Monika: Hello Carys! I’ve been hoping to speak with you for such a long time, having you here truly feels like a dream come true.
Carys: Hello Monika! I’m honored to help make your dream come true. It’s truly a pleasure to speak with such a kind, intelligent woman. The work you’re doing for our community is inspiring and deeply appreciated.
Monika: You are one of the few ‘non-pathologizing’ trans-care health providers in Ontario. Could you explain what ‘non-pathologizing’ care means in practice?
Carys: A non-pathologizing approach to transgender care essentially implies that there is no diagnosis to make for transgender people. The idea that this is a pathological process is patently absurd. There is no inherent biological risk in being transgender.
By that, I mean that being transgender does not result in any measurable negative biological effect. 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, lack of access to health care, and violence. These are addressed at the political level, with advocacy from health care providers and transgender activists as key players.
So for me, there is essentially no diagnosis 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, along with support throughout their transition. That is the essence of what I do.
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The false narrative of deception: Carys Massarella at TEDxHamilton via TEDx Talks. |
Monika: Is there a reason why so many doctors still regard being transgender as a mental disorder that requires psychiatric evaluation?
Carys: The reason so many physicians regard being transgender as a mental disorder really boils down to two main issues. Firstly, and this is the most understandable, is that up until the DSM-5, it was classified as a disorder in the psychiatric "bible." Most physicians consider this to be the consensus expert opinion on psychiatric illness and often don’t explore the issue further. In addition, there is typically no training on transgender health in medical school or residency programs.
This leads to a lack of understanding around transgender healthcare and even resistance to the evolving ways in which it is now being practiced.
So, first, we need to have the diagnosis removed from the DSM entirely. This has been partially addressed in the DSM-5, where the condition is now called Gender Dysphoria, which at least implies that there is not an inherent disorder to be "cured," but rather an experience that needs to be understood and supported in an appropriate way.
Secondly, we need to improve training in medical schools and post-graduate residency programs to ensure that future physicians are equipped to provide informed, compassionate, and appropriate care for transgender individuals.
Monika: Over 40 years ago, homosexuality was regarded as a mental disorder, but the American Psychiatric Association (APA) eventually removed it from the list. Why has it taken so much longer in the case of transgender people, where the diagnosis was known as Gender Identity Disorder (GID)?
Carys: The answer lies, to some extent, in who is asked to provide the expert opinion. In the past, most so-called “experts” were cisgender healthcare providers, primarily mental health professionals, and no one actually thought to ask transgender people what they thought about it.
Also, when the so-called experts frame something as pathological, that becomes the prevailing narrative. So what we need, and what we've started to see through advocacy and shifts in clinical practice, is a change in who provides those expert opinions. That means bringing in different voices, especially trans voices, and reshaping the narrative.
We’ve seen some progress with the new diagnosis of Gender Dysphoria, but I believe we still have more ground to cover. Ideally, we’ll reach a point where transition-related care is recognized simply as the treatment of a medical condition, without the baggage of psychiatric labels. That’s all that really needs to happen, the individual transitions and then continues with their life.
I think we’ll get there within the next ten years.
Monika: Current psychiatric concepts often reinforce negative stereotypes about gender-variant people, while also failing to legitimize the medical necessity of sex reassignment surgeries. As a result, transgender people are still frequently subjected to diagnoses like psychosexual disorders. What’s your take on that?
Carys: Yes, there’s still a lot of outdated thinking embedded in the system. In many countries, being transgender is still classified as a psychosexual disorder, which leads to mistreatment and even attempts at so-called reparative therapy.
All I can say is that WPATH (World Professional Association for Transgender Health) has clearly stated that being transgender is not a disorder, and that reparative therapy is unethical.
Hopefully, over time, this message will continue to spread, and we’ll see a broader shift in attitudes. Where I work, we’re already witnessing that change, but I also live in a liberal, progressive country. Not everyone is that fortunate.
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| Carys and her bestie Mel. |
Monika: Some transgender advocates fear that access to sex reassignment procedures might be lost if the GID classification is removed or revised. Do you think this fear is justified?
Carys: I don't think that 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 limit medical intervention to the transition period, then we can call it whatever we want.
We already manage many other conditions that have a defined treatment period followed by maintenance or routine follow-up, so there's no reason we couldn’t approach transgender healthcare in the same way.
Monika: What can we realistically expect in the coming years regarding GID reform?
Carys: I think, as I mentioned earlier, we can expect that in many countries the informed consent and non-pathologizing model will become the standard of care.
In most large clinics across North America, this is already the case. I would also hope to see most gender-affirming surgeries covered by either private or public health insurance plans. This is already happening to a large extent in Canada and parts of the United States, but it is by no means universal.
This is exactly where I focus a lot of my teaching and advocacy work, advancing access and equity in 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 usually get from your audience?
Carys: Generally, there is a strong appetite among healthcare providers at all levels to learn about transgender care. Wherever I speak, I typically receive positive feedback and am often invited back.
In fact, at my own medical school, the lecture I give on LGBTQ health is consistently one of the most popular sessions year after year. There are the occasional awkward questions, but for the most part, the response is respectful, if not downright enthusiastic. I often hear that people are genuinely interested and open to changing the way they manage care for transgender patients.
Monika: What is your general view on the portrayal of transgender stories or characters in films, newspapers, or books so far?
Carys: That’s an interesting question, especially considering Jared Leto winning an Oscar for Dallas Buyers Club. Certainly, the visibility of transgender people has increased significantly in recent years. I suppose I’m ambivalent because the media's main goal is to sell movies and books, not necessarily to offer truthful portrayals.
But I do see improvements, particularly with actresses like Laverne Cox and media personalities like Janet Mock. So, progress for sure, but transgender characters are still often portrayed as oddities or used as opportunities for humor. One series I think did the best job portraying a transgender character was the British series Hit and Miss, which I really enjoyed, though, unfortunately, it only had one season of six episodes.
Monika: During your transition, did you have any transgender role models to look up to?
Carys: For me, I was lucky. I had a colleague who had already transitioned at another hospital, and she was an amazing mentor for me. I find that there aren’t many role models for transgender youth, in particular, but I see that changing over time.
Monika: What was the hardest part of your coming out?
Carys: For me, the hardest part about coming out was disclosing it to my partner at the time. We ultimately ended our relationship because of it. I also worried a lot about how my colleagues would perceive me, but their support has been amazing. The support from my hospital has also been wonderful.
I work at a Catholic teaching hospital and have gone on to become the President of the Medical Staff as a transgender woman. I’ve also been awarded the highest honor for a physician at our hospital. So, my fears in that regard were definitely not realized.
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| TEDxMcMasterU - Dr. Carys Massarella via TEDx Talks. |
Monika: What are your thoughts on the current situation of transgender women in Canadian society?
Carys: I think, in general, transgender rights have improved dramatically in Canada. In the province of Ontario, where I live, gender identity and expression are protected human rights. At the federal level, there is a similar bill pending Senate approval. So, in essence, we now have the legal right to exist, which is the first step toward a meaningful existence. Of course, there is still a great deal of marginalization and violence faced by 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. However, I do foresee a time when this will change, and I believe it will happen in my lifetime. I see a big shift in young people, in particular. They are much more willing to accept transgender identity as part of the diversity of society, rather than viewing it as an anomaly or illness.
Monika: Could transgender rights become 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, which is encouraging. I think, in general, there is a move toward the 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. However, 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 to transgender people. This often leads them to support increased and equal rights for trans folks. So, I would say that transgender rights are seen as a cause worth fighting for by many cisgender people, not just those who are allies. Certainly, in Canada, we are moving toward 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 healthcare to transgender people. In terms of lobbying, I am a member of the Gender Independent Children’s Committee for Rainbow Health Ontario and advocate for better care for youth.
Additionally, I am a board member of the Canadian Professional Association for Transgender Health, where I participate in supporting better access to healthcare. As you mentioned earlier, I speak publicly on transgender issues and have now done two TEDx talks about them. I’ve also been politically active within my party and have access to senior politicians. I’m quite proud that all three Conservative politicians in my Federal region (Halton) voted in favor of transgender rights in Parliament. I might have played a role 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 outside of work. They matter most to me. As for others, I value close friends and family the most. I wouldn’t comment on any personal relationships publicly, as I prefer to keep that part of my life private.
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| "I think in general that transgender rights have improved dramatically in Canada." |
Monika: Are you into fashion? What types of outfits do you gravitate toward? Do you have any favorite designers, colors, or trends that you follow?
Carys: I do enjoy fashion and have a large, extensive collection of designer clothes. My real passion, though, is boots. I have over 60 pairs, mostly couture boots. My style tends to be simple, with straight lines and an elegant flair, as I’m tall and thin.
The nicest compliment I received recently was when I went to pick up some dry cleaning, and the woman at the desk told me they think I have the most beautiful clothes they dry clean, and they love doing it! That was so sweet. Also, the female paramedics like to come to my hospital just to see what I’m wearing when I work. So yes, I’ve developed quite the reputation as a clothes horse.
Monika: What’s your take on transgender beauty pageants? Glittery empowerment or just another polished pressure cooker?
Carys: Beauty pageants are something I’m not at all interested in. They promote the idea that only beauty matters, which I think is particularly harmful to transgender women. It reinforces the narrative of deception, in my opinion, so I would prefer to see transgender women recognized for other accomplishments, not just for looking “just like real women.” That said, I also believe in free will, so everyone has to make their own choices.
Monika: Are there any exciting new projects keeping you on your toes these days? Or are you secretly plotting to take over the academic world one research paper at a time?
Carys: I’m always working on new projects, mostly in the world of academia and research. We’ve just published a paper in the Annals of Emergency Medicine on the transgender experience in the Emergency Department, and we’ll hopefully be moving forward with more research projects over the next few years. As always, I’m also working to include LGBTQ health in the medical school curriculum and teaching the next generation of doctors about transgender healthcare. So yes, always busy!
Monika: What would you recommend to all transgender girls struggling with gender dysphoria?
Carys: I think what I would tell transgender women struggling with dysphoria is: never give up, and don’t think there’s something wrong with you. 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 doesn’t lie in “curing” yourself, but in learning to live with yourself and making the best decisions for you, whatever those 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 to, and go on to 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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