trans* people – which are mostly applications for surgery – is rejected at the first attempt in order to frustrate trans people and so that they do not even try. Because the case workers and assessors of the medical services must know how exhausting this experience is. This ensures that many people are thrown back on self-funding, if they are eligible for health insurance at all.

The demand is to make application procedures accessible and clear, or to abolish application procedures and the coercive apparatus of health insurance all together.