Oppositional Sexism and Sex Reassignment
As I mentioned in previous chapters, trans people (who have a subconscious sex that is not in concordance with their physical sex) often suffer from gender dissonance, which is best thought of as the psychological strain of having to constantly pretend to be a member of a gender with which they do not identify. Over the years, sexologists have tried everything imaginable to “cure” trans people of gender dissonance, including psychoanalysis, aversion and electroshock therapies, administering assigned-sex-consistent hormones (i.e., androgens for male-bodied trans people, estrogens for female-bodied trans people) and psychotropic drugs—all to no avail. The only thing that has ever been shown to successfully alleviate gender dissonance is allowing the trans person to live in their identified gender.3 There is an extraordinary amount of historical and anthropological evidence to further support this strategy, as trans people across cultures and throughout history have chosen to live as members of the other sex, often taking on the roles, manner of dress, and/or occupations associated with their identified genders and, in some cases, physically and hormonally altering their bodies via castration.4
In the last century, advances in medicine have offered trans people the opportunity to physically transition (via hormones and surgery) in addition to socially transitioning. One of the most prominent advocates for allowing this option was endocrinologist Harry Benjamin (for whom HBIGDA was later named).
Benjamin’s first encounter with trans people took place in the early 1920s, when an MTF spectrum individual sought his help in obtaining female hormones in order to induce female development—a request which Benjamin eventually fulfilled and which led to “emotional improvement” on the part of the trans person.5 Over the years, Benjamin met with countless trans people, often through referrals from other sexologists, and was apparently struck by their desperation, the failure of conventional therapies (such as psychotherapy) to relieve their pain, the medical and psychiatric community’s general unwillingness to take their requests to physically transition seriously, and the fact that many turned to suicide or self-castration when their only option was to remain in their assigned sex.
Since sex reassignment surgery was not generally available in the United States at the time, Benjamin focused on the use of hormone replacement therapy, which he found went a long way toward easing gender dissonance in trans people. While he believed that sex reassignment surgery should be made available in the “more serious and intense cases,” he also advocated the use of hormones to relieve gender dissonance in those trans people who were not able to or did not want to fully transition to the other sex.6 In his 1966 book, The Transsexual Phenomenon, Benjamin outlined a seven-point, Kinsey-esque scale to describe people on the MTF spectrum, ranging from what he called “pseudo transvestites” to “true transsexuals.” Though it was flawed in some respects, his scale did acknowledge that there was a large variation among trans people in terms of their wanting to temporarily, partially, or completely transition to the other sex, and whether that transition would be of a social, hormonal, and/or surgical nature.7
But as transsexuality gained more attention—almost all of it negative—from the mainstream media and the psychiatric and medical establishments, there was increasing pressure to placate the public’s prejudices and fears about sex reassignment.8 In response, many of those who were positioning themselves as gatekeepers argued in favor of an approach that was quite different from the one Benjamin initially advocated, one that would regulate and limit the availability of hormones and sex reassignment procedures only to those trans people who would be able to successfully blend into society as “normal” women and men. According to this strategy, the gatekeepers’ job was to sort out the “true” transsexuals (who would be allowed to fully transition) from all other trans people (who would be denied any medical intervention other than psychotherapy). This highly dichotomous approach to treating trans people reflected the fact that most other sexologists who became involved in transsexuality—such as John Money, who pioneered the use of nonconsensual genital surgeries on intersex infants, and Richard Green, who is renowned for his use of behavioral modification to eliminate femininity in young boys—seemed to be primarily interested in “curing” (i.e., eliminating) sex-, gender-, and sexuality-related ambiguities.
By the late 1960s—with the establishment of several U.S. gender identity clinics and the publication of Green and Money’s medical anthology Transsexualism and Sex Reassignment—a standard protocol for dealing with people who requested sex reassignment had started to emerge.9 These guidelines for treatment were later codified with the release of the original HBIGDA Standards of Care in 1979, and while they have evolved somewhat over time—especially since the mid-1990s, when HBIGDA finally began to incorporate changes suggested by the transgender community—they follow the same basic outline today.10 While this chapter is largely written in past tense (to maintain grammatical consistency), it should be said that most gatekeepers today still follow this same basic protocol, and many still evaluate their trans clients based on the oppositional and traditional sexist criteria that I discuss throughout this chapter. The first step in this process was a period of psychotherapy (lasting at least three months, often more), during which time a mental health professional would evaluate the client. If the trans person received a recommendation from that therapist (which today comes in the form of a diagnosis of gender identity disorder, or GID), they would then be allowed to begin their “real-life test”—a one- or two-year period during which they were required to live full-time in their identified sex. If the real-life test was deemed successful by both the transsexual and the therapist, the trans person would be eligible for hormone replacement therapy (in those cases where hormones were not prescribed before or concurrent with the real-life test) and sex reassignment surgery (which usually required a recommendation from a second mental health professional).
While the gatekeepers consistently argued that these methods were designed to protect the transsexual, the way they were executed (especially prior to the mid-1990s) reveals an underlying agenda. Whether unconscious or deliberate, the gatekeepers clearly sought to (1) minimize the number of transsexuals who transitioned, (2) ensure that most people who did transition would not be “gender-ambiguous” in any way, and (3) make certain that those transsexuals who fully transitioned would remain silent about their trans status. These goals were clearly disadvantageous to transsexuals, as they limited trans people’s ability to obtain relief from gender dissonance and served to isolate trans people from one another, thus rendering them invisible. Rather, these goals were primarily designed to protect the cissexual public from their own gender anxiety by ensuring that most cissexuals would never come face-to-face with someone they knew to be transsexual.
The gatekeepers’ attempts to suppress the number of trans people allowed to transition occurred at virtually every step of the sex reassignment process. For example, the gender identity clinics that were established to treat (and carry out research on) trans people often accepted only a small percentage of those who applied to their programs (for example, the program at Johns Hopkins University only approved twenty-four of the first two thousand requests they received for sex reassignment surgery).11 And simply being accepted into one of these programs was not a guarantee that one would be allowed to transition. First, the trans person had to undergo extensive, sometimes indefinite, periods of psychotherapy designed to evaluate whether or not they met the psychiatrist’s criteria for “true” transsexuals, rather than the arguably more important task of preparing the trans person for the emotional and physical changes associated with transitioning. Those who received recommendations were required to continue in therapy through the entire transitioning process (i.e., until after surgery). This requirement of several years of psychotherapy—in addition to the expenses of hormones, surgery, and other procedures that were generally not covered by health insurance—created a huge financial burden that severely limited the number of people who would have the economic means to transition in the first place.
Those who were allowed to begin the real-life test often faced additional obstacles, as some gender identity clinics (and early versions of The HBIGDA Standards of Care) required trans people to begin their tests prior to starting hormone replacement therapy.12 Since an extraordinarily small percentage of trans people are physically able to “pass” as their identified sex without the aid of hormones, this unnecessarily exposed the transsexual to all sorts of discrimination, harassment, and potential violence. This postponing of hormones essentially perverted the real-life test, turning it into little more than a hazing period designed to weed out transsexuals who were the least “passable” in their identified sex.
The gatekeepers also kept the number of transitioned transsexuals low by requiring them to conform to oppositional sexist ideals regarding gender. This was primarily achieved by making “passing” a prerequisite for transitioning.13 Such criteria ensured that cissexual prejudices about the preferred sizes and shapes of female and male bodies would be the ultimate arbiters of whether a trans person would be allowed to transition or not. Not only did the trans person have to physically “pass” as their identified sex, they needed to exhibit the “appropriate” sexual orientation (heterosexual) and gender expression (masculinity for trans men; femininity for trans women) for that sex as well. Many critics have pointed to these restrictions—particularly the fact that trans people who professed an attraction to members of their identified sex were regularly denied recommendations for transitioning—as evidence of “heterosexism” or “homophobia” among the gatekeepers. Unfortunately, such accusations are overly simplistic and somewhat misplaced. If anything, the gatekeepers were first and foremost cissexist rather than heterosexist. After all, the requirement that trans people had to be heterosexual in their identified sex was enforced long after “homosexuality” had been removed from the DSM.14 Furthermore, the gatekeepers were not only restricting exceptional sexual orientation in transsexuals, but exceptional gender expression as well. So while the gatekeepers generally acknowledged that cissexuals varied significantly in their sexual orientations and gender expressions, they chose to hold transsexuals to a completely different (and more rigid) set of standards.
By focusing so intensely on the transsexual’s ability to “pass” and conform to oppositional sexist notions of gender, the gatekeepers reduced the issue of relieving trans people’s gender dissonance to a secondary, if not marginal, concern. For example, prominent and frequently cited research articles that attempted to assess the efficacy of sex reassignment often relied on factors designed to measure the transsexual’s ability to “pass,” without considering whether or not transitioning improved the emotional well-being of the trans person.15 The tendency to dismiss the profound pain associated with gender dissonance can also be found in the countless condescending remarks that appear in research articles referring to transsexuals as being “impatient” and characterizing their desire for sex reassignment as “obsessive/compulsive.”16 This insensitivity toward trans people’s pain indicates that the gatekeepers were far more concerned with protecting the cissexual world from the existence of transsexuality than they were with treating trans people’s gender dissonance. Perhaps nothing demonstrates this better than the gatekeepers’ willingness to deny trans people treatment (despite knowing how common it was for this group to become depressed and suicidal when unable to transition) solely based on the superficial criteria of trans people’s appearances.
Because relief from gender dissonance depended on one’s ability to live up to these rigid and oppositional sexist expectations, trans people quickly learned (both by reading the research articles and through conversations with other transsexuals) exactly what they needed to say and how they needed to act in order to procure a recommendation for hormones and sex reassignment. For example, most trans women understood that they needed to show up for their psychotherapy appointments wearing dresses and makeup, expressing stereotypically feminine mannerisms, insisting that they had always felt like women trapped inside men’s bodies, that they’d identified as female since they were small children, that they were attracted to men but currently avoided intimate relations because they did not see themselves as homosexual, and that they were repulsed by their own penises. Those who did not follow this script risked having their requests for sex reassignment denied. Of course, the gatekeepers eventually realized that many, if not most, trans people were merely telling them what they wanted to hear, and their resentment around this can be found in the articles they published, which often contain descriptions of transsexuals as being “deceptive” and “liars.”17 Apparently, they found it more productive to vent about their experiences in the medical literature rather than question the legitimacy of their “true transsexual” archetype or acknowledge the role that their own oppositional sexist assumptions played in forcing trans people to lie in order to obtain relief from gender dissonance.
It is particularly hypocritical that gatekeepers accused trans people of being “liars,” as their own protocols typically directed transsexuals to lie about their pasts after transitioning. In what seems to be complete contradiction of the most basic tenets of psychotherapy, trans people were required to invent gender-consistent (i.e., cissexual) histories for themselves, so that if they were ever questioned about their pasts, they would not have to reveal their trans status.18 While this requirement was purportedly put into place to protect the transsexual from the cissexual public, it is clear that what concerned the gatekeepers the most was protecting the cissexual public from the transsexual. Proof of this exists in documents of trans people who were open about being transsexual, or who attempted to financially capitalize on that status (for example, by becoming entertainers or revealing their stories to the public), being described as “sociopathic” in the medical literature.19 Canonical writings on transsexuality also argued that, for transsexuals embarking on their transitions, a “change in geographic location is almost mandatory,” and that “continued association with an employer ... should be terminated so as to avoid any embarrassment to the employer.” (Emphasis mine.)20 Regarding family, gatekeepers suggested, “Young children are better told that their parents are divorcing and that Daddy will be living far away and probably unable to see them.”21 At every turn, the gatekeepers prioritized their concern for the feelings of cissexuals who were related to, or acquainted with, the transsexual over those of the trans person.
The gatekeepers’ requirement that transsexuals so completely hide their trans status created innumerable obstacles for trans people: the shame and self-loathing that is associated with living in the closet; having to cut off relationships with family and friends, thus eliminating any possible social support system they may have had previously; having to look for a new job, in a new location, without being able to reference their past employment history and while continuing to pay the therapy and medical bills necessary to complete their transition—all of this on top of having to navigate their way through the world in their identified gender for the first time. Because of the combination of all of these stresses, it was not uncommon for transsexuals to become highly depressed or suicidal post-transition. Often, gatekeepers would assume that such problems stemmed from the transsexual’s own gender issues rather than from the closeted and isolated lives they were forced to lead. For example, one transsexual who became depressed, primarily because of her fears that others would discover her trans status and that she would be rejected if she were found out, was described by the gatekeepers as “still struggling with the problem of gender identification.”22
What became lost in gatekeeper discourse regarding transsexuality (especially with regard to incidents of post-transition depression and “transsexual regret”) was any distinction between the trans person’s gender dissonance (an intrinsic matter) and the emotional stress the transsexual experienced as a result of having to deal with the gender anxiety of the cissexual public (which was an extrinsic matter). Indeed, the blurring of these separate issues was codified with the invention of the psychological term gender dysphoria, which made invisible cissexual gender anxiety by conflating it with the trans person’s intrinsic gender dissonance.23 The regular use of the phrase by gatekeepers illustrates their assumption that it was the transsexuals’ responsibility to shape their lives around the cissexual public’s prejudice against them. And while most gatekeepers surely saw themselves as “treating” trans people, their own insistence that trans people “pass” as cissexual and hide their trans status after transitioning only enabled societal cissexism.