The Catalan gender identity service

Transit is the official gender identity service in Catalonia, an autonomous region of Spain. Since its creation in 2012 in Barcelona, Transit has expanded to 7 cities, seen more than 5000 patients and trained an unknown number of healthcare professionals. The short history of the service is highly irregular. However, despite the unusual practices and the changes in gender-affirming therapy introduced by other countries, the regional Department of Health hasn’t shown any intention of investigating it.

From a legal vacuum to the gold standard

Learning about Transit has been anything but easy. There haven’t been any whistle-blowers, no testimonies from workers, patients or their families, and they’ve barely published any statistics of their work. Even FOI requests have received only partial replies. Luckily, the founder and director of Transit, doctor Rosa Almirall, considers it part of her job to educate the public about the “trans fact”. It’s enough to go through her lectures and interviews to put together the history of the service, including the bits that would cause a stir in any other branch of medicine.

It all started in 2012 when Almirall found herself with some free time and a new concern. The time came from a suspension from work after being reported for harassment by a co-worker. The concern was that trans people were discriminated against by doctors. It may be a coincidence, but she has said that she was allowed to start the service because her boss owed her a favour. A gynecologist by trade, Almirall was the district director of sexual and reproductive health in Barcelona when she decided to learn about gender identity. One would think that, as a doctor, she’d rely on the scientific knowledge, the papers and the experts behind them. Instead, she decided to approach the associations of trans activists, who complained that the official Gender Identity Unit (UIG) rejected those patients that didn’t fit the criteria for treatment. That’s when she decided to start her own gender identity service with more flexible criteria.

For the first four years, the service existed in a legal vacuum. It didn’t get any resources from the Department of Health, but it wasn’t shut down either. There, Almirall and her colleagues volunteered to do gynecology exams, write medical reports and prescribe hormone treatments. Some people questioned the legality of her actions, to which she answered “which law says that a doctor can’t give testosterone?”, as she recalls during a lecture. This situation lasted until 2016. Transit received too many patients and the volunteer work wasn’t enough. They decided to press the regional government to grant them official recognition and resources, with the help of two allies: the trans activists and the city council. The latter published a report about trans care in Barcelona, with the participation of the gynecologist. Two figures from this report are key to understanding how Transit works: until then, all the patients that requested a hormone prescription had received it, and 87% of them got it in their first visit. This report has the only published data that counts as some sort of quality assessment of their work, a collection of 16 gratitude messages from patients. They look like text messages addressed personally to the director, sending her hugs and calling her guapa, but don’t provide any information about healthcare.

On the other hand, the activists created the Platform to Trans*form Health. They also published a report that’s quite similar to the one from the City Hall, only more informative, since it has data on the evolution in the number, sex and age of patients over the years. The Platform filed an official complaint along with the proposal to make Transit the new official service and met with the Department of Health. As a member of the Platform recalls, the representatives from the Department agreed with them “after the first four sentences”. “We really couldn’t believe what was happening”, he adds.

The new model of trans* care

In 2017, the Department of Health published the “New model for trans* care”. The asterisk is used “to illustrate the great diversity of identities and perceptions of gender: transgender people, transexuals, cross-dressers, genderqueers, agender, non-binary, fluid, transvestites and so many others.” Like Transit, the new model follows a depathologizing model, also known as Informed Consent. The model emphasizes that trans people “do not suffer any pathology, but rather participate in the human diversity that conforms society. Therefore, the access to healthcare in the transition to their felt identity will not be, in any case, from the accreditation of a clinical diagnosis”. The Informed Consent model was proposed in opposition to “gatekeeping” care. The basic premise is that patients don’t need a diagnosis, or any kind of evaluation, to access gender-affirming care. The only requirement is to demand it and sign the informed-consent form.

The model omits that puberty blockers are an off-label treatment, and assures that their use is fully reversible. However, on the next page, it lists several permanent and temporary side effects, going so far as to say that their effect on the development of sexuality is “unknown”, and therefore hardly reversible. In this respect, Almirall has said that some people do “medical terrorism” by talking about the negative effects of hormone treatments. She admits that some of them are known, like a higher risk of breast cancer in men treated with oestrogen, and others are not, but it’s a matter of “taking the risk” while waiting for better studies.

The document states that an overseeing committee will be created to follow the implantation of the new model all over Catalonia, to update it and to evaluate its results. The committee was supposed to meet at least every three months during the (still ongoing) implantation period. I submitted a FOI request and received the minutes from the three meetings they’ve held since 2018, instead of the 15 that should have happened. In the first one, the three members from the Trans*form Health Platform, representing “the trans patients and their families”, complained about the presence of doctors in the meeting.

A family doctor that had worked in Transit for several years, a pediatric endocrinologist and a pediatric and adolescent psychiatrist were part of the committee. The Platform was particularly against the presence of the psychiatrist and announced that they wouldn’t attend the meetings as long as the doctors were there. Dr. Pàmias, the psychiatrist, argued that she was a representative of the Catalan Society of Child and Adolescent Psychiatry, which included psychologists as well. The committee, however, chose to listen to the Platform. From then on, neither healthcare professionals nor representatives from medical or scientific societies would attend the meetings. They could take part in specific work groups, but so far none has been created.

The Transit Report

Last year, the grassroots organization Feministes de Catalunya published a report using the data they obtained through a FOI request. The process took almost a year, and the organization is still negotiating with the transparency committee, as Transit claims not to have basic patient data. Even with the limited information they received, the conclusions are staggering. The report, titled “From adult men to adolescent girls”, showed that the number of girls between 10 and 14 that visited the service has increased by 5700% since 2015. The patient population is clearly segregated by sex and age, as 65% of the underage patients were girls and 69% of those above 30 were men. However, Transit didn’t provide any data regarding treatment trajectories, follow-ups or detransition, and it doesn’t record the sex of a growing number of patients.

The organization has sent the report to all the political parties, but no action has been taken. During an online presentation, a member of the Trans*form Health Platform dismissed the data, suggesting that a satisfaction survey would be far more informative. Almirall, who attended as well, spoke only through the Zoom chat, claiming that she didn’t recognize the data and that she wasn’t worried about the sharp rise in girls. “We’re talking, at most, about a 1 per 1000 teenage girls”, she said. At the end of the meeting, she typed political slogans before leaving – “United trans inclusionary feminists!!!” and “We will do it again!!!” (a motto that became popular in the nationalist protests of recent years). Shortly after, at a conference of LGBT scientists, she announced that Transit had already done a satisfaction study that would be published in 2023. It was an online survey that the director herself had sent by e-mail, asking current and former patients to respond as a retirement gift to her. 352 people replied to the survey, 98% of whom would recommend Transit to a friend.

No official response

In the past months, Feministes de Catalunya has organized three more presentations. The latest one was met with protests. One of the guest speakers, a homosexual man who is also a detransitioner, was called “crazy” and a “fucking faggot” by a demonstrator. Both the media and the government have largely ignored the issues with Transit. Only the Council of Medical Associations of Catalonia has expressed their concern about the findings of the report. The Council published a guidance document that emphasized the need for a multidisciplinary evaluation of the patients before starting gender-affirming therapy, as opposed to the new model of care.

Nothing suggests that the Spanish or Catalan governments are worried about the unanswered questions surrounding gender-affirming therapy. Last winter, Spain passed a gender self-determination law that mandated the depathologization of care. Several organizations of healthcare professionals showed their concern about the lack of scientific input for the legislation. Recently, an official from the Catalan Department of Health, speaking with the media on the Transgender Day of Visibility, remarked on their commitment to the depathologization, as they no longer speak of “dysphoria”, but rather of “people who desire transition”. When asked about the increasing number of patients, he responded that it was mostly due to an increase in medical provision.