“THIS IS not my body; I have to let it go.” This line from the film The Danish Girl (2015) perfectly captures the sentiment of many transgender people who feel that they are living as the wrong sex. The Danish Girl tells the life of Lili Elbe, a Danish transgender woman in the early 20th century. In the movie, Lili undergoes numerous psychological treatments in an attempt to identify her “problem.” At one point, she is even locked in an asylum against her will. 90 years have passed since Lili died during one of the very first sexual reassignment surgeries; nevertheless, many transgender people continue to face similar difficulties today. In Korea, transgender people encounter much societal prejudice, which further corners them into the peripheries of society. Such discrimination leads to tangible difficulties for the Korean transgender community, including problems related to the legal system and receiving proper medical care.
How to become “normal”
According to the 2014 Investigation of Discrimination Regarding Gender Orientation and Gender Identity*, transgender people are discriminated in school, the workplace, medical facilities, and even governmental institutions. Many transgender people choose to receive medical treatment to reassign their sex, as it is often the only way to escape such difficulties. According to the Key Results of the South Korean LGBTI Community Social Needs Assessment Survey**, transgender people undergo medical measures to resolve gender incongruence, to be socially identified as their own gender, and to receive legal sex change.
In an interview with The Yonsei Annals, H, a 21-year-old university student, explains the difficulties he experienced as a transgender man. “When I was in high school, it was mandatory to live in dorms. One day, I confided in my dorm supervisor that I was a transgender man—I thought I could trust her.” Things spiraled downhill from there. The dorm supervisor divulged H’s secret to the dorm dean, H’s homeroom teacher, H’s roommate, and his roommate’s homeroom teacher. This was all done behind H’s back. H recalls this memory with distress.“I was worried about what they would think of me... I even had teachers that I was not close to, and were unrelated to the incident, stop me in the hallway to mention it to me. The gossip only exacerbated as I later realized that my roommate was spreading false rumors that I liked her, and that she felt uncomfortable because of me.” When asked about how he is doing at university now, H explains that it is much better. “As soon as I graduated from high school and came of age, I started receiving hormone therapy. Now, since my voice is much lower and my physique more masculine, people naturally identify me as male.” Indeed, medical treatment for transgender people is important for the individuals’ social life. Moreover, it is a crucial requirement in order for them to legally change their gender.
The crack in the legal system
To change one’s legal gender, the individual has to write a gender correction application and submit it to the court that corresponds to their place of registration. If the court grants permission, the individual can submit the adjudication documents to their district office. In an interview with the Annals, Attorney Chang Suh-yeon explained why legal sex change is important to transgender individuals. “Things that come normal to cisgender people are, at times, serious barriers for those in the transgender community,” said Chang. Chang works at Gong Gam, which is a human rights law foundation that provides legal advice to the socially marginalized. “In their daily lives, transgender people may feel anxious about displaying their ID card; any process that requires identification is a struggle.” One example that Attorney Chang gave was the difficulty of identification at banks. They are also reluctant to vote because the sex indicated on the electoral administration document is incongruent with their appearance. This is because many transgender people only undergo aesthetic surgery to change their appearance, without getting organ surgery—a key qualification for legal sex change.
Legal sex change is important, and there is a way to achieve it. So, what is the problem here? The issue lies in the current criteria of the legal guideline. Currently, South Korea does not have a specific law pertaining to transgender people. However, since the supreme court’s decision to acknowledge legal gender change 14 years ago, respective courts are expected to follow the guidelines of the supreme court’s established rule. The supreme court’s established rules are as follows: the individual must be of age, they cannot be married, they cannot have underage children, they must have undergone full-transitional surgery, and the reason for legal gender change must not be for criminal purposes. Prior to March of 2020, these were “investigatory criteria,” meaning that all criteria had to be met. Since March, however, these have become “consultation criteria.” While this change means that the criteria imposition is somewhat eased, these are still key reference points for the judges. As there are no specific laws and only guidelines, the legal sex change depends heavily on the respective court judges—if they are lenient about the criteria, they are more likely to grant legal sex change. In contrast, if the judge is more conservative, they are more likely to dismiss the application.
The criteria themselves are also problematic, such as the criterion that requires “individuals to undergo sex reassignment surgery.” Not all transgender people want to have sex organ surgery as it depends on the degree of their gender identity disorder. In many cases, transgender people undergo aesthetic surgeries to be socially identified as their sex but are reluctant to receive sex organ surgery. Instead, they undergo medical services such as hormone therapy, chest and facial surgeries that change their appearance which allows them to be identified as the right gender. Nevertheless, because the established rule of legal gender change requires conclusive genital surgery, transgender people have to undergo this process that is costly, difficult to access, and dangerous. According to Attorney Chang, many countries ruled out sex reassignment surgery as a criterion because it is a violation of their constitutional rights. Chang added that the European Court of Human Rights ruled this criterion out as a violation of basic human rights. Yet, many, if not most, Korean courts require irreversible sex reassignment surgery despite the fact that medical treatment for transgender people in Korea is difficult to attain.
Korea’s medical refugees
Medical treatments for transgender people range from psychological treatment, hormone therapy, sex reassignment surgery, plastic surgery, and so on. While there are no strict governmental guidelines for those who want to have transgender medical treatment, patients are recommended to receive a diagnosis from a mental health professional to verify their condition and identify other possible metal health issues, such as depression or anxiety disorder. According to the World Professional Association for Transgender Health (WPATH), this assessment aims to verify “persistent gender dysphoria, capacity to make fully informed decisions, age of majority, and no significant mental health concerns.” After receiving the diagnosis, patients usually receive hormone therapy which will either feminize or masculinize their physique. Genital surgery is considered the conclusive treatment for transgender people***, which is why most physicians advise patients to undergo at least a year of hormone therapy to make sure that patients are fully aware of the implications of irrevocably changing their sex. Patients may receive surgery such as breast/chest surgery, genital surgery, and various aesthetic procedures.
The biggest problem is that there is no consensus on how to view transgender people in the South Korean medical community. In an interview with the Annals, Dr. Jeon Jae-woo explained that the orthodox view is that “gender dysphoria itself is not an illness; thus, the responsibility of medical institutions and professionals is to provide adequate care so that patients can lead a healthy life.” However, there are some medical professionals that interpret this notion of “healthy life” differently. To some, a “healthy life” is to not undergo hormonal or surgical treatment. Instead, they believe that the “adequate care” medical professionals should provide is to force patients to live as their inborn sex. Others may be averse to providing medical care because of their personal religious convictions says Dr. Jeon.
Because there is no unanimous view on how to view gender dysphoria, medical treatment procedures are not taught extensively in medical school. “When I was a medical student, gender dysphoria was mentioned briefly in the mental health section. It was only after years of experience as a doctor that I realized the need to provide proper health services to transgender people.” Dr. Jeon runs the Mu-ji-gae (rainbow) Hospital in Mapo-gu, which is one of the few queer-friendly medical institutions in Korea. He specializes in family medicine, but also provides hormone therapy to patients with gender identity disorder. “Unlike gynecology, pediatrics, gastroenterology, and other specific fields of medicine, there is no field that specializes in transgender issues,”explained Dr. Jeon. Thus, physicians voluntarily follow the guidelines set by the “Standards of Care” published by WPATH, which Dr. Jeon likens to a textbook. In an interview with the Annals, Dr. Choi Ye-hun adds that there are guidelines for transgender hormonal therapy published by the Endocrine Society clinical practice guideline, and other sources published abroad. Dr. Choi is a gynecologist at Salim Hospital located in Eunpyeong-gu. Salim Hospital is one of the biggest and most well-known medical centers in Korea that caters to transgender patients. Like Dr. Jeon, Dr. Choi provides hormone therapy to transgender patients, although Salim Hospital provides mental health counseling as well. While physicians that are open-minded to the transgender community are silver linings, their rarity indicates a fundamental problem within the medical community. Because there are no strict rules, guidelines, or regulations related to gender dysphoria, the possibility of receiving appropriate care is completely dependent on the medical ethics and values of individual doctors.
The “disease” that is perceived as a “lifestyle”
However, this uncertainty surrounding the transgender community is not an issue limited to Korea. Part of Korea’s problems lie in the fact that the international medical community is also in a gradual process of reforming how they view transgender people. According to the latest edition of the Diagnostic and Statistical Manual of Mental Disorder (DSM-5), transgender people are referred to as having “gender dysphoria.” Furthermore, the pre-released International Classification of Diseases (ICD-11)—which will come into effect in 2022—refers to this “condition” as “gender incongruence,” which differs from the current ICD-10 classification as “gender identity disorder.” The nuances of the changing terms reflect the medical community’s gradual rejection that being transgender is a mental disorder.
While declaring that transgender people are not mentally challenged might seem like a progress, many medical professionals—including Dr. Choi—are concerned about the implications. “If transgender people are no longer included in the ICD list, they would be unable to receive insurance for their treatments,” said Dr. Choi. For instance, in Argentina, sex change surgery is a legal right and is therefore treated by the public health insurance****. However, if “gender incongruity” is omitted from the ICD list and loses its diagnosis code, it would be difficult to provide insurance for any kind of transgender related medical treatments.
Despite using the ICD-10 diagnosis code that recognizes “gender identity disorder” as a disease, the Korean National Health Insurance does not cover any expenses for undergoing transgender medical treatment. In the eyes of South Korean society, transgender people are choosing a lifestyle. “The national health insurance can only be implemented for conditions that are unequivocally considered a disease,” remarked Dr. Choi. Thus, the government will not support transgender peoples’ medical fees as long as it is considered a non-essential treatment. For instance, the legitimate use for estrogen treatment in Korea is for menopause. This means that transgender women who are receiving such treatments to become more feminine do not qualify for state insurance.
As their medical expenses are not covered by the government, transgender people have to invest an exorbitant amount of money on medical services just to feel comfortable in their own skin. According to the Key Results of the South Korean LGBTI Community Social Needs Assessment Survey*****, female-to-male (FtM) surgeries cost an average of $1,750, while male-to-female (MtF) surgeries cost an average of $1,810. It is not just the surgical treatments that are economically draining. Because of the lack of medical professionals and facilities that cater to the transgender community, many transgender people have a hard time even accessing proper medical services. Patients who do not live adjacent to queer-friendly hospitals have to save up money just to see a doctor. Dr. Jeon mentions that he even had a patient from Jeju Island, who flew into Seoul for hormone therapy. According to the 2014 Investigation of Discrimination Regarding Gender Orientation and Gender Identity******, many patients face discrimination and are even denied treatment by doctors for being transgender. In such a hostile environment, patients have no other choice but to visit a queer-friendly facility. Those that cannot afford this journey often resort to self-administered hormone treatment. Dr. Choi explained that some patients have come into her office after years of self-administered hormonal treatment they had purchased online. While self-administered procedures are usually harmless, it is oftentimes difficult for patients to be aware of the necessary precautions. Study shows that patients who received hormone therapy from a medical professional, were significantly less likely to smoke during the treatment and less likely to reuse needles****.
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“There is a vicious cycle,” commented Attorney Chang. Changing one’s legal sex is important for transgender individuals to lead a normal life free of discrimination. Thus, individuals strive to receive sex reassignment surgery to fulfill the criteria for legal sex change. However, as transgender medical care is not covered by the National Health Insurance, they have to first secure money for the cost. What is problematic is that transgender people have difficulties finding employment to begin with. They usually have to settle for jobs that do not require identification screening such as day laborers or call center attendants. If they are lucky and meet an employer that is open-minded, they may be able to secure a job. Then again, as Chang points out, they are at the mercy of the employer’s benevolence, putting transgender people in a precarious position.
On one hand, we perceive transgender people as “abnormal.” On the other, we have placed so many obstacles in front of them, that the process of accessing society’s standard of “normality” is herculean. In commemoration of June pride month, take a moment to recognize our society’s rigged system that further marginalizes the transgender community.
*National Human Rights Commission
**Korean Gay Men’s Human Rights Group Chingusai
*** The World Professional Association for Transgender Health
*****Korean Gay Men’s Human Rights Group Chingusai
****** National Human Rights Commission
*******Transgender People’s Access to Health Care in Korea
*Disclaimer: this article's title is listed as "The Toll of Becoming~" in the Contents page of the printed issue. However, "The Cost of Becoming~" is the correct title of the article.