Rosa Almirall

Ashoka Fellow
Illustration of a person's face depicting a fellow
Spain
Fellow since 2019
This description of Rosa Almirall's work was prepared when Rosa Almirall was elected to the Ashoka Fellowship in 2019.

Introduction

Rosa is pioneering a new approach to the way trans* people receive treatment in Spain’s national health care system: from being treated as people with mental disorders to seeing them as experts who should self-determine their healthcare path in terms of timing, treatments and support. Rosa is simultaneously raising awareness to lobby for change at a societal level.

The New Idea

The classifying of transgenderism as “psychologically abnormal”, which is how the World Health Organization classified transgenders until 2018, acts as a powerful tool to legitimize and perpetuate our traditional gender system, as those that reject their biological gender assignment are considered to have a pathological disorder that needs psychiatric treatment. However, trans* is another way of building gender identity that is just as valid and legitimate as any other. Consequently, it cannot be treated as a disease, disorder or abnormality.

Rosa is de-pathologizing the healthcare system for trans* people. De-pathologization means removing the evaluation carried out by psychologists and psychiatrists and granting full capacity of decision to the individual. Rosa has created Trànsit, a public health, free service for any individual based in Catalonia which also offers treatment, advice and counselling both online and by telephone for the trans* community throughout Spain and all around the globe.

In order to self - determine the type of transition that each patient needs, the support they need within society, and the support they need psychologically, Trànsit allows the patient to lead their own identity process without pressure, choosing when to stop or continue. Rosa believes that the patient knows best how they feel regarding their identity and therefore have the right to decide.

Tránsit´s team works closely and individually with each person, giving them expert advice to evaluate all possible treatments and understand in detail the short and long-term secondary effects of any steps taken. This relationship is conceived as a peer to peer, expert to expert process between the health professional and the patient. The team understands the vital role that friends and family play and Trànsit´s service includes a support service for them too.

Trànsit works hard to build awareness within the medical community and offers training to health professionals in order to change the attitudes, stances and beliefs of the traditional healthcare system. Rosa’s educational role to create a trans-positive discourse and environment, means she also works closely with the wider community – the media, teachers, doctors, parents, social workers etc. Rosa’s approach is being replicated in three different regions of Spain.

The Problem

Transgender people have been traditionally stigmatized, discriminated and in many cases forced into hiding or denying their true self and even becoming transphobic themselves. In 2014, the Williams Institute and the American Foundation for Suicide Prevention published research that showed that 46% of trans men and 42% of trans women had attempted suicide. One of its major findings was that trans people across all demographics and ranges of experience have very high levels of attempted suicide.

The transgender population often suffers from chronic stress associated with poor health outcomes, family rejection, bullying and harassment, or feel unsafe for simply being who they are. The trans* population may start as early as 2 years old, and come from every kind of ethnicity and socioeconomic status. Europe is wakening up to the trans* population and their needs, society is becoming more open-minded and governments are beginning to apply equality laws. However, there is a need for concrete, on-the-ground proposals and solutions to push this mindset change forward and for real societal acceptance.

Part of the acceptance problem is how they are treated by the healthcare system. Up until very recently (and still in many cases), these people were labelled with a diagnosis of mental illness, gender dysphoria, according to the criteria defined by the DSM-V (Classification of mental illnesses). Therefore, access to health services to initiate hormonal treatments to modify their bodies requires a psychological and psychiatric evaluation to determine if their gender identity meets the criteria defined in the DSM-V, forcing many people with non-normative gender identities to lie about their experiences regarding their identity.

Access to medical providers is crucial to become who they really feel they are, but too often they receive discriminatory care, with many suffering from subtle harassment, prejudice, refusal of certain treatments or a largely unempathetic medical staff. Health professionals freely admit they need training and education in transgender health as traditionally viewed as a mental health issue, transgenderism is not typically covered in medical schools, and as a result physicians are unprepared to serve transgender clients.

Although it is not known with certainty what proportion of the population is allocated in these categories as is a hidden population, far more people identify as transgender than previously thought. The conventional wisdom was that about one out of 100,000 were transgender, but recent gender identification studies amongst university students suggest that they could represent up to 1% of the population. However, 10% of people treated in these services are finally excluded from the possibility of accessing hormonal treatments and many of them decide to self-treat without any medical control.

The needs of trans people in relation to healthcare services vary hugely depending on their personal characteristics: the level of suffering developing a non-normative gender identity entails, their body experiences, the ideas they have on gender, their expectations regarding the transition, how they want to go through the transition and how far, etc. The system however often has a one-size-fits-all approach, with very reduced appointments (no time to understand the nuances) and the strict application of the “mental health” protocol.

The Strategy

Rosa has created Trànsit an holistic transgender health and social service, within the public health system, focused on patient needs and with the expertise to accompany trans* individuals towards a full and happy life. Rosa’s work is based on three strategic pillars:

1. Supporting self-determination and treatment selection

In order to self – determine, Transit* allows the patient to lead their own identity process without pressure. It is vital to understand that trans people are not a homogeneous group. The diversity among them means that it cannot be assumed that they all need the same care or the same resources. There are those who feel they are the "opposite gender" to the one assigned at birth, those who do not identify with the normative models of male and female, those who are confused, those who are very clear that they do not feel that their assigned birth gender is the right one, but are not sure how to find personal satisfaction and balance, etc.

Therefore, the self-determination process must be absolutely tailored to the individual and in order to do this, Rosa has ensured that the team that addresses this has grown to include doctors, psychologists and family therapists.

In terms of hormone treatment, the information and advice required is offered from a non-binary view of gender and recognition of the diversity of trans subjectivity and bodies. This means respecting the decision of the person at all times in relation to the type and time frame of the hormone treatment. The person also decides if they wish to access the psychotherapeutic support offered by Rosa’s team. Rosa’s service is very cost effective as she is avoiding the economic cost of the psychological and psychiatric evaluation visits and the compulsory months of therapeutic groups.

After the first visit many join a follow-up in their primary care centers with their family doctors or pediatricians as they have a clear road map on how supporting their patients. Trànsit carries out its continued assistance via telephone and email, allowing a model which attends people more intensely at the most crucial moment of the process, which is the beginning of their treatment.

The assistance via telephone, videocall and email means that Rosa is not limited to her physical health centre in Barcelona. Every week, she attends and connects multiple requests via email and telephone from all around Spain and the world. These people contact Transit because other members of the Trans* community have recommended the service to them. She manages to connect trans people, doctors, and their families, in different territories so they can help each other and go through the process collectively. Rosa and the team answer questions and offer a letter of recommendation to that persons´ family doctor in their town of origin. These letters are offered in both Spanish and English and often Rosa puts the patient in touch with other trans* patients in their area who are willing to assist and share their own experiences.

To date, Rosa’s initiative has treated more than 2,500 transgender people directly, half of whom are from outside the Barcelona region. Other Spanish communities, like Navarra and Mallorca, have replicated Rosa’s Trànsit system.

2. Changing the mindset on transgenderism: Education and awareness as key levers

Rosa and her team offer a support service to all those in the immediate affective / family / educational / work circle of the trans* person, because they understand that for the process of social transition to be positive, it is essential that their environment understand and accompany them with a trans-positive vision.

As part of this process, the Transit* team also accompany children to facilitate their acceptance at school, having assisted over 130 boys and girls. Rosa has trained more than 9,000 people from different backgrounds (teachers, doctors, police etc.) and 60 schools to help the inclusion of trans population in society. Rosa is finalizing her Train the Trainer modules to extend her reach to all other regions in Spain.

3. Multiplying the impact

Because Transit was created by Rosa from within the Spanish public health system, she has taken steps to ensure that it can be smoothly replicated by any health professional in other regions. After a short session of theoretical and practical training, the local professionals are motivated to apply this model of care. Generally, doctors spend two to three weeks in Trànsit and then take their learnings back to their own hospitals and health centers, so that Tr+ansit is slowly converting into a Knowledge Center. Rosa has also created an 80-page protocol document which she shares with all interested parties.

The need for a new model and the visibility that Rosa has created is demonstrated by the petitions from the Navarra and Balearic Islands Health Services to implement the Trànsit model in their autonomous communities, as well as the request for interventions in trans * activism days in Galicia, Castilla and León, Castilla and La Mancha, Basque Country, Navarre, Community of Madrid and both the Canary and Balearic Islands. This has also extended to countries beyond Spain, such as England, that has requested to build a similar protocol for the NHS.

Rosa has very close relationships with the many Trans* groups around Spain and she is working with them to create a qualitative study that looks at the process of gender transformation. This study will help to improve the health services offered but will also be a basis from which to lobby for more systemic changes around Spain.

From her experience with feminism in the 70s and 80s where male voices were generally excluded from the debate, Rosa understands that it is vital to include CIS people (people whose gender identity matches the sex that they were assigned at birth) in activity about the trans* population and is leveraging her alliances with schools, police-forces and the health system to create a more inclusive debate resulting in a more inclusive society.

The Person

Rosa was brought up in a quiet town where she was moved by injustice from a very young age. She has always been motivated to question and change injustice, as an intrinsic part of her personality. She moved to Barcelona aged 16 to study and that was a decisive moment in her life. It was in this city that she began to seriously reflect on various issues (racism, abortion, poverty, religion, death penalty, family, etc.). She studied medicine in the 1970s and fought against the ingrained patriarchal system of the time. Rosa became involved in women’s rights, promoting women’s education about sexuality, their right to choose, and access to contraceptive methods and abortion when these things were forbidden or frowned upon in Franco’s Spain.

She eventually chose to specialize in gynecology as she felt that as a woman that was the place where she could best influence, create and change protocols that were dangerous and denigrating for female patients.

Throughout her career, Rosa continually fought to improve the system, at times suffering the consequences of her efforts for change. Currently she is a very well-recognized gynecologist and works as the director of the gynecological department in a public health center in Barcelona.

Eight years ago, Rosa had her aha moment that was to change her life’s work. She saw how one of her work mates refused to offer treatment to a transsexual woman. She then started asking herself why, in her long career, there had been no visits by transsexual people to her medical practice. She started reading and talking with professionals about transsexuality. She also interviewed many transsexual activists to understand their needs and situation. Finally, she convinced the health centre to offer, one day a week outside of normal working hours, within her consultation, a health service specifically for transsexual people. As a result of the dramatic demand for the service, she started Trànsit.

Fighting for the recognition of human rights, for the elimination of discrimination and for the integration of minorities in society has been Rosa’s lifelong ambition. Understanding what transsexuality is, defending more genders than male and female, and facilitating the tools so that everyone can be whoever they want to be have become Rosa’s life commitment. She will be stepping away from running Transit Barcelona so that she can devote more time to spreading Transit’s impact in Spain and beyond and so that her important voice may be heard in the public policy debates and discussions that are emerging about this previously taboo topic.