Category Archives: Trans studies

There Is Nothing Universal to Say About Trans Women and Male Privilege

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There has been a lot of ink spilled lately about trans women and male privilege. I have seen so many discussions recently where people ask the question “Do trans women as a whole have male privilege and if so what kind and how much?” And then you see some trans women writing articles responding to this drivel by arguing “That doesn’t match my experience” and then go on to detail how their lives were not filled with privilege and how in fact they were brutalized for being feminine as children and did not internalize society’s messages about male socialization the same way cis boys did.

And on the other hand, some trans women are writing articles saying “I did have male privilege but I gave it up or am in the process of giving it up oh and btw I’m still a woman” or something along those lines. I’ve seen some of these articles also make the general claim that some types of male privilege were afforded to ALL trans women in virtue of living a life pre-transition as someone who was coded as male. But then other trans women deny this reflects their own experience growing up and we are going in a circle, with universal claims being negated by individuals claims and individual claims being taken as proof of some universal claim.

This is tiresome.

We have a general claim about ALL trans women being refuted by individual claims about SOME trans women. But the trans women who did not experiences themselves as having male privilege often make the same mistake of thinking their experience is universal. That’s what so wrong with this whole discussion. There are no universals. There are no generalizations to be made in terms of ALL trans women – every trans woman has a difference experience of living pre-transition as well as experiences their loss of privilege via transition differently.

And furthermore, people like to frame the discussion in terms of the pointless question of whether trans women’s experiences are identical to cis women’s experiences. But who cares? It doesn’t matter. Our experiences don’t need to perfectly match the cis experience to be representative of womanhood because to think otherwise is to buy into the cis-sexist belief that the cis experience is the “default” and the trans experience is a pale imitation. But in reality the trans experience is equally valid, it’s just more rare.

Personally, my own experience pre-transition featured a good deal of male privilege which I’ve wrote about elsewhere . I’ve retained some vestiges of that male privilege such as the privilege having grown up not thinking of myself as an emotional creature but rather a rational creature. I still have the privilege of not worrying about getting pregnant. But much of the other privileges I gave up during transition or am in the process of giving up. I now fear walking down the street at night whereas before I never did. I now fear cat-calling – before it was not even on my mind. I’ve lost the privilege of not worrying about my drink being drugged at a bar. I’ve lost the privilege of not fearing men. The list goes on.

The point is that privilege is rarely so monolithic or one-dimensional. My privilege as a white person and the vestigial remains of my male privilege is balanced against my loss of privilege as a woman and especially as a trans woman.

But my experience says nothing about the experiences of other trans women, who experienced their gender much differently than I did as a child and as I do now. I was never really made fun of for being feminine – my feminine behaviors were done in secret behind closed doors and so they weren’t a target for harassment. I was able to regiment my personality into a public boyish self and a private feminine self. It’s a myth that gender identity is formed for life within the first 5 years of life. While that might be true for many people it is not a universal truth. My gender identity has evolved significantly since I was 5 years old and I know I am not alone though I have the feeling that many trans people have a bias towards interpreting their memories as having an earlier identity  because that narrative is seen as “more valid” than the ones where gender identity evolution occurs later in life.

Not all young trans girls are able to hide their natural femininity and they are brutalized for it. If someone went through that experience and they are telling you they did not have male privilege then I believe it’s epistemically best practice to head what they are saying and take their narrative seriously. Likewise if a trans woman says she used to have male privilege but has since given most of it up, we need to listen to that narrative as well.

Cishet people seem to be more convinced that if a trait is displayed earlier in life it is “more natural” and thus a product of someone’s core essence. But that’s the wrong question to be asking. Innate or not, natural or not, what we should care about is if a behavior, trait, or personality is authentic and representative of someone’s deepest vision for how they want their life to go, regardless of the “origins” of that vision. If someone’s trans identity originated in their 40’s that does not make their trans identity less authentic than someone who’s trans identity originated in childhood. If someone starts painting in their 40s does that make them “less” of a painter than someone who has been painting since infancy? A painter is someone who paints. A trans person is someone with a gender identity different from their assigned gender. It’s not “gender identity different from assigned gender but also having emerged by five years old”. It just has to be different. But the causal origins of the identity itself in terms of when it originated in the life-line are not relevant for determining the authenticity of of the identity.

My trans identity only surfaced in my late 20s. It would be SO easy and no one could prove me wrong if I began saying things like: “I felt off during puberty but I only learned the words to articulate my feelings years later”. In a sense that would be perfectly true. I did have gender issues at a young age. But I think I would be deluding myself if I claimed I had any awareness of ever wanting to transition at that age. Just like gender identity doesn’t have to be cemented in childhood, neither does dysphoria have to originate in childhood. Dysphoria can surface at any point in a trans person’s life. I didn’t start feeling real dysphoria until my late 20s. The longer we hold onto the traditional narrative that all trans people somehow “knew” then they were children, the longer we will be unable to see the true diversity of the trans community.

The problem comes when we try to generate a one-size-fits-all theoretical framework for thinking about ALL trans women as sharing some kind of universal essence. But that’s a pipedream. There is no universal narrative. The human mind strives to “connect the dots” and create some kind of overarching generalization that is true of all trans women. But we need to resist that and instead focus on studying individual differences.

 

 

 

 

 

 

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Filed under feminism, Gender studies, Trans studies

Let Trans Women Grow

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Left: Me when I first started transition | Right: Me roughly two years later

Trans women are under intense pressure, internal and external, to perform femininity to a high level. They are seen as more “valid” in their identities the better they pass for cis women and in order to compensate for testosterone poisoning some trans women are pressured to wear makeup, accessories, and feminine styles of clothes to be gendered properly by strangers as well as fight their dysphoria. The common assumption is that trans women who are uber feminine are just narrow-minded 1950’s housewife artificialities who are putting on a costume to validate their own womanhood. Our femininity is never seen as natural – always artificial.

But in reality it’s often about pure survival, a defense mechanism. If we don’t perform femininity at a high level we get accused of being too manly and our womanhood is challenged and we are at more risk of misgendering, harassment, violence, and being discriminated against in general. But if we are feminine we get shit for just being caricatures of womanhood who think being a woman is all about dresses and heels. It’s a double bind: damned if you do, damned if you don’t – trans women lose either way.

But I don’t think the problem here is about femininity. The problem is that people don’t like the idea of a male-assigned person transitioning socially and medically. It’s the very idea of trans women that gives people a problem regardless of how well we perform femininity. The double-bind is thus a product of transmisognyny and not fundamental to femininity itself. The problem is that cis identities are seen as fundamentally more healthy and normal than trans identities. And I mean “normal” as in “normative” not “statistical”. Trans people are obviously in the statistical minority – but that alone doesn’t make our bodies or our identities pathological. Anomalous but not necessarily pathological. Trans women often get a lesser metaphysical status in the realm of valid identities but there’s nothing about our transness that is itself intrinsically pathological.

As philosophers like to say, you can’t derive an “ought” from an “is”. It is the case that trans people are rare, but from that it doesn’t entail that we ought to eradicate trans identities. Imagine if we found a “trans gene” that caused transness and scientists had the power to edit that out before or after conception. We has a society would then have a choice whether to eradicate transness out of existence or not. My view is that the world would be much worse off if trans people weren’t around to shake up the cis-normative world.

Part of the pressure for trans women to perform femininity comes from a desire to relieve dysphoria. If I lived on a deserted island that had a Sephora I would still wear makeup because I just enjoy it and it makes me feel better about myself. But part of the pressure comes from how trans women are judged as less valid if we are not uber feminine.

But here’s the thing: trans women are often not even given a chance to grow into our femininity. As soon as we come out as trans we are expected to perform femininity flawlessly. We are expected to know how to do makeup, how to be stylish, have an extensive wardrobe of gender-affirming clothing, look sharp, natural, etc. But cis women have had decades to learn how to perform femininity, experiment with makeup, style, and figure out what looks good for their body shape. Not to mention, not all trans women can afford laser or electrolysis and the makeup techniques to flawlessly cover beard shadow are pretty advanced even for experienced makeup junkies.

Some trans women have been performing femininity from a very young age but that’s not true of all trans women. Some trans women such as myself repressed their feelings deeply and went through very “macho” stages to prove their masculinity to the world before their feelings finally surfaced fully and it was no longer possible to perform masculinity without great pain. But the little crossdressing I did in secret since childhood did not even slightly prepare me the pressure to perform femininity as a transitioned woman. The pressure is felt by all women but trans women feel it especially acutely. So I basically had to learn in a couple years what it took decades for cis women to figure out. Some trans women are just not interested in all that though and they should not be judged for it, no more than cis women should be judged for being butch or tomboys. The “tomboy” trans woman is often judged as less valid than feminine trans women. Many cis women say they are not scared of highly feminine cis passing trans women who have medically transitioned – it’s all those other, “bad ones” they are scared of in women-only spaces, the one who don’t perform femininity to some arbitrarily set cis-normative standard.

We need to let trans women grow into themselves. We are expected to perform femininity flawlessly within months of transition but often it can take years to come into a natural sense of style just like it takes years for cis people to figure out how to perform their genders. We need to let trans women have the space and time to explore themselves before we judge them as “successful”. Or better yet, how about we stop judging people who don’t conform to any gendered expectation and stop placing judgments on whether a transition is a “success” or not. If the trans person is happy at the end of the process it was a success, period. TERFs like to talk about how many trans women are just “pigs in wigs” but usually they are just selectively sampling from trans women just starting transition. Give them a few more years and get back to me. Let trans women grow. Give us time to figure this shit out without invalidating our identities because we have the audacity to look or sound like ourselves and not just flawless imitations of cis women.

Trans people are valid regardless of whether people have a hard time telling whether we are cis. That shouldn’t be the standard. There are no standards. Find me a rule book in the universe that tells me how men and women “ought to look”. There is no such book. There are just atoms in the void – but we place value on some arrangements of atoms and not on others. All value is created from the minds of creatures such as ourselves. Cis people often don’t place much value on trans lives. Our lives are seen as diseased. Just today someone commented on my youtube telling that I am “sick” and “need help”. Yeah – that’s a fun notification to get on my phone. That’s just part of what it’s like to be trans in 2017. And I have it easy! I am very, very privileged as a trans woman, both in terms of passing and my material status, but I still get constant reminders that my existence is seen by many in this country as an existential threat to the moral fabric of society. Here I am just trying to survive and somehow am the threat to society? Yeah, right.

Let trans women grow. Not all trans women have had a strong sense of identity since childhood. That’s the narrative that plays well with cis audiences and trans women are under immense pressure to reshape their histories to conform to that narrative but it’s not representative of the diversity in the community. Some of us need time to unlearn old patterns of behavior and learn new patterns of behavior. Some of us need time to figure out simple things that cis women take for granted like putting your hair up in a bun. Many of us were not taught by female members of our family how to perform femininity. If anything, we were usually punished for displaying the slightest amount of femininity. So how can cis people turn around and expect trans women to be perfect exemplars of femininity when they at the same time stamp out femininity in their own male-assigned children? It’s the double-bind of trans femininity.

When you start to look, the double-bind is everywhere. We cannot escape it. But we must. The liberation of trans women cannot happen unless the double-bind is loosened and we are allowed to grow.

 

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Filed under feminism, Gender studies, Trans studies

Autogynephilia, the Gift that Keeps on Giving

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content warning: this article contains transphobic ideas and terminology

 

Autogynephilia is the gift that keeps on giving and by “gift” I mean “punch in the face”. Autogynephilia is the theory from hell, a literal weapon of the anti-trans brigade to delegitimize trans women and prevent them from transitioning, restrict their access to healthcare, and eradicate their existence from public life. In a nutshell, the “theory” of autogynephilia, or AGP, says that there are two essentially distinct kinds of trans women: those exclusively attracted to men and everyone else. The ones attracted to men are seen as “legit” by the AGP crowd because they are essentially just oppressed femme gay men who are struggling to survive and find men as dating partners.

But what about the trans women who are either bi/pan or exclusively into women? Those people, according to AGP, are just perverted “adult male late transitioners” living out some fetish they have where they get off to the idea of themselves being women. They’re freaks. Deviants. Confused, twisted heterosexual men who transitioned merely to get their rocks off and abdicate familial responsibility. Furthermore, according to the larger ideology of the AGP crowd, letting “autogynephiles” transition was a big mistake and has invariably started the new movement of “genderism” which says that you don’t have to pass as a cisnormative woman in order to be valid as a woman. Genderism has now led to The Modern Era of trans rights, the “tipping point” so to speak.

Really? That’s all I got to say about AGP. As someone who knows many bi/pan/gay trans women, as someone who is a “late transitioning” pan trans woman, this “theory” is totally invalid as a plausible description of the dozens of bi/pan/gay trans women I know. Most trans women I know lead boring normal lives like any other boring normal citizen in America. The idea that trans women would spend hundreds of excruciating hours and thousands of dollars getting facial hair removed as part of a “sexual kick” is the most ridiculous idea ever. The idea that trans women would voluntarily put themselves through so much shit merely in order to enhance their sex life is laughable.

Furthermore, for the way the AGP crowd talks you’d think that gay and straight trans women are from two different planets. While yes some things are statistically different, such as average transition age, with straight trans women transitioning earlier, but the way AGP folks talk you’d think that all trans kids are straight and all trans adults are gay. But the average age for straight trans women to transition is like 30 and for gay trans women it’s about 35 or 40, which isn’t really all that different. It certainly doesn’t suggest they are entirely different species just because of who they are attracted to, which is the only significant difference between the two groups. The AGP crowd likes to talk about how all gay trans women are “pigs in wigs” and all straight trans women are pretty and feminine, but besides being grossly transphobic, I know many counter-examples to that statement and you just can’t read off someone’s sexual orientation from their “passability”. That’s the whole problem with AGP “theory”: it attempts to make massive generalizations about an extremely diverse group of people all based on a simplified account of sexual orientation.

Zinnia Jones and Julia Serano have both dissected and debunked the “science” of autogynephilia in much more detail than I ever aspire to. My point in writing this article is merely to ridicule the theory, to laugh at how absurd it is to say that trans women persist in their transitions merely in order to live out some twisted fantasy. AGP ignores the large swath of trans women who are simply asexual or who have such low libidos as to be practically asexual. There is nothing sexy about being denied healthcare or being forced to go through the gatekeeping system simply to get access to hormones or life-saving surgery. There is nothing sexy about getting murdered in the street. There is nothing sexy about getting your facial hair removed. There is nothing sexy about facing laughter and ridicule by co-workers, friends, strangers, etc.

As Serano has explained, many trans women, before they transitioned, do have what she calls “female embodiment fantasies” – but if you were experiencing dysphoria about your gendered body wouldn’t you too have an active imagination that revolves around the idea of having your correct body? And as Jones points out, when you are forced by circumstance to explore your gender in secret behind locked doors there is going to be an element of novelty and excitement that goes away once you have the freedom to be yourself 24/7. Transition and hormones typically transform female embodiment fantasies into what doctors call “mundane reality”.

There is nothing especially fun or thrilling about being a bi/pan/gay trans woman in 2017. Sure, it’s better than the alternative: being forced to live as a man and suffer your gender dysphoria in silence. But that in no way makes post-transition life some kind of thrill ride of sexual adventure and arousal. The idea that people could think that about such a large and diverse group of women suggests they are not really creating their theory from the data but using propaganda to stigmatize trans women in order to further their political ideology of morally mandating trans women out of existence.

The theory of AGP actually does accurately describe a small segment of the population but it’s not gay/bi/pan trans women: it’s cis men who self-identify as autogynephiles. Such people do exist. There have been books written about them, chronicling their narratives. A very small percent of that population does go on to transition but essentially identify as AGP males. But most true AGPers identify as men but have “crossdreaming” fantasies of some kind. Whether or not they’d actually change their bodies to fulfill their fantasy if given the option is another question. And yeah, it’s great that some people positively self-identify as AGP. But don’t turn around and say it must be true of all trans women either.

AGP just makes no sense as a theory of why trans women go through all the trouble of transition. Can it really be true that out of the millions of trans women across the world they call all be strictly separated into two mutually exclusive groups with no overlap? Could it really be true that the primary reason why trans women transition is either to become “super gay” and attract men or because they want to live out a sexual fantasy? Or, maybe, just maybe, trans women transition for the same reason trans men do (who are TOTALLY left out of AGP theory building, btw) i.e. gender dysphoria, the sense of incongruity between your gender identity and your birth assignment. Furthermore, trans women have existed for thousands of years in cultures all around the world – all that culture is nothing but the product of sexually deviant minds? That would be too incredible.

AGP is the kick in the face that keeps on kicking because it can’t be falsified. Any evidence to the contrary is spun into an epicycle and explained away by the transes being “deceptive” or essentially in bad faith. The AGP crowd has never explained what exactly it would take to prove the theory wrong even though it does not sit with the available evidence. But it fits into a convenient narrative that is spread by both the gender critical crowd and fundamentalist conservatives: trans women are sexual predators and they shouldn’t be allowed in women-only spaces. This is the narrative at the heart of AGP. It’s why the theory is so pernicious. AGP and bathroom bills are two sides of the same coin. They are spun from the same fabricated cloth. The only way bathroom bills are going to die is if AGP also dies a painful death.

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Filed under Gender studies, Trans studies

Gender Identity as a Brain-in-a-vat

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Gender critical feminists (henceforth “GCers”)  are often skeptical about a concept foundational to trans theory: gender identity, the sense of whether we belong to a particular sex/gender or not. GCers are critical of the very idea of having one’s gender be based on your identity as opposed to being grounded in the biological properties of your body. Thus, GCers often define “woman” as an “adult female” where “female” means having certain biological properties such as the capacity to bear eggs, or having the developmental program of egg-production in your DNA-makeup or something like that.

But imagine a GCer named Janice was asleep one night and a group of evil trans neuroscientists decided to kidnap her and whisk her away to a lab, where her brain was extracted from her body and placed in a vat where the biological functions of her brain are supported by a totally artificial body. All that is left of Janice is her brain. No vagina. No breasts. No ovaries or uterus. No capacity whatsoever to make eggs or get pregnant. In many ways her “body” is not gendered at all: it’s just a hunk of brain tissue hooked up to machines. An outside observer would have a hard time determining what the brain’s gender was without knowing its past history as Janice. Furthermore, the evil trans neuroscientists are clever enough as to provide artificial stimulation to the brain such that the brain falsely believes that it actually has a body and is interacting with the world in a normal fashion. Much like Neo being inside the Matrix, Janice would not necessarily “feel” like anything other than her normal self.

What happens to Janice’s sense of identity as a woman now? She once defined her womanhood entirely in terms of biological features which no longer exist. How can she hold onto them? Let’s assume she was given a theoretical knowledge of herself as a brain-in-a-vat by the evil neuroscientists. Perhaps she reasons that her brain still contains the DNA that carries the information needed to reconstruct those body parts she identified with. But in my opinion that’s a terribly flimsy sense of identity, being tied to the mere potential of the DNA in your body to produce something that doesn’t exist. That’s a negative identity, based on that which does not exist. It seems unlikely to be the basis for a strong sense of identity as a man or a woman.

One might think that the GCer would just say that her brain is sexed as female, that she has a “female brain” but the irony is that GCers typically are skeptical of the very concept of brain sex, because brain sex is a foundational concept in trans theory. The most common and mainstream explanation of trans identities is the mismatched brain sex explanation whereby a trans woman might say she needs to transition because she was born with a female brain in a male body. This mismatch of brain and body causes gender dysphoria and since we are infinitely more capable of changing the body rather than the brain the preferred treatment of both the patients and the doctors is to allow a gender/sex transition that helps reallign brain and body by changing the body.

GCers want to morally mandate trans people out of existence and prevent as many transitions as possible so they are opposed to the idea that there is even such a thing as a “female brain” or a “male brain” because that seemingly provides sufficient medical explanation for why transition is necessary. GCers typically believe that male and female brains are only different insofar as they are influenced by society. Otherwise they start off as identical but end up producing different behaviors because they are socialized to do so.

Personally, I feel like any legitimate answer to the nature vs nurture question of sex/gender will probably include at least some nature. In practically all other animal systems in nature there are evolved adaptations in males and females that make their brains distinct in at least some small way – it would seem incredible to me that humans are the drastic exceptions to the entire scheme we see in Nature. While yes it is plausible that nurture is very, very important for the development of brains it is equally likely that our evolutionary history also plays an important role in the sex differentiation of the body, including the brain.

The latest science suggests however that there is more overlap between male and female brains than difference and that your average female brain is composed of not just “female” parts but also many “male” parts. Each of our brains is a mosaic of male and female parts. But in trans people the mosaic is arranged in such a way as to radically mismatch with the body, suggesting that some people’s internal cognitive representation of the sex can be aligned so significantly with one gender/sex or another that it generates gender dysphoria.

Going back to Janice, my feeling is that Janice’s sense of womanhood would be as strong as ever as a brain-in-a-vat. In fact, I would wager that her sense of womanhood would remain almost entirely unchanged. Even if she has an abstract sense of herself as being a brain-in-a-vat the internal representations in combination with the artificial stimulation inside her brain fully determine her subjective experience, including her felt sense of identification as an adult female or woman. But without actually owning a vagina or a womb, can Janice’s claim to womanhood be based on anything other than what trans theorists call gender identity?

This is the great irony of Janice’s predicament: in order to maintain her self of womanhood, Janice’s brain must be creating an internal representation of which sex/gender she belongs to and an alignment of that  representation with the artificial inputs giving her a sense of body. But that internal representation is precisely what trans theorists mean when they talk about “brain sex” and “gender identity” – it’s the brain’s way of telling itself what gender/sex it should belong to, a sense we all have in some way or another, even if that sense is telling us we don’t belong to any gender (a-gender).

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Filed under Gender studies, Trans studies

There I Go Again, Thinking I Have a Basic Right to Exist in Society

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There is a shockingly large contingent of Americans who believe that trans women should not have access to women-only spaces like bathrooms, locker rooms, shelters, prisons, women’s centers, lesbian spaces, festivals, etc. I will call this contingent the Birthers, because they usually say things like only females who had “female” checked off on their original birth certificate can have access to women-only spaces, which would prevent trans women from using the bathroom they feel in their best judgment is most appropriate for them.

Ironically, Birthers usually place a very high value on the idea of freedom yet deny trans women the freedom to be themselves. Birthers are gatekeepers, they want to restrict access to life-saving medical treatment such as puberty blockers, hormone replacement surgery, and surgical treatments. They want to absolutely reduce the numbers of children and adults transitioning, socially or medically. For these people, the only acceptable solution to the “trans problem” is a form of conversation therapy, an attempt to mind fuck trans people into submitting to the fate of their non-consensual birth assignment. The fundamental goal of the Birthers is to eradicate the desire for transition, the possibility of transition, and the pragmatics of transition. Part of the strategy for inflicting this on trans people is by  using propaganda to overly emphasize how gender and thus appropriate social access to gendered facilities is determined by your so-called “innate biological essence”. This is often described by Birthers as a “fact” or “reality” that trans people are somehow “delusional” about. But trans people are not delusional. The difference between the body dysmorphic person and the gender dysphoric person is that the dysmorphic person misperceives the nature of their own body, giving it physical properties that don’t exist. The gender dysphoric person, in contrast, knows full well the reality of their body, that knowledge is usually the basis for medically transitioning and a source of the dysphoria itself.

The Birthers are so quick to point to “middle school biology” to solidify their argument but as Dan Dennett once wisely said “There is no such thing as philosophy-free science – there is only science whose philosophical baggage is taken on board without examination.” The question of whether gender is different from sex is not a question that can be answered purely with science – it is a deeply philosophical question resting on complex questions of personal identity and gender as a performative, socially-embedded, experiential and subjective phenomenom. As Simone de Beauvoir famously said, “One is not born, but rather, becomes a woman.”

Upwards of 60% of trans people say they avoid public bathrooms. Without access to public bathroom facilities trans people are actually at risk of damaging their bladders by being compelled to hold their bladders for too long for fear of using either the men’s room or the women’s room.  Either option presents real dangers and for many trans people the reality is that they don’t use public restrooms at all. If they walk out of a movie, rather than waiting in line, they might just hold it until they get home. This is just one basic illustration of the way in which Birthers want to see trans folks eradicated from society. They want us to accept our birth assignments as absolute biological destiny and would, if possible, totally restrict the small little daily freedoms that allow trans people to exist in a public society of citizens.

But here’s the problem: Birthers will never understand the trans experience. They are not trans and have no concept of what it really means to have an incongruity with your gender. They can’t even fathom it. And if they do attempt to get their heads around it, they often just deny that its fundamental basis is true and go on to insist that the morphological shape of genitals we had as babies determines entirely and forever the very complicated phenomenon of our genders and how we fit into society. Talk about reductionist. Talk about rigid, stale, conservative, anti-freedom, anti-justice. They have no appreciation of the arguments in favor of thinking that gender can come apart from physiological properties. Ironically, most Birthers think that consciousness and the soul can come apart from biology but not gender for some reason, though gender is of course both a deeply social and deeply subjective phenomenon.

The Birthers are fundamentally just hypocrites hiding behind the social force of tradition. They value religious liberty, but not the liberty of trans people to make decisions about their healthcare, or about which bathroom they should use. Birthers justify this restriction of freedom by referencing the hypothetical possibility that a male person could abuse this freedom in order to harm girls and women. But it’s not like there’s a lock on the bathroom door. A cis male can walk in at anytime and there is no magic barrier blocking him from entering the bathroom and assaulting a woman or girl.

Bathroom bills are terrible solutions to a nonexistent problem. There might be a handful of problematic cases existing out there somewhere. With a population of 7.1 billion humans, with trans people accounting for, very roughly ~1 of the population, that makes 71 million trans people across the globe. Out of 71 million trans people it seems statistically likely for there to be at least *some* bad apples. But let me emphasize there is no empirical evidence showing trans women commit crimes at a higher rate than cis women. I repeat. No evidence. All there is is that one misinterpreted Swedish study but the author of the study said herself that nothing about the study suggests that your average trans woman who has transitioned circa 2017 is at any greater risk of being a criminal.

Bathroom bills are not created from the data. They are created from the ideological premise that, as Janice Raymond, the famous “radical feminist” who wrote that trans women are all rapists said, transgenderism must be morally mandated out of existence. Notice how this fits in line with many religious organizations such as the Roman Catholic church, who have said that trans people represent a grave threat to the moral order of society as dictated by the natural law of God. When your feminism aligns perfectly with what the Pope says about trans people being akin to “nuclear weapons” – then I think you need to reconsider your feminism.

Trans people have inalienable rights. We have a right to exist in society how we see fit according to our deepest vision of how we want our lives to go so long as we respect the autonomy of other people as well and think about the happiness of others.

 

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Filed under Gender studies, Trans life, Trans studies, Uncategorized

Are Pussy Hats Inherently Transphobic?

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First off, disclaimer: I didn’t actually attend the local Women’s March, so read what I have to say with a grain of salt.

With that said, I want to comment on the current controversy about whether the cornucopia of pussy-themed images at the Women’s March is inherently transphobic.

The first thing I want to say is that the mere mention of vagina and female anatomy is not inherently transphobic. It is perfectly fine if a cis woman or AFAB person (or post-op trans woman) wants to talk about their anatomy in the context of furthering reproductive rights, such as the right to a safe abortion or access to birth control or in the general context of bodily autonomy and female empowerment. When the Republicans are dead-set on attacking these reproductive rights it is perfectly ok for vagina-owners to talk about their vaginas, pregnancy, rape, and anything else relevant to reproductive health or any other issue facing vagina-owners.

Furthermore, we need to place the pussy images in the proper context, which is Trump’s comments about grabbing women’s pussies. I don’t believe it is inherently transphobic for vagina owners to use pussy imagery to respond to Trump’s misogynistic comments that centered around grabbing AFAB anatomy. Take, for example, the following sign:

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I don’t believe this sign is inherently transphobic because it’s dealing with the GOP obsession with restricting the reproductive rights of people capable of getting pregnant. Furthermore, nothing about this sign indicates that only women have vaginas or that women are defined by their genitalia are that vaginas are the Ur-symbol to represent the Women’s Rights movement, femininity, or feminism in general. So we have set an example in which it is possible to use vagina imagery in a way that is not transphobic. In contrast, let’s look at this other sign:

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This sign is much more problematic than the previous sign. It is obviously a play on “we the people”. In my opinion, the underlying implication of the sign is that the “we” is referring to all women who are fighting back against Trump and the republicans. The problem is that not all women fighting back have pussies. The picture is clearly trying to make a general statement about feminism and the Women’s Rights movement and it is not explicitly focused on the GOP obsession with taking away reproductive rights from vagina-owners. This image is arguably transphobic because it ignores the way in which non-pussy owners are just as much part of the “we” which is fighting for body autonomy and Women’s Rights. This sign is problematic in the same way the next sign is:

laub-womens-march-dc-017.nocrop.w1800.h1330.2x.jpg

“Pussy power” with a female symbol next to it. The underlying implication is that female = pussy and pussy = female and that the power to fight the GOP lies only with pussy-owners. This is transphobic because not all females have pussies. Furthermore, the underlying context of the sign is supposed to represent the power of women to protest Trump and fight back against the Republicans who are taking away women’s rights. But obviously not all the women who have the collective feminine power to fight back have pussies.

However, there is nothing wrong with taking pride in having a pussy, or thinking that pussies are powerful, or in trying to organize with people who also have pussies. But why exclude trans women from the symbolic image of those with the female power to fight Trump and the GOP? Trans women are incredibly powerful fighters. We have so much power to contribute to the fight. Furthermore, trans women are female. We have just as much claim to the female symbol as pussy owners. By associating the female symbol with pussies this works to alienate trans women from the collective female fight against Trump and the GOP.

In conclusion, pussy hats and pussy imagery are not inherently transphobic. Wearing a pussy hat is not inherently transphobic. But the context certainly matters. The nuance of language certainly matters. There are non-transphobic and transphobic ways to use pussy imagery to represent the fight for Women’s Rights. If feminism is going to work in the 21st century it needs to do better to be inclusive of trans women. This is not to say that everything has to be about trans women or that people should give up on using vagina-based imagery altogether. The pussy is still a powerful symbol because the vast majority of women have vaginas and conservatives have traditionally focused on controlling pussies. But the fight for bodily autonomy is a fight that is equally shared with trans women and trans women are powerful allies that feminism excludes at the risk of losing amazingly powerful allies. We can do better.

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Filed under feminism, Gender studies, Trans studies

The Corrective Model of Trans Healthcare

In order to think about the logical limits of the informed consent model (IC) we need to imagine if it was practically feasible to do same-day bottom surgery on trans folks and someone woke up one day wanting gender confirmation surgery (GCS) after spending the entire morning making themselves informed on the risks and benefits. Furthermore, assume they are of sound mind and not having a psychotic episode. Would it be permissible for surgeons to perform GCS on this patient? The case seems absurd because under reasonable assumptions about how IC works there is an implicit assumption that the desire for GCS must not be a whim but rather a deeply held desire. Thus it seems reasonable there needs to be some persistence criterion built into informed consent (IC), and some diagnostic factor to ensure the persistence is there in order to prevent people from making rash decisions that they will later regret.

Furthermore, imagine the case isn’t about trans surgery. Suppose someone walks in same day to get a hysterectomy because they decided that morning they didn’t want kids. Or they have Bodily Integrity Identity Disorder and want to amputate a leg. We can multiply the examples endlessly to show that an extreme informed consent model does not work – some amount of gatekeeping needs to be in place to ensure that the decision is rational and in the best-interest of the patient.

Although the IC model represents a significant advantage over the traditional gatekeeping model, I do not think it goes far enough in addressing the needs of all people who seek out either HRT or GCS. Instead of the medical system, I propose that access to HRT and GCS should be modeled on the basis of the cosmetic surgery industry, where people seek treatment intervention in order to change their bodies to better align with their desired body image, or what I am calling one’s fundamental self-conception. I call this the “Corrective Model”, in the sense that cosmetic surgery is sometimes called “corrective surgery”. But the phrase “corrective” should not imply the Corrective Model assumes the desire for HRT/GCS is necessarily derived from an underlying medical condition or pathology. If I order a laptop off the internet and they send me a perfectly good but wrong model, I can request that they send me the “correct” laptop without assuming the laptop they sent me is in anyway defective. That is, one can desire to “correct” their body to better conform to an ideal image without believing they have a medical condition or underlying pathology. This ideal image I call someone’s “fundamental self-conception”. Not all self-conceptions are fundamental though. Making the distinction between fundamental and non-fundamental self-conceptions will be crucial for my project in carving out the uniqueness of transgender corrective surgery as opposed to traditional cisgender plastic cosmetic surgery.

Intuitively, the Corrective Model seems like a poor fit for the treatment of people seeking HRT and/or GCS. First, many trans people see themselves as having a medical condition, not a cosmetic condition. That is, they claim they want to change their bodies not for vain or superficial reasons but because they have a gender dysphoria, what they see as a medical condition that is characterized by significant distress over their sexed body and/or social role. Furthermore, the Corrective Model seems like a poor fit because of the need of trans people to have their treatments covered by insurance. If we model transgender healthcare after the cosmetic industry then it seems like this would limit access to HRT/GCS because cosmetic surgeries are typically not covered by insurance. The Corrective Model also seems like a poor fit because it treats gender dysphoria individuals on par with so-called “freaks” who want to radically modify their bodies through extreme cosmetic surgery, e.g., the Lizard Man. This invites further stigmatization to a marginalized group of people who just want to be seen as normal.

So the Corrective Model faces steep challenges. But none of these are fatal to the Corrective Model. All these concerns can be adequately addressed. First I will outline several distinct advantages the Corrective Model has over both the gatekeeping model and the IC model. Then I will address several worries about the Corrective Model.

Advantages of the Corrective Model

Lack of Gatekeeping

By modeling transgender healthcare on the Corrective Model, it necessarily removes the paternalistic gatekeeping based on the WPATH SOC that sets up strict requirements for access such as an in-depth documentation of gender dysphoria through a licensed therapist or medical professional. 

Allows for Non-Classical Treatment

There exist men who self-identity as men yet nevertheless desire to have breasts. These men do not want to live as women. They want to keep their male name, wear masculine clothing, and otherwise present themselves as normal cisgender men. Yet they sincerely desire breasts. For many of these men, their desire is sexual in nature. Having breasts would significantly improve their sex life and bring them psychosexual satisfaction. These men are rational and generally have no other mental health problems.

The traditional gatekeeping model would not recommend that these men get access to breast augmentation procedures or HRT. The IC model would also not recommend that these men get access to intervention because it is not a medical issue and there is not enough significant distress to warrant surgical/hormonal intervention.

The Corrective Model would make it permissible for surgeons to treat these men provided they have signed the appropriate waivers recognizing the physical and social risks involved. Crucially, the Corrective Model would not recommend that these treatments are covered by insurance because the desire for treatment is not rooted in dysphoria but rather euphoria at the thought of having breasts. These men are not suicidal because they do not have breasts nor is their psychosocial functioning significantly compromised from not having breasts. Rather, their psychosexual lives would be significantly improved if they had the treatment. I see no principled distinction between a cisgender man seeking breast augmentation and a cisgender woman seeking breast augmentation in order to make her feel better about her appearance. Both people are (1) rational and of sound mind, (2) have a strong desire to change their body, and (3) would not be hurting anyone else in virtue of getting their treatment.

On my view, the principle of autonomy makes it permissible for surgeons to treat these men who want breasts. These men have a fundamental conception of how they want their bodies to look and a vision for how they want their lives to go. They are not hurting anyone and they would be much happier if they had corrective treatment. There would of course be social risks for these men, risking social ostracization. But it should be part of their autonomous decision making process to decide whether the benefits outweigh the social risks.

Removes the stigma of pathologization

Increasingly trans people have started pushing back against the pathologization of their identities. Trans activists were responsible for removing “gender identity disorder” from the DSM, where, for decades, it was considered a mental disorder to have a gender that was different from the gender you were assigned at birth. GID was replaced simply by “gender dysphoria” such that it’s no longer a disorder to be trans in and of itself but dysphoria can be so bad as to warrant a mental diagnosis. Trans activists pushed for the non-pathologization of trans identities because of the societal stigmas that comes with being diagnosed as having a mental health disorder. Trans people were seen as not being rational enough to make autonomous healthcare decisions when it came to access to hormones or surgery.

Although this is a contentious issue in trans communities, I am going to follow the DSM in arguing that being trans in and of itself is not a medical disorder but rather simply a natural variant with the spectrum of human difference, like being tall, or being gay. This has important ramifications for how we think of access to HRT/surgery. If I am right that the correct model is the cosmetic surgery industry, then it’s important that we fully appreciate how surgeons will sign off on giving someone a face lift without needing any kind of well-documented diagnostic referral stating they are in psychological distress over their face lift. Rather, the patient simply consults with the doctor about their desires in accordance with their self-conception about how they want their body to look.
Thus, the advantage of the Corrective Model is that it moves away from the psychiatric conception of people who seek HRT or GCS. The psychiatric conception sees the desire for HRT/GCS as pathological, as a medical condition to be fixed, cured, or managed. While it is true that many trans people do in fact see their transness as a medical condition and many trans people experience gender dysphoria to the point of it being incredibly psychosocially distressing, this is not necessarily the case for all people seeking access to HRT, GCS, or top surgery. Some trans people claim to experience no significant gender dysphoria at all. Rather, their desire for HRT/GCS is rooted in gender euphoria, the palpable sense of relief and joy that comes from having their desired body and/or being treated as their identified gender. The Corrective Model is maximally inclusive because it enables these gender euphorics to actualize their autonomy by giving them a means to change their bodies in accordance with their fundamental desires without having to distort their narratives to fit into the classical transsexual model of gender dysphoria.

A bio-political argument for the corrective model

In his ground-breaking book Testo Junkie (2013) Paul Preciado writes:

I refuse the medico-political dose, its regime, its regularity, its direction. I demand virtuosity of gender; to each one, its dose; for each context, its exact requirement. Here, there is no norm, merely a diversity of viable monstrosities. I take testosterone like Walter Benjamin took hashish, Freud took cocaine, or Michaux mescaline. And that is not an autobiographical excuse but a radicalization (in the chemical sense of the term) of my theoretical writing. My gender does not belong to my family or to the state or to the pharmaceutical industry. My gender does not belong to feminism or to the lesbian community or to queer theory. Gender must be torn from the macrodiscourse and diluated with a good dose of micropolitical hedonist psychedlics. (p. 397)

Preciado’s call for “micropolitical hedonist psychedelics” represents a push towards a “radical” informed consent model that is in line with the Corrective Model. The decision to experiment with hormones, and yes it is nothing but an experiment, must be allowed by the medical profession to create “viable montrosities” of gender and sex through techno-medical treatment. Notice that Preciado is not merely meekly asking for access to HRT but “demanding” it. But where does this demand derive its moral-political authority? The authority derives from the “micropolitical” authority inside all of us, the autonomous center of decision making that helps constitute our personhood. We all have a vision for how we want our lives to go. We are the best authorities on what this vision in – only we can place the valuations upon what hormonal treatment means to us.

An upshot of the Corrective Model and Preciado’s call for virtuosity is that trans people should have the right to experiment with hormones without losing access to legal pharmaceutical drugs. If a doctor values maximizing cardiovascular health during healthcare treatment, but the patient values maximizing the relief of dysphoria through masculinization or feminization, then it should be up to the patient which pathway they choose. The job of the doctor is to provide information that is relevant to the decision making procedure but doctors should not have dictatorial power in influencing what treatment option is pursued. If a trans woman wants to be on 8mg a day of estradiol based on a careful consideration of the risks and benefits but the doctor thinks a conservative 4mg a day is less risky and thus preferable, the trans woman should be able to get access to the extra dosage so long as she signs off on the increased risks. If we are free to cause our own death by smoking excess cigarettes and eating cheeseburgers then presumably we should be able to take on a higher risk in our medical treatment. 

One might think this argument falls apart upon considering a parallel case in healthcare. Suppose a patient on opiates demands a higher dosage but the doctor is worried about the health effects and possibility of addiction. It seems preposterous that the doctor should be obligated to assent to the demands from the opiate patient. So why should patients demanding a higher HRT dose be allowed to get access to that dosage level? The problem with this opiate analogy is that it begs the question against the corrective model because it implicitly assumes we are working in a medical-pharmaceutical model instead of a model that is based on the cosmetic surgery industry. If a patient is demanding more botox, but the doctor thinks that they don’t need it or that they are already attractive enough, it is usually the patient demand that wins out. There are limits to this, however, no doctor would inject more botox than is medically safe in terms of causing immediate dangerous physical consequences. The corrective model does not advocate direct suicidal overdose by doctor prescription though it does advocate for informed risk taking. But the relevant analogical parallel is in terms of evaluating the risk with respect to the psychological effects of changing one’s face with botox. If a patient places enough value on a smoother face then it doesn’t matter if the doctor thinks it risks making them less attractive. It is the prerogative of the patient to get bigger lips or bigger breasts even if the doctor does not place the same aesthetic valuation on the change. The plastic surgeon is essentially a techno-surgical mercenary, willing to perform a procedure so long as the patient can pay for it.

So who pays for Preciado’s micropolitical hedonism? According to the corrective model, it is not the insurance companies unless there is a documented case of gender dysphoria. But Preciado explicitly devows the label “gender dysphoric” to describe himself. He calls himself a gender rebel, a biopolitical gender terrorist, performing a hormonal experiment to make a philosophical point. So gender dysphoria should not be the criterion used for getting a prescription of HRT. But if you want to get it paid for, then you must go through the medical-pharmaceutical-insurance system in order to get a diagnosis. This model is designed explicitly for the United States. In a country with universal healthcase, the question of who pays for micropolitical hedonism is trickier. Following the model of Basic Income, one could argue the government has a responsibility to provide the basic means for citizens to pursue their vision of healthiness and happiness.

Now, onto the objections:

Objection: Cosmetic Surgery is shallow

Reply: Cosmetic surgery is not necessarily shallow

There is a common assumption that when we are talking about cosmetic surgery we are necessarily talking about something that is “shallow” and superficial, that hovers on the surface and is largely inconsequential, that it doesn’t do anything but deal with someone’s vanity or desire to fit into today’s beauty culture. When we think of cosmetic surgery we think of someone unhappy with the size of their breasts, or someone who does not like the fat accumulation in their stomach. When we think of cosmetic surgery we think of treatments that are not medically necessary, that do not save lives or prolong life. Sure, cosmetic surgery might make you happy but you could have just learned to accept your appearance for a lot cheaper.

I believe this conception of cosmetic surgery is deeply flawed. I believe that cosmetic surgery can be both shallow and deep. It can address surface issues such as age-related wrinkles but it can also deal with deep psychological problems. All that “cosmetic” means is that it deals with appearances. But how your body appears is inseparable from how your body is and how your body is is deeply connected to psychological well-being. If a person with severe burn scars on their body wants to change their appearance, is that “superficial” or “shallow”? When we think of cosmetic appearances we think of a superficial focus on beauty, such as wearing makeup. But sometimes appearances can involve fundamental psychosocial issues such as when people with severe facial disfigurement seek out face transplants. Part of the reason these transplants are done is to deal with functional issues such as blinking or sensation, but the primary reason they are done is to deal with the “superficial” issue of how their face looks. But it would be insensitive to dismiss the psychosocial needs of these disfigured people as being superficial or shallow even though they are “cosmetic” i.e. dealing with appearances and not an underlying medical or biophysical problem.   

Feminist Critiques of the Cosmetic Surgery Industry

Studies have shown that cosmetic surgery is on the rise. Feminist scholars and historians argue that the rise of the plastic surgery business is directly a result of the increasing objectification of female bodies in the media, the way that the media judges the validity of a woman based on her appearance rather than her intelligence. With this critique in mind, some have argued that the entire Western obsession with unattainable feminine beauty ideals is an negative influence on young girls and women that has led to an unhealthy obsession with plastic surgery. Thus, if the cosmetic surgery industry is morally suspect then it would be bad to model trans healthcare on such a morally corrupt institution.

Along these lines, one might say to a trans woman seeking Facial Feminization Surgery (FFS) that she is just influenced unduly by society’s beauty norms and should seek self-acceptance instead of surgery in order to deal with the dysphoria she feels about her facial structure. But there is a key difference between “unhealthy” unattainable beauty ideals and the ideal body image of most trans women seeking FFS or other “elective” cosmetic surgeries. Trans women have been stereotyped as wanting to be nothing but Kim Kardashian-esque beauty models but in reality most trans women would be content with being perceived as an “average woman” rather than the most beautiful woman in the room. Feminist critiques of modern beauty culture focus on the cattiness and competitiveness of woman seeking to be the most beautiful in order to seek validation from society and to impress men. But most trans women seeking FFS are doing it fundamentally for themselves, in order to be happy just seeing a woman instead of a man in the mirror. Similarly, trans men seeking top surgery are not seeking approval of society – they are seeking corrective surgery in order to make their bodies line up with a fundamental self-conception of what their body should look like.


Insurance Coverage
One worry about the Corrective Model is that it would potentially take away the insurance coverage that so many trans people need in order to pay for their HRT and surgeries.But thinking about transgender treatment as being analogous to cosmetic surgery does not necessitate that no insurance company could cover the treatments.

When most people think of cosmetic surgery they think of “beauty” enhancing treatments such as botox or face lifts. Surely, goes the argument, the desire for HRT or GCS is different than the desire to have less wrinkles on your face. Imagine April was born without a nose. April’s condition in no way affects her physical health. Yet she suffers extreme psychosocial distress about her appearance. Would plastic surgery on her nose be considered “cosmetic” or “medically necessary”? Arguably it would not be considered medically necessary because her lack of nose does not affect her physical health in any way. But I would argue that it would be ethically obligatory for her nose surgery to be covered by insurance and that even if her treatment is not medically necessary it is psychologically necessary.

In the DSM-V there is no diagnostic category for “nose dysphoria”. Yet April’s lack of a nose is psychologically stressful to the point of causing problems in her life, both at work, socially, and with her family. Why not think of gender dysphoria in the same way as April’s lack of a nose? Gender dysphoria individuals are born with a body that causes them tremendous psychological distress which often leads to a host of psychosocial problems including depression, anxiety, and high risk of suicide. Some trans men believe they should have been born with a penis. This belief causes them an incredible amount of stress and often leads to psychosocial dysfunction. Calling the treatment of their condition “cosmetic” in no way necessitates a lack of appropriate insurance coverage.
The key advantage of the Corrective Model is that it puts the autonomy of treatment decision making into the hands of the patient. The patient gets to decide if they want a procedure to change their bodies in order to relieve their distress.

As we can see there is a fuzzy line between what counts as cosmetic treatment and what counts as medically necessary treatment. The line is so fuzzy that the distinction itself breaks down, especially if the worry is about the distinction between cosmetic treatment and necessary treatment, not just medically necessary. Not all treatments that are necessary are necessarily medical in nature. A treatment can be necessary to the proper psychosocial functioning of an individual without that treatment being necessary in the sense of being life-saving or life-prolonging.

Let us think this through with an example. A cisgender woman who desires breast augmentation in order to make her feel marginally better about herself should not be covered by insurance because it is a “shallow” cosmetic treatment. But now considered Jane, a cisgender woman. Jane has a flat chest. Ever since she was young she has agonized over her flat chest. Her flat chest has caused her endless psychosocial stress and the stress is so great that it prevents her from going out of the house or working. Due to her flat chest, Jane has been contemplating suicide. Although breast augmentation for Jane would be considered “cosmetic” because it is not medically necessary I believe it is ethically obligatory for insurance companies to cover her breast augmentation procedure. We can even imagine an entry in the DSM-V for “cisgender breast dysphoria” and it would parallel the entry for “gender dysphoria”. I see no principled reason for insurance companies to treat transgender breast dysphoria differently from cisgender breast dysphoria so long as the underlying psychosocial distress is equivalent.

Furthermore, the Corrective Model does not assume that the only valid reason for insurance coverage is psychosocial distress. As Judith Butler writes,

Examples of the kinds of justifications that ideally would make sense and should have a claim on insurance companies include: this transition will allow someone to realize certain human possibilities that will help this life to flourish, or this will allow someone to emerge from fear and shame and paralysis into a situation of enhanced self-esteem and the ability to form close ties with others, or that this transition will help alleviate a source of enormous suffering, or give reality to a fundamental human desire to assume a bodily form that expresses a fundamental sense of selfhood. [Butler 2004 92 Undoing Gender ]

The Corrective Model is pluralistic in terms of the justifications for insurance coverage. Arguably a cisgender woman’s desire for liposuction does not conform to a fundamental sense of selfhood in the same way that a trans woman’s desire for breast augmentation does and so the Corrective Model would therefore not endorse all forms of beauty-enhancement for insurance coverage. However, the line here between justifiably “enhanced self-esteem” and unjustified self-esteem enhancement is difficult to draw sharply. The attempt of therapists to demarcate cases of cosmetic enhancement that truly lead to better flourish from those that are vain, shallow, and derived from beauty culture will likely lead to the same gatekeeping problems that plagued the traditional model of trans healthcare. Instead of sharpening up our criteria to separate out moral from immoral cosmetic surgery perhaps it would be more ethical to change the nature of the insurance system to better enable human flourish on a wide scale.

Objection: The CM is Unfair to Cisgender Women

The idea is that if insurance companies cover Facial Feminization Surgery for trans women why shouldn’t they also cover facelifts or rhinoplasties on cisgender women? What’s the philosophical difference?

I believe the difference comes back to the issue of fundamental self-conceptions that don’t have an undue or unhealthy casual history that traces back to unhealthy displays of objectification in the media. For most trans people, it is not a desire for an unattainable beauty ideal they see in the media. It is simply a desire to blend into society, to be perceived a normal functioning member of society who is not a “freak” because of their gender ambiguity. The 55 year old woman who wants a facelift to look 10 years younger might “see herself” as being “really” 45 at heart but she is not exposed to violence, insults, discrimination, etc. in the face of being seen as a normal 55 year old woman. She is not prevented from using public bathrooms because of her wrinkles. Thus, another factor in separating trans cosmetic surgery from cis cosmetic surgery is the issue of justice. Trans people have historically faced injustice at the hands of a system that makes their very identity subject to attack and ridicule. The cisgender 55 year old woman might feel depressed and might be harmed by being exposed to the unhealthy societal beauty ideals but the harms are not directed at her in such a way that expose her to legitimate violence and harassment on the street whereas a trans female who is gender ambiguous faces real violence and trans man without top surgery has to bind their chest daily which can introduce many complications and difficulties that a ciswoman seeking breast augmentation simply doesn’t face.  

Who Ultimately Decides To Change Trans Bodies?

One potential objection to the Corrective Model is that it should ultimately be the doctor who decides whether to go ahead with the treatment, not the patient. Although Hale (2007) agrees with me that the WPATH SOC should be done away with, he still prescribes to the view that transgender treatment should be modeled after the standard medical model, albeit with more emphasis on autonomy than proponents of gatekeeping. He writes:

“[Getting rid of the SOC] is not an endorsement of ‘surgery on demand,’ not even the more moderate view that surgery is a right to be granted upon request. Nor do I support Susan Stryker’s (1997) suggestion that the transsexual, rather than the psychotherapist, should ultimately determine what will happen to the transsexual’s body. Ultimately, decisions about whether to prescribe hormones and perform operations must be made by physicians – not prospective patients or mental health professionals – after careful patient-physician consultation and a thorough informed consent process” (Hale, 2007, 503)

Although Hale disavows any kind of gatekeeping through the SOC and advocates for an informed consent process, he mischaracterizes the nature of the shared decision making process by claiming that “ultimately” it is the doctor who decides what will happen to the trans person’s body.


If a trans patient comes into an IC clinic asking for HRT, the doctor checks for medical contradictions, and then decides to prescribe hormones, is it really the case that the doctor is “ultimately” making the final decision about what happens to the trans patient’s body? I think Hale is failing to distinguish between two different senses of what counts as the “ultimate decision”. On the one hand, the “ultimate decision” can mean the final step of the causal process, meaning that it is the doctor writing down the Rx on his pad that is the “final” decision. But in the other sense, the “ultimate” decision has already been made by the patient seeking HRT because it is their decision at a more fundamental level – they are the ones who stepped forward and made the decision to walk into the IC clinic with the intent of getting HRT. They are the ones who have decided to change their body.
Consider an analogy with an auto mechanic. A customer walks into the auto shop and requests a replacement of their exhaust system in order for it to sound louder. In one sense, it is the mechanic who “ultimately” decides what happens to the car because they are the ones who make the final causal step in agreeing to work on the car. But in another sense, it is really the customer who made the “ultimate” decision about whether to get a new exhaust system because it was their original desire for a louder exhaust system that brought them to the auto shop in the first place.

We can think of standard cosmetic surgery in the same way. A woman goes into the surgeon’s office seeking a face lift. The doctor checks for medical contraindications and then decides whether to go ahead with the treatment. As I see it, it is not the doctor who “ultimately” decides whether to change the woman’s face. The woman decides. It is her autonomous decision to do so. The surgeon is merely a technical expert that assists her and makes sure her desires are satisfied in a safe and effective manner.

Cosmetic surgery might be described as “surgery on demand”. But why is that problematic? It is not like you can walk into a plastic surgeon’s office and demand a surgery that will lead to immediately dangerous medical complications that will cause death the next day. The plastic surgeon still has to check for medical contraindications. So the “surgery on demand” is a red herring. What the Corrective Model really amounts to is “surgery on demand provided the surgery is medically safe”, which sounds decidedly less ominous than the way Hale describes it. Similarly, I believe we should adopt “HRT on demand provided there are no medical contraindications”. If someone just had a heart attack last week they should not be able to walk into a clinic, demand HRT, and then receive them. There are checks and balances in place that prevent such scenarios. But assuming the patient is healthy and of sound mind then it is ultimately the patient who decides what happens to their bodies.


Sexual Reasons for Wanting HRT or GCS

One might argue that treating transgenderism as a medical condition is appropriate because it weeds out “genuine” trans people who seek HRT/GCS from people who seek out HRT/GCS for “sexual” reasons. But this is no reason to abandon the Corrective Model.

Suppose Bob is a cisgender man who wants HRT and GCS because it would lead to a more satisfying sex life. Bob’s lack of HRT and GCS does not cause him any significant psychosocial distress. In my view, it is permissible for doctors to give Bob HRT and surgery on the basis of informed consent but I do not think his treatment should be covered by insurance.

The key difference between Bob and gender dysphoric people is that Bob does not experience significant psychosocial stress from not having HRT/GCS. Bob is not at increased risk of depression and suicide because he cannot have the body he desires.

Obviously it is a fuzzy line between “how much” distress is necessary in order to warrant insurance coverage. But presumably the professional class of doctors/therapists/psychiatrists would be able to determine if the gender dysphoria was significantly affecting the psychosocial functioning of the patient. On the Corrective Model, seeing a therapist is not a requirement for getting access to HRT/GCS but it is recommended. However, on the Corrective Model, if you plan on getting your insurance to cover your treatments then it would be necessary to seek out a professional therapist or psychiatrist to get a diagnosis of gender dysphoria showing that your gender incongruence is significantly causing psychosocial problems in your life.

Body Dysmorphia

Someone might object to the example of April wanting a nose by saying we already have a category in the DSM for people who are unhealthily obsessed with their physical appearance: Body Dysmorphia. People with body dysphoria, e.g., might think that their head is incredibly large and ugly and strongly desire to change their physical appearance. Isn’t this just the same as April, who is obsessed with her nose? Or perhaps this is akin to the anorexic who is obsessed with how their body looks. Treating these issues is not just a cosmetic issue – it is a medical issue. Shouldn’t we think of April’s case similarly as well as gender dysphoria?

The problem with this objection is that body dysmorphia and anorexia are both characterized by misperceptions of reality. The person who hates their head because they have a huge head actually has a normal size head – everyone in their life, doctors, friends, family, all ensure them that they have a normal size head. But no amount of external observation will change the belief that their head is too big. With April and her nose she is not making a perceptual mistake. Her nose really is gone.

Someone might object to my “distress” criterion by saying that the anorexic distress would be alleviated if we helped them achieve their desired thinness. But obviously we should not encourage or help the anorexic to become thinner. So the argument goes, the distress that Jane, the cisgender breast dysphoric, feels should also not be indulged as well. It would be better to put her in therapy in order to get rid of her chest dysphoria. But of course this never happens. If Jane walked into a plastic surgeon’s office seeking breast augmentation the surgeon would not deny her request and refer her to psychiatrist or therapist. He would listen to her desires and recommend the best course of action to satisfy her desires and relieve her chest dysphoria. If Jane’s dysphoria over her chest was so debilitating that she was unable to go out of her house or work a job then her treatment should be covered by insurance in the same way transgender surgery is covered by insurance.  

The Insurance Objection Redux

Someone might object that my distinction between who gets insurance is too fuzzy and reintroduces gatekeeping all over again. If who gets insurance coverage is determined by the amount of psychosocial distress, who gets to decide what amount of psychosocial distress is acceptable? The line seems so fuzzy that doctors and therapists would just be re-introducting their own biases and we have the same gatekeeping system the Corrective Model is meant to replace. Someone might instead argue that we should just have insurance cover all forms of cosmetic surgery rather than trying to argue the cisgender woman wanting breasts is “less deserving” of breast augmentation than the trans woman who wants breast augmentation. I am open to this objection.

Perhaps instead of trying to draw a line between acceptable and non-acceptable cosmetic surgery on the basis of diagnosed levels of psychosocial distress we should just be lobbying local and federal governmental systems to increase funding money for educational programs that seek to correct the fundamental problems of why cisgender women (and some men) seek out what many proclaim to be unnecessary cosmetic surgery. Feminists have long argued that media representations of women objectify and cast them as sex objects as well as give young girls and women unattainable beauty ideals. If we as a society spent more time and money on correcting this problematic media representation, then perhaps the issue of women wanting a face lift would not cripple the insurance system if that system did cover cosmetic surgery. Likewise, insurance companies would then have no basis to distinguish cis and trans desires for cosmetic surgery and everyone would be on equal footing in regards to using medical technology to make us feel more at home in our own bodies.

But this might just been as laughably naive. Cosmetic industry is a booming industry and if health insurance covered it willy-nilly then already rising premiums would increase dramatically. Which brings me back to my original claim: get rid of gatekeeping for cosmetic eligibility but have a system of therapists and professionals in place to assure that the people seeking corrective surgery have levels of distress that significantly affect their well-being. If psychiatrists and therapists can distinguish between sadness and clinical depression then surely they can distinguish between low levels of distress and significant distress when it comes to non-dysphoric individuals seeking cosmetic surgery. If the transgender woman seeking Facial Feminization Surgery is experiencing suicidal thoughts or is depressed by how she “doesn’t pass” because of her masculine facial features then a professional psychiatrist or therapist should be able to offer a diagnosis of dysphoria that enables insurance coverage. The cisgender woman who simply wants a face-lift because she feels “ugly” in contrast to beauty models likely will not receive a diagnosis of any kind unless she suffers from body dysmorphia in which the appropriate treatment would be covered by insurance.

Conclusion

There are two types of gatekeeping: minimal gatekeeping and transphobic gatekeeping. Minimal gatekeeping is about checking for medical contraindications such as heart disease or brain damage or psychosis and it’s about establishing whether someone is of sound mind to understand the risks and benefits of HRT. But I contend that in most cases it does not take 6 months of therapy to assess whether someone is of sound mind to start HRT. Transphobic gatekeeping is the type of gatekeeping whereby trans people are made to jump through many various hoops in order to get access. Transphobic gatekeeping is when trans women get turned down for HRT because they should up to the doctor’s office in jeans and a t-shirt (yes I have heard of such cases in the 21st century). Transphobic gatekeeping is the erasure of non-binary narratives and denying non-binary people access to HRT because they don’t fit into the standard narrative. Minimal gatekeeping is necessary and a part of the doctor’s duty. Transphobic gatekeeping is a much more pernicious idea insofar so it is the product of all the collective social biases we have against trans people and the very idea of transitioning. As a trans person I am highly aware that transphobia is alive and well. Doctors and therapist are not immune to that and thus have their own biases. This manifests in transphobic gatekeeping.

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Filed under Ethics, feminism, Gender studies, Trans studies