“I could have wanted to have my mammary gland holders blown up the size of bowling balls. On the other hand, to have them minimized to flatness, I get to search through a labyrinth of underground information, explore my psyche, subject myself to an intimate emotional relationship with a stranger (aka psychotherapist), spend an extra thousand dollars for the pleasure of psychic probing, relive my whole life for who knows who to see (but they’re the gender professionals, so it’s okay right?), find a support group to help me withstand this… and then find one of the very few surgeons who will do this procedure and get on with it.”
The above quote is an excerpt from a post written by a female-to-male transgender blogger that was shared with a burgeoning online community in the fall of 1994. His experience reflects the battery of testing and prohibitively expensive costs that have been par for the course for anyone considering medical interventions to modify their bodies to more closely approximate their gender identity since the 1970’s. Given that transgender persons are also four times more likely to experience extreme poverty than the general population, a historical reality becomes obvious: legal access to hormones and sex reassignment surgery has been out of reach for many who might otherwise seek them.
Fortunately, at the turn of the century we have entered a new era of public policies regarding transgender populations. A few key events set in motion a dramatic reversal of accepted dogma. For the first time in over half a century, gender nonconformity and cross-gender identification shifted from extreme marginality, stigma, and invisibility to becoming a global health policy priority issue. Rather suddenly, mainstream policymakers at local, state, federal, and international levels started passing transgender-affirmative policies and legislation intended to fund more research on transgender populations to guide further policy changes.
What happened? What changed? To understand how particular phenomena gain the attention of the public and policymakers, it helps to examine their broader institutional and historical contexts.
The Institutional Context Wherein “Transgender” Gained Credibility
Aside from a few token and almost always negative portrayals in media and a handful of high-profile court cases, such as the controversies over tennis player Renée Richards or New Jersey music teacher Paula Grossman, transgender persons have been largely invisible in and insignificant to public culture. Instead transgender visibility has primarily been confined to medical settings. Endocrinologists, psychiatrists, sexologists, plastic surgeons, and others were among the earliest actors to make authoritative claims about the nature of gender transgressive behaviors and what to do about them. These claims were based on a battery of invasive questions and tests to which gender transgressive patients were subjected in the name of research.
These patients weren’t passive victims of medical research, rather they had negotiated a difficult bargain: by offering themselves up for research, medicine could confer credibility and legitimacy to their claims. Availing one’s body and mind to the often stigmatizing, and always invasive, gaze of the clinician became a route to securing legally binding documentation of one’s gender identity. Moreover, motivated to provide “medically sound” treatments for these patients, clinicians developed increasingly sophisticated gender transition-related medical technologies and elaborate patient-screening procedures.
These procedures became enshrined in practice guidelines such as the Standards of Care for Gender Identity Disorders (first published in 1979). By the end of the twentieth-century, hormonal and surgical sex reassignment for so-called “confirmed” transgender patients had stabilized as a reasonable and legitimate treatment (although many doctors continued to refuse to allow their patients access to these treatments). Satisfying the expectations of clinicians was not only necessary to access medical gender transition, but also to secure changes of sex designation on birth certificates and driver’s licenses, and to be able to transition at work without immediately losing one’s job.
The Broader Historical Context
By the end of the twentieth century, the general public became more ambivalent about medical science. The HIV/AIDS epidemic in particular politicized “business-as-usual” in medical institutions, whose discriminatory and ethically questionable practices came into light as the virus decimated gay and transgender communities. While medical professionals were not stripped of their public authority, cracks and crevices in the structures of knowledge production and medical practice were exposed. Transgender advocates gained increasing leverage to make claims against medical authorities – to demand greater respect and dignity for transgender persons, and to challenge some of the elaborate diagnostic procedures that seemed to do little for advancing knowledge or patient well-being.
Meanwhile, the domestication of the Internet gave isolated transgender individuals unprecedented access to what began to look and feel like a community. Individual efforts by transgender patients and advocates could now be coordinated much more efficiently in grassroots fashion. Transphobia emerged as a public relations topic for gay and lesbian rights organizations which had far more political power and societal acceptance. LGB organizations began to include the “T” in their acronyms, and pressure mounted for them to direct at least some of their resources toward transgender-specific causes. Ultimately, mainstream organizations, too, began to feel pressure to include the “T.”
Where Are We Now?
The single most significant outcome of these cultural changes has been the devaluation of the invasive and stigmatizing protocols that were required for hormonal and surgical sex reassignment. New protocols are gaining credibility — such as harm-reduction models that instruct medical providers not to question a patient’s gender identification and simply to advise them of the health risks involved with seeking gender transition (for comparison, see the revised Standards of Care as of 2011). Globally these changes in protocol are reducing barriers for trans-identified persons to access respectful and appropriate care without having to relive their entire lives for a therapist or conform to narrow criteria to “count” as transgender. Even the term “transgender” is falling out of favor, replaced with a broader term “trans*” that is intended to reflect the wide diversity of (trans)gendered experience.
Though transgender populations have gained some visibility in public culture and progress is being made to establish more trans-affirming policies, the impact of these changes is limited by the continued economic and social marginalization of gender nonconforming and cross-gender identified persons. There is much work still to be done.
Demetrios Psihopaidas is a doctoral candidate in Sociology at the University of Southern California. He is currently completing international archival research on his dissertation project “Unsettled lives: How transgender became a global health policy priority.” More information about his research and publications can be found here.