1

Transgendered citizenship in the Norwegian welfare state:

The non-recognition of diversities, or
Gender Equality for all kinds of gender?

Janneke van der Ros,

Assoc. Prof. and Senior Research Fellow
University College of Lillehammer and Regional Centre of Equality, Hamar
Norway

Paper presented at
The European Conference on Politics and Gender,
Organized by the Standing Group on Gender and Politics,

Section: LGBTQI Rights,

Panel: Sexuality and Politics Sexual/Gender Diversities and Assimilationism/Radicalism
Debates

Barcelona 21-23. march 2013

Abstract
The article assesses some central gender equality principles in Norway for people in the transgender
specter by comparing access to transrelated health care and recognition of gender identity in the
legal system for different groups of transgender people: transsexual persons, i.e. trans people
diagnosed with the gender identity disorder transsexualism, and trans people experiencing gender
identity problems, but without a diagnosis. With regards to (trans-) gender equality in the health care
sector, trans people without the diagnosis have no access to gender identity related health care
services in the public health care sector. In the legal system, official recognition of a trans persons
gender identity and providing identity papers congruent with the persons gender identity and
gender expression, is conceivable only for those who accepted and indeed have undergone
irreversible sterilization. Second, gender identity and gender expression are not part of either gender
equality or anti-discrimination legislation, so transgender individuals are unprotected against
discrimination on these grounds. These cases show, the author argues that gender equality policies
seem primarily intended for women and men as understood in a (heteronormativ) binary gender
model. Transgendered people who are or act too different from the gender binaries in the model are
not granted equal citizenship rights and recognition.

Introduction

Equality politics is about handling differences how does a government assure that difference and
diversity among a nation/states citizens is taken into account and that people different from one
another in a number of central ways are treated similarly. In this paper, I argue that Norwegian
gender equality first and foremost is designed for 1) women (and men) well settled in the
heteronormativ binary gender model, and 2) for those in the GLBTQI specter who are assimilated
within this model. Those different from the so-called ordinary women and men gender types
challenge the regular order when demanding recognition for a variety of different gender identities
and claiming inclusion in the state-feminist gender equality project. I refer here to recognition as
understood by political science scholar Nancy Fraser (2003). Similarly, other citizens different from a
white, middleclass, non-Christian, able-bodied, and preferably urban women and men citizen model,
may experience failures of recognition and redistribution policies as well. In this paper though, I
focus predominantly on transgender peoples experiences with a) the Norwegian welfare state with
regard to access to health care services related to their gender identity dysphoria, and b) the noninclusion of transgender issues in Norwegian gender equality legislation, such as anti-discrimination
on grounds of gender identity and gender expression, and access to identity papers congruent with a
persons gender identity and gender expression.
I will present and discuss some results from recently undertaken research on Norwegian transgender
peoples living conditions and life quality in a (trans-)gender and politics perspective: asking how
the state handles/reacts to (trans-) gender differences, i.e. differences between all kinds of gendered
people. What would gender equality policies look like if gender diversity would be recognized and
taken into account in the policy processes?
In order to illuminate my argument, I make a distinction between trans people with the diagnosis of
transsexualism, F64.0 and those without this diagnosis, and discuss some of the implications of this
distinction in the Norwegian welfare state. Gender, gender identity and gender expression, being the
central theme in trans*gender peoples life, I reflect about different meanings of doing gender,
doing gender differently and doing different genders for trans*gender and cisgender individuals,
before showing empirically some of the failures of the Norwegian gender equality project with
regard to those being different from, and of which many choose to stay different from women and
men within the binary gender model.

The trans*gender specter troublesome and troubling terminology

The terminology trans*gender specter is used to imply all those who experience or have experienced
discomfort due to a mismatch between the sex ascribed at birth (and recorded in the birth protocols
and subsequently in all kinds of ID papers, social security numbers, passport etc.) and a persons selfidentified gender. Simply stated (as far as simplicity is possible): trans*gender is about incongruence
between a persons bodily (or anatomical) sex and this persons mental (or psychological) gender, i.e.
her/his/hens gender identity. These incongruences arise because both biological sex, and the social
construction gender traditionally have been considered as dichotomous constructions (Beemyn &
Rankin 2011:19). In the specter we include the experiences of people with nonbinary identities;
gender nonconforming, gender diverse, gender variant people, gender rebels, transsexuals, crossdressers, gender queers and what other labels individuals choose to describe their gender identity or
identities. There are no neutral terms related transgender people (Valentine 2007); classification and
naming is always politically charged (Beemyn & Ranking 2011:16). My reason for distinguishing
between transsexuals and others with transgender experiences is to examine and question the basis
of Norwegian gender equality policies. The first category, transsexuals, designates those who have
been diagnosed with transsexualism; F64.0 in the WHO International Codes of Diseases system (ICD
10) and the second group are those who are not recognized as having a severe (enough) gender
identity disorder or dysphoria and therefore do not qualify for treatment. In Norway this distinction
is decisive for the recognition of a medically important illness, ensuring access to lifelong treatment
in the public health sector (and thus publicly financed). Within the first category, the transsexual
persons, the gender variety corresponds with the binary model: ones gender identity is opposite
ones bodily sex. The conventional narrative for patients at the hospital diagnosing and treating the
disorder (Section of Transsexualism at the Oslo University Hospital, which is the one and only
hospital in Norway certified to offer diagnostic examination, and if the patient qualifies, to provide
treatment) is that a person with transsexualism is born in the wrong body or born with the wrong
sex, and the only solutions to the disorder is to correct the body (medical terminology!) with
hormonal and genital interventions to establish congruence. After these treatments, including
irreversible sterilization, the birth certificate and all other id papers will be adjusted accordingly (to
provide the right judicial gender identity). Transsexuals are thus either male-to-female, or female-tomale, and, in Norway, their interest organization (the Harry Benjamin Resource Center) prefers the
label sex-conversed women and men, or simply women and men. Within the other main category,
transgender people, the gender variety is, as mentioned above, large, can be floating, and gender is
often understood as a continuous rather than a dichotomous feature. But also in this group we find
quite a few FtM and MtF transgender persons; but these have not undergone SRS (Sex Reassignment

5
Surgery), although many will have, or would like to have, modified their bodies and gender
expression to be more in line with their gender identity. The illustration below may provide an idea
of some of the diversity in the trans*specter (and when using the asterix *, I mean to include both
main categories, i.e.: all those who experience/d bodily sex - gender identity dissonance). In the
empirical part of the paper, I focus primarily on trans people who all time or most of the time live in
their preferred gender expression, in harmony with their gender identity, and who have to find ways
to be able to do so, other than through gender confirming treatment implied in the diagnosis F64.0.
If applying results on prevalence from a recent Dutch population study on sexual health (Kuypers
2012), finding that 0,6 % of the male population and 0,2 % of females (sex ascribed at birth), on the
Norwegian population, this would amount to proxy 19.000-20.000 individuals. The question of
prevalence is important according to Winter & Conway: Minorities dont count, if you cant count
them. (2011:1).
Important here to underline: these two categories are not to be considered as identity categories.
We have to perceive classifications in relation to the intention of the classifier. Trans*individuals
choose self-definitions crossing the boundaries of these categories. The terminology is by no means
accepted universally in Norway, but it is considered suitable for the examination in case.
Categories may recognize you, even if you do not recognize the category.
Browne & Bakshi: 2011:63

Gender equality in the Norwegian political climate

Recently the Government published a Green Paper discussing basic principles of gender equality,
with more emphasis on differences based on ethnicity, class and live course (NOU 2012:15). The
point of departure for the Green Papers equality reflections is justice, and the ideal is a just society.

6
The definition of gender equality is ensuring all citizens equal access to equal participation in society
on the same just conditions. (op.cit.: 57) Equal participation in society includes education, labor
marked, political life, but also family life etc. i.e. all societys arenas, political, economic, and
cultural and both public and private spheres are supposed to guarantee equal access for all. Equal
access implies absence of violence and force; and not any hindrances, discrimination, marginalization
or exclusion of certain groups of citizens to any of these arenas. Two conditions the state needs to
ensure so that citizens and groups of citizens can participate on equal foot I highlight is, one:
individual freedom and autonomy to act according to ones own values and preferences, and, two:
cultural recognition and respect for each and every one, meaning no systematic degrading because
of cultural differences and/or specific characteristics or appearances (Fraser 2003). The second
condition is of central importance for trans-gender equality positions. Furthermore, Norwegian
gender quality policies have a human rights foundation. I will assess Norwegian gender equality
according to these two conditions on a few major trans political issues.
A background for my (trans-)gender equality reflections are my observations of living conditions and
treatment trans*folks experience in the Norwegian social democratic welfare state where collective
responsibilities for its citizens life, health and wellbeing, and equality, is a prominent principle.
Simply stated, I want to assess whether there is room for different trans*genders in Norwegian
gender equality policies. Can people with gender identity dysphoria or incongruence be integrated in
gender equality policy considerations? And the other way around: Can trans*peoples needs and
political claims be justified in gender equality terms?

Doing gender, doing different genders, doing genders differently

For people with gender identity questions, dysphoria, incongruence or disorders, or, in short
trans*people, understanding and managing gender issues is dominant, both in practical living and in
theoretical reflections. In this section I want to mention some of the differences regarding
doing/being/performing/etc. gender for trans* and cisgender persons. Cisgender means being a nontrans individual: one for whom resonance between bodily sex and psychological gender/gender
identity is apparent and considered a natural situation. Schilt and Westbrook definition: "/.../
individuals who have a match between the gender they were assigned at birth, their bodies, and
their personal identity, complementing transgender. (2009:43)
We can differentiate between different levels of understanding gender gender as the organizing
principle in society, where gender has a heterosexual and binary content, and organizes the private
and public sphere, family life, the labor marked and, not the least, legislation. The gendered division
of labor plays an important role in constituting gender in society, and establishing a gendered social

7
order. At a symbolic level gender is seen as a cultural principle cultural agreements about what is
recognizable and acceptable as masculine, feminine and androgynous / / (Green 2004:121). At this
level discussions and elaborations about the meaning(s) of sex/gender develop and the limits of
norms and boundaries of different genders are contested. Here too, negotiations about the gender
binary itself evolve, and if/how to transgress binaries, and if/how other genders and gender
expressions and identities can be accepted and recognized as legitimate human expressions and
materialities (Bornstein 1994; Davy 2011; Sapiro 1991; Serano 2007; Valentine 2007; Stryker &
Whittle 2006; Rasmussen 2005).
The third level entails individuals features bodily and psychologically. Here the picture is more
complex; distinguishing between different ways individuals, and here it is important to highlight
differences between trans* and cisgender individuals, with regard to handling the combinations of
sex/gender/gender identities/gender expressions (West & Zimmermann 1987; West & Fenstermaker
1995, van der Ros 2013). In Norwegian gender studies, usual distinctions of understanding gender
are between having a sexed body, being a sexual person, doing gender, and negotiating the doing(s)
of gender and negotiating cultural gender norms (Holter 1996). All these approaches to gender are
seen through binary lenses, and discussions evolve around the different conditions for
doing/having/negotiating gender and gender norms for ciswomen and cismenn. The understandings
of sex/gender have quite different connotations when discussion trans*gender persons gender
identity and gender expression issues.
I want to add another approach to sex/gender with specific importance to trans*gender people.
While doing gender is something the individual controls, individuals are also being gendered,
gender is done to us; that is, others identify us according to the binary model as women or men and
make statements about what sex/gender they figure we are, or look like. And if this other person is
a state official or a professional (police officer, medical staff, pass controller, bank employee, etc.)
their gendering of the person has precedence over the trans*persons own gender identity.
Trans*people meet challenges due to three kinds of incongruence: the first one is the incongruence
between physical sex and mental gender identity. That one brings about a second incongruence
(unless SRS allows for a new judicial gender, as it does for transsexual women and men), namely the
incongruence between ones gender expression and the sex identification stated in the ID papers.
And this incongruence conveys the third one: the incongruence between ones own gender identity
and other peoples ideas about ones sex, based on bodily appearance, and possibly on the ID papers.
And, this other has the decisive saying; off you are to the wrong ward at the hospital. Such a

8
situation is an example of what Bettcher calls a basic denial of authenticity (2009:37). Whose
definition of gender is recognized and respected?
I find the discussion by Bettcher (2007) about trans*persons being met with either a pretender or a
deceiver stigma clarifying for situations and humiliating experiences trans*folks meet with regards
to the incongruence society makes them live with. When a trans woman is read as really a man,
such devaluation makes it more complicated to come out clearly as a trans*person, but it also makes
it difficult to pass as a woman, and not as a transperson. In the first case one can be seen as a
pretender, and in the second situation as a deceiver (Bettcher 2009:39). Either way, none of
these readings shows respect for or recognition of a persons identity. I want to consider such basic
non-recognition of a persons authenticity in light of some of the gender equality principles. This is
especially important in Norway, where we witness very differential ways of treating individuals with
one or more of the above mentioned incongruences related to gender identity, depending on
whether the medical GID team assesses the patients dysphoria severe enough to assign the
diagnosis F64.0, transsexualism.

Trans*gender equality in the health sector

In Norway only one institution is authorized to examine, diagnose and treat people with gender
identity dysphoria: the Section of Transsexualism at the University Hospital of Oslo, (SfT at OUS).
Proximately 100-120 patients yearly are referred to the clinic by their GP or by a Psychiatric ward.
Only about 25 persons are considered to meet the clinics requirements for the diagnosis F64.0, and
these are primarily younger people (i.e. under 30). The average age of patients at the clinic is 23
years. The entire treatment, from examination through one or two years of Real Life Test with
hormonal treatment and finally, genital and other surgical interventions, may take from 8 to 10
years. The entire process occurs at this public University hospital, and is funded over the
governments health care budget.
Those who do not meet the standards/requirements are referred back to their GP, who in most cases
is not familiar with the symptoms and different kind of discomfort related to gender incongruence.
The Norwegian health system does not provide the option of a second opinion. Since these
individuals gender dissonance is not recognized as a serious (enough) disorder by the University
Hospitals medical team, access to public health care related to the gender dysphoria is barred. These
trans*persons needs for some sorts of surgery, such as for instance breast surgery, or face
alteration, are labeled as cosmetic by the national health directorate (Helsedirektoratet 2012), and
as such not valid for public funding. Are they seen as Pretenders or Deceivers?

9
While the treatment is considered a medical necessity for those diagnosed with F64.0, for those
with F64.8, F64.9 or no diagnosis, the treatment is labeled cosmetic. Several of those turned down
at the clinic accomplish treatment such as SRS and hormones abroad, that is: those who can afford
such. In order to apply for the judicial change of sex in ID papers, they must be prepared to meet
some sort of humiliation: they have to prove to the medical team at the clinic (!) that their sex
convergence is real, and that they indeed are irreversibly sterilized. Pretenders or Deceivers?
Two observations related to gender equality: how does this official stand concur with the conditions
of individual freedom and autonomy to act according to ones own values and preferences (NOU
2012:15, 57), and the condition of cultural recognition and respect for each and every one? In my
opinion, transgender individuals are not counted into the gender equality project. Particularly, not
allowing the possibility of a second opinion is a severe devaluation of a citizens right to be seen,
heard and recognized.
Second: Norwegian gender equality legislation is based on human rights, and has signed the UN
Resolution on Economic, Social and Cultural rights. Article 12 of the Resolution assures citizens the
highest possible health standard without any form of discrimination.
Furthermore: the new WPATH SOC7 (2011) states: Being transsexual, transgender, or gender
nonconforming is a matter of diversity, not pathology. And holds the opinion is that all people with
gender identity dysphoria are in need of, and have a right to health care. Neither the Public Health
Care administration, nor the GID clinic seem updated on the latest development within the WPATH
paradigms with regards to new recognition of trans*gender people and the reformulated SOC (7).
A second challenge with regards to gender equality in the health sector concerns those referred to
the clinic examination and transsexual patients. There appears to be a specific dynamic between
individuals with gender identity issues and health professionals at GID clinics that puzzles me. I have
labeled these dynamics as the choreography of distrust; a kind of complicated dance where those
referred to the Clinic for examination use the established discourse, or rhetoric, of being born in the
wrong body in order to get access to trans related health services, and where the medical staff seems
eager unmask eventual deceivers or pretenders. The narratives from my informants are quite
different from what we think of as an ordinary trustful patient-doctor relation.
Another problematic issue with the health services provided at the Clinic for those who get through
is about the treatment of patients (once they have qualified for treatment, they are defined as
gender-correction patients by the Clinics staff). A patients reluctance towards genital intervention
may cause loss of diagnosis. Such hesitancy may be interpreted that the patient has been

10
pretending. The patient is expected to follow the scheme of treatment and accept the whole
package, without individual adjustments. Both types of health care dynamics seem to violate the
individuals right to integrity and autonomy over ones own body and thus, not in accordance with
the conditions for gender equality.
In this section I first showed large differences in access to gender identity related health services
between those with and without the diagnosis, F64.0 (and F64.2 for young persons). For those not
qualified for treatment, no second opinion is available. Second I presented the kind of treatment
transsexual patients meet at the clinic which also leads to that several trans*persons do not want
to be examined at the Clinic at all. This indicates large differences between different types of
patients: mental illness of this kind seems to be met with depreciation; are these patients considered
to have lower human worth?

Trans*gender equality in the legal system?

Here I want to present two issues: the right to change judicial gender i.e. change gender
assignment in ones birth certificate and all other ID papers; and second the right to be legally
protected against discrimination on grounds of gender identity and gender expression. Transgender
studies from all countries present discriminatory behavior towards trans*people in all arenas of life,
(Grant et.al. 2011; Motmans et.al. 2010; Turner et.al. 2009; Whittle et.al. 2007) and that is the case
in Norway as well, albeit less obvious in many instances; a person may lose her job after gender
confirming surgery, but they will present it as due to reorganization of the office (Van der Ros
2013).
With regard to solving the incongruence between gender expression and gender identification in ID
papers, the simplest solution is to have changed ones ID papers, as is possible in Argentina since
July 2012. In order to be able to apply for such change in Norway, the condition is to accomplish
irreversible sterilization. Among those with the F64 diagnosis and access to treatment, several
transsexual persons have reservations about genital reconstruction, and are comfortable with top
surgery and hormone treatment only. However, if they want to obtain congruency between gender
in id papers and gender expression, they too have to accept irreversible sterilization. Quite a few
among the younger transsexuals do not want to submit to this claim, and so they are denied a new
judicial gender, and have to cope with their incongruence. Norway has been approached by the
European Human Rights Commissioner on these grounds the condition of sterilization is considered
a violation of human right over ones body, and a violation of a persons privacy (Hammarborg 2009).
Again, a situation that is not consistent with Norways gender quality conditions.

11
This is one example of different treatment. Transgender people are not equally treated with
cisgender people (where sterilization is not even allowed under the age of 25). For transsexual
patients, written consent from the patient to sterilization is not requested, since this is a part of the
genital reconstruction intervention. Here, I read that transsexual persons bodily integrity is ignored.
Another aspect of the irreversible sterilization condition where we observe differences in trans*
patients rights and other patients privileges, is that other patients (f.i. in case of prostate cancer
bringing about involuntary sterilization), are offered freezing of sperm. This is not an option offered
transsexual patients undergoing genital reconstruction.
The claim of sterilization and the absence of the option of the freezing of sperm may, in the worst
case, be interpreted as the governments fear of transsexualism being a transmissible condition and
fear of the pregnant man.
The second issue in the legal sphere is about being protected against discriminatory actions based on
gender identity or gender expression. Neither Norways anti-discrimination legislation, nor the
gender equality act has incorporated this extended understanding of gender in the legislative
deliberations. New anti-discrimination legislation will be presented March 22nd to Parliament and
rumors are that the inclusion of the discriminatory grounds of gender identity and gender expression
is not recommended. Transsexual individuals and patients are protected under the gender equality
act against discrimination on the basis of gender. Trans persons, on the other hand, those with an
impractical incongruence between gender expression and gender assigned in ID papers, are not.

Summary and concluding remarks

In this paper I assessed gender equality principles and conditions by looking at trans*gender peoples
everyday life experiences in order to tell whether gender equality also could be taken to mean
trans*gender equality. I concentrated specifically on two important conditions for equality namely:
recognition and individuals freedom to act according to their own values and preferences. I focused
on two societal arenas: the public health sector and the legislative sphere.
In the first one, I observed a lack of recognition of gender identity issues for those who did not
qualify for the diagnosis F64.0, in two ways: no option of a second opinion and no further access to
public health care related to their gender identity issues. The experiences that patients at the section
of transsexualism purvey, is a specific dynamics of distrust, where patients feel they are considered
pretenders or deceivers. I further presented differential treatment between F64.0 patients and
other patients with regard to sterilization and the option to freeze sperm/eggs.

12
In the judicial area, an administrative directive claims irreversible sterilization before a trans*gender
person can apply for a change in birth certificate. For those who have undergone SRS at another
hospital than the Norwegian, their sterilization has to be certified by the clinic. The second legal item
I presented was the lack of anti-discriminatory protection on the grounds of gender identity and
gender expression, and thus trans people are left unprotected, another issue the EU Commissioner of
Human Rights has commented on (Hammarberg 2011).
What are the implications of this non-recognition of trans*peoples rights for the trans* people?
To me, it seems the choices are two: 1) being defined as so-called disturbed, the mental health
diagnosis F64.0; a choice open to relatively few in Norway. The second choice is being disturbing,
that is, challenging the gender binary, living with and coping with incongruences.
None of these choices are particularly encouraging. The first one gives access to alleviate the
dissonance between bodily sex and gender identity, and after sterilization the opportunity to nullify
the incongruence between gender expression and ID papers. One can pass as woman or man: nondisturbing. They are considered real woman and men and enjoy the rights and privileges of gender
equality legislation. The other option those who either do not qualify for public health care, and/or
those who do not want to be confined to the gender binary, have to cope with being a disturbing
element in a society organized around the heteronormative two gender model. This implies
managing several incongruences: between bodily sex and gender identity, between gender
expression and gender assignment in ID papers, and finally, the incongruence between ones own
and other peoples ideas of ones gender identity, giving precedence to the others reading. The
disturbing choice implies to be defined as pretender or deceiver, i.e. non-recognition of
persons identity and worth.
Non-recognition of ones gender identity dysphoria leaves a person non-recognized in many other
ways too. The problem is that gender recognition comes in response to medical treatment, instead of
medical treatment in response to gender recognition (Vreer,transserv mailinglist, 25.02.2012).
Gender equality is a more complex and more complicated political issue once we take departure in
an extended understanding of gender, beyond the ramifications of the heteronormative gender
binary. But it is only such policy that will be able to guarantee the authenticity and autonomy of
citizens of all kind of genders. Only then we can talk about equal transgendered citizenship in
Norway.

13

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