Gender Pluralism: How useful is it in supporting the health of transgender people?

Background
Gender pluralist theory was introduced in 2005 as a means of including all sex/gender identities within the realm of plausible identities – it includes unusual, marginalised, and fluid identities as well as those that are normalised and socially accepted. It was developed via an empirical project based in the UK which had contributors who self identified as transsexual men, transsexual women, gender fluid people, cross dressers, intersex people and androgynes. The aim was to find a way of thinking about sex and gender that foregrounded agency and self determination (whether living as male or female, or as another identity), as a basis for positive change. Gender and sex are seen as a spectrum and/or continuum, which includes male and female identities but is not limited to them. Personal choice and autonomy are central tenets of gender pluralism. From a social justice perspective, gender pluralism can be used to develop social models of transgender, gender-variant and intersex health and wellbeing, but the implications of it have not been fully considered. Gender pluralism sits alongside other approaches (degendering and extended ideas of gender) which can be used at the same time to understand sex and gender.

Aim(s)
This paper addresses gender pluralism in the light of recent and current changes to transgender healthcare, wellbeing, and related citizenship rights. It looks at developments such as the emergence of non binary identities, transgender activist moves to challenge the pathologisation of transgender, and changes to legislative and human rights frameworks in Europe that support greater personal choice regarding sex and gender. It also addresses some of the policy changes in healthcare provision and related policy sectors such as education. The paper recognises the differences between intersex and transgender identities, politics and activist agendas and it emphasises the importance of personal choice regarding gender for both these groups. It includes intersex because there are some shared agendas and issues, including in the areas of health citizenship, socially viable identities, and activist strategies. The paper discusses the importance of person-centred healthcare provision where personal choice is recognised, and some of the positive ways in which healthcare professionals and policy makers are responding to calls for change

Main Outcome Measures
The paper draws on six bodies of empirical material: The original UK 1990s study by Monro; three large published pan-European studies carried out by the Fundamental Rights Agency (2013, 2014, and 2016 - the lead author of this paper led the final analysis/report writing for the 2016 study); a qualitative study of non-binary trans identities in Norway (fieldwork conducted by Janneke vd Ros; analysis project underway by Monro and vd Ros); and finally initial findings from a European Commission funded study about Intersex Citizenship in Italy, Switzerland and the UK, led by Monro, with Daniella Crocetti and Tracey Yeadon-Lee (ongoing). The paper will provide an overview of developments in relation to gender pluralism, analysing the utility of the theory, possible ways of extending it, alternative approaches, and specific implications in relation to healthcare.

Methods
This is a conceptual and policy-related paper that is informed by a range of qualitative and quantitative studies and by policy analysis. It does not have specific outcome measures.

Results
The results of this paper concern the utility of gender pluralist theory for understanding trans and intersex peoples' healthcare and related aspects of policy and practice.

Conclusion
Gender pluralist theory is shown to be useful in supporting peoples' autonomy, self determination, and possibilities of considering different healthcare options. Utilising a social model of health, gender pluralist approaches locate the social marginalisation and stress that transgender and intersex people face within wider social forces. These include social traditionalism, religion-related prejudice, sexism, homophobia, biphobia and transphobia, body-prejudice, and bigotry from cisgender women who identify as feminist. A further set of barriers to the wellbeing of gender-diverse people concerns material factors, including economic barriers that prevent trans and intersex people from receiving the healthcare that some of them require.

There are tensions concerning gender-binaried approaches to healthcare in relation to the agendas of non binary-identified people, for example those sometimes espoused by trans men and women and by people who identify as having Disorders of Sexual Development (DSD). Gender pluralist theory finds means of addressing these, by emphasising peoples' autonomy to determine their own identities. Healthcare provision remains important in terms of psychological support for people dealing with minority stress and because of the hormone and surgical treatment that some trans and intersex/DSD people need. This needs to be combined with wider public education regarding gender variance and equality.