Undoing Gender (15 page)

I began this essay by suggesting that the view one takes on keeping or opposing the diagnosis depends in part on how one conceives the conditions for autonomy. In the arguments of Isay, we see an argument that claims that the diagnosis not only undermines the autonomy of children but mistakes their autonomy for pathology. In the argument that Hale offers, we see that the diagnosis itself takes on a different meaning if it is no longer used by mental health professionals. The question remains, though, whether medical practitioners with no particular background in mental health will nevertheless use mental health criteria to make decisions that could be no less favorable than those made by mental health practitioners. If Hale is arguing, though, that it ought to be shifted to medical doctors as part of a drive to redefine the diagnosis so that it no longer contains mental health criteria in it, then he is also proposing a new diagnosis or no diagnosis, since the
DSM-IV
rendition cannot be voided of its mental health criteria. To answer the question of whether the shift to medical doctors would be propitious, we would have to ask whether the inclinations of medical practitioners are generally to be trusted with this responsibility, or whether the world of progressive therapists offers a better chance for humane and successful passage through the process of diagnosis.

Although I do not have a sociologically grounded answer to this question, I consider that it has to be pursued before one can judge the appropriateness of Hale’s recommendation. The great benefit of his view is that it treats the patient as a client who is exercising consumer autonomy within the medical domain. That autonomy is assumed, and it is also posited as the ultimate goal and meaning of the process of transitioning itself.

But this raises the question of how autonomy ought to be conceived in this debate, and whether revisions in the diagnosis itself might provide a way around the apparent stand-off between those who wish to have the diagnosis deleted and those who wish to keep it for the instrumental value it provides, especially for those in financial need. There are two different conceptions of autonomy at work in this debate. The view that opposes the diagnosis altogether tends to be individualist, if not libertarian, and the views that argue in favor of keeping the diagnosis tend to acknowledge that there are material conditions for the exercise of liberty. The view which worries that the diagnosis may well be internalized or damaging suggests that the psychological conditions for autonomy can be undermined, and have been undermined, and that youth are at higher risk for this compromised and damaged sense of self.

Autonomy, liberty, and freedom are all related terms, and they also imply certain kinds of legal protections and entitlements. After all, the U.S. Constitution guarantees the pursuit of liberty. It could be argued that restrictive conditions imposed upon transsexual and transgendered individuals to exercise a liberty proper to that identity and practice is discriminatory. Paradoxically, the insurance companies demean the notion of liberty when they distinguish, say, between mastectomies that are “medically necessitated” and those that constitute “elective surgery.”

The former are conceived as operations that no one readily chooses, that are imposed upon individuals by medical circumstance, usually cancer. But even that conceptualization misrepresents the kinds of choices that informed patients can make about how to approach cancer, when possible treatments include radiation, chemotherapy, Arimidex, lumpectomy, partial and full mastectomy. Women will make different choices about treatment depending on how they feel about their breasts and the prospects of further cancer, and the range of choices made is significantly broad. Some women will struggle to keep their breasts no matter what, and others let them go without much difficulty. Some will choose reconstruction and make some choices about prospective breasts, and others choose not to.

A rather butch lesbian in San Francisco recently had cancer in one breast, and decided, in consultation with her doctor, to have a full mastectomy. She thought it was a good idea to have the other breast removed as well, since she wanted to minimize the chances of a recurrence. This choice was made easier for her because she had no strong emotional attachment to her breasts: they did not form an important part of her gendered or sexual self-understanding. Whereas her insurance company agreed to pay for the first mastectomy, they worried that the second breast was “elective surgery” and that, if they paid for that, it would be setting a precedent for covering elective transsexual surgery. The insurance company thus wanted to limit both consumer autonomy in medical decision making (understanding the woman as someone who wanted for medical reasons to have the second breast removed), and to dismiss autonomy as the basis for a transsexual operation (understanding the woman as a possible transitioner). At the same time, a friend of mine recovering from a mastectomy sought to understand what possibilities existed for her for reconstructive surgery.

She was referred by her doctor to transsexual clients who could introduce her to various technologies and the relative aesthetic merits of those options. Although I’m not aware of coalitions of breast-cancer survivors and transsexuals, I can see how a movement could easily emerge whose main demand would be to petition insurance companies to recognize the role of autonomy in producing and maintaining primary and secondary sex characteristics. All this seems less strange, I would suggest, when we understand cosmetic surgery on a continuum with all the other practices that humans engage in order to maintain and cultivate primary and secondary sex characteristics for cultural and social reasons. I gather that men who want penile augmentation or women who want breast augmentation and reduction are not sent to psychiatrists for certification. It is, of course, interesting to consider in light of current gender norms why a woman who wants breast reduction requires no psychological certification, but a man who wants penile reduction may well. There is no presumption of mental mal-functioning for women who take estrogen or men who take Viagra.

This is, I presume, because they are operating within the norm to the extent that they are seeking to enhance the “natural,” making readjustments within acceptable norms, and sometimes even confirming and strengthening traditional gender norms.

The butch, nearly trans, person who wanted both her cancerous and noncancerous breasts removed understood that the only way she could gain the benefits of a mastectomy was to get cancer in her other breast or to subject her own gender desires to medical and psychiatric review.

Although she didn’t consider herself trans, she understood that she could present as trans in order to qualify for the GID and insurance benefits.

Sometimes reconstructive breast surgery is covered by medical insurance, even if done for elective reasons, but mastectomy is not included as elective surgeries covered by insurance. In the world of insurance, it appears to make sense that a woman might want less breast, but no sense that she would want no breast. Wanting no breast puts into question whether she still wants to be a woman. It is as if the butch’s desire to have the breast removed is not quite plausible as a healthy option unless it is the sign of a gender disorder or some other medical urgency.

But why is it that we do accept these other choices as choices, regardless of what we take their social meaning to be? Society doesn’t consider itself to have a right to stop a woman from enlarging or diminishing her breasts, and we don’t consider penile enhancement to be a problem, unless it is being done by an illegitimate doctor who botches the results. No one gets sent to a psychiatrist for announcing a plan to cut or grow his or her hair or to go on a diet, unless one is at risk for anorexia. Yet these practices are part of the daily habits of cultivating secondary sex characteristics, if that category is taken to mean all the various bodily indicators of sex. If the bodily traits “indicate” sex, then sex is not quite the same as the means by which it is indicated. Sex is made understandable through the signs that indicate how it should be read or understood. These bodily indicators are the cultural means by which the sexed body is read. They are themselves bodily, and they operate as signs, so there is no easy way to distinguish between what is “materially” true, and what is “culturally” true about a sexed body. I don’t mean to suggest that purely cultural signs produce a material body, but only that the body does not become sexually readable without those signs, and that those signs are irreducibly cultural and material at once.

So what are the versions of autonomy at work in these various approaches to the
DSM
diagnosis of Gender Identity Disorder? And how might we conceive of autonomy in such a way that we might find a way of thinking through the very reasonable disagreements that have emerged regarding whether to preserve or eradicate the diagnosis?

Although it is obvious that not all individuals diagnosed with GID are or wish to become transsexual, they are nevertheless affected by the use of the diagnosis to further the aims of transsexuals, since to use the diagnosis is to strengthen its status as a useful instrument. This is no reason not to use it, but it does imply a certain risk, and certain implications. A strengthened diagnosis can have effects that its users do not intend or condone. And though it may well serve an individual’s important needs to secure status and funding for a transition, it may well be used by the medical and psychiatric establishments to extend its pathologizing influence on populations of transsexuals, trans youth, and lesbian, bi-, and gay youth as well. From the point of view of the individual, the diagnosis can be regarded as an instrument by which to further one’s self-expression and self-determination.

Indeed, it can be counted among the very fundamental instruments one needs in order to make a transition that makes life livable, and that provides the grounds for one’s flourishing as an embodied subject. On the other hand, the instrument takes on a life of its own, and it can work to make life harder for those who suffer by being pathologized, and who lose certain rights and liberties, including child custody, employment, and housing, by virtue of the stigma attached to the diagnosis or, more precisely, by virtue of the stigma that the diagnosis strengthens and furthers. Whereas it would no doubt be best to live in a world in which there was no such stigma, and no such diagnosis, we do not yet live in such a world. Moreover, the profound suspicion about the mental health of those who transgress gender norms structures the majority of psychological discourses and institutions, medical approaches to gender, and legal and financial institutions that regulate questions of status and possibilities for financial assistance and medical benefits.

There is an important argument to be made from the perspective of freedom, however. It is important to remember that the specific forms which freedom takes depend upon the social conditions and social institutions that govern human options at this time. Those who claim that transsexuality is, and should be, a matter of choice, an exercise of freedom, are surely right, and they are right as well to point out that the various obstacles posed by the psychological and psychiatric professions are paternalistic forms of power by which a basic human freedom is being suppressed. Underlying some of these positions is a libertarian approach to sex transformation. Richard Green, president of the Harry Benjamin International Gender Dysphoria Association, and a strong advocate for transsexual rights, including the rights of transsexual parents, argues on behalf of this issue as a matter of personal freedom and of privacy. He cites John Stuart Mill, writing that he “argued forcefully that adults should be able to do with their bodies as they wish providing that it did not bring harm to another. Therefore, if the third gender, the transsexual, or the would-be limb amputee can continue to shoulder social responsibilities post-surgery, then the surgical requests are not society’s business.”
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Although Green makes this claim, one he himself calls “philosophical,” he notes that it comes into conflict with the question of who will pay, and whether society has an obligation to pay for a procedure which is being defended as a matter of personal liberty.

I don’t find many people writing in this area, except from within the discourse of the Christian Right, whose response to the GID is to embrace it wholeheartedly and say, “Don’t take this diagnosis away from me! Pathologize me, please!” There are, surely, many psychiatrists and psychologists who insist upon gender identity disorder as a pathology. And there is a well-funded and impossibly prolific professor of neuropsychiatry and behavioral science at the University of South Carolina, George Rekers, who combines a polemical political conservatism with an effort to intensify and extend the use of this diagnosis.
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His main concern seems to be about boys, boys becoming men, and men becoming strong fathers in the context of heterosexual marriage. He also traces the rise of GID to the breakdown of the family, the loss of strong father figures for boys, and the subsequent “disturbance” that it is said to cause. His manifest concern about the emergence of homosexuality in boys is clear from his discussion as well, citing as he does the 1994

DSM
conclusion that 75 percent of GID youth turn out to be homosexual as adults. Rekers has published loads of studies strewn with “data” presented within the context of empirical research protocols.

Although intensely polemical, he understands himself as a scientist and an empiricist, and he attributes ideological bias to his opponents. He writes that “in a generation confused by radical ideologies on male and female roles, we need solid research on men and women who are well-adjusted examples of a secure male identity and a secure female identity.”
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His “solid research” is intended to show the benefits of distinguishing clearly between gender norms and their pathologies “for family life and the larger culture.” In this vein, Rekers also notes that “preliminary findings have been published in the literature which report on the positive therapeutic effects of religious conversion for curing transsexualism… and on the positive therapeutic effect of a church ministry to repentant homosexuals.”
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He seems to be relatively unconcerned with girls, which impresses me as entirely symptomatic of his preoccupation with patriarchal authority, and his inability to see the threat that women of all kinds might pose to the presumptions he makes about male power. The fate of masculinity absorbs this study because masculinity, a fragile and fallible construct, needs the social support of marriage and stable family life in order to find its right path. Indeed, masculinity by itself tends to falter, in his view, and needs to be housed and propped up by various social supports, suggesting that masculinity is itself a function of these social organizations, and has no intrinsic meaning outside of them. In any case, there are people like Rekers who make an adamant and highly polemical case, not only for retaining the diagnosis, but for strengthening it, and they give highly conservative political reasons for strengthening the diagnosis so that the structures that support normalcy can be strengthened.