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The University of Edinburgh School of Social and Political Science ‘Socializing Transgender’ Social Care and Transgender People in Scotland A Review of Statutory and Voluntary Services and Other Transgender Experiences of Social Care Support A Thesis Submitted for the Degree of Doctor of Philosophy to the University of Edinburgh by Kate Norman June 2015 1 2 Declaration Page The work contained within this thesis has been undertaken by myself and is entirely my own. No part of this thesis has been submitted for any other degree or professional qualification, with the exception of extracts within the literature review and methodology sections which were originally included within the research proposal for this thesis, submitted in 2010 to the School of Social and Political Science, University of Edinburgh, for my MSc (Research). Kate Norman 26.06.15 3 4 Abstract A paucity of knowledge of social care services to transgender people in Scotland led to this research. Medical and social care services take very different approaches to the needs of migratory transgender people. The research design involved online questionnaires and interviews with statutory service commissioners and providers, and with voluntary organisations and transgender people themselves. A framework of three research questions underpinned the research, firstly looking at the nature of dedicated and generic support services in Scotland, secondly exploring assistance relating to transgender identity and status, and thirdly considering additional support to transgender people within their relationships and their communities. Data analysis was influenced by grounded theory in the development of themes and sub-themes which structured the research findings. The research findings indicate limited planning, guidance, training and policy development to facilitate access to generic services by transgender people. Dedicated service provision was found to be often limited to adults during transition whilst transgender children and young people, and family members including partners and parents, received limited support. A range of alternative sources of support, including transgender support groups, gender specialists, GPs, counsellors/psychiatrists and social care staff, were found to provide varying levels of support to transgender people with gender identity, transition, family support, documentation, transgender linked mental health problems and with long- term physical or other mental ill health issues. Approximately half of transgender respondents indicated that social work advice and support would be valued for each of the above categories, and that additional support would also be valued regarding making plans for the future, conflicts with family, friends, colleagues or neighbours, social isolation, social rejection, and with developing a more confident community presence. The thesis concludes with a proposal for a re-balancing of the historical systematic ‘medicalization’ of transgender, by a process of socializing transgender, through advocacy work seeking greater understanding and acceptance of transgender people and the adoption of a transgender legal status, and through the provision of the wide range of additional social care support to transgender people noted above, particularly during the socialization phase of transition and beyond. 5 6 Acknowledgements I am grateful for the financial support of the E.R.S.C. and the Scottish Government which enabled me to take time out of my work to undertake three of the five years of this PhD. I have benefited greatly from the thoughtful supervisory support of Lynn Jamieson and Charlotte Clarke, and, in the first year of the PhD particularly, from Liz Bondi too. Their ability to carefully consider the various draft chapters and to feedback suggestions to me, in ways that enhanced the gradual evolution of the thesis, is much appreciated. I am also very grateful to my son, Daniel, who diligently checked my referencing for errors, and read each of the research findings chapters, offering useful suggestions for improvement. The research was aided by the support and cooperation of the Scottish Transgender Alliance who gave feedback on the draft versions of the questionnaires, and who facilitated their circulation to transgender people and transgender organisations across Scotland. Particular thanks are due to James Morton and Nathan Gale for their assistance in these matters. I must also acknowledge the support of the members of Tyne Trans who assisted in the pilot study which preceded my research in Scotland. I am very grateful to Lesley Horne who facilitated the circulation of the questionnaire to each Scottish local authority via the A.D.S.W. Contracts Officers Group, and who, together with Andrea Beavon, gave valuable feedback on the draft version of this questionnaire. Thanks are also due to Joanna Smith, whose conversations over the five years of the PhD have aided me in maintaining momentum and focus, and whose positivity helped to counter some of the seemingly unreasoned and unreasonable criticism of transgender people which I have encountered. I am very grateful to the forty seven transgender people who completed survey one, to the twenty seven transgender people who completed survey two and to the twenty people who completed survey three on behalf of statutory and voluntary agencies. I am also deeply grateful to the nine people who contributed interview material from the statutory and voluntary agencies, and to the ten transgender people who took part in online interviews. Each of these contributors remains anonymous of course despite often offering very personal and thoughtful insights which enhanced the research findings considerably. ai i miei due cari figli che sono vicini a me a tutto quello che faccio… 7 8 Thesis Contents Title Page Declaration Page 3 Abstract 5 Acknowledgements 7 Contents Summary 9 List of Tables 15 Glossary of Terms 19 Introduction 21 9 Thesis Contents (continued) Chapter One: Literature Review Detailed Chapter Contents 25 Introduction 27 Gender, Transgender, Sex, Intersex, and Sexuality 29 Transgender and Society 54 Health and Social Care Services 84 Chapter Summary 100 Chapter Two: The Methodology of the Research Detailed Chapter Contents 103 Introduction 105 The Background to the Research 107 The Research Process 123 Reflexivity 156 Values and Ethical Issues 162 Chapter Summary 169 10 Thesis Contents (continued) Chapter Three: Research Findings (Part One) Surveys and Interviews with the Statutory and Voluntary Sectors Detailed Chapter Contents 171 Introduction 173 The Location of the Organisations 175 Dedicated/specialist social care services to transgender people 177 Generic social care services to transgender people 186 Staffing and training 191 Staff Guidelines and Policy Statements 195 Chapter Summary: Key Findings 199 Chapter Four: Research Findings (Part Two) Surveys and Interviews with Transgender People Detailed Chapter Contents 201 Introduction 203 Preliminary Data: Attribute Information 204 Issues Relating to Coming to Terms with Being Transgender 211 Support with Transitional Issues 229 Chapter Summary: Key Findings 245 11 Thesis Contents (continued) Chapter Five: Research Findings (Part Three) Surveys and Interviews with Transgender People (continued) Detailed Chapter Contents 247 Introduction 249 Support to Family Members in Coming to Terms with Being Transgender 250 Assistance with Documentation During/After Transition 263 Chapter Summary: Key Findings 271 Chapter Six: Research Findings (Part Four) Surveys and Interviews with Transgender People (continued) Detailed Chapter Contents 273 Introduction 275 Mental health problems linked with gender identity or gender role 276 Support with long-term physical/mental ill health, disability etc. 284 Post transitional and societal issues 295 Chapter Summary: Key Findings 309 12 Thesis Contents (continued) Chapter Seven: Discussion Detailed Chapter Contents 311 Introduction 313 Review of the Design and Methodology of the Research 314 Reflections on the Concepts of Sex, Gender and Transgender 319 The Provision of Dedicated and Generic Social Care Services 326 Transgender Identity and Transitional Issues 337 Relationships with Family, Friends, Neighbours and Within the Wider Community 349 The Socializing of Transgender 360 Summary and Conclusion 365 13 Thesis Contents (continued) Appendix One: Legislative Perspectives 369 Appendix Two: Estimated Scottish Transsexual Population by Council Area 373 Appendix Three: Reassignment Surgeries and the Scottish Protocol 375 Appendix Four: Summary, Cross Tabulation and Significance Testing Table of ‘Advice, Information and Support’ Across all Table