Sunday, 13 April 2014

Interview with Carys Massarella

Monika: Today it is my pleasure and honor to interview Carys Massarella, a doctor of emergency medicine at McMaster University and Lead Physician of the Transcare Program at Quest Community Health Centre in St. Catharine’s, Canada. She grew up in Sudbury, Ontario, and graduated from the University of Western Ontario. Hello Carys!
Carys: Hello Monika!
Monika: You are one of few ‘non-pathologizing’ trans-care health providers in Ontario. Could you explain what ‘Non-Pathologizing’ stands for?
Carys: A non-pathologizing approach to transgender care essentially implies that there is no diagnosis to make with transgender people. The idea that this is a pathologic process is patently absurd. There is no inherent biological risk in being transgendered.
In that I mean by being transgendered there is no measurable biological effect in a negative way. The documented poor outcomes for trans-identified individuals are a product of issues related to the social determinants of health that affect all such marginalized populations such as poverty, homelessness, access to health care, and violence. These are corrected at the political level with advocacy from health care providers and transgender activists as key players.
So for me, there is no diagnosis essentially to make. I allow transgender people to claim their identity and then provide safe and medically appropriate access to cross-gender hormone therapy and surgery plus support through the transition. That is the essence of what I do.

The false narrative of deception: Carys Massarella
at TEDxHamilton via TEDx Talks.

Monika: Is there any reason why so many doctors may regard transgenderism as a mental disorder that requires a psychiatric evaluation?
Carys: The reason so many physicians regard being transgendered as a mental disorder really boils down to two issues. Firstly and the most responsible is that up until the DSM V it was classified as a disorder in the psychiatric bible. Most physicians consider this to be the consensus expert opinion of psychiatric illness and would not bother to explore further. As well there is no training in medical school or residency programs for the most part.
This leads to a paucity of understanding around transgender healthcare and even changes to how transgender healthcare is being practiced.
So first we need to have the diagnosis removed from the DSM which has been partially addressed in the DSM V with the condition now called gender Dysphoria which implies at least there is not an inherent disorder that needs to be "cured" but rather an experience that needs to be managed in an appropriate way.
Secondly, we need to have better training in Medical schools and post-graduate residency training programs. 
Monika: Over 40 years ago homosexuality was regarded as a mental disorder but the American Psychiatric Association (APA) decided to remove it from the list of mental disorders. Why do we have to wait for so long in the case of transgenderism that is described as Gender Identity Disorder (GID)?
Carys: The answer lies to some extent in who is asked to provide an opinion. For example, in the past most "experts" were cisgender healthcare providers who were mental health professionals and no one actually bothered to ask transgender people what they thought of this.
Also if the experts pathologize that's what we end up with. So we in essence, through advocacy, and changing practice need different providers to provide expert opinions. Thus changing the narrative so to speak. We are seeing this to some extent with the new diagnosis of gender Dysphoria but I still think we have further to go where it becomes essentially a treatable medical condition. I see the way forward as medical/surgical transition being a treatable condition and then that's really all that needs to be done and the person moves on with their life. I think we will get there in the next ten years.
Monika: The current concepts in psychiatry reinforce negative stereotypes of gender variant people and at the same time fail to legitimize the medical necessity of sex reassignment surgeries. As a result, transgender people fall prey to the diagnosis of psychosexual disorder...
Carys: Yes, there still is a lot of old thinking present in the system, and in many countries being transgendered is considered a psychosexual disorder leading to mistreatment and attempts at reparative therapy. All I can say is that WPATH has stated that being transgendered is not a disorder and that reparative therapy is unethical.
Hopefully, over time this message will get out there and we will see a shift in attitude. Certainly, where I work we are already witnessing this change but then again I live in a liberal progressive country. Not all folks are that fortunate.

Carys and her bestie Mel.

Monika: However, some transgender advocates fear that access to sex reassignment procedures may be lost if the GID classification was revised. Is this fear justified?
Carys: I don't think this fear is justified. Where I live and work we do not require a diagnosis of GID for medical treatment. As for surgery, it will take time but again if we think of it as a treatable condition and confine medical treatment to the period of transition then we can call it anything we want.
We have many conditions that have a defined treatment period and then just maintenance therapy or follow up so there is no reason that we couldn't manage transgender people in the same way.
Monika: What can we expect in the years to come in terms of the GID reform?
Carys: I think as I mentioned previously I would expect in many countries that we will see the informed consent/non-pathologizing model become the standard of care.
In most large clinics in North America, this is already the case. I would hope to see most surgeries also being covered by either private or public health insurance plans. This is happening again to a large extent in Canada and the United States but is by no means universal. This is where I do a lot of teaching and advocacy work with regard to transgender healthcare.
Monika: You travel all over Canada and spend hundreds of hours lecturing about transgender issues at schools across the country. What kind of response do you get from your audience?
Carys: So generally there is a large appetite amongst healthcare providers at all levels to learn about transgender care. Wherever I speak I generally receive positive feedback and usually, I am asked back.
In fact, at my own Medical School, the lecture I give on LGBTQ health is one of the most popular lectures year in and year out. There are the occasional awkward questions but for the most part, the response is respectful if not quite enthusiastic. I often hear that people are genuinely interested and willing to change the way they manage transgender patients.
Monika: What is your general view on transgender stories or characters which have been featured in films, newspapers, or books so far?
Carys: That's an interesting question particularly in light of Jared Leto winning an Oscar for the Dallas Buyers Club. Certainly, the profile of transgender people has increased markedly in the last few years. I suppose I'm ambivalent as the media is there to sell movies and books and not necessarily interested in truthful portrayals.
But I do see an improvement particularly with actresses like Laverne Cox and media personalities like Janet Mock. So progress for sure but transgender characters are still portrayed as oddities or opportunities for humor. One series which I think is the best portrayal of a transgender character was the British series "Hit and Miss" which I really enjoyed but unfortunately only had one season of 6 episodes 
Monika: At that time of your transition, did you have any transgender role models that you could follow?
Carys: For me I was lucky. I had a colleague who had already done this at another hospital and she was an amazing mentor for me. I find that there aren't a lot of role models for transgender youth in particular but I see that changing over time.
Monika: What was the hardest thing about your coming out?
Carys: For me, the hardest part about coming out was disclosing to my partner at the time. We ultimately ended our relationship because of this. I also worried a lot about how my colleagues would perceive me but their support has been amazing and also the support from my hospital has been wonderful.
I work at a Catholic teaching hospital and have gone on to be President of the Medical Staff as a transgender woman and have also been awarded the highest award for a physician at our hospital. So my fears in that regard were definitely not realized. 

TEDxMcMasterU - Dr. Carys Massarella via TEDx Talks.

Monika: What do you think about the present situation of transgender women in Canadian society?
Carys: I think in general that transgender rights have improved dramatically in Canada. In the Province of Ontario where I live gender identity/expression is a protected human right. And at the level of the Federal parliament, there is a similar bill pending Senate approval. So in essence we now have the legal right to exist, which is the first step to a meaningful existence. Of course, there is still a great deal of marginalization and violence surrounding trans populations in Canada and this will take time to change.
There are always one-off success stories like mine but it is not universal. But I do foresee a time where this will change and I believe it will happen in my lifetime. I see a big change in young people in particular. They are much more willing to accept transgender identity as part of the diversity of society rather than as an anomaly or illness.
Monika: Could transgenderism be the new frontier for human rights?
Carys: Certainly this is possible. Joe Biden, the Vice President of the United States called transgender rights the 21st century's civil rights fight. So that's encouraging. I think in general there is a move towards legal recognition of transgender rights in most Western and liberal democracies.
Of course, the same is not true everywhere and we are seeing pushback in certain countries. I think that when most people are presented with the facts about transgender lives they are generally shocked by the degree of marginalization and lack of rights afforded transgender people and will usually support increased and equal rights for trans folks. So I would say that transgender rights are considered a cause worth fighting for by many cisgender people, not just those who are allies. Certainly in Canada, we are moving towards full legal and civil rights for Transgender people.
Monika: Are you active in politics? Do you participate in any lobbying campaigns? Do you think transgender women can make a difference in politics?
Carys: I am not an activist per se. I am more of a person who believes that it is never wrong to do the right thing as I tell my medical students and residents. So I am passionate about delivering better health care to transgender people. In terms of lobbying, I am a member of the Gender Independent Children Committee for Rainbow Health Ontario and advocate for better care for youth.
Also, I am a board member of the Canadian Professional Association for Transgender Health so participate in supporting better access to health care. As you said before I speak publicly on transgender issues and have now done two TEDx talks around transgender issues. I have been politically active in my party and I do have access to senior politicians. I am quite proud that all three Conservative politicians in my Federal region (Halton) voted in favor of transgender rights in parliament. I might have helped there. So yes I suppose I am active to some extent. 
Monika: Could you tell me about the importance of love in your life?
Carys: For me, the loves of my life are my children who I spend as much time as I can with away from work. They matter most to me. As for others I value close friends and family most. I wouldn't comment on any personal relationships publicly as I prefer to keep that part of my life private.

Monika: Do you like fashion? What kind of outfits do you usually wear? Any special fashion designs, colors, or trends?
Carys: I like to wear designer clothes and have a large and extensive collection. My real passion is boots though. I have over 60 pairs of mostly couture boots. It is mostly simple, straight lines and elegant as I am tall and thin.
The nicest compliment I received about my clothes recently was when I went to pick up some dry cleaning the woman at the desk told me they think I have the most beautiful clothes that they dry clean and they love to do it! So that was nice. Also, the female paramedics like to come to my hospital just to see what I'm wearing when I work. So yes I have a reputation as a clothes horse.
Monika: What do you think about transgender beauty pageants?
Carys: Beauty pageants are something I am not at all interested in. It sells the idea that only beauty matters and is particularly harmful to transgender women in my opinion. It again builds into the narrative of deception in my opinion so I would prefer to see transgender women being recognized for other accomplishments. Not just how they look "just like real women". But I also believe in free will so everyone has to make their own choices.
Monika: Are you working on any new projects now?
Carys: I am always working on new projects but mostly in the world of academia and research. We have just published a paper in the Annals of Emergency Medicine on transgender experience in the Emergency Department and will be hopefully moving forward on future research projects in the next few years. And as always trying to include LGBTQ health as part of the curriculum in medical schools and also teaching the next generation of doctors about transgender healthcare. So always busy.
Monika: What would you recommend to all transgender girls struggling with gender dysphoria?
Carys: I think I would tell transgender women struggling with Dysphoria is not to ever give up and don't think there is something wrong with them. You just happened to be born with a gender identity opposite to your biological sex and that's really it. The question is what do you want to do about it.
The answer lies not in "curing" yourself but learning to live with yourself and making the best decision for you whatever that might be. There is no right or wrong answer here. I hope you can find access to compassionate and competent healthcare and transition, if you choose, and lead a meaningful life. That is what I am striving to achieve for all my transgender sisters.
Monika: Carys, thank you for the interview!
Carys: Thanks, Monika!

All the photos: courtesy of Carys Massarella.
© 2014 - Monika Kowalska

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