“In there, I played the game. Everyone knows you have to, but not everyone can manage to do it because you have to remember your lies and answer the same questions again, and again, and again.”

It almost sounds like a line lifted from a dystopian novel. But Tomas, a transgender man who has chosen to remain anonymous, is talking about his mandatory therapy sessions with the state-run Sexologisk Klinik (sexology clinic) at Rigshospitalet in Copenhagen. Hormone treatment is only prescribed after a clinic psychologist gives their stamp of approval.

Tomas was born with a body that is classified as biologically female and needs regular doses of testosterone to align his physical body with his identity as a man. He doesn’t believe he needs therapy for this. He needs hormones. But in Denmark, ‘gender dysphoria’ – a clinical term delineating the experience of not identifying with the gender assigned at birth – is classified as a mental illness.

In the Danish medical lexicon, the official diagnosis is ‘transsexualism.’ This means transgender people fall within the exclusive remit of a clinic specialising in sexual dysfunction, and which also treats people suffering from sexual dysfunction, sexual deviants, and perpetrators of sex crimes.

Once, specialist doctors were able to describe hormone replacement therapy (HRT). But a 2014 health reform lead by the national health authority, Sundhedsstyrelsen, centralised all transgender treatment under the Sexologisk Klinik. According to a report released by Amnesty International Denmark last month, the clinic’s practices are violating human rights.

Amnesty is collaborating with the trans community on a campaign to change the health system and declassify gender dysphoria as a mental illness. They interviewed ten percent of the patients currently receiving treatment at the Sexologisk Klinik and found that very few had been approved for HRT, even after two years in the system.

According to campaign leader Helle Jacobsen, most trans people are subject to a series of degrading and humiliating medical evaluations where they feel constantly forced to prove their identity.

The campaign is critical, says Tomas, because “in there, it’s virtually impossible to win.”

Prove you’re trans

Annlize Troest, Acting Deputy Director at Sundhedsstyrelsen, says that the guidelines for transgender health were changed because they concluded that the treatments on offer to transgender patients at several private gynaecological clinics were uncoordinated and lacked uniform standards.

But the clinic’s approach has been slammed by the trans community as discriminatory and invasive.

Mark Nielsen, a 39-year-old trans man, has attended the clinic for two years. He says that it adheres to outdated gender binaries. As a departure point, the clinic assumes that patients are cisgender – meaning that your biological sex and self-identity match up – unless they can prove they are trans.

To satisfy the clinic’s understanding of what it means to be trans, individuals need to display hallmark traits of their asserted gender. That means acting stereotypically masculine or feminine, and answering ‘correctly’ to questions that range from bizarre, to the deeply invasive.

“On a scale of 1-10, how satisfied are you with your clitoris? Do you think about your parents when you masturbate?” says Nielsen, reeling off a list of questions.

“People look over when you say ‘clitoris’ out loud in a café,” he says gesturing at his coffee and slapping his hand over his mouth in mock horror. “But that’s the kind of stuff we’re being asked at the clinic all the time. And it’s completely irrelevant – my gender is between my ears, not my legs.”

Another time, Nielsen was asked his thoughts on modern dance and ballet.

“Because of course, ‘real men’ aren’t supposed to like dance. My psychologist also asked me if I perform more ‘male’ in bed. I retorted, ‘how do you perform more male in bed?’ I tried to make her come out and ask if I use a strap on, but she chickened out. She wouldn’t answer my question, even though I have to answer all of hers.”

Proving your identity at the clinic can feel like a rigorous exam, scrutinising a person’s personality all the way back to childhood.

“They asked my mother to come in and explain if I had a normal birth,” says Nielsen. “They made me bring in photographs of myself as a child – physical copies, because digital photos can be manipulated. I guess they’ve never heard of scanners.”

Playing the game

While Nielsen has seen no progress at the clinic, Tomas was approved for HRT after just two sessions. He thinks it’s because he had started taking hormones illicitly beforehand, which allowed him to ‘pass’ as a man. He also deliberately wore masculine clothes and pulled out his piercings before he went to meetings at the clinic.

“I knew what to say and how to play the game. And I lied. A lot. About being the kind of man that they thought I should be.”

Tomas also argues that patients must tread carefully within gender boundaries to get what they want.

“Don’t ever, ever say that you used to wear a dress, or that you’ve been sexual with boys. They’ll just tell you that you get turned on by wearing dresses or masculine clothes. Because they’re sex therapists, they think about it in terms of sex.”

Under the new guidelines set by Sundhedsstyrelsen, a multidisciplinary team must carry out the treatment of transgender people. This includes psychiatrists, plastic surgeons and gynaecologists with knowledge of transgender issues.

According to Troest from Sundhedsstyrelsen, the Sexologisk Klinik was the only medical centre which applied to treat transgender people under the new rules, and was found capable of the job. But Nielsen scoffs at the idea that the clinic’s practitioners are gender experts.

“Feminist discourse states that cisgender people don’t have to be traditionally feminine or masculine. Girls can play with cars, and men can be hairdressers. But if you are trans, that’s a different story.”

Nielsen’s psychologist once suggested that he was sexually attracted to children and animals, because he defined himself as pansexual – someone who doesn’t limit their partner to any specific biological sex or gender identity.

“She had to look up the word on Wikipedia. And this is someone who is writing her PhD on gender theory.”

Both Nielsen and Tomas say they are privileged because they already have access to their hormone prescriptions. But other trans individuals are not so lucky, says Nielsen.

“Those people are afraid that if they do not comply and don’t answer these horribly invasive questions about their sex lives, then their cases will be rejected. So they have to play along.”

According to Tomas, playing along takes a profound emotional and mental toll.

“My biggest fear was that I would end up believing what they tell me, or what I tell them, and that I would become someone else. The state is killing my identity. It may sound extreme, but that is exactly how this system works.”

Health risks

Nielsen discovered that he was transgender five years ago and was referred to a specialist. He tried out different kinds of testosterone treatment and settled on a type that produced the fewest side effects. All without any gruelling psychological evaluations.

“I didn’t have to prove anything. He trusts his patients. If you say you’re transgender, you’re transgender.”

Tomas’ story is rather different. Before his official prescription was granted, Tomas hunted for black market hormones. In 2014, he lined up an appointment with a gynaecologist renowned for trans treatment, but before they could meet, the doctor had to stop seeing trans patients due to the impending reform.

Tomas had heard that the Sexologisk Klinik was notorious for prolonging trans cases. He felt there was no choice except to turn to the black market.

“Mentally, I had already begun to transition ahead of my body, and I suddenly couldn’t bear the thought of not having testosterone.”

HRT is sensitive to dosage and can pose side effects, so recipients should be monitored with regular blood tests. Tomas ended up sharing a prescription with a friend, but lied to his doctor in order to receive a blood test, saying he had obtained the testosterone abroad.

“I felt like I had to choose between my mental and physical health.”

Nielsen’s doctor is allowed to continue filling his old prescription. But if his doctor retires, Nielsen has no choice but to rely on the clinic. He also needs the clinic’s permission to have a hysterectomy. This is vital because taking testosterone may increase his chances of ovarian cancer. But after two years at the Sexologisk Klinik, Nielsen is yet to get the green light on the surgery.

“I could die waiting because they won’t take something out of me that I don’t need or want. I know one transgender man dying in hospital right now. They found out too late.”

Mental illness

Admitting to any form of mental illness could also stall your case at the Sexologisk Klinik, says Nielsen.

“For cisgender women, if you want hormone treatment and you have depression, those would be treated like separate issues. But If I want hormone treatment and I have depression, I’d be told to deal with the depression and come back.”

He uses the example of a 19-year-old trans man who suffered from anxiety, after experiencing transphobic violence in his small town. The man was rejected from the clinic three times and told to return when he stabilised. Nielsen says the clinic didn’t consider the possibility that withholding treatment contributed to his mental anguish.

Tomas also worries that trans people suffering from mental illnesses won’t get the necessary help for their psychological issues, because they dare not speak up in the clinic.

“The person deciding what you can do with your body medically should not also be your psychologist. It discourages you from being honest. In fact, I’d say you’d need private therapy after your ‘therapy’ at the Sexologisk Klinik,” he says, adding that gender-confused teenagers are particularly vulnerable in the clinic’s environment.

“It’s such a confusing phase to go through and you need to discuss it in a healthy environment with a gender expert. I would say it’s impossible to figure out your gender in the clinic. It feels like you already need to have all the answers.”

In 2014, a 19-year-old transgender woman, legally known as Jannick Norsted, hanged herself. She had been rejected by the Sexology Klinik for being too young. Nielsen holds the clinic accountable for turning its back on a patient.

“They told her to come back at 25, some arbitrary number. They have blood on their hands.”

One step forward, two back

Jacobsen from Amnesty feels that when it comes to trans rights, Denmark took one step forward, and two steps back. Prior to the reform, Denmark was the first European country to allow its citizens to legally change gender without a clinical diagnosis. This allowed people to self-determine their legal name, or decide what gender is displayed on their social security card.

But after the Sexology Clinic was given the monopoly on transgender treatment, trans people lost their right to self-determination. Jacobsen says the system is discriminatory and threatens Denmark’s international reputation as rights-progressive.

“The health reform doesn’t correspond with Denmark’s general approach to LGBT rights. We’re facing international scrutiny. At the UN periodic review, Holland and Uruguay asked us about this point.”

Tomas is more cynical, however.

“I think Denmark is really good at promoting itself as a nice country, but on so many levels, we’re not. We do it on so many levels with LGBTQ issues, tightening our borders, our treatment of refugees…we have problems with racism and feminism.”

Missing trans voices

Both Nielsen and Tomas agree that there’s a lack of trans visibility in Denmark. There are very few trans voices in the national conversation, says Tomas, which further cements Denmark’s binary ideas about gender and nurtures transphobic attitudes.

While he’s pleased that the media storm around Amnesty’s campaign has drawn attention to the cause, he accuses national newspapers and the state broadcaster, DR, of representing trans people one-dimensionally.

“The national coverage of the campaign has been really shitty. Most of the time, the media makes us feel like circus freaks. ‘Oh, trans people are being asked about masturbating,'” he says, mimicking a reporter. “Just like in the clinic, the sex element is all they care about, not our human rights.”

He also says trans people are often reduced to mere test cases, or expected to exclusively discuss their physical experiences.

“I’d also like to discuss rights. Or I’d like to talk about the many nice and exciting things about being trans. But the media sees Amnesty as the experts, and we trans people are just the samples.”

Tomas says it can be hard to muster up the necessary emotional energy to speak for trans rights and make people aware of the challenges.

“Trans people can be really vulnerable and many of us can’t even get out of bed because it’s so tough to be out there. Now we have to go talk to all these fucking journalists proudly waving their LGBTQ flags and congratulating themselves for discussing these issues. And we have to sit there, and smile, and thank them for inviting us to talk.”

Nielsen says that the struggle for trans people often goes unarticulated, but is ever-present.

“I am just a tired, old man. I drink coffee, vacuum, and go to the movies. I am just as boring as everyone else. But I face a whole lot of problems cisgender people don’t have to deal with. There’s an internal struggle between your mind and body, a possible external struggle with your family or workplace, or when walking down the street holding your boyfriend or girlfriend’s hand.”

Meanwhile, Nielsen agrees that participating in campaign publicity is not always easy for him, but he’s resolved to push on.

“If I can do anything with my name, my face, via photos and interviews, I will. Because I will not have another trans man jump out the window while the parents wonder what the hell happened,” he says.

“No more deaths. Not on my watch.”

Possible changes ahead

Following the release of the Amnesty report, Troest says Sunhedsstyrelsen has met with the Sexologisk Klinik and has planned meetings with a number of interested organisations with a view to alter the guidelines.

“The clinic has taken this very seriously, and will look into their questions and procedures for improvement.”

But even if the current system is altered and the mental illness classification is abandoned, Tomas says that trans health still has a long way to go.

“As far as I know, there has been no long-term research into HRT and its long-term effects anywhere in the world. I think the longest test period is five years. So nobody knows what is going to happen to us. We need medical staff, administrators and doctors who are specially schooled in trans treatment.”

Nor does a new health system mean that Tomas is relieved from the burden of trying to play by the rules of a cisnormative society. He says that transphobia goes to the very heart of Danish society, beyond its health institutions.

“Denmark’s biggest issue is the way we talk about gender. There’s a conservative way of thinking, and we need to open up the conversation before we can really help trans people. Even the terminology of ‘gender dysphoria’ doesn’t make sense. If society were more transfriendly, we wouldn’t feel ‘dysphoric.’ For now, it feels like there is a big fear of people who are gender non-conforming, it makes people uncomfortable.”

He flashes a smile that is both wry and weary.

“Luckily – and sadly – I know how to play the game. Not just inside the clinic. But out there in the streets.” M