A Red State is "Detransitioning" State Employees--Like Me

It's been close to a decade since I legally gender transitioned.

While it was a great relief to finally live authentically in the gender I knew myself to be, transitioning was a process both challenging and tedious. I needed to have my name and gender marker changed in so many databases. This meant awkward interpersonal interactions. (For example, when I went to get a driver's license issued with my new name and gender marker, the person staffing the front desk at the DMV, apparently seeing me as insufficiently manly looking after just a few months on testosterone, responded by exclaiming in front of the crowd waiting in line, "What are you, some kind of pre-op?!").  It meant educating and cajoling and placating administrators of multiple bureaucracies who had never personally changed anyone's gender marker in whatever system they administrated, and were disconcerted to be asked to do so. It meant presenting my court order of name change and state ID showing my "M" marker over and over again.

Running the gauntlet of getting my gender transition acknowledged and implemented took months. It was tiresome. But I managed it, and moved on with my life. As my appearance shifted under the influence of hormone therapy and most people got used to addressing me as "he," the levels of stress involved in just living my life as myself slowly dropped. There were ongoing battles that remained, like my fight against the ban on insurance coverage for transition-related care in the policies offered to Wisconsin state employees, but the legal hassles seemed mostly behind me. I could mostly breathe free and just go about my business.

And for a brief moment, things really started to look up. After eight years of fighting with no success for insurance coverage for the trans care my wife and I required, policy directives under Obamacare forced my state to say it would lift the ban on transition care. The exclusion was to be lifted on January 1, 2017. But in November of 2016, Donald Trump won the presidential election, promising to repeal Obamacare and produce a total change in federal regulations. Now, my Republican governor and state legislature felt empowered to enact transpohobic policies. In December, the "Employee Trust Fund" or ETF--the agency administering all benefits programs for Wisconsin state employees--directed all insurers providing coverage to state employees to reinstate the ban on coverage for trans care.

For a family like mine, with two gender transitioners who had been waiting for many years to access additional care and get coverage for our HRT, that was more than depressing. But at least we saw it coming.

What came like a bolt from the blue was the notice I got a week ago.

It was a Friday afternoon. I'd just given a colloquium talk in my department. The week was winding down, and so was I, sitting in my office going through the day's pile of email--the usual questions from students about assignments and discussions about programming with instructors in the LGBT+ studies program I direct. Then I came across an email from my university human resource specialist, opening with a cheerful "Hello!" It informed me that ETF had changed their policy on gender transitioning in their system (which covers not only health insurance but all benefits, like disability, retirement plans, etc.). It stated that in order to "maintain a gender change," I had to provide additional documentation for myself and for my wife.

We were being detransitioned by the state, though I'd legally transitioned nearly a decade ago, and my wife started her transition in the 1990s. And we did not have the additional documentation demanded.

Reading this email caused an immediate feeling of shock at the attack on our identities. But let me note that reverting our gender markers to what they were years ago does more than emotional or psychological damage. And it impacts more than how others view our genders. For example, I have developed a neurological problem with my arm leading to partial loss of the use of one hand. I'll be seeing a neurologist in a few days--and a mismatch in my identification can mean denial of insurance coverage. That could be very costly to my family--but delaying needed medical care is costly in other ways.

Between a Rock and a Hard Place

Before I get to discussing the additional demands ETF is making, let me point out a very broad problem, and that is the idea that agents of the state can change one's legal status retroactively at any time. Imagine, for example, if the state decided that it wished to make it harder for people to get married, and so it imposed a new requirement--that in order to have a marriage recognized, residents would have to provide DNA evidence proving they and their spouse are not related (an expensive prospect). Then imagine that all married state employees were informed that their status had been reverted to single in employment databases and systems, because they had not complied with the DNA test requirement when documenting their marriages. That's not the way regulatory changes, mundane or shocking, operate--they are applied going forward, but not retroactively.

Now, as for the new procedures for gender transitioning, there are three requirements listed by ETF. The first is that the employee must notify ETF directly, providing their old and new names, old and new gender markers, ETF ID number, and a declaration that they are gender transitioning. Previously, employees notified HR at their place of employment, and employer HR staff changed the gender marker directly in the benefits system. But now ETF will centralize control over implementing transitions, and maintain a database of gender transitioners. In essence, we are being required to register with the state. As a Jewish person who lost extended family in the Holocaust, I find this extremely creepy.

The second thing trans people are required to do is provide "proof of identity," such as a driver's license or military ID showing the new name and gender marker. That's what we had to do in the past, and my wife and I can easily produce our Wisconsin driver's licenses showing our names and most correct binary gender markers. But now ETF is demanding more.

We are now being required to produce a third item, "proof of gender." This is very strange, because a driver's license already provides state-recognized proof of one's gender. Requiring more serves no purpose other than to make it harder for people to get their identified genders recognized. And the new "proof of gender" items are difficult and intrusive items to get.

Let's look at the options. One is a court order of gender change. To get one of these is difficult, expensive, and in many states, like Wisconsin, requires a doctor to testify that one has had surgical sex reassignment. Now, some people cannot have such surgery for medical reasons. Others do not want it--they desire social recognition of their identified genders, not a program of body modifications. And nonbinary gender transitioners often find they are denied access to surgeries. But let me underline that in any case, the very surgeries that ETF is making necessary in order to have one's transition recognized it has also categorically excluded from insurance coverage. My wife and I have been waiting for years to access some surgical interventions that would make our lives easier on many levels, one of which is being able to access things like a court order of gender change. But we can't afford them without insurance coverage. It's a Catch-22, and seems deliberately cruel.

Well. Instead of presenting a court order of name change, another "proof of gender" is a US birth certificate showing the identified gender. Now, in bluer states than mine, amending one's birth certificate sex requires just a letter from a doctor or therapist attesting that a person under their care is gender transitioning. A few states with reactionary policies, like Ohio and Idaho, do not allow birth certificate sex to be changed for gender transitioners at all. But most states, like Wisconsin, will do it for people who have had sex reassignment surgery which is documented in some particular way--in Wisconsin, it's by a court order of gender change. So we're back to square one, for my family and for so many gender transitioners.

What else will ETF accept as proof of gender? Another option is a US passport showing the identified gender. My wife and I have been trying for months to get the documentation we need to get passports issued in our lived genders, but have run into difficulties trying to get certified copies of legal documents. Hopefully these problems will be resolved in time and the rules for gender transition and passports won't shift under us before then. But even if we had them, this option as provided by ETF is highly problematic. Their policy requires that for a passport to "count" as proof of gender, the original passport must be mailed to an ETF P.O. box to be examined. It's crazy to demand that someone hand over their passport, via ordinary mail, with no specified procedure for ensuring its safety, no description of how long it will be held, no contact information given for an employee to inquire about the location of their passport should they not receive it back in a timely fashion, and most of all no explanation as to why the original document has been demanded, rather than just shown to the employee's HR office. So, even if we did have passports, we wouldn't want to mail them off to ETF as required.

Finally, there's the alternative of mailing a letter from a care provider as "proof of gender." At first, this seems the go-to option. Letters from medical practitioners and therapists are employed in many transition contexts. But there are two problems with ETF's letter option. First, ETF will only accept a letter from someone with a doctoral-level credential. The clinic where my wife and I get our medical care is staffed solely by (very competent!) nurse practitioners, with masters-degree-level credentials. So our care provider isn't allowed to write a letter for us.

But there's something more insidious, and that is the content required in the letter. Transition letters are commonplace, and they follow a standard format intended to protect the private medical information of the gender transitioner. The care provider writing the letter makes only a general statement that "appropriate clinical treatment" has been provided. But ETF demands that the letter writer explain what that treatment was. This is none of their business! Moreover, ETF is staffed by bureaucrats and accountants, not medical personnel qualified to review such information.

There's no justification given for the letter to disclose such highly personal information. But given what we've just experienced in terms of retroactive de-recognition of our gender transitions, there's reason to fear. It may be that if certain medical procedures are not listed in the letter, even if the letter is accepted now, at some time in the future employees might find their gender transitions reversed in state records yet again.

Ugh.

So, I've been trying to mobilize my university HR to push back against the detransitioning of me and my wife in the benefits system, and against the imposition of onerous and atypical requirements future gender transitioners. A conference call is planned between ETF and HR administrators. We'll see what the outcome is, but one piece of information I have been given so far by the head HR administrator at my university is that apparently my wife and I are the only people to whom ETF directed a notice be sent that our gender transitions would be reversed unless we produced additional documentation, at least as far as he could determine.

There are two interpretations I can give this disconcerting bit of information. Both turn on the fact that I am quite open about being trans, run an LGBT+ studies program, and as an academic who researches intersex and trans issues, have been interviewed by the media numerous times to provide commentary on related news stories. The first interpretation is that some ETF staffmember has been tasked with identifying trans state employees to receive detransitioning notices, and as I'm simply particularly visible as a trans employee of the state, I and my wife were the first identified. And the other is that because I am a critic of transphobic policy initiatives, my family has been personally targeted in retaliation--which is a pretty unsettling possibility. I suppose there's a third scenario--that every other trans person who is a state employee or receives benefits as family member of a state employee presented their HR office with a court order of gender change or amended birth certificate when they gender transitioned. But given that there are almost 300,000 state employees, how hard it is to get those documents, and the fact that they were not considered necessary until now, this seems extremely unlikely. It's an anxiety-inducing situation to find oneself in under any interpretation.

In any case, the short story is this: around the US and the world, as trans rights have advanced, insurance coverage for transition care has become commonplace, while changing gender markers has shifted to being based upon gender identity, not any particular physical sex characteristic or its modification. States like Wisconsin were lagging behind the curve, but progress was being made. Yes, there were backlashes, like the flurry of so-called "bathroom bills," but under the Obama administration, these were federally identified as discriminatory.

But like so many things, a lot has changed fast. And trans people are among those finding themselves besieged.

And that's how I find myself facing detransition by an agency of the state.

Doors Slamming Shut on Trans Care

A Preamble

So much has happened so quickly since the Trump inauguration, so much of it damaging to marginalized people, that it's difficult for folks to keep up with what is going on. That is clearly the intent of Trump puppeteer Steve Bannon, with his desire to produce shock and awe, stir up society like an anthill, and remake it in his nasty image.

With so much going on, it's important that we make and listen to reports from the many fields of struggle, which is why I'm writing this post. But I do want to preface my report with a call for unity. We've been set up, by this initiation of battles on many fronts via tweets and executive orders. Our opponents in Washington hope to divide us. They hope that we'll splinter into "interest groups," each demanding primacy and seeing calls for help and attention from other embattled groups as acts of betrayal. Remember, the concept of "divide and conquer" is as old as the hills. 

None of us can fight every battle--but we can support one another's efforts. We have to focus our individual efforts on what we can do best to resist in our local communities, with the skillsets we each have. But we also need to have one another's backs.

So: I make this small field report, not to distract people from protesting the ban on refugees and travelers from seven Muslim-majority nations, or from pushing their representatives in Washington to oppose the nominations of unqualified ideologues to head federal agencies, or whatever other actions people are engaging in. I make it because we must keep one another informed of all the negative changes that are taking place. That's what we need in order to keep taking positive steps to resist.

A Trans Report from the Midwest

I am an employee of the state of Wisconsin, teaching at a state university. About a decade ago, the University of Wisconsin system added to its nondiscrimination clause protections based on gender identity or expression. Yet the insurance plans offered to people working and learning at University of Wisconsin schools all banned coverage of "procedures, services, and supplies related to surgery and sex hormones associated with gender reassignment." I've been fighting that ban ever since.

Until the summer of 2016, I got nowhere. It was a strange battle, because at every turn, I encountered expressions of surprise and sympathy from colleagues and benefits staff and administrators in the University of Wisconsin system. Colleagues presumed transition care must be covered by our insurance, since our antidiscrimination policy bans discrimination based on gender identity, and that must mean what it says. Human resources staff presumed the denial of coverage in our insurance plans must have originated with the insurance companies, and be their national exclusion policy. Upper university administrators saw that the discriminatory medical exclusion came from on high--proclaimed for all state employees by an entity called the Employee Trust Fund. But they regretfully stated that the university system couldn't tell the state what to do. They promised to bring the exclusion up as an issue to be addressed at the state level should an opportunity arise.

And so, year after year, I'd repeat this process of approaching people at various levels, reporting on the ongoing discrimination and asking for their help. I'd speak to them personally, and tell them how my family was impacted. With two gender transitioners and two disabled people in the little family of three I support, we couldn't afford any uninsured surgical care, and the lack of coverage for our trans endocrinological care was costing us between $1000 and $2000 a year out of pocket. Between our other medical expenses and the big hit my take-home pay received when the state withdrew much of its benefits support, my family's savings disappeared, and we have been sinking further and further into debt. And not being able to access surgical transition care is not "just" some issue of psychological discomfort for my wife and myself. It means relying on antiandrogens for year after year, with side effects that can be cumulative. It means relying on the extended wearing of chest binders for year after year, with their restrictions on breathing, exercise, and risk of rib injury. It means if we fly, we regularly get stopped by airport security and detained due to our "anomalies."

And year after year, the people I contacted would express sympathy, but do nothing.

Then, in the summer of 2016, the U.S. Department of Health and Human Services posted the "Final Rule to Improve Health Equity under the Affordable Care Act." And one of the things this document said was that health insurance could not discriminate on the basis of gender identity or expression. Blanket exclusions of transition-related care were stated to be unacceptable discrimination.

And lo! Based on this federal guidance, the Employee Trust Fund, the entity declaring policy for state benefits programs, instructed all the health insurers providing insurance to state of Wisconsin employees to remove the ban on trans care.

In the fall of 2016, my family received a letter from our insurer stating that the ban on coverage for transition-related medical expenses would be lifted on December 1, 2017. We put the letter up on the fridge and celebrated.

And then Trump won the election.

I wrote a social media post a few days after the election saying to watch out, because I bet that trans medical care coverage would disappear for people in red states soon after his inauguration in January. A batch of people replied in comments saying that of course things were uncertain, but that I shouldn't be so alarmist. Once rights are granted, they are very hard to take back, they said. Insurers wouldn't want to look bad. If insurers did try to put back blanket bans, they'd face years of lawsuits. And anyway, Trump said he was ok with Caitlyn Jenner using the women's bathroom in Trump Tower.

Who was right? Well, it seems under the Trump administration there is no such thing as an alarmist progressive worry.

What followed Trump's election in Wisconsin was an immediate flurry of activity in the state health insurance regulatory world. Insurers, who a couple of months ago had sent out sunny letters about how they did not discriminate and offered wonderful health care coverage to all, regardless of gender identity, had private conversations with the ETF. Soon, Governor Scott Walker and our anti-LGBT activist state Attorney General, Brad Schimel, were voicing their opinions that the federal bullies who had forced the state to offer trans medical care had no more influence, and the state should reassert its noble, sovereign right to discriminate. The ETF asked the Group Insurance Board for a ruling on whether a "rescission of coverage" would amount to a "breach of duty" to the employees of the state of Wisconsin. The GIB basically ruled, "No, go for it, once Trump is inaugurated."

The very first executive order Trump signed after his inauguration was one stating that Trump intended that Obamacare be repealed, and that meanwhile, all possible actions should be taken "to minimize the unwarrented economic and regulatory burdens" of Obamacare, and give the states "more flexibility and control."

And so, in the name of freedom, states rights, and economic security, the ETF acted. On February 1st, they issued a statement saying that "the exclusion of services related to gender reassignment is reinstated as of today."

One month. That's how long trans medical care needs were acknowledged to be valid in the state of Wisconsin. I didn't even get to have a single refill of my testosterone covered, because of a backorder at my pharmacy.

Hold the Doors

This is a moment where doors are swinging shut all over America. Due to racial and religious bigotry, they are being slammed shut at the national level in the faces of refugees who are fleeing the horrors of war. We must fight for the refugees and immigrants whose lives and livelihoods are endangered by anti-immigrant sentiments and actions. 

But we should also notice and help resist the other doors slamming shut on the smaller levels of state and local action. And the Wisconsin re-adoption of trans discrimination in health care for state employees is one of those actions.

So, can you do anything to help? Well, if you are actually a University of Wisconsin employee, especially an administrator, now is the time to stand up against transphobic discrimination and speak out. Perhaps you didn't know there was a ban on trans medical care coverage before. Perhaps you knew it existed, but thought that was true across the U.S.. Perhaps you knew it was an ETF policy, but thought of it as a sort of ancient fossil, some passive, unconsidered barrier. But now you know. The ETF has pulled the rug out from under your co-workers who are transgender, or have spouses or children who are trans. Coverage is clearly possible, since for one brief month it was offered. It is being denied in a blatant case of discrimination.

I realize that nobody at the University made this decision to reinstate the discriminatory policy. I know that it comes from the state, and that if you are an employee in the benefits office, you don't want to hand out discriminatory plans. University staff supervising and hiring individuals who are trans or have trans dependents don't want them to face unfair financial burdens and negative health and safety outcomes. You are just part of a large system.

But when you hear yourself saying, "I am a cog in a huge machine. I am just following orders," I hope that this makes you shiver, then shake yourself, and do something to resist. This is a habit that we need to develop or redevelop in these times, when talk of creeping fascism is not hyperbole.

Most readers, of course, aren't Wisconsin state employees. But you can help as well. You can contact state legislators via phone or fax. You can make a donation to a trans advocacy organization or the Wisconsin ACLU or other group. Most of all, what you can do is be aware of what is happening here as an example of what is happening in many states and localities now. Find out what is happening with regard to trans health care discrimination in the localities and states you live in or have connections to. Help raise awareness of the issue. There is so much to fight, now: xenophobia, racism, religious discrimination, misogyny. . . I'm not asking people to put transmisogyny and transphobia at the top of some list of deserving causes. I'm asking people to focus on the work they are best at, but when it comes to the list of issues they are not concentrating their personal work on, to make that an inclusive list. We need to have one another's backs, and help one another out where we can, though none of us can effectively take everything on. This is what I am trying me best to do.

And now you know one way to have my back. 

"No, You're Not Going to be an Astronaut When You Grow Up"--Transphobia Translated

(Dr. Richard A. Friedman is a psychiatrist who specializes in the treatment of depression with drugs. He has a side gig writing pop psychology opinion pieces for the New York Times, and on August 22nd, the Times published an op-ed of his on trans people. Friedman has no special knowledge or expertise on trans issues or gender transition. In fact, he cites ridiculously outdated forty-year-old research on the "sissy boy syndrome" (which basically held that boys who wish to and are permitted to play with dolls grow up to be "homosexuals"). But Friedman uses his social authority as a professor of medicine to frame his personal negative opinions about gender transition and trans experience as The Truth. And his opinion piece immediately became one of the Times' most emailed and read items. This blog post is a parody of Friedman's piece, following his line of arguments but replacing sexuality and gender with career paths.) 

How Changeable Are Career Interests?
By Richard A. Friedman, MBA
Professor of Finance, Burberry Business School

Space exploration has been much in the news recently, with the New Horizons spacecraft providing dramatic images of Pluto's "heart," and astronauts on the International Space Station shown munching on lettuce grown in orbit. While astronauts make up a tiny percentage of the employed population, they have been getting a lot of media attention.

Certainly we should allow people to have whatever careers they wish, including atypical ones like becoming an astronaut. Society once looked down at "computer geeks," but today developers of software and applications run successful businesses and are embraced by many. We now know that therapies aimed at curing nerdiness by withholding computers and forcing individuals to play sports or take ballet classes are not effective. Is something similar true for those who profess a desire to pursue a career as an astronaut?

Scientific evidence does seem to show that while most people are intrinsically drawn either to jobs that pay well, or jobs that are stable and secure, career desires exist on a spectrum. Some people are, for whatever reason, committed to careers that are both insecure yet rarely make them wealthy, such as being in a band or venturing into space.

So, how should career counselors approach individuals who profess an interest in becoming a drummer or piloting a space craft, and state they cannot be happy unless they enter these careers?

Unfortunately, research shows that people who pursue these careers do not achieve the happiness they seek. Many aspirant rock stars find themselves playing small gigs in local bars, unable to support themselves, disappointing and angering their parents. The chances of those who wish to become astronauts ever being launched on a mission are low, and those who do go into space face mortal risks that destabilitze relationships with spouses and children. It seems that many would be much better off getting a job in middle management, and making Spotify playlists or building model spaceships as a hobby. And, in fact, this is what many people in the end choose to do. It seems that an interest in unstable careers is more malleable and is more of a choice than a fixed characteristic such as nerdiness.

Still, we are good libertarian individualists, and believe that people should be able to make whatever career choices they wish. If a grown man or woman believes that they could be the next Beyoncé or Neil Armstrong, despite all the eye-rolling they get from others, so be it.

But what about the children?

The issue of whether to encourage children who say they plan to be astronauts when they grow up is extremely controversial. In fact, most career counseling professionals I spoke with refused to discuss the issue on the record. I was warned that if I dared to write about the reasons why such encouragement is a bad idea, I would be attacked by the astronaut lobby. 

But I must speak truth to power. And that truth is that children often have unrealistic fantasies about their future careers. Many children state that they want to dig up dinosaurs or be elected president or become a professional gymnast when they grow up. And studies show that of all the children who write a school essay about their intent to become an astronaut, as many as 80% may grow up to have typical corporate jobs in adulthood.

Now, when astronauts are interviewed, we do find that virtually every one of them first expressed interest in this career as a young child. But how can we possibly tell whether a child who says they want to go into space some day will be one of these "persisters," when most children lose interest in such an insecure career path? So if you are, say, the parent of an 8-year-old who says she is going to be an astronaut, we can see why you might tell the child, "No, you won't."

Some claim that there are many studies that show that supporting children in their atypical career interests increases their self-esteem, improves their mental health, and betters their future financial success. But these are all flawed, because the researchers do not randomly assign the children studied to have typical or atypical career interests! Instead, we should focus on a forty-year-old study that found that boys who were allowed to obsessively play space-themed video games like Asteroid were likely to grow up to be nerds--not astronauts. Clearly, this study is much more relevant, and shows that we should not take a childhood interest in space seriously.

What is troubling is that many parents are in fact not just tolerating their children's probably transitory interests in atypical careers, but encouraging them. If the children claim an interest in space piloting, they are decorating their children's rooms with posters of the solar system, enrolling them in science enrichment courses, helping them with science-fair projects about comets--even sending children as young as 7 to Space Camp. Children who say they want to be pop stars are purchased instruments and enrolled in music lessons, given dance classes, permitted to adopt extravagant hairstyles, and applauded while participating in talent shows and even karaoke.

These actions may be irreversible.

What a school career counselor should do, given the social and psychological realities, is to tell parents to do nothing to encourage a child who expresses an interest in an insecure career, but take a wait-and-see approach. The parents should not enroll the child in science or music camp, or purchase them a telescope or keyboard. They should ask teachers not to encourage their children's stated interests in an insecure career. Children should not be allowed to wear t-shirts picturing the International Space Station or Skrillex. Career counselors should emphasize that most children will outgrow their youthful fantasies and become ordinary and respectable business and professional employees--accountants and assistant managers and customer service representatives.

Activists such as Neil DeGrasse Tyson and advocacy organizations such as the American Federation of Musicians do urge parents to support children's interests in astronomy and music.  They claim that children, even young ones, should be supported in any career interest they express, and that to refuse to do this is equivalent to the conversion therapy that was formerly practiced on computer nerds. Such a position is misguided. Career choices are malleable, and we must not take radical action based on cherished personal beliefs about valuing all careers equally.

We must be skeptical and demand more data, rather than damaging children by supporting their interests.

Testosterone Does Not "Work Better" than Estrogen

Hang around with trans people and you're bound to hear it. Testosterone, it's said, is more powerful than estrogen. It makes for a faster and more robust gender transition, while estrogen works a more subtle form of magic.

According to this reasoning, "trans men 'pass' better than trans women" because we win at hormones.

This is a load of hooey.

As trans people, we are fundamentally opposed to classic biological essentialism. According to classic binary sex essentialism, a person born with XX chromosomes is ever and eternally female, and a person born with XY chromosomes immutably male.  (Biological essentialists tend never to consider nonbinary genotypes like XXY or intersex people generally, because they're all about the ideology of the sex binary.)

Those who gender transition must reject chromosomal sex essentialism.  We live by the tenet that it is gender identity that determines who we really are, not our chromosomes.

But a fair number of binary trans people actually cling to a variety of sex essentialism--specifically, a biological essentialism that centers hormones, not chromosomes or genitals.  Hormone-replacement therapy is the most common medical transition service we access, and we are raised in a culture that treats biological sex as "more real" than gender identities or gender expression.  So many find comfort in framing both their bodies and their psyches as rewrought in nature by testosterone or by estrogen and testosterone-blockers.  Obviously, HRT has visible effects. Our body hair grows more robust or more fine.  Voices drop or breasts bud.  Our faces are gently transformed by the loss or addition of subcutaneous fat and the bulking or shrinking of facial musculature, rounding the cheek of the estrogen-employing, and chiseling the jaw of a person using testosterone. When you've been living with gender dysphoria, these physical changes are very welcome.

I've met my share of people who overgeneralize from the celebrated physical changes of hormone therapy into hormonal essentialism, attributing every change they experience to sex hormones. "Testosterone has made me less interested in talking, talking, talking." "Estrogen has made me a lot better at matching colors."  But sex hormones don't make us more or less verbal, or improve or deaden our color vision.  Those are social effects, and they are culture-bound.

That doesn't make them any less "real," mind you.  Just like hormones, socialization is a powerful thing.  Living as a woman in our society means receiving constant cues about appearance that unconsciously shape behavior, just as living as a man in our society means receiving social deference that makes a person act more boldly.  And these things affect us even if, consciously, we challenge them.  Estrogen doesn't make a person a better parent, nor testosterone make a parent a less-engaged one.  But caring behavior is so intensely socially reinforced in people living as mothers, while those of us living as fathers receive so many messages that we're not expected to know how to braid our kids' hair and should prioritize work obligations over family ones, that we are inevitably shaped by these socializing messages without our realizing it.  We can resist those pressures of which we are conscious, and socializing forces are experienced differently when one's gender identity conflicts with one's perceived sex, but nonconscious socialization is a real and powerful and ongoing process. From the moment we begin a social transition, our behaviors and inclinations are impacted strongly by socialization, which changes our perceptions and our behavior.  (This is one of the things that transphobic radfem "gender crits" get all wrong.  They treat socialization as something that happens when you are young, and then stops, rather than something that is happening to all of us, every day of our lives.)

But taking a shot or a pill seems much more real and concrete to people in our society than does being (re)shaped by social cues.  And one way this manifests that I believe is particularly damaging is in the belief held by many people that "testosterone works better than estrogen."

Here's the thing about gender transitions: it's indeed true that most trans men transition more smoothly and swiftly than most trans women.  But this isn't because testosterone "works better" than estrogen.  It's because of how gender policing works in our society.  Our culture values masculinity and the male while it devalues femininity and the female.

Let's examine how this works through the lens of facial hair.  I've often heard people use as "proof" of the greater efficacy of testosterone the fact that taking T makes a person grow facial hair, while taking E doesn't make a beard go away.  But it would make just as much sense to say that estrogen is more potent an agent of transition, because it makes a person grow breasts, while taking T doesn't make breasts go away.

Let's consider facial hair and transition in greater depth.  Often before even starting hormone treatment, transfeminine individuals seek facial hair removal via electrolysis and/or laser treatments. And many experience ongoing anxiety because some hair may be left behind by these procedures, leaving a trans woman constantly worried that she may have some stubble, as the social consequences of being seen as a trans woman with a beard shadow are high. Those who transition using testosterone, on the other hand, have a much less anxiety-ridden experience in the facial hair arena. Sure, most trans men wait anxiously for their peach fuzz to materialize, and for some, peach fuzz is all they'll ever grow.  But every whisker is celebrated--and not just by us, but by society.

Think about it.  For a trans woman, a few whiskers are seen by a cissexist society as belying her gender identity, and the stubbly trans woman is a figure of mockery. Meanwhile, for a trans man, a few whiskers are all it takes to get a pass from the gender police.  If there were actual parity in treatment, the gender police would be imposing some sort of 50% standard on either side of their gender binary.  But instead, a trans woman must remove 100% of her facial hair to avoid harassment, while a trans man only needs to be able to grow 10% of a full beard to be treated as one of the brotherhood.

It's not testosterone that is working so well to benefit trans men.  It's patriarchy.

Our society trains people, especially cis males, in patriarchal binary-gender-policing from an early age.  Here's how we can imagine the "logic" of this system as operating: (1) immediately upon seeing a person, classify them as male or female.  (2)  If you can't immediately do that, this is a PROBLEM and must be addressed.  (3) When your initial glance leaves you in doubt, always treat the person as male.  Calling a man "she" is a terrible insult--and is dangerous, since a man whose masculinity has been insulted may feel compelled to prove his masculinity by doing violence to your person.  Calling a woman "he" is actually a sort of compliment, since it confers status.  And if a woman is insulted or has her feelings hurt, it's not likely that she's going to punch you in the face as a result, because that would make her look even less feminine.  Anyway, she should work harder to appear feminine and attractive to men.  (4) Now that the immediate snap judgment about whether to say "sir" or "miss" has been made (when in doubt, say "sir"), study the person to figure out what's wrong with them.  Not being instantaneously classifiable into an M or F box is an affront, but maybe it was the last thing the person wanted (it's some really short cishet guy who is sensitive about his height).  Maybe it was "negligence" (a straight cis woman who isn't doing her duty to be attractive).  Or maybe it was intentional (the individual is an "effeminate" gay man, a butch lesbian, a genderqueer "he/she" weirdo, a transsexual).  Intentionally breaking the binary rule of the gender police means that the offender should be punished with disdain, mockery, harassment, or even assault/sexual assault.  And the harshest punishment is to be directed at those who could have had male honor, but are traitors to the brotherhood--the "swishy faggots" and "trannies" and "shemales"--dishonorable freaks all.

So those are the rules of gender-policing engagement.  Now, combine them with what we discussed earlier--the high standards for inspecting the suspected transfeminine body combined with the low standards of inspecting the suspected transmasculine one. Interactively, they produce a situation in which gender policing affects those assigned male at birth much more strongly than those assigned female at birth. Of course, this is counterbalanced by the fact that people perceived as female or feminine (whatever their gender identity or physical status, really) win as a prize the joy of being catcalled and sexually harassed. But think about it.  This means that for a trans man, once you've crossed that scraggly chinpatch threshhold, chances are good you get to avoid both catcalling and gender-policing harassment. The path to male privilege is pretty short. For trans women, the path to freedom from constant misgendering is much longer, much more fraught with danger, and doesn't end with the prize of relative freedom.

I know that nobody is safe from male street violence, even those deferred to as masculine men, but there's a huge difference in the regularity of the onslaught.  And believe me, I understand that the safety experienced by trans men is conditional, and that if we are discovered to have breasts and/or a vagina, the best outcome is usually disgust, and the worst assault or reparative rape.  But most of the time, these body parts are not seen.  Transmasculine individuals just need to show up sporting that minimal evidence of beard stubble (or its inverse, the receding hairline), wearing moderately standard guy clothes, with chest bound or bundled under a sweatshirt, and the gender policing inspection stops. Not for us the unavoidable requirement that every body part be inspected for "questionable" hand size and foot size, adams apple or hairline.

So, please, let's stop spreading the lie that testosterone works better than estrogen, and that this explains trans mens' advantage over trans women.  Patriarchy and the male privilege it produces explain the transmasculine advantage.  And as long as we naturalize this transmasculine advantage, we do our transfeminine siblings a disservice. What we should be doing is fighting gender policing, not treating it as a fact of nature--and doing that fighting from a position that acknowledges it affects trans men less severely.

Trans Gender Body Mods: Who is "Obsessed"?

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.