Moving beyond the gender binary : the treatment of transgender individuals in Iceland

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Moving Beyond the Gender Binary:

The Treatment of Transgender Individuals in Iceland

Author: Maryam Holton Student: 10635386

Email: mbholton@zoho.com Supervisor: Margriet van Heesch Master's Thesis is Sociology Second Reader: Patrick Brown Track: Social Problems and Social Policy July 2014

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Acknowledgements

This thesis would have been impossible without the time given up by my participants. Their insightful stories inspired me throughout this writing process and helped make this thesis a reality. I would like to offer them my sincerest gratitude for their time and for sharing their experiences with me.

I would also like to dedicate this thesis to my partner Adam for his continuous support throughout the writing of this thesis and my two boys who kept this writing process interesting and who I cannot wait to meet.

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1. Being Transgender in Iceland 3

1.1 Transgender Rights in Iceland and Beyond 3

1.2 Methodology 5

1.3 Outline of Thesis 7

2. The Development of Transgender Identity: Contested Discourses and Debates 9

2.1 Introduction: Transgender History 9

2.2 Theorising Sex & Gender: From Medical to Post-Modern Conceptualisations 10

2.3 (Gender) Identity Formation: The Social Construction of Identity 13

2.4 Transautonomy: The Diagnostic and Statistical Manual and the "GID" Debate 16

2.5 Transgender in Iceland: A Hidden Population 19

2.6 Conclusion - Moving Debates Forward 21

3. Transgender Care in Iceland: Medical Authority over Transgender Lives ₂₃

3.1 Introduction - "Disordering" Transgender People in Iceland 23

3.2 The First Steps: Difficulties in Finding Help 24

3.3 A Team of Specialists? Diagnoses and Treatment at the National Hospital 26

3.4 A Team of Gatekeepers: Accessing Hormones and Surgery 30

3.5 Conclusion - Improving Transgender Treatment 33

4. Struggling with Identity: Lack of Awareness and Community 36

4.1 Introduction: The Impact of the Social on Identity Development 36

4.2 Keeping a Secret: The Pain of Hiding one's Identity 37

4.3 Transgender Awareness: Tackling Prejudice and Discrimination in Iceland 39

4.4 The Internet: Access to the Outside World 42

4.5 Conclusion - The Social Nature of Identity Formation 46

5. Moving Beyond the Gender Binary: "De-Pathologising" Transgender Care ₄₈

5.1 Introduction - The Pathologisation of Transgender People in Iceland 48

5.2 Transgender Treatment in Iceland: Power and Control 49

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5.5 Conclusion: Moving Beyond the Medical 60

6. Moving Transgender Right's Forward ₆₂

6.1 Abandoning the Gender Binary 62

6.2 Learning from Lived Experiences 63

6.3 A Move Forward for Transgender People in Iceland 64

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1. Being Transgender in Iceland

1.1 Transgender Rights in Iceland and Beyond

The 1990s would appear to have been an eventful decade in the rights movement for transgender people in the Western world. In 1992 the European Court of Human Rights (ECHR) first recognised that a state's refusal to permit an individual's change of sex in official documents was a violation of the European Convention of Human Rights, sending a strong message to European states and beyond about the rights of transgender people1. Iceland was among countries which recognised this human rights violation and in 1996 the Icelandic former Director of Health, Ólafur Ólafsson set up medical treatment for transgender people at the National Hospital in Iceland, following which transgender people could change their sex in the National Registry.2

However, at the same time growing literature by queer and transgender authors challenged the medical understanding of gender non-conforming individuals or individuals with "Gender Identity Disorder". The "Transgender" concept was developed and increasingly transgender individuals rejected a disorder diagnosis arguing instead for a view of gender fluidity or variety. The T was added to LGB and the systematic oppression, violence and even murder of gender non-conforming individuals became increasingly recognised3. In the few countries of Europe where transgender people's rights are recognised, a disorder diagnosis is still a necessary prerequisite to a change of sex in official documents which is increasingly being recognised as a violation of transgender people's rights4. A contradiction is therefore developing in the current state of transgender rights as two opposing and polarised ideologies about gender non-conforming individuals, that is the medical and what could be called the "Queer", challenge each other's conceptualisations of gender variant individuals (Bornstein, 1992; Feinberg, 2006[1993]; Stone, 2006[1992]).

For transgender people to be denied a change of sex in official documents violates their rights as accurate identification documents are needed for a number of activities in modern

1_{Amnesty International, The State Decides Who I Am: Lack of Legal Gender Recognition for Transgender} People in Europe, 2014. Retrieved from: http://www.amnesty.org/en/library/info/EUR01/001/2014/en

2_{Alþingi, Frumvarp til laga um réttarstöðu einstaklinga með kynáttunarvanda, 2011-2012. Retrieved from:}

http://www.althingi.is/altext/140/s/1174.html

4_{Transgender Europe, Trans Rights Europe Map, 2014. Retrieved from:}

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society. In Iceland and all across Europe, transgender people are forced to seek psychiatric assessments where they are labelled with a disorder in order to change their sex in official documents as well as gain access to hormones and surgery5. As transgender individuals are classified with a disorder for their transgender identity, the systems in place which cause their identity to be viewed as "disordered" are not challenged. By labelling transgender individuals as "ill" the gender binary system is therefore reified, which weakens the rights movement of transgender people.

In this thesis I will look at the status of transgender rights in the country of Iceland. In Iceland transgender people are offered medical treatment but only once they have undergone lengthy psychiatric evaluations and have been diagnosed with a disorder. A disorder diagnosis and hormone treatment are also necessary prerequisites to a change of sex in official documents. I wanted to understand how transgender people experience such treatments and how their struggles are addressed by the treatments currently in place for them in Icelandic society. My research question is as follows:

How does the process of identity formation in transgender communities in Iceland challenge the assumptions that underlie the medical treatment provided to them?

In Iceland the diagnosis is still called "Kynáttunarvandi" which is a loose translation of the term "Gender Identity disorder"6. For this reasons I will refer to the diagnosis as "Gender Identity Disorder" or "GID" in this thesis despite its recent change in the "DSM-V" to "Gender Dysphoria"7

I will argue for the rejection of an understanding of gender non-conforming behaviour which pathologises transgender people and I believe delegitimizes their human rights battle. By focusing on transgender identity as conceptualised by feminist, queer and transgender authors I will show how transgender individuals struggle because of social oppression and not a medical "disorder". Transgender scholar Viviane Namaste (2009) argues that feminist work on gender has often used transgender women as a type of symbol for gender disruption, rather than working towards increasing the life quality of those studied. Academic work has

7_{American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (5th ed.), 2013,}

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therefore often ignored the everyday struggles of transgender people. In this thesis I will be focusing on the point of view of transgender people in Iceland and the struggles they face in Icelandic society. I believe this type of work to be highly important as currently almost no academic work exists about the lives of transgender people in Iceland. I therefore believe that my thesis will be an important contribution of knowledge which will add to the literature about gender variant individuals in Iceland.

1.2 Methodology

As I mentioned, very little has been written about transgender people in Iceland so gathering information about the subject was not an easy task. For this reason I used mixed methods in order to get the most comprehensive information about the subject. These included analyses of various documents and newspaper articles as well as conducting interviews with individuals who identify as transgender. I analysed parliamentary documents containing information about laws concerning transgender people as well as the history of the subject. I further analysed government websites and reports on transgender rights. In order to gain an understanding of the way transgender identity is portrayed and understood in Icelandic society, I conducted archive work, using an online archive of Icelandic magazines and newspapers dating back to the early twentieth century up until today. By doing this I could access all articles about transgender people in Iceland and see the gradual shift in the way gender non-conforming individuals have been portrayed in the media, as well as gather information which otherwise was hard to find. As detailed information about medical treatment was lacking, I contacted Óttar Guðmundsson, psychiatrist in charge of assessment of individuals with "Gender Identity Disorder" but unfortunately was unable to get an interview. My main focus was however the experience of transgender people which is why much of the knowledge I gathered about the medical treatment comes from transgender people themselves or former "patients" of the team.

It was important to me that I would gain information about the status of transgender people's rights and the help offered from transgender people themselves rather than supposed medical specialists. By understanding better the lived experiences of transgender people in Iceland, I believe more informed policies can be developed. My aim was to interview individuals who identify as transgender, but I was aware that this is a hidden population in a small nation and they could be difficult to reach. For this reason I used various methods to

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recruit participants. I began by contacting an individual who I believed would be a "gatekeeper" of the transgender community in Iceland. This individual is Ugla Stefanía Jónsdóttir, chairwoman of "Trans Ísland", Iceland's transgender organisation and spokesperson for "Samtökin 78" the country's leading LGBT organisation. With this method I was able to gain three participants. I further used social media in order to advertise for participants which proved to be unsuccessful. Once I began conducting interviews I used snowball recruitment which resulted in two more participants. Finally, I used my own personal connections and contacted an individual who was willing to participate. Participants were six in total and Interviews were semi-structured. My main focus was on participant's experience of the care provided in Iceland, their opinions on how treatment could be better as well as their stories of coming to terms with their transgender identity. Four interviews were conducted in participants' homes and two via Skype. Interviews ranged from 40 minutes to an hour and twenty minutes. Participants were offered anonymity but all refused which is why I will include their names. Participant information is represented in the table below:

Name Gender Age Occupation Residence

Alda Villiljós Gender-fluid 27 No occupation Stockholm,

Sweden Anna Margrét Grétarsdóttir Transgender woman 61 Student of accounting Reykjavík Inga Birna Kristjánsdóttir Transgender woman 48 No occupation Dalvíkurbyggð

Kira Khashabi Transgender 30 Teacher's

assistant at primary school Reykjavík Ugla Stefanía Jónsdóttir Transgender woman 23 Chairwoman of a transgender organisation, spokesperson for LGBT organisation and BA student of Reykjavík

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Sociology and Gender studies Örn Danival Kristjánsson Transgender man 31 High school student and member of board of LGBT organisation Reykjavík 1.3 Outline of Thesis

I will begin the following chapter with a literature review, tracing the history of the medical treatment of transgender individuals and show how an understanding of transgender identity as "disordered" gradually developed in the 20th century. I will discuss how this understanding is increasingly being challenged by queer theorists and transgender activists. In order to understand the vulnerable position of transgender individuals it is useful to understand concepts such as "gender" and "identity" from the viewpoint of Post-modern theories, and I will focus special attention on the work of Michel Foucault and Judith Butler. I will discuss the disorder diagnosis of gender variant individuals in the "DSM" and explain the complexity of the ongoing debate surrounding the diagnosis. Finally, I will trace the history of transgender people's rights in Iceland and show how medical treatment and laws have developed in the country.

In the third chapter I will demonstrate my main findings about participants' experiences of the medical treatment available to transgender people in Iceland. I will show how participants had difficulties accessing the medical team at the National Hospital and how the help offered was of little use to them. As the background of the team members is mainly in psychiatry, I will show how participants felt the team had inadequate training for their position and were not viewed as knowledgeable about transgender issues. Finally, I will show how sessions with their doctors and the subsequent "GID" label became little more than an "admissions ticket" to hormones and surgery.

In the fourth chapter I will demonstrate my second main findings from interviews. I will show how the struggles of participants could be understood in the context of a lack of awareness of transgender lives in Icelandic society which in some cases resulted in participants being unable to identify as transgender, causing them to feel isolated and struggle

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with their feelings. Lack of understanding can also increase prejudice which most participants had experienced. I will show how participants overcame their difficulties by using the internet to access information and transgender communities, an access which was crucial in their identity development.

In the fifth chapter I will analyse my findings by putting them in a wider context of transgender rights as well as understanding them through the lens of post-modern theory. I will show how the medical treatment at the National Hospital employs an understanding in their treatment which pathologises transgender people and clashes with the ideologies through which transgender identity is increasingly understood by transgender activists and queer scholars. I will show how the treatment at the hospital does therefore not address the social struggles of transgender people and does not serve its purpose of helping transgender people.

Finally in my sixth chapter I will discuss future steps for transgender people's rights in Iceland. I will argue for a depathologisation of transgender care in the country. By focusing more on the experiences of transgender people, transgender care can come to better represent their rights and be better tailored to increasing their life quality rather than making them more powerless and vulnerable. I will discuss how developing medical treatment for transgender individuals cannot be the only focus of their human rights efforts but more weight must be given to the role of social structures which so strongly play a role in the struggles of transgender people.

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2. The Development of Transgender Identity: Contested

Discourses and Debates

2.1 Introduction: Transgender History

The "T" for Transgender was added to the rights movement of LGB people in the 1990s and transgender people are increasingly becoming a more visible minority group as they fight for awareness and human rights. This is an important development as transgender people are a vulnerable group which is at constant risk of prejudice and hate crime as well as having high rates of depression and suicide. However, different from gay and lesbian identities, transgender identity is still viewed as a medical disorder by the medical establishment, which risks further victimisation of transgender people as they are labelled mentally "disordered". However, simply removing the diagnosis could cause transgender people to lose access to medical treatments which can in fact be of vital importance.

The situation is therefore complex and in this chapter I will discuss the complexities surrounding the "Gender Identity Disorder" debate and the way treatment of transgender individuals has developed through a historical process to its current state. I will then show how such a medical understanding increasingly clashes with the more recent conceptualisation of "Transgender identity" and how these conflicting understandings have resulted in tensions and debates around medical treatment as well as the rights of transgender people. In this chapter I will attempt to answer the question,

What historical processes were of main influence in the development of transgender identity?

It is crucial to look at the historical factors which played a large role in the development of the current conceptualisation of gender non-conforming individuals in the Western World. By looking at post-modern theories of the gender binary system we can also come to better understand the struggles of these individuals and the reasons for their incredibly vulnerable position in society. It is by looking at these factors that a better understanding can be made about the status of transgender individuals in modern societies such as Iceland.

In the first section I will explore the historical processes from which the terms "sex" and "gender" were developed. I will then demonstrate how transgender identity was medicalised and how such a view defied the increasingly reified understanding of the

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sex/gender distinction. queer theories further challenged that distinction and I will show how numerous influential publications by transgender activists rejected the medical understanding of transsexualism. I will illustrate how Post-modern theories of identity can help shed a light on the struggle of transgender identity formation and how the gradual institutionalisation of transgender identity is increasingly being viewed as beneficial to transgender people. The placement of "GID" in the "Diagnostic and Statistical Manual for Mental Disorders" was highly controversial and I will discuss the complex nature of that ongoing debate. Finally I will look to Iceland and illustrate how these larger developments influenced an understanding about transgender identity on the local level of Icelandic society and show how the treatment and the rights of transgender people have developed in the country.

2.2 Theorising Sex & Gender: From Medical to Post-Modern Conceptualisations

In this section I will discuss ways in which the social sciences have come to understand sex and gender by looking at the historical development of these terms. By doing so I will demonstrate the fluid nature of the terms and the way the conceptualisation of transgender identity challenged understandings of sex and gender. Finally, I will discuss how transgender identity has gone from being understood solely as a medical condition to being reconceptualised following recent writings in queer and transgender theory.

Although the term gender seems so well known today, it is in fact a relatively recent term. It was only in the middle of the last century that it started to develop towards its current meaning. Sex and gender are terms that have been developing in the West through numerous scientific discoveries, academic work and political activism (Nicholson, 1994). The term gender became important to feminists in the second half of the 20th century because of their criticism of gender roles. Feminists have for decades challenged the strict gender roles of the sexes and one of the most famous feminists who highlighted the socially constructed nature of women was Simone de Beauvoir in her book "Le Deuxiéme Sexe" or "The Second Sex" where she famously asserted "One is not born, but becomes a woman". This way of thinking about gender would later characterise the so called "second wave of feminism" and the social construction of gender became a pillar of that thought (De Beauvoir, 1953; Carrera et al., 2012:997).

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If sex is natural and gender is a social construction, as understood by the second wave of feminism, it raises the question of how transgender people's lives fit into such a distinction. Many of the first popular literature on transsexuality portrayed transgender women as "trapped in a man's body" and relied on stereotypical notions of femininity. Such an essentialist understanding of gender strongly challenged the work done by feminists in highlighting the social construction of gender (Stone, 2006[1993]:224-227). For this reason, some feminists attacked transsexuals, the most famous of such work being Raymond's (1979)

The Transsexual Empire. Raymond went so far as to say that "All transsexuals rape women’s

bodies by reducing the real female form to an artifact, appropriating this body for

themselves" (Raymond, 1979:133).

According to Whittle (2006), Raymond's work had far-reaching effects on feminist ideology. It supported the notion of separatism and sanctioned the oppression of transgender people (196-197). Transgender academics and activists however answered back and a number of influential papers were published in the 1990s (Feinberg, 2006[1992]; Stone, 2006[1993]; Bornstein, 2006[1992]). The current meaning of the term transgender can be traced back to that time or to the work of author Leslie Feinberg (2006[1992]) and her influential pamphlet,

Transgender Liberation: A Movement Whose Time Has Come. In the pamphlet Feinberg

explores the ancient history of "transgendered men and women" writing that gender non-conforming individuals have always existed and it is "passing" that is new (Feinberg, 2006[1992]:207; Stryker, 2006:4). Stone (2006[1993]) further challenged the popular literature on transsexuality as she felt it reproduced harmful gender stereotypes. Instead she called for a new Post-structural understanding of gender identity, which would be open to a more complex understanding of gender and gender variety.

The transgender term and the way it is understood today is therefore very new. It moves away from a definition that focuses on the physical such as "transsexual" and encompasses a more social meaning and a focus on identity. The new ideas and scholarship which emerged in the 1990s were based on the idea that transgender identity was not a disorder, which was a fundamental shift in the way transgender identity was understood and this idea would be further built upon in academia (Whittle, 2006:xii).

Transgender women were excluded by feminist theorists for years but this changed when sociologists started to look at transgender people's lives from the point of view of Harry Garfinkel's (1967) ethnomethodology, or the exploration of the presuppositions of everyday social categories. The work of Kessler & Mckenna (1978) and later West & Zimmerman

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(1987) was influential in highlighting the way gender categories are sustained in everyday practices of speech, behaviour and divisions of labour. Transsexual women's lives and their everyday experiences started to be used by a number of academics to highlight social aspects of gender and gender disruption. The most influential author of this kind being Judith Butler (Connell, 2012:860-861).

Butler's (2006 [1990]) work "Gender Trouble" was hugely influential and inspired a new generation of queer theorists and gender scholars. Instead of focusing on the social construction of gender, Butler argues that sex, gender and the body are conceived as cultural products. Butler therefore rejects the sex/gender construction which was used as a political tool by second wave feminists. A person did not have a natural sex or gender and it was impossible to think of them as a subject prior to cultural construction. In fact, it was the heterosexual matrix which constructed the gender binary, or what she called mandatory heterosexuality. Such a system created gender oppositions as one could only be one gender if there was another gender to differentiate oneself from. With her post-structuralist view on gender Butler transformed feminist theory by moving beyond the social construction/essentialism debate (Jagger, 2008:1-2).

Although it could be argued that these feminist and queer authors had a great impact in transforming the way gender non-conforming individuals were viewed, some believed these theories had little impact on the everyday struggles of transgender people. Namaste (2009) is among such authors and she criticises academic work which used transgender people's lives to prove a point about gender. According to Namaste authors such as Butler used transgender women as objects to increase knowledge about sex and gender. She explains how feminist theory has in fact made transgender women their central object of enquiry for the last twenty years. The everyday aspects of transgender people's lives were however left out rendering the work to be of little benefit to the lives of transgender people (Namaste, 2009:11-28). Calhoun-Davis (2009) also adds that theories of gender fluidity in a way became reliant on transgender people's experiences and they become the ideal representation for gender disruption. She argues that theories with a focus on the "creative agency of individuals" or the fluidity and diversity of gender may undermine the hegemonic power relations in place (Calhoun-Davis, 2009:98-101).

Although much of the original work on transgender identity may not have had a great impact on the everyday struggles of transgender people, they did have a strong impact on the

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way transgender identity came to be understood. Queer theories were also of great influence to transgender studies, a discipline which has gradually been emerging which gives a voice to transgender people and academics. It is an interdisciplinary field which is as concerned with material possessions as representations of gender and is strongly linked with transgender activism. Transgender people themselves are increasingly being heard and marginalised voices are no longer pathologised and silenced. Stryker writes that in the past ten years academic work on transgender identity has undertaken dramatic changes where it started as an interest in abnormal psychology, went on to represent gender disruption and was mainly concerned with the symbolic to finally being concerned with the everyday realities of transgender lives (Stryker, 2006:2-4). However, the medical understanding of transgender identity has not been abandoned and transgender people continue to be diagnosed with a disorder and are pressured to undergo invasive treatments to better fit into the gender binary system. In a way an understanding of gender non-conforming behaviour has become polarised within academia as medical journals continue to write about "Gender Identity disorder" and the social sciences and transgender studies increasingly discuss transgender identity as a sign of gender variety, arguing for a more complex understanding of sex and gender.

In the following section I will show how identity is a topic of central concern to transgender people. Rather than transgender people being mentally "disordered", it is becoming increasingly clear that transgender people may struggle due to the social pressures of the gender binary system. As transgender individuals defy the notion of a solid gender, they may struggle with their own identity formation.

2.3 (Gender) Identity Formation: The Social Construction of Identity

Identity formation is a process which is of central concern to the lives of transgender people. Their identity and mere being disrupts the strict rules of the gender binary system and for these reasons they are punished in society. In this section I will discuss the strong connection between gender and identity by looking at post-modern conceptualisations of identity and I will explain how transgender individuals risk becoming "unintelligible" as they defy the available identity categories in place.

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The social construction and political implementation of collective identities have been of interest to social movement scholars for years (Hunt & Benford, 2004; Polletta & Jasper, 2001; Haunss, 2001). Collective identities can be formed and used strategically as a political tool as in the case of the lesbian and gay rights movements in the 20th century and more recently in the case of transgender identity. What is perhaps less often discussed is the way these collective identities influence the identities of individuals within them.

Identity tends to be discussed as something solid and internal to the individual, this especially seems to be the case with transgender people as they are seen as disrupting the strict rules of gender and rejecting the gender binary system (Calhoun-Davis, 2009:98-101). Michel Foucault and Judith Butler are among academics who have challenged such an understanding of identity and have highlighted the social power involved in identity formation. According to Foucault, what we can be as individuals is restricted by a "regime of truth". Specific terms are presented to us as the available norms through which self-identification can take place and this regime therefore creates our identity for us as other identities become unrecognisable and therefore impossible. Negotiating the "I" will therefore always be in relation to available norms. He goes on to explain that to question such a regime is to question the "I" because it was formed within that framework. Questioning the framework is to question one's ability to tell the truth about oneself or to give an account of oneself (Butler, 2005:22-23).

Butler has written extensively on gender identity and the impossibility of being "intelligible" without a solid gender. According to Butler there is a strong connection between the socially constructed nature of gender and that of identity. Individuals must have a stable sex, gender, sexual practice and desire in order to be viewed as having a solid identity. When this is not in place it disrupts the notion of a identity and individuals become "unintelligible". She therefore asks:

To what extent is identity a normative ideal rather than a descriptive feature of experience? And how do the regulatory practices that govern gender also govern culturally intelligible notions of identity (Butler, 2006[1990]:23)?

Butler understands identity as being performative rather than something which comes from within the individual. Identity is not something which is coherent and solid but simply an ideal which is controlled by the socially constructed and maintained notions of "intelligible" identities.

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By adding to Foucault's argument of the regime of truth, Butler explains that there can be a rupture in the recognised norms resulting in the institutionalisation of new norms (Butler, 2005:24). We have seen in the past how new terms and identities have been formed such as homosexuality, transvestism and transsexuality. If seen from the view of Foucault and Butler, these identities would not have been available in the past but have now become institutionalised to varying degrees. As the transgender term is so new, a transgender identity is one which has only been developing recently and is likely to be developing still.

Transgender individuals defy the very notion of sex and gender and from the view of Butler risk becoming "unintelligible". Transgender people do nevertheless take such risks and a number of studies have looked into the resilience of transgender people. Such literature has been growing in recent years within disciplines such as psychology, counselling and family therapy. Studies are repeatedly finding that access to a transgender community and a positive transgender identity are highly beneficial to the health and wellbeing of transgender people (Piper & Mannino, 2008; Singh et a, 2011; Testa et al, 2013; Riggle et al, 2011). This can be crucial to transgender people as they are at high risk of depression, suicide, discrimination and violence. Testa et al (2013) studied the influence of engagement in a transgender community on the resilience of transgender individuals in the United States and found that awareness of other trans people or having previously met a trans person had a significantly positive influence on early identity formation. Such individuals were far less likely to be fearful, have suicidal thoughts and were more comfortable with their own identity. However this was rare as only 14.5% of their 3087 sample had met others who identified as trans and only 17.5% had any awareness of transgender identity (Testa et al., 2013:41-42).

For an individual to be able to develop a transgender identity they need to know that such an identity exists which in this case was rare. The transgender identity is still developing and has perhaps not been fully institutionalised resulting in many individuals risking becoming "unintelligible" as they defy the strict rules of gender but are unaware of the increasingly institutionalised transgender identity. For an individual who feels their gender does not match that of "male" or "female", growing up and living life in a society where there is no transgender identity or transgender community could therefore be a struggle.

In this section I have looked at the impact of social forces on the conceptualisation of identity as well as touched upon the growing psychology and counselling literature stressing the importance of positive gender identity formation and access to a community. Although

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community and positive identity are increasingly seen as important to transgender individuals, these individuals are still treated by psychologists and psychiatrists as they are viewed as "patients" with "GID". In the following section I will discuss the controversies surrounding "The Diagnostic and Statistical Manual" and it's classification of "Gender Identity Disorder".

2.4 Transautonomy: The Diagnostic and Statistical Manual and the "GID" Debate

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is a manual published by

the American Psychiatric Association which offers standard criteria for the classifications of mental disorders. The manual includes the category of "Gender Dysphoria" or until very recently "Gender Identity 'Disorder"8. The placement of gender non-conforming behaviour in the "DSM" has been debated ever since it was first placed in the manual as "Gender Identity Disorder in Children in 1980"9. In this section I will discuss some of the reasons for this debate and the complex issues at stake.

The "DSM" could be described as the clinical bible of the psychiatric, psychological and social work fields. It has however been severely criticised for being arbitrary and contributing to the pathologisation of human diversity. The psychiatric field has a long history of diagnostic classifications that pathologise diversity in the realms of race, ethnicity, gender, class, disability and sexual orientation. The "DSM" is not a static document but a manual that is influenced by its time and is therefore constantly evolving and changing. Many of the diagnoses surrounding gender and sexuality in the current "DSM" are the legacy of early explorations into human sexual deviations from what was assumed to be "normal" and "common" at that time (Lev, 2008:36-38).

The "GID" diagnosis was controversial from the start and has been a topic of constant debate. Baril & Trevenen (2014) list the various debates around the subject and divide them mostly into three groups. These range from those who have a more conservative view and want to keep the diagnosis as a mental disorder, those who are more pragmatic and want to adapt it and create a balance where treatment can still be accessed but stigma of a mental

8_{American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (5th ed.), 2013,}

Arlington, VA: American Psychiatric Publishing.

9_{American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (3rd ed.), 1980,}

Arlington, VA: American Psychiatric Publishing.

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disorder is removed and finally abolitionists who want to remove it completely from psychiatric categories (Baril & Trevenen, 2014:397-398).

Lev (2008) is among those who sees any diagnosis of transgender people as severely problematic. She explains how the "GID" diagnosis pathologises different gender expressions and leaves little space for gender diversity. Individuals are diagnosed based on how "male" and "female" their behaviour is which reproduces essentialist if not sexist ideas of gender. Those who do not fit into stereotypical notions of masculinity and femininity are therefore excluded. This is especially the case with individuals who feel their identity does not fit into the gender binary of man and woman (Lev, 2008:45-46). By treating transgender people as though they have a disorder, "patients" are in some cases able to access hormones and surgery but the whole system gives weight to ideas which are on a larger scale damaging to gender variant individuals as transgender individuals are deemed "ill" or "wrong" and the gender binary system of male and female, masculinity and femininity are reified (Langer & Martin, 2004:11-12; Meyer-Bahlburg, 2010:463; Winters, 2008:72).

Transgender people have in recent years increasingly challenged the notion that their gender identity makes them disordered and in many ways their human rights efforts resemble the debate which led to homosexuality being removed from the "DSM" in 1973. However, this issue is not as straightforward and even those who want the diagnosis removed from the "DSM" acknowledge the importance of accessing medical treatment. Removing the disorder from the "DSM" could threaten the access to hormones and surgery which is vital to many transgender people (Meyer-Bahlburg, 2010:463; Sennott, 2011:97-98). The issue is therefore very complex as academics, medical professionals and transgender people themselves debate whether the diagnosis of "GID" is beneficial to transgender people or detrimental to their human rights.

Butler (2004) has addressed the complexity of this debate, seeing the main issue at stake being what she calls transautonomy. On the one hand the diagnosis can help transgender individuals achieve their goals by accessing hormones, surgery and a better legal status by receiving support from the medical establishment. On the other hand those who want the diagnosis removed from the "DSM" completely want to live in a world where they are not viewed as "ill" or "wrong", a change which also would increase their autonomy. Because of this complexity, she argues, we need to understand transgender individuals lived experiences as it can be a matter of life and death whether transgender people access medical

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treatment but also whether the stigma and prejudice of the diagnosis remains (Butler, 2004:77-78). The situation is therefore a double edged sword as both options can be both helpful and detrimental to the lives of transgender people.

The complexity of the debate has led many transgender activists to simply accept a "least of all evils" approach by calling for an adaptation of the diagnosis in the "DSM" to alleviate the stigma that accompanies being labelled with a disorder (Sennott, 2011:97-98). This was among the reasons "Gender Identity Disorder" was replaced with "Gender Dysphoria" in the most recent version of the "DSM". Gender Dysphoria is characterised by a strong desire to be treated as the "other" gender or to want to change one's sex characteristics and a strong conviction that one has feelings that are typical for the "other" gender10. Although some might not want the diagnosis in the "DSM" in the first place, "Gender Dysphoria" might be seen as a step forward for those who saw "GID" as pathologising transgender people. The placement of Gender Dysphoria in the "DSM" does in some countries secure equal access to medical treatment for all transgender individuals. If gender non-conforming behaviour is seen as part of human diversity and a choice it might be difficult to justify the coverage of health insurance of such invasive medical treatment. If the diagnosis were to simply be removed, health insurance would perhaps no longer cover the cost of hormones and surgery and such treatments would become unavailable to those who could not pay for them. However transgender people are still being diagnosed by medical professionals who rely on notions of the gender binary system so the improvement involved in such a new diagnosis is questionable (Meyer-Bahlburg, 2010:464)

As I have shown this debate is complex and there is no straightforward answer about the way treatment for transgender people should be arranged. As this debate has to do with matters that so strongly affect the lives of transgender people, it is important that transgender people themselves are able to influence such decisions. Transgender people are increasingly becoming more visible and are able to take part in such debates which is an important step in the right direction. In the next section I will discuss the Icelandic context and show how transgender people have for years been hidden but are increasingly stepping forward.

10

American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (5th ed.), 2013, Arlington, VA: American Psychiatric Publishing.

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2.5 Transgender in Iceland: A Hidden Population

In this section I will make a short overview of the type of legal rights and discourse surrounding transgender people in Iceland and the way this developed in the last two decades. I will show how transgender people are increasingly becoming more visible and are now more than ever voicing their opinions and concerns with the way treatment has been set up.

It would seem that transgender people's lives were for long hidden in Iceland and little was known about the phenomenon until 1996 when medical treatment of transgender people became available11. Up until that point little attention seems to have been given to the issue although on rare occasions newspaper articles had been published on the topic including an anonymous interview from 1994 with a transgender woman explaining the phenomenon and the lack of treatment in Iceland12.

In 1996 the Director of Health [Landlæknir], Ólafur Ólafsson decided to look into the issue as he believed denying individuals medical assistance to be an illegal act. A decision was made to establish a special team in the hospital which would have the role of diagnosing and treating individuals with "GID" and that the treatment would be covered by health insurance13. The treatment would be in the form of psychotherapy, hormone treatment, a "real life test" where the patient would have to live as the "sex they were changing to" and finally a "sex change operation" (kynskiptiaðgerð) as it was known then, was the final stage. Following treatment patients would be able to change their sex and name in the National Registry14.

Although this development was important, this was the only help available to transgender people in Iceland. The treatment started slowly as only around 1-2 people a year contacted the medical team for help. The national Gay and Lesbian organisation, Samtökin 78, did not view transgender issues as part of their focus at that time although then manager Hrafnkell Stefánsson admitted the organisation had been contacted on several occasions by

12_{Tíminn, Varð að gerast Svíi til að fá kynskiptiaðgerðina, 12.3.1994. Retrieved from:}

http://timarit.is/view_page_init.jsp?issId=281977&pageId=4075361&lang=is&q=kynskiptia%F0ger%F0%20A nna%20K

13_{The Ministry of Welfare, Heildarlöggjöf um málefni transfólks á Íslandi fagnað, 5.7.2012 Retrieved from:}

http://www.velferdarraduneyti.is/radherra/raedur-og-greinar-GH-velferdarradherra/nr/33458

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individuals trying to seek help15. No organisation representing transgender people existed in Iceland until 2007 when "Trans Ísland", was founded. The organisation was relatively quiet at first and it was not until much later that any collaboration between the two organisations started to take place, or around 201116.

It was in that same year, in 2011 that the Ministry of Justice and Ecclesiastical Affairs [Dóms- og Kirkjumálaráðuneytið] received a complaint from a transgender woman who had been denied a name change as she had not had gender reassignment surgery and was therefore by law still a man. She had however in her own account "lived socially as a woman" for 12 years. The complaint eventually resulted in the decision to allow the individual a change of sex and name in the National Registry as denying her that change was seen as a violation of privacy. In a way this event seems to have set things into motion as it resulted in the re-evaluation of the laws in place and in 2012 a comprehensive policy for the rights of transgender people in Iceland was passed in Parliament17. In 2013 it further became illegal to discriminate against individuals on the basis of their gender identity. This was a milestone for transgender people as they now had the same legal rights as other minority groups18.

Not only were the rights of transgender people now increasingly shown an interest in Parliament but the media has also started to show an increased interest in the topic in recent years. The visibility of transgender people in the media has without a doubt risen as a number of news articles have recently been published where transgender people tell their life story19. One of the most clear changes in the way transgender people are portrayed in the media is the media's gradual adoption of new terms for transgender people in recent years. In the past the word "kynskiptingur"' was used for all people who "changed their sex". The term could perhaps be translated as "sex switcher". The media have gradually stopped using the term in recent years following pressure from LGBT and queer organisations which described it as

15_{DV, Kynskiptingur í kvennaklefanum, 15.1.2005. Retrieved from:}

http://timarit.is/view_page_init.jsp?issId=349116&pageId=5496774&lang=is&q=Kynskiptingur

16_{Interview with Anna Margrét Grétarsdóttir, 19.3.2014, Reykjavík, Iceland; Interview with Örn Danival}

Kristjánsson, 24.3.2014, Reykjavík, Iceland; Interview with Ugla Stefanía Jónsdóttir, 20.3.2014, Reykjavik, Iceland.

18_{Alþingi, Frumvarp til laga um breytingu á almennum hegningarlögum, nr. 19 12. febrúar 1940, með síðari} breytingum (mismunun á grundvelli kynvitundar og viðbótarbókun við samning Evrópuráðsins um

tölvubrot)2013-2014. Retrieved from: http://www.althingi.is/altext/143/s/0112.html

19

Interview with Anna Margrét Grétarsdóttir, 19.3.2014, Reykjavík, Iceland; Interview with Örn Danival Kristjánsson, 24.3.2014, Reykjavík, Iceland.

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derogatory and negative, resulting in the word mostly being replaced with the terms "transfólk", "transkona" and "transmaður", meaning literally trans people, trans woman and trans man20. One of the country's leading news websites also ran an online show in 2012 about the lives of transgender people called "Trans" where a number of transgender people were interviewed and discussed their transition21.

Iceland has clearly come far in the last few years when it comes to the recognition of the rights and needs of transgender people. The medical discourse however seems to still be powerful although an increasing interest in shown in transgender people's own lived experiences and understanding of their gender. Such portrayals are important as they increase knowledge and understanding about the lives and experiences of transgender people and give more weight to a non-medical understanding of gender diversity. The important work being done by "Trans Ísland" and "Samtökin 78" also gives such minorities a stronger voice and helps create a stronger collective identity.

2.6 Conclusion - Moving Debates Forward

The status of transgender people's rights are complex as a disorder diagnosis can further victimise transgender individuals but also offers, in some cases, access to medical treatments which can be of vital importance. The question whether the placement of "Gender Identity Disorder" in the "DSM" has been beneficial or detrimental to the rights of transgender people has been strongly debated for decades and it is clear there is no simple answer about the way treatment should be set up.

In this chapter I have explored the historical processes behind the current status of transgender people's human rights. By analysing the history behind the treatment of transsexual individuals, a better understanding can be gained about the current debates surrounding the "GID" diagnosis. Essentialist understandings of transgender identity have increasingly been challenged by transgender authors who call for a more fluid understanding of gender identity. Post-modern theories of sex and gender were important to the development of new understandings of gender diversity and came to strongly influence

20_{Fréttablaðið, Notkun orðsins þykir særandi, 29.10.2010. Retrieved from:}

http://timarit.is/view_page_init.jsp?issId=323796&pageId=5086399&lang=is&q=transf%F3lk

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transgender studies. Such an understanding however has caused a clash with the medical conceptualisation of "Gender Identity Disorder" resulting in such treatment being contradictory to the growing literature on transgender identity.

Post-modern theories of the strict nature of identity formation can help shed a light on the struggle of transgender individuals. It is increasingly becoming evident that identity is a concept of central importance to the struggle of transgender people and by increasing awareness about transgender identity, the struggles of gender variant individuals may be combated. Such knowledge has been developed following studies where transgender people are able to tell their stories and their life experiences. It is by giving a voice to transgender people that we may begin to work towards better solutions in the "GID" debate.

Finally I have discussed the context of Iceland and how transgender people were for long a hidden minority group in the country. Following the work of LGBT organisations, transgender awareness has increased fast which has resulted in the formation of important laws on the rights of transgender people, increasing the life quality of trans people in Iceland. By increasing an understanding of the lived experiences of transgender people and factors which play a role in improving their life quality, more informed policies can be developed. This, I believe is a process which already is taking place in Icelandic society and it is my hope that this thesis will be a useful addition to such literature. In the following chapter I will discuss participant's experiences of the help legally provided to transgender people which comes mostly in the form of medical intervention. I will show how participants had difficulties in accessing help and discuss what can be learned from their negative experiences of medical treatment.

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3. Transgender Care in Iceland: Medical Authority over

Transgender Lives

3.1 Introduction - "Disordering" Transgender People in Iceland

One of the questions I most wanted to answer when I began work on this thesis was how transgender people in Iceland experienced the medical treatment available to individuals with "Gender Identity Disorder". It soon became clear to me that the help provided was not adequate as it was rarely experienced as helpful. Although, the only help provided to transgender individuals, participants did not find communication with healthcare professionals useful and some had very difficult experiences. What was perhaps more surprising if not slightly frustrating for me was how unwilling some participants were to be critical of the process and how they still were content with the few services provided. Despite participants not finding communication with healthcare staff helpful, the type of support provided to transgender people in Iceland is among the best in the world and participants seemed to be aware of this. Transgender people are a highly vulnerable group and must in many countries endure prejudice and violence on the basis of their gender identity. Little information is available about the exact ways in which transgender people are treated at the National Hospital in Iceland and this information rarely comes from the point of view of transgender people. I therefore aimed to answer the question,

How is the treatment of individuals with "Gender Identity Disorder" at the National Hospital of Iceland experienced by transgender people?

As I have shown in the previous chapter, numerous academics have highlighted the social construction of sex, gender and gender roles. The placement of "Gender Identity Disorder" in "The Diagnostic and Statistical Manual for Mental Disorders" has therefore been highly controversial and has been criticised from the start. The help provided in Iceland is however solely in the form of medical treatment which has been provided since 1996. Hormones and surgery are covered by health insurance only if transgender individuals seek medical treatment and are diagnosed with a disorder. Although controversial, the diagnosis of "GID" and treatment does ensure such access which the majority of participants in this study found very important.

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Five out of six participants had undergone treatment for "GID" at the National Hospital and a semi-structured interview was conducted with a focus on participants' experience of the medical help provided. I further analysed policy papers and newspapers in order to find information about the history of the medical team and the treatment they provided. In this chapter I will discuss the main themes which arose from interviews combined with the information gathered from policy papers. I will begin by demonstrating the difficulties participants experienced when trying to access help and the lack of information available about treatment. I will then show that participants experienced a centralised power of one individual within the medical team and did not feel there was adequate transgender knowledge among the medical team. It became clear to me that participants' main reason for seeking help was to access hormones and/or surgery so the role of the doctors became solely the role of "gatekeepers". I will show how participants resented the power of the medical team and often did not feel they needed their help. Finally I will discuss participants' negative experiences and show that the main assistance provided to transgender people should not be provided by specialists in psyhiatric disorders.

3.2 The First Steps: Difficulties in Finding Help

Although medical treatment for transgender individuals has been available for almost two decades at the National Hospital, the team was and is small and it would seem that the existence of such a team was not common knowledge among medical practicioners. Some participants found it difficult to access information about treatment and they overwhelmingly did not access this information from their GP's or other medical staff. Instead they had to rely on the knowledge of other transgender people to tell them how to book an appointment with the team and for those who did not know anyone who was transgender, this became a struggle. It took Ugla years to find any information or to access the help she needed. Ugla explained her feelings to her high school guidance counsellor who tried her best in seeking assistance for Ugla but was unable to do so. After seeing a number of psychologists and GP's, Ugla was nowhere closer to attaining information on treatment:

We [her guidance councellor] had been going to GP's and psychologists and others and they didn't really know where I should go or just what it even meant to be transgender so I kind of was repeatedly left with no answers and a

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considerable amount of time went by until I was able to reach another transgender woman who was able to tell me about this psychiatrist.22

In the end Ugla did not receive information about where to get help from healthcare providers as she explains how they had no idea how to help her or what it meant to be transgender. Instead she was finally able to get help after reaching a woman who herself had experience with the medical team. This seemed to be common among participants and what helped many a great deal was being able to go to meetings at relatively new organisation "Trans Ísland". It was at these meetings that they were able to access information about the medical team and their services, often from others who had undergone such treatment in the past. Two participants heard of "Trans Ísland" through a friend and it was only after meetings with them that they were able to ask another trans individual to call the medical team and as Kira explains this was easy as they all knew the psychiatrist in charge:

I went to a meeting and she called him [Guðmundsson] for me...she wasn't an employee, it was just one of those that...oh you know, they of course all know Óttar [Guðmundsson].23

Kira felt it was easy to access help once she had gone to a meeting at the organisation as it was there that she could meet numerous former "patients". It therefore saved her the difficulties of trying to find a transgender person to help her access treatment.

It did therefore appear to be very difficult to access the medical team at the hospital and little was done to ensure easy access to treatment until the recent transgender organisation started offering information. In order to reach the team, many participants had to know someone who had undergone treatment. Although the medical team in the National Hospital has been in place since 1996, it's existence is of little use if it is not accessible to those who need it. It also started to interest me that when discussing the medical team and difficulties in accessing it, participants rarely spoke of reaching a "team" but rather spoke of contacting "the psychiatrist", sometimes simply refering to him as "Óttar Guðmundsson". Although officially a team of specialist, it did indeed seem to be the view of all participants that Guðmundsson was the one in charge.

22_{Interview with Ugla Stefanía Jónsdóttir, 20.3.2014, Reykjavik, Iceland.} 23_{Interview with Kira Khashabi, 26.3.2014, Reykjavík, Iceland.}

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3.3 A Team of Specialists? Diagnoses and Treatment at the National Hospital

When discussing the medical team with participants, the name of Óttar Guðmundsson came up frequently. Guðmundsson is a psychiatrist who has been on the medical team to treat individuals with "GID" since 1996 and in 2012 he received a human rights award from "Samtökin 78", the country's leading LGBT organisation for being a spokesperson for the rights of transgender people in Iceland24.

Although a medical team to treat individuals with "GID" was put in the law in 2012, as was previously mentioned, a team had been in place since 1996. Little information is available on the exact ways in which treatment of transgender people has changed following the new laws. Discussion about the team caused some confusion during interviews as I began to get some contradictory information. Some participants informed me that no medical team had been in place until the 2012 law. Although all participants transitioned after 1996, two participants told me the role of diagnosing and treating transgender individuals had only been in the hands of psychiatrist Óttar Guðmundsson when they had undergone treatment. These comments came from participants who could be assumed to have good knowledge about the subject as they indeed had experienced the whole process and both hold high ranks within the leading LGBT and transgender organisations in Iceland. This is clearly stated by Ugla who started her transition in 2010:

2009, 2010 it's then when I first contacted another trans woman that had been in contact with this team, or this doctor that was doing it then...because you know when I started the process there was no official team, there was only one psychiatrist who took care of the whole thing.25

Being the chairwoman of "Trans Ísland" as well as working for "Samtökin 78", it is not surprising that Ugla seemed knowledgeable about transgender issues. She however had little knowledge diagnosis criteria of "GID" and she was unaware of the history of the medical team. The same goes with Örn who is currently on the board for "Samtökin 78". Örn had very little to say about the medical treatment at the National Hospital and like Ugla believed there had been no medical team in place until 2012:

24

Alþingi, Frumvarp til laga um réttarstöðu einstaklinga með kynáttunarvanda, 2011-2012. Retrieved from: http://www.althingi.is/altext/140/s/1174.html; Morgunblaðið, Mbl.is hlaut mannréttindaverðlaun, 2012, Retrieved from: http://www.mbl.is/frettir/innlent/2012/08/09/mbl_is_hlaut_mannrettindaverdlaun/

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Yeah you know, when I started my transition it was only Óttar Guðmundsson, this team wasn't in place yet so I kind of escaped having to...you know I know that today new trans people have to meet the whole team you know.26

Although Örn started his transition in 2011 when a medical team ought to have been working with transgender individuals, he felt lucky to have "escaped" being assessed by such a team.

Although the only information available would indicate that the diagnosis and treatment of transgender individuals was in the hands of a team of specialists, the impression most of my participants had was that Guðmundsson was in charge of the whole process, which would indicate that they only or mostly were treated by this one psychiatrist. Despite possible changes in the team following the 2012 laws, Anna still felt certain Guðmundsson was the one in charge:

He [Guðmundsson] was in charge of these issues and in fact still is, that is for these transgender people, and then we [her psychologist] decided that I should make an appointment with him and I let her know that I had gotten an appointment and she sent him her file about me.27

According to Anna her psychologist simply contacted Guðmundsson directly rather than the team and it seemed clear to them both that he was the one she should talk to in order to access hormones or surgery.

Although most participants seemed to be treated mainly by one individual, Inga interestingly was assessed by a gynecologist on the team. Inga transitioned in 2009, around the same time as Ugla but different to her was seen a few times by a plastic surgeon as well as a gynecologist:

...it was another one in that team called Arnar, a gynecologist, I went for an interview with him and he didn't think I was in the right place...that I was not the woman that I wanted to be so then it was just a meeting with Óttar

[Guðmundsson] once a month.28

Inga explained how following a single meeting, a gynecologist on the team decided she was not ready to receive treatment, interestingly describing it as her not being "ready to be a woman". It is difficult to imagine how a gynecologist would make such an assesment and it indeed seemed like Inga did not know what factors lay behind his decision. Although she would have prefered not waiting, she simply accepted his decision. I found it strange that

26_{Interview with Örn Danival Kristjánsson, 24.3.2014, Reykjavík, Iceland.} 27_{Interview with Anna Margrét Grétarsdóttir, 19.3.2014, Reykjavík, Iceland.}

28_{Interview with Inga Birna Kristrjánsdóttir, 20.3.2014, conducted via Skype, Reykjavík & Dalvíkurbyggð,}

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Inga was the only participant to mention being interviewed by this gynecologist and I was unable to access information about the role of each member of the medical team in order to make sense of this setup.

Ugla felt that the whole medical team consisted of individuals who did not have the right type of background to work with transgender people and felt that at least some individuals with adequate knowledge of transgender issues should be among the team of specialists. Although she felt some type of supervision was important she felt the team needed to include a representative of transgender people in the process:

This team which is in place, they need to change it or expand it because at the moment they only include so called specialists who in fact have no particular knowledge or experience, or you know they have not completed any type of education on transgender issues so we need to have representatives of transgender people in this committee so they are doing this more along side trans people.29

Ugla did not feel they had the right education as indeed their background is mostly in psychiatric disorders which she indeed did not feel she had. The view that the medical team did not have good knowledge of transgender issues was common among participants. Anna felt that very few people in Iceland knew anything about these issues and therefore felt incredibly lucky when after years of searching she found a psychologist who she felt was knowledgeable about the issue:

In 2006, February, that's when I met a psychologist for the first time who knew something about the matter, there are very few people who know anything about the matter, very few. She was really alone, really one of a kind in this field this

woman.30

Anna felt her psychologist was very special as she had knowledge about transgender issues which she felt certain was incredibly rare in Iceland. Her comments were surprising as she had started seeing this psychologist in 2006, when a medical team of supposed specialists in treating transgender people had been in place at the National Hospital for a decade, a team she was well aware of. She ended up seeing her psychologist for nine years and found their sessions incredibly helpful. She did however have to pay for all their sessions herself which she would rather do than go to the free sessions at the National Hospital. The reason for this was that Anna, in fact had already met with Guðmundssona few years prior and her sessions had been a great disappointment. The two appointments she had with Guðmundsson were so

29_{Interview with Ugla Stefanía Jónsdóttir, 20.3.2014, Reykjavik, Iceland.} 30_{Interview with Anna Margrét Grétarsdóttir, 19.3.2014, Reykjavík, Iceland.}