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.
[Like]
ReplyDeleteWonderful essay. I can very much relate to wanting to live in a world where there is no social stigma against having the combination of visible breasts and a beard or other typically-male sex characteristics. I'm agender and DFAB, but I've come to realize that my sex (not gender) is male, and I've been on testosterone for a little over a year. I don't mind having breasts, and mine are small enough that I don't feel the need to bind, though I do some layering. However, I dearly want the privilege of going topless in public, and may end up getting top surgery primarily for this reason.
ReplyDeleteI appreciate that you do acknowledge that there are people with internal gender dysphoria who would want hormones and/or surgery even if on the proverbial desert island. That's how I currently feel about hormones. I'm fortunate that those are covered by my partner's insurance, and that my medical clinic operates on an informed consent basis. All people of all (and no) genders should have equal access to these services.
Great post. However, I don't think the three reasons you gave at the end are completely accurate. They may hold true for binary trans people, As a genderqueer person, numbers 1 and 2 don't really apply. However, I do experience social dysphoria, when people refer to me by my birth gender or when I'm instantly perceived as my birth gender (via cues such as my clothing). I want to be perceived as not-cis. I would like to "pass" as not male, not female. (Though I know this is a lot to ask in our current society...) Though the eradication of cissexism and transphobia will undoubtedly benefit nonbinary folks too, in many of the same ways. If people stop assuming our genders, the pressure to conform to an androgynous ideal will be lifted, and we will be free to be ourselves and still be validated.
ReplyDelete