June is a propitious time to remember the history of lesbian, gay, transgender and intersex (LGBTI) people and their struggles to overcome discrimination and violence. One of the difficulties confronting them throughout the ages has been how the medical sector and related science view them, and how they should be treated by medical classifications. What is the situation today both locally and globally?
On the positive front, there is the medical issue facing the LGBTI community and everyone else in terms of their right to healthcare and related access. Thailand can be proud that it aspires to provide universal healthcare, whereby people can access the highest attainable standard of health, to the maximum extent of available resources.
The so-called 30-baht medical care system, with little to be paid for medical services as social protection for all Thais, has been recognised worldwide. Of course, there is room for improvement, such as making the system more efficient and more comprehensive in regard to gender diversity, but it is undeniable that medical care has been one of the key successes in policy planning and practice for the past two decades.
On another front, there is more room for debate. At the topmost level of the global health system, it should not be forgotten that even in the medical arm of the UN, gays and lesbians were seen as having a mental disorder till 1990. This embodied a pathological approach that viewed gender diversity as an abnormality, illness or disorder. The shift in mindset in the 1990s helped to "depathologise" in regard to gays and lesbians. Being gay or lesbian is simply a part of human biodiversity, not a disorder. In Thailand, it took the medical sector several years to adjust to that catalytic change.
Regrettably, over 60 countries still criminalise same-sex relations, particularly affecting LGBTI groups. The authorities of some countries still oblige parents to take their children to psychiatrists to change their sexual orientation and gender identity as part of "conversion therapy". Today, several countries are adopting laws against conversion therapy, and judicial intervention in a big Asian country has significantly prohibited such practice.
The medical approach towards transgender people has also been problematic. Previously, the International Classification of Diseases (ICD) under the World Health Organization, a UN agency, viewed transgender people as having a disorder.
Words such as "gender disorder" and "gender dysphoria" were used nationally and internationally to describe the group, compounding the stigma and discrimination against them. This was tantamount to the "pathologisation" of gender diversity emanating from the medical sector, shaping the public perception.
It was only in 2019 that the agency started to depathologise with regard to the classification of transgender people. The revamped ICD was to classify the group as not having a mental disorder but having an issue of "sexual health". This was an improvement, shifting from the previous pathology-based perception.
While this was a progressive stepping stone, some terms in the newer ICD are still ambivalent. For example, phrases such as "gender incongruence of adolescence and adulthood" and "gender incongruence of childhood" appear in the new text covering transgender people. On the one hand, these terms are justified by some quarters as enabling a diagnostic link to enable access to healthcare. On the other hand, from a less medical perspective, even the term "incongruence" might be seen to be stigmatising and discriminatory.
Interestingly, in Thailand, over a decade ago, a dilemma arose concerning the military conscription form which, at the time, classified transgender people as persons with a mental disorder. That classification was problematic, and there was a case before the Administrative Court to invalidate the terminology. The court agreed, and the military proposed to change the classification to "current sex status does not match that of birth". That description is more respectful of gender diversity.
Incidentally, when people undergo surgery to self-identify as transgender, the preferred term is "gender affirmation" rather than "gender reassignment".
There remains a challenging spectrum concerning intersex people who have particular characteristics, with sometimes both male and female organs. A United Nations-related description is as follows: "Intersex people are born with sex characteristics (such as sexual anatomy, reproductive organs, hormonal patterns and/or chromosomal patterns) that do not fit typical binary notions of male or female bodies." This group was raised as a key concern for discussion with the UN Human Rights Council last year and this will be continued this year.
The description found in medical practice is that the group has "disorders of sex development". From the angle of biodiversity, that term is not empathetic. Other terms, such as "variations of sex characteristics", "differences of sex development" or simply "intersex", are regarded as more balanced. With this group, it is important that doctors and parents refrain from deciding on behalf of the child at an early stage and subjecting the child to a medical procedure, choosing the sex/gender of the child. Such a procedure should be left to a later stage when the child has grown up, with due respect for the person's choice.
At a seminar with doctors in which this author participated in Bangkok recently, doctors said they advise parents should wait and not hasten the decision-making until the child reaches a suitable age. In a draft Thai law on this issue, 15 years old is the proposed minimum age for exercising the choice for the procedure.
Given that Thai doctors are at the forefront of universal healthcare with key contributions at the international level, they should leverage well to overcome the stigma and discriminatory remnants of medical classifications and procedures globally.
On a related front, another key initiative which Thailand can propel as a member of the UN Human Rights Council is to vote this year for the extension of the mandate of the UN Independent Expert on Sexual Orientation and Gender Identity as a global monitor of these issues. Without equivocation, the authorities should not abstain but vote "Yes", exhibiting exemplary leadership for progressive, gender-diverse transformative change.