Conflicts between the Medical Establishment and Transgender People
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Sacha M. Coupet states in the chapter, Policing Gender on the Playground: Interests, Needs, and Rights of Transgender and Gender Non-conforming Youth, that there are two aspects of transitioning: social and medical (203-204). Social transitioning includes any changes that can be made in physical appearance (dress, hairstyle, etc) and change in name that allows the individual to live more comfortably in their environment and some choose not to transition any further than this (203). Other individuals however, choose to have medical interventions, which range from fully reversible (pubertal suppression hormone treatments) to irreversible (sex-reassignment surgery (SRS)) (204). Social transitioning may not be easily achieved, as the environment transgender people find themselves in may not be so accepting. However, transgender people who seek medical interventions have for many decades been labeled as ill and consistently denied their rights and safety since early childhood and as a result, suffer the consequences of being unable to find a space in which they belong.
Dean Spade in Mutilating Gender believes that passing is a near universal requirement for “full transitioning”. He states, “perhaps the most overt requirement for transsexual diagnosis is the ability to inhabit and perform “successfully” the new gender category […] because the ability to be perceived by non-trans people as a non-trans person is valorized, normative expressions of gender within a singular category are mandated” (322). All this is to say that “successful transitioning” is based on the ability to “successfully” appear as either male or female. There is virtually no room for a category outside of this, which has harmful consequences. Herculine Barbin: Being the Recently Discovered Memoirs of a Nineteenth-century French Hermaphrodite, vividly narrates the life of an intersex person who tragically committed suicide after being forced to live their life as a male after having been raised female. An excerpt from the memoir reads, “Ah, well! I appeal here to judgment of my readers in time to come. I appeal to that feeling that is lodged in the heart of every son of Adam. Was I guilty, criminal, because a gross mistake had assigned me a place in the world that should not have been mine?” (Barbin 54). Barbin’s sentiments clearly describe significant distress, not necessarily because of how she feels but because of how society has left no space for someone like her and that is the gross mistake. This memoir demonstrates Spade’s critique of the binary and the lack of space for anything outside of this dichotomy as he states: “the medical regime permits only the production of gender-normative altered bodies and seeks to screen out alterations that are resistant to a dichotomized, naturalized view of gender.” (Spade 319). The memoir also illustrates this when the doctors write, ““Finally, to sum up the matter, ovoid bodies and spermatic cords are found by touch in a divided scrotum. These are the real proofs of sex” (Barbin 128). In fact, the entire memoir is filled with Barbin’s despair as the medical examiners and doctors ignore her pleas that she is a woman and examine her body coldly and without care all the while telling her that she must be a man. Spade’s critique and Barbin’s memoir clearly demonstrate the divide between medical establishments and transgender people because they are not being listened to and instead being told what they must be. This process of erasure begins in early childhood, as the classification for Gender Identity Disorder (GID) essentially requires it.
A diagnosis for GID (now known as Gender Dysphoria according to the Diagnostic and Statistical Manual of Mental Disorders 5th ed) is understood to be a requirement for both children and adults seeking SRS. Symptoms of GID in childhood, summarized include: boys wishing to play typical “girl” roles such as playing house and dress-up and avoiding “rough” play with other boys and girls wishing to dress like and play with boys (Spade 320). There is also, “persistent discomfort with his or her sex or sense of inappropriateness in the gender role of one’s assigned sex” (Coupet 191). Two problems arise: 1) the symptoms and requirements for GID/Gender Dysphoria are quite arbitrary, 2) its classification as a mental disorder is problematic and furthermore the symptoms are often caused by forces outside the individual who experiences them. As mentioned, the symptoms of GID appear to be typical gender non-conforming behavior often performed by children. Spade states, “despite the disclaimer in the diagnosis description that this is not to be confused with normal gender non-conformity found in tomboys and sissies, no real line is drawn between “normal” gender non-conformity and gender non-conformity which constitutes GID” (320). The only distinction appears to be that it is a, “persistent, intense, insistent, and profound disturbance,” as all these words appear several times in its entry in the International Statistical Classification of Diseases and Related Health Problems (ICD-10) (Coupet 191). However, what is ignored in the diagnosis of GID is that the stress experienced by both children and adults is brought on by the attitudes of those in their environment. According to Coupet, “research reveals that attitudes toward transgender persons, including children and adolescents, tend to be more negative than those towards lesbians, gays, or bisexuals” (198). Furthermore, “the distress captured in the diagnostic criteria is better understood as a product of societal prejudice and discrimination directed toward transgender persons rather than any inherently internalized pathology” (199). All this is to say, when a transgender child feels and expresses some form of gender atypicality and is met with hostility, resistance, and told they are wrong, naturally they would experience significant distress that could lead to depression and/or anxiety. Spade states that the diagnosis and existence of GID as a mental disorder implies that the fault is with the individual themselves and not with society as it, “likely leads some gender variant people to see their gender deviance through a depoliticized and privatized lens as an individual illness rather than a commentary on the inhabitability of dichotomous gender” (326). GID/ gender dysphoria classification and treatment as a mental illness is incredibly harmful to children as they grow up and seek treatment because they believe something is wrong with them and even as they grow into adults and accept the diagnosis they still face great difficulties getting surgeries.
As Spade himself transitioned from female to male, he emphasizes that he includes his own experiences to illustrate the hardships that come with attempt to transition, particularly in the medical field and the resistance that he and many other transgender people face. A notable struggle is the double standard that arises when seeking surgery that alters physical appearance. Spade recounts a moment with a therapist, “‘You’re really intellectualizing this, we need to get to the root of why you feel you should get your breasts removed, how long have you felt this way?’ Does realness reside in the length of time a desire exists? Are women who seek breast enhancement required to answer these questions?” (321). Spade correctly points out that cis-gendered women and men for that matter are not interrogated or asked to explore their desire for altering their appearance in order to appear more feminine or masculine. It demonstrates a clear failure on behalf of the medical establishment to respectfully help transgender and gender-variant people because it demands that they “prove” who they are when they do not ask this of anyone else (317). According to Spade, “transsexuals must seek and obtain medical treatment in order to be recognized as transsexuals […] I’ve quickly learned that the converse is also true, in order to obtain the medical intervention I am seeking, I need to prove my membership in the category “transsexual”—prove that I have GID—to the proper authorities” (317). It is a Catch-22 of sorts—one must be transgender in order to be diagnosed with GID and one must have GID to be diagnosed as transgender. Making the situation even more grim is that although GID is classified as a mental illness, “trans people have been specifically exempted from the Americans With Disabilities Act as a protected group, and their medical care (including hormones and surgeries) are not covered by most insurance systems” (Dreger 2013). This has left many transgender people with no choice but to lie and “play the script” so to speak, and tell doctors exactly what they want to hear in order to receive treatment and doctors using cruel methods (such as one doctor bullying girls and reasoning “real girls” cry and “gay girls get aggressive”) in order to determine who truly deserves treatment (Spade 326). All the aforementioned difficulties beg the question- why are transgender and gender variant people not allowed to look how they want to? Spade suggests that the success of transitioning not be determined by passing but by how each individual person wishes to appear, whether that is consistent with gender norms or not (324). Practices as they stand however, provide no such room for this and often leave many individuals to take matters into their own hands.
Research suggests that a high percentage of transgender individuals have made some attempt to transition medically by their own doing. According to a study conducted in Ontario, Canada, non-prescribed hormone use has been well documented in sample U.S. transgender communities with 71% of male-to-female gender youth in Chicago, Illinois, for example, reporting obtaining such hormones (American Journal of Public Health 2013). The study concludes, “past negative experiences with providers, along with limited financial resources and a lack of access to transition-related services, may contribute to non-prescribed hormone use and self-performed surgeries” (2013). The attitude of those in the medical establishment and the poor financial situations many transgender people find themselves in pressures them into dangerous situations. Self-mutilation and non-prescribed hormone use can have potentially fatal side effects (2013). The study also revealed that virtually no physician received training in administering and monitoring transition-related hormone regimes even though it fell under their area of practice (2013). This leads to what they consider “informational erasure”—when the information is not produced, shared or believed to be non-existent even when it is available (2013). Many transgender people then find themselves in the position of having to educate their providers on transitioning and hormones (2013). The process itself is testing as it is- with self-administered hormones and self-performed surgeries being the other alternative to the possible rejection, erasure, and scrutiny by medical establishments. Adding to this grueling process, transgender people often find that those who are supposed to be trained to help them end up contributing to the distress they already feel.
As mentioned earlier, many transgender people who display symptoms of GID, seek to transition, or express some distress about their gender are subject to receiving counseling. Problems arise when those administering the counseling either have biases towards or have no training, experience, and or knowledge of how to deal with transgender people. This is demonstrated in the earlier example provided by Spade in which the therapist ignored Spade’s desires to alter gender not just in the form of surgery but in manner of dress, hairstyles, etc and instead believed there was a root problem that Spade was not addressing and wanted to know why that was (321). A study in The Counseling Psychologist suggests that, “language currently used in the counseling fields reinforces the discourse of heterosexist dominance, resulting in unintended microaggressions towards, and oppression of, sexual and gender-transgressive minorities” (Smith et al 2013). Again, the account previously given of the doctor who bullied his patients as he believed existing gender stereotypes would reveal whom the “real” girl was is a perfect example of this because although it was far more intentionally aggressive, it still played into a form of heterosexist dominance. Still, attention must be paid as “acts of oppression through microaggressions can be “many times more harmful” to members of nondominant groups than overt hate crimes” (Smith et al 2013). This is one of the many reasons that lead Spade to conclude that, “the place that is safe to talk about this is in here, with other people who understand the slipperiness of gender and the politics of transition, and who believe me without question when I say what I think am and how that needs to look” (327).
Clearly, there is much area that needs to be covered in the relationship between medical establishments and transgender people. It is crucial to understand that this relationship is essential to transgender studies because as explained and demonstrated by Spade, transgender and gender variant people will mostly like be and are subjected to the often cruel, unjust, and backward policies, treatments, and diagnoses of these establishments. They are led to believe that there is something fundamentally wrong with them and not with society or the rigidity of the existing gender binary. In what is arguably Spade’s most important point, in understanding this we may also find that we should not assume finding comfort in the gender binary is automatically natural or healthy. “Everyone is implicated in this narrative, not only trans people” Spade states (326). Perhaps in understanding this we may be able to provide transgender and gender variant people with the support and access to the services that they need so that they may feel safe and live their lives the way they want to.
Barbin, Herculine, Michel Foucault, and Oskar Panizza. Herculine Barbin: Being the Recently Discovered Memoirs of a Nineteenth-century French Hermaphrodite. New York: Pantheon, 1980. Print.
Coupet, Sacha M. “Policing Gender on the Playground: Interests, Needs, and Rights of Transgender and Gender Non-Conforming Youth.” Children, Sexuality, and the Law. NYU, 2015. 186-217. Print.
Dreger, Alice. “Why Gender Dysphoria Should No Longer Be Considered a Medical Disorder.” Pacific Standard Magazine. 18 Oct. 2013. Web. <http://www.psmag.com/health-and-behavior/take-gender-identity-disorder-dsm-68308>.
Rotondi, Nooshin Khobzi et al. “Nonprescribed Hormone Use and Self-Performed Surgeries: ‘Do-It-Yourself’ Transitions in Transgender Communities in Ontario, Canada.” American Journal of Public Health 103.10 (2013): 1830–1836. PMC. Web. 18 Feb. 2016.
Smith, L. C., R. Q. Shin, and L. M. Officer. “Moving Counseling Forward on LGB and Transgender Issues: Speaking Queerly on Discourses and Microaggressions.” The Counseling Psychologist 40.3 (2011): 385-408. Web.
Spade, Dean. “Mutilating Gender.” The Transgender Studies Reader. By Susan Stryker and Stephen Whittle. New York: Routledge, 2006. 315-29. Print.
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