Antonio Carmona Baéz
Globally, the concept of self-determination in sexuality is used in legal theorywith reference to the rights of individuals to be free of rape, coercion, forcedprostitution and abuse; it implies reproductive rights in some societies, while inothers it is the right to exercise free will over one’s sexual functions (Jansen, 2007;Munro, 2008; Smith, 2007; Walsh and Foshee, 1998). In Cuba, the term ‘sexual self-determination’ (autodeterminacio´ n sexual )1
is associated with the process of emancipation that is linked to the construction of socialist society, and the useof sex education as established by the country’s feminist movement, in order totranslate the political discourse on gender and sexuality, specifically Lesbian, Gay,Bisexual, Transgender (LGBT) sexuality, into social policy (Figueroa, 2009). Morerecently the concept has been used as a counter discourse to the pathologicalapproach to transgender experiences and identities and it is recognized as a fun-damental human right.
In this article, we suggest that the use of ‘decolonial’ and ‘border thinking/epistemologies’ as developed by Walter Mignolo (2000, 2007) and ‘epistemicturn’ as elaborated by Ramon Grosfoguel (2007), based on the critique of the‘geo-politics of knowledge’ (Dussel, 1977; Fanon, 1963, 1967), can help us under-stand the changes associated with sexuality, ethics and public policy that sprangout of Cuban feminism and its emphasis on sex education.
Considering that literature on the intersections of race, class and gender is his-torically rooted in radical feminist and latterly queer critiques of Western capitalistsociety, the political nature of the use of emancipatory discourse in Cuban socialinstitutions comes as no surprise (Glenn, 1985; Lugones, 2007; Namaste, 1994;Wolf, 2009: 19–20). In a similar vein this discourse and recent changes in Cubansocial policy pose a challenge to global conceptions of sexual health in the medicalsciences, the idea of emancipation of sexual identities, and a dissonance in theformation of ethics and human rights discourse internationally. What is particu-larly novel is the institutionalization of such critique and discourse at the statelevel. In addition, the autochthonous Cuban critique of homophobic society andself-evaluation promoted by militants and leaders of the Communist Party of Cuba(PCC), have exposed a narrative that is bent on the decolonisation of politics,policies and practices. The Cuban experience regarding social policy on sexualdiversity is in no way free of contradictions. Sexual self-determination is not anaccomplished project but part of a continuous process.
We do not intend to place a value judgement on these processes, but instead tomap debates and controversies. We will do this by briefly presenting the concept of epistemic decolonial turn, by reviewing the genealogy of Cuban homophobia andthe history of sexual emancipation, and by showing how policies concerning sexu-ality that are assumed by the Cuban state and applauded by broad sectors of itscivil society is based on a discourse that embraces the epistemic turn presented inthis article. The implications of this turn for ethics in medicine and science inter-nationally will be elaborated.We have found that the decolonial project of sexual emancipation in Cuba ismanifested in three essential aspects: (1) Sex education as envisaged by the feministmovement of subalterns; (2) Depathologization of non-heteronormative genderidentities and (3) Sexual self-determination presented as a human right.Ultimately, the Cuban experience presents a dual dynamic: first, decolonizingCuban post-revolutionary politics through the changes in sexual codes, publicpolicy and health ethics on the one hand, and on the other, a displacement of medical-scientific authority over gender and sexuality. Alongside this last issue, theestablishment of new centres of knowledge production in both science and socialtheory will be identified as a challenge to conventional bodies of authority.
Decoloniality and the epistemic turn
There is a growing body of literature in the humanities and social sciences thatlooks at the production of knowledge and its institutionalization as part and parcelof the modern world system of hierarchies (Walsh, 2012). Starting with the premisethat colonialism or coloniality is the flipside of modernity, those who challenge thecentres of power in knowledge production by recognizing other epistemologies,attempt to decolonize knowledge and call their perspective decoloniality .Mignolo (2003), Maldonado Torres (2004) and Grosfoguel (2008) for instance,have concentrated their efforts on, first, recognizing the epistemological violencecommitted by dominant power structures in suppressing or excluding other narra-tives and, secondly, uplifting and taking into consideration the excluded/subalternnarratives, giving them equal if not more value when it comes to socio-politicalphenomena. Decolonial thinkers challenge the universality of modern knowledge,describing it as a ‘provincial pretense’ or largely Eurocentric, and introduce theconcept of the geo-politics of knowledge (Mignolo, 2007: 493). Mignolo, followingLatin American liberation philosopher Dussel (1977), refers to geo-politics in orderto argue for the importance of locating the construction/production of knowledgeand its dissemination. Starting from the premise that all geographies and historiesare local, these recognize that some – specifically those of modernity – have a globaldesign, albeit controlled by certain types of local histories (Mignolo, 2000: 66). Thecontrol of both the local and universal can be found in academia, what Grosfoguel(2012: 9) refers to as Westernized universities – as well as in law, political institu-tions of the state, social movements and political projects for transforming society. Additionally, the decolonial school of thought foregrounds border thinking, whichis an attempt to rescue and employ narratives and histories that have been inten-tionally supressed precisely because they challenge the universal project of euro-centric modernity/coloniality (Mignolo, 2000: 739–45).
Decoloniality looks specifically to the place where knowledge is produced.In order to decolonize knowledge, the geo-political location of theology,European secular philosophies, and later scientific reason (including scientificsocialism which is dependent on European epistemologies exclusively) must beunveiled, and the principles and modes of knowledge that have been ignored byChristianity, Western – i.e. subaltern epistemic perspectives (ethnic/racial/sexual/territorial), must be uplifted along with the epistemic decolonial turn (Mignolo,2007: 463; Grosfoguel, 2007: 212).
For the purpose of this article, we should emphasize that it is not so muchEurocentrism that needs to be underscored in understanding coloniality. Rather,it is the unequal structure of governing bodies of knowledge that have determinedthe course in which ethics have been developed. Cuban social policy has not shed itself completely of colonial epistemologies. At the same time, the striking resem-blances between the trajectory by which Cuban social policy regarding sexualityhas developed and the epistemic decolonial turn, as suggested by Dussel,Grosfoguel, Maldonado Torres, Mignolo and others, merits attention.
To analyse the changes being made in Cuba regarding social policy towardssexual diversity, health and ethics, it is worth looking at where knowledge has beenproduced prior to and under the current political regime. In order to accomplishthis, the genealogy of trans/homophobia can be reviewed from both local andglobal historical frameworks, the transformation of social policies and sexual pol-itics can be considered, and the conceptualization of sexual self-determination examined. Since education throughout the process of social transformation iskey to this study, it is appropriate to identify the influence of Paulo Freire(1970) in understanding popular education and the
pedagogy of the oppressed ,whereby the teacher–student relationship is broken down in order to facilitate adialectics of emancipation (liberation), and to recognize this Latin American heri-tage as an essential tool in the process of decolonizing sexuality, science, humanrights and health.
For Freire, those who are in a position of power must constantly go through aprocess of self-examination (Freire, 1970/1996: 64), contemplating their own role ina world of inequality. Parallel to this is the issue of building an ethically soundrelationship between those who are ‘treated’ by state institutions and the scientificcommunity, including health professionals working with those identified as trans-gender or intersex. While commenting on the question of good treatment of transpersons in the age of de-pathology, Judith Butler concludes: ‘the question is notsimply would you, the authority, permit and recognize my change; rather, wouldmy request produce radical changes in your practice and in your ethical self-under-standing as a professional or practitioner’ (Butler, 2010: 12). Today, as will beargued, the re-education of Cuban society was an essential breakthrough in thatcountry’s experience of depathologization. We identify an epistemic decolonialturn within science, ethics and the Marxist-Leninist-Martiano 2 discourse of egali-tarian socialism. This turn is presented as a challenge to what we call the
religious-modern-socio-scientific bloc that until recently has dominated Cuban society and itsmanagement of sexuality.
Human rights is also a field of study that has undergone critical review from thedecolonial perspective. Mignolo (2009) notes that the notion of human rights fol-lows a modern/colonial trajectory in both theoretical and practical applications.Human rights, reserved for white men of privilege first, and later extended to therest of the world’s population, continues to be shaped by discourses and epistemol-ogies based on the Western experience. The socialist experiment in Cuba, as inmany other places, has challenged universal conceptions of human rights, payingmore attention to socio-economic rights as access to food, housing, health services,education and employment. In 2008, the government of Cuba hosted an inter-national conference of intellectuals, politicians, lawyers, artists and activists,entitled ‘The Universal Declaration of Human Rights: 60 years later’, where in a final statement participants recognized the incompatibility of what they called‘predatory, exclusive, exploiting, racist and patriarchal capitalism’ with the repro-duction of life and the meeting of human needs. In this context, participants upheldcivil, cultural, economic, political, social and sexual rights (MINREX, 2008). Aswill be demonstrated further on, this re-framing of human rights requires a deco-lonial reading of the institutional treatment of non-heteronormative genders andsexualities.
A genealogy of homo- and transphobia
The critique of homophobic society in Cuba stems from two distinct groups of narratives, that are similar only in that they are both politicized. On the one hand,there is the critique of ‘communist state-homophobia’, originating in the politicaldiscourse of Western liberal democracy in opposition to Cuban experiments of radical social change. The reading largely depends on anecdotal documents, vari-ous forms of journalism found in Western media, the writing of biographies andfiction (Epps, 1995; Young, 1981; Sanchez, 2011), and sometimes Western, radicalsocialist discourse which dedicates a considerable amount of attention to the hor-rors of Stalinism and other authoritarian experiments (Farber, 2011: 184–221).Reference is made to ‘concentration camps’ for gays, the maltreatment andforced hospitalization of persons infected with HIV, and the deportation of homo-sexuals and transgendered people, together with the mentally ill or handicappedand individuals prosecuted for anti-social behaviour, petty crimes and religiousfundamentalism (Bejel, 2001; Capo´, 2010; Negro´n-Muntaner, 2008).
The other trajectory of critique of Cuban homophobia is grounded in anautochthonous re-evaluation of social policies and public culture concerning sexu-ality and hegemonic masculinities3 throughout that nation’s history. 4
This readingis closely faithful to the methodology of decolonial thinking, linking historic-colo-nial (modern) constructions of dehumanizing exclusion and compartmentalizationson sexual identities with prejudices, attitudes, and popular and state positionstowards sexual diversities. Here, the story begins with the European, specificallySpanish-Catholic, colonization that brought to Cuba a series of codes, norms,typographies and ideas concerning sexuality that generally prevail throughoutmodern times: ideas about the family, masculinity and exclusive male–femalegender identities. Otherness in sexuality was often racialized and attributed to‘inferior’ cultures, ethnic groups and civilizations.5 Thereafter, with the replace-ment of religion by secular science and its reach to the Americas (Grosfoguel,2008), some of these norms were reinforced by academia and medical science. 6
Marxism-Leninism, as an imported ideology of European origin (albeit with Martiano adjustments made in Cuba), in its ‘anti-reactionary’, anti-religiousstance depended heavily on medical science which was evident at the time inEurope, the United States and the Soviet Union, to create an ideological andsocietal-normative response to sexualities.7 These are found in the pathologizationand treatment of homosexuality, transexuality, and the biomedical treatment of cases of intersexuality. Below, we expose a narrative that takes into considerationthe role of the feminist movement, its emphasis on education and the evolution of astate policy to combat trans/homophobia.
Revolution and emancipation
When it comes to understanding social policy on sexuality, it is important to con-textualize the Cuban revolution within the framework of the Cold War, wherebythe socio-economic, domestic and foreign policies adopted by revolutionary forcessituated the country and its post-revolutionary development trajectory within whatwas called the Soviet bloc. The composition of the Communist Party of Cuba(PCC) and the formation of civil society groups, the Constitution of 1976 and allthe laws and political structures that shaped public policy, education and everydaylife, were largely influenced by the Soviet experience (Carmona Ba ´ez, 2004: 72–9).Although some elements of Soviet-styled public policy proved to be progressive,especially in the advancement of women’s rights, other areas of concern, such asthe pathologization of non-heterosexual practices continued to reinforce the colo-nial and scientific reasoning that perpetuated trans/homophobic postures.Nevertheless, the 1959 Cuban revolution unleashed a complex process of socio-economic and cultural change that provided the basis for dialogue and(violent) confrontation between generations and social classes. During andthroughout that process a reconfiguration of gender relations also, questionedhegemonic masculinities (Castro Espı ´n, 2011a).
In 1960, the Federation of Cuban Women (FMC), an organized mass movementof women participating in the national political process, became the vehicle thatarticulated a project of women’s empowerment as subjects entitled to rights andparticipation in the process of socialist construction. The incorporation of womeninto the field of work outside the home had an impact upon both sexuality andreproductive patterns. Women took on a new public role, including participation innational defence during times of US aggression (Nun ˜ez, 2011; Sa ´nchez Parodi,2011; Waters, 2012).
By 1965, abortion had been legalized and institutionalized as a service providedby the national healthcare system free of charge and, on demand performed byspecialist medical personnel in hospitals with the women’s consent. This measurenot only contributed to the reduction of maternal deaths but also ensured women’srights over their bodies. (Espı ´n Guillois; Sosa, 2008) The initiatives taken up duringthe 1960s were institutionalized in the Family Code of 1975, which advocated equalresponsibilities for the education of children and for household tasks (Stone, 1981:182–200).
This repositioning of women in Cuban society cannot be divorced from otherrelated processes of emancipation, including the partial repositioning of Blackpeople and, the uplift of social sectors such as the unemployed, provincial migrantsand prostitutes (Garcı ´a, 2009). All of these claimed a stake in the revolutionaryprocess and were able to situate themselves in the context of building a radically new society. But it was the new position of women that enabled the questioning of hegemonic masculinities and practices. What it meant to be a ‘man’, a ‘woman’ anda ‘revolutionary’ were topics that enjoyed or suffered decades of public debate.
It was also the country’s feminist movement that brought about changes inattitudes towards sexuality both in the public sphere and in state institutions. Aparticularly remarkable breakthrough was the FMC initiative of facilitating thepublication of numerous scientific books by foreign authors, including El hombre y la mujer en la intimidad (Mann und Frau intim) and En Defensa del Amor (Pla ¨ doyer fu ¨ r die Liebe) by German sexologist Siegfried Schnabl, in 1979. For the first time inCuba, it was possible to read the uncensored opinion of a scientist asserting thathomosexuality was not an illness. It was not until Cuban scientists had access tothese foreign documents that a thorough re-evaluation of state positions on homo-sexuality began, and it was not until after the de-penalization of homosexuality inCuba in 1979, that these documents were made available to the general public.
Sex education
One of the principal actors in organizing feminist demands was chemical engineerand MIT student Vilma Espı ´n Guillois, who headed the FMC from its foundationuntil her death. In 1972, Espı ´n Guillois set up a multidisciplinary National SexualEducation Group (GNTES) to establish the National Programme of SexualEducation, which was recognized as state policy by the first Congress of theCuban Communist Party in 1975 under two resolutions: ‘On the formation of children and youth’ and ‘On the full exercise of the equality of women’ (Rojas,1978: 529–610). These emphazised the eradication of all forms of discriminationagainst women and included sex education in school curricula.Despite great resistance by the Ministry of Education, subjects related to repro-ductive function were formally introduced in school textbooks during the 1970sand 1980s. Still, it was not until 1996 that the Sexual Education Programme inSchool was established under the name of For a Responsible and Happy SexEducation
, with state support for research and publication (Castro Espı ´n, 2002:4–9).
In 1989, GNTES established the National Centre for Sexual Education(CENESEX), a state-financed institution under the Ministry of Public Health,whose mission was to coordinate a permanent but dynamic national programmeof sex education involving both central state administration and civil society organ-izations. The agenda and projects of the national programme were established bythe ministries of Public Health, Education and Culture and by the FMC and theUnion of Communist Youth (UJC). Since then, CENESEX has established a net-work of provincial and municipal working committees to carry out and monitor itsgoals and impact. As will be elaborated later on, its activities are focused ondeveloping sex education strategies in schools and more publicly, promotingsocial research and therapy, the provision of care for the Lesbian, Gay, Bisexualand Transgender (LGBT) community, as well as victims of violence and sexual abuse, and the production of educational materials. Cuba’s national sex educationpolicy evolved from an emphasis on women and their reproductive rights to a morecomprehensive outlook including gender diversity and the rights of individuals todecide over their bodies and identities (Castro Espı ´n, 2011a).
Combatting homophobia
Cuba continues to be a country where male chauvinism and homophobia is dom-inant in popular culture. These characteristics have been endorsed by RomanCatholic doctrine, the legacy of the Spanish Code of Social Defence – later theRepublic of Cuba’s 1938 Code of Social Defence (Roque Guerra, 2011: 218–26)and by modern scientific knowledge that stigmatized homosexuality, and otherbehaviour deviating from the heterosexual norm.
Literature produced in Cuba throughout the 20th century, including post–revolutionary literature concerning sexuality, only enforced homophobic ideas inpsychology, medicine, sociology, ethics and law. A notable exception was Sexologı´ a I, by Angel Arce Ferna ´ndez (1965) (Horta Sa ´nchez et al., 2011) aBlack revolutionary communist and physician who was later recognized as thefounder of Cuban sexology. Fernandez promoted the idea that homosexualitynot be considered an aberration or illness. According to a recent reflection writtenby his daughter, he was harshly criticized and censured (Arce Henderson, 2012).His work and experience provides evidence of debate and confrontation aboutsexual diversity, within medical and political communities of the time.
The existing medical sciences in Cuba acted at the time of the revolution as abloc against practices that were considered as signs of illness, the prelude to insan-ity and a mark of social moral decay. This religious-modern-socio-scientific bloc inhibited the process of shedding the colonial legacy of homophobia. The Cubanvariant of socialism, in which Che Guevara’s ‘new man’ became the central subject,was impotent in resolving this colonial legacy (Roque Guerra, 2011: 218–25). Therevolutionary project of breaking down social structures remained trapped in ahomophobia that was sustained by universal science. Arguelles and Rich (1984:691) attribute this, in part, to the influence that the pre-revolutionary, Stalinist,Popular Socialist Party had on the formation of political discourse regardinghomosexuality. They place responsibility on the ‘lesbian and homosexual intelli-gentsia’ concentrated in the National Union of Cuban Writers and Artists(UNEAC), which provided no public counter critique. However this displacementof blame masks essential structural aspects of homophobia in Cuban society,ignoring the colonial continuities that are to be found in state socialist positionsand social policies concerning sexual diversities.
The religious-modern-socio-scientific bloc favoured discriminatory towards les-bians, gays, bisexuals and transgender people for years. It gave rise to the estab-lishment of the Military Units for Production Support (UMAP) in 1965. Acompulsory civil-military service of forced agricultural labour for idle youth, religious dissidents and homosexuals in a context of continuous aggressions by theUS government, the UMAP was known for its reproduction of homophobia.UMAPs were closed three years later in 1968, as a result of an in-depth militaryinvestigation starting in the province of Camaguey and protests launched by asso-ciates of the UNEAC (Ramonet, 2006: 225).
Recently, Maria Isabel Alfonso, writing on racial dynamics in state policies of the 1960s, noted that the closing down of publishing houses and the censorship of certain authors by institutions like the UNEAC, aided the silencing of homosexu-ality in public culture (Alfonso, 2012). This can be seen as a form of epistemicviolence committed by the revolutionary state against Afro-centric writers, as wellas those belonging to non-heterosexual communities. It is only now, in criticalspaces like the journals Temas (on Culture Ideology and Society), Casa (onLetters and Ideas from Casa de las Americas) and Sexologı´ a y Sociedad (onSexuality and Society, produced by CENESEX) that the extent of the injusticescommitted are being exposed and debated.
The elimination of groups like the UMAP three years after its inception exem-plifies the huge contradictions prevailing during that period. It testifies to the factthat homophobia was contested by some of the progressive sectors of the revolu-tionary leadership. Nevertheless, discrimination resurfaced in other spaces such asthe First National Congress of Education and Culture in 1971. The final declar-ation of this meeting called for depriving homosexuals of the possibility of workingin the areas of education, culture and the media given their substantial influence onchildren and youth (MINED, 1971: 203). This was at a time when medical sciencesconsidered homosexuality to be a mental disorder, and the reinforcement of thismeasure was later called the ‘ parameterization’ (Fornet, 2006: 16). The Ministry of Education’s resolution was annulled in 1975 by the Supreme Court, which con-sidered it unconstitutional, and in 1976, the policy was changed on the initiative of the Ministry of Culture. It was not until 1979, however, that Decree-Law 175 liftedthe penalization of homosexuality in private, although public display of homosex-ual acts was still punishable until 1987 (Fornet, 2006: 19).
Throughout the 1990s, CENESEX carried out public education campaigns, thescreening of queer films and rallies against homophobia. In 2007, CENESEX ledthe first national International Day Against Homophobia, which has become anannual week-long campaign filled with activities and commemorative acts thatpublicize the state’s intention to eradicate homophobia. Central to their educa-tional campaign is the participation of non-heterosexual and transgender personstrained at CENESEX to carry out workshops on discrimination and HIV preven-tion at workplaces and schools. Following methods inspired by Brazilian Marxistpedagogue Paolo Freire, the activities are based on a needs-assessment defined bythose sectors of society most affected by discrimination. What has become veryvisible through these campaigns is the intersection of discrimination from gender,class, racial and territorial (provincial) perspectives, and a recognition that indi-viduals from poorer areas of the country and places where there is less care and support of LGBT people, are more disadvantaged and have greater complexitiesto deal with in their personal development and integration into society. 8 Throughout the provinces, participants in the workshops have identified theneed to work closely with families, especially in the case of transgender individuals,in order to create a support base in the immediate geographical community(Rodriguez et al., 2008: 105–48). Focus groups composed of transgender personsin urban areas have identified problems related to transphobic attitudes exhibitedby the police force (Castro Espin, 2011). Cuba has begun a process of pathologiz-ing sexist and trans/homophobic society. Including the voices of those traditionallypathologized, along with their communities and families, has constituted a shift inthe geo-politics of knowledge. This is where we can identify striking resemblancesbetween the reconstitution of Cuban social policy regarding the LGBT communityon the one hand, and decolonial thought and practice on the other.
Since 2008, the FCW has advocated for a bill modifying the Family Code,including new articles concerning respect for a free sexual orientation and genderidentity, as well as the legal recognition of same-sex couples. (Castro Espı ´n, 2011a)Cuba also signed the UN Declaration on Sexual Orientation and Gender Identityin 2008, an initiative made by the Republic of France (Worsnip, 2008).
Another institution that has been essential in the work to eradicate trans/homo-phobia has been the Cuban Multidisciplinary Society for the Study of Sexuality(SOCUMES), a professional association that through its working commissionsprovides a scientific framework for national public policy. The Commission forSexual Diversity is an associate organization of the International Lesbian, Gay,Bisexual, Trans and Intersex Association (ILGA) and like CENESEX adheres tothe Yogyakarta Principles9 for the application of International Human Rights inrelation to sexual orientation and gender identity (O’Flaherty and Fisher, 2008).
In January 2012, the Communist Party of Cuba (PCC) held a first-time nationalconference as a follow up to the sixth PCC Congress held in April 2011. In the finaldocument which was approved at this conference, the Party adopted a policy forthe active confrontation of racial, gender, religious, sexual orientation and other prejudices that may give rise toany form of discrimination or limit the exercise of people’s rights, among them publicpositions and those who participate in the political and mass organizations and in thedefence of the country. (PCC, 2012: 6)
This was the first time that a PCC document made an explicit statement concerningdiscrimination as regards to sexual orientation. Paragraph 69 of the same docu-ment speaks explicitly to public policy, encouraging the production of audio-visualmaterials and the orientation of the media, to reflect Cuban reality in all its diver-sity, specifically including sexual diversity the and diversity of sexual orientation(Garcı ´a, 2012). The inclusion of gender and sexual orientation in this clause reflectsthe government’s intention of implementing a social policy favouring the rights of LGBT people within the framework of Cuban socialism.
Contradictions and inconsistencies
The evolution of Cuba’s social policy regarding sexual diversity and self-determi-nation has taken an uneven course throughout its national institutionalpractices. This became evident in November 2010 when the UN GeneralAssembly’s Social, Humanitarian and Cultural Affairs Committee held its biennialvote on a resolution condemning extrajudicial, arbitrary or summary executionsbased upon discrimination. The resolution was amended by a number of Africancountries and supported by Caribbean, Asian and Arab States, alongside theRussian Federation. It sought to eliminate the term ‘sexual orientation’from the document and replace it with ‘discriminatory reasons on any basis’(Acosta, 2010). The Cuban delegation voted in favour of the amendment, contra-dicting Cuba’s vote in 2008 for the same resolution. Outraged by this act,a host of Cuban LGBT activists expressed their disenchantment with theMinistry of Foreign Affairs.
SOCUMES, headed by Dr Alberto Roque, together with LGBT activists andrepresentatives from different organizations10 successfully secured a meeting withForeign Minister Bruno Rodriguez Parrilla, who had to explain Cuba’s vote andlisten to grievances. Communist militant and blogger, Francisco Rodriguez Cruz(2010a), pointed out the contradictions between Cuba’s domestic policy and itscompromizing postition in diplomatic manoeuvres. Taking it a step further,Rodriguez Cruz (2010b) stated that professionals and activists had to workharder within Cuba to ensure that all national laws explicitly prohibit andpunish acts of discrimination on the basis of sexual orientation so that the countrycould maintain ‘a leading, coherent and steadfast position at the internationallevel’. One month later, at the 65th UN General Assembly meeting, where theresolution was finally approved, the Cuban delegation read an explanatory notereiterating Cuba’s interpretation of ‘discriminatory reasons on any basis’, whichexplicitly included discrimination against people according to their sexual orienta-tion (Republic of Cuba, 2010).
Scenarios such as the 2010 UN vote and the subsequent debate provideevidence to suggest that sectors of civil society composed of self-identifiedLesbian, Gays, Bisexuals, Transsexuals and Transgender persons are engagedat different levels of the state bureaucracy, combatting the marginalization of these groups in Cuban society and internationally. At the same time, the inter-pretation of official social policy continues to be an arena that presents a chal-lenge to the concept of sexual self-determination and emancipation in thisCaribbean country.
Transgender care and the decolonial epistemic turn
If the production placement and institutionalization of knowledge to be consideredpart and parcel of the modern world system of hierarchies, at few moments is thismanifested more than in the pathologizing of sexualities by governing bodies of scientific/medical authority. Until recently, the hegemonic paradigm for the treat-ment and care of non-conforming sexualities and gender identities was dictatedglobally by institutions vested in the medical sciences. By non-conforming we meanthose sexualities and gender identities that conflict with the modern societal normthat adopts the male–female dyad replicated within scientific literature and clinicalpractices. The most important of these institutions is the American PsychiatricAssociation (APA), which, since 1952 has produced the Diagnostic andStatistical Manual of Mental Disorders (DSM), a text widely used as an authori-tative reference for the diagnosing pathology. Due to debates carried out in themedical communities of Western societies, the DSM has seen the elimination, add-ition and re-articulation of pathologies related to gender and sexuality; amongthese, the pathology and de-patholigization of homosexuality and the separatecategorization of ‘gender disorder’ and gender dysphoria in children and adults(Jorge, 2010).
Within the family of the United Nations, the World Health Organization hassince 1948 endorsed the International Classification of Disease (ICD), also a widelyused text, which has likewise gone through various revisions concerning sexualpreferences and gender identities. The ICD, currently the ICD-10, continues touse the term ‘gender identity disorder’ and ‘transexualism’ to classify a variety of psychiatric disorders related to the incongruences between gender identity assignedat birth and identities assumed by children and adults, i.e. gender non-conformity(WHO, 2102). Finally, there is the World Professional Association for TransgenderHealth (WPATH), previously the Harry Benjamin International GenderDysphoria Association, that publishes and updates its non-diagnostic Standardsof Care (SOCs) and Ethical Guidelines for Health professionals but continues todepend on the DSM and ICD for medical reference and WPATH (2012: 4–20).
Throughout the last decade, the first two governing bodies, APA and WHO,which prepared the publication of revised versions of the DMS-V in 2013 and ICD-11 in 2015 respectively, have had their authority questioned by trans-activistsgroups and various professional associations worldwide, including associates of WPATH (Misse and Coll-Planas, 2010: 15–16). With much media attention,these institutions became the target of campaigns by those who reject the path-ologization of their sexualities. A crisis, of sorts, in the hegemonic paradigmadopted by most contemporary societies has opened the stage to new actors chal-lenging those authorities, that have often committed epistemic violence against thesubjects of scientific debate, i.e. those diagnosed, labelled, treated or cared for. 11
In a country where health care is considered to be a human right and thereforecovered completely by the state, all illnesses and perceived threats to health con-sidered by modern Western medicine are to be treated indiscriminately by health-care professionals. This is also the case with what, in Cuba, was previously called‘gender identity disorder’.
In 1979, at the behest of the FMC, the Cuban Ministry of Public Health createda multidisciplinary workgroup coordinated by GNTES – later CENESEX, for thediagnosis and treatment of transsexual persons. After the team conducted an international comparative study in different countries, it recommended that theMinistry of Public Health adopt the standards and protocols of care suggestedby the Harry Benjamin International Association of Gender Dysphoria (CastroEspı ´n, 2011c). In 1988, Cuban surgeons performed their first (male to female) sexreassignment operation. This action caused uproar at different levels of society andmost importantly within the National Health System, which disapproved the med-ical action (Castro Espı ´n, 2008). It was not until 20 years later, in 2004, that asecond sex reassignment surgery was permitted. Between those years, the multidis-ciplinary team took legal initiatives in assisting 13 individuals to change their firstnames and their identity card photos. It was impossible to change their sex onofficial documents, since during that time legal sex was to be determined accordingto the individual’s genitals (Castro Espı ´n, 2008: 24).
In 2004, CENESEX broadened the composition of the multidisciplinary work-group in charge of diagnosis and care for transgender persons, redefining its object-ives and bringing forth a national care strategy. Initially, this workgroup was calledthe National Commission for Gender Identity Disorder Care. But after havingconducted in-depth research in Cuba and other countries, and leading to the con-struction of a national narrative reflecting a Cuban need to depathologize, thegroup changed its name to the National Commission for Integral Care forTranssexual Persons. Mariela Castro (2008) notes:
We can confirm that transsexual people demanded that they be considered healthymen and women, socially responsible and therefore do not accept that they be treatedas people who are ill and much less as a threat to the social order. (2008: 24)
Currently, the Commission is composed of professionals from the various fields of medicine, psychology and the social sciences. The objectives of this Commissionare to: develop the protocol of care and integral health treatment for transsexualpersons; promote interdisciplinary research on dysphoria; develop educationalcampaigns directed at fostering respect and understanding among the public fortransgender individuals; propose a legal mechanism concerning Transcare; and,implement educational programmes for transgender persons and their families. Anational Strategy for Integral Care has been implemented through dialogue andconsultation with the Supreme Court, the Attorney General’s Office, and theNational Organization of Law Firms, as well as political and civil society organ-isations, including groups associated with the Trans community (Castro Espı ´n,2008: 15–43).
From 2004 onwards, CENESEX and SOCUMES began working from the per-spective of Human Rights, as they started to document the testimonies of trans-gender persons who had conflict been in with the law, police agents and reactionaryelements among the civil population in Havana. Many of those who testified andsought help from CENESEX were found in precarious situations. With the par-ticipation of transgender volunteers, CENESEX developed a needs assessment thatset the stage for depathologization. These same transgender volunteers, formed focus groups and became agents within the national educational strategy, settingup committees throughout the country.
Second only to France, Cuba became among the first in the world to depatho-logize transgender and the first in Latin America to incorporate all transgendercare into an equally accessible national healthcare system. Along with this, thepolicies and strategies adopted by the multidisciplinary Commission since 2010reverses pathologization, looking at hetero-normativity, sexist and traditionalhomophobic postures rampantly existing in contemporary society as the rootcause of gender dysphoria. This is what constitutes the decolonial epistemic turnin Cuba regarding social policy on sexual diversity. Both CENESEX and theabove-mentioned host of organs, commissions and civil society organisations con-tinue to work on the complete institutionalisation of depathologization through thelegal recognition of sex and gender change.
The underlying principle, as has been repeatedly recorded in Cuba, is sexual self-determination. It is the subject who should be empowered to decide over his/heridentity as male, female or other, without having any pressure from the medicalcommunity to modify his/her body. The role of professionals is to ‘accompany’ theindividual in his/her process of self-identification and possible change (CastroEspı ´n, 2011c). Education, which becomes a shared task between professionalsand those affected by trans/homophobia, is geared towards the transformationof society through laws, codes and shared values concerning gender and identity.
Global relevance
Writing on transgender care in the Netherlands, Kuyper (2012: 129) concludes thattransgender needs are not sufficiently taken into consideration and that a signifi-cant portion of the transgender population in the Netherlands does not feel suffi-ciently understood by the medical-scientific community and Dutch societygenerally. This is noteworthy, if one considers that the Netherlands is a countryknown for its advances in the treatment and care of transgender persons. Althoughthere is no room here for exhaustive comparisons of countries, assertions such asthat provided by Kuyper make the Cuban experience much more significant. Theepistemic turn in Cuba is remarkable in that the decolonial critique of sexual andgender pathology is now being incorporated into political discourses as well as theinstitutional treatment of transgender people. This process signals an acknowledge-ment and acceptance of sexual diversity on behalf of the representatives of theCuban state, its army of health professionals and sectors of society.
The consensus to depathologize non-confirming sexuality and gender in Cuba,especially transgender individuals, has had a significant impact upon the debatesthat have occurred worldwide, although this is not always recognized by health careprofessionals or activists in mainstream media. Since 2006, CENESEX andSOCUMES have organized an annual Congress on Sex Education, Orientation andTherapy that is attended regularly by scientists, professionals and activists from over30 countries, including representatives from WPATH, which in 2010 finally issued a declaration urging de-psychopathologization among the global medical community,and producing the WPATH (2011) Standards of Care for the Health of Transsexual,Transgender, and Gender Nonconforming People. WPATH President Dr Lin Fraser(WPATH (2012c)) observed that the 2012 symposium was significant in that it pro-vided a synopsis of their DSM, ICD and SOC consensus process, demonstrating theclinical application of WPATH’s evolution and a snapshot of their human rights andpublic policy work. Furthermore, Cuba has proven to be a bridge linking the work of this international association with professional groups and organizations throughoutLatin America and the Caribbean.
Argentina followed Cuba in the depathologization of transsexuals and trans-gender persons but took it a step further in the legislative field, recognizing andrendering complete sexual and gender-self-determination. The 2012 Argentine Lawof Gender Identity recognizes depthologization, allowing for citizens to decide theirown gender identity and thereby entitling them to change their sex on officialrecords by judicial declaration without the need for any medical intervention what-soever (FNLIG, 2012). The changes in legislation have come under the discourse of human rights, citing the Yogyakarta Principles. US-based physician and ExecutiveDirector of Gender Rights Maryland, Dana Beyer, has remarked that ‘[I]t is arecognition of innate human variation, and the ability of human beings to knowthemselves sufficiently, to live free and pursue happiness. It is the new standard forglobal human rights’ (IGLHRC, 2012).
Finally, on 1 December 2012, the APA announced that its Board of Trusteesapproved the publication of the DSM-V to be published in 2013 (APA, 2012). Thisnewly revised edition has proven to be a step forward in the depathologization of transsexuals and transgender persons, replacing the term Gender Identity Disorderwith Gender Incongruence. While applauding APA efforts, WPATH (2012a) akesissuewiththetermGenderIncongruenceasitcontinuestosuggestthat‘congruenceisthenormandthatincongruenceisperdefinitionproblematic,whichisnotnecessarilythe case’. The professional association prefers the term Gender Dysphoria, the termnow used in Cuba, in order to recognize that diagnosis is only needed in cases wheretransgender individuals experience significant distress associated with their gendervariance. The stress is recognized as fundamentally induced by society and culture.
The call on behalf of transgender persons worldwide to healthcare professionals,as well as to legislators and other governmental authorities, to radically changetheir practices and ethics, as Butler has suggested in 2010, found allies in Cuba’snational health care system. As has been demonstrated, this was made possiblethrough a long process of decolonizing knowledge, drawing on a Cuban feministperspective with an emphasis on popular education and the principle of sexual self-determination.
Final considerations
Our intention here has been to provide a conceptual framework for understandingpublic policy on gender and sexual diversity in Cuba and how it was shaped. Key to this study has been the principle of sexual self-determination as a human right,allowing for each individual to define his or her own orientation, condition andgender identity without the stigmatization proposed by psychiatric pathology orthe religious-modern-socio-scientific bloc that until recently has dominated Cubansocialism and its management of sexuality. This process of emancipation, whichhas its roots in Cuban feminism and its influence upon sex education, cannot beseen as an accomplished deed but as an ongoing process that at times finds itself caught in a battle with state bureaucracy domestically and with internationalbodies.Border thinking, the rescuing of epistemologies of subalterns marginalized bymodernity/coloniality science, medicine and law, has, in the case of Cuba, provento be a useful tool in the reformulation of ethics. What the Cuban experience sug-gests is that universal ideas of emancipation and good treatment cannot be exclu-sively contained in definitions provided by Westernized, scientific hierarchies.Contrarily, the solutions to the problematic of non-conforming identities, sexualor otherwise, can be found in a decolonial reading of the institutions and socialrelations that constitute contemporary society. This requires Cuban policymakersto reconsider the political trajectory of the country, recognizing and denouncing thehorrors committed against non-heterosexual communities, and to shed itself of sci-entific dependency on Western pathology and the legacy of Cold War alliances thatbring to the fore inconsistent positions in the area of human rights.The methodology used in educational programmes and in shaping social policyfocuses on the needs assessment carried out among communities and families of LGBT individuals, exercizing the means proposed by Paolo Freire, and reveals thepossibilities that are to be located within the current political framework.Paramount to this work is an intersectional approach that considers trans/homo-phobia to be related to other forms of discrimination; namely of race, class andgender.What we have found is that the changes in social policy and health care practices,which the Republic of Cuba is now undergoing in its legal application of sexual self-determination, has been guided by the narratives of diverse autochthonous groups,educators, social activists and professional health care providers within a highlypoliticized context. Leading figures of the LGBT community saw to it that socialpolicy fell into the framework provided by the country’s ruling Communist Party.For nearly a decade, between the fall of the Soviet bloc in 1990 and the buildingof friendly relations between Cuba and Venezuela since Hugo Chavez’ rise topower in 1999, Cuba was isolated politically. It is interesting to note that preciselyduring this time of seclusion, social policy regulating gender and sexuality madegreat advances in favour of non-heterosexual communities. These developmentsreceived scant attention in academic journals in North America and Europe. Thepoliticized nature by which the case of Cuba has been studied, however, should nothinder the expansion of research on sexuality and social policy in this country.
The authors of this article recommend that rigorous ethnographical research beconducted in order to assess the impact of the changes in social policy and the way it is experienced by the concerned population in Cuba. This can be done by takinginto consideration the work that has already been achieved by Cuban institutions,which throughout the last two decades have built stronger ties with both scientificbodies that are willing to revise or at least question their own standards, as wellas with LGBT communities internationally. A cross-sectional study of the impactof social policy change, depicting improvement in the quality of life, may prove tobe beneficial in concretizing the notion of sexual self-determination. To this end,the authors also endorse further analysis of the operationalization of new ethicalstandards in clinical practices and research endeavours in Cuba, so as to criticallyidentify areas that need more support in carrying out social and public policy-making regarding gender and sexuality.
Funding
This research received no specific grant from any funding agency in the public, commercial,or not-for-profit sectors.
Notes
1. Also called,
Libre orientacio´ n sexual e identidad de ge´ nero [Free sexual orientation andgender identity]. See Castro Espı ´n (2008: 172); CENESEX Code of Ethics: http://www.cenesex.org/socumes/codigo-de-etica-para-profesionales-de-la-sexologia-en-cuba/(accessed 27 July 2014); Declaracio ´n Hombres por la Diversidad para la Vta JornadaCubana Contra la Homofobia: http://hxdcuba.blogspot.nl.
2. Martiano thought refers to the legacy of Cuban national hero Jose Marti, as stated in theConstitution of the Republic of Cuba.
3. In the late 1980s, Canadian intellectual and bioethicist Blye Frank introduced the conceptof hegemonic masculinities to political economy, arguing that heterosexuality and mas-culinity are ‘social accomplishments of political nature located within a larger set of political, economic and social relations’ (Frank, 1987: 160–1).
4. In 1984, Arguelles and Rich argued: ‘The need for a distinctively Cuban socialist counter-critique on behalf of homosexuality is increasingly evident. It must reconcile lesbian andgay male experiences with the island’s realities and offer the international gay communitycritical insights into the immensely complex, rich, expressive and problematic nature of those experiences. Until such a countercritique exists, the manipulation of the Cuban gayissue by anti-Cuban interests will remain largely unchallenged, and homosexual experi-ence will continue to be marginalised within Cuban society’ (1984: 684–685).
5. For a good read on the racialization of sexual practices and codes, see Stolke (1992).
6. The first documented statement on the need to pathologise homosexuality in Cubawas from Dr Luis Montane ´, author of infamous article ‘La Pederastia en Cuba’, whichwas presented at the first Regional Medical Congress of the Island of Cuba inJanuary 1890.
7. It is particularly the influence of Stalinism in both Cuba’s pre-revolutionary Communistparty (PSP) and the political organisations, which were consolidated into the PCC in 1968that is regarded as the source of politically charged persecution of non-heterosexuals inCuba during the first two decades of the revolution. See Roque Guerra (2011) and Evans(2011). Lilian Guerra (2010: 270) provides the counter argument that assault against homosexuality as well as youth culture in general ‘was intrinsically connected to essen-tialist standards of judging what made a citizen ideologically reliable and worthy of inclusion in the category of ‘‘revolutionary’’’. The problem with this line of argument isthat her depiction of totalitarian society leaves absolutely no room for the changes thatare taking place now, which are rooted in debates that can be found throughout theentire revolutionary period. The debates, other than scant mention of denunciations bywell-known public figures in the article’s abstract, are not documented.
8. It might be interesting to note here that in a 2011 interview conducted by the authorsof this article, CENESEX director Mariela Castro Espı´n commented on the absence of aGay Pride parade in Cuba: ‘We do not have a gay pride parade. We make a Conga, a Cuban dance form that is very satisfactory and more pleasuring from a rhythmicand sound standpoint, visualising among the population the need to work-off prejudice.We do not uphold ‘gay pride’ because there is also heterosexual pride, lesbian pride,the pride of trans people, we do not see just gay. We focus the eyes of the population onhomophobia, that is what we believe should be changed; you must unravel homopho-bia in order to articulate the full respect for the dignity of individuals. Furthermore,homophobia is closely linked to other forms of discrimination that LGBT peoplealso experience, namely: racial discrimination, discrimination by geographical area,between those living in rural and non-urban areas, in being an immigrant and notnative, as a non-white person, as a woman, age, etc. Thus, there are many forms of discrimination and we identify homophobia as a form of discrimination that has notbeen sufficiently dealt with, and it is not yet contemplated by international and nationallaw; and where it is recognised, it is not sufficiently treated by law.’ (Castro Espı ´n,2011b).
9. In 2006, in response to well-documented patterns of abuse, a distinguished group of international human rights experts met in Yogyakarta, Indonesia to outline a set of international principles relating to sexual orientation and gender identity. The result wasthe Yogyakarta Principles: a universal guide to human rights which affirm bindinginternational legal standards with which all States must comply. They promise a differ-ent future where all people born free and equal in dignity and rights can fulfil thatprecious birthright: http://www.yogyakartaprinciples.org/principles_en.htm
10. In Cuba there are over 17 organisations and online blogs promoting sexual diversity andproviding service to sexually diverse communities. See CENESEX website: http://www.cenesex.org/.
11. See Manifesto of the International Network for Trans Depathologization, on StopTrans Pathologization: http://www.stp2012.info/old/en/manifesto
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