April 15, 2016 |

Narratives Transforming Narrative A Call to Rethink our Clinical Approach to Medical Transition

A Senior Honors Thesis submitted in partial fulfillment of the requirements for the degree of Bachelor of Arts with Honors in Science and Society Brown University

Noah Vincenzo Lupica

Science Technology and Society (STS)

Brown University ‘16

Thesis Advisor: Sherine F. Hamdy, Ph.D.

Second Reader: Deborah F. Weinstein, Ph.D.

1

2 Table of Contents INTRODUCTION ...... 6 Sub Heading ...... 6 A Situated Clinical Moment ...... 6 GeMS Program, Boston Children’s Hospital ...... 6 The Production and Interpellation of Language and Categories ...... 14 The Evolution of Language ...... 14 Categories and The Category “Transgender” ...... 16 The Trans CommunityTM ...... 17 Negotiating Narrative and Building Arguments for Medical Transition ...... 21 PART I ...... 23 The Emergence of a New Patient Population ...... 23 Historical Context and the Construction of Sex and Gender ...... 23 Overview ...... 23 The Body and Society as Metaphor ...... 27 Endocrinology and New Possibilities of Sex ...... 33 Biological Essentialism ...... 38 Strategic Essentialism ...... 41 The Collective Transition Narrative ...... 42 Homosexuals, Transvestites, and ‘Dis Interested Science ...... 43 Arguments for AccesSEX ...... 46 Early Case Reports and Patient Narratives ...... 46 Active Negotiation of Narrative ...... 49 PART II ...... 53 Negotiating the Terms of Care ...... 53 Clinical Categories and Processes ...... 53 Overview ...... 53 Language and Identity Categories ...... 54 Current Conventions and Over-Performance ...... 60 First, Do No Harm ...... 62 Situation within Mental Health ...... 67 ICD-10 Terminology and Frameworks ...... 67 DSM-5 Terminology and Frameworks ...... 68 Negotiating The Terms of Care ...... 69 The Rise and Rhetoric of Gender ...... 69 PART III ...... 74 Narratives in Theory and Practice ...... 74 The Action of Rhetoric ...... 74 Overview ...... 74 Interpellation ...... 74 Language as Productive vs. Language as Referential ...... 75 "The Looping Effect of Human Kinds" ...... 75 Metaphor "It's All in Your (genderbr)Head" ...... 76 The Action of Medical Narrative ...... 78 Medical Narrative in Theory ...... 78 Medical Narrative in Practice ...... 79

3 Social Rules Governing Gender ...... 81 Alternative Narratives ...... 82 Threats Perceived from Within ...... 82 Not Trans-Enough ...... 85 Alternative Narratives ...... 86 Somaticorporeal self-concept ...... 87 The Materiality of Reading Gender and the Body ...... 89 Conclusion About Medical Narrative ...... 92 CONCLUSION ...... 93 A New Diagnostic Paradigm ...... 93 Overview ...... 93 The Futility of Mapping Dynamism in its Fixity ...... 94 Challenges to a New Paradigm ...... 95 Informed Consent ...... 96 A Final Word on Behalf of The Trans Community™ ...... 97 Appendix A: ...... 102 Vocabulary and Relevant Terminology ...... 102 Appendix B ...... 103 2016 ICD-10-CM Diagnosis Code F64 - Gender Identity Disorders ...... 103 ICD-10 Criteria and Clinical Information for Diagnosis ...... 103 - 2016 ICD-10-CM Diagnosis Code F64 — Gender Identity Disorders ...... 103 • F64.1 Gender Identity Disorder in Adolescence and Adulthood (Specified Code) ...... 103 • F64.2 Gender Identity Disorder of Childhood (Specified Code) (Pediatric Dx, 0-17 years) .. 103 • F64.8 Other Gender Identity Disorders (Specified Code) ...... 103 • Diagnosis Code F64.9 Gender Identity Disorder, Unspecified (Specified Code) ...... 103 Appendix C ...... 105 DSM-5 Diagnostic Criteria ...... 105 Appendix D ...... 107 Selections From The WPATH Standards of Care, Version 7 ...... 107 Informed Consent ...... 107 Relationship Between the Standards of Care and Informed Consent Model Protocols ...... 107 Overview of Procedures for the Treatment of Patients with Gender Dysphoria ...... 108 Ethical Questions Regarding Sex Reassignment Surgery ...... 108 Reconstructive Versus Aesthetic Surgery ...... 108 Criteria for Surgeries ...... 109 Criteria for Feminizing/Masculinizing Hormone Therapy (One Referral or Chart Documentation of Psychosocial Assessment) ...... 109 Criteria for Breast/Chest Surgery (One Referral) ...... 109 Mastectomy and Creation of a Male Chest in FtM Patients ...... 109 Breast Alteration (Implants/Lipofilling) in MtF Patients ...... 109 Criteria for Genital Surgery (Two Referrals) ...... 110 Hysterectomy and Salpingo-oophorectomy in FtM Patients and Orchiectomy in MtF Patients .... 110 Metoidioplasty or Phalloplasty in FtM Patients and Vaginoplasty in MtF Patients ...... 110

4

5 INTRODUCTION Sub Heading

A Situated Clinical Moment

GeMS Program, Boston Children’s Hospital

“What sort of fantasy role playing did you partake in?” The psychologist could see that her question confused me. My brows furrowed, and my head cocked slightly. She continued,

“For example, what did you choose to be for Halloween?” A deep-set pang and twisting overtook my stomach. The perpetual bounce of my right leg, rocking on the ball of my foot, evaporated. I made every effort to maintain the muscle tension in my face so as not to hint that there was anything behind my initial look of confusion. I stopped breathing. My heart beat faster in my chest, and my mouth went dry. My eyes flitted from the child psychologist, to my mother, back to the psychologist, and to the file she had on me, laid open but out of my view on her otherwise empty desk. The already small room seemed to become smaller, slowly closing in on me––I thought of the garbage compactor that trapped Luke Skywalker, Han Solo, Chewbacca, and Princess Leia in the middle of Star Wars Episode IV. Focus, Noah. Focus. My knuckles grew white from the vise grip my hand had on the knees of my khaki pants. I could feel my palms begin to sweat.

I was fifteen. My mom and I were in our second hour of the day-long interview. The doctors called it a “psychological evaluation,” but I knew what it really was––a gender test.

After six months of obligatory “therapy,” I earned a letter recommending this further evaluation.

I spent those appointments probing for information, studying, preparing––learning this process and what lay ahead. I was good at taking tests. Tests were qualifying, and I was clearly qualified. I was also––though I knew I couldn’t show it––terrified.

6 I made to swallow, but the effort was futile. There was a lump in my desert of a throat. I knew the answer to the psychologist's question. It wasn’t a hard question in that sense. My eyes continued to flit back and forth––to the psychologist, to my mom, to the psychologist, to my mom, to my file on the desk––the rest of my body, still frozen.

I was pretty sure I knew what the psychologist had in my file. I knew what my therapist and this psychologist wanted to hear––what story they were looking for. Consistent, insistent and persistent “cross-gender” identification.1

“Well,” my mother began, hesitant, because, as well as I tried to mask it, she recognized the terror in my eyes. “When you were 2 years old, you were a blueberry.” I nodded slowly. This costume was not one of concern. Nor was the costume I wore the year after––a skunk. But, when I was five, I dressed as Loonette the Clown from “The Big Comfy Couch,” a television program on PBS. She wore oversized salmon colored overalls, black and white striped socks, big glasses, a purple hat with holes for ponytails on each side of her head, and a big red nose. When

I was seven, I dressed as Hermione Granger, complete with Gryffindor house robes, a wand, and a stack of books. I loved both of these characters, and while I wanted to emulate them as people, I had no interest in having bodies like theirs. Even though all of my other costumes were definitively masculine, the incriminating detail––a detail that broke my heart and made my stomach turn––was that Loonette and Hermione were girls. I could not afford to give this psychologist any reason to think I was, at any point, comfortable being a girl. It didn’t matter what “girl,” “boy,” “woman,” and “man” actually meant to me, nor did it matter that, in my mind, a more pressing issue than whether I thought of myself as a boy or girl was the thought of

1 Human Rights Campaign. (2016). Transgender Children & Youth: Understanding the Basics. Retrieved April 15, 2016, from http://www.hrc.org/resources/transgender-children-and-youth-understanding-the-basics/

7 my body becoming a woman. What mattered was that this psychologist might decide that these two Halloween costumes were enough for me to fail this “gender test”––one that assumed the dichotomous opposition between male and female within a wider social structure in which femaleness was denigrated––to be properly male in this context was to reject all aspects of femininity.

I could feel the room begin to swim. Realizing I still had not taken in a breath, I opened my mouth and gave into my autonomic reflexes. With each inhale, my chest rose and fell, fighting against the compressing force of the polyester-spandex blend binding it.2 I pulled at the hem of my argyle sweater vest, attempting to make it lie flat on my body. Futile.

My options were these: 1) lie, 2) omit, 3) disclose. The prospect of lying made my heart race and my mouth go dry again. Guilt weighed on me just at the thought. I forced away the confused expression I held on my face and began to speak.

***

Now, nearly eight years later, I have the distance and analytical skills gleaned from the humanities and social sciences to look back on this experience as an artifact––a moment situated in a certain time and place. The fears and anxieties, which, then, swirled within me, may now seem unfounded, or perhaps irrational, but I can assure you, the concerns and perceptions I express here were of a very real threat––a threat to what medical options I might have in the future, a threat to my social identity, and a threat to my sense of autonomous rule over my body.

2 “Binding” refers to flattening breast tissue to create a male-appearing chest using a variety of materials and methods. For more on binding see, Ira. (2010). Chest Binding 101. Retrieved April 15, 2016, from http://transguys.com/features/chest-binding

8 In this work, I position myself simultaneously, as researcher and as subject. I draw on my own experience as much as draw on theoretical to guide my inquiry and my analysis.

I have spent much of my undergraduate career studying human bodies on the micro and macro scales; beyond an exploring the biological possibilities of the human form and function, I exploring the intersections of identity and medicine. I offer this work as a sort of case study for how medical and scientific ideology can facilitate the formation of both clinical and social identity groups throughout history via the medicalization of identity as it atypically presents itself on the body. My interest in this phenomenon, and my approach to examining the human body, was born from my own experience with gender, body, and surgery early in life. I began my social and medical transition in high school and since then have enmeshed myself within the discourses, ongoing in the present day, around clinical characterizations of trans experience as they relate to the process of diagnosis and treatment which constitute “medical transition.”

I wanted to critically examine the intersection of gender, sex, culture, society and the body beyond my singular experience and subjective understanding. In the summer of 2015, I conducted independent narrative research on trans identity, experience, and embodiment. I spoke with sixteen US college students from around the country. Eleven of my research subjects identified as trans, non-binary, genderqueer, and/or otherwise gender non-conforming.3 Five of my research subjects identified as cisgender, or cis.4 As I will discuss as we go on, these categories of gender are complicated and difficult to define in any universal way. I was interested in how trans and cis students comparatively understood, experienced, and grappled with gender and their own embodiment. Early in the course of my research, I recognized that enormous tension arose

3 A category; an umbrella term referring to anyone who identifies with a gender other than the one typically associated with the sex assigned to them at birth. 4 A category; referring to anyone who identifies with the gender typically associated with the sex assigned to them at birth.

9 among my interview subjects––cis and trans alike––when I asked them to articulate the nature of gender. Given how pervasive and socially engrained the sex/gender5 binary seems to be within contemporary US society, I found this tension curious. In Part I of this work, I will contextualize the emergence of gender and its relation to previous concept(s) of sex/gender in western medicine and society.

In 2013, roughly four years after the child psychologist proctored my “gender-test,” the standards to pass were changed––the diagnosis “Gender Identity Disorder” (GID) present in the

DSM-IV, was replaced by the diagnosis “Gender Dysphoria” in the DSM-5. Since 2013, this revision seemed an odd choice to me and only seemed more curious as time went on. Reflecting back on the moment I described from my evaluation at the GeMS clinic, I did not experience dysphoria, as the psychologist was looking for it, around gender––I understood my discomfort to be entirely physical and more an issue of what I will introduce and term in Parts II and III as

“somaticorporeal self-image.” I make an important distinction, here, between sex as a material somatic and corporeal phenomenon, and gender as a social phenomenon. This distinction, and the failure of medical authorities throughout the late 20th and 21st century United States to fully recognize, grasp the nuances of, and adopt this distinction, is a central tension around which the following arguments and analysis revolve.

Part of the anxiety depicted in the clinical moment I shared with you stems from my internalization of the language used by the field of psychiatry to discuss transgender identity and transition. At the time, I did not have the words to precisely articulate my experience––and to some degree, I am still without them––yet, I knew what I wanted needed for my body. Even here,

5 I will use the term “sex/gender” to indicate the ideas in conflation. When I use the terms separately, I follow the convention embraced by the subjects of my research and The Trans Community™ where sex and gender are distinct, the former referring to the composite of sexed parts and attributes of the body, and the latter referring to the social convention of behavior, performance, and expression.

10 as I reflexively strikethrough the word “want” and replace it with “need,” I illustrate, unintentionally, that social relations and language are co-produced in tension with one another.

For example, I describe the alteration of sex as a “need” because I know that if I describe it only as a “want” then I could be denied medical attention and my credibility as a “worthy” patient–– this is one source of tension.

Another source of tension is the contingency of medical authority. In Part I, I explicate the co-production of a new patient population––the recognition of common complaints among individuals who stood to benefit from similar treatment. I further situate the emergence of what

I call “The Conventional Transition Narrative” within social, cultural, and historical frameworks of western scientific and medical ideologies of sex/gender. The terms of this Conventional Transition

Narrative, are the product of collective ongoing negotiation between patients and providers. I say theses social relations were produced in tension because throughout their negotiations of language, metaphor, and narrative, each party stood with something to lose and something to gain from their involvement with the other. At stake for providers was their reputation in society and in the medical community. At stake for patients was the validity of their claims and their ability access to sex altering procedures and therapies. Patients were beholden to their providers in order to access medical care, and those providers relied on the compliance of their patients to maintain their position as the medical authority on sex alteration and––at various points in time–

–on “transvestism,” “transsexuality,” or “gender dysphoria.”

“Gender dysphoria” is currently a clinical psychiatric diagnosis which qualifies a person to access surgical and/or hormonal procedures to alter the sex of one’s body. How did this criterion, contemporary clinical guidelines, and standards of care become accepted clinical or medical “knowledge” within the frameworks of contemporary western medicine? What

11 conditions enabled sex altering medical procedures to be recognized as medically necessary for certain patients and not others? To answer these questions, I will to Bruno Latour's theories and writings on the production of scientific knowledge. Latour identifies the processes by which rhetoric is strengthened: as a theory or an argument becomes stronger, as the debate surrounding it settles, and the argument is accepted as fact or knowledge, it is removed from its original setting and the context of its construction is erased. Latour's theoretical frameworks are essential tools in any analysis of changing medical, social, or scientific, discourse over time.

The significance of “medical necessity” and the tension, forces, and conditions, which demand its reification and continued demonstration, will be discussed at further length in Parts

II and III. In Part II, I will discuss the construction of diagnostic categories and explicate the terminology and frameworks within which medical transition––the process of making physical alterations to the sex of one’s body––and, what I will call, “The Conventional Transition Narrative” are situated.

“Medical transition”6––as opposed to "social transition"7 or "legal transition"8––is the vernacular term within The Trans Community™ for the process by which an individual undergoes hormonal therapies and/or surgical procedures to physically change or alter the sexed parts or characteristics of their body (e.g. alter patterns of body hair growth, fat distribution, chest/breasts reconstruction, genital reconstruction, etc.). As we will discuss throughout the coming chapters, medical authorities within the contemporary US have accepted a certain model

6 Changing one's sex characteristics through medical procedures, including surgery and hormone therapy. This may require a diagnosis of Gender Identity Disorder (see Appendix C) and/or Social transition. 7 Changing how one is viewed by others by making one's gender identity public, which may also include changing names and asking others to use different pronouns. Being stealth is a form of social transition in which one's gender identity is the only gender one is known as. 8 The legal process by which one changes the legal documentation of their sex/gender, either “M” for male or “F” for female; currently, this process differs enormously in process and possibility from state to state; see also, ID Documents Center. (2015). Retrieved April 12, 2016, from http://www.transequality.org/documents

12 of “transition.” Patients must present themselves and articulate their experiences within certain narrative frameworks, identify certain goals and motivations for transition, undergo certain procedures or therapies according to a certain timetable/schedule, etc. Trans activists, as voices of The Trans Community™, make efforts to qualify the idea of transition––medical, social, and legal––typically recognizing it as a personal and individual––rather than universal––process.

Such qualifications are made so as to push back against ideas that transition is universal, in either its motivation or course, among trans individuals.

In Part II, we will discuss the ways in which prevailing medical authorities on trans health,9 under the political and legal pressure of trans activists, purport to embrace the views and language of The Trans Community™, and then proceed to disregard them, perpetuating the very view of transition as an individual process. Yet, as we will see, clinical guidelines and the use of language to discuss the medical transition seem to contradict. The term "transition" is vague and unspecific with regard to what it refers, even with its modifiers “medical,” “social,” or

“legal.” Although the ambiguity of this term contributes in large part to its adoption by The

Trans Community(TM), I aim to recognize such coded language, elucidate when, where, and to what effect, it is deployed, and ultimately avoid its use in favor of more explicit and direct language. For example, I will avoid using phrases such as “gender affirmation” or “sex/gender reassignment” in reference to medical transition where context permits to avoid using terms of gender when discussing procedures to alter the sex of the physical body.10

9 Fenway Health Defines, “Fenway Health considers trans health care to be an integrated part of primary health care. All medical providers at Fenway Health are trained in and provide trans care, including hormone treatments.” http://fenwayhealth.org/care/medical/transgender-health/ 10 I will also avoid using the phrase “sex change” where context permits, electing instead to use the language sex alteration. The manner in which the phrase “sex change” was employed by and within mainstream popular media in the 20th century United States served to objectify, fetishize, and stigmatize those who sought to change their sex. While the phrase “sex change” most descriptively and directly names what is otherwise known as “medical transition,” the phrase is negatively loaded in the public subconscious of contemporary US society and carries with it years of stigmatizing images and representations in the popular

13 In Part III, we will recognize language as productive of social identities and social relations, rather than merely describing them or referring to them as they already pre-exist outside of language. We will further recognize the manner in which language, metaphor, and narrative shape the possible imaginary. The words and frameworks—with and within which I situated my fears, anxieties, and the narrative I learned to present—are ripe for this analysis.

Further, this moment of clinical evaluation prompts recognition of the influence that the internalization of certain language can have on a person’s own concept of self.

The Production and Interpellation of Language and Categories The Evolution of Language

All language evolves. In discussions of the language and categories that signify, identify, and refer to sex and gender, we must remember that their contemporary uses and meanings are products of linguistic evolution. As discourse applies pressure to a category, that category evolves. Exceptions to categorical rules become more evident, and as these rules approach self- contestation, we reach a node of differentiation—rhetoric reaches a point of no return— where multiple distinct categories are born from a single origin. For example, in the 1960s, second- wave feminism took the singular idea of sex/gender, and made the distinction between “sex” and

“gender.” What complicates and adds to the confusion of this evolutionary process, in particular, is that linguistic differentiation and redefinition occurred, and still occurs, in piecemeal fashion and through multiple sources. That is, there is no single point at which we can locate the divergence of terms. To fit within extant ideological frameworks, existing symbols are retained while the criteria by which their referents are defined undergo incremental change over time.

New categories would be introduced to typify and classify those individuals who, years before,

media. Although the words “change” and “alter” are synonyms, the same historical images have not been attached to each word

14 may have fit and existed within another category, the name of which may still exist, but may now have a distinct, more specific referent. The two categories of individuals may now be disparate entities with distinct labels; whereas before, they may have been an indistinguishable collective coded by the same language. Throughout the negotiation and evolution of language on sex and gender, new signifiers were introduced but old signifiers were rarely discarded, even as their referents diverged, were modified, and were specified. Narrative and nomenclature for sex, gender, and identity, in social, medical, and legal spheres, we will see, evolved through the active negotiation of meaning between laypeople and experts. Involved in these negotiations were those clinicians and researchers who would entertain the idea of mutable sex and certain patients who would endorse and internalize the language of “cross-gender” or “cross-sex” identity to describe their experience. This ongoing linguistic and categorical negotiation is embedded within, and cannot be removed from, the socio-political, socio-legal, and socio-economic fabric of 20th and 21st century western medicine.

While sex was understood in terms of biological differences, regarding genitalia and procreative functions, gender was considered to be a cultural creation that refers to a differential social classification between men and women.11 In the absence of consensus on the exact definition of gender, trans activists were able to leverage uncertainty and offer gender as a form of “psychological sex.” According to trans and queer theory, both sex and gender should be understood as cultural constructions. Oppression spawned a gender construct which then seized on a socially meaningless anatomical difference to create the socially significant category of sex.12

In fact, what might prove to be the case is that the distinction between sex and gender is no

11 Oakley, A. (1972). Sex, Gender and Society. Maurice Temple Smith Ltd. 12 Delphy, C., & Leonard, D. (1984). Close to Home: A Materialist Analysis of Women’s Oppression. University of Massachusetts Press.

15 distinction at all.13 Sex can be understood to be gender, since the sex/gender attributed to individuals is always culturally created.14 When I acknowledge the constructed nature of sex, I refer specifically to the arbitrary distinctions that set the bounds between male and female designations of anatomy.15 The feeling and physical sensation of embodiment––what it feels like to have sexual anatomy––is separately at issue, and more the focus of discussions of sex in this work.

Categories and The Category “Transgender”

Categorization is a means of socially organizing people and ideas. The book Imagining

Transgender is based on David Valentine’s 1990s ethnographic fieldwork among trans populations in New York City. Valentine recognizes "transgender" as “an imagined umbrella category,” encompassing an endlessly broad range of gender-variant individuals and identities and serving as a central cultural site for elucidating the meanings of gender, sexuality and their relation to one another.16 As Valentine further recognizes, the history of “transgender” as an inherently exclusionary category, the bounds of which were imported from, and even imposed by, certain groups with particular agendas and interests that exist(ed) outside the category itself (e.g. social service providers, academics, and trans civil rights and social justice activists).17 Medical providers and sex researchers who worked with patients looking to alter their sex were also heavily implicated in the construction, social import, and imposition of the category transgender and the category transsexual before it.

13 Butler, J. (1990). Gender Trouble: Feminism and the Subversion of Identity. Routledge. 14 Butler, J. (1990). Gender Trouble: Feminism and the Subversion of Identity. Routledge. 15 Fausto-Sterling, A. (2000). Sexing the Body: Gender Politics and the Construction of Sexuality. Basic Books. 16 Valentine, D. (2007). Imagining Transgender: An Ethnography of a Category. Duke University Press. 17 Enke, A. (2009). Imagining Transgender: An Ethnography of a Category (Review). NWSA Journal, 21(2), 198–203.

16 The Trans CommunityTM

Within the fields of medicine and public health, the term “community” simply refers to a population not in the clinical setting. This label reflects the relationship between physicians and the trans patient population––physicians being those who rule the clinical setting and the trans community being those who seek access to it.

The term “community” in non-medical settings names a feeling of fellowship with others, as a result of sharing common attitudes, interests, and goals. In the mid 20th century US, there were efforts to construct a network of transsexual individuals in order to facilitate communication and build this sort of community among individuals with shared experience.

These early trans communities were essential support networks for individuals who often found themselves outcast and isolated from the rest of society. One’s trans community, in the mid-20th century was, for many, a means by which individuals corresponded with each other, shared information on doctors, traveled together for surgery, compared surgical results, and occasionally lived together.18 Then, trans individuals mobilized to establish networks to facilitate a sense of community, to share resources, and to offer support. Today, similar networks exist, but they have largely moved online. The majority of my research subjects reported using social media sites or other online sources to research and learn about transition and trans identity.

Facebook, YouTube, Tumblr, Instagram, and other social media platforms have become sites for the free exchange of ideas, experiences, resources, and narratives among trans individuals.19

18 Meyerowitz, J. (1998). Sex Change and the Popular Press: Historical Notes on Transsexuality in the United States, 1930–1955. GLQ: A Journal of Lesbian and Gay Studies, 4(2), 159–187. 19 The search terms “transgender” paired with any one of these social media platforms yields countless pages of resources, personal blogs, video blogs, narrative accounts, advice columns, chat rooms, transition dairies, before-and-after accounts, pre- and post-op guides, etc.

17 As trans identity has made its way into mainstream American media,20 The Trans Community™ exists as an actor in multiple spheres—social, legal, and political. As The Trans Community™ expanded within the social sphere, more individuals have found a place to situate themselves within the bounds of the category “transgender.”

Today, the use of “community” to describe the social relations between members of the trans population has become an illusion of shared and common circumstances, attitudes, interests, or goals among diversely trans individuals, more than anything else.

In political spheres, the term “community” is employed to name an allied group or population of some unknown size. This term offers, an ambiguity of scale, which leaves the number of those it names uncertain, and in so doing, lends strength to past and present social and political movements for trans visibility and civil rights. Strength is found in numbers.

Arguments mounted by an entire community carry greater weight than if those same arguments were mounted by individuals. The designation “TM”21, is intended to call attention to the flattening and commodification of the collective minority identity; categorical flattening results in intellectual and social practices that ultimately fail to reflect a significant portion of people whom the category purports to encompass, and may even contribute to their disenfranchisement in various social contexts.22

Today, many people refer to The Trans CommunityTM as an entity—a singular, unified, social and political body with vested interests. The Trans Community™, as it exists today, is

20 Keisling, M. (2012). Reflections on a National Media Moment for Trans People (VIDEO) [Blog]. Retrieved April 14, 2016, from http://www.huffingtonpost.com/mara-keisling/reflections-on-a-national_b_1437692.html 21 The use of a trademark symbol (“™”) in reference to The Trans Community™ is borrowed from Cat G, a self-described “intersex, trans woman, 22, artist”; G, C. (2015, November 17). The Rift Between Us — Intersex and Trans Discourse. Retrieved from https://medium.com/gender-2-0/the-rift-between-us-intersex-and-trans-discourse-62dee7f7a73#.mlrd9kfhy 22 For more on the emergence, power, and failures of the category of transgender, Valentine, D. (2007). Imagining Transgender: An Ethnography of a Category. Duke University Press.

18 widely understood by its “members” as a tool for organizing as a collective around the shared social, political, economic, and legal interests. “The Trans CommunityTM,” while similar to

Valentine’s idea of “the category transgender,” seems to better lend itself to the nihilistic perception of the category transgender widely held by trans individuals today. The phrase “the trans community” has become favored in US popular media over phrases like “trans individuals” when referring to the population of those who identify as trans. Most often, references to The

Trans Community™ are made by reporters, politicians, and/or trans activists as a means of speaking on behalf of a great, but unknown, number of people.

When asked about The Trans Community™ and their relation to it, the trans individuals

I interviewed as part of this research, recognized their passive membership within this political body, simply by virtue of their alignment and adoption of trans as an identity category. These participants further recognized that transness––how one conceives of their own trans identity and what it means to them to be trans––and the course and process of transition––whether social, medical, legal––is unique specific to the individual. The diversity of experience and identity within the broad category trans makes feeling a sense of “community” difficult. As one interview subject, Frank Kline (a pseudonym, Subject ID WS500105) shared his experience attending a dinner organized for trans identified students on his campus, stating,

The last time I did something with “The Trans Community,” we just talked about majors and other things we did… The other two people there, from what I could see, were maybe on testosterone, but it didn’t seem that way. We went around and offered our pronouns, and their pronouns were “they/them” and I was like…

Here, Kline paused, his facial expression one seeming to remember his frustration and disappointment in the moment, before continuing on.

Well, I guess I’m just “more conventional.” I feel like I follow a more traditional—maybe not “more traditional”––but I’ve gone through more

19 medical procedures. I mean, what is there to talk about? ‘At first I got misgendered a lot, but now I don’t because went though surgeries and stuff.’

Kline offered this last statement as an example of one possible, but in his view, unproductive contribution he could make to conversation. As he imitated himself, pretending to speak at his community dinner, his tone grew very curt matter of fact. He had a problem, but now he doesn’t. At various other points in my interview with Kline, he revealed a thoughtfulness and sensitivity in reflection on his transition and the process of recognizing his identity. His displays of such openness to me stood in stark contrast to the manner in which he spoke about what he shared in relation to others within The Trans Community™. The absence of his sensitivity and openness to emotional vulnerability in this moment indicated to me that he did not trust these non-operative individuals––even if they identified as trans––to relate to and/or appreciate the full scope of his experience. A significant part of his transness and his transition defined by medical transition and the process of altering his sex is behind him. By offering this bare bones account of his experience to me as he would offer it in this “community setting,” he was trying to illustrate how little he had in common with individuals who had not and/or would not alter their sex.

As the bounds of trans expand and shift as social category, it becomes increasingly apparent that social and medical spheres situate this category within distinct ideological frameworks around concepts of gender, sex, and identity. The strategic employment and reemployment of common terminology enables discourse to continue with different meaning across ideological rifts. That is, those operating within each framework negotiate and ascribe their own referents and meanings to shared symbols. As social frameworks of gender, sex, and identity increasingly shift to embrace their own dynamism, medical frameworks respond by attempting to map their social counterparts in fixity. Thus, while certain binary trans individuals

20 can still fit themselves within antiquated medical ideological frameworks of transition, this is not the case for many other individuals who now fall within the category trans and may benefit from sex alteration. In response, we need to expand the social scope of the category “trans” as well— those who identify with any sex or gender beyond the sex, or typically associated gender, assigned at birth. This would leave room for individuals who embrace the gender expectations and expression typically associated with the sex assigned at birth but who still experience dissonance with some or all of their sex.

Negotiating Narrative and Building Arguments for Medical Transition

The western medical records of surgical alterations to sexual anatomy predate the modern categories “transgender,” “transsexual,” and even “transvestite.” The use of vague and coded language within early medical texts on changing sex in intersex patients enabled the emergence of, and organization behind, a shared, accepted “transition narrative.” Trans patients have long since collectively and iteratively negotiated the authorship of this narrative. Patients offered physicians the authority to collect and synthesize their experiences in exchange for the opportunity to organize and leverage clinical curiosity and care from sympathetic doctors.

Reconstructive surgical alterations to sex in non-intersex patients was originally reported in Germany, Denmark, and the Netherlands in the late 19th and early 20th centuries, but reports of these procedures did not emerge within either popular or medical literature for another several decades. Early in the 20th century, Germany became a hub for sexology and experimental research on changing sex. Case reports and news features on surgical sex changes typically included reflections on the patient’s “cross-gender behavior” and expression early in life, as if to suggest the patient was symptomatic of their condition all along. However, such indicators were typically recognized only in hindsight, leaving these biological essentialist

21 arguments open for re-interpretation. Transsexual individuals saw their experiences reflected in stories of successful sex change, and borrowed the coded language from those intersex cases to articulate their own experience. In the historical record we observe a snowball effect, whereby the release of a new surgical case or story of sex change would bring in influx of letters to the authors, surgeons, or publication’s editors, with requests for resources and access to similar procedures. The language of these inquiries and requests closely mirrored the circulating stories of patients who did successfully access surgical sex change, suggesting that later waves of narrative professions to supplement and justify requests for surgery were the product of strategic essentialism, and were crafted to leverage access to care within the biological essentialist model while simultaneously working to dismantle and recode what indicated “nature’s intent.”

22

PART I The Emergence of a New Patient Population

Historical Context and the Construction of Sex and Gender

Overview

In the contemporary US, “gender” means something very different to trans and gender non- conforming individuals than it means to the medical community. Although providers, especially those who concern themselves specifically with trans medicine, increasingly purport to embrace the idea of gender as it was negotiated with The Trans CommunityTM, they continue to conflate gender with sex. This conflation leaves to question which definition of gender clinicians mean to employ. Is gender dysphoria truly dysphoria with the gender typically associated with natal sex? Or, is gender dysphoria better described as dysphoria with one’s sex itself? With these questions unanswered, the discourse between patients and providers looks different from either perspective—two conversations go on at once. These questions and the resulting linguistic discordance became the basis for my narrative research (see Part III).

This rift in meaning of gender between patients and the providers interferes with communication and ultimately the understanding of the patient experience. As will be discussed later, gender has not always meant something so different to patients and doctors. Before we can discuss the problems that discordant interpretations of language pose within the doctor-patient relationship, however, we must situate and contextualize the emergence of these different interpretations of language. In other words, before we can discuss the central tension that the use of the term “gender” creates between trans patients and their doctors today, we must examine the history, emergence, and attempted disentanglement of sex and gender within western medicine.

23 of 112

In my research, I asked each of my interview subjects the question, “What is gender?”

Gender is pervasive in our society, assigned to us, and forced upon us from the womb.23 Its norms and expectations are both implicitly and explicitly enforced. Yet the challenge to articulate what constitutes gender, in and of itself, rather than simply describing the visible phenomenon, raises more questions than it answers.

I sit there. Smiling. Waiting. Watching the cogs turn.

One subject shakes his head and says, sarcastically, “Starting off with an easy one, are we?”

Another subject sits silently, staring off into the space just over my left shoulder. I could see his grey eyes dart slightly—left, right, left, right, down, right, left. After a long pause, he says, apologetically, “I just… don’t know how to answer that.”

“Well, what does gender mean to you?”

A third subject locks eyes with me and, through a bemused and anxious smile, lets escape a soft and gentle, “Ahhhhhhhhhhhhh…! Why are you asking me that!?” as they slowly lift both hands to cover their face.

I coax my participants away from dictionary definitions and encourage them to reflect on the presence and role of gender in their lives. This prodding elicits feigned panic from some and apprehensive laughter from others. As an interviewer and a researcher, I embrace productive discomfort. It means there is digging to be done. By probing through initial uncertainties, I am able to maneuver participants into their own place of productive discomfort. By questioning the origins

23 Judith Butler argues gender is increasingly performed/uttered even within the womb; the fetus is “girled” with an ultrasound and the utterance: “it’s a girl!”); Butler, J. (2011). Bodies That Matter. Florence, US: Routledge. Retrieved from http://site.ebrary.com/lib/alltitles/docDetail.action?docID=10466496

24 of 112

and sources of their unease, I prompt each subject to look within themselves and to examine their own assumptions about gender and what it means.

I listen to my subjects and their attempts to wrestle with meaning and language in the context of their own experience. My little Samsung digital voice recorder functions as a backstage pass granting me nearly unlimited access to explore the narratives of others. Although each person with whom I speak describes different experiences, cultural upbringings, and belief systems, and although they hail from across the country, a common denominator among them still emerges: frustration with the concept and cultural institution of gender itself. Paradoxically, gender, as it operates in western society, is simultaneously a tacit phenomenon and the social canon—visible and integral to daily social governance, but still rarely questioned.

“I guess… gender is a form of social categorization—the means by which we, as a society, have agreed to label a person ‘man’ or ‘woman.’” She speaks slowly—a remarkable change in pace given the breakneck speed at which she typically carries on conversation. With assurance, she continues, “gender offers a set of expectations, which guide our social behavior and our interactions with others.”

I push her to take me further. “What then makes a person a ‘man’ or ‘woman’?”

She pushes back. “Do you want me to answer that in terms of what society has taught me?

Or in terms of what I actually think?”

“Why don’t you hit me with both—I’ve got time.” I smile widely, appreciating her attempt to steer my line of follow-up questions.

“Well, ‘society’ taught me that ‘men’ have penises, and ‘women’ have vaginas. But, I know there are men without penises and women with them––and I know there are women without

25 of 112

vaginas and men with them…” This first part of her answer flows from her; speed has no effect on how carefully she articulates each of her words. Then she slows again. She twists her head in thought. “I think a ‘man’ is someone who recognizes them self as a man, and a ‘woman’ is someone who recognizes them self as a woman. But, generally speaking, I think that can mean different things to different people.”

This reflection on what makes a ‘man’ or ‘woman’ elucidates the manner in which for this person, gender is situated, enmeshed, and entangled with and within sex. When Candace West and

Don Zimmerman wrote “Doing Gender,” they opened by making, what they described as “the important but often overlooked distinction” between sex, sex categories, and gender.

Sex is a determination made through the application of socially agreed upon biological criteria for classifying persons as females or males. The criteria for classification can be genitalia at birth or chromosomal typing before birth, and they do not necessarily agree with one another.

Placement in a sex category is achieved through application of the sex criteria, but in everyday life, categorization is established and sustained by the socially required identificatory displays that proclaim one's membership in one or the other category. In this sense, one's sex category presumes one's sex and stands as proxy for it in many situations, but sex and sex category can vary independently; that is, it is possible to claim membership in a sex category even when the sex criteria are lacking.

Gender, in contrast, is the activity of managing situated conduct in light of normative conceptions of attitudes and activities appropriate for one's sex category. Gender activities emerge from and bolster claims to membership in a sex category.24

In 1987, drawing such contrast between concepts was radical in its pointedly subtlety. In the

US social and political mainstream, the terms “sex” and “gender” were used regularly, albeit for the most part interchangeably. The choice to introduce entirely new language to name the action of

24 West, C., & Zimmerman, D. H. (1987). Doing Gender. Gender and Society, 1(2), 125–151.

26 of 112

either sex or gender would both call the public’s attention to this change and then require active adoption of new ideas. Redefining existing terms enables immediate employment of the term’s latest meaning. Although these distinctions introduced new ideas, by specifying and delineating the relationships between these words, were, for the most part, inconsequential. Yet, once made, they offered new meaning to existing language, enabling a new breed of identity politics to emerge. These emerging identity politics were situated within the ongoing medical discourses surrounding the definition of sex throughout the 20th century.

The Body and Society as Metaphor

In early anthropology, body and society were introduced as metaphors for one another.

Mary Douglas argued that bodily pollutions and the type of contacts thought to be dangerous to one’s health (e.g. sexual or digestive fluids) carry a symbolic load and are used as analogies for expressing a general view of the social order.25 To discuss past and present beliefs and understandings of sex and gender, I will employ this notion that the body and society exist as metaphors for each other, as an analytical framework.

As we recognize the interwovenness of science and social belief systems, we must also recognize that the ideological products of this relationship are contingent in nature and ripe for analysis. Scientific and medical perceptions and understandings of the body and its potentiality, at any time, reflect the social, political, and moral values, as well as the ongoing discourses, of that moment in time and place. While it may be difficult to identify the ways in which scientific and medical ideologies are infused with our current social and political discourse, it is relatively easy to see how the shifting of social and political influences throughout history has shaped presentations and representations of the body. Medical representations and images of the body––what is “known”

25 Douglas, M. (1966). Purity and Danger: An Analysis of Concept of Pollution and Taboo. Psychology Press.

27 of 112

about the human form at the time they are produced––reflect the societal values of the social, political, and historical moment in which those representations were produced. To lay the groundwork needed to examine contemporary social, political, scientific, and medical views of sex, gender, and the body––and further, to contextualize the emergence of sex, sex categories, gender identity, and gender expression––I begin with the past.

Western notions of sex and gender, past and present, cannot be disentangled from their situation within “the patriarchy” as a framework of and for oppression. Systems and frameworks of oppression are constructed in such ways, which establish and perpetuate a hierarchy of power within and between groups. These systems and frameworks privilege those already in positions of power or authority and disadvantage those without. Theorist Bell Hooks describes “the patriarchy” as an ideological system––wherein men are assumed to be inherently dominant or superior to women–– that can be adopted and acted upon by either men or women.26 It is in the interest of the patriarchy to perpetuate the idea that dictates that social differences must be reinforced sex/gender binary.

It was an accepted notion within medical literature from the ancient Greeks until the late eighteenth century that the male and female bodies were structurally similar.27 Nemesius, the bishop of Emesa, Syria, explained in the 4th century, “women have the same genitals as men, except that theirs are inside the body and not outside it.”28 Although some of the details changed as new discoveries, such as the nature of the ovaries in the last half of the 17th century, offered a more nuanced understandings of anatomical structures, medical scholars from Galen in 2nd century Greece

26 Hooks, B. (2004). Understanding Patriarchy. In The Will to Change: Men, Masculinity, and Love (pp. 17–25). Washington Square Press. 27 Martin, E. (1992). The Woman in the Body: A Cultural Analysis of Reproduction (2nd ed.). Beacon Press. 28 Martin, E. (1992). The Woman in the Body: A Cultural Analysis of Reproduction (2nd ed.). Beacon Press.

28 of 112

to Harvey in 17th century Britain all assumed that women’s internal organs were structurally analogous to men’s external ones.29 (See Figures 1-4)3031

Fig. 1 Vidius’ depiction of the uterus and vagina as Fig. 3 Georg Bartisch’s illustration of phallus-like female analogous to the penis and scrotum. (Vdius 1611, Vol. 3. reproductive organs. (Attributed by Weindler 1908:141 to Photo from Martin 1992:28) Bartisch’s Kunstbuche, 1575. Photo from Martin 1992:29)

Fig. 2 Vidius’ illustration of how the female organs are Fig. 4 Georg Bartisch’s cross-section of the female situated inside the body. (Vdius 1611, Vol. 3. Photo from organs, showing a fetus inside the uterus illustration of Martin 1992:28) phallus-like female reproductive organs. (Attributed by Weindler 1908:141 to Bartisch’s Kunstbuche, 1575. Photo from Martin 1992:29)

To the ancient Greeks, the dictates of gender, as one’s gender affected a one’s role in society, were socially rather than biologically imposed. That is, societal expectations of men and women

29 Laqueur, T. (1986). Orgasm, Generation, and the Politics of Reproductive Biology. Representations, (14), 1–41. 30 Martin, E. (1992). The Woman in the Body: A Cultural Analysis of Reproduction (2nd ed.). Beacon Press. 31 Weindler, F. (1908). Geschichte der Gynäkologisch-Anatomischen Abbildung. Dresden.

29 of 112

demanded each occupy different roles within political and social hierarchies of the day. Male and female bodies were analogous––variations of the same kind within what Galen most notably described as the “one-sex model” 32––because, within the patriarchy of that moment, they could be.

In that context, anatomy did not challenge the social order.

In the late 18th century, the notion of “sex differences” emerged within western social and biological scientific literature, and distinctions were drawn to position male and female structures as opposing in both form and function. At present time, with the bi-potentiality of sex recognized, male and female are once again analogous, understood to share greater similarity than difference, and now, significantly, the mutability of sex is increasingly recognized.

In Galen’s social and political moment in ancient Greece, the existing order of politics and society was seen as a dictate of nature, able to position male above female in social and political hierarchy. Within Galen’s “one-sex model,” he reasoned that, "women were essentially men in whom a lack of vital heat—of perfection—had resulted in the retention, inside, of structures that in the male are visible without ... the vagina is imagined as an interior penis, the labia as foreskin, the uterus as scrotum, and the ovaries as testicles."33

While one's sex is determined by one's anatomical constitution, the ideas of masculine and feminine gender are largely, if not entirely, constructed by a predominantly patriarchal system of cultural values. It should be recognized, however, that the idea of anatomical constitutions and the representations and understandings there of, are also largely, if not entirely, constructed by a predominantly patriarchal system of cultural values. Laqueur proposes that before the

Enlightenment,

32 Martin, E. (1992). The Woman in the Body: A Cultural Analysis of Reproduction (2nd ed.). Beacon Press. 33 Laqueur, T. W. (1990). Making Sex: Body and Gender from the Greeks to Freud. Harvard University Press.

30 of 112

sex, or the body, must be understood as the epiphenomenon, while gender, what we would take to be a cultural category, was primary or 'real.' Gender—man and woman—mattered a great deal and was part of the order of things; sex was conventional ... what we call sex and gender were in the 'one-sex model' explicitly bound up in a circle of meanings from which escape to a supposed biological substrate—the strategy of the Enlightenment—was impossible. ... To be a man or a woman was to hold a social rank, a place in society, to assume a cultural role, not to be organically one or the other of two incommensurable sexes. Sex before the seventeenth century, in other words, was still a sociological and not an ontological category.34

Here, Laqueur argues that this attempt to ground differences between the genders in biology grew out of crumbling ideas about the existing order of politics and society as laid down by “the order of nature.” In these old ideas, men and women, while not different in kind, were arranged in a hierarchy based on their differing degrees of heat. Excess heat was seen as that quality which made men more perfect, enabling them to dominate the public world and moral order.

The new liberal claims of Hobbes and Locke in the seventeenth century and the French

Revolution were factors that led to a loss of certainty that the social order could be grounded in the natural order. If the social order were merely convention, it could not provide a secure enough basis to hold women and men in their places. After 1800, the social and biological sciences were brought to the rescue of male superiority. “Scientists in areas as diverse as zoology, embryology, physiology, heredity, anthropology, and psychology had little difficulty in proving that the pattern of male- female relations that characterized the English middle classes was natural, inevitable, and progressive.”35 The doctrine of two spheres—men as workers in the public, wage-earning sphere outside the home and women, except for the lower classes, as wives and mothers in the private,

34 Laqueur, T. W. (1990). Making Sex: Body and Gender from the Greeks to Freud. Harvard University Press. 35 Fee, E. (1976). Science and the Woman Problem: Historical Perspectives. In M. S. Teitelbaum (Ed.), Sex Differences: Social and Biological Perspectives (pp. 175–223). Garden City, NY: Anchor Press.

31 of 112

domestic sphere of kinship and morality inside the home—replaced the old hierarchy based on body heat.36

These historical examples demonstrate the co-influence society and western scientific and medical thought have on each other and their respective understandings and perceptions of the body. When social order alone was strong enough to enforce a gender hierarchy in society, sex too was related in hierarchy—male over its lesser female analogue, both natural variations of the same kind. As doubt was cast on the rooting of this social hierarchy in the natural order, biology and medicine quickly found evidence that social differences between men and women were the inevitable result of differences between the male and female body––categorical sex was introduced to enable and justify the continued social stratification of men and women in society. Scientists, throughout the 20th century, further argued, in the name of perpetuating this stratification, that social roles, differently prescribed for men and women, were the natural products of different sex. A woman is a woman and feminine because she is female, and likewise, a man is a man and masculine because he is male. In other words, sex was said to determine one’s social behavior and position in society.

Within the oppressive patriarchal frameworks of the contemporary 20th and 21st century

United States, changes to the categorical criteria or boundaries of sex and/or gender could be understood also as challenges and threats to the social order and dominant hierarchies of power of the time. Consider again the operation of systems and frameworks of oppression. Those in positions of power are privileged and advantaged by the existing frameworks. Therefore, those in power are invested in resisting challenges to that system. Presumably, those who challenge the oppressive system are either members of the oppressed minority or otherwise share the interests of the

36 Martin, E. (1992). The Woman in the Body: A Cultural Analysis of Reproduction (2nd ed.). Beacon Press.

32 of 112

oppressed minority––namely interest in not being the subjects of oppression. Going forward, we will examine, situate, and contextualize the means by which sex became something potentially mutable, procedures for sex alteration emerged, and “transsexuals” became a patient population, however small/niche.

Endocrinology and New Possibilities of Sex

Joanne Meyerowitz argues that a transsexual identity of sorts emerged well before the sexological category of transsexualism.37 Meyerowitz referred not to the sense of being “the other sex” or “in the wrong body,” which existed in various forms in earlier centuries and other cultures,38 but specifically to modern transsexuality as defined through requests for bodily transformation via surgery and hormones. Before the sexological category of transsexualism emerged, however, western medical thought had to recognize sex alteration as a possibility for the body. Prior to the 20th century, medical technologies such as synthetic hormones and the surgical techniques that enabled the material alteration of sex did not exist within the medical imaginary. Only once sex was recognized as something mutable, and only once procedures and technologies to alter sex were introduced, could patients reasonably request such bodily transformation.

The new Science of Endocrinology emerged at the turn of the 20th century and sought to address locate the essence of sex, gender, and sexuality in the secretions of the gonads. In an effort to strengthen and reinforce the social divisions and distinctions between men and women, sex, and what constituted sex, needed a clear definition. Rather than observing irreconcilable difference between men and women, however, endocrinologists observed commonality. Identifying such

37 Meyerowitz, J. (1998). Sex Change and the Popular Press: Historical Notes on Transsexuality in the United States, 1930–1955. GLQ: A Journal of Lesbian and Gay Studies, 4(2), 159–187. 38 Meyerowitz, J. J. (2009). How Sex Changed: A History of Transsexuality in the United States. Harvard University Press.

33 of 112

similarity between sex categories created a medical possibility, which before did not exist––similarity afforded the possibility that categorical boundaries of sex could be traversed.

In the early 1910s, standing at the forefront of endocrinology, Eugen Steinach, a physiologist at the University of Vienna, was the first to bring this possibility of surgical sex change into the public eye. Steinach won international acclaim for his "transplantation" experiments on rats and guinea pigs. In 1912, he published an article titled "Arbitrary Transformation of Male Mammals into

Animals with Pronounced Female Sex Characteristics and Feminine Psyche" and subsequently in

1913, he published an article titled "Feminization of Males and Masculinization of Females."

Steinach found that castrated infantile male rodents, when implanted with ovaries, developed characteristics, including sexual behavior, typical of females, and that castrated infantile female rodents, when implanted with testes, developed characteristics, including sexual behavior, typical of males. In his articles, Steinach claimed to have identified the specific effects of "male" and "female" hormones. His research suggested a hormonal basis of sexual behavior and further, the medical possibility of sex transformation. Such experimentation with rodents was followed by experimentation with humans.

At the urging of Steinach in 1915, Robert Lichtenstern transplanted undescended testicles into the abdomens of healthy men who never developed testicles or who had lost them to injury or disease. Lichtenstern and Steinach also attempted to "cure" a few homosexual men by removing a testicle and implanting another taken from heterosexual men. Other surgeons also undertook testicular transplants and similar ovarian transplants from one woman to another.

By the late 19th century, a new paradigm of sex was on the horizon—the theory of human universal bisexuality. Rather than men and women existing as disparate entities, with and of different form or function, this new theory of bisexuality stated that each body had the potential—the

34 of 112

essential building blocks—of both male and female sex. Thus, the differences observed between male and female bodies were said to be the product of those building blocks existing in different proportions.

Although the theory’s exact origin is disputed, variations on the concept of universal bisexuality were quickly embraced by European sexologists of the early 20th century, and, since its introduction, the theory has found its strongest proponents among philosophers and sexologists in

German-speaking countries. In his book Sex and Character, the Austrian philosopher Otto Weininger explains how this new notion of bisexuality differed from previous understandings and conceptions of sex.

I am discussing the existence of not merely of embryonic sexual neutrality, but of a permanent bisexual condition. Nor am I taking into consideration merely those intermediate sexual conditions, those bodily or psychical hermaphrodites upon which, up to the present, attention has been concentrated… Until now, in dealing with sexual intermediates, only hermaphrodites were considered; as if, to use a physical analogy, there were in between the two extremes a single group of intermediate forms, and not an intervening tract equally beset with stages in different degrees of transition.

The fact is that males and female are like two substances combined in different proportions, but with either element never wholly missing.39

As Weininger and his peers envisioned it, sex was a continuous spectrum along which all people fell somewhere within the intermediate span between two distal poles—male and female.

This is not to say the theory of human bisexuality was any more egalitarian than earlier models of separate and opposite sex. While universal bisexuality could be used to challenge the binary division

39 Weininger, O. (1907). Sex and Character. London: W. Heinemann.

35 of 112

of sex, it could also be used to reinforce, rather than overthrow, the hierarchy that assigned male a higher value than female.40

More than just one of the earliest theorists to introduce the theory of universal bisexuality,

Magnus Hirschfeld, a sexologist and researcher in Berlin, in the interest of civil rights and social justice, played a central role in its dissemination. Universal bisexuality, Hirschfeld believed, could position all people—not just “intermediaries”—somewhere along a spectrum of natural variation rather than within discrete categories. In this way, Hirschfeld sought to remove the stigma attached to sexual deviance and to normalize and typify the idea of human sexual variation. For Hirschfeld, hermaphrodites, androgynes, homosexuals, and transvestites—seen by most as distinct types of

“sexual intermediaries” and ostracized for their difference—constituted natural variations that, he supposed, all probably had some inborn, organic basis. In working with these “sexual intermediates,” Hirschfeld came to consider transvestism “a harmless inclination,” and, within the group transvestite, he included those with cross-gender identification as well as those who crossdressed.41, 42 Throughout his research, Hirschfeld paid close attention to the work of his colleague, then soon to be renowned Eugen Steinach.

For the most part, none of these early surgeons made attempts to transform sex from male to female or female to male but attempts were made to “correct” what were assumed to be

40 Weininger associated the female end of the spectrum with “lies and errors,” “profound falseness” and other morally degenerate traits and qualities. In a confluence of misogyny and antisemitism, Weininger associated women with Jews, claiming that, like women, Jews lacked “ deeply-rooted and original ideas.” He used the spectrum of universal bisexuality to oppress and assert the general inferiority of women and Jews, while reserving room for easy exception to his rule. For instance, he used this spectrum to dismiss systemic oppression and inequality, rationalizing that a woman’s success in the world of men, was inherently the product of her possessing relatively more maleness than other less successful women as measured by those metrics of success. In other words, according to Weininger, the only way women could be successful was if they were more like men. See Weininger, O. (1907). Sex and Character. London: W. Heinemann. 41 Hirschfeld, M. (1910). Transvestites: The Erotic Drive to Cross Dress. Prometheus Books. 42 Meyerowitz, J. J. (2009). How Sex Changed: A History of Transsexuality in the United States. Harvard University Press.

36 of 112

abnormalities in the person’s one, true, underlying sex.43 In this way, these early surgical efforts, and the theories of sex behind them, illustrated a biological essentialist understanding human behavior, desires, and identity.

Although Sexology did not emerge as a field until the turn of the 20th century, the study of human sex has long since captured the imagination and curiosity of researchers. In the late 18th century, various natural scientists made attempts to measure and characterize the physical anatomical differences that distinguished women from men. It was commonly assumed among these natural scientists that male and female were designations for two assumed separate, and opposite, but complementary, absolute, and immutable categories of sex. With the emergence of endocrinology and the theory of human bisexuality (not to be confused with the contemporary category of sexual orientation) at the turn of the 20th century, in various measures of the mind and body, women and men were shown to differ as much within their own sex categories as they did across them. Such findings, along with animal research on the composition and mutability of sex, as we will discuss, troubled the notion that men and women fit neatly one of two separate classifications.44 With the mutability of sex recognized, and with the absolute distinctions between sex categories made less absolute, the notion of physically altering one’s sex could be entertained.

Hirschfeld studied variant sex and sexuality throughout the late 19th and early 20th centuries. His early research focused on patients who fell well outside of the predominant sex categories and who today would, for the most part, be considered “intersex.” From this work,

Hirschfeld posited a preliminary alternate theory of sex—the theory of sexual intermediates. Under this model, Hirschfeld attempted to introduce a third category, beyond male and female. Within the

43 Meyerowitz, J. J. (2009). How Sex Changed: A History of Transsexuality in the United States. Harvard University Press. 44 Rosenberg, R. (1983). Beyond Separate Spheres. Yale University Press.

37 of 112

categorical designation “intermediary” fell cases of hermaphroditism, otherwise unusual, mixed, or ambiguous sex, and, often, homosexuality as well. Hirschfeld’s theory of sexual intermediates, however, remained niche within the field of Sexology. Tensions in mainstream sex research grew as efforts to identify fundamental sex differences continued to identify fundamental similarity.

Biological Essentialism

Essentialism is rooted in the belief that all things have a set of characteristics that make them what they are, and that the task of science and philosophy is their discovery and expression. The essentialist doctrine asserts that essence is prior to existence. Biological essentialism is a brand of essentialism rooted in the belief that unchanging biological characteristics are that which make things ultimately what they are. From this assumption, biological essentialism reasons that some underlying biological characteristic exists that explains observed phenomena.

When Lichtenstern and Steinach also attempted to "cure" homosexual men with testicular transplants from heterosexual men, they did so within the framework of biological essentialism.

They assumed that men exhibiting sexual behavior typical of females, sexual attraction to males, were lacking some essentially male component of their physiology. This idea, that feminine men had some “correctable” complication of their biology, which explained their exhibited atypical behavior, allowed for extrapolation. Perhaps a man could have some biological complication of their biology so great his sex appeared female––this at least was one strategic interpretation of endocrinology’s findings on the potential mutability of sex.

Hirschfeld listened to transvestites because he reasoned they had some underlying “inborn, organic basis” contributing to their presentation. Assuming a physiological basis for these observed human phenomena was the means by which biological essentialism enabled Hirschfeld to rationalize and to authenticate what would otherwise be considered deviant.

38 of 112

In the below passage, Chandak Sengoopta describes the logic behind biological essentialist frameworks and how they interpreted and related human behavior and physical condition in the early 20th century.

All males had aspects of the female, and all females aspects of the male. They did not refer simply to masculine and feminine traits; they grounded these traits explicitly in what we now call biological sex. They conflated sex, gender, and sexuality, and posed them all as signs of the physical condition. They argued that all humans were to greater and lesser degrees physically bisexual. In every human body they claimed, one could locate and observe a physical mixture of female and male that created a corresponding mixture of feminine and masculine traits.45

This ideology assumes that the physical and social are easily separable and that the physical condition dictates the social condition. Thus, it further assumes that the social condition indicates, and can be explained by, the underlying physical condition. This ideology takes for granted that social behavior acts as a secondary manifestation for some physical referent. That is, for example, if a person assumed to be male behaves in a feminine manner, the biological essentialist may use an interpretation of the theory of bisexuality to conclude that this person must be either physiologically more female than the average male person or in some way morally bankrupt.

It should also be recognized that under a biological essentialist gender ideology, sex and gender were synonymous, interchangeable terms, which coded for a one of two sets of constructed criteria. The maintenance of binary sexes, through the maintenance of these two sets of criteria, was key to maintaining and perpetuating such a pervasive biological essentialist gender ideology. Under this ideology, "healthy" and uncorrupted men and women would have all vertical criteria in alignment (see chart below), and all these criteria were thought to be the products of one's biological sex which, as the emerging field of Endocrinology argued, was determined and regulated by "sex hormones." It was thought that any deviation from this binary alignment of biological and

45 Sengoopta, C. (2000). Otto Weininger: Sex, Science, and Self in Imperial Vienna. Chicago: The University of Chicago Press.

39 of 112

behavioral criteria indicated a deficit in sex hormone or that any deficit in sex hormone would

manifest in the misalignment of some other criterion. Thus, it was assumed by these early surgeons

that homosexuality indicated insufficient hormone levels, which could be remedied by replacing the

under-producing testicle and implanting the testicle of a heterosexual man who, by their definition,

must be capable of producing sufficient levels sex hormone. In essence, these early surgeons sought

to reify their sex binary by surgically correcting ambiguity and examples of sexual "inversion."

Penis, testicles, prostate Clitoris, vulva, vagina, uterus, ovaries Testosterone (secretions of the testes) Estrogen (secretions of the ovaries) XY XX Male Female Man Woman Attracted to women/females Attracted to men/males Not attracted to men/males Not attracted to women/females Masculine Feminine Adheres to socially subscribed male gender roles Adheres to socially subscribed female gender roles

Table 1. Horizontal (oppositional) and Vertical (aligned) binary divisions of concepts of sex/gender.

Like Hirschfeld, Weininger used the theory of human bisexuality to defend homosexuals

from persecution. The rhetoric behind Weininger's arguments, however, reveals the ways in which

biological essentialism colored and frames the interpretation and perspective of these early sex

researchers. Homosexuals, as Weininger understood them, were “women who physically

approximated men and men who physically approximated women.”46 There is an evident conflation

of what, today, we recognize distinctly as sex, gender, and sexuality. Weininger's essentialism

assumes that heterosexuality—in the interest of biological reproduction—is fundamental to the

46 Meyerowitz, J. J. (2009). How Sex Changed: A History of Transsexuality in the United States. Harvard University Press.

40 of 112

central nature of a person’s being. Therefore, if a person appears to deviate from that norm, it must only seem a deviation, and, further, some underlying explanation for these observations must exist to be uncovered. Since there is no recognition that a person could be attracted to someone of the same sex, the essentialist then must reason alternatively. Here, the distinction is drawn between some

“physical approximation” of man or woman and what is presented as the person’s actual status as man or woman. While his essentialist rhetoric denies the possibility of any orientation alternative to heterosexuality, Weininger’s position leaves open the door to reinterpret the ways in which a person’s sex and gender relate—essentialism becomes a tool to be deployed strategically.

For another example Steinach's work with guinea pigs supported a biological essentialist argument that physical sex, in this case hormonal glandular secretions, dictates social sexual behavior. The language Steinach used to present his findings, however, left room for an alternative essentialist interpretation of this early research. Steinach himself stated, "The implantation of the gonad of the opposite sex transforms the original sex of an animal." The biological essentialist focuses on biology as the basis of social behavior. A more strategic interpretation of Steinach's claim focuses, not on the hormonal basis of behavior, but on the possibility that physical sex, once thought immutable, could be changed.

Strategic Essentialism

Gayatri Spivak, a self proclaimed “practical Marxist-feminist-deconstructionist,” coined the term strategic essentialism which describes, “the ways in which subordinate or marginalized social groups may temporarily put aside local differences in order to forge a sense of collective identity through which they band together in political movements.”47 This sense of collective identity can be internally or externally influenced. As Spivak’s definition namely implies, marginalized populations

47 Spivak, G. C. (1987). In Other Worlds: Essays in Cultural Politics. New York, NY: Psychology Press.

41 of 112

themselves can employ strategic essentialism, whereby the collective presides autonomously over the shaping of their own identity through processes of active, internal, and conscious decision making.

Conversely, and more controversially, essential identities can also be imposed upon marginalized populations by those in positions of relative power and authority. That is, those in positions of relative power and authority can pressure a population to adopt and organize behind a self-inflicted essentialist identity. This brand of essentialism is strategic in that the marginalized population must actively choose to embrace, to organize behind, and to police the essential identity in order to leverage the attention and/or resources of those in positions of relative power and authority.

The Collective Transition Narrative

This version of strategic essentialism can be applied to contextualize and to situate those forces, which enabled the emergence of, and rallying behind, what I call The Collective Transition

Narrative. Today, this narrative is still at the foundation of trans medicine and related diagnostic practices. In order to be recognized by medical providers and granted access to medical intervention, individuals either fit themselves within certain negotiated frameworks and clinical archetypes, or risked rejection. Herein lies the controversy. As early physicians and researchers studied the reports of patients seeking sex alteration, they implicitly introduced the first set of essentialized criteria for medical transition—the physician’s clinical judgment, contingent and situated within their own ideological frameworks of gender, sex, and identity. As researchers and physicians published those early cases and the transition narratives that they endorsed for sex alteration, they validated those certain narratives and patient reports over others, implicitly invalidating alternatives. Thus, to have one’s identity recognized as valid by medical authorities, trans individuals, one after another, adopted those “proven” ideological frameworks within which others could understand them, in order to articulate and approximate their experiences and self-concept to others. Here, strategic essentialism

42 of 112

enabled individuals, previously in isolation, to put aside difference in order to organize around and adopt a collective identity and version of experience. Researchers collected these articulated approximations as evidence to reify and re-inscribe those “proven” ideological frameworks that trans individuals initially adopted in order for their approximation to be collected. Thus, we can understand the agentive role trans individuals played in the construction and reification of the common transition narrative. Rather than clinicians arbitrarily setting some standard, and patients bending to meet it, these prototypical models of transition were actively negotiated in conversation—a dialogue, ongoing between patients and those physicians to which they were, and to some extent are still, beholden.

As patients remain beholden to clinicians, however, clinicians benefit from engaging and leveraging the dependence of their trans patients—the nature of this relationship is tense and built on a foundation of mistrust in the interest self-preservation. Patients rely on their doctors for validation of their existence and for access to medical transition. Doctors who engage with trans patients exercise and maintain their position as a medical authority.

Homosexuals, Transvestites, and ‘Dis Interested Science

For physician Magnus Hirschfeld, sexual science was self-interested science. From the late nineteenth century on, Hirschfeld published widely and campaigned actively on behalf of homosexual rights. While Hirschfeld identified himself as homosexual, he did not, it seems, have the desire to change his sex. In 1910, Hirschfeld published Die Transvestiten (“The Transvestites” in English, translated in 1991) in which he made the first explicit distinction between transvestites and homosexuals.48 Hirschfeld's study of transvestites offers first-person narratives, documents with

48 Hirschfeld, M. (1923). Die Intersexuelle Konstitution. Jahrbuch für Sexuelle Zwischenstufen, (23), 3–27.

43 of 112

scrupulous detail, news reports, published letters, and popular publications describing men who dressed as women and women who dressed as men, dating back to the mid-1800s.

In her biography, Charlotte Wolff documented that many times Hirschfeld characterized homosexuality in ways that had clear strategic value in terms of advancing both his professional reputation and his libertine agenda.49 According to historian Daryl Hill, introducing transvestism within the scientific literature was part of Hirschfeld's emancipatory crusade—one of his many attempts to use science to advance his humanistic goals: civil rights for members of the sexual minority. As Hill states, Hirschfeld sought to "…distinguish transvestites from other categories of sexual experience and identity" in order, as he claims, "…to ensure that those who were not actually homosexuals, such as crossdressers, were not persecuted unfairly."50 It is more than likely that

Hirschfeld did see strategic social and political value in his study of and eventual publication on transvestism, but to what degree his characterization of the category "transvestite" was altruistic–– intentionally curated for the social and political benefit of his subjects––as opposed to self- interested––for the benefit of his own category "homosexual"––is unclear.

Regardless of Hirschfeld's personal motivation, his patients may also have seen strategic value in submitting themselves to his research. In the late 19th century, cross-gender behavior was both clinically and socially subsumed within the broader rubric of "inversion" and was typically associated with homosexuality.51 Hirschfeld created a category separate from the prejudice and persecution attached at the time to homosexuality, and in doing so, he also removed––or at least attempted to remove––from homosexuality the prejudice attached to cross-gender behavior.

49 Wolff, C. (1986). Magnus Hirschfeld: A Portrait of a Pioneer in Sexology. London: Quartet Books Limited. 50 Hill, D. B. (2005). Sexuality and Gender in Hirschfeld’s Die Transvestiten : A Case of the “Elusive Evidence of the Ordinary.” Journal of the History of Sexuality, 14(3), 316–332. 51 Meyerowitz, J. J. (2009). How Sex Changed: A History of Transsexuality in the United States. Harvard University Press. For more on inversion, see Fausto-Sterling]

44 of 112

In Hill's analysis of Die Transvestiten, he concludes critically stating, "the lives of Hirschfeld's respondents failed to fit neatly into the category he was trying to construct," but what Hill seems to overlook is that such an imperfect fit was that which enabled later shifts in gender ideology and within the western scientific and medical discourse. Clinical attention from Hirschfeld, and his eventual publication on their cases, lent scientific legitimacy, if not validity, to the existence of cross- gender identity and experience for his research subjects.

As Hill argues, the clinical narrative Hirschfeld distilled from his scientific data is likely not the reflection he claims it is––of his patient's experiences, desires, and identities––but instead a reflection of his perception and interpretation of his patient's experiences, desires, and identities.

Hirschfeld saw a distinction between what he knew to be homosexual experience and the experiences he observed in the sample of patients on whom he reported–at the time, it was only that distinction which his work sought to elucidate. For each case, he structured his arguments to illustrate his patient's claim to heterosexuality, at times using inconsistent logic and at times apparently antithetical narrative evidence.52,53 Hirschfeld sought to "…build the category of transvestite, [by] constructing a model of their desires and delimiting the range of their experiences…”54 In 1910, however, it did not necessarily matter that Hirschfeld's "transvestism" was a gross over simplification, a conflation of his patient's complex, diverse experiences, or even that it was reflected a partly inaccurate account his patient's narratives–what mattered was that he introduced his synthesis of a common and unified narrative which allowed anomalies— individuals

52 Hill, D. B. (2005). Sexuality and Gender in Hirschfeld’s Die Transvestiten : A Case of the “Elusive Evidence of the Ordinary.” Journal of the History of Sexuality, 14(3), 316–332. 53 Hirschfeld, M. (1923). Die Intersexuelle Konstitution. Jahrbuch für Sexuelle Zwischenstufen, (23), 3–27. 54 Hill, D. B. (2005). Sexuality and Gender in Hirschfeld’s Die Transvestiten : A Case of the “Elusive Evidence of the Ordinary.” Journal of the History of Sexuality, 14(3), 316–332.

45 of 112

previously in isolation—to be seen as evidence of some larger category within which those anomalies could be explained.

Medical practices, academic theories, social movements, and social and legal services and protections still to come throughout the next century would continue to construct and re-inscribe these initial distinctions made between homosexual orientation and cross-gender identity or expression. As these categorical distinctions between sexuality and gender attempted to disentangle homophobic and transphobic stigmas, they simultaneously reinforced hierarchies of race and class according to privileged heteronormative, homonormative, and cisnormative ideological and social frameworks.55

Arguments for AccesSEX Early Case Reports and Patient Narratives

Hirschfeld pioneered arranging early sex-change surgeries in humans. A few patients managed to convince surgeons outside Hirshfeld's affiliation, in Europe and even one or two in the

United States, to alter their sex through by removing various organs such as breasts, uteri, and testicles, but in these isolated examples, the negotiations for operation required patients to cite some medical condition beyond their self-concept to justify surgical intervention.

For example, in 1902 at the age of 28, Earl Lind, who described himself as an invert, androgyne, homosexual, and fairy, was able to convince a doctor in New York to castrate him ostensibly to reduce his sexual "obsession" and as a cure for spermatorrhea, frequent nocturnal emissions which he argued were ruinous to his health. Lind later acknowledged in his autobiography that he may have lived as a man, but that he saw himself as a woman and that he preferred "to

55 Valentine, D. (2007). Imagining Transgender: An Ethnography of a Category. Duke University Press.

46 of 112

possess on less mark of the male," and further, that he hoped castration would reduce or eliminate his facial hair, his "most detested and most troublesome badge of masculinity.”56

In 1917 at the age of 26, Alberta Lucille Hart was able to convince psychiatrist J. Allen

Gilbert to recommend hysterectomy as a means of changing sex. Although Hart was assigned as female at birth and was reared as a girl, he considered himself a boy and in adulthood dressed in a masculine fashion. As with Lind, Hart had to offer an alternative medical justification for surgery, in this case he claimed it would bring relief to painful menstruation and made the eugenic argument, that "sterilization" should be advised for "any individual" with "abnormal inversion" such as himself.

Gilbert was not immediately convinced by these arguments, however, with "long hesitancy and deliberation" he agreed to the operation. Gilbert stated in his case report that with a hysterectomy, a haircut, and a change of clothing, Allen Lucille Hart " started as a male with a new hold on life."57

These few case reports trickled into scientific journals and into the hands of lay readers, many of whom who saw their own experience reflected in these stories of transformation. Some of these lay readers were inspired by the answers and possibility medicine seemed to promise others like themselves. These lay readers, with hope in hand, sought to identify and to persuade physicians to administer care based on the precedent established by those who transitioned before them.

By the mid 20th century, the reports of sex alteration that appeared in the popular press and medical literature used vague and coded language to discuss the cases on which they reported.

Medical professionals were reticent to explicitly discuss the conditions that invited surgical interventions to alter a patient’s genitalia or otherwise sexed body, instead electing to use coded language, referring to a patient’s adherence, or lack there of, to the gender role assigned at birth. At

56 Meyerowitz, J. J. (2009). How Sex Changed: A History of Transsexuality in the United States. Harvard University Press. 57 Meyerowitz, J. J. (2009). How Sex Changed: A History of Transsexuality in the United States. Harvard University Press.

47 of 112

the same time, both American medical and popular literature in the mid 20th century presented narratives of transition that described sex-altering surgery as that which unveiled a "true" but hidden physiological sex. What would otherwise be seen as mutilating surgery could be justified if it was a means of restoring "natural" "biological" status quo. On one side, the press published a stream of sensational stories that hinted at new surgical options for sex transformation. On the other,

American doctors refused to offer or recommend treatment unless the patient could lay convincing claim to an intersexed condition.58 The vague, ambiguous nature of this language, at once, enabled

American medical community to deny the existence and possibility of sex reassignment in the absence of intersex conditions, and enabled mid-twentieth-century Americans who hoped to change sex a glimmer of hope that such procedures to identify possibilities in these stories for themselves.

These less-than-explicit stories of successful sex alteration––“successful” stories being those that were accepted by, and earned the attention of, medical authorities––trickled into the popular press. From the 1930s through the 1950s, certain readers internalized the language and metaphor present in published stories of sex change and included the quest for surgical and hormonal transformation as a central component of their senses of self. Through reading, some trans individuals—self-identified in the terms available in their day, such as eonists, transvestites, homosexuals, inverts, and hermaphrodites—came to a new sense of who they were and what they might become.59

Individuals, who were before without a means to articulate their own experience, were able to recognize themselves in the narratives of others.

The employment of strategic essentialism, whereby sensational and well publicized stories of sex reassignment in the popular press gave language to many individuals who already had various

58 Meyerowitz, J. (1998). Sex Change and the Popular Press: Historical Notes on Transsexuality in the United States, 1930–1955. GLQ: A Journal of Lesbian and Gay Studies, 4(2), 159–187. 59 Meyerowitz, J. (1998). Sex Change and the Popular Press: Historical Notes on Transsexuality in the United States, 1930–1955. GLQ: A Journal of Lesbian and Gay Studies, 4(2), 159–187.

48 of 112

forms of cross-gender identification, enabled individuals to identify themselves and to organize.

These stories often reinforced stereotypes of gender and sexuality by locating the sources of gendered and erotic behavior in the sex of the physical body. This contributed to the conflation of sex/gender and the understanding of gender as a proxy for “true” sex. As the rhetoric of this narrative strengthened, American doctors acknowledged the possibilities sex reassignment presented and adopted the term transsexual as they entered a period of debate on the merits of surgical intervention—the black box containing sex and gender was opened.

Active Negotiation of Narrative

The records we have of Lind and Heart demonstrate the manner in which trans patients actively negotiated their narratives in these early cases of sex alteration. Remember, at this point in the early 20th century, neither “gender identity” nor “The Collective Transition Narrative,” discussed in

Part II and Part III, as we know them today, existed within the social or medical imaginary, let alone did they serve as reason enough to justify hormonal or surgical alterations to sex. Instead, patients had to build their case for sex alteration by other means, namely by finding and putting forth other medical arguments to justify intervention. These arguments cited visible and recognizable corruptions of the body, whether material or moral in nature, as justification for medical attention.

They cited recognized ailments and illness as justification for intervention and further strategically positioned themselves to leverage stigmas and social anxieties of the day (e.g. those attached to sexual inversion and other forms of social and moral transgression). In the cases of Lind and Heart, changing of gender roles was presented as a necessary result of operation. Once these patients were able to access their new role in society, they felt pressure to defend their right to “authentically” occupy the position within the social hierarchy to which they laid claims. Although sex alteration enabled trans bodies to “talk the talk,” trans individuals were remained under pressure from the cis

49 of 112

majority to mount additional arguments to demonstrate they—as people, beyond their bodies— could “walk the walk.” In other words, once an individual whose body was assigned male at birth could, with Hormone Replacement Therapy and surgery, could become female, that individual’s ability to embody what it meant “to be a woman” was challenged. When sex could be reconstructed on the body, opponents of medical transition––clinician and lay critics alike––began to reach for some other means of exclusion from natal categories––those categories assigned at birth––of sex/gender.

Even though sex and gender were still thoroughly enmeshed, entangled— and further, the language to discuss them as separate phenomena was absent from social, political, and medical discourses during this period— by now, the pressure to disentangle these concepts was mounting.

Lind and Heart recognized that to be accepted by those categories within which they sought to position themselves, they needed to explain and articulate why it made sense for them to change sex categories. What indication gave them permission to reject the position “nature” dictated they occupy within the social hierarchy of patriarchal governance? For sex alteration to be accepted by society, its proponents needed to refute claims that social and medical transitions were violations of nature. Trans patients made case studies of themselves to demonstrate they could exist “naturally”— that is, exist invisibly—within mainstream cis society. Trans patients positioned themselves as the instruments of counter laboratories, offering evidence that sex category did not necessarily have to be dictated by natal sex. These counter-laboratories introduced the possibility of some new determinant of “true” sex category.

In an attempt to defend their own position in society, and in the patriarchal hierarchy, many cis individuals mounted arguments against transition. As the field of sexology and surgical innovation introduced the possibility that a person’s sex could be mutable, the boundaries of sex categories could be newly breached and were left vulnerable to expansion. The trans opposition

50 of 112

argued that physically altering sex would leave a person incomplete—a shadow of either sex/gender.

This stipulated that a person’s ability to authentically occupy accepted sex/gender roles and categories was dependent on more than just the physicality of their sex. The argument that a person’s authentic sense of a gendered-self is located outside their sex—a platform remarkably similar to that on which arguments endorsing sex alteration and transition were simultaneously being built.

Lay opponents of sex alteration, and those who dismissed the idea of transition, would argue that there is more to being a man or woman than sex, even though these gendered categories were, until the emergence of this debate, defined by the idea of sex differences. After medical transition, many trans patients could blend in appearance with their cis counterparts. Trans individuals situated themselves and their bodies as "laboratories"––as Latour understands the function and action of both laboratories and counter-laboratories in discourse with each other on either side of a given controversy. The “laboratory instrument”––the measure of their experimental outcome––was a trans individual’s ability to integrate and become invisible within the cis majority. The first experimental question which these laboratories and laboratory instruments sought to answer was, “is it possible to change sex? As discussed earlier in this section, yes, the technologies of modern science and medicine were able to alter the sex of a body. However, doing so threatened the integrity and presumed “essential nature” of dichotomous oppositional categories of sex, and thus the patriarchal and hierarchal social order they reinforced. The experimental question then became, “can trans bodies operate within the patriarchy’s social hierarchy of gender?” This challenge to exist invisibly within and exemplify the socially inscribed roles and expectations of typified sex/gender behavior, performativity, and expression, pressured to trans individuals to over perform sex/gender.

Hyper-masculine and hyper-feminine gender performance was and is a means of compensating for perceived deficits in the fulfillment of other criteria of sex/gender categories. For instance, if an

51 of 112

individual’s sex prompted any doubt about an individual’s membership within a certain category of sex/gender, the conflation of sex/gender enabled that individual to leverage gender performance as a means of satisfying any doubts that their sex may have prompted. In Part II I will further discuss the pressures for over performance present within the social relations of transition.

52 of 112

PART II Negotiating the Terms of Care

Clinical Categories and Processes

Overview

Once American medical authority recognized the alteration of sex, the debate over the moral and ethical merits of medical transition began. Throughout these debates, there was interplay between social and medical spheres––the interests of The Trans Community™ and the interests of the medical providers who cared for them were entangled and in tension with one another. In this section, we will discuss these interests and the stakes of each interested party. Each sphere is situated within the other; they are contingent, and their influences mutually intertwined. The Trans

Community™ would not exist as it does today were it not for the medical authorities to which it was, and is still largely, beholden. Likewise, neither would current medical conceptions of sex/gender and the etiology of transition exist without the narratives collected from patient seeking to alter the sex of their body.

In the last section, we examined the history, emergence, and attempted disentanglement of sex and gender within western medicine. Now, we may begin our discussion of the central tension arising from the discordant use of “gender” by trans patients and providers within the discourse on sex alteration. To reiterate, gender has not always meant something so different to patients and providers, however, we must recognize that today, “gender” means something very different to trans and gender non-conforming individuals than it means to the medical community. In this section, we will explore the interplay between social and medical spheres as providers sought to understand and clinically characterize trans experience. The language and ideological frameworks of diagnostic

53 of 112

criteria and clinical guidelines will be the subject of this analysis as I explicate the tensions in which they were co-produced.

Going forward, I will discuss the language of categories, the conventional medical wisdom, and the pressures to over perform, which exist around medical transition, and further which serve as evidence of present challenges to communication and ultimately barriers to the understanding of trans patient experience.

Language and Identity Categories

Identity categories, and the terms that bound them, are contingent—situated within the social and political environment of their day. For this reason, individuals from history cannot and should not be placed within the modern identity categories we embrace and understand today.

Instead, we must look to understand the categories and terminology that were embraced in their own time and historical context. Only then can we appreciate how meaning and use evolved

In the United States today, the label “trans”—short for transgender—is an umbrella term, which describes those whose gender expression and/or gender identity differs from conventional expectations based on the physical sex assigned to them at birth. Because trans is an umbrella term, it is imprecise and does not adequately describe the particulars of specific identities and experiences.

For example, the identity/experience of a post-operative female-to-male (FTM) transsexual will probably be very different from that of a female-identified drag king who performs on weekends; however, both are often lumped together under “the trans umbrella." Trans is a category of identity, but the bounds of this category have shifted over time, and those who exist within the category today may not be those who would have existed in the category five or ten years ago. This is in part because, five or ten years ago, the category itself did not exist as it does today. At present, trans and transgender are used synonymously as umbrella terms, within which many subcategories of trans

54 of 112

identity exist and undergo renegotiation. Moreover, in a seemingly exponential expansion of language, new subcategories of trans are routinely introduced.

Virginia Prince is often credited with the introduction of the label “transgender,” first using the term "Transgenderal" in 1969 as a play on the term “Transsexual,” which was in common use by the early 1960s.60 In 1976, Prince introduced the term “transgenderism” while publishing Transvestia magazine (1980), which recognized a category intermediate between transvestism and transsexualism. Psychologists in the 1980s, however, adopted this label and overtly ascribed different meaning to it. After recognizing their departure from Prince’s use of the term, one psychologist explained,

…[W]e define transgenderism as full-time living in the cross-gender role in the absence of sexual reassignment surgery, with oscillation, however rare, back and forth from one gender role to the other. Without oscillations the full-time cross- gender living would qualify in our definition as transsexual behavior. …These individuals may represent cases in transition towards secondary transsexualism. However, full-time living in the cross-gender role as part of an extended real-life test preliminary to possible sex-reassignment surgery should not be described as transgenderism. We prefer the term “preoperative transsexual,” simply to indicate that reassignment procedures are anticipated.61

By this point in the early 20th century, the meanings attached to the terms transvestite, transsexual, sex, and gender, were all in the midst of flux and active renegotiation. The word

“gender,” once undisputedly synonymous with physical sex, was reintroduced as an essential determining component of every person’s identity and self-concept; although, this reintroduction was far from universally received or accepted. The distinction between sex and gender enabled clinicians and sexologists to introduce and alter labels to differentiate between categories of people.

The label “transsexual” was introduced to refer to, and specifically group within one category, those

60 Williams, A. (2012, March 17). Who First Coined the Term “Transgender”? [Blog]. Retrieved from https://www.quora.com/Who- first-coined-the-term-transgender 61 Docter, R. F. (1988). Transvestites and Transsexuals: Toward a Theory of Cross-gender Behavior. Plenum Press.

55 of 112

individuals who sought sex alteration. Those others who exhibited cross-gender behavior, such as cross-dressing, without seeking to alter sex would not be categorized within this new group,

“transsexual,” but to them, the label “transvestite” could still be applied.

The introduction of new identity categories gives voice to those for whom the categorical definition does not resonate entirely and thus allows for more authentic self-definition. By narrowing one’s alignment to those who more precisely share experience, a category can invite a more nuanced interpretation of meaning from the social information offered by its membership.

While Harry Benjamin made efforts in 1966 to make clinical distinctions between transsexual and transvestites, Virginia Prince sought to introduce a new category open to more trans individuals, many who were excluded from clinical categories at that time. The emergence of “transgender” was a confluence of many forces in dialogue within medicine and society. Situated in this social, political, and historical context of linguistic renegotiation, Prince’s “Transgenderal” called attention to those who, omitted from the clinical category transsexual, were embraced by and existed within the still emerging identity category. Although Prince’s exact term did not stick, it initiated a discourse that sought to differentiate between transsexuals who wanted to change their sex and cross-dressers

(commonly referred to as “transvestites” at the time) that wanted to change only their “gender" and not their anatomical sex. When this distinction was made, there was no recognition or acknowledgement that a person may be identify outside either binary of sex or gender. The term

“transvestite,” the original label applied to all those professing cross-sex/gender inclination, was retired and repurposed as the terms “gender” and “transsexual” were introduced.

Throughout this period, and still today, the language used to describe categories of people is inconsistent, despite efforts to standardize terminology. For example, most clinical and sociological literature published between 1960 and late 1980s uses the terms “transvestite” and “transsexual.”

56 of 112

However, among trans activist and within social spheres outside of academia, we observe the emergence and adoption of the term “transgender,” rather than “transvestite,” to name those who experience a constant sense of cross-gender identity, without seeking to alter their sex alteration.

Within these trans activist social spheres, there began a movement to create distance from the term transvestite in an effort to also create distance from the social stigma attached to it, and by extension, attached to the clinical condition of “transvestic fetishism” (see Appendix B and

Appendix C).

One hundred yeas ago, however, neither the word transgender nor transsexual yet existed, at least not with the meanings most commonly ascribed to the terms today. At present, one trans activist defined them on behalf of The Trans Community™,

Transexual has traditionally meant people who fit in the gender binary of male or female, they just identify with the exact opposite category than they were assigned at birth.

Transgender has two meanings. Sometimes it’s used as an umbrella term to gather together a variety of gender variant terminology, like apple is an umbrella term for Granny Smith, Cortland and my current favorite, Empire. Other times it can mean someone who doesn’t fit male or female perfectly. Perhaps they feel like they’re in the middle, or maybe they feel like a third gender. That said, these are all relatively new words and their exact meanings are still fluid, so just take this as a general guideline.62

These labels, or linguistic “symbols,” endured within medicine and society; yet, as time went on, their action and referents evolved. “Transsexual,” first began as a clinical category––an observation of patterns in patient accounts. As clinicians recognized more patterns, “transsexual” then became a pathology and a “prototypical” patient account. We refer to this prototypical account as “The

Conventional Transition Narrative.” With this prototypical patient account in hand, “transsexual” then

62 Scout, D. (2015). Here Are the Most Common Questions About the Trans Community, Answered [Blog]. Retrieved from http://www.huffingtonpost.com/scout-phd/here-are-the-most-common-questions-about-the-trans-community- answered_b_7140728.html

57 of 112

became a diagnostic category—a tool for physicians to identify and label other future patients.

Pathology and diagnosis gave rise to stigma. Simultaneously, the term “transsexual” was subject to re-appropriation—the phenomenon whereby a stigmatized group revalues an externally imposed negative label by self-consciously referring to itself in terms of that label.63 The re-appropriation of stigmatizing, pathologizing, and/or oppressive language rejects harmful or damaging import, and instead, imbues group labels with positive connotations.

The mere presence of a group label can activate stereotypic information about the group,64,65 and information consistent with these activated connotative meanings of labels is more easily processed, assimilated, and integrated into memory and is thus also more likely to be retrieved in the future.66 One issue that trans activists took with the label “transsexual”––beyond its limitation as a descriptor for only those who wished to physically alter their sex/gender––was that it perpetuated the sexualization and fetishization of trans individuals. Although the term rather accurately described the action of sex alteration within binary frameworks of sex/gender––the switching between two dichotomous, opposite, and mutually exclusive categories of sex––the word “sexual” made up half of the term. Given the moral and cultural attachments to sex within the 20th and 21st century United

States, distance from the idea of sex––whether anatomical or sensual in variety––was essential if The

Trans Community™ was to gain any social and/or political footing or credibility. The other reason to embrace the label transgender over the label transsexual was for the sake of the greater flexibility of gender categories, and the rising rhetoric around gender identity as that which indicates one’s

63 Adam D Galinsky, Kurt Hugenberg, Carla Groom, & Galen V Bodenhausen. (2003). The Reappropriation of Stigmatizing Labels: Implications for Social Identity. In Identity Issues in Groups (Vol. 5, pp. 221–256). Emerald Group Publishing Limited. 64 Devine, P. G. (1989). Stereotypes and Prejudice: Their Automatic and Controlled Components. Journal of Personality and Social Psychology, 56(1), 5–18. 65 Lepore, L., & Brown, R. (1997). Category and Stereotype Activation: Is Prejudice Inevitable? Journal of Personality and Social Psychology, 72(2), 275–287. 66 Stangor, C., & McMillan, D. (1992). Memory for Expectancy-Congruent and Expectancy-Incongruent Information: A Review of the Social and Social Developmental Literatures. Psychological Bulletin, 111(1), 42–61.

58 of 112

“true” sex within the prevailing frameworks of 20th century ideologies of sex/gender. Transgender was a term that both transsexual individuals and others who considered themselves in some way

“gender non-conforming” could organize behind. The rhetoric behind drawing distinction between sex and gender and behind the embrace of transgender as an umbrella term for sex/gender variant identities then shifted the language used to articulate those identities.

Labels, and the categories to which they refer, serve as guiding themes and organizing principles, and they help us to interpret the meaning not only of social information but also of our social identities. In the case of the category transgender, the label “transgender” guided those who aligned themselves with this category to articulate their identities in terms of gender rather than in terms of sex. Conversely, those who aligned themselves with the label transsexual articulated their identities in terms of sex, rather than in terms of gender.67

In the process of negotiating The Conventional Transition Narrative with physicians, patients embraced “transsexual” as an identity. Allied behind an identity category, individuals were able to organize as a collective. Trans activists acting on behalf of The Trans Community™ began shifting the language of their rhetoric away from the term transsexual and towards the term transgender.

Nonetheless, it remains clear that throughout most of the 20th century, patient reports of cross-sex/gender identification was not a compelling enough reason on its own for physicians to offer or recommend sex altering surgery—there had to be some externally validated “clinical rational.”

67 Holman, C. (2006). I Changed My Sex. Now What? Retrieved April 14, 2016, from http://clatl.com/atlanta/i-changed-my-sex- now-what/Content?oid=1256582

59 of 112

Current Conventions and Over-Performance

Today, conventional wisdom states that medical transition is warranted in cases where individuals experience discontinuity between their “gender identity” and the gender role ascribed to the sex assigned to them at birth. In order to medically transition, a person must be discontent with the gender assigned to them and assumed by others based on perceived sex.

Gender identity was introduced as a means by which individuals could claim membership within a sex category when the sex criteria were lacking or contrary to that category. Gender expression was adopted as a means by which others could measure, assess, and authenticate a person’s gender identity. As gender––identity and expression–– becomes an increasingly social and behavioral phenomenon, I want to set it aside and let it exist and continue to evolve as its own entity––perhaps still entangled with, but nonetheless distinct from sex and sex categories. As sex, sex categories, gender, and gender identity were separated and delineated, their criteria and meanings were negotiated in parallel. This process of negotiation and delineation, however, did not resolve the conflation of sex/gender, instead the process seemed to shift the conflation, implicitly tying together sex category and gender expression as they emerged.

Although by 1966 Harry Benjamin had already acknowledged a spectrum of gender nonconformity,68 the initial clinical approaches to trans medicine largely focused on identifying who was an appropriate candidate for sex reassignment and facilitating a physical change from male to female or female to male as completely as possible.69 Given the controversial nature of sex reassignment surgery, practicing surgeons typically endorse extensive and thorough pre-surgical patient evaluation and the need for copious documentation that the patient’s “condition,” “clinically

68 Benjamin, H., Lal, G. B., Green, R., & Masters, R. E. (1996). The Transsexual Phenomenon (Vol. 966). New York, NY: Julian Press. 69 Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman, J., … Zucker, K. (2012). Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7. International Journal of Transgenderism, 13(4), 165–232.

60 of 112

valid” indication for sex alteration, is persistent, insistent, and consistent in nature.70,71 Now, let us return to the introduction and the brief moment we shared in the office of a child psychologist.

There was tension in the air and pressure to over-perform gender in order to satisfy the clinician proctoring my “gender-test.” While I was most visibly under pressure to over-perform, it should not go unrecognized that the child psychologist, and the institution backing her––Boston Children’s

Hospital––also engaged in over-performance, theirs not of gender, but of the rigor of selection criteria in order to account for those who dismiss medical transition as a legitimate medical practice.

Clinicians needed rigorous diagnostic criteria in place as a means for screening and judging the

“medical necessity” of transition and establishing the legitimacy of medical procedures before they could stand behind their decision to intervene. For the medical community to view an intervention—a procedure or therapy––as valid, there must first, be some accepted diagnosis that intervention serves to treat, and second, the medical necessity of intervention must be established.

This was especially true for the alteration of attributes that were so essential to the integrity and organization of the larger social body of the 20th and 21st century United States.

Diagnostic classifications applied to trans persons seeking medical intervention for transition appear in the two major diagnostic manuals used by mental health professionals worldwide, the

American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM, currently in its fifth edition, DSM-5) and the International Statistical Classification of Diseases and

Related Health Problems (ICD, currently in its tenth edition, ICD-10).

As it appears in the ICD-10, transsexuality is a medical, rather than psychological, diagnosis.

Gender dysphoria is a psychological diagnosis in the DSM. Gender dysphoria, as it appears in DSM-5,

70 Richard Green M.D., J. D., & B.A, D. T. F. (1990). Transsexual Surgery Follow-Up: Status in the 1990s. Annual Review of Sex Research, 1(1), 163–174. 71 Hastings, D. W. (1974). Postsurgical Adjustment of Male Transsexual Patients. Clinics in Plastic Surgery, 1(2), 335–344.

61 of 112

is a revision of DSM IV's criteria for “gender identity disorder” which was itself a revision from the

DSM III's criteria for “transsexualism.” This distinction and the identity politics, which have at once grown out of, and contributed to, the introduction and use of these diagnostic categories, will be, in part, the subject of this analysis.

First, Do No Harm

Victus quoque rationem ad aegrotantium Also I will, according to my ability and salutem pro facultate, judicioque meo adhibebo, judgment, prescribe a regimen for the health of the noxamvero et maleficium propulsabo sick; but I will utterly reject harm and mischief

––The Hippocratic Oath in Latin with English translation72

In the early 20th century, procedures to alter sex were controversial and experimental. These surgical interventions were perceived to be hugely dangerous, physically taxing, and in the end, were thought to leave the body marred, damaged, and incomplete—a poor imitation of sex.73 Further, since procedures for sex alteration were, and are, so radical and so permanent, there was, and is, enormous—and quite unfounded—anxiety about patient regret after surgery.74 The fear and anxiety expressed by members of the lay public about “transitions regret”75––the idea that trans individuals would regret their transitions––is rooted in concern that, should sex alteration be made too accessible, a cis person may have their sex altered and essentially be rendered trans. To alter the sex of one’s body is, as the concerned lay public recognizes, physically taxing, exorbitantly expensive,76

72 Smith, C. M. (2005). Origin and Uses of Primum Non Nocere—Above All, Do No Harm! The Journal of Clinical Pharmacology, 45(4), 371–377. 73 Cotten, T. T. (2012). Hung Jury: Testimonies of Genital Surgery by Transsexual Men. Transgress Press. 74 Tannehill, B. (2014). Myths About Transition Regrets [Blog]. Retrieved from http://www.huffingtonpost.com/brynn- tannehill/myths-about-transition-regrets_b_6160626.html 75 Tannehill, B. (2014). Myths About Transition Regrets [Blog]. Retrieved from http://www.huffingtonpost.com/brynn- tannehill/myths-about-transition-regrets_b_6160626.html 76 Scout, D. (2015). Here Are the Most Common Questions About the Trans Community, Answered [Blog]. Retrieved from http://www.huffingtonpost.com/scout-phd/here-are-the-most-common-questions-about-the-trans-community- answered_b_7140728.html

62 of 112

radical, and permanent interventions––these realities are enough to ward off those who do not stand to benefit from sex alteration.

For procedures to be deemed medically necessary, trans interests had to demonstrate that not doing anything and denying medical intervention would instead do more harm and be a bigger violation of the Hippocratic Oath than the intervention would be to begin with. Given the level of harm involved when medical care is denied, and given how unusual regret is, denying medical care to everyone based on the outliers makes no logical or ethical sense. In other words, you would do more harm to more people by denying everyone access than by keeping the system we have in place or even expanding access.77

Thus, for medical transition to be condoned, let alone endorsed, those patients, clinicians, and legal advocates in favor of its introduction needed to demonstrate that procedures to alter sex are medically necessary and an improvement on these risks. To demonstrate the greater harm done by inaction than by medical intervention, these arguments turned to “minority stress.”

Stigma can lead to prejudice and discrimination, resulting in “minority stress.”78 Minority stress is unique additive to general stressors experienced by all people), socially based, chronic, and is thought to leave transsexual, transgender, and gender-nonconforming individuals more vulnerable to developing mental health concerns such as anxiety and depression.79 In addition to prejudice and discrimination in society at large, stigma can contribute to abuse and neglect in one’s relationships with peers and family members, which in turn can lead to psychological distress. Although, these symptoms are socially induced and are not inherent to being transsexual, transgender, or gender- nonconforming, explicit demonstration of common negative psychological effects associated with minority stress was essential in building arguments for medical transition as a medical necessity. The

77 Tannehill, B. (2014). Myths About Transition Regrets [Blog]. Retrieved from http://www.huffingtonpost.com/brynn- tannehill/myths-about-transition-regrets_b_6160626.html 78 Meyer, I. H. (2003). Prejudice as Stress: Conceptual and Measurement Problems. American Journal of Public Health, 93(2), 262–265. 79 Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities, Board on the Health of Select Populations, Institute of Medicine of the National Academies, & Graham, R. (2011). The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. Health Policy and Management Faculty Publications.

63 of 112

need to demonstrate medical necessity gets back to the principles of beneficence and non- maleficence––doctors should “first, do no harm” and second, work to improve the condition or state of their patient’s health.

The WPATH Standards of Care (SOC) Version 7 attempts to address the concerns of trans activists, by identifying the symptoms of gender dysphoria as the products of minority stress, rather than of trans identity. The SOC explain, “[diagnostic] systems attempt to classify clusters of symptoms and conditions, not the individuals themselves.” A disorder is a description of something with which a person might struggle, not a description of the person or the person’s identity. Thus, transsexual, transgender, and gender-nonconforming individuals are not inherently disordered.

Rather, according to the SOC, the distress of gender dysphoria, when present, is the concern that might be diagnosable and for which various treatment options are available.

In order to do so, a significant number of health professionals called for a standard for eligibility for sex reassignment surgery. This led to the formulation of the original Standards of Care

(SOC) of the Harry Benjamin International Gender Dysphoria Association, now World Professional

Organization of Transgender Health Professionals (WPATH), in 1979. However, in creating standards, clinicians implicitly adopted the notion that patients must be vetted to determine their candidacy and eligibility for transition. Clinicians purport that the diagnostic and screening processes are for the protection of patients. However, these guidelines are just as much, if not more so, in place to protect the interests and reputations of involved medical providers. Should a patient actually regret their transition, the treating physician is ultimately the one who would be responsible for needlessly “disfiguring” a healthy body.

In cases of sex reassignment, surgeons have the most at stake, as they are the ones who could be held liable for “castrating” a healthy person. In the first case of sex reassignment in Egypt

64 of 112

to appear in the media, it was only the operating surgeon who experienced legal consequences and had his medical license temporarily revoked., despite the presence of multiple doctors and psychiatrists.80 Thus, surgeons, seeking to protect themselves, are often the most reifying and policing of gender ideologies, the conventional wisdom on trans medicine, and The Conventional

Transition Narrative. The SOC are designed to minimize the surgeon’s liability and give the clinician confidence that patients who are able to meet eligibility criteria pose low risk to the surgeon’s reputation and moral standing. The patient must build and defend their case for transition. They may be required to put forth multiple clinical and psychological evaluations and letters of recommendation from other providers, demonstrating that “gender dysphoria” has persisted for a certain period of time.

A patient must be evaluated and recommended for medical transition by a mental health professional––and submit thorough and extensive documentation thereof––before most surgeons will permit them to make an appointment for consultation (see Appendix D). WPATH established that the responsibility to evaluate was separated from the responsibility to surgically intervene. In the absence of any reliable quantitative assessment, the responsibility to evaluate and recommend a patient for surgery has been typically reserved for mental health professionals. Should the outcome of a patients transition not follow the expected trajectory, copious and through documentation serves as a safeguard for all providers involved in facilitating care— documentation absolves them of responsibility for the patient’s deviation from the normative path. Nonetheless, it is in the surgeon's best interest to demonstrate that whatever metric they use to determine eligibility is an effective one. The WPATH Standards of Care serve as a safe guard for surgeons, who bear full legal responsibility for the outcome of an operation.

80 The unpublished papers of Sherine F. Hamdy, Ph.D.

65 of 112

In an article published in the Seminars of Plastic Surgery, titled “Sex Reassignment Surgery in the Female-to-Male Transsexual,” the authors explicitly endorsed this screening process to qualify their involvement in patient care and justify the surgical alterations they made to the patient’s sex. In this article, they stated,

Transsexual patients have the absolute conviction of being born in the wrong body and this severe identity problem results in a lot of suffering from early childhood on. Although the exact etiology of transsexualism is still not fully understood, it is most probably a result of a combination of various biological and psychological factors. As to the treatment, it is universally agreed that the only real therapeutic option consists of “adjusting the body to the mind” (or gender reassignment) because trying to “adjust the mind to the body” with psychotherapy has been shown to alleviate the severe suffering of these patients. Gender reassignment usually consists of a diagnostic phase (mostly supported by a mental health professional), followed by hormonal therapy (through an endocrinologist), a real-life experience, and at the end the gender reassignment surgery itself.

As to the criteria of readiness and eligibility for these surgical interventions, it is universally recommended to adhere to the Standards of Care (SOC) of the WPATH (World Professional association of Transgender Health).81

The WPATH asserts that their organization releases and revises its Standards Of Care in order to minimize the risk of patient regret and provide clear guidelines for patients and clinicians to follow. They reason that their metrics for evaluation will identify those who stand to benefit from surgical or medical intervention and will, more critically, help recognize those who do not stand to benefit and are misguided in their search for care. The WPATH holds that the conventional process of evaluating and only treating those judged to be “appropriate candidates” for sex alteration has been extensively evaluated and proved to be highly effective.82 Across WPATH cited studies,

81 Monstrey, S. J., Ceulemans, P., & Hoebeke, P. (2011). Sex Reassignment Surgery in the Female-to-Male Transsexual. Seminars in Plastic Surgery, 25(3), 229–244. 82 Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman, J., … Zucker, K. (2012). Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7. International Journal of Transgenderism, 13(4), 165–232.

66 of 112

outcomes reflect high rates of satisfaction, ranging from 87% of MtF patients to 97% of FtM patients and a low incidence of regret 1%–1.5% of MtF patients and < 1% of FtM patients.83, 84

In effect, the process WPATH endorses assumes that only those who truly stand to benefit will make it through the entire lengthy, costly, and arduous process of compiling the requisite evaluation, documentation, recommendation, consultation, etc. These SOC present an endurance test.

Situation within Mental Health ICD-10 Terminology and Frameworks

The International Statistical Classification of Diseases and Related Health Problems (ICD) is the international "standard diagnostic tool for epidemiology, health management and clinical purposes.” The ICD is also the primary means by which physicians report to and communicate with reimbursement systems. Thus, a clinician’s view of the patient and of clinical diagnosis is limited to, and shaped by, the options for diagnostic coding available to them within the ICD. Further, with each claim filed and approved, more precedent is set for insurance companies to require a certain record of documentation before approving a patient’s reimbursement eligibility for covered procedures. The ICD-10 incorporates “transsexualism,” “dual role transvestism,” and “gender identity disorder of childhood” within the category “gender identity disorder.”

The ICD-10 defines transsexualism as:

[a] desire to live and be accepted as a member of the opposite sex, usually accompanied by a sense of discomfort with, or inappropriateness of, one's

83 Richard Green M.D., J. D., & B.A, D. T. F. (1990). Transsexual Surgery Follow-Up: Status in the 1990s. Annual Review of Sex Research, 1(1), 163–174. 84 Friedemann, P. (1993). Regrets After Sex Reassignment Surgery. Journal of Psychology & Human Sexuality, 5(4), 69–85.

67 of 112

anatomic sex, and a wish to have surgery and hormonal treatment to make one's body as congruent as possible with one's preferred sex.85

Transsexualism, however, is rarely, if ever, used by clinicians—in fact, in this most recent edition of the ICD, there is no code attached to the term. Instead, “transsexual” is only listed as an

“approximate synonym” for gender identity disorders (Appendix B). The convention of and process by which physicians and insurance reimbursement systems collect appropriate documentation to demonstrate the medical necessity of intervention has been built around the paradigm of psychologically disordered gender identity.

DSM-5 Terminology and Frameworks

The politics of and around both sex and gender are controversial and situate our understanding and utility of each, which has ultimately led to a proliferation of terms whose meanings vary over time as well as across and within disciplines. Before we can analyze the diagnostic criteria for “gender dysphoria” as it appears in the DSM-5 (Appendix C), we must recognize what meaning clinicians ascribe to the language surrounding sex and gender (Table 1).86

The DSM-5 defines sex as “the biological indicators of male and female (understood in the context of reproductive capacity)”, and gender, as the “public (and usually legally recognized) lived role as boy or girl, man or woman.” These definitions of sex and gender and the DSM’s attempt to define other related terms reflects many years of pressure directly from trans activists, as well as shifting societal understandings of what separately constitutes sex and gender. The distinction made by the DSM seems to align with that made by “The Trans CommunityTM,” whereby the terms male and female are definitively used to describe biological sex, and the terms boy, girl, man, and woman are

85 World Health Organization, W. H. O. (2005). International Statistical Classification of Diseases and Health Related Problems ICD-10. Stylus Pub Llc. 86 American Psychiatric Association, A. P. A. (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5®). American Psychiatric Pub.

68 of 112

reserved to describe gender. A closer reading reveals that the DSM-5 does not, in fact, follow this convention of separating the terms of sex and gender— it proceeds to ignore the very convention it seems to have just acknowledged.

Immediately following the definitions of sex and gender, the term gender assignment is defined as “the initial assignment as male or female. This occurs usually at birth and, thereby, yields the ‘natal gender.’” Here, the DSM-5 uses the labels male and female—labels reserved within The Trans

CommunityTM to name categories of sex—instead to name categories of gender. The diagnostic manual makes the same conflation again when it defines gender identity as, “a category of social identity and [referring] to an individual’s identification as male, female, or, occasionally, some category other than male or female.” The use of male and female within the medical definition of gender identity reflects the ambiguity and lack of certainty clinicians have with the terms and language of their trans patients. This discrepancy in the use of language and meaning ascribed to it connotes a growing ideological rift between The Trans CommunityTM and the medical profession.

Negotiating The Terms of Care The Rise and Rhetoric of Gender

As previously noted, a central tension exists within contemporary trans medicine between trans individuals and the clinicians on whom many of trans individuals must rely. Although, the medical community has recognized that gender identity and gender expression have emerged and are being actively employed by The Trans Community™ as a means of articulating identity, clinicians attempted to adopted this distinction without fully understanding it. Some within the medical community purport to recognize the distinction trans activists make between sex and gender–– identity and expression––but the language used by physicians who deal most closely with trans patients, both verbal and in print, does not demonstrate that they fully grasp the nuance or the

69 of 112

action of gender as it is understood within the trans populations they serve. With different meaning(s) and understandings of gender between trans patients and providers, the term “gender” was introduced within medical spheres when it became apparent that, in cases of ambiguous genitalia (i.e., “intersex” individuals), biological indicators could not predict or be uniformly associated with the lived role in society and/or the identity as male or female that these individuals would embrace. To physicians, physical abnormality clearly warranted medical intervention so as to

“correct” and make typical that ambiguity. The term gender was introduced and deployed as essential determinant of “correct” sex in cases of physical ambiguity. Strategic employment of gender expanded the scope of its own application. That is, the notion of gender being part of an intersex person’s essential nature and separate from their sex enabled certain dyadic87—having a uniform set of classical biological indicators—individuals who sought sex alteration to argue that they too were in a state of ambiguity and in need of the same “corrections” medical intervention offered to intersex patients.

Mid-20th century researchers reasoned that the etiology of cross-sex/gender inclination must be psychological given the absence of any identifiable physical abnormality in trans individuals.

Many trans activists considered the diagnosis of “gender identity disorder” (GID) insulting and pathologizing. While some trans activists do consider the term “gender dysphoria” an improvement over GID, (“dysphoria" being a state of emotional and mental discomfort as a symptom of discontentment, restlessness, dissatisfaction, malaise, depression, anxiety or indifference), others pressure the American Psychiatric Association to remove “transsexualism,” under any guise, from the DSM. Many trans activists believe that making mention of gender-nonconformity in any form within a document describing mental health conditions and disorders leads to a misperception that

87 G, C. (2015). The Rift Between Us — Intersex and Trans Discourse. Retrieved from https://medium.com/gender-2-0/the-rift- between-us-intersex-and-trans-discourse-62dee7f7a73#.mlrd9kfhy

70 of 112

holding trans identity is a mental health condition, rather than as an inborn trait.88 Other trans activists point out, however, that the current social, medical, and legal frameworks for medical transition and insurance billing have been constructed around the DSM and the mental health model of diagnosis. They argue that to have a diagnosis within the DSM is essential to ensure insurance coverage and reimbursement.89 Whether or not there exists some diagnosis within the DSM that would justify the alteration of sex is beside my point. I argue that the language presently used to discuss “the trans experience” with regard to what drives a person in their choice to pursue or go without procedures to alter their sex, must change.

The existence of a diagnosis for such dysphoria with gender, and media representations of transition which perpetuate this model, often facilitates access to health care and can guide further research into effective treatments.”90 The WPATH SOC indirectly acknowledges that any set of diagnostic criteria serves to pathologize the state or condition it attempts to diagnose. Nonetheless, the authors make clear attempts to rationalize and justify the inclusion of “gender dysphoria” within diagnostic manuals by creating distance between the clinical condition and the identity category so often associated. They clarify, gender nonconformity refers to the extent to which a person’s gender identity, role, or expression differs from the cultural norms prescribed for people of a particular sex.91 Gender dysphoria, they explain, refers to discomfort or distress that is caused by a discrepancy

88 Gender Centre. (2014). Transsexualism. Retrieved from http://www.gendercentre.org.au/resources/fact-sheets/transsexualism.htm 89 For more on the arguments for and against the inclusion of some diagnosis within the DSM, see Knudson, G., Cuypere, G. D., & Bockting, W. (2010). Recommendations for Revision of the DSM Diagnoses of Gender Identity Disorders: Consensus Statement of the World Professional Association for Transgender Health. International Journal of Transgenderism, 12(2), 115–118. 90 Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman, J., … Zucker, K. (2012). Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7. International Journal of Transgenderism, 13(4), 165–232. 91 Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities, Board on the Health of Select Populations, Institute of Medicine of the National Academies, & Graham, R. (2011). The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. Health Policy and Management Faculty Publications.

71 of 112

between a person’s gender identity and that person’s sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics).92, 93

For a person to be diagnosed with “gender dysphoria” there must be a marked difference between the individual's expressed/experienced gender and the gender others would assign him or her, and it must continue for at least six months (Appendix C).94 I call into question the assumption, made by WPATH and the DSM, that all those who desire medical intervention for transition will experience gender dysphoria. The assumption that there exists some fundamental alignment between “gender identity”––seen by members of The Trans Community™ as a person’s understanding of their social self––and a person’s “true” sex, enabled the emergence of sex alteration as legitimate practice. Even so, The Conventional Transition Narrative, which this assumption reinscribes, creates a tension among many within The Trans Community™ who may stand to benefit from some alteration to the sex of their body. This tension, discussed in Part III, is a self policing of the clinical category transgender, as individuals judge their own narratives in light of The Conventional Narrative and judge themselves to be “not trans enough” to be taken seriously. that a person may be “not n that the

Discussions between patients and providers about a patient’s drive to alter the sex of their body, must take place in explicit terms of sex and of the body––rather than in terms of gender. As I discuss in Part III, the current clinical conventions of medical transition acknowledge that hormonal and surgical procedures––medical rather then psychiatric therapies––are the known to “alleviate” a trans individual’s dysphoria with their experience of “gender identity” as it relates to their body.

92 Fisk, N. M. (1974). Editorial: Gender Dysphoria Syndrome––The Conceptualization That Liberalizes Indications for Total Gender Reorientation and Implies a Broadly Based Multi-Dimensional Rehabilitative Regimen. Western Journal of Medicine, 120(5), 386–391. 93 Knudson, G., Cuypere, G. D., & Bockting, W. (2010). Recommendations for Revision of the DSM Diagnoses of Gender Identity Disorders: Consensus Statement of the World Professional Association for Transgender Health. International Journal of Transgenderism, 12(2), 115–118. 94 Gender Centre. (2014). Transsexualism. Retrieved from http://www.gendercentre.org.au/resources/fact-sheets/transsexualism.htm

72 of 112

Insofar as far as the American medical profession is concerned, today the term “gender” is still very much a proxy for sex, however much, contemporary literature on medical transition purports otherwise. As my narrative research revealed, within and among members of The Trans

Community™, the term “gender” refers to an entirely social phenomenon of identity, behavior, and self-expression––separate and distinct from their body. With such a rift in the meaning of gender between patients and the providers on whom they rely, “gender dysphoria” can be recognized as a misnomer. As I explicate in Part IV, this misnomer for what I argue is ultimately a drive to embody what I term one’s “somaticorporeal self-concept”––a person’s physical sense and understanding of their body and what it should be. To clinicians, this idea of somaticorporeal self-concept may sound similar to gender, as the medical community understands it. This, however is exactly the issue to which I aim to call attention and alarm––to The Trans Community™, a paradigm of medical transition based around an individual’s somaticorporeal self-concept would entirely change the nature of present discourses around sex alteration.

73 of 112

PART III Narratives in Theory and Practice

The Action of Rhetoric

Overview

In this section I offer several analytical principles and frameworks which will guide my discussion and critique of The Conventional Transition Narrative. These principles will also serve in the analysis of certain narratives I collected as a result of my research. Here, I will use my analysis of these alternative narratives to trouble the assumptions implicitly made about the relation of sex/gender and the motivation for medical transition within The Conventional Transition Narrative.

Interpellation

Interpellation, a term coined by French Marxist philosopher Louis Althousser, describes the process by which ideology addresses the individual.95 To illustrate how interpellation functions in the context of ideology, Althousser used the example of a policeman shouting "Hey, you there!" At least one individual will turn around (most likely the right one) to "answer" that call. At this moment, when one realizes that the call is for oneself, one becomes a subject relative to the ideology of law and crime. Similarly, the use of a pronoun, for example "he," paired with a response from someone, is another example of interpellation in action––in this instance, the individual responding to the pronoun "he" becomes a subject relative to the ideology of gender categories. We are all always caught up in the process in which we voluntarily acknowledge the validity or relevance of the dominant ideology in which we live for ourselves and thus subject ourselves to it.96 As we interact

95 Brooker, P. (1999). A Concise Glossary of Cultural Theory. Arnold. 96 Brooker, P. (1999). A Concise Glossary of Cultural Theory. Arnold.

74 of 112

with and adopt emerging ideologies around gender, sex, and identity, we acknowledge the validity and relevance of those ideologies.

Language as Productive vs. Language as Referential

A language ideology is the framework one adopts to govern their judgments and understanding of how language is and should be used. Most people adopt a language ideology that states that language is referential. That is, their ideology states that there is a world, and that language communicates what that world is to an observer. Linguists and linguistic anthropologists, however, have been arguing that language is productive of social relations. That is, language is that which produces, gives meaning to, and shapes social relations. Language distinguishes between things.

Language distinguishes between people. Language creates categories. It can be a marker to name and to designate similarity or difference. Language offers new metaphor and therefore a new way to imagine something.97

"The Looping Effect of Human Kinds"

Human kinds are, as Hacking describes them, are categories of sorts––"classifications that could be used to formulate general truths about people; generalizations sufficiently strong that they seem like laws about people, their actions, or their sentiments."98 These kinds are the products of modern social science, constructed for use in classification, quantification, and intervention. The study of affected populations and "disease states" in the construction of diagnostic categories is a means by which medical authorities create these "human kinds" as Hacking imagines them. The

"looping effect of human kinds" states that by classifying individuals within these constructed categories, both the individual and the category undergo change. The act of categorizing people

97 Tannen, D., Hamilton, H. E., & Schiffrin, D. (2015). The Handbook of Discourse Analysis. John Wiley & Sons. 98 Hacking, I. (1995). The Looping Effects of Human Kinds. Causal Cognition: A Multidisciplinary Debate, 351-394.

75 of 112

offers new ways for them to think about and imagine themselves, new ways to behave, and new ways to think about their pasts. For instance, in Part II, we observed this phenomenon shape clinical categories with the shift from Gender Identity Disorder to Gender Dysphoria in the DSM and shape the ways trans individuals conceptualize themselves and their experience within the frameworks of the medical authority.

Metaphor "It's All in Your (genderbr)Head"

Metaphors shape possibility of our imaginary. When we introduce new metaphor to argue a point, it affects our framing of the subject. As we use metaphor, we re-inscribe the idea to which our metaphor refers, while simultaneously re-inscribing the metaphor itself as a means of conceptualizing the subject of our arguments.99

The "Genderbread Person" is a teaching tool and a visible example of the ways in which metaphor as a medium for argument shapes the way we conceptualize the phenomena of debate. It is often used to reduce, flatten, and explain those ideological frameworks of gender, sex, and identity within which The Trans CommunityTM situates its rhetoric so as to make them digestible and accessible to outsiders. The infographic is often used by activists and educators to articulate, illustrate, and disentangle concepts that are regularly conflated within the discourses surrounding social and medical transition and trans identity more broadly. Sam Killermann claims to have introduced the teaching tool in 2011, however, mounting evidence suggests that Killerman— a cis, heterosexual, white man––appropriated the concept from trans individuals who introduced a version of the graphic (albeit a less aesthetically pleasing version) online.100

99 Lakoff, G., & Johnson, M. (2008). Metaphors We Live By. University of Chicago Press. 100 The Genderbread Plagiarist. (2014). Retrieved March 21, 2016, from http://storify.com/cisnormativity/the-genderbread-plagiarist

76 of 112

The earliest public versions of the "Genderbread Person" were posted online in 2005 and are collectively thought to be, as one trans/non-binary individual put it, "part of a community-wide collaboration to make tools to understand our own genders and also teach other people about them."101 We can see an active internal negotiation of language and of the metaphor from within

The Trans CommunityTM, as versions of the graphic are edited and revised for released to outsiders.

One such negotiation involved strategic dismantling of the metaphor of gender as a social language.

Figure 1. Left: version 1, released in 2011; Right: Version 2, released in 2013

The metaphor of gender as an essential identity and a form of expression was newly introduced. The idea of “neurological sex”—having a corporeal or somatic sense of what sex should be––was too radical a thought for most within the cis majority. By prevailing logic, sex was essential. End. Full stop. Therefore, in order to contest the essential nature of sex, and further to reposition sex as the consequence of something new, an attribute––one heralded as still more essential than biology––was needed. Enter gender identity.

101 The Genderbreadperson: A History. (n.d.). [Blog]. Retrieved from http://whatdoesenbymean.tumblr.com/post/62247473507/itspronouncedmetrosexualcom-plagarised-the

77 of 112

The construction of gender identity and the metaphor of "misalignment" between gender identity and sex leveraged Cartesian Duality. Cartesian Duality was introduced in answer to The

Mind-Body Problem, and it stipulated that people are composed distinctly of matter and of mind.102

The Mind-Body Problem––how to articulate and explain the relationship between physical and non- physical states and experiences. Cartesian Duality served to address similar issues presented by the physical and non-physical parts of The Conventional Transition Narrative. Framing gender identity as a mental state reified its separation from the physical body and enabled us to envision a person in two forms––their internal or mental self, versus their external physical self. Thus, given the positioning of cis manifestations of sex/gender––those who understood their experience and expressions of gender and sex to be in typical “alignment”––as "normal" and "ideal," the argument for "bringing sex into alignment with gender identity" was embraced. Further, this imaginary of the internal and external self––gender identity––separate and distinct from body––invited the metaphor of trans experience as a person "born in the wrong body."

The Action of Medical Narrative Medical Narrative in Theory

According to modern medical belief, sharing patient stories and accounts from many different perspectives offers a better and more inclusive picture of these patients and may offer providers a more nuanced understanding of patient experience. Physicians are able to understand patient narrative and provide better, more personalized treatment as a result. Further, with a larger collection of patient narratives, physicians are better able to recognize the “pattern” of presentation for a given condition and thus, are better able to recognize the same condition in other patients.

This is how the medical community currently perceives the effect of narrative on practice.

102 Crane, T., & Patterson, S. (2012). History of the Mind-Body Problem. Routledge.

78 of 112

Medical Narrative in Practice

However, we should ask ourselves, to what degree does the telling of stories actually set the parameters of which stories can be told? As each person shares their story and as it is accepted, the parameters within which the story must be told are set. In the communication of meaning, the subject shares a story, but almost more significantly, the audience must then interpret that story. The meaning a story or narrative carries is dependent less on that information which the subject presents and far more on how the audience makes sense of and interprets the information presented. Thus, when there exists pressure or incentive for a story or narrative to be accepted by others, the audience, knowingly or otherwise, is awarded the authority and power to shape the narrative and the information a subject may present. In this sense, we can understand the collection of patient histories as the discursive negotiation of a shared narrative—The Conventional Transition Narrative. This positions the individual as one member of a larger patient population, and the single patient’s truth is awarded less significance and seen as less authentic than the constructed collective truth.

Paradoxically, however, as the individual’s truth is awarded less significance than the collective’s, that individual is positioned and pressured by both evaluating clinicians and by the beholden The Trans CommunityTM, to which they necessarily belong, to represent and uphold The

Conventional Transition Narrative. In this sense, The Collective Transition Narrative is constantly at stake.

Each trans individual seeking sex alteration holds the power and potential to contest and dismantle

The Conventional Transition Narrative. Likewise, as we examine the ways in which trans individuals speak about their experience and their social relation to The Trans Community™ and it’s other members, we can elucidate the ways in which threats to The Conventional Transition Narrative are perceived within The Trans Community™ it self.

79 of 112

The Conventional Transition Narrative is an effective tool with which trans patients can structure their narrative and approximate their experience to be reliably judged as “authentic” and “deserving” of intervention. I argue that we need to recognize that the conventional wisdom around medical transition has been negotiated—it is situated within an ongoing discourse between trans patients,

The Trans CommunityTM, and interested clinicians, and further cannot be removed from the larger social, political, medical, and legal landscapes of the 21st century United States. This is not to suggest that trans narratives are false or that they should be disregarded, nor is it to suggest that trans patients should be thought of as either dishonest, deceitful, disingenuous, or unreliable. It is, however, to suggest that we recognize that social relations, language, and metaphor are co-produced in tension with one another. This recognition should prompt a reevaluation of our clinical approach to trans medicine.

In the negotiation of The Conventional Transition Narrative, each party––patients and providers––had to consider their own interests and stakes, set conditions, and make compromises.

Certain interested providers saw sex alteration as an opportunity to expand their clinical expertise.

At the same time, the social and moral implications of altering the sex of a body put the reputations of these interested providers at stake. Before they could consider their patients’ best interests, they had to consider the social and professional implications of their involvement within their society.

Patients who sought to alter their sex relied entirely on medical providers to validate and authenticate their experience, and further, to grant them access to hormonal and/or surgical interventions. The endorsement of a medical provider would lend legitimacy to a patient’s claims and position in society; yet as gatekeepers, providers reserved the authority to deny any patient access to sex altering procedures. Therefore, it is in a patient’s interest to––whether consciously or subconsciously––curate and express their narrative in accordance with the provider’s expectations,

80 of 112

and further, to use language and metaphor which fits within the framework of prevailing sex/gender ideologies of the medical authority of their particular moment in time and place.

Case studies, and other publications, medical or popular, which articulated the clinical understanding and view of those seeking sex alteration––at the time of publication––served to ease the reification of The Conventional Transition Narrative. Case reports and other published accounts of medical transition offered precedent language—proven in cases where others sought the same diagnosis, prognosis, and prescription. Physicians began to perceive confirmation bias as pattern and implicitly curated narratives became the evidential basis of clinical diagnostic tools. These tools would make explicit the criteria with which patients would be evaluated and have their eligibility for sex alteration determined.

Social Rules Governing Gender

One of the most explicit social rules of our society––specifically the United States, although this rule may extend to other societies as well––is that people are expected to unambiguously present themselves in public situations in a manner consistent with their anatomical sex. Today, the lay

American public makes an implicit assumption that everyone has, or should have, a single, unambiguous, anatomical sex. With emerging discourses around ambiguous sex, trans activists–– borrowing from the distinction made by second-wave feminism between sex and gender–– introduced gender as a phenomenon essential to person’s nature and a dictate sex in cases where sex could not be determined by conventional means. Here, there exists another implicit assumption that everyone should have a single unambiguous anatomical sex and that their sex should necessarily be aligned with their “gender identity.” This leaves no possibility for a person to experience an authentic “misalignment” between their gender and corporeal identities. The arguments to legitimize sex alteration, medical transition, and the existence of The Trans Community™ relied not just on

81 of 112

the reification of existing sex and gender binaries, but on the assumption that alignment between these binary distinctions (see Table 1 in Part I) was a “natural” and “fundamental” state which must be achieved. This assumption contributes to the conflation of sex/gender and does not leave room for many of the alternative narratives I present here to exist and be recognized as authentic.

Alternative Narratives

Threats Perceived from Within

Why is the collective narrative constantly put at stake if the individuals feel such pressure to fit the collective? The collective narrative is at stake because each individual has the potential to resist that pressure to fit within. For example, Buck Angel is, as one of my interview subjects put it,

“a seemingly hyper masculine, ripped dudebro, pornstar,” but he loves and claims ownership of his vagina. This seeming contradiction is a threat to The Conventional Transition Narrative and thus to the integrity and validity of arguments for the merits of medical transition because it suggests that bottom surgery is not medically necessary. Given the paucity of representations of trans people in the mainstream U.S. media, Buck Angel, like any other person who places themselves within the category trans, implicitly represents all trans people, and he breaks The Narrative. The Trans

CommunityTM, specifically its members who need access to medical transition, recognize that dynamic and the friction it creates.

This friction exists on multiple levels; social, political, and legal movements, but also on the individual level. Frank Kline (a pseudonym, Subject ID WS500105) self identifies as a trans-man, and is in the midst of his medical transition. Kline articulated the tension and self-doubt he experienced when he first encountered an alternative to The Conventional Transition Narrative in the way of non-operative genderqueer identity. These non-operative individuals also laid claimed space within the identity category trans––the same category within which Kline places himself.

82 of 112

When I first heard that some people could be trans, without surgery or hormones, and feel okay with their bodies, it made me question what I was doing and why I was putting myself through all of this medical transition––I felt like, if they could be trans without medically transitioning, then my trans identity, and my choice to transition, was less valid. But then I thought about it and I realized that I did need surgery and hormones to feel okay with my body, and it was alright.

The self-doubt Kline expresses here, as he recognized whom he shares space in his trans identity category was similarly reported by other subjects as well. One tension here arises for Kline when others apply the same label to name an experience than his own. This tension prompts the self doubt he articulated. From this tension arises another conflict similar to the one Buck Angel presents––if some people can be trans without surgery, what grounds to other trans individuals have to claim they need to alter the sex of their bodies? Even with pressure from The Trans

Community™ to ally behind and within the singular umbrella category “trans” to organize and mobilize for greater protection of civil rights under the law, this tension gets internalized. Those who do seek to medically alter sex harbor resentment towards those who do not––non-operative trans individuals seem to have less at stake, yet are entitled to equal membership and inclusion under the trans umbrella. Those non-operative trans individuals recognize this resentment and, as I discuss further below, articulate their feelings of being “not trans enough.”

So if Buck Angel exists, does he not too threaten your paradigm idea that the problem is one of locus in the body? No, Buck Angel doesn’t threaten my paradigm— he supports it. My paradigm states that his doctors should concern themselves with addressing the discordance he experienced within his body and his corporeal sense of self. The current model would not have allowed him to tell his doctors that he “loved” his vagina—he would have had to omit that detail or act as though he was ultimately considering bottom surgery, but he could not swing it in the near future either for cost or because the surgery “is not good enough yet.” This is one example of how trans narratives are policed by clinicians and the very idea of narrative medicine.

83 of 112

The categorical boundaries of transgender and transsexual are still being actively negotiated.

The Conventional Transition Narrative––having a consistent, insistent, persistent experience of gender identity being “misaligned” with the sex assigned to them at birth, and further feeling the need to alter that assigned sex to achieve a state of fundamental alignment between their essential gender identity and physical sex. This tension becomes visible when trans activists qualify and excuse members of The Trans Community™ who have not taken steps to alter their sex. For example, one trans activist, writing for the Huffington Post, poses and proceeds to answer the question,

What if someone hasn’t had any surgeries, is he or she still transgender/transexual?

Any idea how much the surgeries cost? For a trans woman, it’s easily $100,000. Can you imagine if people wouldn’t call you by your name until you paid $100,000? Now maybe it’s easier to understand that we respect who people say they are, regardless of surgery, hormones or the information on their drivers license.103

These activists do not want to exclude anyone who situates themselves as a member of The

Trans Community™––to do so would be to refuse political allies and decrease in both number and social influence. Therefore, the cost of procedures and limited access to skilled surgerons is offered a means of explaining away those trans individuals who do not fit within the binary vision of medical transition––those who transition “all the way” in that they pursue all available hormonal and surgical intervention to align themselves most closely within the category, under a dichotomous model of sex, opposite the one assigned to them at birth.

103 Scout, D. (2015). Here Are the Most Common Questions About the Trans Community, Answered [Blog]. Retrieved from http://www.huffingtonpost.com/scout-phd/here-are-the-most-common-questions-about-the-trans-community- answered_b_7140728.html

84 of 112

Not Trans-Enough

The subjects of my narrative research commonly expressed this feeling. Subjects would recognize The Conventional Transition Narrative and, within it, the implicit definition of the category transgender. This implicit definition of The Conventional Transition Narrative was made explicit in my interview with Logan Norse (a pseudonym, Subject ID WS500118) when they104 said,

I identify as Genderqueer. I’m not entirely sure what that word means, but it sounds better and more accurate than any other word I’ve found— I want to say I’m transgender, but then I’m not entirely sure I’m all the way transgender… I don’t know. It’s just kind of a whole complicated mess that never clarifies itself the more I think about it.

Before going on, I will point out, the uncertainty with which Norse described the identity category “genderqueer”––an identity they claim as their own––speaks to the appeal of this category for many. Queerness denotes ambiguity and a resistance to exist within conventional or typified categories. In this way, queerness, paradoxically, becomes a category for those who reject and place themselves outside of categories. Genderqueerness is at once an identity and an active recognition of gender categories as socially and culturally constructed. The identity genderqueer is one that embraces the hollowness of gender as a larger social convention and rejects the restrictions it places on a person’s behavior and expression of self. I asked Norse, in follow up, “What does transgender mean to you?” They responded,

I was raised as a girl. I only used the woman’s restroom, and then, when I realized that I wasn’t a girl, it wasn’t really that much of a shock—it was kind of a slow realization, but then I thought to myself, “Well, okay, being transgender would mean that I’m a boy––not just that I want to be a boy, but that I am a boy,” and I didn’t quite feel that way. I thought a lot about masculinity, and I wanted to be masculine, but there are some aspects––not all of the aspects. I don’t want to be a woman, but there are some aspects of femininity that I do like, and I do sort of identify with under certain conditions, and I don’t really want to give those up.

104 Here I use the singular “they” to refer to my interview subject, Logan Norse.

85 of 112

Norse does not place them self entirely within either the typified categories of gender the gender binary––boy/man or girl/woman. Although today trans activists claim to reject the dichotomous and oppositional binaries of sex and gender, The Trans Community™ had a hand in their reification. The Conventional Transition Narrative, and the authority that The Trans Community™ awarded physicians to police what brand of gender expression made a person eligible for transition from one category of sex/gender to “the other,” have significantly reified the assumed alignment between dichotomous sex/gender binaries. Without experiencing this same alignment, many of my non-operative genderqueer and non-binary trans subjects were left with the feeling that they were

“not trans enough” to make legitimate claims to fit within the category transgender, due to what they internalized about what it meant to be “transgender” according to The Conventional Transition

Narrative.

Alternative Narratives

The Conventional Transition Narrative, gender dysphoria, and sex alteration/medical transition emerged and were negotiated within western medicine under one definition of sex/gender which positioned gender as a visible social proxy for “true sex” and implicitly assumed that there existed some necessary fundamental “alignment” between one’s gender identity and sex. First, I argue that gender has come to mean something different––rather than a social proxy for any sex, gender is understood now as a social identity, entirely distinct from sex. Second, I contest the necessary fundamental alignment between sex and gender identity. Third, I argue that, with gender as the basis of medical transition, patients who may benefit from alterations to the sex of their body may be denied access based on the current model of care. Therefore, fourth, I argue that we remove gender from the discussion of what is right for a patient’s sex. Fifth, after the results of my research suggest that gender identity, given what gender is today, is not that which drives a person to alter the sex of

86 of 112

their body––instead, I believe there exists a more physical motivation towards intervention. I believe that, today, a discontinuity of what I call “somaticorporeal embodiment of self-concept” is ultimately what drives a person to alter their sex. Thus, given my fourth and fifth arguments, I further argue, sixth, that medical providers need to ask different questions of their trans patients.

Somaticorporeal self-concept

In my interviews and my reading of trans narratives shared elsewhere––in magazines, over social media, and/or by news outlets, I observe a growing rift between the ways in which trans patients articulate their drive to alter sex, and the ways in which The Conventional Transition Narrative expects them to articulate this drive in order to access procedures for medical transition. The drive and motivation to hormonally or surgically alter one’s sex may be exacerbated by, but does not seem to stem from, the social convention of gender. Rather, those subjects who did and those subjects who did not wish to alter their sex were concerned with the continuity of what I name

“somaticorporeal self-concept” ––a person’s internal sense of what their body should and should not be.

In the absence of experiencing discontinuity for one’s self, this idea may be difficult to grasp.

I want to draw a distinction between somaticorporeal self-concept––an individual’s sense of what their body should be, and what “just feels right”––and “body image”—a individual’s perception of the present physicality of their body. The subjects of my research did not report or demonstrate an unrealistic perception of their body. On the contrary, their body images seemed exceptionally realistic––for some, upsettingly so.105 Those trans subjects who sought to alter their sex reported a concrete and felt sense of sense of dissonance between they knew should be and what actually was.

105 Those who sought to alter their sex did not feel their physicality allowed them to embody their somaticorporeal self-concept and had an arguably heightened consciousness of their own physicality and sense of somatic self-awareness. Even non-operative trans subjects had considered and questioned their relation to their own physicality. Given the productive nature of language, I understand these social relations to the body––questioning one’s feeling of embodiment––as a product of The Conventional Transition Narrative. By placing them self within the category trans, conventional medical wisdom assumes the individual will medically transition. Therefore, so too does the individual who internalizes the adopts the category “trans” as it was produced, in part, by that conventional medical wisdom.

87 of 112

Those trans subjects who were non-operative also reported a similarly concrete sense of what their body should be, however, these individuals articulated the absence of conflict with the parts of their natal physicality that they elected not to alter. I recognize this concept may be difficult to envision or imagine for those who have not experienced such dissonance for themselves.

Imagine for a moment––with no other change to your current state of mind, body, mood, activity, position, etc.––a third arm protruding from your right side. Imagine the weight of this extra appendage. Imagine the look of it, hanging from your body. Imagine the contact it makes with your clothes and the chair you are sitting in as you read this. Imagine yourself moving and imagine the movement and physical sensation of that arm articulating in response. I offer this exercise as an approximation of experience––it is meant to give a taste of the physical bodily discomfort reported by those research subjects who sought to alter their sex in some way. This exercise is an example of an incitement to discourse. The problem is that what I just had you imagine sounds ridiculous.

Humans do not typically have more than two arms––and if an individual does, the extra appendage was not likely the result of spontaneous growth. So you may reason that of course a third arm would feel foreign and unwelcome, so how does this help us understand the motivation to physically alter otherwise perfectly functional sex? As ridiculous as spontaneously growing a third arm may sound, for many seeking to alter their sex, the feelings inspired by this exercise––as imperfect as it is––are an attempt to convey and approximate the experience of feeling some physical dissociation with a body part. We may recognize this exercise as a tool used to trouble the tacit, or perhaps as a new metaphor to imagine and construct that for which language has not yet been introduced. These subjects adhere to more fluid and less restrictive understandings of gender and its possibilities, suggesting that a person can have no dysphoria around their gender, and enormous dysphoria around their sex.

88 of 112

The Materiality of Reading Gender and the Body

As we discussed earlier, rather than make arguments that parts of a seemingly "healthy" body are at issue, it proved more effective to build arguments around what was visible. The naked trans body appears asymptomatic in the absence of medical transition. Medicine is the science or practice of the diagnosis, treatment, and prevention of the disease. We “read” people’s bodies––the act of surveying and making judgments of what we, as the reader, believe to be “true” and “authentic” in and of our observations––to determine what gender we expect a person to express, but we also read gender expression to indicate what body we expect a person to occupy.

Misgendering is a reading of the body through gender and a reading of the body through gender. It is at once a reading, assignment, and reminder of the physical body, as well as a reading, assignment, and reminder of all the assumptions and expectations attached to the physical reading of the body. Misgendering is also a denial of recognition—it sends a message to the subject explicitly that their conception of self is not valid in the eyes and minds of others and simplicity that their conception of self is not valid at all. The drive to alter or hide sex is a corporeal/somatic drive—a physical discomfort exacerbated by daily/constant reminders of those traits or characteristics from which subjects felt dissociated, or by which subjects felt the integrity of their body was violated.

To illustrate reading gender through the body, let us return to Logan Norse. After sharing, with excitement, that they just ordered a binder––a tool/garment for chest compression, typically made out of strong synthetic elastic fabric, to make breasts less visible by physically binding them to the chest wall––I asked them why they chose to get a binder.

The reason people think I’m a girl is that I have long hair and boobs. If I can get rid of or hide one of those attributes so that people don’t see it—it’s a masculinity boost. It’s a sort of validation card that I can show people as a way to say, “look, I’m not a girl because I do this—I intentionally alter the shape of my body for

89 of 112

gender expression.” It also lets me wear some of the shirts my brother gave me and not have them fit weird.

Here, Norse expressed that their primary motivation for altering the shape––but not the sex––of their body was to affect how others read their gender and placed them with a given category of gender. Norse did not report experiencing a sense of dissonance between their internal somaticorporeal self-concept with regard to the present physicality of their “long hair” or “boobs.” If anything, they expressed a sense that their long hair—however “feminine” it may be considered within the mainstream 21st century United States—and their “boobs” were both significant parts of their somaticorporeal self-concept. Norse recognized the role the sex of their body played in the presentation and reading of their gender by others, and even though long hair contributed to their misgendering by others, Norse did not consider cutting or surgically altering the hair or breasts, respectively, of their body.

To illustrate reading gender through the body, let me introduce, interview subject, Carey

Morton (a pseudonym, Subject ID WS500199). When someone Misreading gender places the subject within in a sex category to which that subject does not belong and invalidates the body’s authentic physical constitution. When the body betrays the individual by prompting others to question its “authenticity” as natal biology––that anatomy with which a person is born; considered

“normal” and “authentic” in form.

Here, Morton shared their first experience of recognizing discomfort when parts of their body were made visible.

Growing up, I never liked the way I looked in “girls” clothing. I didn’t like the way it felt, I didn’t like how my body was developing as a female. …When I was younger— I may have been maybe, nine or ten— I had a younger cousin who was six or seven and since we were young, we would take showers together, and take baths together— because that’s just what we did when we were younger. I

90 of 112

remember, one day when I got undressed to take a bath, she noticed that my breasts were developing and she commented on it. I had never felt more uncomfortable with my body until that moment. I just wanted to go back to when I was completely flat chested. Since then, my relationship with the parts of my body that are more female, like my breasts has been, kind of uncomfortable. I tried binding, which I still do occasionally, but I found that binding causes physical problems that I don’t like. It’s just kind of something that I’ve had to reinforce with myself that, because I have breasts doesn’t make me any less non- binary— even though people will probably see my breasts and probably assume that I am a woman, that doesn’t change my identity.

Before puberty Morton was comfortable with their body. That which conflicted with

Morton’s somaticorporeal self-concept, however, did not manifest on the body until puberty— menstruation and breast development. The progression of puberty and the development of certain sex characteristics brought Morton’s body into conflict with the image they held of their body. The younger cousin who called attention to these body parts of Morton’s body actively recognized

Morton’s physicality. Recognition by another made the body less deniable––it had been seen and become known by another.

In the contemporary US, there is great social and cultural attachment of femininity and womanhood to those sexed parts of the body. In this sense, when Morton’s body is read by another as “feminine” or “woman” those same sexed parts of their body are once again actively recognized, this time through gender. The ability for gender to communicate the physicality of body complicates the efforts made by The Trans Community™ to entirely disentangle the ideas of sex and gender.

This complication, however is specifically with regard to how others read, assess, and judge their perception of the body. This is typically a physician’s approach to patients––the doctor’s job is to offer an objective analysis of the patient’s symptoms and find patterns which inform conclusions.

With regard to identity and the patient’s experience of sex and of gender, the physician must defer to the patient’s account of experience and the conclusions they draw.

91 of 112

Why, then, is it so hard to trust people? Fear. Fear that others will threaten what we have and claim as our own. Endorsing a trans person to transition allows that person to place themselves within other sex and/or gender categories. Cis individuals in the categories that transition enables trans individuals to join feel that the integrity and standards of their category is being threatened.

The mutability of sex, which transition represents, troubles the foundations upon which these categories were built and by which cis people define themselves. Thus, trans people are perceived to challenge the authenticity of cis people’s understanding of themselves.

Conclusion About Medical Narrative

The assumption that collecting patient narratives will enable the categorical definition or characterization of patient experience is flawed. If patient narratives of transition tell us anything as a collective, they tell us that attempts to categorically define a group have a pigeonholing effect. In the search to identify the bounds of a category, we are bound to unduly overlook and exclude people from that category. The value of patient narrative is not to enable broad generalizations about patient experience, but instead to serve as a reminder that patient experience is diverse.

92 of 112

CONCLUSION A New Diagnostic Paradigm

Overview

While I argue that gender categories as they have come to exist today are dynamic, dynamism should not be confused with uselessness. On the contrary, in its dynamism becomes all the more meaningful––the dynamism of its categories and their expansion call attention to the fluidity and flexibility of social conventions. The uselessness is found, not in the dynamism of gender, but in attempts to map gender in its fixity (e.g. attempts to use gender as a diagnostic tool for evaluation). Building the argument for medical transition around gender, and the emergence of

"trans" as a visible category enabled us to understand both gender and sex as more fluid. Listening to and collecting patient narratives does not always enable us to better understand and treat patients.

My research suggests that,

a) in the negotiation of The Conventional Transition Narrative, patients, whether explicitly

or implicitly, were––and more often than not, are still today––beholden to that certain

negotiated narrative, and felt pressure to reproduce it or else be denied care by the

medical authority;

b) that which drives a person to alter sex is “dysphoria,” not with gender, but with certain

sexed parts or characteristics of their body;

c) popular social, medical, political, and legal discourses in the 21st century United States

have largely come to accept that a person’s gender and sex may not always be aligned,

however, these discourses still operate on the assumption that a sex should be in

alignment with gender identity;

93 of 112

d) the notion that there exists some “correct,” “fundamental,” or “natural” alignment

between sex and gender identity, enabled patients and clinicians to communicate a

motivation to alter sex which positioned the cis majority as “normal” and the trans

patient minority as “abnormal,” and further, as “needing correction” was strategically

and effectively employed in the collective negotiation of The Conventional Transition

Narrative, however this conventional wisdom, which states that the drive to transition

must be to reach this . The reification of this conventional wisdom, leaves many people

who may benefit from sex alteration without access, or at least believing they are without

access. Thus, we should change our diagnostic paradigm and look at body, not gender.

The Futility of Mapping Dynamism in its Fixity

In attempts to recognize patterns, standardize, and diagnostically evaluate, we assume that for something to have meaning, it must be static. Gender is not static. It is dynamic—readily and constantly negotiated, redeployed, and re-signified. If we embrace these assumptions, we may jump to conclude that categories like “gender” are useless, in and of themselves. I caution. We should not be so quick to jump. If we question this assumption and allow ourselves to recognize the meaningfulness of and within dynamism, it becomes clear that, we find uselessness and futility instead in our efforts to map the dynamic in its fixity.

In the pathologization of “transsexuality” and in the production of associated diagnostic criteria in the 20th century, gender was offered and assumed to be a fixed idea. The criteria that displays of “gender dysphoria” must be persistent, insistent, and consistent assumed that gender was fixed and enduring within the individual, and further, that gender was universally experienced and expressed across individuals. The continued coding of gender as sex within medical literature perpetuates the typifying and tying of gender/sex together.

94 of 112

Challenges to a New Paradigm

The rhetoric behind arguments for sex alteration as legitimate practice––that gender identity is the dictate of sex, and the essential, fundamental, and assumed to be universal, alignment of gender identity and sex is absolute––has been reified and re-inscribed beyond the social relations of patient and provider. Now that arguments for the medical necessity of procedures have been mounted and legally defended, and the right to such fundamental alignment has been written into both law, and insurance policy, this language becomes more and more deeply engrained within the fabric of society in the 21st century US. The introduction of new language or the shifting of ideological frameworks and paradigms is made more difficult when law and policy have adopted and reified previous models. For example, transgender exclusionary clauses were removed from the

Medicare program in May 2014 coverage for “medically necessary sex reassignment surgery.” The government policy now states, “coverage decisions for transition-related surgeries will be made individually on the basis of medical need and applicable standards of care, similar to other doctor or hospital services under Medicare.”106 In one change of policy, the governing body of the United

States endorsed the current paradigms of medical transition and the rhetoric associated with it. Each time a patient accesses procedures of sex alteration, they re-inscribe existing paradigms, social and diagnostic categories, and the assumptions––both implicit and explicit––on which these arguments and The Conventional Transition Narrative were built. Not only would a new paradigm of medical transition pose a challenge to convention within medical frameworks, the challenge to convention becomes a challenge to legal and bureaucratic frameworks as well.

106 National Center for Transgender Equality. (2016). Medicare. Retrieved April 14, 2016, from http://www.transequality.org/know- your-rights/medicare

95 of 112

Informed Consent

Today, some progress towards this new vision has been made in certain pockets of primary care. The “Informed Consent” model of care is being increasingly embraced—Fenway Health, the

LGBTQ Health Center in Boston, MA, adopted a new protocol for the administration of Hormone

Replacement Therapy and recommendations for certain surgery (See Appendix E). Now, in theory, any provider within Fenway Health is able to follow this protocol to evaluate patients (mental health evaluation is conducted to ensure the patient is free from underlying mental health concerns) and their motives for transition. In theory, the patient could be administered HRT the same day. In practice, I found that the details and implications of this policy and protocol are not yet common knowledge among trans patients—even among those who study trans health. For instance, most of my research subjects had little or no awareness of the informed consent model of care, now emerging in certain areas of the country. Networks of communication among trans individuals, particularly around current health information, occur largely online. Networks, such as youtube, tumblr, Instagram, and facebook, among other blogs and websites) are used specially to spread news of changes that limit or award autonomy over one’s own body and to share experiences with transition and with navigating healthcare.

Although these online networks and “communities” work to facilitate the sharing of information (another trans person is the most reliable resource to whom to turn regarding trans- friendly/sensitive care and how to access trans-resources), the same networks can also be used to perpetuate distrust in medical authorities. Every version of The Collective Transition Narrative published online reifies a certain perception of what the medical authority wants to hear. We are seeing the emergence of new counter laboratories. More narratives of genderqueerness non-binary and otherwise gendernonconforming individuals are being shared. This sharing of alternative

96 of 112

narratives gives permission to the next reader to embrace their own alternative narrative should they more authentically recognize themselves in said alternative. My hope is that we can unite these emerging counter laboratories and, rather than reifying any one model of gender, we reify the idea of patients as a diverse collective of individuals whose care should be discussed and negotiated as such.

To alter one’s sex is no small decision, but rather than this being a reason to further restrict access, let us consider that patients recognize the implications such a decision has on their body and its position within our larger social body. Medical transition is not undertaken lightly, but possibly the worst part of the transition process was navigating the healthcare systems only purporting to facilitate access. “Being trans is hard enough without being challenged to defend my subjectivity and file mountains of paperwork to document the process of its defense.”

A Final Word on Behalf of The Trans Community™

Current diagnostic models works adequately for trans individuals who fit into, or can fit into the binary model of sex/gender––I am an example of the latter case. I suggested with the vignette I included in the introduction, my narrative and experience of my gender and of my sex did not align with the narrative which the “gender test” prescribed. I was, however comfortable enough justifying to myself the use of what I knew was the clinically accepted terminology, and further was able to perform gender as I needed to until I was able to complete my medical transition. Having already leveraged the care that I needed, I am now able to speak out against this conventional model of medical transition, which identifies “gender dysphoria” as the primary drive and criteria for alterations to sex. It is important to recognize, however, that I am only able to speak out against this model only because I am no longer beholden to its authority. This however, is not the case for all trans individuals. This narrative research was in part an effort to use my position and subjectivity to give voice to some of those silenced voices and narratives, which may not otherwise be heard.

97 of 112

I want to return to consider once again how Adrian Mills, one interview subject, explained what it takes to be a “man” or a “women.” Her emphasis was not on the body’s sex—in fact, she acknowledged the now increasingly antiquated assumption that sex and gender are necessarily tied.

Instead, she emphasized the active recognition and positioning of the self as a gendered actor.

Although few were as eloquent as the subject quoted above, this paradigm of gender was eventually articulated by almost all of my research participants. With the rise of a new paradigm of gender and sex visible within today’s social and political discourse, I argue that the scientific and medical positioning of sex and gender within the body must change.

When I say language, I do not refer here to language as a linguistic system. I refer to what society accepts currently as language that should be validated and socially reproduced. Linguists say every language is adaptable and capable of expressing anything. When people say, “there is no language for that” they are actually marking social difference. When we standardize language, we are upholding social inequality—we’re upholding the people who are privileged by the language we make standard and socially reproducing the privilege that language awards them. Therefor, I recognize the introduction of new vocabulary within the past several years to discuss, articulate, and bring to light different facets and interpretations of gender, sex, and identity as an act of resistance and an effort to combat social inequality.

The language, the metaphor, and the narrative of transition negotiated between the western medical and social spheres, ongoing throughout the 20th and 21st century, should be appreciated as a resistance against social inequalities and the oppressive patriarchal frameworks of binary sex/gender.

Self-definition empowers its subjects to set their own terms for the production of their own social relations. I introduce the idea of somaticorporeal embodiment to resist the social inequality which favors

98 of 112

trans individuals who can place themselves within the binary operative model of medical transition and fully adopt The Conventional Transition Narrative as their own.

As allies gather behind these emerging ideologies and as adopters grow in number, so too does new rhetoric grow in strength. For instance, each time a trans individual seeks diagnosis for gender dysphoria, that individual validates the existence of the diagnostic category and further reifies the paradigm wherein patients must submit their experience with gender to qualify for a mental health diagnosis before access to sex augmentation is granted. The re-inscription of this paradigm, its instruments, ideologies, conventions, and practices reifies and reimports the certain model of trans medicine that has come to be.

The feeling of somaticorporeal embodiment––the wholeness and sense of connection one feels when one’s body image and corporeal self concept matches the reality of one’s physical state––is currently tacit. Language is understanding’s limiting factor; we lack the linguistic capability, the precision and dimensionality to name what it is we are even talking about. Appropriate words to describe this phenomena––one which most people experience without recognition––do not exist, and why would they when most are never prompted to recognize their absence?

So we negotiate meaning, we make compromises, and we reduce the complexity of our experience so as not to exceed the complexity of the terms we have to communicate it. We bend and shape language, and we give meaning to words so that we have words that mean something to us. Still, we are dependent on the goodwill of a field to which most of us do not have access, so we must play their game by their rules or else be denied the opportunity to play at all. We must exist for them within the bounds of their imaginary, or else we cannot exist. We say “we” because together, we find strength in numbers, even when, for so many of us, the only company we have is isolation.

We tell our stories because inspiring empathy in others approaches them understanding, and it hurts

99 of 112

to be alone; to hear or read a person’s narrative is, implicitly, a recognition both of that person’s existence and of our own.

How does one represent/narrate a state or an idea when there is no language ideology to accommodate it? What society accepts currently as language reflects that which it deems should be validated and socially reproduced. The absence of language to describe a certain phenomenon reflects that society does not condone the expression of that certain phenomenon. This is not to say that we can’t actually find words to articulate or at least approximate what we aim to express—in fact, we know we can because the trans community has done amazing things in this regard to alter everybody's use of language. Still, as new words are accepted, what is left subject to question is not the validity of the words used to express the state or idea but the validity of the state or idea itself.

I am not arguing that “Gender Dysphoria,” or other diagnoses related to gender identity or expression, be removed from the DSM and the purview of mental health providers. I am not just arguing in favor of the consent-based model of care. I am not just arguing that mental health care providers have no business serving as gatekeeper for patients seeking to alter their sex.The underlying issue at hand is that “gender” has come to mean something very different to trans patients than it does to the providers on whom they rely for care.

I mean to trouble the presumption of some fundamental alignment between gender identity and sex. When discussing the prospect of medical transition, and procedures to alter sex, we need to stop speaking in terms of gender. This is not to say that gender is unimportant, but rather, that it is largely, if not entirely, irrelevant to what physicians stand to offer their patients. Medical transition and procedures to alter sex do just that––they alter sex. A patient’s gender identity, given the trans patient’s understanding of gender as a purely social convention, may exist as well, but does not

100 of 112

necessarily dictate what they envision for their body—that which I term a person’s “somaticorporeal self-concept.”

101 of 112

Appendix A: Vocabulary and Relevant Terminology

TABLE 1 — RELEVANT TERMINOLOGY AS DEFINED IN THE DSM-5-1

refer to the biological indicators of male and female (understood in the context of reproductive sex / sexual capacity), such as in sex chromosomes, gonads, sex hormones, and nonambiguous internal and external genitalia

disorders of sex conditions of inborn somatic deviations of the reproductive tract from the norm and/or development discrepancies among the biological indicators of male and female

cross-sex hormone the use of feminizing hormones in an individual assigned male at birth based on traditional therapy biological indicators or the use of masculinizing hormones in an individual assigned female at birth.

the public (and usually legally recognized) lived role as boy or girl, man or woman, but, in contrast to gender certain social constructionist theories, biological factors are seen as contributing, in interaction with social and psychological factors, to gender development

the initial assignment as male or female. This occurs usually at birth and, thereby, yields the “natal gender assignment gender.”

somatic features or behaviors that are not typical (in a statistical sense) of individuals with the same atypical gender assigned gender in a given society and historical era; for behavior, gender-nonconforming is an alternative descriptive term. gender reassignment an official (and usually legal) change of gender

a category of social identity and refers to an individual’s identification as male, female, or, gender identity occasionally, some category other than male or female.

a general descriptive term refers to an individual’s affective/cognitive discontent with the assigned gender dysphoria gender but is more specifically defined when used as a diagnostic category.

the broad spectrum of individuals who transiently or persistently identify with a gender different transgender from their natal gender.

an individual who seeks, or has undergone, a social transition from male to female or female to male, transsexual which in many, but not all, cases also involves a somatic transition by cross-sex hormone treatment and genital surgery (sex reassignment surgery).

102 of 112

Appendix B 2016 ICD-10-CM Diagnosis Code F64 - Gender Identity Disorders

From: http://www.icd10data.com/ICD10CM/Codes/F01-F99/F60-F69/F64-/F64 ICD-10 Code Classification:

- Mental and behavioral disorders

• Disorders of adult personality and behavior (F60-F69)

- Gender identity disorders (F64)

ICD-10 Criteria and Clinical Information for Diagnosis

F64 is not a specific ICD-10-CM diagnosis code as there are 4 codes below F64 that describe this diagnosis in greater detail. All 4 codes below F64 are grouped within Diagnostic Related Group (MS-DRG v32.0): 887 — Other Mental Disorder Diagnoses. Reimbursement claims with a date of service on or after October 1, 2015 require the use of ICD-10-CM codes. This is the American ICD-10-CM version of F64. Other international ICD-10 versions may differ.

2016 ICD-10-CM Diagnosis Code F64 — Gender Identity Disorders F64.1 Gender Identity Disorder in Adolescence and Adulthood (Specified Code) Clinical Information: A disorder characterized by recurrent sexual urges, fantasies, or behaviors in a heterosexual male involving cross-dressing. Disorder characterized by recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving cross-dressing in a heterosexual male. The fantasies, urges, or behaviors cause clinically significant distress or impairment in social, occupational or other areas of functioning. (from APA, DSM-IV, 1994) Severe gender dysphoria, coupled with a persistent desire for the physical characteristics and social roles that connote the opposite biological sex. (APA, DSM-IV, 1994) The act of dressing like and adopting the behavior of the opposite sex, often for sexual gratification. The urge to belong to the opposite sex that may include surgical procedures to modify the sex organs in order to appear as the opposite sex. Applicable To: Dual role transvestism, transsexualism Approximate Synonyms: Transsexualism with asexual history, Transsexuality with heterosexual history, Transsexuality with homosexual history, Transvestism F64.2 Gender Identity Disorder of Childhood (Specified Code) (Pediatric Dx, 0-17 years) Clinical Information: None listed. ICD-10-CM Coding Rules: F64.2 is applicable to pediatric patients aged 0-17 years inclusive F64.8 Other Gender Identity Disorders (Specified Code) Clinical Information: None listed. Diagnosis Code F64.9 Gender Identity Disorder, Unspecified (Specified Code) Clinical Information: A disorder characterized by a strong and persistent cross-gender identification (such as stating a desire to be the other sex or frequently passing as the other sex) coupled with persistent discomfort

103 of 112

with his or her sex (manifested in adults, for example, as a preoccupation with altering primary and secondary sex characteristics through hormonal manipulation or surgery). Applicable To: Gender-Role Disorder Not Otherwise Specified (NOS) Approximate Synonyms: Gender Identity Disorder

104 of 112

Appendix C DSM-5 Diagnostic Criteria107

Gender Dysphoria in Children

302.6 (F64.2)

1. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months’ duration, as manifested by at least six of the following (one of which must be Criterion A1): a. A strong desire to be of the other gender or an insistence that one is the other gender (or some alternative gender different from one’s assigned gender). b. In boys (assigned gender), a strong preference for cross-dressing or simulating female attire; or in girls (assigned gender), a strong preference for wearing only typical masculine clothing and a strong resistance to the wearing of typical feminine clothing. c. A strong preference for cross-gender roles in make-believe play or fantasy play. d. A strong preference for the toys, games, or activities stereotypically used or engaged in by the other gender. e. A strong preference for playmates of the other gender. f. In boys (assigned gender), a strong rejection of typically masculine toys, games, and activities and a strong avoidance of rough-and-tumble play; or in girls (assigned gender), a strong rejection of typically feminine toys, games, and activities. g. A strong dislike of one’s sexual anatomy. h. A strong desire for the primary and/or secondary sex characteristics that match one’s experienced gender. 2. The condition is associated with clinically significant distress or impairment in social, school, or other important areas of functioning.

Specify if: With a disorder of sex development (e.g., a congenital adrenogenital disorder such as 255.2 [E25.0] congenital adrenal hyperplasia or 259.50 [E34.50] androgen insensitivity syndrome).

Coding note: Code the disorder of sex development as well as gender dysphoria.

107 American Psychiatric Association, A. P. A. (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5®). American Psychiatric Pub.

105 of 112

Gender Dysphoria in Adolescents and Adults

302.85 (F64.1)

1. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months’ duration, as manifested by at least two of the following: 2. A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or in young adolescents, the anticipated secondary sex characteristics). 3. A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics). 4. A strong desire for the primary and/or secondary sex characteristics of the other gender. 5. A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender). 6. A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender). 7. A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender). 8. The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specify if: With a disorder of sex development (e.g., a congenital adrenogenital disorder such as 255.2 [E25.0] congenital adrenal hyperplasia or 259.50 [E34.50] androgen insensitivity syndrome).

Coding note: Code the disorder of sex development as well as gender dysphoria.

Specify if: Posttransition: The individual has transitioned to full-time living in the desired gender (with or without legalization of gender change) and has undergone (or is preparing to have) at least one cross-sex medical procedure or treatment regimen—namely, regular cross-sex hormone treatment or gender reassignment surgery confirming the desired gender (e.g., penectomy, vaginoplasty in a natal male; mastectomy or phalloplasty in a natal female).

106 of 112

Appendix D Selections From The WPATH Standards of Care, Version 7

http://www.wpath.org/uploaded_files/140/files/IJT%20SOC,%20V7.pdf As for all previous versions of the SOC, the criteria put forth in the SOC for hormone therapy and surgical treatments for gender dysphoria are clinical guidelines; individual health professionals and programs may modify them. Clinical departures from the SOC may come about because of a patient’s unique anatomic, social, or psychological situation; an experienced health professional’s evolving method of handling a common situation; a research protocol; lack of resources in various parts of the world; or the need for specific harm-reduction strategies. These departures should be recognized as such, explained to the patient, and documented through informed consent for quality patient care and legal protection. This documentation is also valuable to accumulate new data, which can be retrospectively examined to allow for health care—and the SOC—to evolve.

Informed Consent

Feminizing/masculinizing hormone therapy may lead to irreversible physical changes. Thus, hormone therapy should be provided only to those who are legally able to provide informed consent. This includes people who have been declared by a court to be emancipated minors, incarcerated people, and cognitively impaired people who are considered competent to participate in their medical decisions Providers should document in the medical record that comprehensive information has been provided and understood about all relevant aspects of the hormone therapy, including both possible benefits and risks and the impact on reproductive capacity.

Relationship Between the Standards of Care and Informed Consent Model Protocols

A number of community health centers in the United States have developed protocols for providing hormone therapy based on an approach that has become known as the Informed Consent Model (Callen Lorde Community Health Center, 2000, 2011; Fenway Community Health Transgender Health Program, 2007; Tom Waddell Health Center, 2006). These protocols are consistent with the guidelines presented in the WPATH Standards of Care, Version 7. The SOC are flexible clinical guidelines; they allow for tailoring of interventions to the needs of the individual receiving services and for tailoring of protocols to the approach and setting in which these services are provided (Ehrbar & Gorton, 2010). Obtaining informed consent for hormone therapy is an important task of providers to ensure that patients understand the psychological and physical benefits and risks of hormone therapy, as well as its psychosocial implications. Providers prescribing the hormones or health professionals recommending the hormones should have the knowledge and experience to assess gender dysphoria. They should inform individuals of the particular benefits, limitations, and risks of hormones, given the patient’s age, previous experience with hormones, and concurrent physical or mental health concerns. Screening for and addressing acute or current mental health concerns is an important part of the informed consent process. This may be done by a mental health professional or by an appropriately trained prescribing provider (see section VII of the SOC). The same provider or another appropriately trained member of the health care team (e.g., a nurse) can address the psychosocial implications of taking hormones when necessary (e.g., the impact of masculinization/feminization on how one is perceived and its potential impact on relationships with family, friends, and coworkers). If indicated, these providers will make referrals for psychotherapy and for the assessment and treatment of coexisting mental health concerns such as anxiety or depression.

107 of 112

The difference between the Informed Consent Model and SOC, Version 7, is that the SOC puts greater emphasis on the important role that mental health professionals can play in alleviating gender dysphoria and facilitating changes in gender role and psychosocial adjustment. This may include a comprehensive mental health assessment and psychotherapy, when indicated. In the Informed Consent Model, the focus is on obtaining informed consent as the threshold for the initiation of hormone therapy in a multidisciplinary, harm-reduction environment. Less emphasis is placed on the provision of mental health care until the patient requests it, unless significant mental health concerns are identified that would need to be addressed before hormone prescription.

Overview of Procedures for the Treatment of Patients with Gender Dysphoria Ethical Questions Regarding Sex Reassignment Surgery

In ordinary surgical practice, pathological tissues are removed to restore disturbed functions, or alterations are made to body features to improve a patient’s self image. Some people, including some health professionals, object on ethical grounds to surgery as a treatment for gender dysphoria, because these conditions are thought not to apply. It is important that health professionals caring for patients with gender dysphoria feel comfortable about altering anatomically normal structures. In order to understand how surgery can alleviate the psychological discomfort and distress of individuals with gender dysphoria, professionals need to listen to these patients discuss their symptoms, dilemmas, and life histories. The resistance against performing surgery on the ethical basis of “above all do no harm” should be respected, discussed, and met with the opportunity to learn from patients themselves about the psychological distress of having gender dysphoria and the potential for harm caused by denying access to appropriate treatments. Genital and breast/chest surgical treatments for gender dysphoria are not merely another set of elective procedures. Typical elective procedures involve only a private mutually consenting contract between a patient and a surgeon. Genital and breast/chest surgeries as medically necessary treatments for gender dysphoria are to be undertaken only after assessment of the patient by qualified mental health professionals, as outlined in section VII of the SOC. These surgeries may be performed once there is written documentation that this assessment has occurred and that the person has met the criteria for a specific surgical treatment. By following this procedure, mental health professionals, surgeons, and patients share responsibility for the decision to make irreversible changes to the body.

Reconstructive Versus Aesthetic Surgery

The question of whether sex reassignment surgery should be considered “aesthetic” surgery or “reconstructive” surgery is pertinent not only from a philosophical point of view, but also from a financial point of view. Aesthetic or cosmetic surgery is mostly regarded as not medically necessary and therefore is typically paid for entirely by the patient. In contrast, reconstructive procedures are considered medically necessary—with unquestionable therapeutic results— and thus paid for partially or entirely by national health systems or insurance companies. Unfortunately, in the field of plastic and reconstructive surgery (both in general and specifically for gender- related surgeries), there is no clear distinction between what is purely reconstructive and what is purely cosmetic. Most plastic surgery procedures actually are a mixture of both reconstructive and cosmetic components. While most professionals agree that genital surgery and mastectomy cannot be considered purely cosmetic, opinions diverge as to what degree other surgical procedures (e.g., breast augmentation, facial feminization surgery) can be considered purely reconstructive. Although it may be much easier to see a phalloplasty or a vaginoplasty as an intervention to end lifelong suffering, for certain patients an intervention like a reduction rhinoplasty can have a radical and permanent effect on their quality of life, and therefore is much more medically necessary than for somebody without gender dysphoria.

108 of 112

Criteria for Surgeries

As for all of the SOC, the criteria for initiation of surgical treatments for gender dysphoria were developed to promote optimal patient care. While the SOC allow for an individualized approach to best meet a patient’s health care needs, a criterion for all breast/chest and genital surgeries is documentation of persistent gender dysphoria by a qualified mental health professional. For some surgeries, additional criteria include preparation and treatment consisting of feminizing/ masculinizing hormone therapy and one year of continuous living in a gender role that is congruent with one’s gender identity. These criteria are outlined below. Based on the available evidence and expert clinical consensus, different recommendations are made for different surgeries. The SOC do not specify an order in which different surgeries should occur. The number and sequence of surgical procedures may vary from patient to patient, according to their clinical needs.

Criteria for Feminizing/Masculinizing Hormone Therapy (One Referral or Chart Documentation of Psychosocial Assessment)

Initiation of hormone therapy may be undertaken after a psychosocial assessment has been conducted and informed consent has been obtained by a qualified health professional, as outlined in section VII of the SOC. A referral is required from the mental health professional who performed the assessment, unless the assessment was done by a hormone provider who is also qualified in this area.

1. Persistent, well-documented gender dysphoria; 2. Capacity to make a fully informed decision and to give consent for treatment; 3. Age of majority in a given country (if younger, follow the SOC for children and adolescents); 4. If significant medical or mental concerns are present, they must be reasonably well controlled.

Criteria for Breast/Chest Surgery (One Referral) Mastectomy and Creation of a Male Chest in FtM Patients

1. Persistent, well-documented gender dysphoria; 2. Capacity to make a fully informed decision and to give consent for treatment; 3. Age of majority in a given country (if younger, follow the SOC for children and adolescents); 4. If significant medical or mental health concerns are present, they must be reasonably well controlled. Hormone therapy is not a prerequisite.

Breast Alteration (Implants/Lipofilling) in MtF Patients

1. Persistent, well-documented gender dysphoria; 2. Capacity to make a fully informed decision and to give consent for treatment;

109 of 112

3. Age of majority in a given country (if younger, follow the SOC for children and adolescents); 4. If significant medical or mental health concerns are present, they must be reasonably well controlled. Although not an explicit criterion, it is recommended that MtF patients undergo feminizing hormone therapy (minimum 12 months) prior to breast alteration surgery. The purpose is to maximize breast growth in order to obtain better surgical (aesthetic) results.

Criteria for Genital Surgery (Two Referrals)

Hysterectomy and Salpingo-oophorectomy in FtM Patients and Orchiectomy in MtF Patients

1. Persistent, well-documented gender dysphoria; 2. Capacity to make a fully informed decision and to give consent for treatment; 3. Age of majority in a given country; 4. If significant medical or mental health concerns are present, they must be well controlled; 5. 12 continuous months of hormone therapy as appropriate to the patient’s gender goals (unless hormones are not clinically indicated for the individual). The aim of hormone therapy prior to gonadectomy is primarily to introduce a period of reversible estrogen or testosterone suppression, before a patient undergoes irreversible surgical intervention. These criteria do not apply to patients who are having these surgical procedures for medical indications other than gender dysphoria. Metoidioplasty or Phalloplasty in FtM Patients and Vaginoplasty in MtF Patients

1. Persistent, well-documented gender dysphoria; 2. Capacity to make a fully informed decision and to give consent for treatment; 3. Age of majority in a given country; 4. If significant medical or mental health concerns are present, they must be well controlled; 5. 12 continuous months of hormone therapy as appropriate to the patient’s gender goals (unless hormones are not clinically indicated for the individual); 6. 12 continuous months of living in a gender role that is congruent with their gender identity. Although not an explicit criterion, it is recommended that these patients also have regular visits with a mental health or other medical professional. The criterion noted above for some types of genital surgeries—that is, that patients en- gage in 12 continuous months of living in a gender role that is congruent with their gender identity—is based on expert clinical consensus that this experience provides ample opportunity for patients to experience and socially adjust in their desired gender role, before undergoing irreversible surgery.

110 of 112

111 of 112

112 of 112