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If God wanted you to have larger breasts….

piny

A trans woman from the Bay Area was not allowed to undergo a breast augmentation at a Catholic hospital in Daly City:

God made you a man.”

That’s what Charlene Hastings said she was told when she called to inquire about breast enlargement surgery at Seton Medical Center, a Catholic hospital in Daly City.

Now the San Franciscan is suing the hospital, claiming officials there discriminated against her because she had a sex-change operation.

Hastings, 57, had already had the major surgery she needed to become a woman. She had chosen a San Francisco plastic surgeon with privileges at Seton to perform the breast augmentation in October 2006. But the surgeon, Dr. Leonard Gray, told her that Seton no longer allowed him to operate on transgender patients, Hastings said.

When Hastings called Seton to learn more, a surgical coordinator said the hospital would not allow its facilities to be used for transgender surgery, according to the lawsuit, “She was saying, ‘It’s not God’s will,’ ” Hastings said. “I couldn’t believe it. It’s a blatant case of discrimination.”

Seton has no problem allowing breast augmentation for cissexual women, and Hastings’ surgeon performs those procedures at Seton. The argument is not the artificiality of breast implants but the artificiality of any surgery related to physical transition:

“Seton Medical Center provides medically necessary services to all individuals,” Nikels said in a prepared statement. “However, the hospital does not perform surgical procedures contrary to Catholic teaching; for example, abortion, direct euthanasia, transgender surgery or any of its related components.” The hospital did not comment directly on the lawsuit.

Gray still performs breast enlargement surgeries at Seton on women who are not transgender.

When it was owned by Catholic Healthcare West, a large hospital conglomerate, Seton apparently did allow transgender surgery. But when the Daughters of Charity, which took ownership of the hospital in 2002, learned in 2006 that such surgeries were still taking place, they were stopped, said two sources who asked not to be identified because they were not authorized to speak publicly for their organizations.

“Transgender surgery” refers to several different procedures; I assume that Seton’s definition is broad. It can include procedures which are both “medically necessary” and necessary to transition for some patients, e.g. hysterectomy. It can also cover cosmetic procedures that constitute both reconstruction and “transgender surgery”–say, for example, a transmasculine person undergoes a double mastectomy because of breast cancer but requests masculinization for hir new chest. Seton wouldn’t be the first hospital to err on the side of endangering trans patients.

37 thoughts on If God wanted you to have larger breasts….

  1. If I wanted to be extremely nasty, I’d suggest that the RCC doesn’t permit gender reassignment surgery becuase the priests prefer to rape little boys.

    But I guess I’m not going to be that nasty. Instead I’ll just say that if the Church won’t let its hospitals do basic medical procedures, then the Church needs to get out of the hospital game.

  2. Seton Medical Center provides medically necessary services to all individuals…

    i’m curious how breast enhancement surgery is considered a “medically necessary service”.

  4. it seems to me that the more catholic organizations take over hospitals the fewer things they will do and allow…if you ask me, and no one has…this is a serious conflict of interest for a catholic organization to own and run a hospital…i just don’t think that religious organizations should own things intended for public use, like medical treatment facilities unless they are going to be open minded and still extend services to all people w/o discrimination…i know i don’t make a legal argument, but i think i make sense…

  5. So if God made you an A-cup, Seton is more than happy to take your money and give you God’s-will-defying surgery, because at least you’ll be pleasing some man and that’s all women are for.

  6. It’s important to realize that this kind of discrimination against transgender health care is not limited to Catholic hospitals. There are plenty of other hospitals, not affiliated or run by any religious organization, that have forced health care practicioners who provide services to trans people to go elsewhere.

    The usual excuse has been that there’s too much insurance liability with trans health care because it’s not universally recognized as valid, necessary “real health care.” But of course that’s a catch-22 situation that keeps trans health care marginalized and out of the reach of many trans people. It’s a good indication of how messed up access to trans health care is when the most cost-effective way to go to a good surgeon for some of the most common trans surgeries is to fly to the other side of the world to Thailand, where the medical establishment doesn’t have a “not in my hospital” attitude. And with that route, travel expenses are a huge chunk of the cost, still making health care access difficult, often prohibitively so, for many poor trans folks.

    The real problem is that trans health care is not recognized as valid. There are more and more cases challenging that notion and lots of doctors, medical researchers, and health care professionals are quite willing to line up and give expert testimony that trans health care is medically necessary for many trans people. But at the same time, trans people are explicitly written out as an exclusion in almost all standard health insurance policy, like it actually says “no medical care related to changes of gender,” and nobody has successfully called the insurance companies on that discrimination yet. Institutions that don’t want to provide or pay for this kind of health care, whether due to transphobia or penny-pinching (and it is pennies on the dollar compared to health problems like say, lung cancer or even “erectile dysfunction”) will fight tooth and nail even in the face of expert medical testimony. There was a case in Philadelphia recently where they even dragged out some counter-experts out of Johns Hopkins, who decided trans people were untreatable decades ago and shut down their creepy, misogynist gender-training clinics.

    Trans people deserve to be able to go to a hospital. I know too many trans folks who have had to get surgery in really unpleasant conditions with little or no outpatient care — done in cramped offices or surgeon’s houses or barns in the countryside, I shit you not. I should be clear that I’m not necessarily spreading “Special Victims Unit” style scare stories about crazy doctors and unsanitary conditions, a lot of the surgeons I’m talking about are highly competent and even the barn was completely sterile.

    But you know what — when I go with a friend to get some kind of surgery, I want to be able to hold that friend’s hand by the side of their bed in a hospital where they can rest until they’re ready to move around. I don’t want to have to carry them from the operating room out onto the street, into a cab, drive to a pharmacy to pick up copious quantities of pain meds ourselves, then to a spare bed in another friend’s house where we all have to band together to get groceries and cook and help change dressings and make sure stitches aren’t popping out all the things that you know, usually nurses and hospital staff can do. I don’t know how to do some of that stuff! And I wish I could gush about how wonderful it is when a community pulls together to fill in the gaps left by discrimination and marginalization… but just knowing how things really OUGHT to be has left me in tears far too often.

    That was kind of a digression. But seriously, I hope Christopher Dolan and his team, who appear to be personal injury attorneys, know what they’re doing. I hope they’re consulting or getting in touch with the Transgender Law Center, because I have a feeling, based on experience with these kinds of cases, that just claiming this is discrimination against trans people under the Unruh Act is a risky proposition that a court might not accept. The hospital will of course be able to claim that if Ms. Hastings showed up with a broken leg or wanting a mole on her chin removed, they’d do it no problem, but there are certain procedures that they just don’t do. It’s even more tricky than the “denying fertility services to lesbians” case from a while ago because the hospital may try to claim that the procedure is different somehow for trans women and non-trans women, and that the procedure for trans women is experimental, risky, unproven, etc.

    Oh, I was just reminded that California is actually one of the states where there’s a good decision in this regard, G.B. v. Lackner, where part of the decision says about trans surgery:

    “The evidence presented in these proceedings establishes that J. D. has an illness and that as far as her illness affects her, the proposed surgery is medically reasonable and necessary and that there is no other effective treatment method.”

    So that’s potentially good news.

  7. Thanks for the addendum, Holly. I don’t think it’s a digression at all. It’s meatier than my post was.

    Also–

    The real problem is that trans health care is not recognized as valid. There are more and more cases challenging that notion and lots of doctors, medical researchers, and health care professionals are quite willing to line up and give expert testimony that trans health care is medically necessary for many trans people. But at the same time, trans people are explicitly written out as an exclusion in almost all standard health insurance policy, like it actually says “no medical care related to changes of gender,” and nobody has successfully called the insurance companies on that discrimination yet.

    Despite this, transition anything–a GID diagnosis, hormone use, surgery–is used to reject transpeople who apply for individual policies.

  8. The insurance companies are protecting what they see as the interests of their customers, most of whom are joining a risk pool. Trans stuff isn’t really a “risk” as most of the folks buying the Blue Shield policies see it.

    There are two solutions to providing this care that I can see. The first solution is government mandates requiring that everyone be enlightened, in essence – “this is right, so do it”. Probably not politically feasible.

    The second solution is for people who ARE willing to pool risk with transgender people to create insurance policies that cover those needs. Some kind of insurance co-op is perfectly feasible, you would only need a few hundred thousand folks to have a decent pool.

  9. So if God made you an A-cup, Seton is more than happy to take your money and give you God’s-will-defying surgery – mythago

    Indeed. From a Jewish point of view, it has been argued (although this opinion I guess would be controversial in some circles) that gender re-assignment surgery is fine — after all, “God made you a woman” but somehow by sport of nature, your body is that of a man (or visa-versa): gender re-assignment surgery is no different than, e.g., fixing a cleft palate or a fistula. OTOH, if God made you an A-cup, She might just very well intend you to be an A-cup … and, in any case, since the surgery isn’t really fixing something that needs to be fixed, it represents an un-necessary injury to the body which God has given you.

  10. I was at first skeptical, but the woman here truly has no good alternative to filing suit. Apparently Dr. Gray excels at breast augmentation. And Seton is where he performs most of his surgery, though his website says he has hospital privileges elsewhere in the Bay Area. Still, operating where he is most familiar should provide the best outcome.

    From my study of Catholicism, I don’t see how bulking up even a man’s breasts would imperil the hospital’s immortal soul. The M.D. here is not performing sex reassignment surgery itself, but simply making her look more feminine. Would selling makeup or dresses to trans women imperil the sellers’ immortal souls?

  11. Is insurance even an issue? Most breast implants are considered cosmetic and therefore not insurable. Unless this falls into the same category as post-mastectomy reconstruction.

    I do have an issue with the idea that breast implants are “medically necessary.” Which I suppose is an Overton Window issue, in that if breasts of a certain size are deemed to be essential/medically necessary to femaleness, where does that leave flat-chested cisgendered women?

  12. In the same place as flat-chested transwomen who don’t want breast augmentation, I suppose. Or cisgendered men who don’t want surgery for their gynecomastia. Or transgendered men who like having breasts.

    I don’t think that insurance companies or hospitals need to settle the essential nature of physical femaleness in order to recognize that transsexuality is real or that procedures related to transition are not cosmetic.

    “Medically necessary” should not be based on a checklist of SRS-related procedures that transsexuals all undergo in order to achieve a fully transitioned body. It should be based on what the patient needs in order to alleviate dissonance and feel comfortable. Sometimes that has to do with issues like passing, and sometimes it has to do with body-image feelings that are heavily influenced by social meanings attached to breasts or other body parts.

  13. Yeah the funny thing (and possibly the counter to any claim that this would be a different procedure depending on whether the patient is XX or XY) is that Hastings already has breasts. It’s not like the hospital is going to put them on there — she’s already developed breasts via the same biological mechanism as any other woman, and the surgery is just for a breast enhancement, same as many other women’s. I guess the only “moral” argument against it would be that you’re abetting something that was immoral to begin with… hopefully at the very minimum, they wouldn’t be allowed the same logic to refuse basic medical services to the same people, which has certainly led to the unnecessary deaths of trans folks before.

  14. Maybe I’m just not getting it, but if an insurance company would pay for and a hospital would allow breast reconstruction for a cancer patient who had partial or full removal, then wouldn’t the refusal to cover any other sort of reconstruction be cause for a lawsuit? A person does not medically NEED a breast, yet surgeries are performed every day.

    Put me on the jury, please! Fair is fair!

  15. It should be based on what the patient needs in order to alleviate dissonance and feel comfortable. Sometimes that has to do with issues like passing, and sometimes it has to do with body-image feelings that are heavily influenced by social meanings attached to breasts or other body parts.

    Well, I guess that’s part of my concern, the social meanings influencing what’s considered “medically necessary.” If it’s medically necessary to have C-cups because of social meanings attached to breasts, doesn’t that in some sense pathologize small breasts? Particularly when, as Holly noted, the transitioning process often results in breasts anyhow.

    The social meaning of breasts seems to be the stick up Seton’s ass, in any event, in that they’re more than happy to let similarly-situated cisgendered women get cosmetic implants, and they’re probably not going to allow women whose large (non-cancerous) breasts have become a physical problem for them have them removed entirely. Women Have Breasts And Men Don’t, seems to be their reasoning, and to them Hastings is Not a Woman.

  17. Well, I guess that’s part of my concern, the social meanings influencing what’s considered “medically necessary.” If it’s medically necessary to have C-cups because of social meanings attached to breasts, doesn’t that in some sense pathologize small breasts? Particularly when, as Holly noted, the transitioning process often results in breasts anyhow.

    That isn’t a bet I’m particularly happy to have to take, and I’m winning.

    I think that there are problems with any overriding standard for “medically necessary” transition procedures that privileges either physical similarity to cissexual bodies or physiological parallels to cissexual bodies. It is true that feminizing hormones will cause breast development, but this is dependent on all sorts of variables. (And should hormone therapy be standardized itself? Estrogen levels aren’t exactly unfraught for cisgendered women, either.)

    It seems to me that self-determination is the least dangerous general rule. I think that “cosmetic” places a whole lot more of a burden on people than the overton-window problem. Cisgendered women might well feel even more pressure to obtain breast implants, but the alternative is to prevent many transwomen from obtaining them under any circumstances and for any personal reason.

  18. I have to agree that you can’t really call breast enhancement surgery (as opposed to reconstructive surgery) “medically necessary.” It’s cosmetic surgery.

    But, in a way, that makes their refusal even more egregious, to me: they have a patient who wants a cosmetic procedure done that they will do for other patients. There is NO medical reason to refuse the procedure to this particular patient. So why the refusal? Clearly, it’s because of prejudice, because it’s a procedure that they’re happy to perform for other patients.

    Like any service provider, from a restaurant to a taxicab, they can’t just do a blanket refusal to serve “those people.” It’s that kind of refusal that has cost Denny’s millions of dollars. In California, I really don’t see how the hospital thinks it’s going to be able to win. The Church doesn’t have nearly as much money as they did before the child molestation scandals. (Ironic 😉

  19. I definitely hear you there–I have an unhealthy fixation on my tit size (and shape and density and so on). And yes, I see other examples of that same sense of self all around me. I’m sorry if I sound like I’m downplaying that problem; I don’t want to. Women are taught to feel like they are their tits. And I think that transwomen make some of the decisions about their bodies–and breasts–for reasons analagous to those of cissexual and cisgendered women, and that they feel the never-enough in the same way.

    But even if I cannot deny that level of internalized misogynistic metonymy, I can’t come up with any general standard that doesn’t carry the same risk. So it seems like self-determination is the best idea, even if it carries the risk of pathologizing unchanged bodies.

  20. I agree with piny about the “cosmetic” label, which is used to discredit all kinds of trans health care, not just breast implants, being more of a problem than the general issues of social pressure on everyone to fit unrealistic and far-from-average body standards.

    Here’s my take on the medical necessity of this specific surgery… I believe the most common medical practice is to only recommend breast implants if a trans woman’s body is not doing a “sufficient” job of growing breasts on its own, with the right amounts of estrogen and/or progesterone. There are some people who can’t develop breasts like they would have if they had grown up with a estrogen-dominant hormone profile, and this tends to correlate with age and health. I think that kind of thing puts the possibility of breast implants into a slightly different category, more similar to women who lose breast tissue or don’t develop breast tissue like they otherwise would have due to some kind of health condition.

    However, I put “sufficient” in quotes for a reason, because I think that’s extremely subjective, and influenced by cultural standards of how big women’s breasts should be. Trans women may have a lot of reasons for wanting their breasts to look a certain way, just as non-trans women do… plus fear about not passing, self-esteem problems related to being trans, the feeling of having spent so many years in the wrong body without breasts, etc. I don’t think there’s a clear dividing line between “medically necessary” and “what’s best for an individual’s overall well-being, given the society we live in” for either trans or non-trans people, when it comes to this stuff. I’m also very leery of a slippery slope that exists when it comes to trans people feeling like they have to live up to an even higher standard than most people when it comes to “performing gender correctly” with our behavior and bodies. This doesn’t just get trans people slapped with accusations and mockery related to “over-compensating” and looking like “gender stereotypes,” it also really affects and interacts with body dysphoria and the kinds of choices people make about what surgeries they need. Do I think most trans women “need” breast implants? I’d have to say no. Do I think some definitely do medically, and that for others it may be a choice that’s the best for their well-being? Yeah. The same could be said for other “cosmetic” procedures that fall under “facial feminization,” however, and that’s where I feel like a very grey area begins. I certainly don’t know where to draw a line — and maybe that’s because no “line” can really be drawn across a set of individuals with very different needs, trying to get by and live in a very imperfect and hostile world.

  21. I think that “cosmetic” places a whole lot more of a burden on people than the overton-window problem. Cisgendered women might well feel even more pressure to obtain breast implants, but the alternative is to prevent many transwomen from obtaining them under any circumstances and for any personal reason.

    I agree that transwomen should not be denied implants under any circumstances or for any personal reason. My issue, again, is with the “medically necessary” designation. I suppose this is a case of Why Oh Why Don’t We Have Decent Healthcare In This Country, but it just seems odd that breast implants might be considered medically necessary for Hastings, who has breasts but just isn’t happy with their size, and not for a cisgendered woman who isn’t happy with the size of her breasts. Shouldn’t the idea be to put transwomen and cisgendered women on the same footing in terms of access?

    And FWIW, I think you *are* being a little too casually dismissive of the risk of pathologizing perfectly healthy bodies. Surely there’s some way to approach this that does not give transwomen self-determination at the cost of even more social pressure on cisgendered women to meet some ideal that they, too, may not be able to afford to achieve.

  22. ‘I have to agree that you can’t really call breast enhancement surgery (as opposed to reconstructive surgery) “medically necessary.”’

    I’m not sure. Cosmetic surgeons who think about these things normally justify these operations as a treatment for a psychological problem – not fixing something that’s physically broken. The patient’s unhappy with their body and making physical changes to it increases their psychological wellbeing, and is justified on that basis. So you diagnose the psychological condition and offer the operation as a treatment; if they have the condition (‘I feel unhappy with the way my body looks’) and you can fix the way it looks you offer the operation, if they don’t (‘it’s a present for my husband’) or you can’t fix the problem because they’ve unrealistic expectations then you don’t offer the operation.

    If someone’s really unhappy about how their breasts look and you could cure that unease by giving them a pill or therapy most people would say that’s “medically necessary”. The cosmetic surgeon’s argument would be that it’s equally necessary and appropriate to remove that unease by physically changing the way their breasts look. I know in practice most surgeons do the operation for the money without asking questions, and there’s also a big fuss about whether surgery actually works in terms of increasing psychological wellbeing, but there you go.

  24. Women Have Breasts And Men Don’t, seems to be their reasoning, and to them Hastings is Not a Woman.

    Now I wonder where electrolysis fits in Seton’s moral calculus: “God says you must have five o’clock shadow.”

    On Holly’s point of sufficiency: The existence of say, adult ciswomen with AAA cups, and adult ciswomen with facial hair shouldn’t be used as a yardstick to judge what is reasonable for transwomen to want to look like.

  25. “I agree that transwomen should not be denied implants under any circumstances or for any personal reason. My issue, again, is with the “medically necessary” designation. I suppose this is a case of Why Oh Why Don’t We Have Decent Healthcare In This Country, but it just seems odd that breast implants might be considered medically necessary for Hastings, who has breasts but just isn’t happy with their size, and not for a cisgendered woman who isn’t happy with the size of her breasts. Shouldn’t the idea be to put transwomen and cisgendered women on the same footing in terms of access?”

    New chimer here,
    I really really like this statement.

    It got me thinking. What does it mean to be a woman? Are breasts integral to this experience? If so, who decides? Isn’t it another form of opposing an image onto femininity and womanhood?

    And would it be fair to implement a health insurance policy that covers surgeries for a trans woman and not cover it for ciswomen? Each individual wants to change her body. I am unsure that it is possible to be consistent in one’s reasoning if you agree for the surgery for a trans woman and not for ciswomen.

  26. So God makes us the way we are, and as doctors they are not allowed to medically intervene in such a way that they would interfere with God’s “master plan”? What? If God didn’t want you to die of cancer, you wouldn’t have a brain tumor? They would be out of a job if they turned every patient away because God made them that way in the first place. God gave you AIDS… who am I to intervene? Oh wait.

  27. The main difference is that with few exceptions, trans women’s bodies do not automatically develop breasts; with few exceptions, non-trans women’s bodies do. Trans women rely on some form of medical intervention to develop breasts. One form of medical intervention is administration of the same hormones that non-trans women’s bodies produce so that genetic instructions are activated, causing cellular growth in the breasts. Hormones are often likened to functioning as a “key turning in a lock,” and that’s basically what happens with trans people’s bodies too. A different set of instructions is activated.

    The other form of medical intervention, of course, is breast implants. The reasons to prefer hormones over breast implants are basically that they’re cheaper, less invasive and traumatic, and much more abstractly, more “natural” — but that gets into all sorts of hazy territory about natural and artificial and preconceived notions about breast implants. However, in some people’s cases Plan A doesn’t work and Plan B is necessary. This is true of non-trans women too. The last time we had a huge long discussion about this, there was a lot of argument about whether breasts are medically necessary at all, breast-feeding aside. I mentioned an old friend of mine who had a childhood accident that left her with only one breast responding to hormones and developing during puberty. She got a matching implant that was considered medically necessary not only because “women are supposed to have breasts” but because she felt lopsided without it. And that is not only a social thing, it’s also a bodily thing. Breasts are not an important part of our bodies just because of breast-feeding and because of their social and sexual meanings; they’re important because they’re part of our bodies. Our proprioception, the map of our body in our brain, tells us that they should be there — even when they’re not for various reasons. There is more to bodies than JUST social meanings.

    The simplest and best answer to these questions:

    What does it mean to be a woman? Are breasts integral to this experience? If so, who decides?

    …are that you decide. Are your breasts integral to your body? Do they relate to your sense of your own gender? Everyone will have a slightly different answer. Some people, if their breasts suddenly fell off, would rejoice. Others wouldn’t really care one way or the other. And others still would say, hey, I needed those, I want them back. And that’s all OK.

    I strongly believe in every human being’s right to exist in a body that functions well for them. That can mean a lot of different things. It can mean getting your breasts reduced or removed because you have terrible back pain; it can mean having a vasectomy so you don’t have to worry about fertilizing people; it can mean changing your genitals and your secondary sex characteristics; it can mean penis enlargement or breast implants; it can mean amputating a “healthy” limb.

    The central question should always be, what does this individual need for their well-being? In some cases the answer might actually be counseling. It might be a lover who says “baby, your dick is just the right size.” In other cases, that’s not enough, and it’s an individual assessment that is often correctly described as the most challenging and demanding role of health care professionals.

    None of this means we can’t ask questions about “why.” Why do trans women need breasts? Why does that particular person need a vasectomy? Why does that guy feel he needs a bigger dick? We may assume we know all the answers to those questions, because we know that there are certain kinds of social pressures… but it would be totally silly to assume that the answer is always so simple, especially in cases like being trans where people struggle for years over their personal answer. That would be akin to assuming that young women are all getting abortions for the same reason due to social pressure to be young and single, and that there’s no difficult road to figuring out what the best choice is, what each person’s needs are.

    In so many cases, people’s needs and decisions are wrapped up in what society believes is correct. I don’t think any of us can just mentally lift ourselves out of our social context to consider these kinds of thing — the world in which we live in is part and parcel of what is necessary for our well-being. This is why it’s so misguided to say “well, person X doesn’t really have this need. If only society were different, they wouldn’t need that.” For one thing, social pressure isn’t usually the whole story; for another, society isn’t different. Taking care of the well-being of each person as an individual is not something you can do by abruptly “fixing society” in a day, a year, a decade, or even a single lifetime.

  29. If someone’s really unhappy about how their breasts look and you could cure that unease by giving them a pill or therapy most people would say that’s “medically necessary”. The cosmetic surgeon’s argument would be that it’s equally necessary and appropriate to remove that unease by physically changing the way their breasts look. I know in practice most surgeons do the operation for the money without asking questions, and there’s also a big fuss about whether surgery actually works in terms of increasing psychological wellbeing, but there you go.

    Okay, I can see that.

    I guess my issue would be with deciding that breast implants are “medically necessary” for a transwoman but that they wouldn’t be “medically necessary” for a cisgendered woman no matter what her situation is. I guess I’m nervous that we’re getting back to the whole argument that breast implants are always bad, because big breasts are bad, which means that those of us who grew D-cups or bigger are automatically bad.

    If you want breast implants, you should be able to get them unless there’s a medical contraindication, and whether you’re cisgendered or transgendered shouldn’t matter when deciding who gets them and who doesn’t. Hell, they’re giving them to otherwise straight men who want to win a bet — what’s the “moral problem” of letting a transwoman have them so she can be more comfortable in her body?

    It should be about what the individual wants and what’s medically safe, not what the hospital thinks is “moral.”

  30. The main difference is that with few exceptions, trans women’s bodies do not automatically develop breasts; with few exceptions, non-trans women’s bodies do. Trans women rely on some form of medical intervention to develop breasts. One form of medical intervention is administration of the same hormones that non-trans women’s bodies produce so that genetic instructions are activated, causing cellular growth in the breasts. Hormones are often likened to functioning as a “key turning in a lock,” and that’s basically what happens with trans people’s bodies too. A different set of instructions is activated.

    Breasts are not an important part of our bodies just because of breast-feeding and because of their social and sexual meanings; they’re important because they’re part of our bodies. Our proprioception, the map of our body in our brain, tells us that they should be there — even when they’re not for various reasons. There is more to bodies than JUST social meanings.

    These two statements are incongruent. If are bodies are more than just social meanings, yet trans women need medical intervention to unlock locked genetic instructions, how is this not changing the social meaning of our bodies? Speaking about the map of our brains is pretty deterministic and gets into different arguments about biological sex and gender that does not help the cause of the trans movement. Because is it possible to know that trans people brains are wired in a specific way? And if we just want to presuppose that their brains are wired in a specific way, then whose to say that another women’s body isn’t wired in a specific way to have really large breasts?

    Again, this is not to say that people shouldn’t have surgeries or that they should be discriminated against, but these are questions that IMO are important to consider.

    Lastly, while people have the right to live their lives as they see fit AND to have access to economic, social, and political opportunities and rights (I believe in positive rights!), is it the responsibility of society to fund or financially support surgically invasive procedures in which the standards for who receives it and who doesn’t is pretty subjective?

    How much could health care providers question and interrogate trans and cis women about their desire to have surgeries? Should they take these women’s requests at face value and provide these procedures for everyone? What standards would we use to decide who and who doesn’t get their surgery insured.

    These are not rhetorical questions, but serious questions as to how we want to implement change (the buzzword of the season!)

  31. Actually, I think there are fairly sound answers to your questions — or at the least, “operating answers” that are used right now to get things done and help people survived. That’s a kind of answer I think we always ought to question, but let’s look at the current understanding:

    Because is it possible to know that trans people brains are wired in a specific way?

    It’s not, at least not with current technology. I don’t think it’s necessary to, however, nor do we need to rely on biologically determinist arguments. It’s not necessary to say “well this person has a ‘woman brain’ so they should have a ‘woman body,’ next patient please” because that would be a gross oversimplification of someone’s experiences and condition that easily falls into dumb stereotypes about male/female biological differences, many of which are socially ingrained. It’s not even necessary to rely heavily on gender categories to say, look there are biological differences between people; some people have breasts and some don’t; some people have a strong and very uncomfortable sensation that they shouldn’t have breasts when they do, or vice versa.

    In other words, we know that trans people’s brains are different somehow not just because scientists have been dissecting trans people’s brains (which they have) but because people with gender dysphoria behave a certain way and describe themselves as experiencing certain sensations and symptoms. All of that comes from our brains, regardless of whether it’s “biological” or “social,” and really I don’t think the distinction is as clear as we pretend it is sometimes, nor do I think it makes a difference; you can’t just wave a magic wand and change the “social” part, or disentangle it from the biological layers of experience, nor does gender dysphoria respond to any psychiatric treatment that has ever been tried.

    At this point in time, we don’t necessarily understand why that is, in most cases. In some cases it’s because there’s something else going on, and in others it’s not as explicable, or can be described as part of gender dysphoria. Because a large number of people have presented with the same symptoms without correlating other mental health issues, there’s a diagnosis of gender dysphoria. That isn’t to say that maybe there aren’t people whose brain-map is telling them that they should have larger breasts; seems quite possible to me, although that’s quite a different experience than say, deciding that you want larger breasts for a number of more tangible, accessible reasons than “this feels horribly wrong” which is what a lot of trans people describe.

    The key thing is that we don’t just say “you’re crazy, go get mental help” and write people off if they are going against the grain of what’s expected of them socially (i.e. most trans people) and we don’t say “well, you’re just succumbing to social pressure” if they seem to be conforming to some expectation. We treat people as individuals, including counseling. Now, right now “cosmetic surgery” that you pay for out of your own pocket is totally elective; there’s no diagnosis or counseling involved. That’s not the case with trans surgeries, where trans people are generally supposed to go through a battery of checking to make sure there’s not “something else” going on (i.e. some other psychological issue, etc.) The system isn’t perfect, and some people think everything should just work on the basis of informed-consent, if you understand what the consequences are, it’s your body, just like cosmetic surgery. Personally I’m concerned about the lack of mental health care in this country and think that ideally, there would be a lot more good professional counseling available at various stages of people’s decisions about these things to help them make decisions and to avoid misdiagnosis.

    Lastly, while people have the right to live their lives as they see fit AND to have access to economic, social, and political opportunities and rights (I believe in positive rights!), is it the responsibility of society to fund or financially support surgically invasive procedures in which the standards for who receives it and who doesn’t is pretty subjective?

    The reason it’s less than entirely subjective is that there are health care professionals involved in diagnosis. Of course, that’s still subjective; it’s also subjective when a doctor or other trained person decides on a diagnosis and recommends a course of treatment for someone with a heart condition or a cleft palate or clinical depression. Usually the recommendation is for the well-being of the patient, with expense a secondary factor. There are a lot of reasons to avoid “unnecessary surgery” besides just expense, because most surgeries carry some level of risk, even of fatality. But trans-related surgeries are often tarred and feathered as “unnecessary” even when health care professionals working in the area of trans health care have exercised their judgement that they are medically necessary, and all too often that’s because of misunderstanding or prejudice.

    As for other kinds of procedures, or the question in general — what level of suffering does a society take fiscal responsiblity to alleviate? I think it comes down to a question of triage. Also, for any given course of treatment, once you ask an institution or society to pay for it, I think it’s pretty clear you can no longer rely purely on a “I want this for myself” model as you can with today’s “cosmetic surgery.” You cross the line into an area where needs assessment and diagnosis and medical professionals have to exercise their judgement in tandem with the patient’s self-determination.

    How much could health care providers question and interrogate trans and cis women about their desire to have surgeries? Should they take these women’s requests at face value and provide these procedures for everyone?

    So in other words, trans people are heavily interrogated and have been for decades. To an overkill extent, even, because trans health care is seen from a “common sense” point of view as being wildly against social norms. Non-trans women don’t have to go through any interrogation at all, and just have to consent to a surgery.

    Informed consent models are superior in many ways in my opinion, but ideally need to be accompanied by GOOD mental health care options and counseling, emphasis on GOOD because all too often that’s where the point of failure is. I also think there are big questions about how to evaluate needs and do “triage” about who gets served and who doesn’t, when resources are scarce, i.e. society can’t pay for everyone who wants a surgery to get it. But I think medical ethics does provide some answers about how to do that, and there is also the route of attempting to provide lower-cost options first. For instance, most health clinics for low-income people that provide trans health care cannot possibly afford to provide surgery for all their clients. What they do is provide hormones, often on an informed-consent basis with counseling available, because that’s what they actually can financially manage to do.

  32. I’m just wondering.

    Say the hospital did, unknowingly, allow a BA on a fully transitioned transwoman.

    And then they found out after the fact.

    Do you think the hospital would insist on removing them and refunding the money?

  33. I’ve never heard a better argument for universal healthcare. Get religion out of medicine once and for all.

  34. As someone who’s in the process of educating herself about trans issues, I just wanted to thank everyone for the thoughtful questions and comments.

    I really like the idea of placing self-determination at the heart of health care (and all other aspects of sex/gender identity). And I appreciate the recognition that starting with self-determination doesn’t erase the importance of asking why we might want to do something (eg get breast augmentation), whether we’re trans- or cissexual . . . just that the person making the final decision should be the person who’s body is at the heart of the question.

    Gee, kinda like the reproductive justice issue . . .

  36. samfan at #30: For me, it makes no difference whether its biological, socialogical, or some combination of the two. Even if the social concept of gender was totally non-existent (which I actually hope is something that happens at some point), I *still* would be very uncomfortable with the body I was born with. I am much more comfortable with having a more curvaceous body with tits (which I have largely achieved); I am still very uncomfortable with the genitals that I was born with and I will feel more at home in my body when my body has a vulva rather than a penis.

    I identify as a woman because I *have* to, in our current society, for my own safety and sanity.

    We can wish for a certain society – and believe me I do wish for a society without gender – but we have to live in society as it now exists, while we at the same time push for changes.

    The need / desire to change one’s body to make it a more welcoming home for one’s self is something that many cisgender people have a tough time understanding. It’s fine to have difficulty with that concept. But why do cis people so often have to follow that with a (stated or implied) judgement that “if we didn’t have gender, you would not have to change your body, so the fact that you are changing your body now makes you regressive / anti-feminist / gender-binary-reinforcing”?

    And you better believe it, that if someone asks if I support someone wanting to amputate one of their own limbs so that they can feel more comfort with their body, my answer is “yes”.

    Being comfortable with one’s body is not a luxury.

  37. I couldn’t understand some parts of this article te » If God wanted you to have larger breasts…., but I guess I just need to check some more resources regarding this, because it sounds interesting.

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