Moving Beyond Cissexist Models of Transsexuality
The last fifty years of sexological and sociological discourses regarding transsexuality have been nothing more than a charade, where the opinions of those who have academic and clinical credentials always trump those of transsexuals themselves; where trans people are treated as nothing more than blank slates for cissexual gender researchers to inscribe their pet theories upon. And while researchers in the humanities often frame their work as being in opposition to that of the gatekeepers, it seems to me that the similarities between both groups far outweigh the differences. Both clinicians and academics are obsessed with meticulously documenting and subcategorizing the transgender population; both display the effemimanic compulsion of focusing primarily on MTF spectrum trans people; and both view transsexuals as anomalies that require explanation and justification rather than viewing us as a part of human diversity that just simply exists.
The needs, desires, and perspectives of transsexuals have become lost in a shameful tug-of-war between those who wish to show that stereotypical gender differences arise naturally from biological predisposition and those who wish to demonstrate that those same gender differences are entirely socially constructed. As a transsexual, my lived experiences are at odds with both strict gender essentialist and social constructionist accounts of gender. And while the idea that gender is a combination of many things—some biological and others sociological—does not make for a catchy sound bite or a sexy “hook” for one’s book or thesis, it appears to me to be indisputable. And maybe once most sexologists and sociologists finally come to accept this fact, they will stop exploiting and dissecting the lives of transgender people and others who have exceptional gender inclinations and sex characteristics.
If there is anything to be learned from sexological and sociological accounts of transsexuality, it is that cissexism—i.e., the tendency to hold transsexual genders to a different standard than cissexual ones—runs rampant not only among the general public, but also throughout the medical and psychiatric establishments and in the ivory towers of academia. If sociologists truly wanted to better understand transsexuality, rather than focus exclusively on the behaviors and etiology of transsexuals, they would study the irrational animosity, fear, and disrespect that many cissexuals express toward trans people (and others with exceptional gender and sexual traits). If sexologists were truly interested in transsexuals’ mental and physical well-being, they would not try to micromanage our transitions, but rather focus their energies on correcting the huge disparity that exists between cissexual and transsexual access to gender-related healthcare. It is the gatekeepers’ failure to adequately advocate on behalf of their trans patients that has allowed U.S. insurance companies (which regularly cover cissexual hormone replacement therapy, genital and breast reconstruction, and procedures to enhance or enable cissexual fertility and sexuality) to get away with denying coverage for similar treatments for transsexuals. And the popular stereotype that transsexuals are “crazy”—that our identified genders are merely the product of overactive imaginations and are not to be taken seriously—is also the result of the same medically and psychiatrically sanctioned double standard: while cissexuals are free to choose from hundreds of different types of surgical body modifications without being pathologized or requiring anyone else’s permission, procedures required for transsexuals to lead full and healthy lives are singled out for gatekeeper approval and an accompanying diagnosis of gender identity disorder.
Despite the recent civil rights progress that has accompanied the rise of transgender activism in the 1990s, the gatekeeper model of transsexuality still dominates in the United States. While HBIGDA has slightly liberalized its Standards of Care in recent years, it still requires transsexuals to gain psychiatric approval in order to gain access to hormones, obtain surgery, and change their legal sex. This system is inherently cissexist, as it requires trans people to accommodate and appease the gender presumptions of individual therapists (who potentially harbor traditional sexist, oppositional sexist, and/or cissexist biases) in order to have our identified genders recognized. It’s time we replace the existing gatekeeper model with one that’s centered on the needs of trans people themselves. This begins with the public acknowledgment that all people have the right to self-identify (even if that identity falls outside of the male/ female binary), and that one’s self-identified gender is necessarily more legitimate than the one that is rather naively assigned to them by others. Further, the process of socially and legally changing one’s sex should be entirely uncoupled from medicine and psychiatry: No specific medical procedure should be required for one to have one’s identified sex recognized, nor should any medical or psychiatric professional have the authority to prevent someone from living in their identified sex. Those trans people who feel that they need to hormonally or physically transition in order to ease their gender dissonance should be allowed that option if they wish (in the same way that cissexuals ultimately choose for themselves whether or not to undergo hormone replacement therapy, genital or breast reconstruction, fertility and sexuality-related procedures, etc.).
The idea that trans people should decide for themselves whether or not to physically transition—what some have disdainfully referred to as “sex change on demand”—has been opposed by the gatekeeper establishment from the beginning. The most common argument is that the system as it stands acts as a safeguard to prevent people who are not transsexual (e.g., cissexuals who are merely embarrassed or confused about their atypical sexuality or who exhibit “delusional” or “antisocial” behavior) from undergoing potentially irreversible medical procedures.80 Once again, such practices reveal the cissexist biases of the gatekeepers: Trans people are denied immediate treatment of their gender dissonance in order to protect the well-being of a rather small minority of cissexuals. One can only imagine how furious and frustrated most cissexuals would feel if they had to undergo psychotherapy for three to six months (so that a psychiatrist could rule out the possibility that they were transsexual) before obtaining permission to undergo hormone replacement therapy or gender-related surgeries they required.
The gatekeepers’ fear of “sex change on demand” rings particularly hollow in a world where most trans people cannot even afford to take the medically and psychiatrically sanctioned route to transition. Psychotherapy is prohibitively expensive for those who do not have adequate insurance; many trans people rely on underground markets and overseas pharmacies to obtain affordable hormones without a prescription. Many undergo sex reassignment surgeries in countries like Thailand, where it is much less expensive and where there are fewer restrictions than in the United States. Clearly, gatekeeper micromanagement of transitioning has only served to force a significant percentage of trans people (who either cannot afford to follow the HBIGDA standards of care or fail to convince their therapists that they are “true” transsexuals) out of the system.
Those gatekeepers who believe that they alone should have the authority to determine who should and should not be allowed to transition ignore the obvious fact that gender dissonance has always been a “self-diagnosed” condition: There are no visible signs or tests for it; only the trans person can feel and describe it. Once we make the arduous decision to transition—letting go of other people’s perceptions of us in favor of being true to ourselves—there is really nothing anyone can do to stop us. For these reasons, medical and mental health professionals should turn their attention away from regulating sex reassignment and toward facilitating the safe access to the means of transitioning. Thankfully, some have already begun working toward this goal, designing programs that provide trans people with affordable access to information, hormones, and the appropriate medical tests to ensure a safe transition.81 Others in the field of psychiatry have similarly advocated that mental health professionals move away from the gatekeeper model and toward one focused on helping the transsexual manage the emotional stress and obstacles they are faced with when transitioning.82
While all of these changes represent a promising start, true equality for transsexuals and transgender people will remain elusive as long as gender variance remains pathologized by the American Psychiatric Association, which publishes the DSM. Human beings show a large range of gender and sexual diversity, so there is no legitimate reason for any form of cross-gender behavior or identity to be categorized as a mental disorder.
That said, I also take issue with those who argue for completely demedicalizing transsexuality, or who advocate removing GID from the DSM without first ensuring that there are provisions in place to allow people who choose to transition affordable access to transsexual-related medical procedures. Some have suggested creating a medical diagnosis for transsexuality to replace the current psychiatric diagnosis of GID; this makes sense, being that most transsexuals feel that our problem lies not with our minds, but with our bodies. 83 Once these medical provisions are in place, the importance of psychiatrically depathologizing transgenderism cannot be underestimated. After all, it is the popular misconception that gender variance constitutes a mental illness—that transsexual and transgender people are the ones who have the problem—that enables cissexual and cisgender prejudice against us.