(First of all, mille grazie to Holly for typing up that gargantuan Whipping Girl passage, plus several more paragraphs, since I don’t have it available here.)
Q made some comments on the Gendercator thread (http://feministe.powweb.com/blog/archives/2007/05/22/questioning-the-evil-transgender-robot-army/) comparing transition to abortion. I was going to reply in comments, but it sort of mutated into a post—then into a very long post. I’m snipping, and I hope I’m not misrepresenting.
http://feministe.powweb.com/blog/archives/2007/05/22/questioning-the-evil-transgender-robot-army/#comment-106123
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Holly, I used the word hedonism, so the criticism should be leveled at me, not at Crouch. I think that Kathleen’s post #34 is part and parcel of that hedonism. If one pursues surgery on one’s body, that is a modification, and in as far as the goal is to decrease personal pain and increase pleasure (quality of life) on a level that is labeled “personal” but which is indeed political, hedonism is a factor. I am more free as a woman to pursue body modification through surgery (breast augmentation *or* SRS) than I am to pursue an abortion. That’s a dangerous continuum for all women. And in that vein, where a woman’s choice to pursue body modification through surgery is a *normative* choice, then all those who lie outside the norm become suspect because of their reluctance to toe that particular line.
No one is free to pursue SRS, because SRS is not treated as simple body modification. It is not available on demand. You cannot walk into a doctor’s office and demand hormones or a referral for them. You cannot walk into a surgeon’s office and schedule surgery. Here are the current standards for seeking to transition via hormones:
(available here: http://www.genderpsychology.org/transsexual/hbsoc_2001.html; the formerly-Harry-Benjamin website, the World Professional Association for Transgender Health, http://www.wpath.org/, has a pdf version)
1. Age 18 years;
2. Demonstrable knowledge of what hormones medically can and cannot do and their social benefits and risks;
3. Either:
a. A documented real life experience of at least three months prior to the administration of hormones; or
b. A period of psychotherapy of a duration specified by the mental health professional after the initial evaluation (usually a minimum of three months).
[Note that therapy is not an absolute requirement; still, it’s standard.]
In selected circumstances, it can be acceptable to provide hormones to patients who have not fulfilled criterion 3 – for example, to facilitate the provision of monitored therapy using hormones of known quality, as an alternative to black-market or unsupervised hormone use.
Readiness Criteria. Three criteria exist:
1. The patient has had further consolidation of gender identity during the real-life experience or psychotherapy;
2. The patient has made some progress in mastering other identified problems leading to improving or continuing stable mental health (this implies satisfactory control of problems such as sociopathy, substance abuse, psychosis and suicidality;
3. The patient is likely to take hormones in a responsible manner.
And here are the requirements for surgery:
1. Legal age of majority in the patient’s nation;
2. Usually 12 months of continuous hormonal therapy for those without a medical contraindication (see below “Can Surgery Be Provided Without Hormones and the Real-life Experience”);
3. 12 months of successful continuous full time real-life experience. Periods of returning to the original gender may indicate ambivalence about proceeding and generally should not be used to fulfill this criterion;
4. If required by the mental health professional, regular responsible participation in psychotherapy throughout the real life experience at a frequency determined jointly by the patient and the mental health professional. Psychotherapy per se is not an absolute eligibility criterion for surgery;
5. Demonstrable knowledge of the cost, required lengths of hospitalizations, likely complications, and post-surgical rehabilitation requirements of various surgical approaches;
6. Awareness of different competent surgeons.
…
1. Demonstrable progress in consolidating one’s gender identity;
2. Demonstrable progress in dealing with work, family, and interpersonal issues resulting in a significantly better state of mental health; this implies satisfactory control of problems such as sociopathy, substance abuse, psychosis, suicidality, for instance).
In order to obtain SRS, you have to undergo therapy. Then you have to get a mental-health professional to attest that your gender identity is stable and that you really need this surgery. They also have to assert that you’re stable and sane enough to handle transitioning. If your mental-health professional doesn’t want to write your letter, you have no recourse. You may need to satisfy additional requirements unilaterally imposed by them, or start over with a new therapist.
Moreover, we’re talking about the prime rate option. Most applicants will probably face a great deal of prejudice on any number of other grounds, so their practical requirements might be a lot higher and more expensive. Bear in mind that you may also only have access to a doctor who is ignorant of transsexuality or hateful towards it; you might have to educate them and accept degradation in your level of care in order to obtain transition-related treatments.
These days, it is possible in some places to obtain hormones via informed consent, and the availability of informed-consent treatment is increasing. Most transpeople do not have that option; most care providers do not support it. It is also true that some surgeons will perform surgery on people who do not have the proper documentation, but they’re a minority and they typically will perform surgery only on those people who are already otherwise transitioned—a transguy who’s been on hormones for four years won’t suddenly become physically transitioned after top surgery.
Oh, and then there’s the enormous trouble and expense, almost none of which is covered or supported in any way. We are talking about a series of procedures that typically cost several thousand dollars, and can wind up costing a lot more. Mind you, this doesn’t include things like taking off work for surgery or changing jobs in transition. That alone disqualifies tens of thousands of potential recipients.
This regime strikes me as really restrictive–in some ways, more restrictive than current legislation on abortion. Some of it is strikingly similar to abortion policy pre-Roe. We can talk about the justice of these or any requirements, but self-determination is simply not the status quo.
Why all the restriction? It is not true that gender-reassignment–the social, hormonal, or surgical aspects of it–has been used to resolve a social problem, certainly not gender non-conformity in people who then became transsexuals. That isn’t how the gender-clinic model worked, or how the HBSOC were set up or even how they currently operate. It is vital to understand the actual process if you’re gonna talk about how transsexuality/transgender-spectrum identities have been managed by the medical profession and the powers that be.
As Julia Serano puts it in Whipping Girl:
But as transsexuality gained more attention–almost all of it negative–from the mainstream media and the psychiatric and medical establishments, there was increasing pressure to placate the public’s prejudices and fears about sex reassignment. In response, many of those who were positioning themselves as gatekeepers argued in favor of an approach that was quite different from the one Benjamin initially advocated [more patient-centered, less punitive], one that would regulate and limit the availability of hormones and sex reassignment procedures only to those trans people who would be able to successfully blend into society as “normal” women and men. According to this strategy, the gatekeepers’ job was to sort out the “true” transsexuals (who would be allowed to fully transition) from all other trans people (who would be denied any medical intervention other than psychotherapy). This highly dichotomous approach to treating trans people reflected the fact that most other sexologists–such as John Money, who pioneered the use of nonconsensual genital surgeries on intersex infants, and Richard Green, who is renowned for his use of behavioral modification to eliminate femininity in young boys–seemed to be primarily interested in “curing” ( i.e. eliminating) sex-, gender-, and sexuality-related ambiguities.
By the late 1960s–with the establishment of several U.S. gender identity clinics and the publication of Green and Money’s medical anthology Transsexualism and Sex Reassignment–a standard protocol for dealing with people who requested sex reassignment had started to emerge. These guidelines for treatment were later codified with the release of the original HBIGDA Standards of Care in 1979, and while they have evolved somewhat over time–especially since the mid-1990s, when HBIGDA finally began to incorporate changes suggested by the transgender community–they follow the same basic outline today. While this chapter is largely written in past tense (to maintain grammatical consistency), it should be said that most gatekeepers today still follow this same basic protocol, and many still evaluate their trans clients based on the oppositional and traditional sexist criteria that I discuss throughout this chapter. The first step in this process was a period of psychotherapy (lasting at least three months, often more), during which time a mental health professional would evaluate the client. If the trans person received a recommendation from that therapist (which today comes in the form of a diagnosis of gender identity disorder, or GID) they would then be allowed to begin their “real-life test”–a one- or two-year period during which they were required to live full-time in their identified sex. If the real-life test was deemed successful by both the transsexual and the therapist, the trans person would be eligible for hormone replacement therapy (in those cases where hormones were not prescribed before or concurrent with the real-life test) and sex reassignment surgery (which usually required a recommendation from a second mental health professional).
While the gatekeepers consistently argued that these methods were designed to protect the transsexual, the way that they were executed (especially prior to the mid-1990s) reveals an underlying agenda. Whether unconscious or deliberate, the gatekeepers clearly sought to (1) minimize the number of transsexuals who transitioned, (2) ensure that most people who did transition would not be “gender-ambiguous” in any way, and (3) make certain that those transsexuals who fully transitioned would remain silent about their trans status. These goals were clearly disadvantageous to transsexuals, as they limited trans people’s ability to obtain relief from gender dissonance and served to isolate trans people from one another, thus rendering them invisible. Rather, these goals were primarily designed to protect the cissexual public from their own gender anxiety by ensuring that most cissexuals would never come face-to-face with someone they knew to be transsexual.
The gatekeepers’ attempts to suppress the number of trans people allowed to transition occurred at virtually every step of the sex reassignment process. For example, the gender identity clinics that were established to treat (and carry out research on) trans people often accepted only a small percentage of those who applied to their programs (for example, the program at Johns Hopkins only approved twenty-four of the first two thousand requests they received for sex reassignment surgery). And simply being accepted into one of these programs was not a guarantee that one would be allowed to transition. First, the trans person had to undergo extensive, sometimes indefinite, periods of psychotherapy designed to evaluate whether or not they met the psychiatrist’s criteria for “true” transsexuals, rather than the arguably more important task of preparing the trans person for the emotional and physical changes associated with transitioning. Those who received recommendations were required to continue in therapy through the entire transitioning process ( i.e., until after surgery). This requirement of several years of psychotherapy–in addition to the expenses of hormones, surgery, and other procedures that were generally not covered by health insurance–created a huge financial burden that severely limited the number of people who would have the economic means to transition in the first place.
Those who were allowed to begin the real-life test often faced additional obstacles, as some gender identity clinics (and early versions of The HBIGDA Standards of Care) required trans people to begin their tests prior to starting hormone replacement therapy. Since an extraordinarily small percentage of trans people are physically able to “pass” as their identified sex without the aid of hormones, this unnecessarily exposed the transsexual to all sorts of discrimination, harassment, and potential violence. This postponing of hormones essentially perverted the real-lief test, turning it into little more than a hazing period designed to weed out transsexuals who were the least “passable” in their identified sex.
The gatekeepers also kept the number of transitioned transsexuals low by requiring them to conform to oppositional sexist ideals regarding gender. This was primarily achieved by making “passing” a prerequisite for transitioning. Such criteria ensured that cissexual prejudices about the preferred sizes and shapes of female and male bodies would be the ultimate arbiters of whether a trans person would be allowed to transition or not. Not only did the trans person have to physically “pass” as their identified sex, they needed to exhibit the “appropriate” sexual orientation (heterosexual) and gender expression (masculinity for trans men; femininity for trans women) for that sex as well.
So, the pre-gender-clinic medical-professional dialogue didn’t go,
First Doctor: Dang, there are all these gendervariant people who don’t act masculine or feminine enough.
Second Doctor: Let’s push SRS on them and force them to live as the opposite sex.
First Doctor: That will solve everyone’s problem!
It was more like,
First Doctor: Dang, all these freaks keep coming into my office and demanding that they be allowed to live in their identified gender–and given hormones and surgery to help them along!
Second Doctor: Same here! I’ve tried electroshock therapy, psychoanalysis, hormones to try and make them act more like their assigned gender, and even Raid, but nothing makes them shut up or go away.
First Doctor: They have this really annoying tendency to attempt suicide when they can’t have their way, too. Sometimes they even try to castrate themselves. What are we gonna do?
(beat)
(beat)
(pause for decades of pleas, agitation, and misery)
Second Doctor: Well, maybe we could…try giving them what they want?
First Doctor: But how can we keep them from ever bothering us again? They’re so icky. We can’t be responsible for unleashing transsexuals on decent men and women.
Second Doctor: Wait, wait, maybe there’s a way to kill two birds with one stone! We’ll offer transition, but only to the transsexuals who can make themselves completely invisible! We’ll just refuse to treat the ones that won’t obey. That way, no one will ever have to acknowledge transsexuality ever again!
First Doctor: I like it!
Transition–the demand from transsexuals to be allowed to live as their identified gender and bring their bodies into alignment with their proprioception–was the impossible problem. The gender clinics evolved not to impose that option, but to manage and restrict it. And they initially managed it right out of the question for most transsexuals who sought it. Those who were approved had to submit to an arduous, dangerous, humiliating test of their committment before they could even start hormones–a test that came with double-binds galore. This test was designed to weed out as many candidates as possible, and to make it abundantly clear to the others that they could expect neither aid nor respect.
Historically and currently, the gatekeepers have acted to make transition harder rather than easier to access. Nor are these restrictions limited to a regime consistent with minimizing variance in the general population–it isn’t only visible, out, or queerly gendered transpeople who are typically hindered or denied. Transition is not a social endeavor, not a public-health measure. It’s frightening, and it constitutes a demand to be variant in and of itself.
It is true that transition is not illegal, but hey: as anti-choice activists across the country have figured out, why bother with illegal when you’ve got impossible? There was no historical need for prohibition because there was no historical availability to combat. Call me cynical, but I think that legislators might well have stepped in if the medical profession had started at self-determination. There are certainly plenty of punitive, arbitrary regulations around transition now.
It is undoubtedly true that SRS has become part of the normative conception of transsexuality, but that is not the same as being “the normative option”–particularly not given the traditionally and currently restrictive nature of transition or the way that birth sex still often supercedes post-op status. When someone asks, “Have you had the surgery yet?” they aren’t actually giving post-op transsexual genitalia parity with the cissexual kind. They are establishing a power differential. The question and the criterion are inseparable. “Are you acceptable to me yet? Have you given me reason enough to respect your identity in some situations? Which level of lesser creature are you?”
Were this not the case, SRS would not be as sensationalized as it is. That surgery on trans genitals would not be exempt from traditional privacy mores around other surgeries on cissexual genitals. Finally, SRS would actually be a dividing line that protected some transsexuals from transphobia some of the time. It would not be characterized as artificial, imitative, perverse, or inadequate. The actual feelings of transsexuals would take precedence.
Transition is sort of like abortion in that sense, as is the grudging provisional autonomy both women and transsexuals are granted over their own bodies. It’s an option that only became available because care providers realized that prohibiting it was even messier–for them, not for the people involved–and it only became available as part of an oppressive administrative strategy. And the “good transition” is sort of like the “good abortion:” virtually impossible to obtain.
SRS is not something that all transpeople want or need. (There I go again.) However, it is something that many if not most transsexuals seek out at some point, or would seek out if it were not so totally unfeasible for so many people. But it’s much more than that. It has become something of a metonymic focus—sort of like abortion for women, or the buttsex for gay men. Non-transsexuals are obsessed with it, and it is this fixation that transpeople are right to focus on.
The rules governing SRS–medical and legal–also affect every transperson by virtue of the control they arrogate over trans bodies. Again, look at abortion: even a woman who cannot get pregnant or who would never seek an abortion herself is right to feel extremely afraid of anti-choice legislation. It represents control over all female bodies by virtue of their sex, and the ethos driving it certainly doesn’t limit itself to teminating pregnancies.
SRS is not treated in the same way as surgery–just as abortion is not. It is not viewed with the same palliative faith and transsexuals are not viewed as uncomplicated subjects to receive it. It remains deeply suspect in the absence of grounds for suspicion–not because it stands to injure people who undergo it, but because it represents a destabilizing influence on the boundaries society reserves for its own comfort.
For these reasons, it is extremely unlikely that the government or the religious right will ever try to force sex-reassignment on a group of people to enforce congruity, whether they are actually transsexual or not. And that’s why it was really irritating to see a “dystopian vision” that completely elided all of that by ignoring the societal distinction between transsexual and non-transsexual bodies, lives, and identities.