Many—though by no means all—trans people seek at least some body modifications (hormone replacement therapy, hair removal, surgery, etc.).
In this post I want to talk about why we do this, and to critique the way seeking trans body mods is often framed. The common medical framing presumes a cost-benefit analysis in which reduction of internal psychological distress is weighed against medical risks. And the common layperson’s framing centers the problematic idea of us seeking to “pass.”
In my last post, I explained why I believe the language of “passing” is damaging. I know that there are some trans people who get upset by such critiques, because they hear an attack on the language of passing as a dismissal of the pain of their gender dysphoria or the intensity of the transphobic violence and disrespect they face. This post should make it clear that I want to do the very opposite of that. I just want us to approach this discussion in a way that facilitates change.
Let me start with a personal example.
A while back I participated in a study on chest binding. In filling out the questions, it became clear to me that the researchers framed chest binding in terms of a risk-benefit analysis. They presented the benefit of reducing bodily dysphoria by binding the chest as balanced against physical risks associated with binding. This is a framing that I find to be commonplace today in medical circles. A trans person is presented as engaging in practices considered physically risky (binding or tucking, taking hormones that increase cardiovascular risks, undergoing surgeries that cause pain and always involve the danger of infection, a poor reaction to anesthesia, etc.). If these physical costs are seen as outweighed by the mental health benefit of reducing psychological dysphoria with the body, then the physical risks are justified.
This is such a very American professional framework for transition: economic, rational, and individualistic. In its deployment by many cis laypeople, the same framework is given a rather sadistic moral cast. Undergoing painful and dangerous body modifications is understood as the price trans people must pay if we want to be respected in our identified genders. (This is why, I believe, many cis people feel they have the right to ask us whether we’ve “had the surgery,” despite our protests that other people’s genitals are none of their business. They feel that if they are being asked to respect our gender identities, they deserve to know if we have paid in coin of blood for that recognition. The idea that we should not have to pay to have our genders respected any more than they do is apparently novel to them.)
Anyway, back to the study: the tension that I saw in the survey is one familiar to many people seeking medical transition services: paternalism. It seemed to me that the researchers believed some binding practices (such as the use of duct tape or ace bandages or binding for extended periods of time) are too risky to be justified by any psychological benefit. This will sound familiar to many trans people who have sought medical transition services. Often we are turned away, as medical gatekeepers have declared hormones or surgery too risky for us. My own spouse had had a doctor refuse to refill her prescription for estrogen because her total cholesterol level on one blood test was 201, 1 point into the “high” range. It was blindingly obvious to my wife, to me, and to most any trans person that the risks involved in withdrawing transition services were much higher than the risk posed by a single cholesterol point of possible added cardiovascular risk. But under medical paternalism, it is not the trans person zirself who decides if the benefits of medical transition outweigh the risks—it is the doctor. This gives a doctor’s idiosyncratic beliefs about trans people a great deal of power. This is evident, for example, in how many genderqueer people seeking medical transition services have found they have to present themselves falsely as having a binary trans identity in order to access those services. Presenting as genderqueer/agender/etc. is a disadvantage because doctors often impose their personal belief that nonbinary identities are weak, wishy-washy, impermanent, or insufficiently “real” to justify the risks of treatment.
After being rejected by paternalistic medical gatekeeping to transition services, some trans people just give up, resigned to lives of psychological misery. Other, shall we say, more self-actualizing individuals simply turn to the grey and black markets, for example by buying hormones online. Responding to this reality, the modest number of regional trans clinics mostly operate under the “harm reduction” philosophy, under which clients are advised of the risks involved in hormone replacement therapy, permitted to sign an informed consent form, and then allowed access to hormones.
I’m fully in favor of the harm reduction approach, which grants trans patients the human dignity of being allowed to make informed decisions for ourselves. But the framing of decisions about transition under harm reduction is just as individualistic as the paternalist model. It’s about a contract being signed by a rational actor weighing physical risks against psychological benefit.
As no man, woman, person of any other gender, or person of no gender at all is an island, I find this pretty silly.
We are not atomized individuals free-floating in space, making decisions about whether and how to modify our sexed bodies. We are social creatures, with employers and coworkers, partners and offspring, schoolmates and neighbors. And so many of the current risks and benefits of trans body modifications are social in nature, not medical.
Anyone who gender transitions does so because they wish social recognition of their gender identity. If it is enough for us to know in our own minds what our true gender is, then being forever misgendered by others matters not at all, and transition is unnecessary. Note that I am not equating gender transition generally with medical transition—many people transition socially without the use of hormones or surgery. But whether we choose to and are able to access medical services, choose not to do so, or try but are unable to access them, the acts of coming out to others and of asking that others change the pronoun by which they address us are social in nature.
And this brings up the thorny issue of being accepted in our identified genders. For many binary gender transitioners, this is conflated with the idea of “passing,” or being perceived as a cis person of one’s identified gender. (I’m very critical of the term “passing”—you can read my full critique here if you like.) In my ideal world, gender identities would be accepted in the same way that, say, religious identities are: we just take someone’s word for it. If someone tells you they are Catholic or Hindu, you say, “OK.” If someone tells you they have converted to Judaism, you say, “Oh, OK,” and maybe you ask them about their experience, but you never say, “I refuse to acknowledge your Jewish identity because you don’t have a Jewish nose. If you get a nose job maybe I’ll think about it, but since you didn’t grow up Jewish, I really don’t think you can know what it is to be a real Jew.” (By the way, I’m Jewish, and I am aware that there are some Jews who see Jews-by-choice as less authentically Jewish, though that is against both Torah and rabbinical advice. But I’ve never in my life encountered a person, Jewish or otherwise, who has said “I won’t acknowledge you as a Jew unless you get plastic surgery to make your nose look Jewish.”)
Unfortunately, my ideal world where gender identities would be respected when announced, without regard to physical appearance, is far from the world we live in today.
In the real world we have no choice but to negotiate, not only is transphobia, or hatred of trans people, rampant, but so is cissexism. Cissexism is the belief that cis people’s gender identities are authentic, innate and unquestionable, while trans peoples’ identities are questionable performances. One aspect of cissexism is the belief that one has the right to choose to respect a trans person’s gender identity or not—that one sits in judgment on our identities and presentations. And central among the criteria that cissexist people use in deciding whether to respect or mock us is physical appearance, especially bodily configuration. To be deemed “worthy” of the pronoun “she,” cissexism holds, one must have a body that looks like that of a cis woman. To be granted the right to the pronoun “he” requires a body appearing cis male. And to be acknowledged as genderqueer, a person is expected to be completely androgynous in physical form.
Now, the prize that cissexism dangles before us turns out often to be illusory. Cissexism is deeply bound with enforcing the gender binary and essentialist notions of binary sex. No matter what a person’s body looks like, it turns out, cissexist people generally treat all nonbinary genders as jokes, refusing to use nonbinary pronous or just “forgetting” all the time to try. A trans man can bulk up, grow a beard, and get top and bottom surgery, but no matter—many cissexists will assert that he doesn’t have a “real” penis, and is thus a poor simulacrum of a man they will call “he” out of pity. And transfeminine peole have it worst of all. Transmisogynistic hatred focused on trans women is intense, presenting them as deceivers of straight cis men, potential rapists of cis women, and some unspecified but ominous threat to children. Cissexist gender policing of trans women’s bodies is most extreme, inspecting necks for adam’s apples, staring at the size of hands, scrutinizing chests, and monitoring jawlines. If they are visibly trans gender under this scrutiny—as so many trans women are—they are the subject of constant ire and harassment, mocked as “shemales” and “he-shes.” Only the most model-perfect are granted the prize of being treated as women. And even this prize turns out to be booby-trapped, because their very cis-conformity is reframed in romantic and sexual contexts as a sham, a trap, tormenting cis straight men by somehow making them gay.
So: cissexism is rampant in our society. Its claim that it will grant us respect, if and only if our bodies “match” our identities, is largely a sham—and yet it is compelling to so many of us as trans people. It keeps masses of trans people in the closet, convinced they can never transition because their bodies appear too stereotypically cis male or female. We transition so that others will respect our gender identities, and if we are convinced no one ever will respect us because we don’t have the price of a nice suburban home to spend on plastic surgery, or that even if we spent a million dollars, it would never be enough, then many of us decide there’s no point in even trying.
For those of us who do come out, bod mods often become almost an obsession. If you take a look at the mass of trans support sites, and you will find a million posts entitled “How well do I pass?—X months on HRT.” Go to some genderqueer support groups, and you will find masses of people binding their chests, agonizing over whether they would look more androgynous if they took a little estrogen or testosterone, or commiserating over wanting some of the effects of HRT but not others. The way this is framed by psychotherapists and doctors is as an individual preoccupation that is a keystone of the formal diagnosis of gender dysphoria. It’s treated as an internal psychodrama of alienation from one’s flesh, the idea of feeling “born in the wrong body.” And it’s certainly true that many trans people are driven to transition in part by a sense of unhappiness with their curves or lack thereof. But this feeling does not emerge in a vacuum. It is born from a life lived in the context of cissexism and its insistence on “passing” as cis gender as the gateway to respect for trans people.
We’re the ones diagnosed with a mental illness, but it’s society that is sick. Doctors say that we as individuals are weirdly obsessed with our sexed bodies, but it’s gender policing by a cissexist society that makes us rationally preoccupied with how our bodies appear.
I’ve had conversations with various trans friends that start, “If you were living your life alone on a desert island. . . ,” as we have tried to disentangle personal wishes for body modification based on internal dysphoria from social forces pushing us toward them. It’s an impossible exercise on many levels, because we’re never going to live such a life, and because social forces have shaped our feelings and understandings on an unconscious level. Still, it’s interesting to me, because while some friends have said nothing would change for them, other people I’ve had such conversations with have said they’d want fewer body modifications. Personally, if I were living on that proverbial desert island, or, slightly less implausibly, in some sort of trans gender utopian commune, what would change for me is my attitude toward top surgery. I want it now, living in my Midwestern American context, but I wouldn’t in an ideal or asocial setting.
If nobody was around gender policing me, I could deal with having moobs. I mean, I wouldn’t mind looking like Michelangelo’s David, but I'm a middle-aged guy with reasonable expectations and hardly obsessed with having a model body. Early in my transition, I wore my binder every waking hour, but now, as soon as I get home from work, unless there’s company, I immediately take it off and relax. Let’s face it: for most of us who wear them, binders are really uncomfortable. But my attitude of relaxation and body acceptance has very little effect on my binding behavior outside the house—I bind tightly, whenever I’m stepping out my door, which often means for 12-18 hours a day.
Now, here’s where I return to that study I mentioned (remember the binder survey?). According to the health information given with the survey, binding for more than 8 hours a day is medically risky. As a rational individual, I should balance my dysphoric urge to bind against physical risks, and apparently I'm doing a poor job of it—I’m too obsessed with my body, making me put it at risk.
But I’m not obsessed with my body.
I’m not binding for long days due to psychological reasons. I don’t want top surgery because my body revolts me, or because my moobs feel like alien flesh somehow appended to my chest, or because I have a desire to live “stealth,” hiding my trans status. I am responding to a social context in which the risks of my not binding or getting top surgery are huge. I teach large lecture classes full of Midwestern undergraduates. I sit in meetings with Midwestern administrators. They all know I'm trans—I’m not in the closet—and there are rough patches, but mostly I get by pretty well by wearing jacket and tie, growing my beard, and binding my chest to pass muster with gender policing. I recognize that in this I am privileged. But if I suddenly showed up with size D breasts bouncing around under my shirt, I have no doubts that it would trigger a cissexist freak-storm. It’s one thing for your standard cissexist onlooker to see that I’m short and wide-hipped for a man, and have a somewhat odd-shaped chest. I fall short of the masculine ideal, but it’s clear I’m making an effort. Presenting as a man with a free-flying and quite substantial set of breasts, however, is a crime according to the gender police.
Unintentionally violating the cissexist law that gender identity and body must “match” gets you stigma, but overtly flouting this law is treated as a much more serious crime. Now, the results are generally much worse for the transfeminine than they are for transmasculine people like me. But there would be consequences—material consequences—for me, for example in the form of poor student evaluations and negative interactions with colleagues, and I am the sole economic support for a family of three. Furthermore, the other members of my family have physical disabilities, meaning they must rely on me to do tasks like the shopping that would be made much more difficult and potentially dangerous if I appeared, not just as trans, but as “flaunting” a nonconforming body.
I know that there are people in the U.S. walking around in public with the combination of beard and big breasts and an androgynous body, if not in the Midwestern setting I live in. Frankly, I’m in awe of their strength. If I were single, maybe I would find out if I am strong enough to take the body I’m comfortable with in the privacy of my own home, and live with it in full view of a cissexist society. Maybe I could dare to swim in a public pool, furry moobs exposed, or mow the lawn with my shirt off, like my cis male neighbors do, and dare the police to arrest me for bodily nonconformity. Certainly I’d love to give the finger to our society’s gender policing, sexualization of body parts deemed female, and general body shaming.
But I am not just an individual with political goals and psychological impulses. I am embedded in a society and in a family. And I have duties to my spouse and child that mean that since I cannot afford top surgery, and my insurance excludes coverage of transition-related services, I have to bind my chest for more hours a day than is medically approved.
Any study or theory of trans experience that presents us as acting solely in response to internal psychological impulses deeply misrepresents our lived reality. And a medical establishment that withholds hormones or surgery based on a cost-benefit analysis that only takes into account medical risks, and not the social stigma, unemployment, and violence that those of us transitioning in a cissexist society risk without those services, does trans people a great disservice.
At the same time, it’s very important to me to resist naturalizing and internalizing gender policing by evaluating myself using the language of “passing.” Besides implying that my presenting myself as a man is deceptive, the language of “passing” puts trans people in an impossible position, where the “success” of our transitions are determined by something we cannot control: the way we are treated by others. No matter what body mods we seek, or voice training we do, or how carefully we choose our clothing, other people can still mispronoun us, either consciously and cruelly, or based on their unconscious cissexist ideas about bodies without actively intending to be cruel. We cannot control whether we “pass”—we can be passed as cis gender by others who honor our gender identities, or not passed as cis gender by those who do not, and control of that lies with them, not us.
So I want to emphasize that I am advocating for the great import of trans body modification and access to medical transition services largely because of our social context of constant gender policing. Ideally, I believe, what requires change are not trans bodies, but society. It’s cissexism that drives so much of our preoccupation with body mods. What we must most fight for is the social acceptance of visibly trans bodies as being fully as valid and attractive and as deserving of respect as cis bodies. In an ideal future, when all gender identities are fully supported and respected, I believe trans people will seek to change our bodies less than we do now. But since we live neither in that ideal future, nor on desert islands, we must cope with the fact that social change is slow, and we have to live in the world as it is now, even as we fight to change it.
Right now, trans people of all genders pursue body modifications for three reasons: (1) to reduce the social risks of stigma and mistreatment that are aimed at visibly trans bodies, (2) to get the social benefits of respect that are currently granted only to cis-appearing bodies, and (3) to reduce internal gender dysphoria. The first of these, reducing mistreatment, I see as a necessary evil: something we rationally try to do to protect our safety, but much more effectively addressed by putting an end to transphobic discrimination and violence, making protective camouflage unnecessary. The second of these, seeking to appear cis to get respect, I see as a dangerous illusion, because we cannot control whether people will grant us that respect, and because it perpetuates the idea that trans bodies like ours are inferior. It’s only the third—seeking changes in our bodies that reduce our personal, internal gender dysphoria—that I believe would persist, in a world that moved beyond transphobia, transmisogyny and cissexism.
May that day soon arrive.