Gender medicine in Cuba: Ministerial Resolution 126
An overview of the highly-publicized policy on trans healthcare
Adopted in 2008 by the Ministry of Public Health, Ministerial Resolution 126 is arguably the most widely-known Cuban policy related to trans rights. While other policies relate to the topic, this is the one that people are usually referring to when they describe the Cuban government as having enacted pro-trans policy in the later years of the Castro era. This piece marks the beginning of an ongoing project, Cuba In Plain English, in which I aim to relate information about the law and society of socialist Cuba to an anglophone audience. The first entries in this project concern Cuban policies that affect what you might call “sexual minorities”, including trans people and people of non-heterosexual orientation.
In the present article, I specifically aim to explain MR126 to people who cannot read Spanish. This landmark resolution established trans healthcare as an official element of Cuba’s national health system. Contrary to popular misconceptions, this did not mark the beginning of gender medicine in revolutionary Cuba, but it made clinical treatment of trans patients far more systematic and organized.
We should note, with little surprise, that the Ministry of Public Health’s initial resolution does not address social transition — with one exception, which I mention below. For example, no mention is made of participation in sex-segregated sports or access to sex-segregated public facilities and services. When I find sources relevant to those topics I will include them in future entries in the series.
My conclusion is the only information I aim to add to the resolution. If you speak Spanish, I’d encourage you to read the original text linked above. As an obligatory disclaimer, I am not a lawyer or a native Spanish speaker. Please contact me if you see any errors in my translation that distort the resolution’s legal meaning.
Context of the resolution
Work on the policy was initiated in 2005 by Mariela Castro Espín, who directs the National Center for Sex Education [Centro nacional de educación sexual], often referred to by the initialism CENESEX. She has served for many years as a member of Cuba’s primary legislative body, the National Assembly of People’s Power. Her entry on the Cuban wiki EcuRed (link in Spanish) indicates she represents the Plaza de la Revolución district of Havana. According to an article in Mexico’s La Jornada, she became the director of CENESEX “five years ago” as of 2006, i.e. in 2001.1
Castro Espín is the daughter of Raúl Castro Ruz and Vilma Espín Guillois. Her father is the brother of now-deceased revolutionary leader Fidel Castro Ruz and a revolutionary hero in his own right. At the time that MR126 was adopted, her father had recently taken office as president, having been elected by the Assembly following Fidel’s retirement from the position. Her mother was a chemical engineer and a revolutionary leader as well. She also played a major role in Cuban socialist feminism, being a co-founder and president of the Federation of Cuban Women. Though herself married to a man, Castro Espín is one of the highest-profile advocates for sexual minorities in the country.
According to the article in La Jornada, her work on MR126 has roots in the late 1970s, when a trans-identified adult came to Havana seeking treatment. Not long after, the government made hormone treatments and therapy available to “diagnosed transsexuals”. In 1988, a different patient underwent male-to-female reassignment operations without complications. After the publication of news of this event, authorities put a hold on treating further patients surgically “until the issue could be properly explained" to the public.
An interview in the Havana Times indicates that she met with “a group of transvestites and transsexuals” in 2004, presumably in her capacity as CENESEX director, and this meeting presumably led her to take up the issue again. CENESEX soon hired some transsexual people as sex educators teaching about HIV, according to La Jornada, which also mentions that hormonal treatments remained available at this time. On the state of the work in 2006, La Jornada says that “[i]n essence, the proposal states that as soon as a person is diagnosed with a gender identity disorder … the person’s legal documentation can be changed, from the birth certificate to the passport [and the] person will also have the right to a sex change operation.”
Castro Espín said, in 2006, “We have studied 74 subjects identified as transsexuals, but only 25 have been diagnosed ... [these diagnosed patients] are waiting for the chance to have their operation.” The following section will address some potentially confusing terminology found in this quotation. Given the role played by CENESEX in Cuban public policy, especially in regards to HIV and homosexuality, it comes as no surprise that their work resulted in the adoption of MR126 by the Ministry of Public Health.
Several years after the passing of the resolution, Castro Espín was the first legislator in the history of Cuba’s democratic era to vote against a measure proposed in the Assembly. She dissented in 2014 regarding a bill on employment discrimination because it did not include gender identity in addition to its provisions on “race, gender, and sexual orientation”. It is unclear to me whether the meaning of “gender identity” in this context matches the language of the resolution.
Vocabulary of the resolution
Before we consider what the resolution says, we must clearly understand how it says it. Very helpfully, the resolution includes a glossary of its key terms:
sex: A collection of anatomo-morphological characteristics that define human beings as males or females.
assigned sex: The sex identified [lit.: adjudicated] by a medical professional based on the appearance of a newborn’s external genitalia.
gender: Sociocultural and historical construction referring to the psychological, social, and cultural characteristics that each society attributes to a person according to the person’s sex.
gender identity: The personal private conviction that each person has of belonging to one or another gender (woman or man).
transsexual person: Designates those people who, in general, since early childhood and throughout their lives, demonstrate their indissoluble feeling of belonging to a gender (masculine or feminine) that does not match their sex assigned at birth.2
eligibility criteria: Objective and specific criteria that establish the norms [procederes] of care for transsexual people at different moments: assessment [lit.: study], diagnosis, and treatment up to sex reassignment.3
availability criteria: Objective and specific criteria that establish the ensuing consolidation of gender identity or improvement in mental health [i.e. outcomes following treatment].
sex reassignment surgeries: Medical, surgical, or psychological procedures, masculinizing or feminizing, that concern the alignment [lit.: correction] of the sex characteristics of a transsexual person with the person’s gender identity. The use of at least one such procedure, with these aims, is considered partial treatment.
This vocabulary clearly distinguishes between sex and gender without going into detail on the definition of sex. I take the expression “a collection of anatomo-morphological characteristics” to imply the common model of biological sex wherein an organism’s sex is determined by the presence of most (but not necessarily all) of the defining aspects of one distinct sex of its species: chromosomal profile, reproductive anatomy, et cetera. Such a model allows for disorders of sexual development as well as infertility or endocrine disruptions, which may occur without rendering the organism sexually ambiguous or inhibiting other processes of sexual maturation.
It may seem a bit bizarre to include “assigned sex” as its own concept given the fact that the policy recognizes that there exist two distinct sexes in humans. In fact, this term is not used in the text of the resolution, only in other glossary entries. It seems they needed it in order to clearly establish what is meant by their definition of a “transsexual person”. In other words: there are two sexes recognized, everyone has one “assigned” at birth, and being “transsexual” means you have had — since early childhood, at least “in general” — an “indissoluble feeling of belonging to” the “gender” that corresponds to whichever of the two sexes you were not assigned at birth.
The clarification “(woman or man)” in the definition of “gender identity” underscores the binary, i.e. sex-based, character of this resolution. The definitions of “gender” and “gender identity” are grounded in human sexual dimorphism, rendering them incompatible with concepts like performativity or models of “gender identity” as one’s felt location on a continuum between two socially-constructed “genders” or as an individual “essence” defined without reference to the sexes.4
Note that the definition given for “eligibility criteria” includes diagnosis as an aspect of trans healthcare. This makes it clear that the Ministry considers physical interventions like hormone replacement therapy and sex reassignment surgeries to be treatments for a diagnosable medical condition. Similarly, the definition of “availability criteria” indicates expectations that treatment should improve measures of a patient’s psychological well-being. On this basis I will use the term “[gender] dysphoria” as shorthand for the “feeling” mentioned in the definition of “transsexual person”, separate from its “indissoluble” qualifier.
Provisions of the resolution
The resolution begins with a preamble describing the legal basis of its authority and the context of its content. This section mostly concerns the legal mandate of the Ministry of Public Health, as well as specifying the sources of earlier regulation referred to in the body of the resolution. Notably, it refers to MR235, which created CENESEX in 1988, and to the work that CENESEX has done on the subject much as I described above. The text is grammatically rendered in the first person because it has the format of a decree of the contemporary Minister of Public Health, Dr. José Balaguer Cabrera.
In its first two points, MR126 establishes two regulatory bodies for trans healthcare in Cuba. The first point creates the Comisión Nacional de atención integral a personas transexuales, which I will refer to as the Commission. The Commission is under the direction of CENESEX.
The second point creates the Centro de atención a la salud integral de las personas transexuales, which I will refer to as the Center, as “the sole institution of the National Health System authorized to perform total or partial sex reassignment treatments”. Note here that the name says “comprehensive health of transsexual people” [salud integral de las personas transexuales] rather than the Commission's “comprehensive care for transsexual people” [atención integral a personas transexuales].
In its third point, the resolution indicates that the Center falls under the jurisdiction of the General Regulation on Hospitals [Reglamento General de Hospitales]. This basically means the Center’s practitioners are held to the same professional and ethical standards as practitioners in existing public hospitals.
The fourth point of the resolution gives the Commission the following functions:
To develop, implement and coordinate national policy for the comprehensive care of transsexual people
To promote the comprehensive care of transsexual people
To nominate [lit.: propose] trans care specialists to the Ministry of Public Health
To approve, according to the eligibility and availability criteria contained in treatment protocols, the appropriateness [pertinencia] of sex reassignment surgeries
To direct the methodological operation [dirigir metodológicamente el funcionamiento] of the Center
To promote research that contributes to the development of multidisciplinary scientific knowledge of transsexuality
To advise of the Ministry of Public Health on the design of policies with regard to transsexuality
According to the fifth point, the Center’s functions are as follows:
To offer comprehensive health services for transsexual people, including assessment [estudio], diagnosis, treatment, clinical research [investigación asistencial] and monitoring
To perform, following medical protocols, the treatment required by each transsexual person
To coordinate with the National Public Health System’s Healthcare Unit, the Center’s headquarters, other standards of care [procederes de atención] required by transsexual people during their comprehensive care at the Center
Therefore, the Commission under CENESEX is responsible for policy on trans healthcare, and the Center under the Ministry of Public Health is responsible for its implementation.
A brief sixth point indicates that the glossary should be consulted in interpreting these provisions, and that it constitutes an “integral part” of the resolution.
In the seventh point, the resolution grants CENESEX the power to designate, “by authority of [mediante] the resolution”, professionals authorized to issue a gender identity certificate to transsexual people, which is the only such document recognized by the Ministry of Public Health and which authorizes the recognition of the bearer’s gender identity in all legal processes and proceedings [cualquier trámite o proceso legal]. This is the only aspect of the resolution that addresses social transition, though it limits itself to functions of the government. The certificate allows people to change sex markers on documents like passports and birth certificates.
The remaining points are formalities like the preamble. They concern the preparation of offices for the Center, the provision of personnel and services, et cetera. At the end, commands are given to keep everybody in the loop and file the resolution in the official archive, followed by the signature of Minister Balaguer Cabrera.
Conclusion and interpretation
While the policy expressed in MR126 is a so-called “transmedicalist” one, we should note that definition of “objective and specific” criteria for eligibility and availability falls under the authority of the two bodies created by the resolution. In the future, I intend to look at the output of those bodies since the enactment of the resolution, to see if they have changed or clarified the model outlined in the resolution. Where available I also want to examine the treatment protocols they advise.
Under MR126, clinicians are held responsible for availability criteria that include expectations of “consolidation of gender identity” or improved mental health following treatment. Gender care patients in Cuba do not waive their rights by absolving clinicians of such trivial responsibilities as “actually improving the patient's health”, as occurs in a so-called “informed consent” model. Sex reassignment treatments are therefore not available on a simply elective basis, despite the fact that elective cosmetic surgery is permitted in Cuba.5
In addition, nothing in MR126 suggests that practitioners ought to make medical interventions available to “non-binary” patients. While the definition of “transsexual person” includes identification with “a gender” other than the one “assigned at birth”, it is made clear at multiple points that only two “genders” exist because they are defined as social constructs that correspond to dimorphic biological sex. (I suspect they avoid saying “the opposite” sex or gender so as not to imply some kind of inequality or inherent conflict between men and women, but this is just a guess.)
Outcomes of the resolution
The non-”affirmative” character of the Cuban approach is evidenced by the fact that fewer than 10% of applications to the Center had resulted in surgical intervention as of 2019, according to Cubaplus Magazine. In 2019 the country had roughly 11 million people, which means the 120 “applications” to the Center represent about 0.0011% of the population. Compare this to estimates of the prevalence of gender dysphoria in general reported in Psychology Today that range from 0.005-0.014% for natal males and 0.002-0.003% for natal females, both of which are higher than this 2019 rate.
A linguistic factor arises to complicate assessment of the policy’s impact — namely, the resolution’s awkward definition of “sex reassignment surgeries”. The glossary definition of “sex reassignment surgeries” includes not only “surgical”, but “medical” and “psychological” procedures of a “masculinizing or feminizing” nature. Cubaplus claims that “nearly a dozen sex change surgeries [had] been performed” between 2008 and 2019. However, the article does not indicate whether Cubaplus are using the resolution’s definition, which actually refers to medicalization in general, or specifically referring to surgical interventions like vaginoplasty and bilateral mastectomy.
It also says that MR126 “legalized the procedure”, i.e. the “sex change surgery”. This is imprecise, and it overlooks the fact that surgical reassignment is not a single procedure. The selection and extent of procedures surgeons may perform on “transsexual persons” differ based on natal sex and individual needs. Additionally, many of the possible interventions are indicated for unrelated conditions, such as cancers of the breasts or testicles, thus in and of themselves many “reassignment” procedures were already “legal” to perform due to obvious medical necessity.
Note also that the resolution contains no language suggesting that a clinical presentation of gender dysphoria, even if “indissoluble”, indicates any particular form of medicalization in itself. This suggests to me that a “transsexual person” in technical terms is not necessarily someone seeking the fullest extent of medical intervention available, but any dysphoric patient whose condition may be improved by some level of medicalization. I find it probable that a higher proportion of those 120 applicants received what the resolution calls “partial treatment”, such as cross-sex hormone replacement, but that their symptoms did not indicate surgical procedures as appropriate. For clarity I will continue to use “medicalization” for what the glossary calls “sex reassignment surgeries”, reserving the term “surgery” for literal surgical procedures.
I find the glossary definition confusing because it leaves it unclear whether all gender therapy in the psychological or psychiatric setting is seen as a medicalizing intervention on the level of hormone replacement or genital surgery. My best guess is that there exist post-diagnostic “psychological procedures” I have never heard of that accompany physical interventions, intended e.g. to “consolidate” the patient's gender identity. This would imply that initial “psychological procedures” that might establish a patient's “transsexual” status do not require approval by the Commission or oversight by the Center, which would make sense and would suggest the existence of patients treated for dysphoria who required no referral for medicalization at the Center.
On its face, the gap between expected rates of dysphoria and “applications” described in the first paragraph might suggest that the Cuban health system has only managed to treat less than half of the likely population of gender medicine patients, even at the lower bound of estimates. However, with the above context, we can see that Center’s services do not apply to all clinical cases of gender dysphoria. If the “applications” figure includes only those who proceed to medicalization, approval of which the resolution recognizes as the responsibility of the Commission rather than the Center itself, the picture is a bit different.
With the caveat that I am speculating in this paragraph and the next based on these observations, we might extrapolate from other research on dysphoria to assess the resolution’s impact on trans healthcare in Cuba more generally.6 According to one paper cited in the link, up to 87% of dysphoric preteens desisted (“outgrew” their symptoms), with two-thirds of patients studied maturing into a non-heterosexual orientation without persisting dysphoria. Lower rates of desistance still in excess of 60% are reported in other studies, but the overall research on this subject is insufficient for me to pretend to have solid numbers. Extrapolation is made still shakier by the fact that age plays a large role in these studies and I have no demographic data for the Cuban patients.
Nonetheless, if we generously stipulate that 40% of those who initially present with dysphoric symptoms are appropriate candidates for medicalization, the 120 “applications” could reflect at least 300 patients who have received some kind of care for gender dysphoria. The resulting rate of 0.0027% of the population remains on the lower end of estimates of the prevalence of dysphoria, but the gap closes notably with my interpretation. Alongside these figures we should consider the presence, in Cuba as in most countries, of stigmatizing social factors that keep people from seeking gender care of whatever type. We should also consider Cuba’s relative lack of social factors that inflate rates of attempts to access medicalization directly in the anglosphere, which are confounded by cases where patients do not present with diagnosable gender dysphoria.
Speculation aside, the low-end figures clarify that Cuban policy for trans healthcare focuses on the holistic treatment of diagnosable conditions with the aim of improving patients’ comprehensive health outcomes. Contrast this with the transhumanist attitude of “affirmation” that dismisses the Hippocratic oath, reducing doctors to technicians who provide whatever interventions technology allows on the basis that patients want them to do so. Given the state of medical research at the time this policy came into effect, I consider it highly scientific and well-reasoned.
A specter is still haunting the Caribbean
The policy does not make any explicit ideological justification of itself, but we can infer something about its political character from the Havana Times interview of Mariela Castro Espín linked above. In that interview she expresses a need for Cuban socialism to remain “dialectical” and become ever more “participatory”. This perspective on her advocacy for sexual minorities has parallels to her mother’s role in the Federation of Cuban Women, the idea being that Cuba has to address its internal contradictions actively rather than allow obstacles like the embargo to overshadow the project of Cuban socialism itself.
This seems like a reasonable argument, given that the persistence of internal contradictions put on the back burner in favor of issues beyond the state’s control provides opportunities for counterrevolutionaries to exploit them. The Cuban government can ill afford to allow rainbow capitalists in places like Miami to position themselves as the real friends of Cuban sexual minorities, nor to allow social and economic marginalization to inhibit the participation of any minority population in democratic life.
While I remain personally uncertain of the extent to which I agree with Castro Espín on the nature of sexual orientation and gender identity, she has undoubtedly done great work in Cuba. In any case the work done on this resolution is not hers alone, but also represents the input of many clinicians and public health experts in a country that excels in that field. My overall impression is that MR126 represents a responsible application of available evidence by a government with a well-earned reputation for medical excellence.
If you read this article in English, bear in mind that the original Spanish does not make a gender distinction in possessive pronouns like “his” and “her”.
Trying to translate indisoluble is a pain. I suspect it means “persistent” in the sense that the patient does not outgrow it as is known to occur in homosexual adults who presented with dysphoric symptoms before or during puberty. This is, however, an educated guess.
I am unsure whether “tratamiento hasta la reasignación sexual” means “treatment up to the point of sex reassignment surgeries” or “treatment contributing to sex reassignment”. Also, I have translated procederes as “norms” but it may also denote “procedures” in a non-medical sense, as opposed to procedimientos in the medical sense.
The definition of “gender identity” also contains the surprising — to me, at least, being in disagreement with it — assertion that “each person” has one.
Elective cosmetic surgeries are, to my knowledge, not covered by the national health system, whereas reassignment treatments are. Many cosmetic surgery patients are medical tourists who pay in foreign currency the country needs for imports.