Sunday, December 2, 2012

The Transsexual Empire, Transnormativity, and other Bugaboos


I'm around 50 years old, and a lot has changed in the queer community since my youth. And yet, the more things change, the more they stay the same, and I want to discuss some of these ironic consistencies with you. They relate to gender policing.

Here's something that has changed: when I was in college, there was no recognized trans* student community—there was just the “lesbian and gay” community, and it was small. When I showed up at college, there was a welcome party for the new “lesbian and gay” students, and out of a class of 1200 freshpeople, four of us showed up. Today, when I attend the welcome reception for new LGBT+ students on the campus where I am the director of an LGBT+ studies program, it's more like a hundred happy new faces. Out of the four of us who showed up when I was a freshperson, two of us were actually trans* identified, but that was something we had no way to articulate. This was the era of lesbian separatism. “Transsexuals” were framed on campus as men who pretended to become women in order to try to seize control of “womyn's spaces,” à la Janice Raymond's Transsexual Empire. Bisexuals were supposedly gay men and lesbians who were afraid to really come out of the closet and were traitors to the community. The only accepted identities were lesbian or gay. Today, things are quite different. Students at the welcome reception self-identify proudly under a panoply of terms: queer, asexual, demisexual, polysexual, heteroflexible, bi, bear, furry, trans*, genderqueer, neutrois, etc. etc.—and oh yes, lesbian and gay.

As you might imagine, I had a hard time fitting in to the “lesbian and gay” community of my college years. At my university, there were two organizations at the time, one “lesbian and gay” collective that was really understood as the gay men's group, and one lesbian separatist organization. Having never identified as a lesbian, I started going to meetings of the mostly-gay-men's collective. I was there because, inside, I identified with the men, but the idea of a trans* man was not yet on anyone's radar, and even I only thought of myself as sort of spiritually akin to the boys. My deepest secret—that I was born with a sex-variant body—I told no one. Like most intersex people of the time, I understood my differences to be a shameful secret, and my sex assignment a permanent status I would always live with. So while I was attending the guy's meetings, and feeling I was in the right place, nobody, including myself, thought of me as being there because I was “really” a man. The best I could do at the time was to fill the role of one of the few token women participating, and keep my private incohate identity to myself.

A bunch of my gay male friends referred to me by a term they thought was cute: I was their “fag hag.” I hated that term with a passion—the way it excluded me, treated me as a groupie, and framed me as someone who must only hang around gay men because “she” was a hag who couldn't get a real boyfriend. The thing is, that was also how I was understood by the women in the lesbian separatist group. They saw me as a lesbian who had been blinded by the patriarchy into thinking she'd get more status by hanging out with men, who were contaminating me.

And so the lesbian separatist group staged an intervention. They called me to a meeting, and when I arrived, they sat in a circle around me and told me that it was their duty to break through my false consciousness, and that I must stop betraying the lesbian community and change my errant ways. I was injuring the lesbian community by the ways I was dressing, identifying, and behaving, and they were going to stay by my side and monitor me intensively and break through my false beliefs and bring me home.

And then they lay down the rules. First, they didn't think I really understood that I was a “womyn,” born innately different from and better than the men. (They were right.) Men, who always tried to steal women's power, were using me as their little wifey in their organization, and I was putting myself at risk of rape by spending so much time with them. I had to agree to at least go to as many meetings of the lesbian separatist group as the “men's collective.” They would work with me to get me to understand my essential womanly nature, as they were shocked when I said I didn't really think of myself as different from the men. I needed to identify with the goddess within me and see myself as the womb of creation.

The second rule they lay down was that I had to stop calling myself (using the term available at the time) “bisexual.” I was betraying them when I refused the label “lesbian,” and they all apparently felt deeply wounded. As for actual sexual behavior, sleeping with men would be sleeping with the enemy. Yes, men could be attractive—a number of them had had male partners in the past—but to be true to the lesbian community, they wouldn't do that any more, and I shouldn't either.

Interestingly, it was the third rule that the group was most incensed about, and that pertained to how I dressed. Most days I wore jeans and tank tops, but other days I wore what today I'd call femme drag—I had some 1950s dresses, and would wear them with elbow-length gloves and cat-eye makeup. My gay male friends always liked that, and would ask to borrow my dresses when they wanted to dress up for a drag party. The lesbian separatist group was horrified. They told me that I was a victim of patriarchal false consciousness who believed the myth that lesbians, in mockery of heterosexual power relations, engaged in butch-femme relations, and that sometimes I was acting like a butch, and sometimes a femme, and that this was terrible. I had to understand that the personal was political, and this meant I had to dress like the women in the group. And Politically Correct Dress (the actual term they used) was androgynous. They gave me a long, long lecture on correct androgynous fashion, showing me their own soft pants and political t-shirts and labrys jewelry. They told me I should never again wear a skirt. (Sheer bloodyminded rebelliousness in the face of this explains why I, someone who didn't identify as a woman, wound up wearing skirts much of the time for the rest of his college career.)

So, the rules boiled down to this: there was a correct identity (lesbian), a correct way to behave (avoid men), and a correct was to dress (androgynously). I was a problem in need of much intervention. So while I devoted a great deal of my time during my college years toward community activism, I never really felt comfortable or at home in the community I spent so much time trying to serve.

Fast forward 30 years, and clearly a whole lot has changed since my gender and sexuality were policed at college. I have since gender transitioned, and as an openly intersex trans man am “allowed” to coordinate the LGBT+ studies program at the university where I now teach. Recognized identities have proliferated, and the queer community is much larger and more visible. But the rituals of daily queer life remain much the same. There are meetings and conferences, “awareness days” and dances, poetry readings and protests, and informal but regular hanging-out in coffeeshops, clubs and bars.

And separatism and exclusion? They're still happening at these venues, if not in the formal way of my own queer youth.

If you had told me about the queer community as it exists now around my current college campus, it would have sounded like paradise to me. It's full of people who, like me, were assigned female at birth but don't identify as such, and who like to play with gender presentation. They identify as genderqueer, as bois, as neutrois, as trans gender, as genderflexible—in any way they please. They are full of a sense of radical mission in subverting the gender binary.

But you know what? I'm still often getting the cold shoulder as someone who seems to have betrayed the cause. Even worse is is the treatment my spouse, an intersex trans woman, gets: they freeze up when she approaches, glare at her, nudge eachother, and turn away, making it quite clear they consider her unwelcome at their events.

I've written before about this business of genderqueer people who were assigned female at birth excluding trans* women from their party (see here). I find it both cruel and ironic that what gets raised, informally this time instead of as written doctrine, is Transsexual Empire logic for excluding trans* women, complete with misgendering: “I'm am a sexual assault survivor and I don't feel safe around men,” or “Well, I'll say 'she' to be polite, but I think 'she's' carrying a lot of male privilege into the space.” What I want to talk about today is a new twist I've been running into of late in the midwestern LGBT+ academic spaces I occupy: the pejorative label of “transnormativity.”

Transnormativity is a neologism born of the term “homonormativity,” which has been bandied about in queer academic circles for some time. Usually, the term “homonormative” as been used by queer scholars to diss gay men and lesbians who have the aspiration or privilege of being able to live almost heteronormative lives: getting married, buying a house in the suburbs, raising a kid, assimilating. It's been used to express the usual self-righteous disdain of the more radical for the more normative. A few months ago, however, I was at a conference where the term was being used differently. A young, white, middle-class, cis, femme bi grad student presented on her masters thesis about homonormativity. She employed the term as her nodding peers apparently do as well: to critique the “homonormative narrative” that a real queer person experiences homophobic oppression. Apparently, when she met her girlfriend and came out to friends and family as bi, nobody had a problem with it. The way that this grad student felt oppressed was in attending meetings of the queer students' group at her college, because people talked about experiences of family rejection, being bullied at school, and other traumas that attended their coming out. She felt that because she had no such story, she was viewed as “failing to uphold the homonormative narrative of coming out,” and that other LGBT+ students' stories were unfairly more valorized than hers.

It certainly seemed to me that this grad student and her circle of friends were recasting their relative privilege as a form of oppression. If you show up to a support group, and your experiences are much less traumatic than that of others in the group, are you really oppressed by the other group members when they focus their support on those who are dealing with more trauma? If members of the grad student's queer college group had said, “Oh, your story shows how bisexually-identified people never experience true oppression and people like you aren't welcome here,” I'd agree with terming that homonormative. But saying, “I am oppressed by the homonormative narrative that queer people are oppressed” just strikes me as bizarre.

The conference where this paper was presented was a Wisconsin state conference, and as is my general experience around here, there were not a lot of people attending who were out as trans* people who had medically transitioned. I met one other guy and one woman who were out as having transitioned. There was also a woman from the local community attending who sat by herself, ignored by the people around her at all the panels we both attended, often with empty seats on either side of her. Her trans* status was visible in her wig and the hair on her hands. I saw her at lunch sitting at an otherwise totally empty table, and joined her and invited some others to sit with us. She told us her sad midwestern story: she wanted very much to transition legally and medically, but her priest and wife had forbidden it, so she “crossdressed” to attend a few conferences every year in secret. It's always disheartening to me to see people like her who are experiencing such difficulties in their lives come to a community event hoping for some recognition and support, only to face more social ostracism at the place they hoped to meet with understanding.

Among the people who stayed far away from the “crossdressing” trans-identified woman at the conference were a bunch of young, mostly white, female-assigned-at-birth (FAAB) students who identified as as some flavor of genderqueer: as bois or androgynes, genderflexible or genderfucks, as neutrois, as trans gender. On the second day of the conference I asked to sit at a table of them for lunch, but was told the two empty seats were being saved. So I sat at the next table—but interstitially I heard bits of the conversation at the table of genderqueer students, and that conversation was about “transnormativity.”

I've heard transnormativity come up a lot in such spaces of late. I'm absolutely in agreement that there is a transnormative narrative, and that it's problematic. That narrative is that a “real” trans person is someone with a binary gender identity, who has known since childhood that they were “born in the wrong body,” having a medical disorder which if not treated with hormones and surgery leads to suicide, which is cured upon completion of genital surgery and the achievement of “passing” status. That narrative sets up a standard for “true transsexuality” that most trans* people never meet. I certainly don't, as I've had neither chest nor genital surgery. Chest surgery I'd like, but finances haven't permitted it (one salary for a family of three containing two gender transitioners and two people with disabilities makes for a very lean budget). Genital surgery holds no interest for me, as an intersex person who knows all about the risk of loss of sensation and is all in favor of genital diversity. So, even though I am recognized as a man at law and socially, according to the transnormative narrative, I haven't “really” or “fully” transitioned. That's silly and irritating.

But just as the grad student who presented on homonormativity used the term differently than I'd heard it used before, the genderqueer students at the table next to mine (and in other venues I keep entering) used the term “transnormative” differently. Basically, they used “transnormative” as a pejorative for any trans* person whom they read as “reinforcing the gender binary.” In translation, what that meant was trans* men they saw as “passing,” and almost all trans* women. They viewed such trans* people as those given social recognition, unlike the real gender warriors, the genderqueer people who were breaking down the gender binary. They presented the supposedly transnormative group as complicit with cisnormative people in oppressing them.

Let's unpack that a little. It is certainly true that there are some transsexual people who dismiss genderqueer people as confused or as dabblers. It reminds me a lot of how lesbian separatists in my own youth derided bisexuals. It's cruel when people who are marginalized draw up identity battle lines and tell people “you're with us or against us—no sitting on the fence.”

But I am not doing that; in fact, I, like many people who make use of medical transition services, reject the ideology of the gender binary. I'm intersex, after all. I know the huge amount of violence that lies behind the enforcement of the ideology of a sex binary—and my spouse, with her loss of capacity for sexual sensation that doctors sacrificed in imposing a male sex assignment on her in infancy, knows better than I. I personally identify with a male place in the gender spectrum, but fluidly so. I'm a genderflexible guy. But apparently they can't see my genderquerity.

I will tell you what I see from my perspective. It's not that privileged transsexuals and privileged cis people are united to gang up on genderqueer folks. It's much more like a reconfiguration of my own college experience.

You'll remember that back when I started college there were four of us first year students who attended the “lesbian and gay” welcoming event, and that two of us were really trans* identified, but given no way to express that. The political focus back then for FAAB people was on enforcing a presumed essential sex binary, and fencing in the womyn-only space. I was forced into that space. The other prototrans person was assigned male at birth, and “he” was kept out—her request to be able to attend a meeting mocked and seen as proof that “men” really did want to take over lesbian spaces.

Today, the exciting queer political action for FAAB people is not in enforcing the gender binary, but in rejecting it. But oddly, despite this reversal, the end result is eerily similar. Welcomed to the party are people perceived as androgynous but FAAB, while others get the cold shoulder. Supposedly those informally enforcing this rule do so to fight the oppressive ideology of the gender binary, but I see a sex binary being reinscribed. I see these genderqueer FAAB circles as working to keep the “men” out.

Let's consider another conference that I was recently involved in organizing as an illustration. Sitting in the back of the large conference room for most of one day was a large contingent of young, white, genderqueer-identified FAAB folks. They sported a fair number of piercings, asymmetrically-bobbed hairstyles, and other fashion signifiers that someone familiar with midwestern college queer culture could identify as signs of genderflexible affilation. But generally these individuals could walk around most places passing as cis women without a second glance, facing no transphobic harassment. Now, as someone who passed as a woman for decades without wanting to, I know that that can be painful. If you want people to recognize you as genderqueer and call you by a gender-neutral pronoun and they never do, that hurts and makes you feel invisible. Not wanting the group to feel marginalized, I walked over to them before the first panel and invited them to sit closer to the front. All I got were a lot of blank silent stares, however. I felt like I was being perceived as The Man impinging on their space, so I took my suit and beard away and left them in peace. As a trans* guy who is fairly often taken for a cis man, I recognize my privilege, and I try not to deploy it at people when I can avoid it, but nobody likes a cold reception.

Later, my wife arrived. An intersex trans* woman, she's very androgynous. Seeing her feminine face and breasts on her very tall, solid frame, her long, waving hair and her tough boots breaks binary sex and gender for people all the time, and she's a magnet for transphobia. She faces constant street harassment here in the midwest—laughter and stares, people yanking their children away from her, spitting at her, throwing bottles out of cars at her head. She's living proof of the powerful enforcement of the gender binary, and you would think that to any genderqueer person, she'd be a hero. But when she arrived at the conference and was looking for a seat, she faced a wave of hostile stares and mutters from the FAAB genderqueer contingent in the back. This happens to her all the time at queer events around here—even ones that say “all genders welcome.” She's had FAAB gender-flexible-identified people call her “he” many, many times, and treat her with disdain and/or fear.

The apparent “logic” behind this mistreatment is the belief that FAAB people transgress gender binaries while male-assigned-at-birth (MAAB) people reinforce them when they act in similar ways. A FAAB person in a tux is doing important gender-dismantling work. A MAAB person in a dress? Amusing if it's drag, insulting or creepy if it's not. This transmisogyny appears to be based on imputed motives. The “logic” goes like this: a FAAB person is oppressed by male privilege and so understands gender and wants to dismantle it, while benefitting from male privilege blinds the MAAB person to how gender operates, making trans* women actually nontransgressive female imposters. This is pure Transsexual Empire transphobic reasoning. . . Yet FAAB genderqueer circles can deny this by allowing in the occasional trans woman who looks physically like a cis woman and who “gets it” (meaning she shares the style of dress and cultural interests of the FAAB genderqueer circle), as well as by celebrating all of the trans bois in their midst who are visibly FAAB.

The formal radical womyn's-only spaces of my queer youth seem to have been replaced by informal radical FAAB-looking-only spaces around midwestern college campuses. The two milieux even have a very similar androgynous dress code.

So: who's oppressing whom? According to the “transnormative” talk I've been hearing recently, transsexuals join cissexuals in oppressing the noble and radical genderqueers. In practice, I see many FAAB genderqueer people joining cis people in treating most trans* woman like pariahs.

It makes me sad that my genderqueer identity is as invisible to a lot of FAAB genderqueer people as their own genderqueer identities are to most cis people. But I can live with it. Not having your identity validated is painful, but material oppression is a lot worse. The levels of violence, bullying, sexual assault, unemployment, and general social ostracism that people face when they are read as gendertransgressive males or trans* women are appalling. They are foundational to sexism and patriarchy, and we must fight them.

So, I say to my genderqueer siblings: we must dig out the roots of Transsexual Empire reasoning born of gender essentialism if we are ever going to see the gender spectrum flourishing and free. You cannot queer gender unless you embrace all trans* people—not just the ones who pass as FAAB. People with bodies of any age and race and size, with any set of sex characteristics, must be equally welcome to the gendertransgressing party. For decades I've watched queer communities excluding some of their own—the most marginalized cast as a danger and dumped on, and it's time to put an end to that.

You cannot queer gender and police sex at the same time.

Wednesday, November 14, 2012

Best Practices Checklist for Providing Medical Care to Trans Patients


I have been asked by some organizations to provide them with a pamphlet or list of best practices that they could share with medical practitioners regarding the care of trans patients.

I suggest as a substantial resource for outlining trans medical care standards  the materials provided by the Center of Excellence for Transgender Health, which can be accessed here.  

What I've done is write up a checklist that others can share with medical practitioners that is succinct and that includes practical suggestions highlighting key concerns raised by many trans people.  This checklist is founded on the presumption that transphobia is unacceptable in health care practice, and that care providers wish to provide high quality care to all patients, including sex and gender minorities.

Best Practices Checklist for Providing Medical Care to Trans Gender and Gender-variant Patients

Compiled by Dr. Cary Gabriel Costello

  1. Members of your practice group have received cultural competence training in interacting with trans gender and gender-variant individuals, and medical training in the needs of trans gender and gender-variant patients. ( An outline of standards of care is available from the Center of Excellence for Transgender Health.)
  1. Your medical records are kept in such a manner that the name the patient uses appears at the top of files. (If that name differs from the patient's legal name or the name on the patient's insurance card, it is the name that the patient uses which is first seen by any staff interacting with patients, so that the patient is always called by the name the patient uses.)
  1. Patient records prominently display the pronoun that the patient uses, and staff are careful always to use that pronoun.
  1. Sex/gender characteristics are recorded in the following manner based upon patient self-identification:
        a.  Patient's gender identity: male____ female____ self-designation_________
        b.  Patient's gender identity matches the sex patient was assigned at birth: yes____ no____
        c.  Patient is intersex/has a DSD/is physically sex-variant: yes___ no____
  1. At least one member of your practice is able to supervise hormone replacement therapy for individuals who gender transition medically.
  1. Members of your practice can present interested patients with a list of practitioners in the area who perform transition-related surgeries, including orchiectomy, chest reconstruction, and genital surgeries. Staff are aware that patients may wish to access all, some, or none of these services.
  1. When a trans gender/gender-variant patient visits, the patient is treated with discretion, and attention is not drawn to the patient's status as a gender minority. For example, a patient's trans gender status is not discussed where other patients can overhear; other medical staff are never invited into the examination room to educate those other staff about trans bodies unless the patient volunteers to serve as an educator; pelvic examinations are never performed with the bed facing the door so that the patient's genitalia might be exposed if the door were unexpectedly to open.
  1. When a trans gender/gender-variant patient is examined, practitioners use language to describe body parts that does not undermine the patient's gender identity; e.g. for a trans man, say “chest” not “breasts,” “pelvic exam” not “vaginal exam;” for a trans woman, say “genitals” not “penis.” If robes are provided to patients, they should not be gender-marked in a way that undermines the patient's gender identity.
  1. Trans gender and gender-variant patients and the general patient pool are protected from uncomfortable situations in waiting rooms, testing facilities, etc. For example, the presence of a visibly trans gender person in a mammography waiting room can cause stress for the trans person and for the other patients. The solution to such situations should always center the patient's gender identity—for example, allowing the patient to wait in a private room. Trans women are never asked to wait in a room that says “men” and trans men are never made to wait in a room that says “women.”
  1. Medical staff are prepared for patients to “come out” about being trans gender or gender-variant. Staff respond with composure and empathy, and focus on the patient, not on how member's of the patient's family or community will react. Staff are able to inform the patient about what medical transition entails if the patient is interested, and can provide the patient with a list of therapists in the area who work with clients who are considering medical transition.
  1. Members of your practice are aware that children can have trans gender or gender-variant identities, and are able to refer these children and their families to appropriate pediatric and family therapists for support.
  1. Treating trans gender and gender-variant patients respectfully and well is one of the criteria of medical staff review. Those who do so are credited; any staff who treat trans gender/gender-variant patients disrespectfully are disciplined.



Monday, September 3, 2012

On Masculine Honor

It may seem like an odd thing for a trans guy to say, but I've realized that I'm more secure in my masculinity than many men.

It's peculiar because, like other trans folks, I have to live with a great mass of cis people perceiving my gender as “fake.” I know that lots of people think that guys like me can't be “real men.” Many flatten all issues of sex and gender down to genitals and judge trans men as deficient, whether we've medically transitioned by one route or another, or not. Others prejudicially deny the reality of gender transition. They claim they can spot us a mile away, and if they can't, that we've deceived them, and deserve to be threatened with violence or humiliation.

You'd think that living under such circumstances would make me much less secure in my masculinity than most cis men, but I've not found that to be the case. It's not that I'm some icon of rugged manhood. I'm 5'2”. I have the musculature of a middle-aged college professor, which is what I am. I bind my chest, and my knees creak.

But all of that is fine with me, because I have no fear that it negates my male status. I am a man because I identify as such. That's all there is to it. I've walked the awkward and bemusing path of gender transition, and while I'm not done with that journey, I am fortunate enough to now be acknowledged as legally male, which certainly doesn't hurt. But by the precepts of the trans ethos, a person's gender is determined by their identity—not by the size of their feet or their phalloclitoris; not by whether they excel or suck at sports; not by bureaucratic rules or the marker on their passport.

However, for so many cis men, manhood is governed by the Code of Masculine Honor, not gender identity. According to this Code, status as a “real man” is a privilege, and can be revoked at any time. And what negates it is any whiff of feminine gender expression. Masculinity is defined negatively as the rejection of all things feminine, and femininity is defined through a disturbing concatenation of weakness, sexual desirability, technical incompetence, emotional tenderness, powerlessness, nurturance, and beauty. The result is the fodder for so much humor, middle-school fag-baiting, and towering insecurity based on feminine challenges to “true manhood.” A dude can find his masculine honor called into question in innumerable ways.  It could be by being discovered by others to be walking a chihuahua, crying at a “chick flick,” earning less than a female coworker, having a gay son, shaving his legs, being unable to throw a football, holding his girlfriend's purse or his daughter's Hello Kitty backpack, being technically incompetent and relying on his wife to fix the car or the computer, enjoying ballet, losing an armwrestling match to a woman, being a “cuckold,” or wearing any one of a panoply of feminine-coded garments, accessories, or cosmetics.

It's a tediously familiar scene. The new kid at school is discovered to lisp. A man at the office is publicly dressed-down by his female boss. As a guy bends over to tie his shoes, lacy underwear peeps out of his pants. What follows is a ritual tormenting by a group of other males: the victim is called a sissy, a bitch, a fag, a wuss, a GIRL, often in high-pitched, mock-feminine voices. The challenge to masculine honor is iconically avenged through violence—honor restored if the victim becomes the dominant aggressor. There are other ways out. The victim can clown around and try to turn the hazing into a joke. He can verbally disdain the harassment and assert that he has other forms of masculine power that matter more (income, political power, sexual prowess, physical strength). He can defend sensitive modern manhood. But under the Code of Masculine Honor, only the response of physical reprisal is seen as fully restoring “real man” status. Deck your challenger, and you can stand over him and crow, “Who's the bitch now?”

The ritual enforcement of the Code of Masculine Honor leaves swaths of cis men eternally insecure about their masculinity. Nobody can embody all of the precepts of ideal manhood—being tall and muscular and hung like a horse, able to fix machines with ease, being a sports hero, a deadly fighter, having political authority over others and enviable wealth and harems of nubile sexual partners. That's the stuff of fantasy. Of comic book heroes and gangsta personae. Mere human males can never meet such a standard, and so all are left aware of their “failings.” And to deflect attention away from these failings, the insecure call attention to others' in the endless ritual of hazing. They avoid any association with “sissies” and “fags”--even if they themselves are gay. Just look at all the men-seeking-men ads that frame the seeker as hulking and “straight-acting” and not interested in feminine men.

The thing is, the Code of Real Manhood doesn't just hurt men. It's built around class privilege and homophobia, and most especially, around misogyny. It centers on the idea that femininity is humiliating—that the worst thing imaginable is to be a “girl.” For this reason, feminists have long critiqued it, and championed gentle, sensitive masculinity. This is turn has led to one of the most longstanding and powerful bits of antifeminist rhetoric: that feminists are seeking to “unman” men. We may live in an era in which masculine behavior is evolving. Today, a man may change his baby's diaper without being laughed at as henpecked, as he would have been in the 1950s. Guys may pluck their unibrows without causing much of a stir. Middle-school boys may chide their friends for calling everything they dislike “gay.” But the hazing maintenance of the Code of Real Manhood retains great potency.

Gender transition has brought me many good things. One of these is that in order to do the hard work of coming out to family and friends and coworkers and negotiating the many hurdles of gender transition, I had to reach a place of surety that my masculine gender identity defined my status as a man in a way others must respect. This gave me security in my manhood. But gender transition also came with some “gifts” I could do without. One of those was a welcome into the world of random challenges to fight. As an academic and a shrimp, I don't get a ton of them, but it periodically happens. A guy cuts me off pulling out of an alleyway nearly causing an accident, and then storms out of his car and tells me to be a man and get out of mine, spoiling for a fight. Three large young men brimming with insecure cockiness follow me down a street, commenting on how faggy my pink hair is and how I'm too much of a faggot to turn around when they're talking to me.

Though I find myself in these situations, I've yet to get into a fight. One teenaged boy slugged me once and ran off, but that was random and not interactive enough to count as a “fight”--which is exactly the point. I haven't found myself in a fistfight because I don't rise to the bait to defend my masculine honor. It's not that I don't feel that if I had to defend myself, I couldn't. (And I don't say that to prove I'm a man—I think that most people of any gender can learn to defend themselves if they have to.) I don't rise to the bait because I don't feel challenged. My masculinity is not based on my vehicular dominance or the color of my hair or my physical strength, but on my gender identity. Inside, when I'm called a “fag” for dying my hair pink for a while, I'm rolling my eyes. Outwardly, being sane, I simply don't respond. And when my cheek is metaphorically slapped for a ritual duel and I don't return the slap, generally the fight fizzles. The Code of Masculine Honor is not served by fighting with girls, or with people who don't care if you call them one.

That doesn't mean I don't think the Code poses a serious problem for trans people. Those who enforce “real manhood” guard its territory closely, and are often hugely transphobic. They refuse to let people in or out of the man club based on their gender identities. While as a trans person I don't feel undermined by claims that my behavior is incompatible with honorable masculinity, I'm deeply hurt when people assert that I am literally not a man. And I am fearful of the fact that some defenders of “real manhood” engage in a very ugly form of violence—not individual duels of masculine honor, but warlike boundary guarding, involving group attacks on people who reject the archaic Code: fagbashing, gang rape, brutal trans murders.

The sad ubiquitous fact is that trans women are at particular risk from enforcers of the Code of Masculine Honor. From the perspective of the Code, they enact the ultimate treason when they leave the man camp to embrace their female identities. In asserting that they experience being a woman as preferable to enjoying the privileges of masculinity, they speak heresy.

As a result, women who are visibly trans gender suffer appalling levels of violence. I ache for what my trans wife must cope with on a daily basis: the ongoing harassment; the regular challenges to fight posed through body-checking and name-calling; the random terrorism of boundary policing in the form of bottles thrown at her out of cars or attempts at sexual assault. Whereas I face few overt threats, and have been able to diffuse them, the level of violent enforcement of the Code of Masculine Honor she encounters makes it hard for her to live a life not constantly on the defensive.

And what I find particularly sad about the violence my spouse faces is that most of it comes from men who are marginalized, and face challenges under the Code due to that marginalization. Guys with low incomes and men of color. Self-hating, repressed homosexuals. Pubescent boys. It's amazing how often the men who get in my spouse's face and tell her she's a “disgrace” are very short.

The Code of Masculine Honor operates not only to perpetuate masculine privilege, but to perpetuate marginalization. It keeps men who face discrimination for various reasons from uniting to change systems of social power. It mobilizes insecurity to divide and conquer. And it generates a constant level of self-doubt that leads to a situation in which I, a trans guy, am more secure in my masculinity than so many of the cis-privileged men around me.

As a man, I say down with masculine honor.

Thursday, August 9, 2012

Nature, Nurture, and Hormonal Transition

We are all constantly flowing with a complex mix of hormones. They cycle like tides, they interrelate in fascinating ways, and they are always shifting in response to our physical and social environments. Among these are the “sex steroids,” such as estrogen, progesterone, and testosterone. All of us, whatever our sex, normally produce both the “female” and “male” sex hormones—in fact, calling them “male” or “female” is very odd, considering that a man requires estrogen to produce viable sperm, and a female relies on testosterone for healthy muscle tone. It is the relative balance of estrogen and testosterone—not the absence of one or the other—that determines our secondary sex characteristics, such as the development of breast tissue or facial hair. This balance varies from person to person, because all sex characteristics exist on a spectrum (with some of us living in the middle intersex territory).

We like to tell a simple story in which people have a biological sex, over which is laid social gender (such as the clothing we wear, what we do with the hair on our heads and bodies, or what careers our society deems appropriate for us). Our physical makeup is presented as asocial and unchanging. In fact, we are naturally social beings, born to have our biological makeup affected by our social experiences. For example, humans are born with a capacity for language, but what language we learn depends on the society into which we are born. And the language we learn, in time, affects our brains. Depending on what phonemes are used in the language(s) we learn as children, we become capable of distinguishing some sounds and not others. If we learn a language in which compass-point direction is incorporated when referring to objects, we develop a much stronger innate sense of direction. If we learn to communicate in sign language, the centers of our brain recruited to produce communication develop quite differently. The brain is a “plastic” organ, shaped by social experience.

In my last post I critiqued the argument that having a trans identity should be understood as an intersex disorder of the brain, necessitating genital sex reassignment. I critiqued this argument because (1) I'm intersex and abhor the argument that it is “necessary” to surgically alter our genitals, and (2) the experience of the intersex community cautions that if there were indeed a medical test for some morphology deemed to represent a "trans brain," the result would be eugenic abortion. I got a lot of negative feedback on that post. Interestingly, some people thought it implied an argument against medical transition, which it is most assuredly not my intent (I've transitioned hormonally). My argument was only with the idea that the way to win civil rights is to champion a biological etiology for trans identity. As for etiologies of gender identity or sexual orientation, my take is that I'm sure they're incredibly complex, but also that they are as irrelevant as the etiology of identifying as a "cat person" versus a "dog person," or, less flippantly, the etiology of identifying with a particular religion. Many people affiliate with the religion (or lack thereof) their parents expect them too, but some do not, and either way, their religious identities should be respected, without needing to look for a biological etiology of religious preference to justify respect.

In any case, in this post I'd like to discuss the interrelationship of biology and social factors in hormonal transition.

In my own life, I've lived under four different hormone balances. First, I had the standard prepubertal hormonal milieu of low sex steroids. At puberty, my gonads kicked in and I developed secondary sexual characteristics—and because I had three gonads (two ovaries and an ovotestis), I developed a lot of them. In later adulthood, my internal reproductive organs were removed, and my sex steroid levels soon fell to almost nil (with less testosterone, estrogen or progesterone than what would be expected for a 90-year-old menopausal woman). And several years later I began hormone replacement therapy with testosterone, or “T,” leading to my living with typical male levels of T, unaccompanied by the usual male levels of estrogen or progesterone. I duly note that none of the three hormonal balances I have lived under as an adult are typical ones. What I can report on is what I experienced with a high, estrogen-dominant hormone load, what it's like to live with no sex steroids, and what changed when I went from no sex steroids to T alone.

There is no doubt that hormone replacement therapy has biological effects. When a person takes estrogen, “E,” (sometimes accompanied by progesterone, “P”) to gender transition, she develops breasts, deposits fat around the hips, and develops softer skin and ligaments. When a person undergoes HRT with T to transition, his voice changes, his phalloclitoris enlarges, and he grows more facial and body hair. But we often talk about other changes. In the contemporary U.S., we think of men as aggressive and dominant, and women as empathetic and emotionally labile, and we expect these conditions will develop with HRT. Often, friends and family worry that a trans man will become violent if he undergoes hormonal transition, or that a trans woman will become irrational. It's as if people see testosterone as the Hormone of War, and estrogen as the Hormone of Overwhelming Emotion (helpfully pictured in my little graphic above). In fact, the effects they produce are much less drastic.

Changes that follow HRT are real. But this does not mean that they are only biological, not social. Consider something simple, like voice. A few months after starting HRT, my voice changed. I was very happy about this, as I was never comfortable with my voice. Clearly, T precipitated changes in my vocal cords and larynx. But a lot of the changes in my voice over the course of my transition have been socially produced. First, there's the fact that I consciously chose to “work” at my voice so that I spoke out of a lower part of my register. It's extremely likely that this has affected my physical vocal apparatus, just as a singer's vocal cords are affected by voice training. But many of the changes in my speaking voice were not conscious, while hardly being biological. They emerged from my being perceived as a guy, without my much noticing what was happening.

Consider this: have you ever noticed that you can often guess the gender of the person a guy is speaking to on the phone by how he is talking? Men in the U.S. today tend to speak with a higher pitch and to articulate more clearly when speaking to women, while speaking in a more mumbled, lower range to other guys. “Hi, Mia. Oh, sure, I can meet you at 4 instead. See you then!” vs. “Hey, bro. Uh-huh. Yeah, well. See ya.” So I found myself on the receiving end of bro-talk, and as a result, the way I speak changed. My spouse teases me about my grunted, blasé “uh-huhs.” Social interactions changed the way my voice sounds. You can't tease out the physical sex and social gender effects, because they interact to produce my voice, but they are both there, each influencing the other. And both components are equally “real.”

So: even the embodied changes during HRT that seem physical and simple are both biological and social. The social effects on the more social aspects of our masculinity/femininity are almost certainly more pronounced. Let's consider the idea that men are more aggressive, that this must be biologially caused by T, and thus that HRT with T will make a person more dominant and violent. This belief is shaped by two things: first, by a cultural ideology shared by all patriarchal societies that men's dominance of society is natural, and secondly, by media reports on the phenomenon of “roid rage” in cis men who use T illegally to build muscle mass for sport or body building.

Let me talk about “roid rage” first. This occurs in people who abuse T because they take it in large and irregular doses, causing big hormone spikes. And hormone swings do make people irritable. This is seen, for example, in cis women who experience premenstrual mood swings, because the level of P rises, then falls abruptly before the menstrual period. I can report from my own experience that swings in P level made me much more irritable than changes in T level. Note, however, that we call a woman who is hormonally irritable “bitchy” rather than “raging,” and see her as less threatening. . . In any case, my experience on T has been that since my T level remains fairly constant as I use a moderate and regular dose, I don't “rage” at all. My irritability levels are no higher than they were when I was completely empty of sex steroids, and are much lower than they were under the three-gonad-circus levels I produced naturally before gonadectomy.

What's really interesting, though, is that my behavior has become a lot less dominating and aggressive than it was before my hormonal transition. I used to be very vigorously argumentative. As an academic who was read as a woman, I had to be quite assertive in order to have authority in a classroom or at a conference. It's part of our gender culture that men interrupt women, assuming greater authority in conversation, and engage in the phenomenon of “mansplaining” (i.e., explaining to a woman something she already knows in a patronizing manner). To avoid loss of social prestige as an academic, I was therefore very assertive in conversation, so as not to allow myself to be interrupted or to appear “weak” in the presentation of my ideas to (male) students or colleagues.

After some time on HRT, I found myself taken aback by how I was being perceived. People had become more reserved around me, and somehow more hesitant in conversation. I made a couple of female students cry when critiquing their comments. My behavior had not changed at all—but my social gender had. The level of dominance I'd asserted for many years was now coming across, not as simple authority, but as intimidating. I wonder if some people thought T had made me “mean,” or that I was acting in the gender-stereotyped manner cissexism claims to be characteristic of trans people. In any case, I had to consciously modify my behavior. It took me a while to retrain myself to be more restrained and gentle in my presentation. It was kind of amusing to learn how much more intimidating the assertive comments of a person who is 5'2” would be taken once he was understood as male—but also sad proof of the greater authority granted men in our society. Such is male privilege. . .

So: my take on the idea that T biologically induces rage and dominance is that it is pretty much bullpucky. Big fluctuations in the level of T can cause irritability, as do big swings in the level of E and P, but that's about it.

I don't mean to come across as saying that none of the changes that we associate with temperament and relate to sex hormones have any biological basis. One that I can speak to is crying. For many years, with my high hormone load being dominated by E and P, I cried a lot, and I hated it. The crying stopped when my gonads were removed, and did not resume when I started taking T, to my great relief. And I see that my friends on HRT with E cry much more easily. The thing is, this does not mean I don't get sad or frustrated any less often than I did in the past, or that they used to be emotionally insensitive and now are oversensitive. One of my trans women friends sees being able to cry when upset as one of the greatest gifts of HRT, because people will finally acknowledge the depth of her feelings. I am happy that I don't tear up easily anymore because I have always enjoyed being treated as having an emotional even keel. These relate clearly to gender roles, in which being emotionally expressive is valued in women and devalued in men. Hormones may affect how often we cry, but it's society that gives that great meaning.

Consider this: like crying, hiccups are also related to higher levels of estrogen. I used to get the hiccups a lot; now I don't. However, since hiccups are not burdened by any gender meanings in our society, nobody else has noticed or gives a fig leaf how often I hiccup. Also related to estrogen are more mobile bowels—people with high E suffer from irritable bowel syndrome a lot more than people with low E. A less irritable bowel is another thing I've enjoyed about my T-only hormonal balance that is clearly biologically-induced, but given no social meaning in my transition. The fact that I don't cry much anymore, however, has been remarked upon a lot, and is treated as highly significant.

So, the relationship between nature and nurture in producing “sex difference” is complex. What is clear is that since humans are such profoundly social beings, social forces shape even those things that are usually thought of as “purely biological,” like the effects of sex hormones. It's one of the things that makes understanding humans fascinating.

Friday, August 3, 2012

On Trans Gender Identity and the "Intersex Brain"


Once upon a time, in the fairly recent past, people often asked what made a person gay or lesbian—taking the perspective that homosexuality was a pathology that needed explanation. Various theories were proposed: psychological (could a domineering mother and passive father be the cause?); moral (was it a failure to embrace “traditional Christian family values”?); and biological (was there some hormone imbalance or brain abnormality at fault?).

Today, when someone comes out as lesbian, gay, or bisexual, the question of etiology is rarely raised. Lesbian, gay and bisexual rights advocates are much less likely to spend their time tossing back at the homophobic the questions, “What made you straight? When did you realize you were straight? Could you do something to change your heterosexuality if you tried?” Sexual orientation is generally treated as a fact, something that is not pathological and that requires no etiological explanation.

Back in the 20th century, however, many advocates for “gay rights” sought to find a physical cause for homosexuality. They hoped that finding proof that there was some immutable, biological reason for homosexuality, beyond the individual's control, would lead to greater social acceptance. In fact, it was political activism, not scientific discoveries, that led to the social shift to viewing LGB people as a minority deserving of protection from bigotry. But for a while, many “gay rights” activists were focused on finding proof that there was such a thing as the “gay brain,” and research on the topic persists today. The size of the hypothalamus of gay men has been argued to be more similar to straight women's than straight men's. It's been posited that straight men and lesbians have brains with a right hemisphere slightly larger than the left, while straight women and gay men have balanced brains.

Implicit behind these arguments is a belief that gay men are in some way effeminate, and lesbians masculine. But LGB activists scoff at this belief today—the idea that gender expression relates to sexual orientation now seems offensive and ridiculous. So while scientific research continues to look for ways in which gay male brains are “feminine” and lesbian brains are “mannish,” LGB rights advocates no longer pay much attention.

We've not come to this point, however, in the struggle for trans gender rights. Trans people today are making strides, but we're now in the position LGB people were decades ago. We face a great deal of discrimination and disgust from the cis gender population, and we are constantly asked, “What made you trans? Was it psychological trauma, is it that you don't respect traditional Christian family values, or is there something wrong with you medically?”

And just like lesbian, gay and bisexual people in the 20th century, trans people today face such virulent bigotry that many trans people hope finding scientific proof that there is some immutable, physical reason for trans gender identity, beyond the individual's control, will lead to greater social acceptance. Today many trans activists are eager to trumpet neurological studies that purport to show that the brains of trans men are more like the brains of cis men than of cis women, or that the brains of trans women are more like those of cis women than cis men.

It was the philosopher Descartes who first argued that the brain contains localized areas that control the body. He declared that the soul occupied the pineal gland—a theory sounds ridiculous today, when we know that the pineal glad is more prosaically the structure that secretes melatonin. But today, many trans people (it must be clear by now that I am not one of them) are looking for a brain structure housing gender identity. They argue that people are born with a “brain sex,” and that if this “brain sex” differs from the individual's genital sex, they suffer from an intersex condition that must be treated via gender transition.

I am deeply uncomfortable with this intersex theory of gender dysphoria. While I know from personal experience that it gives some trans people great comfort, and while I worry about seeking to demolish what others feel is their life raft, I want to lay out my objections.

My first objection is a scientific one: gender identity and gendered behavior are deeply complex. They are no more located in the hypothalamic unciate nucleus than the soul is located in the pineal gland. If many of ares of the brain are involved in something as comparatively simple as speech, how many more must be involved in matters as complex as sense of self?

A second objection relates to the entire field that Cordelia Fine names “neurosexism.” Basically, the entire field of neurological study of sex differences is pervaded by sexism and flawed by a teleological approach: “We know that men are good at math, logic and sport, while women are good at nurturing and communicating, so let's pin these to some brain differences we can locate.  This will show that politically-correct resistance to the idea of eternal gender roles is pointless.” By linking claims to trans rights to this body of science, we're tying ourselves to gender stereotypes and a regressive social agenda.

A third objection is that the brain is a very “plastic” organ, meaning that it changes over time. For example, when a deaf person communicates via sign language, different areas of the brain are “recruited” to process communication than just those used for oral speech. Furthermore, early and late learners of sign have different patterns of brain activation when they observe another person signing. In other words, the brain, like other parts of the body, is affected by life experience and use--it varies greatly from individual to individual, and for one individual over time. Even if we were to find that trans men resemble cis men in their patterns of brain use, this would not mean that such a similarity is inborn. It would just mean that trans people have life experiences similar to cis people who share their identified sex, cultural norms, and gendered behavior.  This is certainly proof that we experience our gendered identities and lives in the same way cis people do.  It is not proof that trans people are born with intersex brains.

Another objection I have is to the foundational premise at hand: that trans men and cis men are uniformly masculine in their gendered behavior and style, and hence distinct from feminine trans and cis women. In fact, there are plenty of men, cis and trans, who are nurturant parents, or who like the color pink, or who are bad at sports. There are many women, cis and trans, who are dominant athletes, have bad verbal skills, are excellent at spatial relations, or who hate primping. Furthermore, plenty of trans people are genderqueer in identity, which can't be explained in the least by this dyadic, reductionist framework.

I also object as someone who is intersex by birth to the framing of trans identity as an intersex condition. The difficulties faced by intersex people can indeed relate to gender identity, since children born intersex today are forcibly assigned a dyadic sex at birth, and often subjected to sex reassignment surgery to which they cannot consent. If the child grows up not to identify with the sex to which ze was coercively assigned, gender dysphoria results. But no test has ever been developed that can determine what the eventual gender identity of an intersex person will be—not in the brain, the chromosomes, the gonads or the genitals. And the issues intersex people face center on forced sex assignment in childhood--something which advocates of the intersex brain thesis tacitly support when they argue that since trans status arises from an intersex brain, it "must" be treated medically. Like many intersex people, I boggle resentfully at the idea held by some trans people that intersex people are “lucky,” have a privileged relationship to the medical community, or are free from stigma in our lives. The belief that being categorized as intersex would lead to advantages, which causes some trans people to frame trans identity as an intersex condition, is deeply flawed.

Finally, I would argue that this entire issue is a distraction. Remember that it was not the discovery of a brain area “causing” homosexuality that led to the relative successes of the LGB community in gaining civil rights. It was activism that led to those gains. The belief that if differences could be shown to be inborn, liberation would result, seems hopelessly naïve to me. Bear in mind that for many decades, scientists argued that women should not be permitted to vote or attend college because their brains were too small. More starkly, consider the Holocaust, which was founded on a belief in inborn racial inferiority.  Some intersex conditions can be detected prenatally, but this has not led to more widespread acceptance of intersexuality.  When these conditions are detected, doctors typically offer to terminate the pregnancy.

For all these reasons, I urge people not to hitch the wagon of trans rights to the idea of inborn, dyadic, neurological differences. Brains are extraordinarily complex and shaped by culture and experience over time. Gender identities are multiple, gender roles constantly evolving, and gender expression varies widely from individual to individual. Intersex people face huge obstacles, and framing us as the lucky group to be emulated denies our suffering.

The solution to transphobia is not neurology, but political activism.

Sunday, May 6, 2012

Trans and Intersex Children: Forced Sex Changes, Chemical Castration, and Self-Determination


Children’s lives lie at the center of social struggles over trans gender and intersex issues. If you talk with trans and intersex adults about the pain they’ve faced, the same issue comes up over and over again, from mirror-image perspectives: that of medical interventions into the sexed body of the child. Intersex and trans adults are often despairing over not having had a say as children over what their sexes should be, and how doctors should intervene. Meanwhile, transphobes and the mainstream backers of intersex “corrective” surgery also focus on medical intervention into children’s bodies. They frame interventions into the sexual characteristics of intersex children as heroic and interventions into the bodies of trans children as horrific.

The terms and claims that get tossed around in these debates are very dramatic. Mutilation. Suicide. Chemical castration. Forced sex changes.

We need to understand what’s going on here, because it’s the central ethical issue around which debates about intersex and trans bodies swirl. The issue here is the question of self-determination, of autonomy. Bodily autonomy is the shared rallying cry of trans and intersex activists, though we might employ it in opposite ways. Refusing it to us is framed as somehow in our best interests by our opponents.

In this post we will look at how four groups frame the issue: intersex people, trans people, the mainstream medical professionals who treat intersex people, and opponents of trans rights.

If you talk to people who were visibly sexvariant at birth, you hear a lot of pain and anger and regret about how their bodies were altered. This is crystallized in the phrase of intersex genital mutilation, or IGM. As a result of infant genital surgery, many intersex people suffer from absent or reduced sexual sensation—something mainstream Western medicine presents as unethical female genital mutilation (FGM) when similar surgeries are performed on girls in other societies. There are further sources of pain: as a result of “corrective” surgeries, intersex people can suffer a wide range of unhappy results, such as loss of potential fertility, lifelong problems with bladder infections, and/or growing up not to identify with the binary sex to which they were assigned. It is extremely painful to identify as female and to know one was born with a vagina that doctors removed with your parents’ consent, or to identify as male and to know one’s penis was amputated. Imagine if someone performed a forced change on you--would you not feel profoundly violated?

So the intersex perspective is that no one should medically intervene in a person’s body without that person’s full informed consent. Bodily autonomy is a fundamental right. Nobody except you can know how you will feel about your bodily form, whether you might want it medically altered, what risks of side-effects you’d consider acceptable. Routine “corrective” surgery performed on intersex infants is thus a great moral wrong.

When you speak with trans people, childhood medical intervention again comes up with an air of great regret, but now the regret is that one was not permitted to access it. Almost every person I’ve ever spoken with who wants to gender transition medically, whether they’re 18 or 75, has expressed the same fear to me: “I’m afraid I’m too old!” For a while this mystified me (how is 22 “old”?), until I realized what they meant was, “I’m post-pubertal.” For many trans people, childhood was awkward but tolerable, as children’s bodies are quite androgynous. Puberty, however, was an appalling experience. Secondary sexual characteristics distorted the body—humiliating breasts or facial hair sprouting, hips or shoulders broadening in ways no later hormone treatments could ever undo. Many trans people live with lifelong despair over how so much maltreatment and dysphoria could have been avoided if they could just have been permitted to avoid that undesired puberty.

So for trans activists, advocating for trans children so that they might avoid this tragedy is vitally important. The child’s autonomy is central, as it is for intersex advocates, but here the issue is getting access to medical treatment in the form of hormone suppressants, rather than fighting medical intervention. What trans activists seek is the right of children to ask for puberty-postponing drugs, to give the children’s families and therapists time to confirm that the children truly identify as trans, and fully understand what a medical transition involves. Then the individual can medically transition to have a body that looks much more similar to that of a cis person than can someone who has developed an unwanted set of secondary sex characteristics.

So for trans and intersex people, children’s autonomy is paramount when it comes to medical interventions into the sexed body. No child should have their sex (e.g. genitals, hormones, reproductive organs) medically altered until they are old enough to fully understand what is involved and actively ask for such intervention. Conversely, once a child is old enough to fully understand what is involved in medical interventions into the sexed body, and requests such intervention, then it should be performed—whether the child is born intersex or not.

This is not yet mainstream medical practice, however. Today, one in every 150 infants faces medical intervention into the sexed body to which they cannot object or consent. Doctors routinely perform such “corrective procedures” on babies with genital “defects” and “malformations.” Meanwhile, few trans-identified children are supported in their identities by families and medical practitioners—and great controversy and resistance swirls around them when it does happen.

So let’s look at the arguments made by mainstream medicine and transphobic activists. How do they counter the cry for autonomy, given that self-determination and freedom are such central ideals in Western societies? What we’ll see is that they employ two opposing claims based in medical ethics: the duty to save a life, and the duty to first do no harm. If we want to protect the rights of trans and intersex children, we have to understand these arguments and be able to counter them.

When intersex advocates try to fight the framing of intersex children’s bodies as “defective” and somehow in need of surgical “correction,” mainstream medicine responds with a claim of medical necessity. In some very rare cases, particular intersex conditions can be associated with actual functional problems such as an imperforate anus, clearly a serious medical problem that necessitates surgery. But the vast majority of medical interventions into intersexed bodies take place without any such functional, physical problem exsting. They are responses to a social issue (discomfort with sex variance) rather than a physical one. What doctors do, however, is reframe social issues into medical ones. “If we don’t do this surgery, this child will be mocked and humiliated—“he” won’t be able to stand to pee, “she” won’t be able to have “normal sex,” “it” will never be able to marry. The child will be a social pariah and thus be at risk for suicide.”

Through this line of argument, altering the body of the sexvariant infant is cast as a noble act that doctors perform out of their duty to save lives. To counter this, what we need to do is point out that actual studies of intersex adults show that while we do have a heightened risk of depression and suicide, these are caused by unhappiness with our medical treatment rather than prevented by it. Loss of sexual sensation, feelings of having been humiliated by doctors, pain from years of “repair” surgery after “repair” surgery, and for those who do not identify with the binary sex to which we were assigned, the vast sense of betrayal that those who were supposed to care for us subjected us to a forced sex change—these are what lead to an increased risk of suicide. What would really help is would be for doctors to follow the precept of “first do no harm,” to perform no procedures upon us without our full informed consent, and meanwhile, to provide intersex children and their families with social support.

Invocations of “primum non nocere,” first do no harm, and of despicable medical impositions on the lives of innocents are also raised by anti-trans advocates. Transphobic activists generally frame all medical transition interventions as mutilations, and this rhetoric rises to fever pitch when the issue of trans children arises. Recently, anti-trans rhetoric has framed the medical provision of puberty-postponing drugs as “chemical castration” (e.g. in this blog post).

“Chemical castration” is an odd concept. First off, if you read any medical article on the topic, you will find it starting by pointing out that the term is a misnomer, as none of the medications used in “chemical castration” destroy the gonads. The term is nevertheless employed due its specific history as a treatment being given by court order to “sexual deviants” to suppress their ability to have sex, where some prior courts had employed actual surgical castration. Today, some jurisdictions use “chemical castration” in cases of pedophilia, but it the past it was a treatment imposed on men convicted of sodomy—that is, to gay men in an era in which gay male sex was criminalized. Transphobic activists use the term “chemical castration” to evoke an aura of adult sexual deviance, in a manner calculated to frame doctors who provide puberty-suppressant drugs as sexually abusing children.

There is a curious twist in this matter of “chemical castration,” in that universally when court-ordered in the past, and often still today, it did not consist of testosterone suppression drugs as you would expect. Instead, injections of estrogen and/or progesterone were (and are) given. In essence, it caused a forced sex change. Thus, for example, when codebreaking British war hero Alan Turing was convicted of homosexuality in 1952 and sentenced to “chemical castration,” he found the unwanted sex changes in his body so horrifying and humiliating that he committed suicide two years into “treatment.”

In the case of trans-identified kids today, the use of the term “chemical castration” is thus a double misnomer. Firstly, no child is castrated—instead, puberty is simply postponed so that if the child, family, and therapist all agree later that a medical transition is appropriate, unwanted secondary sexual characteristics will not have developed. Plenty of adolescents are “late bloomers” by nature; in fact, puberty today occurs many years earlier than it did through most of human history, when human diets lacked sufficient fats and nutrients to support early puberties. So postponing puberty carries no significant dangers. Further, the point of hormone suppression is not to cause a sex change, in contrast to court-ordered “chemical castration treatments.” The point is merely to buy time to ensure that the trans child in question fully understands zir gender identity and the implications of medical transition.

So: we’ve seen a lot of charged language, of claims and counterclaims regarding mutilation versus vital treatment, cruel withholding of medical assistance versus the imposition of sex changes on unconsenting children. How should trans and intersex advocates respond?

What I would do is to point out that strange and conflicting ideas about children’s autonomy and free will are presented by our opponents. When specialists in intersex “corrective” treatments speak to parents or write in medical journals, they urge that genital surgery be performed in infancy, before age two and a half if at all possible. They claim that this way the child will not remember the treatment and will thus adjust well to the altered genitals and/or sex status. (As if medical monitoring and intervention did not often extend throughout the child’s life, and the procedures left no scars and caused no loss of sensation, so the child would “never notice.”) The age of two and a half came out of now largely-discredited ideas of a milestone of “gender constancy” occurring then, based upon notions of the developing brain that directly relate to autonomy. Before age 2.5, it was basically argued, the baby is irrational and lacks agency, and thus thinks magically about bodily sex, including accepting the “crazy” idea that the sex of the body can change. So, in urging very early intervention into intersex bodies today, conventional medicine is urging the total avoidance of the child’s rational thought and agency.

When it comes to treating trans children, on the other hand, instead of rushing things, all sorts of actors want to draw them out. Most doctors and clinics only provide transition services to legal adults. Those few who treat trans children are extremely cautious about providing any medical interventions other than the postponing of puberty.

Both of these approaches deny children autonomy over their bodies and their lives.

What we must urge is that society consistently respect the rights of children. No children should ever be subjected to sexual surgery without their consent. No children should be forced to have cosmetic surgery. But as children mature, they become able to consent to medical treatment that they do actively desire.

How old is “old enough” to agree to medical interventions into the sexed body? That answer depends on the given child—but 2.5 is certainly too young, and 18 is in most cases too old. What I suggest is that when addressing a medical practitioner urging genital surgery on an intersex infant, that we ask, “Would you perform a sex change on a child of this age who was not intersex?” Conversely, when facing transphobic activists saying that no one who is not a legal adult can be old enough to consent to medical transition services, we should ask if our opponent would say the same if the child were intersex. For example, a child with congenital adrenal hyperplasia may be born with a penis externally, and a uterus and ovaries internally. At around age 12 or 13, if there has been no medical intervention, that child can begin to menstruate through the penis, develop breasts, etc. Would the opponent argue that the child could not be old enough to say that he identifies as male and wants to take testosterone (or that she identifies as female and has decided that she wishes to have surgery to feminize her genitalia)? Would the opponent argue an intersex pubescent child should not at least be able to take puberty-postponing medications to avoid unwanted penile menstruation if they and their family and support professionals were still unsure whether to commit to any more permanent intervention?

What we must ask is that society treat intersex and trans-identified children consistently. We all raise our children to learn to make good decisions, so that they can lead good lives. We must nurture children’s autonomy as they grow, understanding that there are some decisions only they can make for themselves. To force a person to live in a sex with which they do not identify is cruelty; to impose unwanted bodily alterations unconscionable. Wishing happiness for our children, we must nurture and then defer to their right to self-determination over interventions into the sexed body.

Sunday, March 25, 2012

TSA Body Scanning and the Trans Body

Recently I had an unpleasant experience while travelling: for the first time, I faced TSA screening at the airport with an “Advanced Imaging Technology” body scanner. These are the devices that see through clothing, with the supposed intent of revealing hidden weapons or explosives. While they haven’t yet foiled any terrorist plots, they do lead to a great loss of physical privacy, and for trans people, add a new level of anxiety to air travel. And as my experience illustrates, that anxiety is justified. We are treated as if our bodily differences pose some sort of potential terrorist threat.

I am a trans man. While I am legally male and my ID reflects that, like many trans people I have not had any reconstructive surgery. It is expensive and not covered by my insurance, and while I would like chest surgery, as someone born intersex I am not interested in genital reconstructive surgery. I therefore wear a chest binder and a genital prosthesis. Wearing the binder and genital prosthesis is very important to me. While I’m not in the closet about being trans, I am fortunate in that with my beard and substantial body hair, while wearing the binder and prosthesis my male identity is rarely questioned by strangers, despite my lack of surgery. This gives me the privilege to avoid a lot of harassment that trans people suffer all the time when their trans status is visible to the public.

Traveling while trans is anxiety-producing. Many trans people, especially trans women, have had experience facing harassment from police officers and others in uniforms, and having to be screened by stern-faced uniformed TSA officers isn’t comfortable. Any “discrepancy” in ID is cause for being detained and denied access to one’s flight, and this includes a perceived discrepancy between the gender marker on one’s ID and the TSA agent’s reading of one’s gendered appearance. I’m fortunate enough that no agent has ever questioned the M on my license based on a visual inspection. But body scanners see beneath clothing. . .

I’ve traveled by plane a fair number of times since my legal transition, but always managed to be screened through a standard metal detector before. Though I’ve been concerned about being outed in the process, I’ve never had a problem. In March, however, that luck ran out, and while flying to a conference to present on intersectional identity and intersex issues, I wound up having to go through a body scan. After stepping through, I was told that the scanner revealed "multiple anomalies.” I looked back at the display and saw four markers appearing over the outline of my body: two at the top of my left ear where I have two earrings, and two on my chest, one over each nipple area.

I’d always been most worried about being found to be wearing a genital prosthesis. Other trans men have had problems when outed as wearing them during TSA screening in the past. Complaints about this have in fact helped lead to the one explicit TSA screening policy said to protect trans people: “travelers should neither be asked to nor agree to lift, remove, or raise any article of clothing to reveal a prosthetic and should not be asked to remove it.”

But what the scanner picked up on, besides the fact that I have a couple of earrings, were “chest anomalies.”

I was taken aside for a patdown. I asked that this be done in privacy, and was taken to a room by two TSA (cis) male agents. One blocked the closed and locked door, and the second stood in front of me. They asked me to answer yes or no, did I have any medical implants or a pacemaker, and I said no. I was then given a through full body patdown, which took some time. The agent doing the patdown seemed concerned that I was concealing something under my shirt. I could have explained what the issue was, but the TSA agent, while acting thus far in a detached and professional manner, had not given me any opportunities to speak spontaneously, but just allowed me to answer yes or no to his questions. The question he asked me next was whether I was wearing a back brace. I said no.

The TSA agent then asked me to open my shirt. While I am uncomfortable revealing my chest wearing just my binder, I did so. The two TSA agents then stared at my chest in the binder for a while. The TSA agent doing the patdown finally asked me what my garment was. I said that it was a chest binder, which I wore because I was a trans gender man. The agent said, “A what?” I had to explain what that meant. The agents looked both dubious and uncomfortable.

I was extremely concerned that I was going to be asked to remove the binder, but, after some silent staring and thinking, the TSA agent told me he would screen the garment for explosives with swabs while I was wearing it. While less humiliating for me than being forced to reveal my breasts, the screening for explosives involved having the agent thoroughly rub a series of small swabs over the entire surface of the binder: sides, back and front. This was quite psychologically disturbing for me. The TSA agent’s expression was one of controlled distaste.

After my binder was indeed found not to be a terrorist weapon, I was allowed to leave. The process was not only humiliating, but time consuming, and I had to rush for my plane.

As my experience reveals, it is obvious that the TSA agents need additional training on dealing with trans gender travelers. The TSA agents who screened me were not only completely unfamiliar with what a chest binder is, they had apparently never even heard of trans men. Their standing there staring at me in me with my shirt open to reveal my chest binder while apparently trying to evaluate whether what I said was plausible was very embarrassing to me. The thorough swabbing of my binder involved what was essentially a groping of my chest. Trans people like myself who have not been able to access the reconstructive surgery that we wish are often very private about our bodies. Having to expose my chest triggers dysphoria for me, and I wear my binder even in intimate situations with my spouse.

Some trans organizations have been quite encouraged by the federal policy stating that TSA agents are not to ask travelers to reveal or remove their prosthetics. A group of which I am a member posted the TSA website, including this policy and the link to a complaint procedure for violations of TSA regulations. So I followed the link and filed a complaint. In it I noted that TSA agents such as those who screened me obviously need training in dealing with trans passengers. I wrote “This training must include the fact that the majority of us have not ‘had the surgery,’ because of the high uncovered expense, and that our nonconforming bodily status is something we keep deeply private. The training should spell out the prosthetic devices and garments we may wear, such as penile prosthetics and chest binders for trans men, and breast forms and tucking underwear for trans women. No passenger should be asked to reveal these prosthetic items or garments or to remove them. Furthermore, if a body scanner reveals ‘anomalies’ in the chest or groin areas, TSA agents should be instructed to ask if the passenger is trans gender and is wearing any special undergarments or prosthetics because of that. If the passenger says yes, then the ‘anomaly’ is explained.”

Unfortunately, my complaint led to no results. The official who reviewed it for the TSA Office of Civil Rights and Liberties did not find a violation of policy (I presume because in his view, I was not asked to reveal or remove my genital prosthesis, and a chest binder is not a prosthetic). He viewed the complaint as one not of violation of my civil rights, but as an issue of professionalism, and forwarded my complaint to the TSA Contact Center to be addressed. That office sent me a form letter “response” from a do-not-reply email address. The form letter merely repeated the information posted on the TSA website: that passengers must be screened; that body scanning equipment will detect prosthetics; that if an “anomaly” is revealed, the passenger must accept a pat-down or be refused access to the terminal; and that passengers may request a private pat-down. I wrote back to the Office of Civil Rights asking that I receive an actual response to my request for further TSA training, but never got a reply.

After my experience, I do have some advice for trans travelers. If you wind up in line for a body scanner, be aware that you can ask to skip it and have a pat-down. If you do go through the scanner, if you look back at it you will see a small simplified display with an outline of a body, and colored rectangles over any detected “anomaly,” which will let you know, if you are called aside for further screening, what part of your body they will focus on. You can then, if you wish, pre-emptively state to the agents that you are wearing a binder or breast forms or whatever seems the likely issue. I’d suggest calmly stating that TSA policy forbids requiring a passenger to reveal or remove a prosthesis. You also have the right to request a private screening (although, if the TSA agent seems hostile and you fear mistreatment, a public screening may in fact be safer, even though it involves more public stares).

I’d also suggest that if you are subjected to bodily scrutiny as a trans person that makes you uncomfortable or delays you, that you complain to the TSA Office of Civil Rights and Liberties. I didn’t get a response, but perhaps if you specifically state that you believe your right not to have to reveal or prosthetic was violated, you would. In any case, the more complaints they receive, the more likely it is that eventually something will be done, or at least that someone can document how many complaints have been filed with no result.

For now, anyway, as trans people we have to deal with a system that treats us as potential terrorists because of our bodily differences, which is nonsensical and insulting.