There is a comprehensive, trans, self-help guide, Trans Bodies, Trans Selves (New York, 2014), the trans equivalent to the iconic feminist text Our Bodies Ourselves.36 There is a lavishly illustrated, colour-pictured guide to gender affirmation surgery, which does not spare the reader the lows as well as the highs of vaginoplasty and phalloplasty, and may not prove to be the best publicity for such procedures.37 There are medical guides to assist health-care professionals in their treatment of trans patients, which, in contrast to earlier doctor–patient interactions (as we will learn), stress ‘a therapeutic physician–patient alliance’.38 Such humane principles have been comprehensively enshrined in the ‘Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7’ (2011), with its proclamation that being trans ‘is a matter of diversity, not pathology’, and in the World Professional Association for Transgender Health declaration (2018) that ‘opposes all medical requirements that act as barriers to those wishing to change legal sex or gender markers on documents’.39
There are foundational Transgender Studies Readers, representing both Transgender Studies 1.0 and Transgender Studies 2.0.40 There is a new transgender studies textbook, written by a nonbinary trans academic, intended for use by high-school and college students, and with significant input from trans contributors, including a section in each chapter called ‘writings from the community’.41 There is an anthology of trans poetry and poetics: ‘Strange that you’d let me / give birth to my own body / even though I know I’ve always been / a boy, moving / toward what? Manhood?’42 There are trans archives. The Transgender Archives at the University of Victoria, in Canada, is a relatively new archive (2011), formed out of the collection of Rikki Swan and the papers of Reed Erickson.43 Cyberspace provides the scope for ‘transgender history to be provoked, recorded, disseminated, accessed, and preserved in ways untethered from traditional, offline, and analog practices of history’; the curated Digital Transgender Archive is a most impressive demonstration of that very potential.44 The Tretter Transgender Oral History Project of the University of Minnesota provides nearly 200 moving-image oral histories online.45 There is a growing portfolio of trans photography: most recently, Zackary Drucker and Rhys Ernst’s moving catalogue of a trans/trans relationship, and Mark Seliger’s beautiful images of trans masculinity and femininity, and those in-between – ‘endless possibilities of potential selves’, in Janet Mock’s words.46 Vice.Com has set up the online Gender Spectrum Collection, providing free stock photographs of trans and nonbinary models (taken by Drucker) to increase the visual presence and enhance the media representation of those ‘beyond the binary’.47 See Illustration 1. Although it has just stopped publication, for ten years trans men had their own, genuinely innovative, magazine, Original Plumbing, edited by Amos Mac and Rocco Kayiatos, which, both visually and in prose, shows the sheer range and vibrancy of trans male culture.48 See Illustration 2.
1 A transmasculine doctor in front of his computer.
Hence, it has become possible to ask, ‘Is Pop Culture having a Trans Moment?’49 Time magazine cover stories can proclaim a ‘Transgender Tipping Point’ (with the black, trans woman Laverne Cox on its cover) and ‘Beyond He or She’.50 The National Geographic, no less, has had a special edition on ‘The Shifting Landscape of Gender’.51
I will be using the literature of psychology, psychiatry, and modern surgery among my source material. But that does not mean that I have been captured by what is usually called the medical model, where trans is viewed through the lenses of the medical and psychiatric experts, the gatekeepers of transition. Some trans advocates, as we will see, are deeply suspicious of such influences; others have opted to work strategically within the system.52 The trans community has long been divided on such issues.53 On the one hand, the medical model provides (some) access to health care and (as a legitimizer) to legal advocacy, even if many of those involved do not really believe in the paradigm. On the other hand, it is resisted because it not only pathologizes but also privileges a particular kind of transgender, excluding more flexible forms of transness as well as those (the majority) precluded by poverty.54 As Riki Lane expresses it, the ‘tension between seeking approval for treatment and resisting pathologization is a defining characteristic of the relationship between clinicians and TGD [trans and gender-diverse] people, both as individuals and as a social movement’.55
Obviously, the medical model has framed discussion and shaped the lives first of transsexuals and then of transgender people; it has determined the rules, the parameters, the gates to treatment, and even self-perception. Austin Johnson’s labels ‘hegemonic’ and ‘normative’ are entirely appropriate.56 The sociologist Myra Hird was horrified by the attitudes of psychiatrists, physicians, and psychologists when she attended a gender identity conference in 2000, including ‘highly stereotyped notions of gender’ and the continued framing of transsex (and homosex) as pathology.57 Many commentators have pointed to the persistent gender essentialism and heteronormativity of the paradigm still present in the regime of DSM-5.58
Yet, despite this dominating role, there has still been room for trans agency, evidence of what Dean Spade has termed ‘a self-conscious strategy of deployment of the transsexual narrative by people who do not believe in the gender fictions produced by such a narrative, and who seek to occupy ambiguous gender positions in resistance to norms of gender rigidity’.59 Judith Butler once referred to San Francisco’s ‘dramaturges of transsexuality’, who coached trans men in the gender essentialism which they did not personally hold – yet needed when they approached the psychiatrists and doctors who were the gatekeepers to the sought treatment.60 ‘I braced myself for a conversation where not adhering to stereotypes and clichés could undo this whole plan’, the British trans woman Mia Violet recalled of her encounter with her therapist in the 2000s. ‘I recited my history of gender dysphoria on cue.’61 She carefully avoided complicating the expected narrative.
2 Original Plumbing, Issue 20, featuring Amos Mac and Rocco Kayiatos.
What clinicians took for patient duplicity could be interpreted as trans agency – as in the case of the famous Agnes, discussed in a later chapter. L. M. Lothstein, the psychologist at Case Western Reserve Medical School in Cleveland, whom we will also encounter later, held group therapy sessions in the 1970s in which patient power was evident. Some black trans women brought their street alliances (forged in sex work) into the clinic, where it became black patient versus white clinician. One, Ann, ‘argued that the real experts on transsexualism were the patients and that the therapists were learning a lot about them via the group therapy’. She claimed that therapists could be ‘bullied into recommending all patients for surgery’.62 When a surgeon was invited in to show slides of gender reassignment, ‘the group focused on the “ugliness” of the constructed vagina’.63 In a later study, Lothstein and his team claimed that such therapy revealed material that had been ‘denied’ and ‘falsified’ in earlier evaluations, again evidence of patient initiative.64
Elroi J. Windsor has outlined the strategies (apart from submission) available to trans men when negotiating therapy: what Windsor