Our real-life stories demonstrate that these women in Denmark partake in hazardous self-medication, unsafe strategies, and sex work as tactics for accessing the treatment while left on hold by the healthcare system.
Denmark is often described as one of the most progressive countries when it comes to its legal framework regarding transgender persons. Danish national law does not require Gender Identity Disorder ”diagnosis” for legal gender recogntion, which is often not the case in other many countries. In spite of this (which seems more a product of pinkwashing and neo-liberally soaked articles about the West as a queer paradise), empirical data suggests that the waiting time for someone with transgender condition to receive approval to start with Hormone Replacement Therapy (HRT) can take even more than one year. This practice by Danish Sexologisk Klinik is not considered appropriate or supportive by many human rights organizations such as Amnesty International. Twenty-one percent of Danish transgender persons have “felt discriminated against by the health professionals“. This is problematic considering the fact that gender affirming surgery is central to physical and psychological well-being of many trangender persons, and its delay often leads to “severe psycological distress, disorders, and sometimes suicidal tendencies“.
This article is written from my perspective as a migrant woman with a history of gender-affirming process. I am based in Scandinavia, and I am someone who shares many identity characteristics with my binary transgender women interviewees. I had a chance to encounter these four persons, discussed here, for the first time in a support group called Transgruppen, which operates within a Danish organisation LGBT Denmark where I conducted my internship as a part of a masters in Gender Studies at Lund University. They revealed the employment of various forms of self-medication and other strategies in order to propel the feminization process, mostly while on the waiting list to access HRT through the Danish healthcare system.
The purpose of this article is to reveal the personal experiences of some transgender women residing in Denmark and to critically evaluate the government’s responsibility for transgender well-being. Our real-life stories demonstrate that these women in Denmark partake in hazardous self-medication, unsafe strategies, and sex work as tactics for accessing the treatment while left on hold by the healthcare system. In addition, even the safe and circumspect ways of self-medication are often considered damaging by medical authorities in Denmark who centralise the Western-oriented medical treatment as the one and only way for transitioning “properly.“ When it comes to relation between the government of Denmark and its transgender residents, I believe that Antonio Gramsci’s argument related to the State as an instrument of rationalisation can be useful in pinpointing the hierarchical dynamics between the government and the less accepted, non-cisgender subjects. As a final aim, I would single out my intention to inform future legal and political decisions affecting the transgender community in Denmark by generating knowledge about experiences that are insufficiently represented.
Clara is a thirty-eight year old computer programmer from Århus. Although she has been aware of her transgender identity from high school days and was thinking about self-medication, Clara had not started with HRT until 2019. As she puts it, “I wanted a system to take care of me, I needed guidance.” Regardless of being aware that her assigned psychiatrist in Sexologisk Klinik was asking unpleasant questions related to her sex life and how she is stereotypically a transgender woman, Clara says that it did not bother her, knowing that she must go through the process if she wants to access HRT. There is no place for complaints, insurgent behavior, and dissent if one wants to be approved for it within the system. In relation to his argument about the State as an instrument of rationalization, Gramsci sees the state apparatus as the one that creates the actual conditions “in which a certain way of life is possible.’’ This rationale can certainly be employed in relation to Clara’s introductory narrative about her experiences within the healthcare system in Denmark.
Among transgender women, “a strive for thinness as an attempt to suppress features of one’s biological gender, or accentuate features of one’s desired gender” is described in a research article written by Ålgars in 2012. The important dynamics about relationality between transgender identity and eating disorder are revealed by Clara who lost 18 kg and went from 100 to 73 after she came out publicly. As she puts it: “Losing weight made me happy, I felt more female-like”. Consequently, dieting represents one of the strategies employed by transgender women to achieve a skinny, “feminine” figure.
Sex work stands as an additional strategy among transgender women I interviewed. For Clara it had both confirmatory and financial dimension: the former being expressed the best in her quote: “Being desperate to get acceptance and be perceived as a woman,” while the latter is embodied in her need to pay for her transition-related treatments. Clara used a sex work website xHamster Live on which she was showing herself naked in front of the camera. Camming was Clara’s way of coming out precisely to men and being confirmed as a woman by the male audience. Feminist transgender scholar Jack Halberstam talks about the reproduction of the heteronormative male gaze on the trans bodies who are icons of otherness. In the contemporary cinema with transgender characters, a trans figure is always the one who “never controls the gaze” and serves as a fetish figure in a charged political conflict. This example confirms that there is no reciprocity in ‘gazing,‘ and there is an absence of a ‘trans gaze.’ Returning to the financial dimension, the reflections about being trans in a capitalist society is important as well. As Clara puts it: “I have figured it out how expensive women’s life is.”
Clara reflects on two options of self-medication that transgender people in Denmark often choose while waiting for the state-funded HRT. The first option is an online medical clinic for transgender persons called Gender GP where they can get condition diagnosis, counselling, and prescription medication. Here it is important to reflect on a financial dimension and privilege of those who are able to become the clients in Gender GP, which is based in the UK: you have to pay for your life-saving treatment, and this is a moment when‘transness‘ becomes a class issue. The second option for those friends of ours who lives in poverty, are undocumented, or have a migrant status, includes HRT alternatives that can be either beneficial, neutral, or very hazardous to their well-being. One of these hazardous alternatives is the birth control pills that are generally used by cisgender women as a method to prevent pregnancy. When it comes to the transgender community, the focus is on an ingredient called Ethinyl Estradiol that can affect breast growth and increase feminine features when taken in larger quantities. While cisgender women on contraceptives usually take one pill per day, Clara’s acquaintance has been taking four pills per day and has felt side effects such as headache and stomach pain. The common side effects also include various forms of fungal infections and the risk of developing breast cancer. Note that this acquaintance of Clara has an asylum-seeking status in Denmark, and according to Danish law, she is unable to access the state transgender healthcare.
Anna is a twenty-nine year old transgender woman from Copenhagen. Currently she has been on the waiting list for her first appointment at Sexologisk Klink for almost one year. Anna says that she often shares naked photos of herself online when she thinks that she looks “good enough“ and to receive the aforementioned male gaze. Her main reason for this endeavour is the reactions of men: their positive comments somehow heal the spiritual pain of denied femininity. In addition to this confirmatory dimension, the financial dimension is expressed in the fact that Anna was also engaged in sex work in order to get funds needed for her gender affirmation procedures.
While being on the waiting list for HRT, Anna is seriously considering self-castration. “I think a lot about it. It is actually quite easy: you do it in a way that a sheep is castrated, and it is not painful. It is basically just a tight rubber band around the testicles that makes them eventually fall off.“
Mia is a fifty-three year old transgender woman who works as a chef in a restaurant in Copenhagen. She has started with the state HRT, and now she is waiting for her surgeries. A frustration that Mia currently has in relation to Danish healthcare system is the allowance for transgender woman to have a top surgery. Namely, if one’s breasts are “big enough,“ then they are not allowed to have an operation funded by the healthcare system. While not familiar with the criterion of “big enough“ and the standards of this measurement, Mia is hoping to access this service in the near future. We can think about her trans body as “caught up in a system of constraints and privations, obligations and prohibitions“ in a disciplinary apparatus’ branch such as Sexologisk Klinik.
She came out in 2009 after her divorce, and that was the moment when she got a document from Stratsforvaltningen saying that she would not be able to see her daughter while being dressed as a woman since “it is the best for the kid.“ Statsforvaltningen is a state administration organized under the Ministry of Social Affairs in Denmark. As a consequence, Mia had a suicide attempt due to the pressure from her relation with her daughter and the very fact of coming out during a crucial moment of divorce. Around the same time, Mia developed an eating disorder.
Magdalena is a fourty-four year old insurance consultant and a transgender woman residing in Copenhagen. While being on the waiting list for accessing HRT, Magdalena uses a medicine called Proscar prescribed by her doctor for the prevention of hair loss. Magdalena intentionally wanted to get this prescription because Proscar has the side effects of breast tissue development. However, Magdalena is also aware that one of its side effects is also the development of prostate cancer, which was explained by her doctor. Magdalena states that she often needs to work overtime in order to to pay for hair transplantation as well as body waxing treatments.
The self-medication among the interviewed transgender women in Denmark employed either by them or their trans female acquaintances include two modalities. The first modality is expressed in the act of going beyond the Danish healthcare system and accessing the HRT via private clinics such as Gender GP. The second modality includes alternatives to HRT: birth control pills as well as the medicines with Dihydrotestosterone-blocking effect such as Proscar. On the other extreme of feminization strategies stand more hazardous ways to achieve the feeling of being feminine, such as strict dieting and even a possibility of self-castration.
Feminization tactics among transgender women also include sex work in the form of camming or escorting as well as a need to work overtime to be able to get funds for their feminization process. The feminization process among transgender women has the confirmatory dimension of sex work (camming or escorting), where validation of one’s womanhood comes from men.
The lack of systematic healthcare support expressed in the long waiting list for accessing the HRT often leads to hazardous modes of self-medication, unsafe strategies, and tactics such as sex work that make these persons even more vulnerable in heteronormative and cisgender society. The transgender respondents have experienced situations in which the cisgender medical experts are the ones who can either approve or deny issues ranging from their transgender identity to breast enlargement surgery. The migration authorities are the ones who restrict non-Danish nationals from accessing the state-level HRT. The Western doctors are the ones who decide which medicines are part of HRT and which are not. Stratsforvaltninen is a managing authority that frames the meetings between a trans parent and her child around the control of her visual appearance and the way of parenting to which she has to consent in order to be able to see her family. Lastly and in order to have a better contextual understanding of transgender healthcare in the Nordic region, it is useful to note that the Swedish transgender community often faces similar sets of problems when it comes to this issue. As someone who is based in Stockholm and works as a migration consultant for transgender asylum seekers, among others, I am familiar with dispartities and struggles specific for our target group. Namely, transgender asylum seekers in Sweden do not have a right to trans-related healthcare (HRT, procedures, and surgeries) until their asylum process is over and completed with a positive decision from the Swedish Migration Agency. Meanwhile they have a right only to “emergency healthcare,“ which excludes anything related to gender affirming processes. Additionally, transgender healthcare in Sweden is jeopardized even for those who have a Swedish residency / citizenship due to the fact that during COVID-19 time, transgender-related surgeries and procedures are put on hold as something that is not urgent. While I wait to see how the situation is going to develop and when our lives will become urgent, I am full of hope that this article will shed more light not just on our vulnerability, but also on our survival skills and solidarity, which neither the Nordic governments nor Corona can take from us.
Ines Lukac is a sociologist specializing in Gender Studies at Lund University and a researcher and feminist activist interested in topics such as transgender studies, queer migration, and asylum politics. She is working closely with queer asylum seekers in Sweden as a migration consultant at RFSL Stockholm, as well as a group leader for Newcomers Youth at RFSL Ungdom. Her recent research report is LGBT Asylum Seekers in Sweden: Conceptualising Queer Migration Beyond the Concept of “Safe Third Country” published by Oxford Research.